Retinopathy of Prematurity

By Fatimah Bassem Alshiekh211504259

Introduction Introduction

is a proliferative retinopathy affecting premature infants of very low birth weight, who have often been exposed to high ambient oxygen concentrations.

Vascularisation of Retina -The retina 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.

Pathology of ROP

• The incompletely vascularized retina is particularly susceptible to oxygen damage in the premature infant.

• the avascular retinaproduces VEGF which in utero is thestimulus for vessel migration in the developing retina.

Pathology continue … • 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.

Risk Factors

• Gestational age at birth younger than 32 weeks gestation .

• Birth weight of less than 1500 g, especially less than 1250 grams.

• Supplementaloxygen, hypoxemia, hypercarbia, concurrent illness.

Grading According to Location • Zone 1

is a circle the radius of which is twice the distance from the disc to the centre of the macula.

is very small and changes can occur very quickly, within days. The hallmark of the disease worsening is by the increasing dilation and tortuosity of the vessels. any disease in ZONE 1, and certainly any plus disease, requires treatment.

Grading According to Location• Zone 2

extends concentrically from the edge of zone 1. its radius extends from the centre of the disc to the nasal ora serrata.

Grading According to Location• Zone 3 consists of a residual temporal

crescent anterior to zone 2.Aggressive disease rarely is seen in

this zone. Typically, this is slowly vascularizing and requires evaluations every few weeks.

Staging

• Stage 1 (demarcation line) is a thin, flat, tortuous, grey-white line running roughly parallel with the ora serrata. It is more prominent in the temporal periphery.

• Stage 2 (ridge) arises in the region of the demarcation line, has height and width, and extends above the plane of the retina.

• Stage 3 (extraretinal fibrovascular proliferation) extends from the ridge into the vitreous.

• Stage 4 (partial retinal detachment).

• Stage 5 is a total retinal detachment.

Staging

Staging

Other features • 1 ‘Plus’ disease signifies a

tendency to progression and is characterized by the following:

• Failure of the pupil to dilate associated with gross vascular, engorgement of the iris.

• Vitreous haze. • Dilatation of veins and tortuosity of

the arteries involving at least two quadrants of the posterior fundus.

• Increasing preretinal and vitreous haemorrhage.

Other features

• ‘Pre-plus’ disease is characterized by abnormal

dilatation and tortuosity by abnormal dilatation and tortuosity that is insufficient to be designated as plus disease.

Other features

‘Threshold’ diseaseneovascularization (stage 3

disease) in zone 1 or zone 2, associated with plus disease, and is an indication for

treatment.

Other features

• Aggressive posterior (‘rush’disease)

is uncommon but if untreated usually progresses to stage 5. It is characterized by its posterior location, prominence of plus disease and ill-defined nature of the retinopathy. It is most commonly observed in zone 1 and does not usually progress through the classical stages 1–3.

Other freatures

Other ocular morbidity Very low birth weight infants,

especially those treated for ROP, are at a substantially

higher risk of developing strabismus and myopia than term infants and require follow-up till the age of visual maturity .

Regression

In about 80% of cases ROP regresses spontaneously even occur in eyes with partial retinal detachments .

Screening of ROP- Screening should begin 4–7 weeks

postnatally to detect the onset of threshold disease.

- Subsequent review should be at 1–2-weekly intervals depending on the severity of the disease.

- Only about 8% of babies screened actually require treatment.

Thepupils in a premature infant

are dilatedwith 0.5% cyclopentolate

and 2.5%phenylephrine.

Treatment 1 Laser photocoagulation

• recommended in infants with threshold disease.

• successful in 85% of cases.2 Intravitreal anti-VEGF agents.• The potential for systemic complications

and long-term effects is undefined in this age group.

• optimal timing, frequency, and dose are yet to be established.3 Lens-sparing pars plana

vitrectomy• for tractional retinal detachment not

involving the macula (stage 4a) can be performed successfully with respect to anatomical and visual outcome.

• Bad e visual outcome in stages 4b and 5, in which the macula is involved.

Any Question

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