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| Retinopathy of prematurity | |
|---|---|
| Classification and external resources | |
| ICD-10 | H35.1 |
| ICD-9 | 362.20, 362.21 |
| OMIM | 133780 |
| DiseasesDB | 11442 |
| MedlinePlus | 001618 |
| eMedicine | oph/413 ped/1998 |
| MeSH | D012178 |
| This article needs additional citations for verification. Please help improve this article by adding citations to reliable sources. Unsourced material may be challenged and removed. (June 2011) |
Retinopathy of prematurity (ROP) or Terry syndrome,[1] previously known as retrolental fibroplasia (RLF), is a disease of the eye affecting prematurely-born babies generally having received intensive neonatal care. 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 it 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.
Contents
- 1 Causes
- 2 Pathophysiology
- 3 Risk Factors
- 4 Screening
- 4.1 Indications
- 4.2 Timing
- 4.3 Procedure
- 5 Diagnosis
- 5.1 International classification of retinopathy of prematurity (ICROP)
- 5.2 Plus disease
- 5.3 Prognosis
- 6 Differential diagnosis
- 7 Monitoring
- 8 Management
- 8.1 Treatment
- 8.2 Follow up
- 9 Sequelae
- 10 History
- 11 Clinical studies
- 12 Epidemiology
- 13 References
- 14 External links
Causes[edit]
In the fetal period already the fourth month of pregnancy the unborn child develops in the vascularization of the retina. Such formation of blood vessels appears to be very sensitive to the amount of oxygen supplied artificially and that present in the air. In rare cases it has been found in some patients with ROP a mutation in the NDP gene, which is normally associated with the more formidable Norrie disease.[2][3][4]
Pathophysiology[edit]
During development, blood vessels grow from the central part of the retina outwards. This process is completed a few weeks before the normal time of delivery. However, in premature babies it is incomplete. If blood vessels grow normally, ROP does not occur. If the vessels grow and branch abnormally the baby develops ROP. That may lead to bleeding inside the eye. When the blood gets resolved, it may give rise to band like membranes which may pull up the retina, causing detachment of retina and eventually blindness before 6 months.
Normally, maturation of the retina proceeds in-utero, and at term, the medial portion of the retina is fully vascularized, while the lateral portion is only incompletely vascularized.[5] If a pre-term infant is treated with oxygen, the oxygen may cause constriction of the retinal blood vessels.[5] This vasoconstriction can lead to a lack of oxygen (ischemia) in the retina. This leads to the production of molecules that cause the growth of new blood vessels (VEGF).[5] These blood vessels are abnormal, and negatively affect the normal development of retinal vasculature. Thus, retinopathy of prematurity occurs when the normal development of retinal blood vessels is prevented.
The key disease element in ROP is fibrovascular proliferation. This is growth of abnormal new vessels that may regress, but frequently progress. Associated with the growth of these new vessels is fibrous tissue (scar tissue) that may contract to cause retinal detachment. 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. Restricting supplemental oxygen use does not necessarily reduce the rate of ROP, and may raise the risk of other hypoxia-related systemic complications.[citation needed]
Other physicians have suggested that supplemental oxygen, specifically oxygen tents given to pre-term infants specifically causes ROP. The hypothesized mechanism involves the degradation and developmental cessation of blood vessels in the presence of excess oxygen. When the excess oxygen environment is removed, the blood vessels begin forming rapidly again and grow into the vitreous humor of the eye from the retina, sometimes leading to blindness.[6] This does not preclude the dangers of hypoxic environments for premature infants.
Patients with ROP, particularly those who have developed severe disease needing treatment are at greater risk for strabismus, glaucoma, cataracts and shortsightedness (myopia) later in life and should be examined yearly to help prevent or detect and treat these conditions.
Risk Factors[edit]
| This section requires expansion. (March 2013) |
Various risk factors contribute to the development of ROP. They are:
- Prematurity[7]
- High exposure to Oxygen
- Low birth weight
- Various types of infections
- Cardiac defects
Screening[edit]
Indications[edit]
Evidence suggests that almost all infants with ROP have a gestational age of 31 weeks or less (regardless of birth weight) or a birth weight of 1250 g or less; these indications are generally used to decide whether a baby should be screened for ROP, but some centres may extend birth weight screening criteria to 1500 g.[8]
Any premature baby with severe illness in perinatal period (Respiratory distress syndrome, sepsis, blood transfusion, Intra ventricular haemorrhage, apnoeic episodes, etc.) may also be offered ROP screening.
Timing[edit]
Retinal examination with scleral depression is generally recommended for patients born before 30–32 weeks gestation, or 4–6 weeks of life, whichever is earlier. It is then repeated every 1–3 weeks until vascularization is complete (or until disease progression mandates treatment).
Procedure[edit]
Following pupillary dilation using eye drops, the retina is examined using a special lighted instrument (an indirect ophthalmoscope). The peripheral portions of the retina are sometimes pushed into view using scleral depression. 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. The stage of ROP refers to the character of the leading edge of growing retinal blood vessels (at the vascular-avascular border).
Diagnosis[edit]
The stages of ROP disease have been defined by the International Classification of Retinopathy of Prematurity (ICROP).
In older patients the appearance of the disease is less well described but includes the residua of the ICROP stages as well as secondary retinal responses.
International classification of retinopathy of prematurity (ICROP)[edit]
The system used for describing the findings of active ROP is entitled The International Classification of Retinopathy of Prematurity (ICROP).[9] ICROP uses a number of parameters to describe the disease. They are location of the disease into zones (1, 2, and 3), the circumferential extent of the disease based on the clock hours (1-12), the severity of the disease (stage 1-5) and the presence or absence of "Plus Disease". Each aspect of the classification has a technical definition. This classification was used for the major clinical trials. It was revised in 2005.[10]
Zones of the retina in ROP
The zones are centered on the optic nerve. Zone 1 is the posterior zone of the retina, defined as the circle with a radius extending from the optic nerve to double the distance to the macula. Zone 2 is an annulus with the inner border defined by zone 1 and the outer border defined by the radius defined as the distance from the optic nerve to the nasal ora serrata. Zone 3 is the residual temporal crescent of the retina.
The circumferential extent of the disease is described in segments as if the top of the eye were 12 on the face of a clock. For example one might report that there is stage 1 disease for 3 clock hours from 4 to 7 o'clock. (The extent is a bit less important since the treatment indications from the Early Treatment for ROP[11])
The Stages describe the ophthalmoscopic findings at the junction between the vascularized and avascular retina.
- Stage 1 is a faint demarcation line.
- Stage 2 is an elevated ridge.
- Stage 3 is extraretinal fibrovascular tissue.
- Stage 4 is sub-total retinal detachment.
- Stage 5 is total retinal detachment.
Plus disease[edit]
Plus disease can be present as a major complicating factor at any stage. It is characterised by:
- Significant level of vascular dilation and tortuosity observed at the posterior retinal arterioles. This reflects the increase of blood flow through the retina.[12]
- Vitreous haze and anterior chamber haze[12]
- Iris vascular engorgement[12]
- Tunica vasculosa lentis or immature blood vessels growing over the lens which also restrict the dilatation of the pupils.[12]
Prognosis[edit]
Stages 1 and 2 do not lead to blindness. However, they can progress to the more severe stages. Threshold disease is defined as disease that has a 50% likelihood of progressing to retinal detachment. Threshold disease is considered to be present when stage 3 ROP is present in either zone I or zone II, with at least 5 continuous or 8 total clock hours of disease, and the presence of plus disease.[13] Progression to stage 4 (partial retinal detachment), or to stage 5 (total retinal detachment), will result in substantial or total loss of vision for the infant.
Differential diagnosis[edit]
The most difficult aspect of the differential diagnosis may arise from the similarity of two other diseases:
- familial exudative vitreoretinopathy which is a genetic disorder that also disrupts the retinal vascularization in full-term infants.
- Persistent Fetal Vascular Syndrome also known as Persistent Hyperplastic Primary Vitreous that can cause a traction retinal detachment difficult to differentiate but typically unilateral.
Monitoring[edit]
In order to allow timely intervention, a system of monitoring is undertaken for infants at risk of developing ROP. These monitoring protocols differ geographically because the definition of high-risk is not uniform or perfectly defined. In the USA the consensus statement of experts is informed by data derived by clinical trials and published in Pediatrics 2006. They included infants with birthweights under 1500 grams or under 30 weeks gestation in most cases. The first examination should take place within the first 4 weeks of life, and regular, weekly examination is required until it is clear that the eyes are not going to develop disease needing treatment, or one or both eyes develop disease requiring treatment. Treatment should be administered within a 48 hours, as the condition can progress rapidly.
Management[edit]
Treatment[edit]
The retina (red) is detached at the top of the eye.
The silicone band (scleral buckle, blue) is placed around the eye. This brings the wall of the eye into contact with the detached retina, allowing the retina to re-attach.
- 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. Cryotherapy, an earlier technique in which regional retinal destruction was done using a probe to freeze the desired areas, has also been evaluated in multi-center clinical trials as an effective modality for prevention and treatment of ROP. 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. Further more recent trials have shown that treatment at an earlier stage of the disease gives better results.[14]
- Scleral buckling and/or vitrectomy 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.
- Intravitreal injection of bevacizumab (Avastin) has been reported as a supportive measure in aggressive posterior retinopathy of prematurity.[15]
In a 2011 clinical trial comparing bevacizumab with conventional laser therapy, intravitreal bevacizumab monotherapy showed a significant benefit for zone I but not zone II disease when used to treat infants with stage 3+ retinopathy of prematurity.[16] However, the safety of this new treatment has not yet been established in terms of ocular complications as well as systemic complications. The latter are theoretically possible, as the active ingredient of bevacizumab not only blocks the development of abnormal blood vessels in the eye but may also prevent the normal development of other tissues such as the lung and kidney.
Follow up[edit]
- Once diagnosed with ROP lifelong follow up (yearly) is mandatory.
- Immediately after lasers, for at least 2.5 months follow up at regular 1-2 weekly interval.
- All other premature infants irrespective of having ROP, yearly follow up till the age of 5 years is advisable to rule out sequelae.
Sequelae[edit]
- Refractive errors (most common)
- Squint
- Amblyopia
- Retinal detachment and blindness
- Glaucoma
History[edit]
This disease was first detected in the premature baby in 1942. A significant time in the history of the disease was between 1941–1953, when a worldwide epidemic of ROP was seen. Over 12,000 babies worldwide were affected by it. Soul musician Stevie Wonder, actor Tom Sullivan as well as jazz singer Diane Schuur are a few famous people who have the disease.
The first case of the epidemic was seen on St. Valentine's Day in 1941, when a premature baby in Boston was diagnosed. Cases were then seen all over the world and the cause was, at that point, unknown. By 1951 a clear link between incidence and affluence became clear: many cases were seen in developed countries with organized and well-funded health care. Two British scientists suggested that it was oxygen toxicity that caused the disease. Babies born prematurely in such affluent areas were treated in incubators which had artificially high levels of oxygen. Studies on rats made this cause seem more likely, but the link was eventually confirmed by a controversial study undertaken by American pediatricians. The study involved two groups of babies. Some were given the usual oxygen concentrations in their incubators, while the other group had "curtailed" oxygen levels. The latter group was shown to have a lower incidence of the disease. As a result, oxygen levels in incubators were lowered and consequently the epidemic was halted.[17]
Clinical studies[edit]
- BEAT ROP Trial: Bevacizumab (Avastin) vs Laser in ROP
- HOPE Study: High Oxygen Percentage in ROP
- STOP Trial: Supplemental Oxygen for ROP Treatment
- ETROP Trial: Early Treatment for ROP
Epidemiology[edit]
ROP prevalence varies, from 5–8% in developed countries with adequate neonatological facilities, to up to 30% in middle-income developing countries (.[18]
There is increasing evidence that ROP and blindness due to ROP are now public health problems in the middle income countries of Latin America, Eastern Europe and the more advanced economies in South East Asia and the Middle east region. In these countries ROP is often the most common cause of blindness in children.[19][20] ROP is highly likely to become an increasing problem in India, China and other countries in Asia as these countries expand the provision of services for premature infants.
There is also evidence that the population of premature infants at risk of severe ROP varies depending on the level of neonatal intensive care being provided.[19] In countries with high development indices and very low neonatal mortality rates (e.g. north America, western Europe), severe ROP is generally limited to extremely preterm infants i.e. those weighing less than 1000g at birth. At the other end of the development spectrum, countries with very low development indices and very high neonatal mortality rates (e.g. much of subSaharan Africa) ROP is rare as most premature babies do not have access to neonatal intensive care and so do not survive. Countries with moderate development indices are improving access to neonatal intensive care, and in these settings bigger, more mature babies are also at risk of severe ROP as neonatal care may be suboptimal(i.e. those weighing 1500–2000 g at birth). These findings have two main implications: firstly, much can be done in countries with moderate development indices to improve neonatal care, to reduce the risk of severe ROP in bigger babies and increase survival of extremely preterm infants, and secondly, in these settings bigger more mature babies need to be included in ROP programs and examined regularly so as to detect those babies developing ROP requiring treatment.
In 2012, the World Health Organization published data on rates of preterm birth and the number of premature babies born in different regions of the world.[21] The main findings of this report are threefold: 1. premature birth has many different causes, and prevention is challenging 2. prematurity is the commonest cause of neonatal death in many countries: 1 million infants die every year due to complications of preterm birth, and 3. the number of preterm births is currently estimated to be 15 million, and increasing.
References[edit]
- ^ "Terry Syndrome". Stedman's Medical Dictionary. Lippincott Williams & Wilkins. 2006.
- ^ Shastry, BS; Pendergast, SD; Hartzer, MK; Liu, X; Trese, MT (1997 May). "Identification of missense mutations in the Norrie disease gene associated with advanced retinopathy of prematurity.". Archives of ophthalmology 115 (5): 651–5. PMID 9152134.
- ^ Dickinson, JL; Sale, MM; Passmore, A; FitzGerald, LM; Wheatley, CM; Burdon, KP; Craig, JE; Tengtrisorn, S; Carden, SM; Maclean, H; Mackey, DA (2006 Sep-Oct). "Mutations in the NDP gene: contribution to Norrie disease, familial exudative vitreoretinopathy and retinopathy of prematurity.". Clinical & experimental ophthalmology 34 (7): 682–8. PMID 16970763.
- ^ Shastry, Barkur S (1 January 2010). "Genetic susceptibility to advanced retinopathy of prematurity (ROP)". Journal of Biomedical Science 17 (1): 69. doi:10.1186/1423-0127-17-69. PMID 20738858.
- ^ a b c Kumar, Vinay (2007). "Chapter 29: Eye, Retina and Vitreous, Retinal Vascular Disease". Robbins basic pathology (8th ed.). Philadelphia: Saunders/Elsevier. ISBN 978-1416029731.
- ^ Guyton, Arthur; Hall, John (2006). "Chapter 17: Local and Humoral Control of Blood Flow by the Tissues". In Gruliow, Rebecca. Textbook of Medical Physiology (Book
|format=requires|url=(help)) (11th ed.). Philadelphia, Pennsylvania: Elsevier Inc. p. 200. ISBN 0-7216-0240-1. - ^ Karna, P.; Muttineni, J.; Angell, L.; Karmaus, W. (2005). "Retinopathy of prematurity and risk factors: A prospective cohort study". BMC Pediatrics 5: 18. doi:10.1186/1471-2431-5-18. PMC 1175091. PMID 15985170. edit
- ^ Jefferies, AL; Canadian Paediatric Society, Fetus and Newborn Committee (1). "Retinopathy of prematurity: Recommendations for screening". Paediatrics & Child Health 15 (10): 667–0. PMC 3006218. Retrieved 9 March 2013.
- ^ Committee for the Classification of Retinopathy of Prematurity (1984 Aug). "An international classification of retinopathy of prematurity". Arch Ophthalmol. 102 (8): 1130–1134. doi:10.1001/archopht.1984.01040030908011. PMID 6547831.
- ^ Committee for the Classification of Retinopathy of Prematurity (2005 Jul). "The International Classification of Retinopathy of Prematurity revisited". Arch Ophthalmol. 123 (7): 991–999. doi:10.1001/archopht.123.7.991. PMID 16009843.
- ^ Early Treatment for Retinopathy of Prematurity Cooperative Group (2003). "Revised indications for the treatment of retinopathy of prematurity: results of the early treatment for retinopathy of prematurity randomized trial". Arch Ophthalmol. 121 (12): 1684–1696. doi:10.1001/archopht.121.12.1684. PMID 14662586.
- ^ a b c d Retinopathy of Prematurity at eMedicine
- ^ Phelps, D.L. (2001). "Retinopathy of Prematurity: History, Classification, and Pathophysiology". NeoReviews 2 (7): e153–e166. doi:10.1542/neo.2-7-e153.
- ^ Dobson, V.; Quinn, G. E.; Summers, C. G.; Hardy, R. J.; Tung, B.; Good, W. V.; Good, W. V. (2011). "Grating Visual Acuity Results in the Early Treatment for Retinopathy of Prematurity Study". Archives of Ophthalmology 129 (7): 840–846. doi:10.1001/archophthalmol.2011.143. PMID 21746974. edit
- ^ Shah PK, Narendran V, Tawansy KA, Raghuram A, Narendran K. (2007). "Intravitreal bevacizumab (Avastin) for post laser anterior segment ischemia in aggressive posterior retinopathy of prematurity". Indian journal of ophthalmology 55 (1): 75–76. doi:10.4103/0301-4738.29505. PMID 17189897.
- ^ Mintz-Hittner, HA; Kennedy, KA; Chuang, AZ; Beat-Rop Cooperative, Group (2011). "Efficacy of intravitreal bevacizumab for stage 3+ retinopathy of prematurity". The New England Journal of Medicine 364 (7): 603–15. doi:10.1056/NEJMoa1007374. PMC 3119530. PMID 21323540.
- ^ Silverman, William A. (November 1980). Retrolental fibroplasia: a modern parable. Grune & Stratton. Retrieved 21 September 2013.
- ^ Gergely, K.; Gerinec, A. (2010). "Retinopathy of prematurity--epidemics, incidence, prevalence, blindness". Bratislavske lekarske listy 111 (9): 514–517. PMID 21180268.
- ^ a b Gilbert, C.; Fielder, A.; Gordillo, L.; Quinn, G.; Semiglia, R.; Visintin, P.; Zin, A.; International No-Rop, G. (2005). "Characteristics of Infants with Severe Retinopathy of Prematurity in Countries with Low, Moderate, and High Levels of Development: Implications for Screening Programs". Pediatrics 115 (5): e518–e525. doi:10.1542/peds.2004-1180. PMID 15805336. Retrieved 9 June 2013.
- ^ Limburg, H.; Gilbert, C.; Hon, D. N.; Dung, N. C.; Hoang, T. H. (2012). "Prevalence and Causes of Blindness in Children in Vietnam". Ophthalmology 119 (2): 355–361. doi:10.1016/j.ophtha.2011.07.037. PMID 22035577. edit
- ^ "Born Too Soon: The Global Action Report on Preterm Birth". World Health Organization. 2012. Retrieved 9 June 2013.
External links[edit]
- Retinopathy of Prematurity Resource Guide from the National Eye Institute (NEI).
- Merck Manual entry on ROP
- Retinopathy of Prematurity (ROP), with animation — The Hospital for Sick Children
- Retinopathy Of The Newborn Is Due To Hypoxia Not Oxygen Toxicity
- Appelbaum, Alfred (1952 Oct). "Retrolental fibroplasia; blindness in infants of low weight at birth.". California medicine 77 (4): 259–65. PMC 1521441. PMID 13009470.
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UpToDate Contents
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- 1. 未熟児網膜症 retinopathy of prematurity
- 2. 幼児および小児における緑内障の概要 overview of glaucoma in infants and children
- 3. 白色瞳孔を有する小児に対するアプローチ approach to the child with leukocoria
- 4. Short-term complications of the preterm infant
- 5. 新生児疼痛の予防および治療 prevention and treatment of neonatal pain
English Journal
- Platelet mass index in very preterm infants: can it be used as a parameter for neonatal morbidities?
- Okur N1, Buyuktiryaki M1, Uras N1, Oncel MY1, Ertekin O1, Canpolat FE1, Oguz SS1.
- The journal of maternal-fetal & neonatal medicine : the official journal of the European Association of Perinatal Medicine, the Federation of Asia and Oceania Perinatal Societies, the International Society of Perinatal Obstetricians.J Matern Fetal Neonatal Med.2016 Oct;29(19):3218-22. doi: 10.3109/14767058.2015.1121475. Epub 2015 Dec 23.
- OBJECTIVE: Platelet mass index (PMI) is related to the platelet functionality. The aim of this study was to evaluate the correlation between PMI and the occurrence of various inflammation-related morbidities of prematurity, such as bronchopulmonary dysplasia (BPD), necrotizing enterocolitis (NEC), r
- PMID 26697923
- Antenatal corticosteroids: analytical decision model and economic analysis in a Brazilian cohort of preterm infants.
- Ogata JF1, Fonseca MC2, de Almeida MF1, Guinsburg R1.
- The journal of maternal-fetal & neonatal medicine : the official journal of the European Association of Perinatal Medicine, the Federation of Asia and Oceania Perinatal Societies, the International Society of Perinatal Obstetricians.J Matern Fetal Neonatal Med.2016 Sep;29(18):2973-9. doi: 10.3109/14767058.2015.1111331. Epub 2015 Nov 30.
- OBJECTIVE: To analyze the hospital costs and the effectiveness of antenatal corticosteroid (ACS) therapy in a cohort of Brazilian preterm infants.METHODS: Infants with gestational age (GA) 26 to 32 weeks, born between 2006 and 2009 in a tertiary university hospital and who survived hospitalization w
- PMID 26513273
Japanese Journal
- 未熟児網膜症の過去, 現在, 未来
- 日本周産期・新生児医学会雑誌 = Journal of Japan Society of Perinatal and Neonatal Medicine 41(4), 684-685, 2005-12-20
- NAID 10016939471
- ケースノート 未熟児網膜症に続発した緑内障発作の1症例
- 眼科 47(1), 78-82, 2005-01
- NAID 40006605460
Related Links
- fibroplasia [fi″bro-pla´zhah] the formation of fibrous tissue, as occurs normally in the healing of a wound or abnormally in certain tissues. adj., adj fibroplas´tic. retrolental fibroplasia retinopathy of prematurity. ret·i·nop·a·thy of pre·ma·tu ...
- Retrolental-fibroplasia definition, an unusual eye disease occurring in premature infants, usually from being given high concentrations of oxygen, which causes abnormal formation of fibrous tissue behind the lens and often results in ...
Related Pictures
★リンクテーブル★
| リンク元 | 「未熟児網膜症」「水晶体後線維増殖」 |
| 関連記事 | 「fibroplasia」 |
「未熟児網膜症」
- 英
- retinopathy of prematurity, ROP
- 同
- 未熟網膜症、水晶体後部線維増殖症, 水晶体後線維増殖症, 後水晶体線維増殖症, retrolental fibroplasia, RLF、テリー症候群, Terry syndrome
- 関
- 経皮酸素分圧監視、特発性呼吸窮迫症候群
予防
- PaO2≦80mmHg (QB.O-107)