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Retinopathy of prematurity (ROP)

 

Retinopathy of prematurity (ROP):
Previously known as retrolental fibroplasia (RLF), is an eye disease that affects prematurely born babies. It is thought to be caused by disorganized growth of retinal blood vessels which may result in scarring and retinal detachment. ROP can be mild and may resolve spontaneously, but may lead to blindness in serious cases. As such, all preterm babies are at risk for ROP, and very low birth weight is an additional risk factor. Both oxygen toxicity and relative hypoxia can contribute to the development of ROP.
 
Pathophysiology
 
Normally, vascularization of the retina starts from the optic disc and progresses towards the periphery and in most of the normal neonates its almost complete, However, in preterm infants, the retina is often not fully vascularized and ROP occurs when the development of the retinal vasculature is arrested and then proceeds abnormally. Multiple factors can determine whether the disease progresses, including overall health, birth weight, the stage of ROP at initial diagnosis, and the presence or absence of "plus disease". Supplemental oxygen exposure, while a risk factor, is not the main risk factor for development of this disease.
Patients with ROP are at greater risk for strabismus, glaucoma, cataracts and myopia later in life, and should be examined yearly to help prevent and treat these conditions.

Diagnosis
 Dilated fundus examination with an indirect ophthalmoscope using scleral depression is most important in diagnosing ROP. Examination of the retina of a premature infant is performed to determine how far the retinal blood vessels have grown (the zone), and whether or not the vessels are growing flat along the wall of the eye (the stage). Once the vessels have grown into Zone 3 (see below) it is usually safe to discharge the child from further screening for ROP
Retinal examination with scleral depression is generally recommended for patients born before 30–32 weeks gestation, with birthweight 1500 grams or less, or at the discretion of the treating neonatologist. The initial examination is usually performed at 3–6 weeks of life, and then repeated every 1–3 weeks until vascularization is complete (or until disease progression mandates treatment).
Treatment:
1.    Laser photocoagulation: Peripheral retinal ablation is the mainstay of ROP treatment. The destruction of the avascular retina is performed with a solid state laser photocoagulation device, as these are easily portable to the operating room or neonatal ICU.
2.     Cryotherapy, an earlier technique in which regional retinal destruction was done using a probe to freeze the desired areas. However, when laser treatment is available, cryotherapy is no longer preferred for routine avascular retinal ablation in premature babies, due to the side effects of inflammation and lid swelling.
3.    Intravitreal injection :  Intravitreal injection of bevacizumab (Avastin) has been reported as a supportive measure in aggressive posterior retinopathy of prematurity.
4.    Scleral buckle : The silicone band (scleral buckle) is placed around the eye. This brings the wall of the eye into contact with the detached retina, allowing the retina to re-attach.
5.    Vitrectomy :vitrectomy and/or  scleral buckling surgery may be considered for severe ROP (stage 4 and 5) for eyes that progress to retinal detachment. Few centers in the world specialize in this surgery, because of its attendant surgical risks and generally poor outcomes.
 















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