Retinopathy of Prematurity Geoffrey T Tufty MD Sanford

Retinopathy of Prematurity Geoffrey T. Tufty, MD Sanford Clinic Ophthalmology

Definition Failure of the peripheral retina to vascularize

ROP

Objectives To understand the etiology of ROP To understand the anatomy of the eye To understand the stages/severity of ROP To understand the zones/location of ROP To understand the screening guidelines for ROP To understand the treatment options for ROP To understand the long term affects of ROP

ROP-historical 1942 - Terry Leading cause of childhood blindness Retro lental fibroplasia 4 million premature babies born each year 14, 000 have ROP 90% of those are mild cases and resolve

Retro lental fibroplasia Fibrous mass behind the lens is detached retina

Risk factors Low birth weight Early gestational age Anemia Respiratory distress Poor weight gain Blood transfusion Multiples Intraventricular hemorrhage Low vitamin E ? light exposure

When to Screen? ? BW <1500 grams <32 weeks >32 weeks with a difficult clinical course 4 weeks of age or 31 weeks which ever is first

Normal Retinal Development Nasal(32 weeks) then temporal (40 weeks) VEGF Stimulates normal development-reduced by hyperoxia-cessation of growth Hypoxic retina upregulates VEGF and thus ROP Immature retina-hyperoxiaproduces VEGF and neo grows- ROP

Anatomy of the Eye Tear film Cornea Iris Lens Vitreous Retina-macula Optic nerve

Retina Normal retina fully developed

Tools of the trade Dilating drops-cyclomydril Anesthetic drops

Tools of the trade

Indirect Ophthalmoscope

Good help You need to swaddle the baby and take your time but be efficient. Get a good look. Using the “force” does not work

Ret-Cam Used for retinal photos to detect ROP and other forms of retinal pathology

Let’s set the Stages are the severity of the ROP The higher the stage the worse the disease

Stage 1 ROP A demarcation line between normal retinal vasculature and avascular retina

Stage 1

Stage 1 ROP

Stage 2 ROP The demarcation line between vascular retina has increased volume

Stage 2 ROP The demarcation line has volume to it.

Stage 3 ROP Neovascularization on the dividing line between vascular and avascular retina

Stage 3 ROP Continuous neovascularization Popcorn Sausage

Stage 3 ROP

Stage 4 A ROP Extra foveal retinal detachment

Stage 4 A ROP Peripheral retina is being pulled off of the attachments-traction

Stage 4 B ROP Traction and detachment of the fovea-center vision

Stage 5 ROP Bad- total tractional retinal detachment

Stage 5 ROP Poor overall visual outcomes despite aggressive treatment

Plus Disease Increase in venous and arteriolar dilation Due to blood shunting Indicates severity

No Zoning Out

Get into the Zone Location of ROP in the eye Higher the zone-the better

Zone I A circle with the optic nerve as the center and extends twice the distance from the optic disc to the macula

Zone II From zone I to the nasal peripheral retina

Zone III Temporal retinal crescent

Follow up Exams 1 week Early zone II Zone I stage 1 or 2 progression 2 weeks Zone II immature Zone II stage 1 or 2 Zone II no ROP 3 weeks Zone III

When to treat? ? Zone 1 ROP any stage with Should be treated within plus disease 72 hours Zone I stage 3 no plus Zone II stage 2 or 3 with plus

Treatment In the NICU? In the OR? Sit down with family and cover everything-layman’s terms

Treatment Cryotherapy

Cryotherapy Cryo ROP study in 1986 reduced unfavorable outcomes from Eyes are red and sore

Cryotherapy

Laser Portable Learning curve Less painful

Laser

Laser ROP may get worse before it gets better

Avastin Anti VEGF therapy

Injection Dosage- half the adult dose 30 g needle Betadine Pars plana

Avastin Risks of injection Infection Cataract Normal vascularization What is the correct dosage Frequency Developing brain and organs Long term follow up

Vitrectomy Surgical reattachment of the retina 40% of stage 5 2/3 rds of stage 4 Visual outcomes are generally poor

Risk Factors of Treatment Blindness Retinal detachment-traction Strabismus Myopia Anisometropia Cataract Amblyopia Low vision

Aids Glasses Low vision aids Magnifiers Computers/tablets CCTV Large print books Good lighting Low vision teachers School for the blind Good communication with parents and teachers

Questions? ? ? When it comes to ROP there is no zoning out. If you do, you will set the stage for disaster Thank you!!!