Retinopathy of prematurity: an update on screening and management

Question 1

Incidence of ROP before 31 wks?

Answer 1

40-50% develop some form of ROP
7-8% develop severe ROP
5-6% require treatment

Question 2

Difference between threshold and prethreshold ROP?

Answer 2

Threshold - 5+ contiguous areas OR 8 total clock hours of stage 3 ROP in zones I and II (in the presence of plus disease)
Prethreshold - high likelihood of progressing

*Threshold and more severe forms of prethreshold ROP included in type 1 category

Question 3

Indications for tx of ROP?

Answer 3

Zone 1 - any stage with plus disease
Zone 1 - stage 3 ROP without plus disease
Zone 2 - stage 2 or 3 with plus disease

(zone 2 later to vascularize - any ROP in a more mature retina more concerning?)

Question 4

Findings in 5 stage of ROP?
Plus disease means?
Pre-plus disease?

Answer 4

Stage 1 - line separating avascular to vascular retina
Stage 2 - ridge in area of demarcation line
Stage 3 - extraretinal fibrovascular proliferation & neovascularization (extending into vitreous)
Stage 4 - partial retinal detachment
Stage 5 - total retinal detachment

Plus disease - increased vascular dilatation and tortuosity of posterior retinal vessels
Pre-plus disease - more vascular dilatation and tortuosity than normal

Question 5

Difference between type 1 and type 2 ROP?

Answer 5

Type 1:

• Zone 1, any stage ROP with plus disease
• Zone 1, stage 3 ROP without plus disease
• Zone 2, stage 2 or 3 ROP with plus disease

Type 2:

• Zone 1, stage 1 or 2 without plus disease
• Zone 2, stage 3 ROP without plus disease

Question 6

Which pts need ROP screening?

Question 7

In a 2014 literature review, risk for severe ROP is greatest in which groups?

Question 8

When should the first ROP screening exam start based on GA?

Answer 8

• 31 weeks PMA for 22-27 weeks GA
• 32 weeks PMA for 28 weeks GA
• 33 weeks PMA for 29 weeks GA
• > /= 34 weeks PMA for >/=30 weeks GA

(PMA = GA + chronological age)

If

Question 9

What is the evidence around digital retinal photography?

If RetCam is used for initial screening, what follow-up is needed?

Answer 9

Accurate for detecting clinically significant ROP
- Sensitivity for detection of mild ROP less certain

Need at least 1 indirect ophthalm exam before tx/stopping screening

Question 10

What is the conventional tx of ROP and when should it start?

Answer 10

Retinal ablation of avascular part of retina – decreases production of angiogenic growth factors

Start tx within 72h of detecting stage 1 ROP

Question 11

What is the evidence around the use of anti-VEGF vs laser therapy in ROP?

Answer 11

• More effective than laser for zone I but not posterior zone II
• At 30 mos, more myopia in lasered pts

Question 12

Side effects of anti-VEGF in neonates?

Answer 12

?transient effects with recurrence of ROP
?effect on normal angiogenesis in other organs
?adverse effects on neural retina

Question 13

Findings requiring f/u in 1 week?

Answer 13

(1) Immature vascularisation in zone I/extending into posterior zone II
(2) Stage 1 or 2 - zone I
(3) Stage 3 - zone II
(4) Agressive posterior ROP

Question 14

Findings requiring f/u in 1-2 weeks?

Answer 14

(1) Immature vascularisation in posterior zone II

(2) Stage 2 - zone II

Question 15

Findings requiring f/u in 2 weeks?

Answer 15

(1) Immature vascularisation in zone II

(2) Stage 1 - zone II

Question 16

Findings requiring f/u in 2-3 weeks?

Answer 16

(1) Stage 1 or 2 - zone III

(2) Regressing ROP, zone III

Question 17

Indications to stop screening?

Answer 17

• Vascularisation in zone III (without previous zone I/II ROP)
• Full retinal vascularisation close to ora serrata for 360 deg
• PMA 50 weeks with no prethreshold ROP
• Regression of ROP