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Retinopathy Of Prematurity (ROP)
Mariam Mohamed Gebril
Assistant professor
FRCS (Glasgow)
Pediatric ophthalmologist
In 1942 Terry described ROP as “retrolental fibroplasia” due to the appearance of a complete retinal detachment behind the lens.
Many causes were investigated, but was not until the mid-1950s that a randomized multicenter trial showed a clear association between increased incidence of ROP and increased duration of exposure to oxygen.
HISTORY
- The overall incidence of ROP is 16-17% for all premature infants, and 2-5 % become blind.
- In infants with birth weight below 1251 grams , the incidence is around 66%.
- >90% cases undergo spontaneous regression, <10% cases develop significant cicatrization and 2-5 % become blind.
EPIDEMIOLOGY
THE 5 Ws
The retina is unique among tissues in that it has no blood vessels until 14-15 week of gestation…these vessels reach the nasal retina after the 34-36 week of gestation …the temporal retina until after delivery.
With a speed of 0.1 mm per day.
WHY
HYPOXIA
NORMAL
WEEKS LATER
WHO IS AT RISK?
Definite and well accepted
1. Gestational age less than 32 WK, Birth Wt. less than 1500 gr.
2. (O2) supplementation (100%).
The use of supplemental oxygen, oxygen concentration, duration, and prolonged mechanical ventilation were among the most frequently identified risk factors for severe and treatment-requiring ROP.
WHO
Associated factors
1. Apnea.
2. Infection.
3. Respiratory distress syndrome.
4. Asphyxia \hypoxia.
5. Shock.
6. Hypercarbia\hypocarbia..
7. Acidosis\alkalosis.
8. Intraventriculer hge..
9. Blood transfusions \anemia..
10. Flactuations in O2 blood saturation.
WHAT IS ROP?
ROP is classified according to
1.location.
2.Severity.
3.Extent
WHAT
Immature Retina
Mature Retina
ZONES
STAGES
STAGE 1
STAGE 2
PLUS
STAGES
Prethreshold ROP
Threshold ROP
STAGE 3
STAGE 4
STAGE 5
WHEN TO SCREEN?
WHEN
Smaller age , smaller wt.
1.Screen all premature less than 1500 gr.
2.Screen all babies at less than or equal to 32wk of post conceptional age.
3.Special criteria with larger size baby . Respiratory distress syndrome, sepsis, blood transfusion, Intra ventricular hemorrhage, apneic episodes .
4—6 weeks post-delivery as first screen.
Then the following examinations scheduled according to every situations.
Until visual maturation 6-8 years .
And for longer time for certain cases .
Screening protocol
WHAT TO DO?
Sequelae of regressed ROP
1.Refractive error.
2.Squint.
3.Cataract.
4.Glaucoma.
5.visual field change.
INTERVENTIONS
Cryotherapy
Laser therapy
Anti VEGF
Surgery
As an ophthalmologist :
DIAGNOSIS
DONE BY:
1. Binocular Indirect Opthalmoscopy.
2. RETcam.
WHAT
Wait and see for vascular maturation
WHAT TO DO AS NEONATOLOGIST ?
The main goals are the prevention and monitoring of a timely diagnosis.
It is thus necessary to prevent premature births, apply adequate therapeutic management in the NICU, and avoid exposure to factors that increase the risk of ROP.
Prenatal steroids use is a well-known approach to prevent respiratory distress
and intraventricular hemorrhage, two important risk factors of ROP.
Judicious use of blood transfusions (Transfusion of packed RBCs is another ROP risk factor).
Also delay umbilical cord clamping .
Judicious oxygen therapy :
perinatal Oxygen level in the blood should be continuously monitored using a pulsoxymeter. A target of 90-95% SpO2 in all newborns on any respiratory support, including oxygen therapy, should be maintained.
One should avoid 100% oxygen in the labour room and use a blender to target SpO2 needed level.
Strategies in the Prevention of ROP
Postnatal weight gain predicts risk of retinopathy of prematurity; poor weight gain increases the risk of severe ROP.
So ensuring early administration of colostrum, exclusive and aggressive use of mothers own milk or donor milk.
Human milk fortification, kangaroo mother care, mothers involvement in baby care are some of the interventions in improving the nutritional status of preterm infant.
Vit E
Erythropioten
STILL AHEAD!
Neonatal infections, particularly fungal infections, are risk factors for ROP.
Infections
Major Clinical Trials of Retinopathy of Prematurity:
Oxygen-regulation trials:
STOP-ROP (96–99% SaO2 vs. 89–94% SaO2)
No significant difference in retinopathy of prematurity between the two groups; adverse pulmonary effects with 96–99% SaO2.
SUPPORT (85–89% SaO2 vs. 91–95% SaO2)
Increased mortality with 85–89% SaO2; among survivors, lower rate of retinopathy of prematurity with 85–89% SaO2.
BOOST II(85–89% SaO2 vs. 91–95% SaO2)
Higher survival rate with 91–95% SaO2
CONCLUSION
from these trials:
avoid high SaO2.
(recommendations vary; generally agreed to
keep SaO2 at <95% for the first few weeks
of life), until more is known about morbidity
and mortality with low SaO2 (85–89%)
ANY QUESTIONS?