ROPROP

الرحيم الرحمن الله الرحيم بسم الرحمن الله بسم

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Retinopathy of pre-maturity

By

DR/Mohamed Abdel-AzizM.SC(ophthalmology)

Retinopathy of prematurity (ROP):Is an ischemic retinopathy of premature and low-birth-weight infants.

ROP-Definition

ROP : Risk FactorsROP : Risk Factors

Gestational age: less than 32 weeksGestational age: less than 32 weeks

Birth weight: less than 1500 gmBirth weight: less than 1500 gm

Oxygen therapy : Excessive oxygen Oxygen therapy : Excessive oxygen useuse

Retinal Retinal vascularizationvascularization

Nasal side Temporal side

Timing of vascularization of the peripheral retina

ROP -Classification ROP -Classification

International International Classification- Classification- Conceptual OverviewConceptual Overview

ZoneZone : describes the extent of : describes the extent of vascularization.vascularization.

StageStage : describes the degree of : describes the degree of vascular pathology. vascular pathology.

Sectors Sectors : Clock hours used to quantify : Clock hours used to quantify the circumferential extent pathology.the circumferential extent pathology.

Plus Disease :Plus Disease : describes the activity of describes the activity of the disease.the disease.

International International Classification – ZonesClassification – Zones

Zones: Zone 1 is posterior, Zone 2 is Zones: Zone 1 is posterior, Zone 2 is equatorial and Zone 3 is anterior.equatorial and Zone 3 is anterior.

Zone 1 – High RiskZone 1 – High RiskZone 2 – Intermediate RiskZone 2 – Intermediate RiskZone 3 – Low RiskZone 3 – Low Risk

Zone 1

Zone 2

Zone 3

II

II

IIIIIIIIII

MaculaMacula

Optic discOptic disc

33 99

1212 1212

33

6666

99

Right Right eyeeye

Left Left eyeeye

Ora Ora serrataserrata

ROP – Classification –ROP – Classification –ZonesZones

IIIIII IIIIII

International International Classification-StagesClassification-Stages

Stage 1 – Demarcation Line – Low Stage 1 – Demarcation Line – Low RiskRisk

Stage 2 – Ridge --Intermediate RiskStage 2 – Ridge --Intermediate RiskStage 3 – Fibrovascular proliferation Stage 3 – Fibrovascular proliferation

-- High Risk-- High RiskStage 4 – Partial Retinal DetachmentStage 4 – Partial Retinal DetachmentStage 5 – Total Retinal DetachmentStage 5 – Total Retinal Detachment

Stage 1Stage 1.. Demarcation Demarcation line between the line between the normal retina (left) normal retina (left) and the non-and the non-vascularized retina vascularized retina (right). (right).

ROP Classification-ROP Classification-StagesStages

ROP Classification- ROP Classification- StagesStages

Stage 2Stage 2 - - ridge (R) of ridge (R) of scar tissue and new scar tissue and new vessels in place of the vessels in place of the demarcation line. The demarcation line. The white line now has white line now has width and height, and width and height, and occupies some volume. occupies some volume.

Small tufts of new Small tufts of new vessels ("popcorn vessels ("popcorn vessels")vessels")

ROP Classification-ROP Classification-StagesStages

Stage 3Stage 3 - Increased size - Increased size of the vascular ridge , of the vascular ridge , with growth of fibro-with growth of fibro-vascular tissue on the vascular tissue on the ridge and extending out ridge and extending out into the vitreous.into the vitreous.

Fibrous scar tissue is Fibrous scar tissue is

beginning to form in this beginning to form in this stage, with attachments stage, with attachments between the vitreous gel between the vitreous gel and the ridge.and the ridge.

ROP Classification-ROP Classification-StagesStages Stage 4Stage 4 - Partial retinal - Partial retinal

detachment. detachment.

Stage 4A - detachment does not Stage 4A - detachment does not include the macula, and the include the macula, and the vision may be good. vision may be good.

In Stage 4B - macula is In Stage 4B - macula is detached, and the visual detached, and the visual potential is markedly decreased.potential is markedly decreased.

Stage 5Stage 5 - Complete retinal - Complete retinal detachment.detachment.

International International Classification—Classification—Stages--SectorsStages--Sectors

Clock hours refer to 30 degree Clock hours refer to 30 degree sectors around the eye.sectors around the eye.

Zone 1

Zone 2

Zone 3 Sectors = 30 degrees

121

2

3

Pathology described by clock hours

e.g. stage 3 from 2-3

International International Classification -- Classification -- Plus disease Plus disease

Posterior arterial tortuosity and Posterior arterial tortuosity and venous dilation venous dilation

Iris vessel dilation and rigidityIris vessel dilation and rigidityVitreous hazeVitreous haze

Plus Disease

Stage 1

Stage 1

Stage 2

Stage 2 Popcorn

Stage 3

Stage 3 Moderate

Stage 3 Moderate

Stage 3 Moderate

Stage 3 Severe

Stage 3 Severe

Stage 4B

Stage 4B

Stage 5

Stage 5

ROP - ManagementROP - Management

ROP - ManagementROP - Management

PREVENTION - PREVENTION - Prevent preterm labor.Prevent preterm labor.

(Optimal) minimum use of oxygen.(Optimal) minimum use of oxygen.

Prevention of complications.Prevention of complications.

ROP - ManagementROP - Management

SCREENING-SCREENING- All infants < 34 wks gestational age All infants < 34 wks gestational age

AND < 1500 g birth weight are screened AND < 1500 g birth weight are screened between 4-6 weeks of age.between 4-6 weeks of age.

Treatment CriteriaTreatment Criteria

Treat when threshold ROP is reached.Treat when threshold ROP is reached.

Threshold ROP:Threshold ROP:

5 contiguous clock hours or 8 total clock hours 5 contiguous clock hours or 8 total clock hours of stage 3 and plus disease in zone 1 or 2.of stage 3 and plus disease in zone 1 or 2.

ETROP ETROP RecommendationsRecommendations

Stage 1 Follow twice weekly

Stage 2 Follow twice weekly

Stage 3 Treat <48hr

Stage 1 Treat <48hr

Stage 2 Treat <48hr

Stage 3 Treat <48hr

Stage 1 Follow No Change

Stage 2 Follow weekly

Stage 3 Follow twice weekly

Stage 1 Follow No Change

Stage 2 Treat <48hr

Stage 3 Treat <48hr

Zone 1

Zone 2

No Plus

Plus

No Plus

Plus

Treatment OptionsTreatment Options

CryotherapyCryotherapy

Laser photocoagulation – standard Laser photocoagulation – standard treatmenttreatment

Surgical interventionsSurgical interventionsScleral bucklingScleral buckling

VitrectomyVitrectomy

New treatment options for New treatment options for ROPROP

Avastin alone for ROP stage 3 may Avastin alone for ROP stage 3 may become primary treatment replacing become primary treatment replacing LASER therapy LASER therapy (Helen et al.,2009).(Helen et al.,2009).

Recently ,Recently ,chen et alchen et al., ., report in a report in a retrospective study effective outcomes retrospective study effective outcomes using trans-scleral diode laser instead using trans-scleral diode laser instead of transpupillary laser treatment for of transpupillary laser treatment for threshold ROPthreshold ROP(Chen et al.,2011)(Chen et al.,2011)

Intravitreal Avastin for Zone I ROP, NO macular dragging nor myopia

LASER therapy for Zone I ROP, macular dragging and 17 diopters of myopia

Long Term Complications Long Term Complications of ROPof ROP

Retinal Dragging and Folds

Others:

Glaucoma

Late onset Retinal Detachment

Significant myopia

Anisometropia

AmblyopiaStrabismus

Who ?Who ?

1.1. << 28 weeks gestation or 28 weeks gestation or

2.2. << 1500 gms or 1500 gms or

3.3. >> 1500 gms if unstable 1500 gms if unstable

REMEMBER THIS !!!

When ?When ? Examine 4 –6 weeks after birthExamine 4 –6 weeks after birth

REMEMBER THIS !!!

ConclusionConclusion

Ultimate prevention = prevent premature Ultimate prevention = prevent premature births.births.

ROP is a lifelong disease with sequelae ROP is a lifelong disease with sequelae manifesting into the 2manifesting into the 2ndnd decade. decade.

Surgical intervention preserves vision in ROP-Surgical intervention preserves vision in ROP-related retinal detachment esp. before related retinal detachment esp. before macular detachment.macular detachment.