Trans 014 Ocular manjfestation of systemic disease part 2 Flashcards
Important cause of blindness in
middle income economies
Retinopathy of prematurity
Initially termed retrolental fibroplasia
vasoproliferative disorder of the eye affecting premature neonates -
Characterized by local ischemia and subsequent development of retinal neovascularization
• A disease of pre-term infants where the immature retina undergoes changes related to / caused by ischemia and insufficient retinal vascularization leading to a wide spectrum of abnormalities ranging from mild peripheral retinal ischemia, vessel tortuosity, to severe exudative and tractional retinal detachments
ROP
Pathophy of ROP
Biglang napanganak si baby na premature pa ang retina, magugulat yun and retinal vessels will constrict, so ischemia will occur. Then, VEGF will release from the ischemic retina. Then magkakaroon ng new vessels.
DEFINITE AND WELL ACCEPTED RISK FACTORS ROP (3)
. • Low gestational age
The younger the patient, the more prone. Yung pinanganak
ng 32 weeks and lower at risk yan. • Low birth weight
1,500 grams and lower at risk yun
• Supplemental oxygen delivery
Yung mga pinanganak, di maka.hinga, binigyan ng oxygen at
di maxado na.titrate
Maternal and perinatal risk factor
For ROP
MATERNAL • Infection during pregnancy • Placenta previa • Poor nutrition • Pre-Eclampsia/eclampsia • Premature rupture of membrane • Multigestation PERINATAL • Anemia • Apnea • Jaundice • Seizures • Sepsos • Blood transfusion
can lead to arrest of vascular development, leaving an area of avascular retina
• No longer considered the sole factor in the development of
A. RISK FACTORS
1. DEFINITE AND WELL ACCEPTED RISK FACTORS
IV. PATHOPHYSIOLOGY
ROP
• Important contributing factor
Excessive oxygen concentration
Vasculature reaches nasal ora serrata at what week? Temporal ora n?
32-36 week
Shortly after birth
last to be vascularized ( 39-42 weeks)
• Susceptible to ROP longest
Temporal retina
% of high risk babies never develop any stage of
ROP
85
% of high risk babies develop some form of ROP
15
% ( only 1% of all high risk babies) of those who
have ROP progress to visually debilitating stages (stages4B& 5 )
5-6
In the Philippines % of premature infants develop ROP
14-15 %
yung pinaka.dangerous sa lahat. Na Rop
APROP Aggressive Posterior ROP (APROP)
What zone is bounded by an imaginary circle, the radius of which is twice the distance from the disc to the centre of the macula. With a 28 dioptre binocular indirect lens, only zone I is seen if any part of the optic nerve head is visible.
Zone one
What zone extends concentrically from the edge of zone I; itsradius extends from the centre of the disc to the nasal ora serrata.
Zone 2
What zone consists of a residual temporal crescent anterior to zone II.
Zone three
Stages of RoP?
Stage 1 - demarcation line between posterior vascular and peripheral avascular retina
Stage 2 - elevated ridge
Stage 3 - extraretinal neovascularization
Stage 4a - subtotal retinal detachment not involving macula Stage 4b - subtotal retinal detachment involving macula
Stage 5 - total retinal detachment
A more florid form of ROP
• Increasing dilation and tortuosity of vessels
• Iris vascular engorgement
• Pupillary rigidity
• Vitreous haze indicating progressive vascular incompetence
Plus disease
Plus disease means lang that the blood vessels are dilated and tortuous, engorged vessels ng iris and the pupils do not dilate, its very rigid and hazy na ang vitrous.
Vascular abnormalities that are insufficient for the diagnosis of PLUS disease
• More arterial tortuosity and venous dilatation than normal
“Pre-Plus” Disease
- Rapidly progressing, severe form of ROP
- Usually progresses to Stage 5 ROP if untreated
- Characteristics:
- Posterior location
- Prominence of plus disease
- Ill-defined nature of the retinopathy
Aggressive Posterior ROP
Current Screening Guidelines of ROP in the ph
Less than or equal to 32 weeks less than or equal to 1500g
least 2 dilated funduscopic examinations using binocular indirect ophthalmoscopy for all infants with:
o birthweightof<1500grams
o gestationalageof32weeksorless
o selected infants between 1500 and 2000 grams with unstable clinical course (high risk infants)
o gestational age > 32 weeks with an unstable clinical course who are believed to be at high risk by their attending pediatrician or neonatologist
Recommend screening guidelines by the ophthalmologists
<35 weeks GA and/or <2,000 grams BW
cannot pick up everything esp Zone 3 lesions
• Is not necessary for ROP screening
• Useful for mass screening
• Useful to document, teach residents and fellows , inform
parents
• Useful for follow-up esp if fundus is difficult to visualize
• Some models are capable of fundus fluorescein angiography
Ret cam
Means of ablation?
Cryotherapy
• Laser Indirect Ophthalmoscopy (LIO)
• Laser photocoagulation (Diode laser with an indirect
Criteria for cryotherapy for ROP
Zone I or II ROP, stage 3 more than 5 contiguous or cumulative hours with plus disease
• Treatment is mandatory, risk of progression to retinal detachment is 50% if left untreated
Criteria for ablation new threshold
•
Early Treatment of ROP
o Type I ROP: perform retinal abation
▪ Zone I, any stage with plus disease
▪ Zone I, stage 3 without plus disease
▪ Zone II, stage 2 or 3 with plus disease
o Type II ROP: consider treatment only if they progress to type I
▪ Zone I, stage 1 or 2 without plus disease ▪ Zone II, stage 3 without plus disease
Anti vegf in ROP
Bevacizumab ( Avastin)
• Ranibizumab ( Lucentis)
• Aflibercept ( Eylea)
Uses of anti VEGF in rop
• In eyes with APROP
• In eyes with zone 1 ROP (allow vascularization to develop
before retinal ablation)
• In eyes with media opacity due to anterior segment
neovascularization/ synecheae
• Adjunct to laser treatment or prior to vitrectomy in APROP
• Less myopia/astigmatism*
• Eliminate visual field loss due to retinal laser ablation
Disadvantages in using Anti-VEGF
- Possible systemic complications
- Infection
- Trauma to the lens
- Temporary effect
- Contraction of membranes
REMAINS THE ONLY
WELL-ESTABLISHED THERAPY FOR THRESHOLD ROP
PERIPHERAL RETINAL ABLATION
