ROP Retinopathy of Prematurity Jean Escalante Kristin Filkins Erika Garcia   SPE-516 Structure and Function of the Visual System

What is Retinopathy of Prematurity? When an infant is born early or not completely developed their eyes may be lacking in development as well. Infants born before 30 weeks gestation or are under 3 pounds when born are at greater risk for this congenital disorder . Blood vessels in the eyes may grow abnormally, or stop growing altogether. These vessels may cause leaking or bleeding in the eye which may cause retina detachment or in severe cases, vision loss. Scar tissue on the retina from vessels may also cause vision loss.

Premature Eyes Premature infants eyes are not completely formed. Blood vessels are not extended outward toward the edge of the retina.

Premature Retina and Oxygen Since the Retina is not mature, oxygen outside of the womb such as nasally with oxygen therapy, or even room air oxygen can cause the vasculature of the eye to grow abnormally. The problem is controlling the amount of oxygen to keep a child alive and not give too much oxygen to cause ROP.

Vasculature of the Infant’s Eye If the blood vessels grow abnormally, they can bleed, the bleeding will cause scarring, which could potentially cause detachment of the retina.

Infant Eye Exam Referral to an ophthalmologist if under 34 weeks gestation. ROP has no signs or symptoms. Only an ophthalmologist can detect ROP via an exam.

What are the five stages of Retinopathy of Prematurity? Stage I: There is mildly abnormal blood vessel growth. Stage II: Blood vessel growth is moderately abnormal. Stage III: Blood vessel growth is severely abnormal. Stage IV: Blood vessel growth is severely abnormal and the retina is partially detached. Stage V: The retina is completely detached.

Treatment Treatment for ROP depends on the stage of the condition. Stage I and II usually require nothing more than observation and will improve on their own within weeks. Surgical procedures may be required when ROP becomes more severe as in stages III, IV, and V.

Laser therapy: physicians use a laser to remove abnormal blood vessels Laser therapy:  physicians use a laser to remove abnormal blood vessels. The laser "burns away" the periphery of the retina, which has no normal blood vessels. Cryotherapy : physicians use an instrument that generates freezing temperatures to briefly touch spots on the surface of the eye that overlie the periphery of the retina. This “freezing” will help the abnormal vessels slow or stop their growth.

In the later stages of ROP, other treatment options include: Scleral buckling: A band is placed on the eye to help prevent fluid inside the eye from pulling on scar tissue. This helps prevent retinal detachment. The band is removed at a later date as your child grows. Scleral buckling is performed at stages IV and V.

Vitrectomy: a surgical procedure that involves removing the vitreous and replacing it with a saline solution. After the vitreous has been removed, the scar tissue on the retina can be peeled back or cut away, allowing the retina to relax and lay back down against the eye wall. Vitrectomy is performed only at stage V.

THE EMERGING ROLE OF INTRAVITREAL AVASTIN Avastin is part of a class of drugs that block the growth of abnormal blood vessels. These drugs have been used as part of cancer treatments. .

Other Problems Infants with ROP are considered to be at higher risk for developing certain eye problems later in life, such as retinal detachment, myopia (nearsightedness), strabismus (crossed eyes), amblyopia (lazy eye), and glaucoma. In many cases, these eye problems can be treated or controlled. Regular follow-up is needed to monitor and treat these conditions.

Implications Usually children will benefit from early intervention and sensory stimulation. Adaptions such as high illumination, high contrast materials, a light box, magnification for close work, a slant board, telescopes for distance viewing are recommended depending on severity of the disorder. It is very important to evaluate the child’s abilities as they grow to see if the ROP has changed. Depending on the severity a low vision evaluation and/or braille should be considered.

Case Study Name: Dustin Johnson-Born 6/28/2009 Born at 26 weeks 4 days gestation and weighed 1.68 pounds Immediately after birth was transferred to the neonatal intensive care unit. Due to his prematurity, the ophthalmologist conducted an ophthalmoscopy in which he dilated Dustin’s pupils with eye drops and determined that the retina was showing signs of trouble. Immediately after birth the doctors made sure Dustin’s oxygen levels were not too high.   Dustin’s oxygen saturation were kept around 85-86% to make sure there was no further damage done to his eyes.

Case Study The doctor determined that Dustin had stage 3 Retinopathy of Prematurity which means that his growth of retinal vessels is severely abnormal. The ophthalmologist felt the best option for Dustin would be to receive laser therapy on his eyes to stop the overgrowth of unhealthy vessels on the retina.  The laser would be used to burn small parts of the retina affected by ROP. The surgery was completed and Dustin stayed in the NICU for 10 weeks after he was born until he was able to eat independently and have continued stabilized oxygen saturation levels so he could go home.  

Case Study- After Hospital Management Caregivers needed to closely monitor infant’s eyes for signs of infection. Frequent examination of the retina (7-14 days) post-surgery until retina fully attached. Semi-yearly examinations after re- attachment until child was school age.

Case Study- 3 years later Dustin continued to thrive as he grew, but at the age of 3 years 2 months his mother noticed that he still had some vision field losses. She mentioned this to Dustin’s ophthalmologist at his semi-yearly examination. The doctor determined that due to his laser treatments Dustin had some peripheral vision loss and a refractive error, myopia (OD -4.25, OS -4.75).

Case Study: Educational Services Recommended Ensure that all staff working with Dustin are aware of the vision impairment Since Dustin has a refractive error in addition to the ROP, teachers must ensure that he wears his glasses at all times Dustin will need good lighting for academic tasks, while the use of shiny surfaces (reflected light should be avoided) Dustin will need modified materials such as bold black text, bold outlines on drawings, colored paste, using clear bold illustrations to cut around, bold lined paper As a student with ROP, Dustin tends to be very clumsy and have mobility difficulties, classrooms should be free of clutter and have clear and defined paths Verbal descriptions and auditory cues may be necessary

References Cassin, Barbara, and Melvin L. Rubin, MD. “Retinopathy of Prematurity." Dictionary of Eye Terminology. 6th ed. Gainesville, FL: Triad Pub., 2012. 243. Print. DeRespinis, Patrick MD (Pediatric Opthalmologist) Retiniopathy of Prematurity (February 4, 2011) retrieved July 15, 2013 from http://youtube.com Dictionary of Eye Terminology 6th Ed., Barbara Cassin and Melvin Rubin, MD, Editor, 2012, Gainsville, FL., pg. 243. Dictionary of Eye Terminology 6th Ed., Barbara Cassin and Melvin Rubin, MD, Editor, 2012, Gainsville, FL., pg. 292. Lueck, A. (ed.). (2012). Functional vision: A practioner’s guide to evaluation and intervention. NY: American Foundation for the Blind., pg. 480-481. Retinopathy of Prematurity. (May 4, 2011). Retrieved July 8, 2013 from http://www.nlm.nih.gov/medlineplus/ency/article/001618.htm Retinopathy of Prematurity. (June 17, 2013). Retrieved July10, 2013 from http://www.drugs.com/cg/retinopathy-of- prematurity.html University of Michigan Kellogg Eye Center (2012). Eye Conditions: Retinopathy of Prematurity. Retrieved July 8, 2013 from http://www.kellogg.umich.edu/patientcare/conditions/retinopathy.prematurity.html Retinopathy of Prematurity (n.d.) retrieved July 15, 2013 from http://www.aao.org/theeyeshaveit/non- trauma/retinopathy-prematurity.cfm Retinopathy of Prematurity (n.d.) retrieved July 13, 2013 from http://www.kidshealth.org/parent/system/surgery/rop.html