RETINOPATHY OF PREMATURITY DR ADNAN

Definition It is a developmental vascular proliferative disorder that occurs in the incompletely vascularized retina of primarily premature infants. ROP is one of the most common causes of blindness in children. Retinopathy of prematurity (ROP) was formerly known as retrolental fibroplasia

Vascular Development of the Eye Nasal side Temporal side

RISK FACTORS Prematurity <28 wks Low birth weight<1500g Prolonged O2 administration birth weight <1250 g-66% <1000 g-82%

PATHOGENESIS At 4-5 months of IU mesenchyme cells grow from the region of disc to periphery. Nasal retina vascularised at 36 wks ,temporal at 40 wks,shortly after birth. Vascular precursor tissue susceptible to endothelial cell cytotoxicity.

EFFECT OF O2…. Primary-Retinal vasoconstriction & vaso obliteration Secondary-retinal neovascularisation VEGF plays a major role. Other factors-LBW, illness, pCO2 has a role.

Pathogenesis Formation of shunts and its progression decides the staging of the disease. Shunts –located at demarcation line between vascular & avascular retina. Premature infant without ROP has anterior ,gray,avascular retina blends with vascular retina. In ROP-clear demarcation line is seen

EXAMINATION DIRECT OPHTHALMOSCOPY

INDIRECT OPHTHALMOSCOPY

DILATATION

INTERNATIONAL CLASSIFICATION OF ROP Location Zone 1- 60 deg circle with Optic Disc as centre & radius 2DD. Zone 2- from Zone 1 to Nasal Ora Serrata Zone 3- remaining Temporal Crescent Extent Number of clock hours of retina involved

STAGING OF ACUTE ROP ZONE 1 Z 2 Z3 OD FOVEA

CLASSIFICATION SEVERITY Stage 1: Demarcation line Stage 2: Ridge Stage 3: Ridge with extraretinal FVP Stage 4: Subtotal RD A : Extrafoveal B : RD with foveal involvement Stage 5 :Total RD with funnel

PLUS DISEASE Florid form of acute ROP Retinal vascular dilation and tortuosity in the posterior pole. Vitreous haze with pupillary rigidity Increasing Preretinal & Vitreous haemorrhage Indicates actively progressing phase of the disease

RUSH DISEASE PLUS DISEASE in Zone 1 or 2-has a very rapid progression THRESHOLD DISEASE PLUS DISEASE with Zone 1 or 2 ROP STAGE 3 5 confluent hrs of stage 3 or 8 cumulative hrs of extraretinal neovascularization

DIFFERENTIAL DIAGNOSIS STAGES 1-3 FEVR(Familial exudative vitreo retinopathy) Avascular retina . Neovascularisation develops late . Family history/neg h/o prematurity STAGES 4&5 (causes of RD & Leucocoria) a)RETINOBLASTOMA Family history no prematurity Asymmetrical USG B scan -diagnostic

DD..(contd) PERSISTENT HYPERPLASTIC VITREOUS No h/o prematurity Unilateral Congenital Asso. microcornea microphthalmos USG B-Scan –No RD,stalk frm OD to vitreous

Examinaton schedule 42 wks-95% at less risk infants develop ROP Crucial window period is 32 -42 wks 1st examn.done after 4-6 wks of birth or at 31 -33 wks ,whichever is later Follow up examn at wkly intervals till retina gets fully vascularised.

Follow up.., WEEKLY EXAMINATION ROP Zone 1 less than threshold ROP Stage 2 with plus disease ROP Zone 3 with or without plus ,not requiring ablation

FOLLOW UP.., 1-2 WKLY EXAMINATION ROP Zone 2 but less severe No ROP but incomplete vascularisation in Zone 1 2-3 WKLY EXAMINATION No ROP but incomplete vascularisation in Zone 2

TREATMENT

INDICATONS FOR ABLATION TYPE 1 ROP Zone 1 ROP with plus & stages 1,2,3 Zone 2 ROP with plus & stages 2&3. Stage 3 without plus disease TYPE 2 ROP-(WAIT &WATCH) Zone 1 – Stage 1 or 2 without plus Zone 2 - Stage 3 without plus

TREATMENT contd., STAGE 4 Scleral buckling with vitrectomy STAGE 5 Vitrectomy+release of FVP + other re-attachment procedures

CRYOTHERAPY

LASER

ANTI VEGF

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