Retinopathy of prematurity (ROP) is a vasoproliferative retinal disorder that affects premature infants. It occurs when the normal vascularization of the retina is disrupted due to preterm birth. ROP can range from mild non-proliferative changes to severe proliferative retinopathy with retinal detachment. Risk factors include preterm birth before 30 weeks gestation or low birth weight below 1500g. International classification systems grade ROP based on location within the retina and stage of disease progression. Treatment may involve laser therapy or anti-VEGF injections to promote vascularization and prevent retinal detachment. Complications can include myopia, strabismus, and vision loss if untreated ROP progresses.
2. Overview
• Introduction
• Risk factors
• Pathophysiology
• Forms of ROP
• International classification of ROP
• Treatment and follow-up
• Complication
• Ddx
3. Introduction
• Is a vasoproliferative retinal disorder unique to premature infants
• First described in 1950s
• ROP is leading cause of childhood blindness
• Second only to cerebral visual impairment
5. Pathophysiology
• Retinal vascularization begins during week 16 of gestation
• Mesenchymal tissue grows centrifugally from the optic disc
• Reaching nasal ora serrata by 36 weeks
• Temporal ora serrata by 40 weeks
• ROP results in abnormal growth of these retinal blood vessels in
premature infants
• Because of complex interaction between VEGF and insulin growth
factor (IGF-1)
• Can occur in phases
6. Phases of interaction of VEGF and IGF-1
PHASE 1
Occur at 22-30 weeks gestational age
Retina is hyperoxic (relative to intrauterine oxygen levels)
VEGF levels are low
Retinal blood vessels stop growing; this arrested growth is
1. worsened by high oxygen levels
2. Low levels of IGF-1
3. Correlated with poor weight gain
7. PHASE 2
Occurs at 31-34 weeks gestation
Avascular retina is hypoxic
VEGF levels rise
Neovascularization occur
8. International Classification of ROP
• 1. Location
• Zone I ( posterior pole)
• A circle centered on the optic disc with a radius equal to twice the
distance from the center of the disc to the macula
• Clinically, the temporal edge of zone I is visible with a 25 or 28 D lens
• With the other edge of the field of view centered on the nasal disc
margin
• Zone II
• A circle center on the optic disc with a radius equal to the distance
from the center of the optic disc to the nasal ora serrata
9. • Zone III;
• Residual cresent anterior to zone II
2. Extent-specified as hours of the clock as observers looks at each eye
17. Forms of ROP
1. Pre Plus and plus disease
2. Aggressive posterior ROP (AP-ROP)
3. Cryotherapy for ROP (CRYO-ROP)
4. Early treatment ROP (ETROP)
18. PRE PLUS DISEASE;
• Dilatation and tortuosity that are abnormal but less than that seen in
standard photograph
PLUS DISEASE;
• Marked arteriolar tortuosity and engorgement of the posterior pole
vasculature at least 2/3 of posterior fundus
• Is diagnosed by comparison with standard photograph
• It implies vascular shunting through the new vessels
• Other features include failure of the pupil to dilate and vitreous haze
20. • Signifies severe disease
AGGRESSIVE POSTERIOR ROP;
• Formerly known as Rush disease
• Severe form of ROP
• Defined as zone I or posterior zone II disease
• Associated with plus disease
• Involving all 4 quadrants of the posterior pole retina vessels, shunt
vessels and flat neovascularization at the junction between
21.
22. Vascularised and avascularised retina
• Without treatment AP-ROP progress to stage 4 or 5 ROP
CRYOTHERAPY FOR ROP ; TRIAL
• Threshold disease as 5 contiguous or 8 total clock hours of stage 3
ROP in zone I or II in the presence of plus disease
23. EARLY TREATMENT ROP TRIAL;
• Prethreshold disease as all zone I and II ROP changes
• That do not meet threshold treatment criteria
Type of ETROP classification
1. Type 1
• Zone I , any stage ROP with plus disease
• Zone I, stage 3 ROP without plus disease
• Zone II, stage 2 or 3 ROP with plus disease
• Treatment is recommended within 72 hours
24. 2. Type 2
• Zone I, stage 1 or 2 ROP without plus disease
• Zone II, stage 3 ROP without plus disease
• Requires observation
25. Diagnosis
• SCREENING, who to be screened;
Babies born at or before 30-32 weeks gestational age
Babies weighing 1500g or less
Severe-illness for other premature
• EXAMINATION,
Dilation of pupil- combination eye drop of relatively low concentration
Cyclopentolate 0.2-0.5% and phenylephrine 1-2.5%
Anaesthetic is instilled
26. Neonatal eyelid speculum is used
Monitor apnoea
Can use indirect ophthalmoscope with 28 D lens or2.2 panfundoscopic
volk lens and scleral depression
Wide field retinal camera with careful oversight
27. • RECOMMENDATION INTERVALS FOLLOW-UP EYE EXAMINATION FOR
ROP WITHOUT EYE DISEASE
1 week or less
Immature vascularization :zone I or posterior zone II
Stage 1 or 2ROP : zone I
Stage 3 ROP :zone II
Presence or suspected presence of aggressive posterior ROP
28. 1 or 2 weeks
Immature vascularization : posteror zone II
Stage 2 ROP :zone II
Unequivocally regressing ROP :zone I
2 Weeks
Stage 1 ROP :zone II
Immature vascularization :zone II
Unequivocally regressing ROP :zone II
29. 2 to 3 weeks
Stage 1 or 2 ROP :zone III
Regressing ROP: zone III
30. • CRITERIA FOR DISCONTINUATION OF ROP SCREENING EXAMINATION
1.Full vascularized retina
2. Zone III vascularization without previous zone I or II ROP
3. Lack of development of prethreshold or worse ROP by 50 weeks
4. Regression of ROP in zone III without abnormal vascular
31. TREATMENT
• Laser ablation- of avascular peripheral retina, replaced CRYOTHERAPY
• Intravitreal anti-VEGF agents- The BEAT-ROP (Bevacizumab Eliminate
the Angiogenic Threat of Retinopathy Of Prematurity)
• Pars plana vitrectomy- for tractional retinal detachment not involving
the macular (stage 4A) -90% success & visual outcome .
-stage 4B -60%
-stage 5- 20%
• Lensectomy or anterior vitrectomy
