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A) What is retinopathy of newborn ?
 Retinopathy of newborn is a disorder of the blood vessels of the retina. ROP
is most common in premature babies. The blood vessels of the retina
proliferate and scar when exposed to certain postulated incriminating
factors. This disorder has in the past been called retrolental fibroplasias.

B) What causes retinopathy of prematurity?
The exact mechanism of ROP is not fully understood. The retina is the thin layer
of light-sensitive nerve fibers and cells that covers the inside and back of the eye.
The blood vessels of the retina are not completely developed until the baby
reaches full term. When a baby is born prematurely, the blood vessels may not
have fully developed. The vessels proliferate and scar when exposed to high and
prolonged levels of oxygen , blood transfusion, sepsis other factors.
The scarring and bleeding can lead to retinal scarring or detachment from the
back of the eye, resulting in vision loss.

C) Why is retinopathy of prematurity a concern?
ROP occurs in 16 percent of all premature births. Each year in the US, over
2,100 children experience the complications of ROP. There are five stages of
ROP, from a mild Stage 1 to severe Stage 5 when the retina detaches in the eye.
Babies with Stage 1 and 2 ROP are called prethreshold, and those with Stages 3
through 5 are called threshold. About 90 percent of babies with Stage 1 and 2
ROP show improvement without treatment. However, about half of babies with
Stage 3 and most of those with Stage 4 may develop serious eye damage. Each
year, approximately 400 to 600 children are blinded by ROP.

D) Screening newborns for ROP

Which Babies are Screened?

1.      All babies who are:
     1. <1250g birth weight, or
     2. <30 weeks gestation, or
  3. Selected infants ≥1250g and ≥30 weeks with an unstable clinical course
     (on ventilators, requiring high FIO2, ) who are believed to be at high risk
     by their attending neonatologist.

D) Consistently reported risk factors for the development of ROP


        2. Intrauterine growth restriction

        3. Male gender

        4.Hyperoxia. Note that although the initial epidemic of ROP in the mid
          20th century was due to excessive oxygen administration, this is not
          proven to be the only causative agent.

        5. Erythropoietin (in high cumulative doses), sepsis, blood transfusions,
          postnatal dexamethasone use and GM-IVH have been implicated as
          associations, but may reflect extreme prematurity and severity of
          illness rather than causation.
E) Classification of ROP

                  Demarcation line -a flat, thin, whiteish,
  Stage 1         clear-cut demaraction between
                  vascularised and avascular retina
                  (normal retina has a tenuous, non-
                  linear, feathery border)
                  Elevated ridge - demarcation line now
  Stage 2         has "3" dimensions

                  Neovascularisation - extra-retinal,
  Stage 3         fibrovascular proliferative tissue

                  Retinal detachment - may be exudative
  Stage 4         and/or tractional, and may be partial or
                  4A – macular not involved

                  4B – macular detached

                  Total retinal detachment
  Stage 5

                  Presence of dilatation and tortuosity of
  Plus Disease    the posterior pole blood vessel involving
                  at least two quadrants of the retina.
                  This is associated with severe disease
                  and worse outcomes.
                  It is more likely to occur with higher
                  stages and lower zones
                  Pre-Plus Disease: more arterial
                  tortuosity and venous dilatation than
                  normal but not severe enough to be
                 classified as "Plus disease".
                 "Rush" Disease (Aggressive Posterior
                 ROP, AP-ROP): A rare and severe form
                 of ROP with increased tortuosity and
                 dilatation of vessels present in all 4
                 quadrants of zone 1 and sometimes
                 zone 2. May not sequentially advance
                 through Stage 1 to 3 but often rapidly
                 advances to stage 4 or 5.

F) Treatment of ROP

   1. Laser photocoagulation- this procedure produces scars which then seal
   the borders of the retina preventing retinal detachment.

    2. Cryopexy- this method uses freezing to stop the process of vascular

    3. Angiogenesis and the study of how the retinal vessels proliferate is an
   exciting potential option for the treatment of this disease.

G) Prevention of ROP. Preventing premature births is the key to
   preventing ROP. Research is ongoing to find ways to treat this and other
   problems of premature babies. During anesthetic care, most
   textbooks recommend keeping the FIO2 as low as possible (at
   least <60%) while tolerating a SPO2 as low as 88%. Newborns
   are considered to be at risk for ROP from hyperoxia up until 45
   weeks gestation age.

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