ROP

1. RETINOPATHY OF PREMATURITY
DR. JASIR.K

2. REFERENCES
 Nelson text book of pediatrics 20th e
 Cloherty Manual of neonatal care 8th e
 NNF guidelines
 Rashtriya bal swasthya karyakram , guidelines for universal eye screening in
newborns inclu ding retinopathy of prematurity 2016

3. DEFINITION
 It is a multifactorial vasoproliferative retinal disorder that increase in incidence with
decreasing gestational age
 Approximately 65% of infants with birth weight <1250 gms and 80% of those with a
birth weight <1000 gms will develop some degree of ROP.

4. NORMAL DEVELOPMENT
 Retinal Vascularization begins – 16 weeks
 Angiogenesis :normally proceeds from the optic disc to periphery
 Reaching the outer rim of the retina [ora serrata] nasally by about 36 weeks and
extending temporally by 40 weeks

5. PATHOGENESIS
 Various theories have been proposed for the pathogenesis
1.Classical theory
2.Gap junction theory
Classical theory:
1.Hyperoxic phase:
 It occurs immediately after birth due to exposure to hyperoxic environment
 The maximum Paco2 is 35mmHg.After birth this increase to 60-80 mmHh
 Increased 02 delivery to retina results in vasoconstriction,irreversible
vasoobliteration and dissolution of the retinal capillary endothelial cells

6.  Hypoxic phase:
On withdrawal of the hyperoxic environment,an ischemia induced
vasoproliferative response is seen,resulting in development of ROP

7. RISK FACTORS
Three crucial risk factors:
 Birth weight
 Gestational age
 Prolonged oxygen exposure
Other risk factors:
 Blood transfusions
 Sepsis
 Intra Uterine Growth Retardation (IUGR)
 Failure of increase in weight
 Respiratory Distress Syndrome (RDS)
 Multiple apneic episodes
 Hypercarbia, Acidosis
 Intra Ventricular Hemorrhage (IVH)
 Anemia
 Seizures.

8. CLASSIFICATION
 ZONE
 EXTENT
 STAGE
 PLUS

9. ZONES
An i,maginary circle with
optic nerve at the center
and a radius of twice the
distance from the optic
nerve to the macula
Extends from zone 1 to the ora
serrata on the nasal side of
theeye and approximately half
the distance to the ora serrata
on the temporal side
Outer crescent shaped area
extending from zone 2 out to the
ora serrata temporally

10. EXTENT
Circumferential location of disease and is reported as clock hours in the appropriate zone

11. STAGE

12. STAGE I : DEMARCATION LINE
White in color

14. STAGE III : EXTRA RETINAL
NEOVASCULARIZATION

15. STAGE IV a
Macula Spared
STAGE IV b
Macula involved
STAGE IV : PARTIAL RETINAL DETACHMENT

17. PLUS DISEASE
 posterior venous dilation and arteriolar tortuosity of at least 2 quadrants
 Arises gradually or very rapidly.
 Due to AV shunting mainly in ridge tissue
 Severity indicator Often associated
• Iris vessel
engorgement
• Miosis
• Resistance to dilating
medications
• Vitreous haze

18.  Preplus disease: vascular abnormalities of the posterior pole more than
normal, less than PLUS

19. CLINICALLY SIGNIFICANT TERMS
Threshold ROP: CRYO ROP study
Zone I stage III with Plus
Zone II Stage III with Plus
( 5 contiguous or total 8 clock hours)
Prethreshold ROP:
Zone I Stage I, II, III with plus
Stage III without plus
Zone II Stage II and III with plus
 Plus disease has increased in importance while the extent (clock hours) of disease has
diminished

20. Aggressive posterior ROP [AP-ROP]
 Earlier known as ‘RUSH Disease’
 posterior location
 Rapidly evolving preplus and plus disease , neovascularization that may be
subtle or even intraretinal in nature.
 Progress to stage IV & V in 2-3 weeks without passing through characteristic
stages II and III
 Requires laser treatment more than once

21. TREATMENT
 Therapy for ROP is directed at treating the underlying pathogenesis by
decreasing VEGF levels
 Either by completely ablating the peripheral avascular retina that produces
the VEGF [LASER therapy/Cryotherapy] or by iactivating VEGF b binding it
after its production[anti-VEGF therapy]

22.  LASER[Light amplification by stimulated emission of radiation]
 Treatment modality of choice
 This prevents the progression and cause the regression of an established
ROP
CRYOTHERAPY LASER
ANAESTHESIA GA LOCAL/SEDATION
PAIN +++ +
EFFICACY DIFFUSE MORE PRECISE
RETINAL DETACHMENT POSSIBLE RARE
POST PROCEDURE
CHEMOSIS/LID EDEMA
+++ NIL

23. ANTIVASCULAR ENDOTHELIAL GROWTH FACTOR DRUGS
 BEVACIZUMAB[AVASTIN]
 RANIBIZUMAB

24. SURGICAL MANAGEMENT
Done for the treatment of retinal detachment
1. Scleral buckling
2. Vitrectomy
 Lens sparing
 With lensectomy

25. SCREENING

26. INTERNATIONAL
Birth Weight<1500gGA<32weeks
HigherBW/GAwith risks(unstablebabies)
31weeksPCAor4weeksCA,whichislater
GOVT OF INDIA 2016
BW<2000g
GA<35weeks
HigherBW/GAwith risks(unstable
babies)
31weeksPCAor4weeksCA,whichisearlier
[Infantsweighinglessthan1200gramsandperiod
ofgestation24-30weeksfirstscreeningshouldbe
doneat2-3weeksafterdelivery,andnotlaterthan
3weeks]
 NNF
BW<1750G
GA<34W
34-36 W/1750-2000G IF RISK
FACTOR
FIRST SCREENING WITHIN 4
WEEKS OF POST NATAL AGE[2-3
WEEKS IF <28W,GA<1200G

27. END OF SCREENING
 COMPLETE VASCULARIZATION
 VASCULARIZATION in ZONE III (till 1 DD of temporal ora) – if no previous ROP in zone I
& II
 REGRESSED ROP ( b/w 40 -44 weeks PCA)– no active disease left
 45 weeks PCA with less than pre threshold disease

28. THANKS