Retinopathy of Prematurity:

Changing Paradigms
Darius M. Moshfeghi, MD
Stanford University
 Overview
• Definition & History
• Classification
• Natural History
• Studies & Treatment
• Scope of Disease
• Guidelines
• Telemedicine
• Future
DEFINITION & HISTORY
 What is Retinopathy of
Prematurity?
• ONLY premature infants with
incompletely vascularized retina

• abnormal retinal vascular development

• characterized by neovascularization
and cicatricial response
 Risk factors for ROP
• Short gestation (prematurity)

• Low birth weight

• Complex hospital course

• Prolonged supplemental oxygen

 Spectrum of Disease

No Sequelae and Complete Maturation

 Spectrum of Disease

Complete Retinal Detachment & Blind

 History of ROP
• “Extreme prematurity and fibroblastic
overgrowth of persistent vascular
sheath behind each crystalline lens: I.
Preliminary report.”
Terry TL. Am J Ophthalmol 1942;25:203-204

• “Retrolental Fibroplasia”
 History of ROP
• Oxygen supplementation implicated in
1950’s

• Reduction of oxygen—Idiopathic
Respiratory Distress Syndrome
Patz A, Survey of Ophthalmology 1969;14:1-29
Historical Treatments for ROP
• Scleral buckle

• Xenon Photocoagulation

• Cryotherapy
Yamashita Y. Jpn J Ophthalmol 1972;26:385-93
CLASSIFICATION
 International Classification of
ROP (ICROP)
• Location
• Extent
• Staging
• Pre-Plus and/or Plus disease
• Aggressive, Posterior ROP

Arch Ophthalmol 1984;102:1130-1134.

Arch Ophthalmol 1987;105:906-912.
Arch Ophthalmol 2005;123:991-999.
 ICROP Classification
• LOCATION
– 3 zones of the retina
– Each centered on the optic disc
– An eye is classified by the lowest zone in
ANY clock hour

Arch Ophthalmol 1984;102:1130-1134.

Arch Ophthalmol 1987;105:906-912.
• zone I Arch 30º
subtend Ophthalmol 2005;123:991-999.
centered around optic disk
• zone II extends nasally to ora serrata
• zone III is remaining temporal crescent
 ICROP Classification
• EXTENT
– Number of clock hours of retina involved
– Each clock hours represent 30° of extent

Arch Ophthalmol 1984;102:1130-1134.

Arch Ophthalmol 1987;105:906-912.
Arch Ophthalmol 2005;123:991-999.
 ICROP Classification
• STAGING
– “Immature” if no ROP
– 5 stages of ROP
Arch Ophthalmol 1984;102:1130-1134.
Arch Ophthalmol 1987;105:906-912.
Arch Ophthalmol 2005;123:991-999.
 ICROP Classification
• Stage I—demarcation line
• Stage II—ridge
• Stage III—extraretinal fibrovascular
proliferation (ERFP)
• Stage 4
– 4a—subtotal retinal detachment sparing the fovea
– 4b—subtotal retinal detachment involving the
fovea
• Stage 5—funnel retinal detachment
 ICROP Standard Photo
Stage 1—demarcation line
ICROP Standard Photo
Stage 2—ridge
ICROP Standard Photo
Stage 3—ERFP
Stage 3 Disease

Courtesy of ROPARD
Stage 4B Detachment

Courtesy of ROPARD
Ridge-to-Lens, Nerve
 ICROP
• PRE-PLUS
– Insufficient for diagnosis of PLUS, but more
arterial and venous dilation than normal
Arch Ophthalmol 2005;123:991-999.PLUS

• PLUS
– Posterior veins are enlarged and arterioles are
tortuous

Arch Ophthalmol 1984;102:1130-1134.

Arch Ophthalmol 1987;105:906-912.
ICROP Standard Photo
Plus Disease
 ICROP Classification
• AGGRESSIVE, POSTERIOR ROP
– Posterior location
– Prominence of plus disease
– Ill-defined nature of retinopathy

Arch Ophthalmol 2005;123:991-999.

Aggressive Posterior ROP
Aggressive Posterior ROP
Aggressive Posterior ROP
 ICROP Classification
• REGRESSION
– Growth of vessels beyond the ridge

Arch Ophthalmol 1984;102:1130-1134.

Arch Ophthalmol 1987;105:906-912.
 ICROP Standard Photo
Regression: RPE change and vessel
maturation
Regression beyond ridge
NATURAL HISTORY
 Natural History Data:
CRYO-ROP
• 4099 infants <1251 grams
• 65.8% of all infants developed ROP
• 81.6% of infants <1000 grams developed ROP
• 17.8% of all infants developed prethreshold,
with 33.5% developing threshold
• 6% overall developed threshold disease
• Lower birthweight and lower gestational age
associated with higher risk of ROP
• Black infants less susceptible
 Natural History Data:
CRYO-ROP
• Threshold disease
– Median 36.9 postmenstrual weeks
– 90% between 33.6-42 postmenstrual
weeks
 Natural History Data:
CRYO-ROP
• 10 week interval from 32 weeks
postmenstrual age to 42 weeks will identify
95% of all children with active ROP

• Postconceptional age more important than

postnatal age in predicting ROP
– Suggests “…innate developmental
progress of the retinal vessels determines
the timing of this disorder’s progression”

Ophthalmology 1991;98:1628-1640
 Natural History Data:
CRYO-ROP
• Increased risk of threshold ROP
– Lower birth weight
– Younger gestational age
– White race
– Multiple birth
– Being born outside a study center
 Natural History Data:
CRYO-ROP
• Risk of Unfavorable Outcome
– Zone I
• Stage 3—59.3%
– Zone II
• Stage 3+, 9-12 hours—43.9%
• Stage 3+, 5-8 hours—22.5%
– Zone III
• All stages—0.2%

Arch Ophthalmol 1994; 112:903-912.

 Natural History Data:
CRYO-ROP
• “…eyes with zone II ROP without plus
disease or any zone III ROP are at very
low risk (<1%) of an unfavorable outcome.
(Indeed, our findings are inconclusive as
to whether zone III ROP ever leads to
unfavorable anatomical outcome.”
Arch Ophthalmol 1994; 112:903-912.
STUDIES & TREATMENT
 Multicenter Trials
• CRYO-ROP
• ETROP
• STOP ROP
• HOPE ROP
• LIGHT ROP
 Cryotherapy for ROP Study
(CRYO-ROP)
• Designed to evaluate cryotherapy
safety and efficacy for treatment of
ROP
• Inclusion
– <1251 grams
– Informed consent to examine at 4-6 weeks
of age
 CRYO-ROP Study
• Examined every 2 weeks until prethreshold
– Zone I any stage
– Zone II, stage 2 with plus disease
– Zone II, stage 3

• Examined weekly until threshold (level of

severity at which blindess risk estimated at
50%)
 CRYO-ROP Study
THRESHOLD
• Five continuous clock hours of Stage 3,
zone I or II, with plus disease

OR

• Eight interrupted clock hours of Stage

3, zone I or II, with plus disease
 CRYO-ROP Study
• randomization
– Observation
– Cryotherapy to avascular retina

• Cryotherapy performed within 72 hours

of detection of threshold disease
Ideal Spacing of Cryotherapy Burns
in the CRYO-ROP Study
 CRYO-ROP Study Outcomes
• Retinal fold involving the macula

• Zone I retinal detachment

• Retrolental tissue or “mass”

 CRYO-ROP Study
• 80% chance of detecting a 35%
reduction in unfavorable outcomes

• Estimated 300 infants needed for the

study
 CRYO-ROP Study Results
• 3 month data
– 49.3% reduction in unfavorable outcomes
for treated group
Arch Ophthalmol 1988;106:471-479.
 CRYO-ROP Study Results
• 1 year—37.8% reduction in unfavorable
outcomes
Arch Ophthalmol 1990;108:1408-1416.

• 3.5 year—42.5% reduction in unfavorable

outcomes (p<0.0001)
Arch Ophthalmol 1993;111:339-344.

• 5.5 year—41% reduction in unfavorable

outcomes (p<0.001)
Arch Ophthalmol 1996;114:417-424.
 ETROP Study
• Type 1 ROP
– Zone I, any Stage, with Plus
– Zone I, Stage 3, without Plus
– Zone II, Stage 2 or 3, with Plus
• Type 2 ROP
– Zone I, Stage 1 or 2, without Plus
– Zone II, Stage 3, without Plus

Arch Ophthalmol 2003;121:1684-1696.

 ETROP Study
• Reduction in unfavorable visual acuity
outcomes from 19.5% to 14.5% (p=.01)
• Reduction in unfavorable strutural
outcomes from 15.6% to 9.1% (p<.001)

Arch Ophthalmol 2003;121:1684-1696.

 Multicenter Trials
• CRYO-ROP
• ETROP
• STOP ROP
• HOPE ROP
• LIGHT ROP
 Supplemental Therapeutic Oxygen for
Prethreshold Retinopathy of
Prematurity (STOP-ROP)

No!
• Does supplemental therapeutic O2 in
infants with prethreshold ROP prevent
progression to threshold ROP?
 STOP-ROP Results
• Two arms:
– Conventional oxygenation at pulse
oximetry of 89-94%
– Supplemental oxygenation to maintain
pulse oximetry of 96-99%

Pediatrics 2000;15:295-310.
 STOP-ROP
• No statistically significant difference
between the two groups
• Subgroup analysis showed a benefit
for patients without plus disease
– 32% progressed in supplemental group vs.
46% in conventional group (p=0.004)
• No harm in supplemental oxygen for
patients with prethreshold disease
Pediatrics 2000;15:295-310.
 STOP-ROP Results
OUTCOME Conventional vs. Supplemental

Pneumonia 8.5% vs. 13.2%

Hospitalized 6.8% vs. 12.7%

at 50 weeks
PMA
Oxygen 37% vs. 46.8%
supplement
Diuretics 24.4% vs. 35.8%

Pediatrics 2000;15:295-310.
High Oxygen Percentage in ROP
Study (HOPE ROP)
• Do fewer high oxygen percentage
infants progress to threshold
compared to STOP-ROP infants?
Probably NOT!
• Patients in this group had baseline
Spo2 >94% at prethreshold diagnosis

Pediatrics 2002;110:540-544.
 HOPE ROP
• 25% of HOPE ROP progressed to
threshold vs. 46% of STOP ROP

• Odds ratio 0.607, 95% CI 0.359—1.026

Pediatrics 2002;110:540-544.
 LIGHT-ROP
• Does reduction in ambient light in very-
low-birthweight children result in
No!
reduction of incidence of retinopathy of
prematurity?

Reynolds JD, N Engl J Med 1998;338:1572-1576.

 LIGHT-ROP Results
• 205 randomized to goggles, 204 to
control group
– 54% of goggles vs. 58% of controls
developed ROP (p=0.50)
• No subgroup identified in which there
was a significant difference between
goggles and controls

Reynolds JD, N Engl J Med 1998;338:1572-1576.

 TREATMENT IN 2007
Prethreshold or Threshold
 Treatment Practices in the
“Modern” Era
• Cryotherapy rarely utilized
• Diode or Argon indirect laser
photocoagulation
 Diode Indirect Photocoagulation
• Treat avascular retina
• Rate of progression in dense laser pattern
– 3.6% overall
• 0% zone I eyes
• 3.8% zone II eyes
Banach, et al, Ophthalmology 2000;107:324-328.
Diode Indirect Photocoagulation
SERIES REGRESSION

CRYO-ROP 74%
McNamara 1992 25/28 eyes (89%)
Hunter 1993 16/17 eyes (94%)
Benner 1993 9/9 eyes (100%)
Goggin 1993 16/21 eyes (76%)
Tsitsis 1997 27/31 eyes (87%)
Seiberth 1997 25/25 eyes (100%)
Dense 54/56 eyes (96%)
Less Dense 36/51 eyes (71%)

•All eyes have at least 3 months follow-up

Banach, et al, Ophthalmology 2000;107:324-328.

Diode Indirect Photocoagulation

Banach, et al, Ophthalmology 2000;107:324-328.

Diode Indirect Photocoagulation
• Postoperative Intraocular Hemorrhage
– 22.3% in CRYO-ROP
– 4-11% in diode laser
– 10% in diode laser treating ridge

Steinmetz, et al, Retina, 2002;22:48-52

Good Laser Distribution

Courtesy of Mike Trese, MD

Poor Laser Distribution

Courtesy of Massie Research Labs

TREATMENT IN 2007
Retinal Detachment
 Lens-Sparing Vitrectomy
• Original description by Maguire and
Trese in 1992
• Spares the crystalline lens
• 2-port vitrectomy instead of usual three
port, with an infusing light pipe
• Ports placed just posterior to limbus
 Lens-Sparing Vitrectomy
• 40 eyes of 31 patients with 4A
detachments
– 90% developed complete anatomic
attachment and fixing behavior (mean 6
month f/u)
– 2 eyes developed glaucoma

Capone A Jr & Trese MT Ophthalmology 2001;108:2068–2070

 Lens-Sparing Vitrectomy
• 90% developed complete anatomic
attachment and fixing behavior (mean 6
month f/u)

Capone A Jr & Trese MT Ophthalmology 2001;108:2068–2070

 Vitreoretinal Surgery
• Removal of the vitreous gel
• Lysis and peeling of epiretinal
membranes
• Reattachment of retina
• Endolaser photocoagulation
• Temporary tamponade
 Anatomic Goals
• Reattach retina
• Relieve vitreoretinal traction
• Remove media opacities
• Spare the lens
 Lens-Sparing Vitrectomy
• 2-port vitrectomy instead of traditional
3-port
– Infusion/light port
– Cutting port
• Bimanual dissection
• Release of tractional vectors
 Tractional Vectors
• Ridge-to-Ridge
• Ridge-to-Lens
• Ridge-to-Eyewall
• Ridge-to-Nerve
Tractional Vectors In ROP

Illustrated by Butch Colyear

Ridge-to-Lens

Illustrated by Butch Colyear

Ridge-to-Eyewall

Illustrated by Butch Colyear

Ridge-to-Ridge

Illustrated by Butch Colyear

Ridge-to-Nerve

Illustrated by Butch Colyear

 Guiding Principal
• Avoid retinal breaks at all costs

• Better to terminate surgery without

achieving anatomic goals than to
create a retinal break
SCOPE OF DISEASE
 Scope of the Problem:
United States Births 2004
• 4,112,052 live births
• 508,356 births preterm (<37 weeks)
– 12.5% of all live births
– 33% increase since 1981, 18% increase
since 1990
• 81,645 births very preterm (<32 weeks)
– 2.01% of all live births

National Vital Statistics Report, Dec. 18, 2002

 Birth Weight
• VLBW < 1500 grams
– 1.48% = 60,858 infants
 Applying natural history data in
2007
• 78,505 babies in 2004 <32 weeks or
<1500 grams
– 51,656 are predicted to develop ROP
– 3099 will develop threshold disease
– 150-821 will develop an unfavorable
outcome
GUIDELINES
 Screening
“An ounce of prevention is worth a
pound of cure”
-Benjamin Franklin
 ROP: Framing the Problem
• Changing paradigm: From TREATMENT to
CAPTURE
– Effective treatment exists
– Need to ensure eligible infants are screened

• CAPTURE transcends national economic

development status
– Too few specialists, too many babies
– Low reimbursement, high costs
 Gold Standard ROP Exam
“…should have retinal screening
examinations performed after pupillary
dilation using binocular indirect
ophthalmoscopy…”

Joint statement of AAP, AAPOS, & AAO Pediatrics

2006;117(2):572-576,
Pediatrics 2006;118(3):1324
 Gold Standard ROP Exam
“Retinal examinations in preterm
infants should be performed by an
ophthalmologist who has sufficient
knowledge and experience to enable
accurate identification of the location
and sequential retinal changes of
ROP.”

Joint statement of AAP, AAPOS, & AAO Pediatrics 2006;117(2):572-

576,
Pediatrics 2006;118(3):1324
 Extended Ophthalmoscopy
92225/92226
• “Retinal disorder…”
• “Retinal drawing that requires sufficient
detail…”
Gold Standard—Week 1
Gold Standard—Week 2
Gold Standard—Week 3
Gold Standard—Week 4
Gold Standard—Week 5
Gold Standard—Week 6
Gold Standard—Week 7
Gold Standard—Week 8
Gold Standard—Week 9
Gold Standard—Week 10
Gold Standard—Week 11
Wrong Gold Standard
 Changing the Gold Standard
• U.S. Treasury abandoned the Gold
Standard in 1933
– Speculation
– Great Depression
 How Solid is the Gold Standard?
• No studies demonstrating efficacy
• No inter- or intra-clinician studies
Time for a New Standard?
NEW STANDARD
NEW STANDARD
NEW STANDARD
 Rationale for Photographs
• Standardized screening
• Longitudinal view
• Hard-copy
• Efficacy
• Cost
Why Now?
 Two Recent Changes
• Modified screening criteria
• Declining pool of trained screener
ROP Screening 2007 and beyond
• Who
– Birth weight ≤1500 grams OR
– Gestational age of 30 week or under OR
– >1500 grams, but felt to be high risk

• When
– 31 weeks PMA OR
– 4 weeks chronological age, whichever is later

Joint statement of AAP, AAPOS, & AAO Pediatrics 2006;117(2):572-576,

Pediatrics 2006;118(3):1324
 Screening Frequency
• Every 48-96 hours
– Type 2 ETROP

• Weekly
– Near-Type 2 ETROP

• Every 2 weeks
– Zone II immature/stage 1 without plus
Joint statement of AAP, AAPOS, & AAO Pediatrics 2006;117(2):572-
576, Pediatrics 2006;118(3):1324; and Pediatrics 2004;114:490-91.
 Evidence-based screening:
Termination Criteria
• 45 weeks PMA without prethreshold or
worse, OR
• Progression of vascularization into
zone III without previous zone II ROP,
OR
• Full vascularization

Reynolds JD, et al, Arch Ophthalmol 2002;120:1470-1476

AAO Retinopathy of Prematurity Survey

February 2006

Prepared for: Prepared by:

#7281
 Currently Treat or Screen ROP

Overall about 50% of doctors treat or screen ROP.

Yes
54% No
46%

Q. Do you currently treat or screen infants or children with ROP?

Base: Total Respondents (n=224).
 Plan to Continue to Treat Patients With ROP

Yes
No
Unspecified
100%

80%
About three quarters of current treaters plan on continuing to
77% treat patients with ROP. Those that will not continue treating
60%
(18%) mainly feel it is outside their expertise and that the
liability is too high.
40%

20%
18%

0% 5%
Total
Q. Do you plan to continue to treat patients with ROP?
Base: Those Currently Treating (n=120).
AAO Retinopathy of Prematurity Survey

February 2006

Prepared for: Prepared by:

#7281
 Currently Treat or Screen ROP

Overall about 50% of doctors treat or screen ROP.

Yes
54% No
46%

Q. Do you currently treat or screen infants or children with ROP?

Base: Total Respondents (n=224).
 Plan to Continue to Treat Patients With ROP

Yes
No
Unspecified
100%

80%
About three quarters of current treaters plan on continuing to
77% treat patients with ROP. Those that will not continue treating
60%
(18%) mainly feel it is outside their expertise and that the
liability is too high.
40%

20%
18%

0% 5%
Total
Q. Do you plan to continue to treat patients with ROP?
Base: Those Currently Treating (n=120).
 Factors That Influenced the Decision to Stop Treating ROP
(Extremely/Very Influential)

Medical liability 67%

Complexity of care scheduling 50%

Insurance reimbursement 37%

Lack of hospital support (e.g., no satisfactory

27%
protocol for tracking and follow-up care)

Developments in the management of ROP patients 12%

0% 20% 40% 60% 80% 100%

 Practice Focus

100%

80%

60%
60%

40% 36%

20% 18%

0%
Retinal/Vitreous Pediatric Ophthalmology Comprehensive/General Ophthalmology

Q. Please indicate your practice focus?

Base: Total Respondents (n=224).
 Practical Implications
• More eligible infants
– Increased from 60,000 to 80,000
• More screening exams
• Fewer ophthalmologists with “… sufficient
knowledge and experience”
 Solution?

Telemedicine for ROP

TELEMEDICINE
VALIDITY OF PHOTOGRAPHS
• Identification of plus
• Identification of clinically-relevant disease
• Identification of all Zone II

Ophthalmology 2000;107:25-28
Ophthalmology 2003;110:2113-2117
Br J Ophthalmol 2006;90:1292-1296
Arch Ophthalmol 2006;124:322-327
 PHOTOROP TRIAL
• Limitations of Indirect Ophthalmoscopy
– Interpretations vs. actual retinal features
– Interpretation is presumed to be correct

Retina 26:S4–S10, 2006

 PHOTOROP TRIAL
• Trained pediatric retina screeners vs.
RetCam and reading center

• Prospective, multicenter

Retina 26:S4–S10, 2006

PHOTOROP TRIAL

Retina 26:S4–S10, 2006

Retina 26:S4–S10, 2006
 PHOTOROP TRIAL
• Retcam
– 100% sensitivity
– 97% specificity
– No referral-warranted disease missed
– Recommended laser 2 weeks earlier than
humans

Retina 26:S4–S10, 2006

 FI NAN CI AL DI SCL OSU RE
• Sc ien tifi c Adv is or y Boar d,
Cl arity Med ica l Sy ste ms
(Mak er o f th e RetCa m)
 PU RPO SE
• Teleme dicine s cr eenin g f or
ROP
• St an for d-P ackar d af filia te d
NICU’ s
 RATI ONALE
• Ex pa nde d a cc ess to te r tia r y
ca r e
• Under ser ved ar eas
• Cen traliz ed readin g
• St an dar diz ed sc r eenin g
pr ot oc ol
• Lo ngit ud ina l vie w
• Har d-c op y
• Ef fi cacy
 PHOTOROP Trial
• Trained pediatric retina screeners
vs. RetCam and reading center
• Prospective, multicenter
 DES IGN of SUN DR OP
• Retc am I I or CMS S hu tt le
ca me r as
• NICU On-s ite phot og r aph er s
• HIPAA -complian t ima ge
tr an sf er
• Con tract s tip ula tin g
r esp ons ib ilitie s
• Cen traliz ed readin g c en ter
 Redwood City

San Jose

Sant a C ruz
Fremont

Santa C lara
 SU NDR OP P r otocol
• NICU ide ntif ies e ligib le
pa tients
• Notifica tion to MD
• St an dar d p ho to g r aph s ar e
ob tain ed
• HIPAA -complian t ima ge
tr an sf er
• Rep or t gene r ate d
• Rec om me nda tions for r epe at
scr eenin g a nd /o r i nter venti on
 NICU TRAI NING
• On-s ite tr aining a t ea ch of 5
sites p rior to “go -li ve”
• Cer ti fied ph oto g r apher f r om
Cl arity Med ica l Sy ste ms
• Tr aining aft er 1 st e xa min ation
by R OP MD (DMM )
• Follo w-up tr ainin g a s n ee ded
by Clar ity ph ot og r aphe r
Ret Cam II
PR OTOCO L PH OTOGRAPH S

OD OS
CEN TRALI ZED READI NG
CEN TER
 ONE YEAR DATA
• Retr os pec tiv e
• 2 s ite s
• 12 /1 /20 05 th r oug h 1 1/3 0/20 06
• At lea st o ne sc r eenin g
exami na tion
 EN DPO INTS
• Ref er r al-w ar r ante d dis ea se
• Type 1 or T ype 2 ET ROP
• T hreshold d isease
• Sta ge 4 o r g reater disease
• Pre-p lus o r plu s d ise ase
• Di schar ge f r om N ICU
 REFERRAL & DISC HAR GE
• Al l exams pe rf or med by o ne
MD (DMM)
• Outpa tient e xam wi thin 1
wee k o f d ischar ge f r om N ICU
(DMM)
• Tr eatme nt by o ne MD ( DM M)
REF ERRAL-W ARRAN TED ROP
REFERRAL- WARRAN TE D R OP
 RESU LTS
• 42 inf ants th r ou gh 1 yea r
• 12 9 unique e xami natio ns
• 13 11 p ho to g r aph s
• Aver a ge 1 0.2 photo s pe r e xam,
me dia n 1 0
 RESU LTS
• Det ectio n o f Ref er r al-
War r an te d ROP
• 100% s ensitiv ity
• 95% s pecifi city
• 100% n e gativ e predic tiv e va lue
• 50% p ositiv e p redic tive v alu e
 RESU LTS- -SAFETY
• No r etin al de ta chmen t
• No ha r m to inf an ts
 REA SON S F OR REPE AT
EXAMIN ATION
• Ina de qu ate e xpo sur e
• Inc omp let e p ho tog r aph s et
• Ar tif act
 TECH NICAL DI FF ICU LTI ES
• Ima ge tr an sf er
• Ima ge co nver sio n to . jp g
 W ha t does SU NDROP d o?
• Sc r een s for r efer r al-w ar r an te d
ROP
• Pr ovide s ad equa te
visualiza tio n o f a ll o f z on e II
• Ide nt ifies Plu s dis ea se
 W ha t d oes SU NDR OP not do?
• Can not clear a n inf ant
• 3 c riteria as e sta blis hed b y
ETROP f or t er minatio n

• No s cr ee nin g o f in fan ts
follo wing l aser or vitr ec to my —
mu st be pe rf or med by tr eatin g
MD
 SU NDR OP E ndp oints
• Ref er r al-w ar r ante d dis ea se

• Di schar ge f r om ho sp ita l
• all outp atie nt visit s with DMM
• Patie nts screened u ntil either
treatm ent o r m eeting
ter minatio n c riteria
 Futur e Dir ecti ons
• Impr oved au to ma tion of ima ge
de liv er y
• Tr ackin g s ys tem simila r to
AL GO f or a t-risk pa tients
• Com mun ity ac ces s to
SUNDR OP d ataba se
 Conc lusi ons
• NICU p er so nne l adapt to
SUNDR OP q uic kl y
• Good s upp or t fr om Clar ity
r e ga r din g tr ain ing of sit es
• No di f fi culty to date i n
ide nt if ying r efer r al-w ar r ant ed
dis eas e
• Lo ngit ud ina l and h ar d-c op y
r eco r ds of scr een ing
FUTURE DIRECTIONS
 BLOCK ROP Trial
• Bevacizumab for ROP
Thank You!