Retinopathy of prematurity (ROP) is a retinal vascular disorder that occurs primarily in preterm infants. It develops due to interrupted retinal vascularization and abnormal blood vessel growth caused by premature birth. Infants with very low birth weight (<1500g) or gestational age (<32 weeks) are most at risk. If left untreated, ROP can cause blindness or severe vision impairment. Screening, timely diagnosis, and treatment with laser photocoagulation or anti-VEGF injections can help prevent vision loss from ROP.

1. Retinopathy of
prematurity
Dr. Tareq rahman ,
Resident Phase B , Neonatology,
Bangabandhu Sheikh Mujib Medical University( BSMMU).

2. Definition
Retinopathy of prematurity (ROP), formerly
known as retrolental fibroplasia because of its
end-stage appearance, is a developmental
vascular proliferative disorder that occurs in
the retina of preterm infants with incomplete
retinal vascularization.

3. Epidemiology
• Most studies report ROP incidences that are
about 60% for babies less than 1500 g (Zin and
Gole, 2013)
• The worldwide prevalence of blindness due to
ROP is approximately 50,000.
• In India the incidence of ROP is between 38
and 51.9% in low-birth-weight infants.

4. BSMMU experience :
- 1st case was reported in 2004
- Between 2013 to 2015 , 446 babies were
screened where 82 ( 19%) were diagnosed as
ROP and APROP 6% .

5. Embryology of retinal blood vessels
• Retinal vascularization begins
at 15 to 18 weeks’ gestation.
• Retinal blood vessels extend
out from the optic disc and
grow peripherally.
• Vascularization in the nasal
retina is complete at
approximately 32 – 34 weeks
and temporal retina by 40
weeks.
• Insulin-like growth factor-1
(IGF-1) supports normal retinal
vascular growth and interacts
with VEGF under influence of
hypoxic state in utero.

6. Pathogenesis

7. • Premature delivery interrupts normal vascular growth
• Phase 1 : delayed retinal vascularisation (birth-31/32
weeks)
• Developing retina exposed to hyperoxic environment
(ambient andsupplemental)
• Reduces angiogenic factors delaying retinal
vascularisation
• Phase 2 : neovascularisation
• Neuroretina continues to develop causing hypoxia
with overproduction of angiogenic factors especially
VEGF causes uncontrolled retinal blood vessel growth.

9. Risk factors for ROP
• Three crucial risk factors:
– Low Birth weight specially less than
1500 gm
– Prematurity specially 32 weeks of GA
– Unrestricted oxygen
supplementation
– Other risk factors:
– Anemia
– Blood transfusions
– Intra Uterine Growth Retardation
(IUGR)
– Failure of increase in weight
– Respiratory Distress Syndrome (RDS)
– Fluctuations in Sa O2
– Multiple apneic episodes
– Hypercarbia, Acidosis
– Sepsis
– Intra Ventricular Hemorrhage (IVH)
– Low level of the serum IGF-I in early
postnatal period
– Raised level of erythropoietin.
– Necrotising enterocolitis.
– Bronchopulmonary dysplasia
• Our baby is preterm (
30 weeks) and low
birth weight ( 1500
gm)
• He got MV , CPAP
support
• He had sepsis ,
acidosis and h/o
multiple apneic
episodes.
• Had h/o blood
transfusion due to
anaemia.

10. International Classification for
Retinopathy of Prematurity (ICROP)
• 5 parameters:
- Zone (1-3)
– Stage (1-5)
– Clock hours: The extent of the developing
vasculature that is involved quantified from 1-
12 clock hours.
– Plus disease (Plus disease is a primary factor in
treatment decision).
– Pre-plus disease

11. • Aggressive posterior
ROP (AP-ROP) is a
severe form of ROP that
rapidly causes total
retinal detachment
without going through
the normal stages of
ROP

12. Anterior-posterior location
Zone
• Zone I is the posterior
retina within 60 degrees
of the optic disc
• Zone II is a concentric
circle extending from
Zone 1 to the nasal ora
serrata
• Zone III is the remaining
temporal retina

13. Stage 1

14. Stage 2
Demarcation line with elevation between
vascular and avascular area

15. Stage 3

16. Stage 4

18. STAGE 5 : TOTAL RETINAL DETACHMENT

19. Stage 5
Stage 5. Total retinal detachment

20. • Plus disease:
Presence of dilated and tortuous vessels of
the posterior pole present in two or more
quadrants

21. • Preplus disease:
Abnormal vascular dilation and
tortuosity that is insufficient for
diagnosis of plus disease present in two
or more quadrants

22. Threshold ROP :
ROP is defined as five contiguous clock hours
or eight total clock hours of stage 3 and plus
disease in zone 1 or 2.

23. • Prethreshold ROP — Prethreshold ROP is
defined as one of the following –
 ROP at any stage less than threshold in zone I
 Stage 2 and plus disease in zone II
 Stage 3 without plus disease in zone II
 Stage 3 with plus disease in zone II but with
fewer clock hours of stage 3 than required to meet
threshold

24. • High-risk prethreshold ROP includes –
 Any stage ROP with plus disease in zone I
 Stage 3 ROP without plus disease in zone I
 Stage 2 or 3 ROP with plus disease in zone II

25. Long Term Complications of ROP
Retinal Dragging
and Folds
Others:
Acute angle closure glaucoma
Late onset Retinal Detachment( 22%)
Significant myopia (80%)
Anisometropia
Amblyopia
Strabismus

26. Criteria for screening
• United States: infants with a gestational age
of ≤30 weeks or birth weight of <1500 g and
selected infants with a gestational age of >30
weeks and an unstable clinical course.
• United Kingdom: infants with a gestational
age of ≤31 weeks or birth weight of ≤1500 g
• Canada: infants with a gestational age of ≤30
weeks, or birth weight of ≤1250 g
M. Elizabeth Hartnett et al , N Engl J Med 2012;367:2515-26.

27. ROP screening-current UK guideline
Which infant should be screened?
All infants born < 32 weeks of gestation or <1500g
When should the first screening examination be performed?
Gestational age at birth (weeks) Postnatal age at first ROP examination
(weeks)
23 7
24 6
25 5
26 4
27 4
28 4
29 4
30 4
31 4

28. ROP screening – in BSMMU
All neonates weighing <2000 g and/or with a gestation <35
weeks admitted to the NICU are being routinely screened for
ROP.
Neonates with birth weight ≥ 2000 g or gestational age more
than 35 weeks are being screened if they have an unstable
neonatal including those requiring cardiorespiratory support for
prolonged period.

29. ROP screening – in BSMMU
At a 4 weeks of postnatal age for infants born at
or more than 32 weeks of gestation or birth
weight ≥1200 g and at a 3 weeks of postnatal age
for infants less than 32 weeks of gestation or
birth weight <1200 g.

30. Diagnosis
• Ophthalmologic examination by an expert examiner usually
confirms the diagnosis.
• Binocular indirect ophthalmoscopy (BIO) is generally used.
• Newer digital camera technology demonstrated 100%
sensitivity in detecting ROP requiring treatment. But it does
not permit adequate assessment of retinal periphery.

31. Ophthalmoscopy
• Pupillary Dilation : 2.5% phenyl ephrine + 0.5%
Tropicamide – 3 times , 10 mins apart 30 mins
before exam
• Speculum
• INDIRECT ophthalmoscope
• PLUS DISEASE to be looked for before
speculum and scleral depression

32. Treatment
• Indications for treatment - Retinal ablative therapy is indicated
for eyes with threshold retinopathy of prematurity (ROP) and
eyes with high-risk prethreshold retinopathy of prematurity
(ROP) based on clinical findings.
• High-risk prethreshold ROP includes –
 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
• When treatment should start?
Once a treatment decision has been made, treatment should be
performed within 48-72 hours.

33. Treatment

34. • Treatment modalities –
 Cryotherapy
 Laser photocoagulation – Standard treatment
 Antivascular endothelial growth factor (VEGF)
monoclonal antibody (Bevacizumab)
- stage 3 and plus disease in zone I.
 Surgery - vitrectomy, Scleral buckling.
- Results are best when done before the fovea
has detached.

35. Outcome of treatment
• Treatment of acute ROP generally results in normal or near
normal anatomy of macula and posterior retina.
• Treatment fails in small proportion of cases and retinal
detachment ensues.
• Prompt vitreoretinal surgery may be needed to preserve
vision.
• Severe visual impairment continue to occur in some infants.

36. Follow - Up

37. Care in NICU
• Maintain SpO2 88 – 93 %
• Avoid flactuation of SpO2 while on O2
supplementation.
• Keep Hb level not less than 10 gm/dl
• Ensure adequate weight gain.

38. Prognosis
Spontaneous regression:
• Stage I - and stage-II: 90%.
• Stage III+ disease : 50%.

39. • PREVENTION - Interventions to prevent or limit the
progression of retinopathy of prematurity (ROP) have been
unsuccessful, although further evaluation may be needed.
Because oxidant injury contributes to ROP, antioxidant
therapies, such as vitamin E, D-penicillamine, and limited
exposure to light, have been tested.

40. Concerning matter ?
• Retinopathy of prematurity has become a leading
but preventable cause of childhood blindness
worldwide.(M. Elizabeth Hartnett et al, 2012)
• ROP occurs primarily in infants of low birth
weight and low gestational age at birth.
• Infants with ROP having higher risk for developing
certain eye problems later in life
- retinal detachment, myopia, strabismus,
amblyopia, glaucoma.

41. Reference
• www.uptodate.com
• www.medscape.com
• American Academy of Ophthalmology

42. THANK YOU