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Retinopathy of prematurity
Transcript of Retinopathy of prematurity
previously known as retrolental fibroplasia (RLF).
it is a disease of the eye affecting prematurely-born babies .
ROP can be mild and may resolve spontaneously, but it may lead to blindness in serious cases.
Pathophysiology of ROP
The retina is unique among tissues in that it has no blood vessels until the fourth month of gestation, at which time vascular complexes emanating from the hyaloid vessels at the optic disc grow towards the periphery. These vessels reach the nasal periphery after 8 months of gestation, but do not reach the temporal periphery until about 1 month after delivery. The incompletely vascularized retina is particularly susceptible to oxygen damage in the premature infant. A model of ROP suggests that the avascular retina produces VEGF (vascular endothelial growth factor) which in utero is the stimulus for vessel migration in the developing retina. With premature birth the production of VEGF is down-regulated by the relative hyperoxia and vessel migration is halted. Subsequently the increased metabolic demand of the growing eye allows excessive VEGF production which leads to the neovascular complications of ROP
Vascular Development of the Eye
Main Risk Factors
High exposure to Oxygen
Infants born under 32 weeks gestation
Weight less than1500 grams (the lower the birth rate, the higher the incidence)
Other Risk Factors
High carbon dioxide levels
Bradycardia (low heart rate)
Intraventicular hemorrhage (bleeding into the brain)
Multiple prenatal maternal factors including heavy smoking, diabetes, and preeclampsia
: Current evidence suggests that screening infants with:
1- Gestational ages of 30 6/7 weeks or less (regardless of birth weight) and
2- Birth weights of 1250 g or less
Any premature baby with severe illness in perinatal period (Respiratory distress syndrome, sepsis, blood transfusion, Intra ventricular haemorrhage, apnoeic episodes, etc.) may also be offered ROP screening
ICROP uses a number of parameters to describe the disease. They are location of the disease into zones (1, 2, and 3), the circumferential extent of the disease based on the clock hours (1-12), the severity of the disease (stage 1-5) and the presence or absence of "Plus Disease".
International classification of retinopathy of prematurity (ICROP)
The zones are centered on the optic nerve.
is the posterior zone of the retina, defined as the circle with a radius extending from the optic nerve to double the distance to the macula.
is an annulus with the inner border defined by zone 1 and the outer border defined by the radius defined as the distance from the optic nerve to the nasal ora serrata.
is the residual temporal crescent of the retina.
The Stages describe the ophthalmoscopic findings at the junction between the vascularized and avascular retina
Stage 1 is a faint demarcation line.
Stage 2 is an elevated ridge.
Stage 3 is extraretinal fibrovascular tissue.
Stage 4 is sub-total retinal detachment.
Stage 5 is total retinal detachment.
In addition, Plus disease may be present at any stage. It describes a significant level of vascular dilation and tortuosity observed at the posterior retinal vessels.
About 20% of infants with active ROP will develop cicatricial complications which may be extremely severe and bilnding.
minimal peripheral retinal pigmentary disturbance and haze at the vitreous base.
myopia caused by either increased axial length of the eye or alteration of the lens.
fibrous bands in the temporal retinal periphery
secondry angle closure glaucoma this develops in some eyes with total retinal detachment due to the formation of posterior synechiae.
Stages 1 and 2 do not lead to blindness. However, they can progress to the more severe stages. Progression to stage 4 (partial retinal detachment), or to stage 5 (total retinal detachment), will result in substantial or total loss of vision for the infant.
The first examination should take place within the first 4 weeks of life, and regular, weekly examination is required until it is clear that the eyes are not going to develop disease needing treatment, or one or both eyes develop disease requiring treatment. Treatment should be administered within a 48 hours, as the condition can progress rapidly.
Once diagnosed with ROP lifelong follow up (yearly) is mandatory.
Immediately after for at least 2.5 months follow up at regular 1-2 weekly interval .
All other premature infants irrespective of having ROP, yearly follow up till the age of 5 years is advisable to rule out sequelae
Peripheral retinal ablation is the mainstay of ROP treatment. The destruction of the avascular retina is performed with a solid state laser photocoagulation device
Cryotherapy, an earlier technique in which regional retinal destruction was done using a probe to freeze the desired areas.
Scleral buckling and/or vitrectomy surgery may be considered for severe ROP (stage 4 and 5) for eyes that progress to retinal detachment.
Intravitreal injection of bevacizumab (Avastin) has been reported as a supportive measure in aggressive posterior retinopathy of prematurity.
Refractive errors (most common)
Retinal detachment and blindness