Retinopathy of

prematurity (ROP)
Sagar hospital
Definition:
Multifactorial vaso-proliferative retinal disorder that
increases in incidence with decreasing gestational age.
History :

First epidemic : 1940 – increased use of oxygen

Reduced in 1950 d/to decreased use of oxygen –
increased mortality and CP
Second epidemic : 1960 – NICU introduced , more
smaller and less mature surviving
Incidence :
<1500gm – 27-35%
<1000gm – 16-48%
M > F
PATHOGENESIS:
Normal development
Retinal elements migrate from optic disk to periphery
Photoreceptors : 80% distance by 28 weeks – get oxygen
by diffusion from choroidal vessel
Vessel begin at 16 weeks and finish by
 Nasal - 36 week
 Temporal – 40 weeks
Mechanism of injury
First stage : Insult – vasoconstriction, ↓ vascular
endothelial growth factors(VEGF) →arrest in vascular
development
Second stage : Hypoxic retina → excess angiogenic
factors(VEGF) → neovascularization → permeable so
hemorrhage and edema → severe extra retinal fibro
vascular proliferation → retinal detachment
Risk factors
Low gestational age, low birth weight, prolonged oxygen
Hyperoxia, Hypoxia
Hypotension, acidosis
Sepsis, apnea
Blood transfusion,IVH, PDA
Threshold ROP
≥ 5 or more contigous or 8 cumulative clock hours( 30
degree sectors) of stage 3 with plus disease in either
zone 1 or 2
Risk of blindness – 50%
Risk of blindness with treatment – 25%
Prethreshold ROP

Type 1 prethreshold ROP

ZONE 1
 Plus disease
 Stage 3 without plus disease

Zone 2
 Stage 2, 3 with plus disease
Type 2 prethreshold ROP( without plus disease)
Zone 1 : stage 1,2
Zone 2 : stage 3
Protocol of screening
Aim:
Detect ROP early, follow it up closely during its
evolution and treat if it reaches a potentially serious
severity.
Screening window:
Hardly detected- before 32 weeks, before 2weeks of
age
Mean age of detection of stage 1 ROP – 34 weeks
Prethershold – 36 weeks
Threshold – 37 weeks
Vascularization complete by – 40-44weeks
Window period – 32 to 40 weeks
Critical phase is 34-37 weeks
Indication :
< 1750gm
≤ 34 weeks
Unstable clinical course
Time:
<26 weeeks – at 31weeks
>26weeks- at 4 weeks
Best 3-4weeks of post natal age
Further follow up

≤ 1 week follow up
Zone 1 – satge 1 , 2
Zone 2 – stage 3
1-2 weeks
Zone 1 – immature vascularization, regression ROP
Zone 2 – satge 2
2 week
Zone 2 – stage 1, regression ROP
2-3 weeks
Zone 2 – immature vascularization
Zone 3 – stage1 ,2 , regression ROP
At 6months, 1 year
Stop :

Zone 3 – without previous zone 1 , 2 ROP

Full retinal vascularization
>45weeks , no prethershold disease
Regression of ROP
Examination :

Indirect ophthalmoscopy, wire speculum, 20D-30D lens

Dilation
One drop tropicamide 1% X every 15 min X 4 times one
hour before
One drop phenylephrine 2.5% ( 10% dilute in 4 ml) X just
before
Not fed recently – vomiting and aspiration
Sedation
Topical – proparacaine
Oral sucrose
Treatment
 Modalities :
Cryotherapy Laser ablation (prefered)

Trans scleral ablation Direct ablation

Painful Less painful

Require ventilation during procedure No need of ventilation

Substantial lid swelling and conjunctival oedema Less local complication

Posterior retina difficult to reach Posterior retina can be reached more readily

Myopia and retinal detachment Less common

Anti VEGF factors: intravitreal bevacizumab , under
trail
Retinal reattachment:
Indication – macula detaches in stage 4b, 5
Vitrectomy with or without lensectomy , membnrane
peeking
Peripheral detachments- scleral buckling
Efusional detachment – drainage of fluid
Redetachemnt is common
Prevention of ROP
Judicious oxygen therapy
Oxygen is drug
Pulse oximetry, oxygen analyser, blender is a practical
way
Spo2 = 90-93%, Alaram @ 88 – 95%
PaO2 = 50 – 70 mmhg
Permissive hypercapnia
Hypocapnia is a risk factor
Aim – PaCO2 @ 50 – 55 mmhg if pH >7.25
Lower ventilator setting- ↓CLD -↓ Oxygen use
Judicious use of blood transfusion
PCV is a risk factor
Adult RBC – releasing excess oxygen
Guidelines for PCV for Hct
 Ventilated – 40%
 Cardiopulmonary – 35%
 Sick – 30%
 Symptomatic anemia – 25%
 Asymptomatic anemia – 20%
Strict clinical and electronic monitoring
Vitamin E supplementation : all < 1500gm = 15 – 25 IU
daily
Prenatal steroids
Screening program
Early nutritional support, normal IGF 1 levels,
adequate weight gain – low risk
PROGNOSIS:
Short term prognosis
stage 1 ,2 – spontaneous regression
Prethreshold ROP
 Type 1 – 31.5 % regress spontaneously
 Type 2 – 77% regress spontaneously

Stage 3 – excellent prognosis

Long term prognosis
Risk of – high myopia, anisometropia, strabismus,
amblyopia, astigmatism, late retinal detachment,
glaucoma
Residual scarring in retina , retinal detachment later
Retinal detachment occurred- vision will be poor even
with treatment
Thank you