Retinopathy of prematurity
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Aug 06, 2016
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About This Presentation
retinopathy of prematurity
Slide Content
Retinopathy Of PrematurityRetinopathy Of Prematurity
Dr. samarth mishraDr. samarth mishra
Dr. samarth mishraDr. samarth mishra
Introduction Introduction
Retinopathy of prematurity (ROP) was formerly known Retinopathy of prematurity (ROP) was formerly known
as retrolental fibroplasia (RLF).as retrolental fibroplasia (RLF).
It is a developmental proliferative retinopathy that It is a developmental proliferative retinopathy that
occurs in the premature infants due to incomplete occurs in the premature infants due to incomplete
vasculogenesis of the retina at the time of birth.vasculogenesis of the retina at the time of birth.
““Vision 2020 program”- important cause of blindness in Vision 2020 program”- important cause of blindness in
children.children.
Retinopathy of prematurity (ROP) was formerly known Retinopathy of prematurity (ROP) was formerly known
as retrolental fibroplasia (RLF).as retrolental fibroplasia (RLF).
It is a developmental proliferative retinopathy that It is a developmental proliferative retinopathy that
occurs in the premature infants due to incomplete occurs in the premature infants due to incomplete
vasculogenesis of the retina at the time of birth.vasculogenesis of the retina at the time of birth.
““Vision 2020 program”- important cause of blindness in Vision 2020 program”- important cause of blindness in
children.children.
Incidence Incidence
Overall incidence: 16-17% for all premature infants.Overall incidence: 16-17% for all premature infants.
68% ROP in BW < 1250 g68% ROP in BW < 1250 g
98% among those having BW < 750 g98% among those having BW < 750 g
Overall incidence: 16-17% for all premature infants.Overall incidence: 16-17% for all premature infants.
68% ROP in BW < 1250 g68% ROP in BW < 1250 g
98% among those having BW < 750 g98% among those having BW < 750 g
Risk Factors Risk Factors
Pathogenesis Pathogenesis
Normal Retinal Vascular DevelopmentNormal Retinal Vascular Development
Nasal side Temporal side
8 months
Normal Retinal Vascular DevelopmentNormal Retinal Vascular Development
Nasal side Temporal side
8 months
Stage 1 Vasculogenesis
Formation of primitive Vascular tube
Stage 2 Angiogenesis
Formation of primitive Vascular tube
Stage 2 Angiogenesis
Newly develop hypoxic
Neural retina
Secreted VEGF
Neural retina
Secreted VEGF
From birth to postmenstrual age
30-32 wks
Relatively hyperoxic condition
(supplemental O2) suppresses VEGF
mRNA & normal VEGF driven growth
Apoptosis of vascular endothelial cells &
Vaso-obliteration
Begins around 32-34 weeks
Post-menstrual age
Nonvascularized retina becomes
Metabolically active due to continued
Development of retinal neural cells
Hypoxia which stimulate over
Production of VEGF
30-32 wks
Relatively hyperoxic condition
(supplemental O2) suppresses VEGF
mRNA & normal VEGF driven growth
Apoptosis of vascular endothelial cells &
Vaso-obliteration
Begins around 32-34 weeks
Post-menstrual age
Nonvascularized retina becomes
Metabolically active due to continued
Development of retinal neural cells
Hypoxia which stimulate over
Production of VEGF
Increased level of VEGF with IGF
uncontrolled neovascularization
Vascular growth into vitreous & finally RD
uncontrolled neovascularization
Vascular growth into vitreous & finally RD
Classification of ROPClassification of ROP
International Classification of ROP International Classification of ROP –– 1984 1984
1.1.ZZoneone
2.2.ExtentExtent
3.3.SStagetage
4.4.PPlus diseaselus disease
International Classification of ROP International Classification of ROP –– 1984 1984
1.1.ZZoneone
2.2.ExtentExtent
3.3.SStagetage
4.4.PPlus diseaselus disease
Zone:Zone:
Zone 1: Zone 1: circle centered on disc with radius = 2 x “circle centered on disc with radius = 2 x “disc to foveadisc to fovea””
distancedistance
Zone 2: Zone 2: circle centered on disc with radius = “disc to nasal ora” circle centered on disc with radius = “disc to nasal ora”
distance (nasal ora to temporal equator) but outside Zone 1distance (nasal ora to temporal equator) but outside Zone 1
Zone 3Zone 3: remaining temporal crescent beyond Zone 2 : remaining temporal crescent beyond Zone 2
Extent: Extent:
Divide the retinal surface into 12 segments (clock hours).Divide the retinal surface into 12 segments (clock hours).
Stage of retinopathy can vary among segments.Stage of retinopathy can vary among segments.
Zone 1: Zone 1: circle centered on disc with radius = 2 x “circle centered on disc with radius = 2 x “disc to foveadisc to fovea””
distancedistance
Zone 2: Zone 2: circle centered on disc with radius = “disc to nasal ora” circle centered on disc with radius = “disc to nasal ora”
distance (nasal ora to temporal equator) but outside Zone 1distance (nasal ora to temporal equator) but outside Zone 1
Zone 3Zone 3: remaining temporal crescent beyond Zone 2 : remaining temporal crescent beyond Zone 2
Extent: Extent:
Divide the retinal surface into 12 segments (clock hours).Divide the retinal surface into 12 segments (clock hours).
Stage of retinopathy can vary among segments.Stage of retinopathy can vary among segments.
Stages ( 1-5) Stages ( 1-5)
Stage 1:Stage 1:
Demarcation lineDemarcation line -a flat, thin, whitish, clear-cut -a flat, thin, whitish, clear-cut
demarcation between vascularised and avascular retina. demarcation between vascularised and avascular retina.
Stage 1:Stage 1:
Demarcation lineDemarcation line -a flat, thin, whitish, clear-cut -a flat, thin, whitish, clear-cut
demarcation between vascularised and avascular retina. demarcation between vascularised and avascular retina.
Stage 2:Stage 2:
Elevated ridge Elevated ridge -- demarcation line has ”3D” appearnce & demarcation line has ”3D” appearnce &
extends anteriorly from the retinal plane as a ridge into the extends anteriorly from the retinal plane as a ridge into the
vitreous.vitreous.
Elevated ridge Elevated ridge -- demarcation line has ”3D” appearnce & demarcation line has ”3D” appearnce &
extends anteriorly from the retinal plane as a ridge into the extends anteriorly from the retinal plane as a ridge into the
vitreous.vitreous.
Stage 3:Stage 3:
NeovascularisationNeovascularisation - Extraretinal fibrovascular tissue begins - Extraretinal fibrovascular tissue begins
to grow on the top of the ridge or posterior to the ridge and to grow on the top of the ridge or posterior to the ridge and
extends into the vitreous.extends into the vitreous.
““Pop-corn lesion”Pop-corn lesion”
NeovascularisationNeovascularisation - Extraretinal fibrovascular tissue begins - Extraretinal fibrovascular tissue begins
to grow on the top of the ridge or posterior to the ridge and to grow on the top of the ridge or posterior to the ridge and
extends into the vitreous.extends into the vitreous.
““Pop-corn lesion”Pop-corn lesion”
Stage 4: Stage 4: Partial RDPartial RD
1.1.4A: Extra-Foveal4A: Extra-Foveal
2.2.4B: Foveal4B: Foveal
Stage 5: Stage 5: Total RDTotal RD
1.1.Open-Open funnelOpen-Open funnel
2.2.Open-Narrow funnelOpen-Narrow funnel
3.3.Narrow-open funnelNarrow-open funnel
4.4.Narrow-Narrow funnelNarrow-Narrow funnel
1.1.4A: Extra-Foveal4A: Extra-Foveal
2.2.4B: Foveal4B: Foveal
Stage 5: Stage 5: Total RDTotal RD
1.1.Open-Open funnelOpen-Open funnel
2.2.Open-Narrow funnelOpen-Narrow funnel
3.3.Narrow-open funnelNarrow-open funnel
4.4.Narrow-Narrow funnelNarrow-Narrow funnel
Plus DiseasePlus Disease
Venous dilatation or arteriolar tortuosity in at least two quadrantsVenous dilatation or arteriolar tortuosity in at least two quadrants
poor pupil dilatationpoor pupil dilatation
vitreous hazevitreous haze
vascular engorgement of the iris with extension onto anterior lens surface vascular engorgement of the iris with extension onto anterior lens surface
k/a tunica vasculosa lentis.k/a tunica vasculosa lentis.
HHallmark of rapidly progressive ROP & noted by adding a allmark of rapidly progressive ROP & noted by adding a ““++”” sign after the sign after the
number of ROP stage.number of ROP stage.
Venous dilatation or arteriolar tortuosity in at least two quadrantsVenous dilatation or arteriolar tortuosity in at least two quadrants
poor pupil dilatationpoor pupil dilatation
vitreous hazevitreous haze
vascular engorgement of the iris with extension onto anterior lens surface vascular engorgement of the iris with extension onto anterior lens surface
k/a tunica vasculosa lentis.k/a tunica vasculosa lentis.
HHallmark of rapidly progressive ROP & noted by adding a allmark of rapidly progressive ROP & noted by adding a ““++”” sign after the sign after the
number of ROP stage.number of ROP stage.
ICROP Revisited 2005ICROP Revisited 2005
1.1.Aggressive posterior ROP (APROP)Aggressive posterior ROP (APROP)
2.2.Pre-plus DiseasePre-plus Disease
3.3.Clinical pearl for clarification of the extent of Zone 1Clinical pearl for clarification of the extent of Zone 1
1.1.Aggressive posterior ROP (APROP)Aggressive posterior ROP (APROP)
2.2.Pre-plus DiseasePre-plus Disease
3.3.Clinical pearl for clarification of the extent of Zone 1Clinical pearl for clarification of the extent of Zone 1
Aggressive posterior ROP (APROP)Aggressive posterior ROP (APROP)
Ill defined ROP with plus Ds in Zone 1 or sometimes posterior Ill defined ROP with plus Ds in Zone 1 or sometimes posterior
Zone 2Zone 2
Posterior pole vessels show increased dilatation & tortuosity Posterior pole vessels show increased dilatation & tortuosity
in all 4 quadrants out of proportion to periphery in all 4 quadrants out of proportion to periphery
Direct AV shunting Direct AV shunting
Doesn’t progress through classic stages 1 to 3Doesn’t progress through classic stages 1 to 3
Neovascularization may be flat, featureless Neovascularization may be flat, featureless
Typically extends circumferentially & is often accompanied by Typically extends circumferentially & is often accompanied by
a circumferential vessel.a circumferential vessel.
Observed in smallest premature infants & requires prompt Observed in smallest premature infants & requires prompt
laser T/tlaser T/t
Previously called “Rush Ds”.Previously called “Rush Ds”.
Ill defined ROP with plus Ds in Zone 1 or sometimes posterior Ill defined ROP with plus Ds in Zone 1 or sometimes posterior
Zone 2Zone 2
Posterior pole vessels show increased dilatation & tortuosity Posterior pole vessels show increased dilatation & tortuosity
in all 4 quadrants out of proportion to periphery in all 4 quadrants out of proportion to periphery
Direct AV shunting Direct AV shunting
Doesn’t progress through classic stages 1 to 3Doesn’t progress through classic stages 1 to 3
Neovascularization may be flat, featureless Neovascularization may be flat, featureless
Typically extends circumferentially & is often accompanied by Typically extends circumferentially & is often accompanied by
a circumferential vessel.a circumferential vessel.
Observed in smallest premature infants & requires prompt Observed in smallest premature infants & requires prompt
laser T/tlaser T/t
Previously called “Rush Ds”.Previously called “Rush Ds”.
APROPAPROP
zone 1
zone 2
shunt vessel
avascular retina
zone 1
zone 2
shunt vessel
avascular retina
Pre-Plus DsPre-Plus Ds
More arterial tortuosity & more venous dilation of More arterial tortuosity & more venous dilation of
posterior pole that are insufficient for Dx of Plus Ds.posterior pole that are insufficient for Dx of Plus Ds.
Dx of Pre-plus Ds has prognostic value.Dx of Pre-plus Ds has prognostic value.
More arterial tortuosity & more venous dilation of More arterial tortuosity & more venous dilation of
posterior pole that are insufficient for Dx of Plus Ds.posterior pole that are insufficient for Dx of Plus Ds.
Dx of Pre-plus Ds has prognostic value.Dx of Pre-plus Ds has prognostic value.
Clarification of the extent of Zone 1Clarification of the extent of Zone 1
Spontaneously regressed ROPSpontaneously regressed ROP
Peripheral changes:Peripheral changes:
1.1.Telangiectatic retinal vesselsTelangiectatic retinal vessels
2.2.Pigmentary changesPigmentary changes
3.3.Lattice like degenerationLattice like degeneration
4.4.Vitreous membraneVitreous membrane
5.5.Localized tractional detachmentLocalized tractional detachment
Posterior pole changes:Posterior pole changes:
1.1.Tortuous vesselsTortuous vessels
2.2.Narrow temporal arcadeNarrow temporal arcade
3.3.Disk dragDisk drag
4.4.Macular heterotopiaMacular heterotopia
5.5.Falciform foldFalciform fold
regressed stage
Peripheral changes:Peripheral changes:
1.1.Telangiectatic retinal vesselsTelangiectatic retinal vessels
2.2.Pigmentary changesPigmentary changes
3.3.Lattice like degenerationLattice like degeneration
4.4.Vitreous membraneVitreous membrane
5.5.Localized tractional detachmentLocalized tractional detachment
Posterior pole changes:Posterior pole changes:
1.1.Tortuous vesselsTortuous vessels
2.2.Narrow temporal arcadeNarrow temporal arcade
3.3.Disk dragDisk drag
4.4.Macular heterotopiaMacular heterotopia
5.5.Falciform foldFalciform fold
regressed stage
Differential DiagnosisDifferential Diagnosis
SCREENING GUIDELINESSCREENING GUIDELINES
Recommendations based on review of data from the CRYO-Recommendations based on review of data from the CRYO-
ROP and LIGHT-ROP studiesROP and LIGHT-ROP studies
Screening method Screening method
1.1.IDO with a 20 or 28 D lens. IDO with a 20 or 28 D lens.
2.2.Eye speculum Eye speculum
3.3.Scleral indenterScleral indenter
Whom to screen Whom to screen
1.1.BW < 1500 g or BW < 1500 g or
2.2.Gestational age < 30 weeks or Gestational age < 30 weeks or
3.3.Infants with an unstable clinical course who are at high risk Infants with an unstable clinical course who are at high risk
(as determined by paediatrician)(as determined by paediatrician)
Recommendations based on review of data from the CRYO-Recommendations based on review of data from the CRYO-
ROP and LIGHT-ROP studiesROP and LIGHT-ROP studies
Screening method Screening method
1.1.IDO with a 20 or 28 D lens. IDO with a 20 or 28 D lens.
2.2.Eye speculum Eye speculum
3.3.Scleral indenterScleral indenter
Whom to screen Whom to screen
1.1.BW < 1500 g or BW < 1500 g or
2.2.Gestational age < 30 weeks or Gestational age < 30 weeks or
3.3.Infants with an unstable clinical course who are at high risk Infants with an unstable clinical course who are at high risk
(as determined by paediatrician)(as determined by paediatrician)
In Indian ScenarioIn Indian Scenario
BW < 2000 gBW < 2000 g
GA < 34-35 weeksGA < 34-35 weeks
Initial screening recommended between 20-30 days of Initial screening recommended between 20-30 days of
life.life.
Early screening (i.e. < 20 days of life) is strongly Early screening (i.e. < 20 days of life) is strongly
recommended for babies < 30 weeks of GA.recommended for babies < 30 weeks of GA.
BW < 2000 gBW < 2000 g
GA < 34-35 weeksGA < 34-35 weeks
Initial screening recommended between 20-30 days of Initial screening recommended between 20-30 days of
life.life.
Early screening (i.e. < 20 days of life) is strongly Early screening (i.e. < 20 days of life) is strongly
recommended for babies < 30 weeks of GA.recommended for babies < 30 weeks of GA.
Indications of treatment Indications of treatment
CRYO-ROP StudyCRYO-ROP Study: : Treat “Threshold disease” of ROP Treat “Threshold disease” of ROP
1.1.Stage 3 ROP in zone 1, or zone 2 Stage 3 ROP in zone 1, or zone 2
2.2.Involving 5 or more contiguous or 8 cumulative clock Involving 5 or more contiguous or 8 cumulative clock
hours hours
3.3.presence of plus diseasepresence of plus disease
With threshold disease there is a 50% predicted risk of With threshold disease there is a 50% predicted risk of
blindness. blindness.
CRYO-ROP StudyCRYO-ROP Study: : Treat “Threshold disease” of ROP Treat “Threshold disease” of ROP
1.1.Stage 3 ROP in zone 1, or zone 2 Stage 3 ROP in zone 1, or zone 2
2.2.Involving 5 or more contiguous or 8 cumulative clock Involving 5 or more contiguous or 8 cumulative clock
hours hours
3.3.presence of plus diseasepresence of plus disease
With threshold disease there is a 50% predicted risk of With threshold disease there is a 50% predicted risk of
blindness. blindness.
8 Noncontiguous or 5 Contiguous Clockhours of NV (Stage 3) 8 Noncontiguous or 5 Contiguous Clockhours of NV (Stage 3)
ETROP studyETROP study
Type 1/ High risk Pre-threshold ROP:Type 1/ High risk Pre-threshold ROP:
1.1.Zone 1 ROP, any stage with plus disease Zone 1 ROP, any stage with plus disease
2.2.Zone 1 ROP, stage 3 without plus disease or Zone 1 ROP, stage 3 without plus disease or
3.3.Zone 2 ROP, stage 2 or 3 with plus disease Zone 2 ROP, stage 2 or 3 with plus disease
Type 2/ Low risk Pre-threshold ROP:Type 2/ Low risk Pre-threshold ROP:
1.1.Zone 1, stage 1 or 2 without plus DsZone 1, stage 1 or 2 without plus Ds
2.2.Zone 2, stage 3 without plus DsZone 2, stage 3 without plus Ds
Type 1 ROP should be treated promptly within 72 hrs of DxType 1 ROP should be treated promptly within 72 hrs of Dx
Type 1/ High risk Pre-threshold ROP:Type 1/ High risk Pre-threshold ROP:
1.1.Zone 1 ROP, any stage with plus disease Zone 1 ROP, any stage with plus disease
2.2.Zone 1 ROP, stage 3 without plus disease or Zone 1 ROP, stage 3 without plus disease or
3.3.Zone 2 ROP, stage 2 or 3 with plus disease Zone 2 ROP, stage 2 or 3 with plus disease
Type 2/ Low risk Pre-threshold ROP:Type 2/ Low risk Pre-threshold ROP:
1.1.Zone 1, stage 1 or 2 without plus DsZone 1, stage 1 or 2 without plus Ds
2.2.Zone 2, stage 3 without plus DsZone 2, stage 3 without plus Ds
Type 1 ROP should be treated promptly within 72 hrs of DxType 1 ROP should be treated promptly within 72 hrs of Dx
Treatment ModalityTreatment Modality
Principle: Principle: To remove the stimulus (VEGF) for growth of To remove the stimulus (VEGF) for growth of
new blood vessels by ablating the peripheral avascular new blood vessels by ablating the peripheral avascular
retina.retina.
1.1.CryotherapyCryotherapy
2.2.Laser photocoagulation – standard treatmentLaser photocoagulation – standard treatment
3.3.Surgical interventionsSurgical interventions
A.A.Scleral bucklingScleral buckling
B.B.VitrectomyVitrectomy
Principle: Principle: To remove the stimulus (VEGF) for growth of To remove the stimulus (VEGF) for growth of
new blood vessels by ablating the peripheral avascular new blood vessels by ablating the peripheral avascular
retina.retina.
1.1.CryotherapyCryotherapy
2.2.Laser photocoagulation – standard treatmentLaser photocoagulation – standard treatment
3.3.Surgical interventionsSurgical interventions
A.A.Scleral bucklingScleral buckling
B.B.VitrectomyVitrectomy
CryotherapyCryotherapy
Trans-scleral or TransconjunctivalTrans-scleral or Transconjunctival
Complication:Complication:
1.1.IOHIOH
2.2.Eyelid edemaEyelid edema
3.3.Conjunctival hematomaConjunctival hematoma
4.4.Conjuntival lacerationConjuntival laceration
5.5.BradycardiaBradycardia
6.6.Respiratory distressRespiratory distress
Trans-scleral or TransconjunctivalTrans-scleral or Transconjunctival
Complication:Complication:
1.1.IOHIOH
2.2.Eyelid edemaEyelid edema
3.3.Conjunctival hematomaConjunctival hematoma
4.4.Conjuntival lacerationConjuntival laceration
5.5.BradycardiaBradycardia
6.6.Respiratory distressRespiratory distress
Laser PhotocoagulationLaser Photocoagulation
less invasiveless invasive
less traumatic to the eyeless traumatic to the eye
causes less discomfort to the infantcauses less discomfort to the infant
Easy to apply in posteriorly located disease. Easy to apply in posteriorly located disease.
Both Argon green and Diode red wavelengths laser can be delivered Both Argon green and Diode red wavelengths laser can be delivered
through an indirect ophthalmoscope. through an indirect ophthalmoscope.
Aim: Aim: near-confluent ablation of peripheral avascular retina near-confluent ablation of peripheral avascular retina with burns with burns
spaced one half burn-width apart, from ora serrata upto the ridge for 360 spaced one half burn-width apart, from ora serrata upto the ridge for 360
degree.degree.
Complication: corneal burn, hazy, Iris burn, cataract, burns of tunica Complication: corneal burn, hazy, Iris burn, cataract, burns of tunica
vasculosa lentis causing IOH.vasculosa lentis causing IOH.
less invasiveless invasive
less traumatic to the eyeless traumatic to the eye
causes less discomfort to the infantcauses less discomfort to the infant
Easy to apply in posteriorly located disease. Easy to apply in posteriorly located disease.
Both Argon green and Diode red wavelengths laser can be delivered Both Argon green and Diode red wavelengths laser can be delivered
through an indirect ophthalmoscope. through an indirect ophthalmoscope.
Aim: Aim: near-confluent ablation of peripheral avascular retina near-confluent ablation of peripheral avascular retina with burns with burns
spaced one half burn-width apart, from ora serrata upto the ridge for 360 spaced one half burn-width apart, from ora serrata upto the ridge for 360
degree.degree.
Complication: corneal burn, hazy, Iris burn, cataract, burns of tunica Complication: corneal burn, hazy, Iris burn, cataract, burns of tunica
vasculosa lentis causing IOH.vasculosa lentis causing IOH.
Before laser therapy After laser therapy
SurgicalSurgical
Scleral buckling or lens sparing vitrectomy are indicated for Scleral buckling or lens sparing vitrectomy are indicated for
stage 4 ROPstage 4 ROP
Lens sacrificing vitrectomy for stage 5 ROPLens sacrificing vitrectomy for stage 5 ROP
Scleral buckling or lens sparing vitrectomy are indicated for Scleral buckling or lens sparing vitrectomy are indicated for
stage 4 ROPstage 4 ROP
Lens sacrificing vitrectomy for stage 5 ROPLens sacrificing vitrectomy for stage 5 ROP
Current Trends in ROP Treatment Current Trends in ROP Treatment
BEAT-ROP (Bevacizumab Eliminates the Angiogenic Threat in BEAT-ROP (Bevacizumab Eliminates the Angiogenic Threat in
ROP) 2011ROP) 2011
RCT (150 infants, 300 eyes) RCT (150 infants, 300 eyes)
SStudy: tudy: Stage 3, plus, Stage 3, plus, Zone 1 and posterior Zone 2 Zone 1 and posterior Zone 2
CCompare: ompare: Intravitreal Bevacizumab (Intravitreal Bevacizumab (0.625 mg / 0.025ml, 2.5 mm post 0.625 mg / 0.025ml, 2.5 mm post
limbus) limbus) vs. vs. Peripheral Laser (ETROP) Peripheral Laser (ETROP)
Results:Results:
1. Bevacizumab reduced recurrence of ROP 1. Bevacizumab reduced recurrence of ROP
Bevacizumab recurrence: 6 of 140 eyes (Bevacizumab recurrence: 6 of 140 eyes (4%4%) )
Laser recurrrence: 32 of 146 eyes (Laser recurrrence: 32 of 146 eyes (22%22%) )
2. Bevacizumab benefit over laser in Zone 1 2. Bevacizumab benefit over laser in Zone 1
3. Bevacizumab allowed continued peripheral vascularization into 3. Bevacizumab allowed continued peripheral vascularization into
avascular retina avascular retina
ROP) 2011ROP) 2011
RCT (150 infants, 300 eyes) RCT (150 infants, 300 eyes)
SStudy: tudy: Stage 3, plus, Stage 3, plus, Zone 1 and posterior Zone 2 Zone 1 and posterior Zone 2
CCompare: ompare: Intravitreal Bevacizumab (Intravitreal Bevacizumab (0.625 mg / 0.025ml, 2.5 mm post 0.625 mg / 0.025ml, 2.5 mm post
limbus) limbus) vs. vs. Peripheral Laser (ETROP) Peripheral Laser (ETROP)
Results:Results:
1. Bevacizumab reduced recurrence of ROP 1. Bevacizumab reduced recurrence of ROP
Bevacizumab recurrence: 6 of 140 eyes (Bevacizumab recurrence: 6 of 140 eyes (4%4%) )
Laser recurrrence: 32 of 146 eyes (Laser recurrrence: 32 of 146 eyes (22%22%) )
2. Bevacizumab benefit over laser in Zone 1 2. Bevacizumab benefit over laser in Zone 1
3. Bevacizumab allowed continued peripheral vascularization into 3. Bevacizumab allowed continued peripheral vascularization into
avascular retina avascular retina
Cons & Pros of Anti VEGFCons & Pros of Anti VEGF
Anti-VEGF agents are being used in ROP treatment as Anti-VEGF agents are being used in ROP treatment as
1. Monotherapy 1. Monotherapy
Becoming less desirable if periphery not perfused Becoming less desirable if periphery not perfused
Concern for late retinal detachments Concern for late retinal detachments
2. Adjunctive therapy with laser (or cryotherapy) 2. Adjunctive therapy with laser (or cryotherapy)
3. Perioperative therapy to induce NV regression3. Perioperative therapy to induce NV regression
Dosing, schedule, and ROP recurrence patterns are still uncertain Dosing, schedule, and ROP recurrence patterns are still uncertain
Retinal detachments after anti-VEGF have occurred Retinal detachments after anti-VEGF have occurred
Long term safety data still uncertain Long term safety data still uncertain
Extended follow up is required for anti-VEGF treated ROP eyes with Extended follow up is required for anti-VEGF treated ROP eyes with
incomplete vascularization incomplete vascularization
Screening ~ every 1-2 weeks Screening ~ every 1-2 weeks
Anti-VEGF agents are being used in ROP treatment as Anti-VEGF agents are being used in ROP treatment as
1. Monotherapy 1. Monotherapy
Becoming less desirable if periphery not perfused Becoming less desirable if periphery not perfused
Concern for late retinal detachments Concern for late retinal detachments
2. Adjunctive therapy with laser (or cryotherapy) 2. Adjunctive therapy with laser (or cryotherapy)
3. Perioperative therapy to induce NV regression3. Perioperative therapy to induce NV regression
Dosing, schedule, and ROP recurrence patterns are still uncertain Dosing, schedule, and ROP recurrence patterns are still uncertain
Retinal detachments after anti-VEGF have occurred Retinal detachments after anti-VEGF have occurred
Long term safety data still uncertain Long term safety data still uncertain
Extended follow up is required for anti-VEGF treated ROP eyes with Extended follow up is required for anti-VEGF treated ROP eyes with
incomplete vascularization incomplete vascularization
Screening ~ every 1-2 weeks Screening ~ every 1-2 weeks
Recombinant human erythropoietin (rhEPO) has been Recombinant human erythropoietin (rhEPO) has been
tried.tried.
tried.tried.
Long Term Complications of ROPLong Term Complications of ROP
70% became myopic due to macular heterotopia (temporal 70% became myopic due to macular heterotopia (temporal
macular drag) & straightened blood vessels.macular drag) & straightened blood vessels.
Curvature myopiaCurvature myopia
Astigmatism >2D, if uncorrected leads to amblyopia.Astigmatism >2D, if uncorrected leads to amblyopia.
Strabismus 20.3%Strabismus 20.3%
Late onset RD 25.6%Late onset RD 25.6%
Cataract 83.7%Cataract 83.7%
GlaucomaGlaucoma
Exudative retinopathyExudative retinopathy
Retinal
Dragging and
Folds
Strabismus
70% became myopic due to macular heterotopia (temporal 70% became myopic due to macular heterotopia (temporal
macular drag) & straightened blood vessels.macular drag) & straightened blood vessels.
Curvature myopiaCurvature myopia
Astigmatism >2D, if uncorrected leads to amblyopia.Astigmatism >2D, if uncorrected leads to amblyopia.
Strabismus 20.3%Strabismus 20.3%
Late onset RD 25.6%Late onset RD 25.6%
Cataract 83.7%Cataract 83.7%
GlaucomaGlaucoma
Exudative retinopathyExudative retinopathy
Retinal
Dragging and
Folds
Strabismus
AdvancesAdvances
Computer-assisted Quantification of Plus DsComputer-assisted Quantification of Plus Ds
TelescreeningTelescreening
Important in areas with limited access to ophthalmic careImportant in areas with limited access to ophthalmic care
Take the picture of immature fundus using RetCam by trained Take the picture of immature fundus using RetCam by trained
nurse or technician.nurse or technician.
Multiple image telemedicine perform to determine the stages Multiple image telemedicine perform to determine the stages
n early initiation of treatment n follow up.n early initiation of treatment n follow up.
Important in areas with limited access to ophthalmic careImportant in areas with limited access to ophthalmic care
Take the picture of immature fundus using RetCam by trained Take the picture of immature fundus using RetCam by trained
nurse or technician.nurse or technician.
Multiple image telemedicine perform to determine the stages Multiple image telemedicine perform to determine the stages
n early initiation of treatment n follow up.n early initiation of treatment n follow up.
Conclusion Conclusion
Ultimate prevention = prevent premature births.Ultimate prevention = prevent premature births.
The role of VEGF and IGF-1 may lead to pharmacologic The role of VEGF and IGF-1 may lead to pharmacologic
interventions in preventing progression.interventions in preventing progression.
Evidence based data reshape our understanding of who to Evidence based data reshape our understanding of who to
screen and determines the critical timing of treatment.screen and determines the critical timing of treatment.
Surgical intervention preserves vision in ROP-related retinal Surgical intervention preserves vision in ROP-related retinal
detachment esp. before macular detachment.detachment esp. before macular detachment.
Ultimate prevention = prevent premature births.Ultimate prevention = prevent premature births.
The role of VEGF and IGF-1 may lead to pharmacologic The role of VEGF and IGF-1 may lead to pharmacologic
interventions in preventing progression.interventions in preventing progression.
Evidence based data reshape our understanding of who to Evidence based data reshape our understanding of who to
screen and determines the critical timing of treatment.screen and determines the critical timing of treatment.
Surgical intervention preserves vision in ROP-related retinal Surgical intervention preserves vision in ROP-related retinal
detachment esp. before macular detachment.detachment esp. before macular detachment.
THANK YOU….!THANK YOU….!
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