ROP Flashcards
What was the old name of ROP of the 1940’s
Retrolental Fibroplasia (RLF)
What caused the 1st epidemic of ROP?
How many babies were blind?
O2 piped into the isolette for survival from HMD
12,000 worldwide
What was the set point of FiO2 after the RCT study that showed much less ROP if FiO2 was <50%.
Did it work?
< 40%
No, for ever 1 baby whose sight was saved, 16 babies died. Many more had CP.
What is the current FiO2 recommendation based on evidence?
Keep SpO2’s >90% in <28 wk preemies
although still depends on HgbF/A in baby so not always accurate
When you target 1 organ, you must think of….?
All the other organ systems you may be neglecting (or affecting).
What were the 2 types of Retinal Ablative Tx (in 1990)?
Cryotherapy
Laser therapy
The second Epidemic of ROP was in what decade?
1970’s
The third epidemic of ROP was when?
Mostly where?
Why?
Are the babies bigger or smaller than US babies who get ROP?
Current
Middle-income nations (India, S. America)
Don’t have the equipment or specialists needed.
Much bigger
The Sclera is the _______ connective tissue that __________ the Retina with O2 and nutrition
Vascular
Nourishes
The Retina accepts _____ waves and _______ information to the optic nerve.
Light waves
Transmits
The ______ is the pit in the Macula where precise central vision is.
We always want to preserve the _______
Fovea
Macula
Vessels grow from the _____ _____ of the Optic Nerve in a spray outward.
Optic Disk
The _______ ____ secretes ______ _______ that cause the vessels to grow toward the Avascular Area
Avascular Area
Growth Factors
What does VEGF stand for?
Vascular Endothelial Growth Factor
What does IGF-1 stand for?
Insulin-Like Growth Factor 1
VEGF is secreted by the ________ ____
and production is regulated by _______
Avascular Retina
Oxygen
In Hypoxic state, Increased/Decreased VEGF is secreted?
Inreased
In Hyperoxic state, Increased/Decreased VEGF is secreted?
Decreased
Normal Uterine environment is?
Hypoxic
Best pO2 25-30mmHg
SpO2~60-70%
What does IGF-1 do to VEGF?
ACTIVATES it
When does IGF-1 increase in utero?
Where is it located in large amounts?
3rd Tri
Amniotic Fluid
Where does IGF-1 come from postnatally?
Nutrition
What does VEGF do to the vessels?
Draws the vessels toward the Avascular area
There are ____ phases of ROP
2
During the 1st phase of ROP after premature birth, the Retinal Development ____ _____ leading to decreased _____ & ______
Shuts down
VEGF & IGF-1
(because of increased oxygen state vs. in utero)
Once hit with O2, the vessels that have begun to grow literally “_____”
“cringe” or shrink back
When does the 2nd phase of ROP happen?
4 wks after birth
What happens in the 2nd phase of ROP?
What happens if IGF-1 levels remain low due to inadequate nutrition?
Avascular Retina increases it’s Metabolic Needs by becoming ischemic/hypoxic—>VEGF Production (again).
If IGF-1 levels remain low, VEGF accumulates awaiting IGF-1 to reach threashold levels for revascularization
What happens if IGF-1 levels reach threashold early and VEGF levels are NOT excessive?
ROP will NOT develop
What happens if IGF-1 levels reach threashold late–(VEGF levels will be excessive)?
ROP WILL occur
So-nutrition is SUPER important
What does excessive VEGF cause?
Out-of-control Angiogenesis at the demarcation of Vascular and Avascular Retina.
- Ridge (360 deg. w/tissue tufts that hook into vitreous)
- AV shunts
- Vessels leak proteins
The Retina is like ___ _____ on the eyeball.
With extensive scarring, what can happen?
Wall Paper
Retinal Detachment
What 3 things put infants at risk for ROP?
- Prematurity
- Severity of Illness
- Number of Complications
Are the classifications of ROP accepted worldwide?
Yes, by zones and clock hours
The zones are circles that move outward from numbers __-__ from the ____ ____
1 - 3
from Optic Disk
Zone 1 is where ____% of central vision is located
80%
The stages of ROP are based on?
Over-production of vessels at the border of the Vascularized and Avascularized Retina
How is the location of ROP described?
In clock hours 1-12
What are the number of stags of ROP?
Which is the worst?
1-5
5
W/Stage 1 ROP you would see?
A distinct line (flat/thin) between the Vascular and Avascular Retina
W/Stage 2 ROP you would see?
The line between Vascular and Avascular Retina has become a ridge with a little depth (inward) & height
W/Stage 3 ROP you would see?
Vessels extend beyond Retina (over the Ridge) into the Vitreous itself (the liquid in the eyeball)
W/Stage 4 ROP you would see?
4a?
4b?
Partial Retinal Detachment
4a-Macula is Spared (Not covered by Retinal Detachment)
4b-Macula is Involved (Covered by Retinal Detachment)
W/Stage 5 ROP you would see?
Complete Retinal Detachment (blind)
What is PLUS Dz?
If a child has PLUS Dz, what does it indicate?
Important clinical marker in ROP Screening
Need Laser Tx
True/False: Current studies say WITHOUT PLUS Dz , it’s always better to Tx w/Laser right away.
False, it’s better to do nothing-better outcome (WITHOUT Plus Dz).
How is Plus Dz determined?
By the state of blood vessels in Zone 1 near Optic Disk-Posterior Pole
What happens as ROP becomes more severe?
Veins become Dilated
Arteries become Tortuous
True/False: W/PLUS Dz, it’s easier to Dilate pupils
False, it’s more difficult to dilate pupils (due to the blood flow)
Is “pre-PLUS” Dz an accepted term?
How is it generally defined?
Controversial/Subjective.
Vascular abnormalities in the Posterior Pole, but less severe than true PLUS Dz.
What are the protocol for screening babies for ROP?
< 30 wks at birth
< 1500 gm BW
Or difficult course or lots of O2 need.
What does the term Incomplete mean?
Is it bad?
The vessels just haven’t grown yet.
No, just need to wait and watch.
How long after ROP exam should the lighting be kept low?
4 hours.
Their eyes are dilated and they don’t know not to open them–>causes stress
Retcam is a good screening tool for ____ areas.
Rural
What is Optical Coherence Tomography?
Why might it be beneficial?
Why isn’t it used much
OCT-Visualization of the eye structure at a microscopic level. (macular edema-quantify PLUS dz)
May lead to earlier Dx and Tx
-no bright light in eye
-no need for eye clip or local anesthesia
-No direct contact of equipment to eye
Not used much d/t $
When does ROP need TX?
W/PLUS Dz.
What is the most dangerous type 1 ROP that needs tx?
When does tx need to happen?
Zone 1 (central vision) -Any Stage WITH PLUS Dz. OR -Stage 3 WithOUT PLUS Dz (hooking into the vitreous)
Probably w/in 48 hrs (24 hr better, for sure by 72 hrs)
When does Type 1 ROP in Zone 2 need Tx?
-any Stage 2 OR 3 WITH PLUS Dz.
What is “RUSH dz”?
Why is it so devastating?
ROP in Zone 1 w/Severe PLUS Dz
(also known as Aggressive Posterior ROP or AP-ROP)
Can quickly lead to Retinal Detachment w/in 24-48 hrs.
When we “wait and watch”?
Why?
Type 2 ROP, Zone 1/2; Stage 1,2,3 Without PLUS
May regress on own
ROP in Zone 1, type 2 needs……?
To be watched VERY carefully
What ROP seen initially has the Worst prognosis?
ROP in Zone 1
What ROP seen initially has the Best prognosis?
ROP in Zone 3
is mild and recovers fully (usually)
T/F, Do most infant’s with ROP undergo Regression?
What happens in Regression?
Yes
The ridge flattens and becomes faint line. The vessels have been able to cross the ridge.
If regression occurs without distortion or detachment of the Retina, they will have _____.
Vision
Still may lose some peripheral vision
Can people have problems from ROP later?
Yes
A late complication of ROP is Retinal dragging and folds. What is the result of this?
Results in decreased vision, but not blindness. May have “ambulatory vision”.
Name the Late Complications of ROP
Retinal Dragging/Folding Myopia (near-sightedness) Strabismus (crossed-eyes) Amblyopia (lazy-eye) Glaucoma Late onset Retinal Detachment
What is the risk of Myopia (near-sightedness) for a preemie?
W/mild ROP?
W/treated ROP?
3 x’s that of a term infant (6%)
12 x’s that of term (24%)
70-80% that of term infant–the damage gets worse, does not stay where it was at correction.
Can infant’s who never had signs of ROP develop it later in life?
Yes.
Just being born prematurely is a risk factor.
Why do they patch the strong/predominant eye in a child w/Amblyopia?
To force the brain to use the weaker eye, other wise the brain will stop the connection to that eye and they will be blind in that eye.
All infants meeting ROP criteria need F/U at what agees?
6 months
3 years
Yearly in adolescence/early adulthood
What is the Purpose of laser treatment for ROP?
Eliminate abnormal vessels before they lay down enough scar tissue to produce Retinal Detachment
What does Lasering do?
How?
Causes destruction of the remaining Avascular Retina—>No more VEGF production (and no more vessels)
Condensates protein material by controlled use of light rays
Only needs topical anesthesia and IV sedation (no General)
Why don’t they Laser the ridge?
It can cause Vitreous Hemorrhage
What is Cryotherapy?
How is it performed?
Is it still used?
Very cold probe placed on the sclera until ice balls form on Retina
Under General anesthesia, metal probe dipped in liquid nitrogen.
No, Laser is preferred method
Laser spot is significantly Larger/Smaller than spot of Cryotherapy?
How many spots w/Laser can be done?
How many w/Cryo?
Smaller
600-1000
30-50
Laser is done through the _____ or with Severe PLUS, could be done through the _____.
Pupil
Slcera (can’t get pupil dilated)
What is Bevacizumab (Avastin)?
How long does it last systemically?
Anti-VEGF factor
2 wks
When is Avastin indicated?
Vascular congestion precluding laser tx
Progression of ROP despite Laser (last option)
Primary Tx
Is Avastin FDA approved?
No, not yet.
Dosing is not known
How is Avastin given?
30 gu. needle (topical anesthetic & Fentanyl)
What are the benefits of Avastin vs Laser?
What are the unknowns?
Less:
Cost, time, anesthesia, myopia
Systemic effects, optimal dosing/timing, may need prolonged F/U (one baby had recurrence ROP 5 mos out)
True/False: A benefit of Avastin is the ridge and tufts will go away and the vessels can grow up all the way
True :-)
When is Scleral buckling used?
Is it once and done?
4a & 4b Retinal Detachment
No, the band must be changed w/age/growth.
What is a Vitrectomy?
When is it done?
Removes scar tissue (exchanges vitreous w/NS) to decrease traction on Retina.
Done w/Stage 5 ROP or Lg Vitreous Hemorrhage. Must be done prior to Laser-(they can’t see to do it).
What is the success rate of Retinal Reattachment?
25-50%
What vision is left after Retinal reattachment?
It can provide ambulatory vision, but only 1/4 will be able to reach out and grab an object.
What are possible future Tx’s?
EPO (anti-EPO drug?-but would suppress RBC production)
Propanolol (beta-blocker: safety concern of bradycardia, hypotension)–working on topical solution
Omega-3 Long Chain Polyun. FA’s (need balance of omega 3 & 6 to prevent ROP)
How can we Prevent ROP?
What are 2 predictors of highest risk ROP?
Protein intake ______’s IGF-1
Nutrition!
1. poor postatal wt gain 2. Low serum IGF-1
Increases it.
Breastmilk Increases/Decreases incidence of ROP?
What about Donor BM?
Decreases incidence
No benefit w/Donor
What maternal state is an Anti-angiogenic state?
What might this do for babies?
It Increases/Decreases any stage of ROP by 60%
It Increases/Decreases Severe ROP by 80%
Pre-Eclampsia
Mature Retinal vasculature preventing ROP
Decreases
Decreases
Decreased Oxygen is helpful in the ____ phase of ROP.
Increased Oxygen is helpful in the ____ phase of ROP
First
Second
Avoid hyPERoxia in the first/later wks life.
First
Strict monitoring if O2 starts when?
In the DR
Avoid HYPOxia in the first/later wks life
Later
