1. Prevention of blindness from retinopathy of prematurity (ROP) in India Dr Praveen Kumar Professor, Neonatology Post Graduate Institute of Medical Education and Research Chandigarh

2. Severe visual loss from ROP – global annual incidence

3. Blindness from ROP in India India - highest number of preterm births Number of infants presenting with advanced ROP to tertiary eye units increasingly dramatically across the country Number will continue to increase as services for preterm infants (SCNUs) expand Control is urgently required

4. Risk factors for sight threatening ROP Infant factors Increasing prematurity Intrauterine growth retardation Neonatal care factors Too much / poorly monitored oxygen from after birth Sepsis Poor nutrition

5. Control of visual loss from ROP High quality prenatal care High quality neonatal care - can prevent most ST-ROP High quality programmes for detection, treatment and follow up

6. NNF indications and guidelines Which babies to examine ? <1750g BW or <34 weeks GA AND 34-36 weeks or 1750-2000g if exposed to risk factors First examination not later than 4 weeks of age or 30 days of life infants ≥28 weeks GA 14-21 days of life infants <28 weeks GA or <1200g BW

7. Control of visual loss from ROP Teamwork Clear roles and responsibilities Skilled clinicians Documentation Communication Involved parents

8. TEAMWORKTEAMWORK

9. TEAMWORKTEAMWORK

10. Prevention of ROP Best practices in SCNUs - bundle approach o monitor oxygen therapy o prevent infections o mother’s milk - nutrition bundle o avoid blood transfusion Target group -- nurses and doctors Challenge—How to translate/implement the knowledge

11. Basic newborn care at birth in maternity units Resuscitation ( room air –blended oxygen-air) Essential newborn care Best ‘clean’ practices at birth by obstetricians or ANMs / Nurses Safe clean labour room Avoid over crowding

12. First “golden hour” management Stress on DR resuscitation - oxygen abuse ‘Gentle’ Stabilization Early CPAP - avoid ventilation Safe transportation

13. Prevention by obstetricians Safe ‘in-utero’ transport and delivery at appropriate facility capable of newborn care Antenatal corticosteroids Appropriate management of chorio- amnionitis/pPROM Avoid multiple births via IVF Education of mothers for follow up and eye examination

14. Screening and treatment Bedside by local teams or nearby eye care provider Preparation Pain alleviation Monitor vital signs

15. What do health authorities need to do ? Infrastructure and Supplies:  Ensure Clean and safe delivery and resuscitation facilities  Compressed air supply  Blenders  Pulse oximeters—adequate number as per number of babies  Ensure adequate hand-hygiene related supplies Staff esp. nurses  Adequate numbers  Adequate training

16. What do health authorities need to do ?... For screening for ROP  Indirect ophthalmoscopes  Trained ophthalmologists linked to each SCNU—public or private  Initial screening and follow-up in SCNU  ROP result mandatory part of SCNU database  Use ASHA for Follow-up For treatment---regional centres—pre-identified for each SCNU

17. Goals…. No baby should go blind due to lack of screening or laser Each unit will promise to do self audit and for self improvement Local Teams of Obstetricians, Pediatricians, Nurses and Ophthalmologist Good communication with parents/care-givers Tertiary care units will do hand holding and capacity building for SCNUs

18. ROP program National ROP Task Force established by Ministry of Health National Summit October 2013 Program areas identified at Summit

19. ROP program Program Areas 1.Advocacy and communication 2.Improving neonatal care 3.Model programs integrated into health system in selected States 4.Increasing awareness among professionals 5.Increasing awareness among parents 6.Monitoring and evaluation 7.Dissemination of information (website)