This document discusses the need for training and screening in retinopathy of prematurity (ROP). It notes that ROP is a major cause of preventable childhood blindness worldwide. While developed countries have screening programs that detect ROP early, many developing countries lack adequate screening. The document outlines the magnitude of the problem in India, where millions of premature infants are at risk of ROP but screening capacity is limited. It emphasizes the need to train more ophthalmologists and neonatologists to conduct ROP screening according to standardized protocols. Workshops have helped boost awareness and establish new screening centers, but more infrastructure and manpower are still needed to address the growing ROP burden in India. Regular screening can detect ROP before

1. Need for Training and Screening in
Retinopathy of Prematurity
Prof. Rajvardhan Azad
MD, FRCS, FAMS
Professor and Chief
Dr. R.P. Centre for Ophthalmic Sciences
AIIMS New Delhi

2. Presentation Layout
 ROP: Defined
 Magnitude of Problem: Demography
 Training Types:
 Awareness programs/ workshops
 Training in ROP Management
 Screening Need
 Screening net quantum vs. manpower available
 Capacity building and infrastructure development
 Summary and Conclusion

3. ROP: Definition
 Primarily a vasoproliferative
disorder of retina
 Principally occurring in
premature children but not
exclusively
 Spontaneous regression
 Potentially blinding
 If detected early and timely
blindness preventable

4. Magnitude of the Problem
50 million (world)
2 million blind children (4% of the total)
Blinds
57% is preventable {ROP}
22% has retinal causes {ROP}
0.2% of blind school survey – lower estimate

5. ROP – World Perspective
 Highly developed Countries
 HDI Ranking 1 -3 3 to 13%
 Sweden, US*, UK+
Nordic countries, Eire
 Modularly Developed
 HDI ranking - 30-100
 Argentina+, Brazil, Chile, Peru 0 -60%
 Paraguay, Ecuador, Colombia
Cuba, Bulgaria, Romania, Albania
Hungary, China, SriLanka*, Thailand
 Poorly Developed
 South Africa+, Mongolia 0 to 10%
Cambodia, Uganda, Ghana
Kenya, Nigeria, Malaysia
Ethiopia, India, Pakistan*
Guatemala , Uzbekistan
* - Minimum
+ - Maximum

6. ROP – Asian perspective
Name of UNDP Source of Data No of %
Countries Rank samples
Malaysia 59 Blind school 332 6.0%
Thailand 76 Blind school 65 16.9%
Philippines 83 Blind school 179 8.4%
China 94 Blind school 1131 1.9%
Srilanka 96 Blind school 226 0.0%
India 127 Blind school 2360 0.2%
Pakistan 142 Blind school 760 0.0%

7. ROP - Indian Disease Burden
Child birth / year Premature At risk to develop ROP
26 million 2 million ROP Screening net: 7.5
lakhs
All ROP: 2.25lakhs
Treatable ROP: 0.5 lakhs

8. ROP: Blinding Statistics
 Azad et al 1999 2.3% (<1600gm)
 Bassi et al 1998 3.35% (very premature)
 Phelp DL 1992 2.4% (<1Kg)

9. ROP India Agenda
Summit
 Insufficient medical care  State of Art Medical Care

10. ROP- Typical to India
 More severe cases
 Lack of awareness
 Lack of access to care
 Referral reluctance among
colleagues
 Late arrivals

11. R.P. Centre, AIIMS – Apex Centre
 Comprehensive ROP Eye
Care Centre
 Screening
 Laser Treatment
 Surgery
 Research
 Training

12. Tertiary ROP Care centre
Chandigarh PGI
Delhi RPC
Hyderabad LVPEI
Coimbatore Arvind eye hospital
Chennai Shankar Netralaya

13. Are we ready to face the challenge??
( GOI Data)India 2008:
27 million live births annually
2% premature : 260,000 – 520,000 infants.
Every two
hours, 3
babies in India
are reaching
the threshold
of treatment of
ROP Ophthalmologist population ratio:
1:40,000
VR surgeons : 280
Paediatric retina specialists: <20

14.  ROP Pursuits: Public Health & Social
 A ROP child blind will remain so for 60 years
 Rs.2000 maintenance cost, Rs.2000 lost productivity cost =
Rs.4000 per month.
 For sixty years - Rs.28.8 lakh (57600 US$)
 The average cost of treatment of treatable ROP in India -
Rs.15,000 (300 US$) (treatment charges + consumables)
Azad R. Retinopathy of prematurity a giant in the developing world.
Indian Pediatr. 2009 Mar;46(3):211-2.

15. Training Type
 Awareness Programs/ Workshops:
 Concept of Paired workshop
 Training of pediatrician and ophthalmic nurse in
Asian situation
(Retinopathy of prematurity screening by non-retinologists.
Azad RV et al. Indian J Pediatr. 2006 Jun;73(6):515-8.)
 Training in ROP Management:
 Screening of ROP (Diagnostic Skills)
 Laser Management of ROP (Therapeutic Skills)
 Surgical Management of ROP (Therapeutic Skills)

16. ROP Awareness Program in India
 Initiation by Ministry of Health & WHO
 Paired Workshop – New concept
Neonatologist
Ophthalmologist
 2 day - 7 workshops all over India
 New Delhi (3) Hyderabad (1) Mysore (1) Patna (1)
Lucknow (1)

17. Impact of workshop and awareness
 Initiative of Ministry of Health, Govt. of India
 180 Neonatologist and Ophthalmologist trained in a
two days paired workshop during 1999-2001.
 Pre and Post workshop questionnaire scores
showed a highly significant result (p<0.0001)using
paired T test.
 Outcome of this workshop has resulted in
emergence of new viable ROP Centres (12) all over
the country.

18. SightSavers ROP Workshops
 12 ROP workshops in collaboration with Sightsavers
India (2009-2010) in various cities
 To spread ROP awareness and train ophthalmologists
and neonatologists.
 Trained nearly 650+ such doctors

19. SightSavers ROP Workshops
 Pune 1-2 November 2008
 Mumbai 11 January 2009
 Lucknow 25-26 April 2009
Four more workshops
 Delhi 25-26 July 2009
under MOHFW
 Belgaum 29-30 August 2009
•March 2012: PGI
 Kolkata 4 October 2009
Chandigarh
 Trichy 6-7 March 2010
•April 2012: Arvind eye
 Cuttack 20-21 March 2010 hospital, Coimbatore
 Sangli 24-25 July 2010 •May 2012: BHU
 Mussoorie 29 August 2010 Varanasi
 Bangalore 5 September 2010 •June 2012: Shankara
 Ranchi 2-3 October 2010 Netralya Chennai
 Forthcoming: Hyderabad (4-5 January 2012)

20. RPC: Sightsavers ROP Workshops
India
Pune
Mumbai
Lucknow
Delhi
Belgaum
Kolkata
Trichy
Cuttack
Sangli
Mussoorie
Bangalore
Ranchi
Patna

21. REPUTED FACULTY

22. INTERACTIVE WORKSHOPS

23. SightSavers ROP Workshops
 The pre and post workshop questionnaires analysis
of 200 forms (with MCQs) have revealed significant
improvement in knowledge of the delegates
(P<0.005).
 Post workshop feedback on phone: Of the 236
people who were willing to respond to the survey, 57
had a ROP screening program, and 45 more were
able to start a screening program successfully.

24. ROP Status Among
Pediatricians
Prevailing clinical practices regarding screening for
retinopathy of prematurity among pediatricians in
India: a pilot survey.
Azad R et al. Indian J Ophthalmol. 2011 Nov-
Dec;59(6):427-30.
 A total of 234 pediatricians responded out of 406
calls made.
 Hundred percent awareness of ROP and need for
screening in premature babies was found.

25. ROP Status Among
Pediatricians
 Only 135 (58 %) pediatricians always screened for
ROP, 80 (34%) did not screen at all and 19 (8%)
screened sometimes.
 Screening protocols were not consistent with only
25% of pediatricians of those who were screening
regularly with standard screening guidelines.
 Major deterrent in screening for ROP was perceived
as non availability of trained ophthalmologists.

26. ROP Status Among
Pediatricians
Retinopathy of prematurity screening by non-
retinologists.
Azad RV et al. Indian J Pediatr. 2006 Jun;73(6):515-8.
 To detect screening efficiency of general
ophthalmologists/ non-ophthalmologists (pediatric
residents and nurses posted in NICU) in screening
ROP on the basis of posterior pole vascular changes
 Given adequate training, general ophthalmologists
and non-ophthalmologists are independently reliable
in detecting posterior pole changes in ROP babies.

27. What is screening in ROP?
ROP fulfills the criteria for screening
First possible Final critical
Disease Onset detection point Usual time of diagnosis
OUTCOME
A
B
Screening time
A Usual outcome
Lead time
B Improved outcome

28. Purpose
Screening intends to:
 Detect retinopathy of prematurity at or
before threshold stage – Critical point.
 Treat all babies reaching the critical
point.
 Redefine critical point – Early
treatment.
 Prevent or reduce unfavorable
outcome.

29. Important Periods in Screening
Whom to screen (Include all babies at risk)
 1200gm and 32wks
 1600gm and 32 wks
 1600gm and 36wks
When to Screen (Three critical stages )
• First - 32 -34 weeks
• Second - 35-37 weeks
• Third - 39-42 weeks
First screening
At 32 weeks or 4 weeks postnatal whichever is
earlier

30. Benefits of a good screening
program
 Targets all the “at risk” babies.
 Can be easily performed “in the field”
 Treatment institution possible before irreversible
damage occurs.
 Laser Ablation known to affect the outcome.
 Reduced incidence of unfavorable outcome through
screening and timely treatment.
 Studying course of disease, changing pattern and
aggressive behavior of zone І ROP has instituted
ETROP.

31. Benefits of a good screening
program?
Changing Profile of ROP in two study period
Period I Period II
1993-94 1999-2000
No. of patients 66 76
No. of patients with ROP 13/66(19.69%)
24/76(31.5%)
Grades of ROP
Stage I & II 7/66(10.6%) 19/76(25%)
Stage III 6/66(9.0%)
5/24(6.57%)
*Results of ongoing screening programme at AIIMS Nursery by RPC Consultants
Threshold ROP treated cases

32. Conclusions
•ROP is emerging as a giant of childhood blindness
•Indian epidemic is sitting on summit of two volcanoes
•Insufficient expertise in ROP may cause blindness among
neonates who have to live for 50 years or longer
•Screening intends to detect ROP before it reaches critical
stage (Type I ROP) and prevents blindness due to ROP
•Screening involves combined efforts from ophthalmologist,
neonatologist and parents
•Benefits of screening include earlier detection and
management of ROP which is changing profile of these
patients.

33. Dr. Rajendra Prasad Centre for Ophthalmic Sciences,
All India Institute of Medical Sciences, New Delhi, India