Retinopathy of prematurity

Retinopathy of Prematurity

1. Retinopathy of Prematurity Brought to you by: Dr Maila K.G In Association with Dept Of Paediatrics…. Plk / Mnk Complex

2. Presentation structure Introduction Definition Epidemiology>>>>>Embryology Risk Factors Pathogenesis Screening, Diagnosis and Classification Prevention and Treatment Long term outcomes Take home message References

3. Introduction Leading cause of preventable childhood blindness in middle-income countries. Most data indicates an increasing incidence in both industrialized and developing countries An effective screening is essential for prompt diagnosis Evidence suggest that majority of premature infants who go blind from ROP, Do so due to screening failure Goal of treatment is prevention of retinal detachment/scarring and optimization of visual outcome 3 different pandemics have been described

4. Definition Multifactorial vaso -proliferative retinal disorder of preterm newborns Increasing in incidence with decreasing gestational age Nearly all cases occur in neonates BW<1500 and gestational age <32 weeks It is a disease of the developing retinal vasculature

5. Epidemiology Incidence of 6-18% cases of blindness in developed countries Estimated global incidence of 20 000 infants per year. In S.A est 16000 infants are at risk of ROP and require screening each year 1995 ROP accounted for 10,6 % of cases of blindness in schools for the blind Prevalence for LBW in SA tertiary hospitals remain low Any ROP 16,3-24,5%, CSROP 1,56-4,4% and sight threatening ROP 0,6-2,9%

6. Retinal development

7. Retinal development 16 weeks: retinal vessels arise from hyaloid vessels at optic disc and migrate outwards By 28 weeks: photo receptors migrate 80% of the distance towards ora-serrata 36 weeks: migration is complete on nasal side 40 weeks: migration is complete on temporal side

8. Risk factors Major risk factors Alternative Risk factors Prematurity Prenatal and perinatal Maternal factors Low birth weight Chorioamnionitis Hypertensive disorders of Pregnancy Oxygen Infant Factors Maternal diabetes Gender: >boys than girls Twin/ multiple births Neonatal Sepsis…Candida sepsis Multiple transfusions and IVH Hypotension

9. Pathogenesis

10. Stage II

11. Who must I screen and When <32/40 gestation VLBW Preterm weighing 1500-2000g MAY also be at risk Multiple T/F, cardiac arrest or severe HIE 4-6 weeks chronological age or 31-33 weeks post conception

12. Preparation for screening Request form should be completed in duplicate by treating doctor Cyclomydril : 1 drop to each eye every 15-20 minutes. Starting 45 minutes before the examination until pupil is dilated Benoxinate : 1 drop at outset Chloramphenicol: 1 drop at end of examination

13. Diagnosis Ophthalmologist with expertise in neonatal assessment Binocular indirect ophthalmoscopy Generally used method Requires local anaesthetic , together with pupil dilatation Retcam Wide angle digital pediatric retinal imaging system Avoid stress and expertise of I/O exam but as sensitive and specific as I/O Useful for telemedicine diagnosis, and response to treatment follow up

14. International Classification of ROP

15. Stages of ROP

16. Plus disease

17. Final Assessment No ROP if the retina was fully vascularised or if normal vascularisation was noted in zone III with no signs of ROP • ROP present: • T1 ROP • T2 and earlier ROP • Screening failure if stage 4 or 5 present.

18. Terminologies Pre-Plus disease: vascular abnormalities of posterior pole present but insufficient for +disease APROP: rare, rapidly progressive, severe form Posterior location and prominence of plus disease out of proportion to peripheral retinopathy Threshold ROP: >5 contigous or 8 cumulative clock hours of stage 3 with Plus disease in Zone 1/2

19. Prevention and treatment Avoid Iatrogenic premature births Stringent regulated use of oxygen Use a pulse oximeter soon after birth Adhere to target sats Aggressive nutrition Poor postnatal weight gain is an important factor Start enteral feeds early as soon as clinical condition allows Avoid hypotension

20. Treatment Conventional treatment is retinal ablation d irected towards the avascular part of retina Goal is to decrease production of angiogenic growth factors Laser photocoagulation (gold standard) Anti-VEGF therapy Surgical management Lens sparring vitrectomy Vitrectomy with lensectomy

21. Long term complications Glaucoma Cataracts Myopia Strabismus Exudative retinopathy Late onset retinal detachment

22. References