582019

1

ihabsaadhotmailcom

Retinopathy of Prematurity

Diagnosis and management What

Can we to change outcomes

Ihab Saad Othman MD FRCS

Professor of Ophthalmology

Cairo University

Director EyeWorld Hospital

Egypt

No financial Disclosure

EOS 2019

ihabsaadhotmailcom

Retinopathy of Prematurity

bull Pathological process in

immature retinal tissue

bull Abnormal retinal

vasculogenesis

bull May progress to

proliferative bilateral

vitreoretinal disease with

potential blindness

582019

2

ihabsaadhotmailcom

Pathogenesis

bull Retinal developmentndash Retinal maturation is

complete in full term infants

ndash Nasal retinal vasculature reaches ora serrata before temporal retina

ndash In preterm development of the retina is incomplete towards the periphery

Pathogenesis of ROP

582019

3

ihabsaadhotmailcom

Background

bull Infant Mortality Rate (IMR) ndash 601000 live births NO ROP

bull IMR lt 101000 Live births ndash ROP 6-20 of childhood blindness

ndash In the United States ROP remains the second most common cause of childhood blindness

bull IMR 10-601000 Live births ndash ROP emerging as a major cause of childhood blindness

bull IMR in Egypt 20-291000 Live births (Urban vs Rural)2014

Children in Egypt 2015 Unicef 2015

Gilbert C Rahi J Eckstein M et al Retinopathy

of prematurity in middle-income countries

Lancet 199735012ndash4

Epidemiology

bull 19 of pediatric blindness worldwide

bull 66 of infants with1251g BW or less

bull 82 of infants with 1000 g BW or less

bull A disease of middle economy countries

which has passed in 3 epidemics

582019

4

Preventing blindness from prematurity in a child with 60plusmn years life expectancy is

worth all of our efforts

NO

Dr Hassan Mounir El-Sady

Prof of Financial Economics

Cairo University College of Commerce

Economics amp Burden of

Blindness in Infants in Egypt

582019

5

bull Egypt annually receives 26 million children

bull 10 to 12 of births are preterm or LBW

bull This mean that about 260000 children born underweight

bull The number of births less than 1500 grams is 78000

bull The number of births less than 1000 grams is 26000

bull This can result in visual impairment or blindness because of the abnormal growth of blood vessels in the retina leading to a higher visual loss

bull Approximately 24000 preterm children are subject to loss their vision (23 of the 78000+26000)

The Problem Setting

bull The cost for each infant to be examined = US$ 18ndash The main cost drivers were for staff making up 78 of the costs

ndash Equipment and maintenance account for 17

bull The cost for each infant to be treated is US$ 398 with 47 of the cost incurred for equipment and 45 for staff

bull Training cost per newborn was US$ 29

bull Incremental cost ndash Diagnosis and treatment for all at-risk infants US$ 80 per infant

ndash Two hospitalization daily costs (US$ 240 and US$ 389) the length of stay

Total Cost = 18 + 398 + 80 + 240 +389 = $1125

bull The Total Cost is Expected to be reduced to almost $600 or 10000 Egyptian Pound per infant subject to high risk of blindness

Cost of Preventable Blindness Per

Infant ndash Global Standards (Brazil)

582019

6

bull Assume thatndash Monthly Extra Cost of a Blind Person between 2500 LE and 5000

LE

ndash Egyptian Average Age = 69 years

ndash Lifetime Extra Cost = 2500 69 12 = 2070000 LE

Or

Lifetime Extra Cost = 5000 69 12 = 4140000 LE

bull The Future Value (FV) of Extra Cost per Blind Person 6 Interest Ratendash FV = 30579150 LE (Using 2500 LE per Month)

ndash FV = 61158300 LE (Using 5000 LE per Month)

bull The Present Value (PV) of Extra Cost per Blind Person 6 Interest Ratendash PV = 491956 LE (Using 2500 LE per Month)

ndash PV = 983912 LE (Using 5000 LE per Month)

Lifetime Extra Cost Per Blind Infant

bull Assume that

ndash The Blind Person can be employed when he is 25 years old and retired when he is 55 years old

ndash Heshe can receive 5000 LE per Month

ndash Lifetime lost Income = 5000 35 12 = 2100000 LE

bull The Future Value (FV) of the Lost Income per Blind Person 12 annual inflation

ndash FV = 94179015 LE

bull The Present Value (PV) of Extra Cost per Blind Person 6 Interest Rate

ndash PV = 196395 LE

Lifetime Lost Income Per Blind Infant

582019

7

bull In 69 years from the birthdate Future Value (FV)

ndash FV = 30579150 + 94179015 = 124758165LE

(Using 2500 LE per Month)

ndash FV = 61158300 + 94179015 = 155337315 LE

(Using 5000 LE per Month)

bull In Today Value Present Value (PV)

ndash PV = 491956 + 196395 = 688351 LE (Using 2500

LE per Month)

ndash PV = 983912 + 196395 = 1180307 LE (Using

5000 LE per Month)

Total Lifetime Extra Cost and Lost

Income Per Blind Infant

bull Return On Investment (ROI)

ndash ROI = 680 (Using 2500 LE per Month)

ndash ROI = 1800 (Using 5000 LE per Month)

bull Internal Rate of Return (IRR)

ndash IRR = 125 (Using 2500 LE per Month)

ndash PV = 150 (Using 5000 LE per Month)

Return on Investment (ROI) and

IRR of Preventable Blindness Per

Infant

582019

8

What a Great Investment in

Preventable Blindness helliphellip

1st Epidemic

1940s -1950s

High Economy

Basic NICUs

Poor Screening

Liberal Oxygen

2nd Epidemic

1960s -1970s

High Economy

Better NICUs

Improved

Screening

Restricted Oxygen

The 3 Epidemics of ROP

3rd Epidemic

1980s ndashPresent

Day

Middle Economy

Improved NICUs

Poor Screening

582019

9

ihabsaadhotmailcom

Screening Target population

bull Birth weight lt 1500 gm

bull Gestational age lt 32 weeks

bull Incubator and receiving excessive oxygen

bull Comorbidities

Intraventricular Hemorrhage

Neonatal Sepsis

bull Others

bull

ihabsaadhotmailcom

Target population

bull Birth weight 1500 -2000 gms

bull Gestational age gt 32 weeks

bull Unstable clinical course (at discretion of

neonatologists)

582019

10

ESTABLISHING THE ROP PROJECT

Coordinated effort between

bull Ophthalmologists

bull Pediatricians

bull Parents

bull Nursing Staff

bull Social Workers

bull Administration

Distribution of ResponsibilitiesPediatrics

1 Primary Prevention

2 Notification

to ophthalmologist

baby meets

ldquoscreening criteriardquo

582019

11

Distribution of ResponsibilitiesOphthalmology

1 Who will do the screeningtrained residents FellowsConsultants Retina Pediatrics

2 Who will do the treatment3 Local regional will you need to

transport baby

ihabsaadhotmailcom

How do we Screen Premature

Babies

582019

12

ihabsaadhotmailcom

In Incubators Outreach Program

ndash Mydriaticsbull Phenylephrine 25

bull Cyclopentolate 01 (cyclomydril)

bull Topical anesthesia

ndash How much

bull 1-2 drops could maintain mydriasis for 120 min

bull Examine at 90 min

ndash Complications of mydriatics

bull Oculocardiac reactions (resuscitation)

bull Corneal clouding

bull Transient cataract

bull Postpartum intraretinal hemorrhage

bull Poor visualization persistant tunica vasculosa lentis

bull Cyclopentolate 1 rarrvomiting or ileus

Vicente GV et al JAAPOS Aug 2013

ihabsaadhotmailcom

Who Does the Screening

Expert Ophthalmologist

582019

2

ihabsaadhotmailcom

Pathogenesis

bull Retinal developmentndash Retinal maturation is

complete in full term infants

ndash Nasal retinal vasculature reaches ora serrata before temporal retina

ndash In preterm development of the retina is incomplete towards the periphery

Pathogenesis of ROP

582019

3

ihabsaadhotmailcom

Background

bull Infant Mortality Rate (IMR) ndash 601000 live births NO ROP

bull IMR lt 101000 Live births ndash ROP 6-20 of childhood blindness

ndash In the United States ROP remains the second most common cause of childhood blindness

bull IMR 10-601000 Live births ndash ROP emerging as a major cause of childhood blindness

bull IMR in Egypt 20-291000 Live births (Urban vs Rural)2014

Children in Egypt 2015 Unicef 2015

Gilbert C Rahi J Eckstein M et al Retinopathy

of prematurity in middle-income countries

Lancet 199735012ndash4

Epidemiology

bull 19 of pediatric blindness worldwide

bull 66 of infants with1251g BW or less

bull 82 of infants with 1000 g BW or less

bull A disease of middle economy countries

which has passed in 3 epidemics

582019

4

Preventing blindness from prematurity in a child with 60plusmn years life expectancy is

worth all of our efforts

NO

Dr Hassan Mounir El-Sady

Prof of Financial Economics

Cairo University College of Commerce

Economics amp Burden of

Blindness in Infants in Egypt

582019

5

bull Egypt annually receives 26 million children

bull 10 to 12 of births are preterm or LBW

bull This mean that about 260000 children born underweight

bull The number of births less than 1500 grams is 78000

bull The number of births less than 1000 grams is 26000

bull This can result in visual impairment or blindness because of the abnormal growth of blood vessels in the retina leading to a higher visual loss

bull Approximately 24000 preterm children are subject to loss their vision (23 of the 78000+26000)

The Problem Setting

bull The cost for each infant to be examined = US$ 18ndash The main cost drivers were for staff making up 78 of the costs

ndash Equipment and maintenance account for 17

bull The cost for each infant to be treated is US$ 398 with 47 of the cost incurred for equipment and 45 for staff

bull Training cost per newborn was US$ 29

bull Incremental cost ndash Diagnosis and treatment for all at-risk infants US$ 80 per infant

ndash Two hospitalization daily costs (US$ 240 and US$ 389) the length of stay

Total Cost = 18 + 398 + 80 + 240 +389 = $1125

bull The Total Cost is Expected to be reduced to almost $600 or 10000 Egyptian Pound per infant subject to high risk of blindness

Cost of Preventable Blindness Per

Infant ndash Global Standards (Brazil)

582019

6

bull Assume thatndash Monthly Extra Cost of a Blind Person between 2500 LE and 5000

LE

ndash Egyptian Average Age = 69 years

ndash Lifetime Extra Cost = 2500 69 12 = 2070000 LE

Or

Lifetime Extra Cost = 5000 69 12 = 4140000 LE

bull The Future Value (FV) of Extra Cost per Blind Person 6 Interest Ratendash FV = 30579150 LE (Using 2500 LE per Month)

ndash FV = 61158300 LE (Using 5000 LE per Month)

bull The Present Value (PV) of Extra Cost per Blind Person 6 Interest Ratendash PV = 491956 LE (Using 2500 LE per Month)

ndash PV = 983912 LE (Using 5000 LE per Month)

Lifetime Extra Cost Per Blind Infant

bull Assume that

ndash The Blind Person can be employed when he is 25 years old and retired when he is 55 years old

ndash Heshe can receive 5000 LE per Month

ndash Lifetime lost Income = 5000 35 12 = 2100000 LE

bull The Future Value (FV) of the Lost Income per Blind Person 12 annual inflation

ndash FV = 94179015 LE

bull The Present Value (PV) of Extra Cost per Blind Person 6 Interest Rate

ndash PV = 196395 LE

Lifetime Lost Income Per Blind Infant

582019

7

bull In 69 years from the birthdate Future Value (FV)

ndash FV = 30579150 + 94179015 = 124758165LE

(Using 2500 LE per Month)

ndash FV = 61158300 + 94179015 = 155337315 LE

(Using 5000 LE per Month)

bull In Today Value Present Value (PV)

ndash PV = 491956 + 196395 = 688351 LE (Using 2500

LE per Month)

ndash PV = 983912 + 196395 = 1180307 LE (Using

5000 LE per Month)

Total Lifetime Extra Cost and Lost

Income Per Blind Infant

bull Return On Investment (ROI)

ndash ROI = 680 (Using 2500 LE per Month)

ndash ROI = 1800 (Using 5000 LE per Month)

bull Internal Rate of Return (IRR)

ndash IRR = 125 (Using 2500 LE per Month)

ndash PV = 150 (Using 5000 LE per Month)

Return on Investment (ROI) and

IRR of Preventable Blindness Per

Infant

582019

8

What a Great Investment in

Preventable Blindness helliphellip

1st Epidemic

1940s -1950s

High Economy

Basic NICUs

Poor Screening

Liberal Oxygen

2nd Epidemic

1960s -1970s

High Economy

Better NICUs

Improved

Screening

Restricted Oxygen

The 3 Epidemics of ROP

3rd Epidemic

1980s ndashPresent

Day

Middle Economy

Improved NICUs

Poor Screening

582019

9

ihabsaadhotmailcom

Screening Target population

bull Birth weight lt 1500 gm

bull Gestational age lt 32 weeks

bull Incubator and receiving excessive oxygen

bull Comorbidities

Intraventricular Hemorrhage

Neonatal Sepsis

bull Others

bull

ihabsaadhotmailcom

Target population

bull Birth weight 1500 -2000 gms

bull Gestational age gt 32 weeks

bull Unstable clinical course (at discretion of

neonatologists)

582019

10

ESTABLISHING THE ROP PROJECT

Coordinated effort between

bull Ophthalmologists

bull Pediatricians

bull Parents

bull Nursing Staff

bull Social Workers

bull Administration

Distribution of ResponsibilitiesPediatrics

1 Primary Prevention

2 Notification

to ophthalmologist

baby meets

ldquoscreening criteriardquo

582019

11

Distribution of ResponsibilitiesOphthalmology

1 Who will do the screeningtrained residents FellowsConsultants Retina Pediatrics

2 Who will do the treatment3 Local regional will you need to

transport baby

ihabsaadhotmailcom

How do we Screen Premature

Babies

582019

12

ihabsaadhotmailcom

In Incubators Outreach Program

ndash Mydriaticsbull Phenylephrine 25

bull Cyclopentolate 01 (cyclomydril)

bull Topical anesthesia

ndash How much

bull 1-2 drops could maintain mydriasis for 120 min

bull Examine at 90 min

ndash Complications of mydriatics

bull Oculocardiac reactions (resuscitation)

bull Corneal clouding

bull Transient cataract

bull Postpartum intraretinal hemorrhage

bull Poor visualization persistant tunica vasculosa lentis

bull Cyclopentolate 1 rarrvomiting or ileus

Vicente GV et al JAAPOS Aug 2013

ihabsaadhotmailcom

Who Does the Screening

Expert Ophthalmologist

582019

3

ihabsaadhotmailcom

Background

bull Infant Mortality Rate (IMR) ndash 601000 live births NO ROP

bull IMR lt 101000 Live births ndash ROP 6-20 of childhood blindness

ndash In the United States ROP remains the second most common cause of childhood blindness

bull IMR 10-601000 Live births ndash ROP emerging as a major cause of childhood blindness

bull IMR in Egypt 20-291000 Live births (Urban vs Rural)2014

Children in Egypt 2015 Unicef 2015

Gilbert C Rahi J Eckstein M et al Retinopathy

of prematurity in middle-income countries

Lancet 199735012ndash4

Epidemiology

bull 19 of pediatric blindness worldwide

bull 66 of infants with1251g BW or less

bull 82 of infants with 1000 g BW or less

bull A disease of middle economy countries

which has passed in 3 epidemics

582019

4

Preventing blindness from prematurity in a child with 60plusmn years life expectancy is

worth all of our efforts

NO

Dr Hassan Mounir El-Sady

Prof of Financial Economics

Cairo University College of Commerce

Economics amp Burden of

Blindness in Infants in Egypt

582019

5

bull Egypt annually receives 26 million children

bull 10 to 12 of births are preterm or LBW

bull This mean that about 260000 children born underweight

bull The number of births less than 1500 grams is 78000

bull The number of births less than 1000 grams is 26000

bull This can result in visual impairment or blindness because of the abnormal growth of blood vessels in the retina leading to a higher visual loss

bull Approximately 24000 preterm children are subject to loss their vision (23 of the 78000+26000)

The Problem Setting

bull The cost for each infant to be examined = US$ 18ndash The main cost drivers were for staff making up 78 of the costs

ndash Equipment and maintenance account for 17

bull The cost for each infant to be treated is US$ 398 with 47 of the cost incurred for equipment and 45 for staff

bull Training cost per newborn was US$ 29

bull Incremental cost ndash Diagnosis and treatment for all at-risk infants US$ 80 per infant

ndash Two hospitalization daily costs (US$ 240 and US$ 389) the length of stay

Total Cost = 18 + 398 + 80 + 240 +389 = $1125

bull The Total Cost is Expected to be reduced to almost $600 or 10000 Egyptian Pound per infant subject to high risk of blindness

Cost of Preventable Blindness Per

Infant ndash Global Standards (Brazil)

582019

6

bull Assume thatndash Monthly Extra Cost of a Blind Person between 2500 LE and 5000

LE

ndash Egyptian Average Age = 69 years

ndash Lifetime Extra Cost = 2500 69 12 = 2070000 LE

Or

Lifetime Extra Cost = 5000 69 12 = 4140000 LE

bull The Future Value (FV) of Extra Cost per Blind Person 6 Interest Ratendash FV = 30579150 LE (Using 2500 LE per Month)

ndash FV = 61158300 LE (Using 5000 LE per Month)

bull The Present Value (PV) of Extra Cost per Blind Person 6 Interest Ratendash PV = 491956 LE (Using 2500 LE per Month)

ndash PV = 983912 LE (Using 5000 LE per Month)

Lifetime Extra Cost Per Blind Infant

bull Assume that

ndash The Blind Person can be employed when he is 25 years old and retired when he is 55 years old

ndash Heshe can receive 5000 LE per Month

ndash Lifetime lost Income = 5000 35 12 = 2100000 LE

bull The Future Value (FV) of the Lost Income per Blind Person 12 annual inflation

ndash FV = 94179015 LE

bull The Present Value (PV) of Extra Cost per Blind Person 6 Interest Rate

ndash PV = 196395 LE

Lifetime Lost Income Per Blind Infant

582019

7

bull In 69 years from the birthdate Future Value (FV)

ndash FV = 30579150 + 94179015 = 124758165LE

(Using 2500 LE per Month)

ndash FV = 61158300 + 94179015 = 155337315 LE

(Using 5000 LE per Month)

bull In Today Value Present Value (PV)

ndash PV = 491956 + 196395 = 688351 LE (Using 2500

LE per Month)

ndash PV = 983912 + 196395 = 1180307 LE (Using

5000 LE per Month)

Total Lifetime Extra Cost and Lost

Income Per Blind Infant

bull Return On Investment (ROI)

ndash ROI = 680 (Using 2500 LE per Month)

ndash ROI = 1800 (Using 5000 LE per Month)

bull Internal Rate of Return (IRR)

ndash IRR = 125 (Using 2500 LE per Month)

ndash PV = 150 (Using 5000 LE per Month)

Return on Investment (ROI) and

IRR of Preventable Blindness Per

Infant

582019

8

What a Great Investment in

Preventable Blindness helliphellip

1st Epidemic

1940s -1950s

High Economy

Basic NICUs

Poor Screening

Liberal Oxygen

2nd Epidemic

1960s -1970s

High Economy

Better NICUs

Improved

Screening

Restricted Oxygen

The 3 Epidemics of ROP

3rd Epidemic

1980s ndashPresent

Day

Middle Economy

Improved NICUs

Poor Screening

582019

9

ihabsaadhotmailcom

Screening Target population

bull Birth weight lt 1500 gm

bull Gestational age lt 32 weeks

bull Incubator and receiving excessive oxygen

bull Comorbidities

Intraventricular Hemorrhage

Neonatal Sepsis

bull Others

bull

ihabsaadhotmailcom

Target population

bull Birth weight 1500 -2000 gms

bull Gestational age gt 32 weeks

bull Unstable clinical course (at discretion of

neonatologists)

582019

10

ESTABLISHING THE ROP PROJECT

Coordinated effort between

bull Ophthalmologists

bull Pediatricians

bull Parents

bull Nursing Staff

bull Social Workers

bull Administration

Distribution of ResponsibilitiesPediatrics

1 Primary Prevention

2 Notification

to ophthalmologist

baby meets

ldquoscreening criteriardquo

582019

11

Distribution of ResponsibilitiesOphthalmology

1 Who will do the screeningtrained residents FellowsConsultants Retina Pediatrics

2 Who will do the treatment3 Local regional will you need to

transport baby

ihabsaadhotmailcom

How do we Screen Premature

Babies

582019

12

ihabsaadhotmailcom

In Incubators Outreach Program

ndash Mydriaticsbull Phenylephrine 25

bull Cyclopentolate 01 (cyclomydril)

bull Topical anesthesia

ndash How much

bull 1-2 drops could maintain mydriasis for 120 min

bull Examine at 90 min

ndash Complications of mydriatics

bull Oculocardiac reactions (resuscitation)

bull Corneal clouding

bull Transient cataract

bull Postpartum intraretinal hemorrhage

bull Poor visualization persistant tunica vasculosa lentis

bull Cyclopentolate 1 rarrvomiting or ileus

Vicente GV et al JAAPOS Aug 2013

ihabsaadhotmailcom

Who Does the Screening

Expert Ophthalmologist

582019

4

Preventing blindness from prematurity in a child with 60plusmn years life expectancy is

worth all of our efforts

NO

Dr Hassan Mounir El-Sady

Prof of Financial Economics

Cairo University College of Commerce

Economics amp Burden of

Blindness in Infants in Egypt

582019

5

bull Egypt annually receives 26 million children

bull 10 to 12 of births are preterm or LBW

bull This mean that about 260000 children born underweight

bull The number of births less than 1500 grams is 78000

bull The number of births less than 1000 grams is 26000

bull This can result in visual impairment or blindness because of the abnormal growth of blood vessels in the retina leading to a higher visual loss

bull Approximately 24000 preterm children are subject to loss their vision (23 of the 78000+26000)

The Problem Setting

bull The cost for each infant to be examined = US$ 18ndash The main cost drivers were for staff making up 78 of the costs

ndash Equipment and maintenance account for 17

bull The cost for each infant to be treated is US$ 398 with 47 of the cost incurred for equipment and 45 for staff

bull Training cost per newborn was US$ 29

bull Incremental cost ndash Diagnosis and treatment for all at-risk infants US$ 80 per infant

ndash Two hospitalization daily costs (US$ 240 and US$ 389) the length of stay

Total Cost = 18 + 398 + 80 + 240 +389 = $1125

bull The Total Cost is Expected to be reduced to almost $600 or 10000 Egyptian Pound per infant subject to high risk of blindness

Cost of Preventable Blindness Per

Infant ndash Global Standards (Brazil)

582019

6

bull Assume thatndash Monthly Extra Cost of a Blind Person between 2500 LE and 5000

LE

ndash Egyptian Average Age = 69 years

ndash Lifetime Extra Cost = 2500 69 12 = 2070000 LE

Or

Lifetime Extra Cost = 5000 69 12 = 4140000 LE

bull The Future Value (FV) of Extra Cost per Blind Person 6 Interest Ratendash FV = 30579150 LE (Using 2500 LE per Month)

ndash FV = 61158300 LE (Using 5000 LE per Month)

bull The Present Value (PV) of Extra Cost per Blind Person 6 Interest Ratendash PV = 491956 LE (Using 2500 LE per Month)

ndash PV = 983912 LE (Using 5000 LE per Month)

Lifetime Extra Cost Per Blind Infant

bull Assume that

ndash The Blind Person can be employed when he is 25 years old and retired when he is 55 years old

ndash Heshe can receive 5000 LE per Month

ndash Lifetime lost Income = 5000 35 12 = 2100000 LE

bull The Future Value (FV) of the Lost Income per Blind Person 12 annual inflation

ndash FV = 94179015 LE

bull The Present Value (PV) of Extra Cost per Blind Person 6 Interest Rate

ndash PV = 196395 LE

Lifetime Lost Income Per Blind Infant

582019

7

bull In 69 years from the birthdate Future Value (FV)

ndash FV = 30579150 + 94179015 = 124758165LE

(Using 2500 LE per Month)

ndash FV = 61158300 + 94179015 = 155337315 LE

(Using 5000 LE per Month)

bull In Today Value Present Value (PV)

ndash PV = 491956 + 196395 = 688351 LE (Using 2500

LE per Month)

ndash PV = 983912 + 196395 = 1180307 LE (Using

5000 LE per Month)

Total Lifetime Extra Cost and Lost

Income Per Blind Infant

bull Return On Investment (ROI)

ndash ROI = 680 (Using 2500 LE per Month)

ndash ROI = 1800 (Using 5000 LE per Month)

bull Internal Rate of Return (IRR)

ndash IRR = 125 (Using 2500 LE per Month)

ndash PV = 150 (Using 5000 LE per Month)

Return on Investment (ROI) and

IRR of Preventable Blindness Per

Infant

582019

8

What a Great Investment in

Preventable Blindness helliphellip

1st Epidemic

1940s -1950s

High Economy

Basic NICUs

Poor Screening

Liberal Oxygen

2nd Epidemic

1960s -1970s

High Economy

Better NICUs

Improved

Screening

Restricted Oxygen

The 3 Epidemics of ROP

3rd Epidemic

1980s ndashPresent

Day

Middle Economy

Improved NICUs

Poor Screening

582019

9

ihabsaadhotmailcom

Screening Target population

bull Birth weight lt 1500 gm

bull Gestational age lt 32 weeks

bull Incubator and receiving excessive oxygen

bull Comorbidities

Intraventricular Hemorrhage

Neonatal Sepsis

bull Others

bull

ihabsaadhotmailcom

Target population

bull Birth weight 1500 -2000 gms

bull Gestational age gt 32 weeks

bull Unstable clinical course (at discretion of

neonatologists)

582019

10

ESTABLISHING THE ROP PROJECT

Coordinated effort between

bull Ophthalmologists

bull Pediatricians

bull Parents

bull Nursing Staff

bull Social Workers

bull Administration

Distribution of ResponsibilitiesPediatrics

1 Primary Prevention

2 Notification

to ophthalmologist

baby meets

ldquoscreening criteriardquo

582019

11

Distribution of ResponsibilitiesOphthalmology

1 Who will do the screeningtrained residents FellowsConsultants Retina Pediatrics

2 Who will do the treatment3 Local regional will you need to

transport baby

ihabsaadhotmailcom

How do we Screen Premature

Babies

582019

12

ihabsaadhotmailcom

In Incubators Outreach Program

ndash Mydriaticsbull Phenylephrine 25

bull Cyclopentolate 01 (cyclomydril)

bull Topical anesthesia

ndash How much

bull 1-2 drops could maintain mydriasis for 120 min

bull Examine at 90 min

ndash Complications of mydriatics

bull Oculocardiac reactions (resuscitation)

bull Corneal clouding

bull Transient cataract

bull Postpartum intraretinal hemorrhage

bull Poor visualization persistant tunica vasculosa lentis

bull Cyclopentolate 1 rarrvomiting or ileus

Vicente GV et al JAAPOS Aug 2013

ihabsaadhotmailcom

Who Does the Screening

Expert Ophthalmologist

582019

5

bull Egypt annually receives 26 million children

bull 10 to 12 of births are preterm or LBW

bull This mean that about 260000 children born underweight

bull The number of births less than 1500 grams is 78000

bull The number of births less than 1000 grams is 26000

bull This can result in visual impairment or blindness because of the abnormal growth of blood vessels in the retina leading to a higher visual loss

bull Approximately 24000 preterm children are subject to loss their vision (23 of the 78000+26000)

The Problem Setting

bull The cost for each infant to be examined = US$ 18ndash The main cost drivers were for staff making up 78 of the costs

ndash Equipment and maintenance account for 17

bull The cost for each infant to be treated is US$ 398 with 47 of the cost incurred for equipment and 45 for staff

bull Training cost per newborn was US$ 29

bull Incremental cost ndash Diagnosis and treatment for all at-risk infants US$ 80 per infant

ndash Two hospitalization daily costs (US$ 240 and US$ 389) the length of stay

Total Cost = 18 + 398 + 80 + 240 +389 = $1125

bull The Total Cost is Expected to be reduced to almost $600 or 10000 Egyptian Pound per infant subject to high risk of blindness

Cost of Preventable Blindness Per

Infant ndash Global Standards (Brazil)

582019

6

bull Assume thatndash Monthly Extra Cost of a Blind Person between 2500 LE and 5000

LE

ndash Egyptian Average Age = 69 years

ndash Lifetime Extra Cost = 2500 69 12 = 2070000 LE

Or

Lifetime Extra Cost = 5000 69 12 = 4140000 LE

bull The Future Value (FV) of Extra Cost per Blind Person 6 Interest Ratendash FV = 30579150 LE (Using 2500 LE per Month)

ndash FV = 61158300 LE (Using 5000 LE per Month)

bull The Present Value (PV) of Extra Cost per Blind Person 6 Interest Ratendash PV = 491956 LE (Using 2500 LE per Month)

ndash PV = 983912 LE (Using 5000 LE per Month)

Lifetime Extra Cost Per Blind Infant

bull Assume that

ndash The Blind Person can be employed when he is 25 years old and retired when he is 55 years old

ndash Heshe can receive 5000 LE per Month

ndash Lifetime lost Income = 5000 35 12 = 2100000 LE

bull The Future Value (FV) of the Lost Income per Blind Person 12 annual inflation

ndash FV = 94179015 LE

bull The Present Value (PV) of Extra Cost per Blind Person 6 Interest Rate

ndash PV = 196395 LE

Lifetime Lost Income Per Blind Infant

582019

7

bull In 69 years from the birthdate Future Value (FV)

ndash FV = 30579150 + 94179015 = 124758165LE

(Using 2500 LE per Month)

ndash FV = 61158300 + 94179015 = 155337315 LE

(Using 5000 LE per Month)

bull In Today Value Present Value (PV)

ndash PV = 491956 + 196395 = 688351 LE (Using 2500

LE per Month)

ndash PV = 983912 + 196395 = 1180307 LE (Using

5000 LE per Month)

Total Lifetime Extra Cost and Lost

Income Per Blind Infant

bull Return On Investment (ROI)

ndash ROI = 680 (Using 2500 LE per Month)

ndash ROI = 1800 (Using 5000 LE per Month)

bull Internal Rate of Return (IRR)

ndash IRR = 125 (Using 2500 LE per Month)

ndash PV = 150 (Using 5000 LE per Month)

Return on Investment (ROI) and

IRR of Preventable Blindness Per

Infant

582019

8

What a Great Investment in

Preventable Blindness helliphellip

1st Epidemic

1940s -1950s

High Economy

Basic NICUs

Poor Screening

Liberal Oxygen

2nd Epidemic

1960s -1970s

High Economy

Better NICUs

Improved

Screening

Restricted Oxygen

The 3 Epidemics of ROP

3rd Epidemic

1980s ndashPresent

Day

Middle Economy

Improved NICUs

Poor Screening

582019

9

ihabsaadhotmailcom

Screening Target population

bull Birth weight lt 1500 gm

bull Gestational age lt 32 weeks

bull Incubator and receiving excessive oxygen

bull Comorbidities

Intraventricular Hemorrhage

Neonatal Sepsis

bull Others

bull

ihabsaadhotmailcom

Target population

bull Birth weight 1500 -2000 gms

bull Gestational age gt 32 weeks

bull Unstable clinical course (at discretion of

neonatologists)

582019

10

ESTABLISHING THE ROP PROJECT

Coordinated effort between

bull Ophthalmologists

bull Pediatricians

bull Parents

bull Nursing Staff

bull Social Workers

bull Administration

Distribution of ResponsibilitiesPediatrics

1 Primary Prevention

2 Notification

to ophthalmologist

baby meets

ldquoscreening criteriardquo

582019

11

Distribution of ResponsibilitiesOphthalmology

1 Who will do the screeningtrained residents FellowsConsultants Retina Pediatrics

2 Who will do the treatment3 Local regional will you need to

transport baby

ihabsaadhotmailcom

How do we Screen Premature

Babies

582019

12

ihabsaadhotmailcom

In Incubators Outreach Program

ndash Mydriaticsbull Phenylephrine 25

bull Cyclopentolate 01 (cyclomydril)

bull Topical anesthesia

ndash How much

bull 1-2 drops could maintain mydriasis for 120 min

bull Examine at 90 min

ndash Complications of mydriatics

bull Oculocardiac reactions (resuscitation)

bull Corneal clouding

bull Transient cataract

bull Postpartum intraretinal hemorrhage

bull Poor visualization persistant tunica vasculosa lentis

bull Cyclopentolate 1 rarrvomiting or ileus

Vicente GV et al JAAPOS Aug 2013

ihabsaadhotmailcom

Who Does the Screening

Expert Ophthalmologist

582019

6

bull Assume thatndash Monthly Extra Cost of a Blind Person between 2500 LE and 5000

LE

ndash Egyptian Average Age = 69 years

ndash Lifetime Extra Cost = 2500 69 12 = 2070000 LE

Or

Lifetime Extra Cost = 5000 69 12 = 4140000 LE

bull The Future Value (FV) of Extra Cost per Blind Person 6 Interest Ratendash FV = 30579150 LE (Using 2500 LE per Month)

ndash FV = 61158300 LE (Using 5000 LE per Month)

bull The Present Value (PV) of Extra Cost per Blind Person 6 Interest Ratendash PV = 491956 LE (Using 2500 LE per Month)

ndash PV = 983912 LE (Using 5000 LE per Month)

Lifetime Extra Cost Per Blind Infant

bull Assume that

ndash The Blind Person can be employed when he is 25 years old and retired when he is 55 years old

ndash Heshe can receive 5000 LE per Month

ndash Lifetime lost Income = 5000 35 12 = 2100000 LE

bull The Future Value (FV) of the Lost Income per Blind Person 12 annual inflation

ndash FV = 94179015 LE

bull The Present Value (PV) of Extra Cost per Blind Person 6 Interest Rate

ndash PV = 196395 LE

Lifetime Lost Income Per Blind Infant

582019

7

bull In 69 years from the birthdate Future Value (FV)

ndash FV = 30579150 + 94179015 = 124758165LE

(Using 2500 LE per Month)

ndash FV = 61158300 + 94179015 = 155337315 LE

(Using 5000 LE per Month)

bull In Today Value Present Value (PV)

ndash PV = 491956 + 196395 = 688351 LE (Using 2500

LE per Month)

ndash PV = 983912 + 196395 = 1180307 LE (Using

5000 LE per Month)

Total Lifetime Extra Cost and Lost

Income Per Blind Infant

bull Return On Investment (ROI)

ndash ROI = 680 (Using 2500 LE per Month)

ndash ROI = 1800 (Using 5000 LE per Month)

bull Internal Rate of Return (IRR)

ndash IRR = 125 (Using 2500 LE per Month)

ndash PV = 150 (Using 5000 LE per Month)

Return on Investment (ROI) and

IRR of Preventable Blindness Per

Infant

582019

8

What a Great Investment in

Preventable Blindness helliphellip

1st Epidemic

1940s -1950s

High Economy

Basic NICUs

Poor Screening

Liberal Oxygen

2nd Epidemic

1960s -1970s

High Economy

Better NICUs

Improved

Screening

Restricted Oxygen

The 3 Epidemics of ROP

3rd Epidemic

1980s ndashPresent

Day

Middle Economy

Improved NICUs

Poor Screening

582019

9

ihabsaadhotmailcom

Screening Target population

bull Birth weight lt 1500 gm

bull Gestational age lt 32 weeks

bull Incubator and receiving excessive oxygen

bull Comorbidities

Intraventricular Hemorrhage

Neonatal Sepsis

bull Others

bull

ihabsaadhotmailcom

Target population

bull Birth weight 1500 -2000 gms

bull Gestational age gt 32 weeks

bull Unstable clinical course (at discretion of

neonatologists)

582019

10

ESTABLISHING THE ROP PROJECT

Coordinated effort between

bull Ophthalmologists

bull Pediatricians

bull Parents

bull Nursing Staff

bull Social Workers

bull Administration

Distribution of ResponsibilitiesPediatrics

1 Primary Prevention

2 Notification

to ophthalmologist

baby meets

ldquoscreening criteriardquo

582019

11

Distribution of ResponsibilitiesOphthalmology

1 Who will do the screeningtrained residents FellowsConsultants Retina Pediatrics

2 Who will do the treatment3 Local regional will you need to

transport baby

ihabsaadhotmailcom

How do we Screen Premature

Babies

582019

12

ihabsaadhotmailcom

In Incubators Outreach Program

ndash Mydriaticsbull Phenylephrine 25

bull Cyclopentolate 01 (cyclomydril)

bull Topical anesthesia

ndash How much

bull 1-2 drops could maintain mydriasis for 120 min

bull Examine at 90 min

ndash Complications of mydriatics

bull Oculocardiac reactions (resuscitation)

bull Corneal clouding

bull Transient cataract

bull Postpartum intraretinal hemorrhage

bull Poor visualization persistant tunica vasculosa lentis

bull Cyclopentolate 1 rarrvomiting or ileus

Vicente GV et al JAAPOS Aug 2013

ihabsaadhotmailcom

Who Does the Screening

Expert Ophthalmologist

582019

7

bull In 69 years from the birthdate Future Value (FV)

ndash FV = 30579150 + 94179015 = 124758165LE

(Using 2500 LE per Month)

ndash FV = 61158300 + 94179015 = 155337315 LE

(Using 5000 LE per Month)

bull In Today Value Present Value (PV)

ndash PV = 491956 + 196395 = 688351 LE (Using 2500

LE per Month)

ndash PV = 983912 + 196395 = 1180307 LE (Using

5000 LE per Month)

Total Lifetime Extra Cost and Lost

Income Per Blind Infant

bull Return On Investment (ROI)

ndash ROI = 680 (Using 2500 LE per Month)

ndash ROI = 1800 (Using 5000 LE per Month)

bull Internal Rate of Return (IRR)

ndash IRR = 125 (Using 2500 LE per Month)

ndash PV = 150 (Using 5000 LE per Month)

Return on Investment (ROI) and

IRR of Preventable Blindness Per

Infant

582019

8

What a Great Investment in

Preventable Blindness helliphellip

1st Epidemic

1940s -1950s

High Economy

Basic NICUs

Poor Screening

Liberal Oxygen

2nd Epidemic

1960s -1970s

High Economy

Better NICUs

Improved

Screening

Restricted Oxygen

The 3 Epidemics of ROP

3rd Epidemic

1980s ndashPresent

Day

Middle Economy

Improved NICUs

Poor Screening

582019

9

ihabsaadhotmailcom

Screening Target population

bull Birth weight lt 1500 gm

bull Gestational age lt 32 weeks

bull Incubator and receiving excessive oxygen

bull Comorbidities

Intraventricular Hemorrhage

Neonatal Sepsis

bull Others

bull

ihabsaadhotmailcom

Target population

bull Birth weight 1500 -2000 gms

bull Gestational age gt 32 weeks

bull Unstable clinical course (at discretion of

neonatologists)

582019

10

ESTABLISHING THE ROP PROJECT

Coordinated effort between

bull Ophthalmologists

bull Pediatricians

bull Parents

bull Nursing Staff

bull Social Workers

bull Administration

Distribution of ResponsibilitiesPediatrics

1 Primary Prevention

2 Notification

to ophthalmologist

baby meets

ldquoscreening criteriardquo

582019

11

Distribution of ResponsibilitiesOphthalmology

1 Who will do the screeningtrained residents FellowsConsultants Retina Pediatrics

2 Who will do the treatment3 Local regional will you need to

transport baby

ihabsaadhotmailcom

How do we Screen Premature

Babies

582019

12

ihabsaadhotmailcom

In Incubators Outreach Program

ndash Mydriaticsbull Phenylephrine 25

bull Cyclopentolate 01 (cyclomydril)

bull Topical anesthesia

ndash How much

bull 1-2 drops could maintain mydriasis for 120 min

bull Examine at 90 min

ndash Complications of mydriatics

bull Oculocardiac reactions (resuscitation)

bull Corneal clouding

bull Transient cataract

bull Postpartum intraretinal hemorrhage

bull Poor visualization persistant tunica vasculosa lentis

bull Cyclopentolate 1 rarrvomiting or ileus

Vicente GV et al JAAPOS Aug 2013

ihabsaadhotmailcom

Who Does the Screening

Expert Ophthalmologist

582019

8

What a Great Investment in

Preventable Blindness helliphellip

1st Epidemic

1940s -1950s

High Economy

Basic NICUs

Poor Screening

Liberal Oxygen

2nd Epidemic

1960s -1970s

High Economy

Better NICUs

Improved

Screening

Restricted Oxygen

The 3 Epidemics of ROP

3rd Epidemic

1980s ndashPresent

Day

Middle Economy

Improved NICUs

Poor Screening

582019

9

ihabsaadhotmailcom

Screening Target population

bull Birth weight lt 1500 gm

bull Gestational age lt 32 weeks

bull Incubator and receiving excessive oxygen

bull Comorbidities

Intraventricular Hemorrhage

Neonatal Sepsis

bull Others

bull

ihabsaadhotmailcom

Target population

bull Birth weight 1500 -2000 gms

bull Gestational age gt 32 weeks

bull Unstable clinical course (at discretion of

neonatologists)

582019

10

ESTABLISHING THE ROP PROJECT

Coordinated effort between

bull Ophthalmologists

bull Pediatricians

bull Parents

bull Nursing Staff

bull Social Workers

bull Administration

Distribution of ResponsibilitiesPediatrics

1 Primary Prevention

2 Notification

to ophthalmologist

baby meets

ldquoscreening criteriardquo

582019

11

Distribution of ResponsibilitiesOphthalmology

1 Who will do the screeningtrained residents FellowsConsultants Retina Pediatrics

2 Who will do the treatment3 Local regional will you need to

transport baby

ihabsaadhotmailcom

How do we Screen Premature

Babies

582019

12

ihabsaadhotmailcom

In Incubators Outreach Program

ndash Mydriaticsbull Phenylephrine 25

bull Cyclopentolate 01 (cyclomydril)

bull Topical anesthesia

ndash How much

bull 1-2 drops could maintain mydriasis for 120 min

bull Examine at 90 min

ndash Complications of mydriatics

bull Oculocardiac reactions (resuscitation)

bull Corneal clouding

bull Transient cataract

bull Postpartum intraretinal hemorrhage

bull Poor visualization persistant tunica vasculosa lentis

bull Cyclopentolate 1 rarrvomiting or ileus

Vicente GV et al JAAPOS Aug 2013

ihabsaadhotmailcom

Who Does the Screening

Expert Ophthalmologist

582019

9

ihabsaadhotmailcom

Screening Target population

bull Birth weight lt 1500 gm

bull Gestational age lt 32 weeks

bull Incubator and receiving excessive oxygen

bull Comorbidities

Intraventricular Hemorrhage

Neonatal Sepsis

bull Others

bull

ihabsaadhotmailcom

Target population

bull Birth weight 1500 -2000 gms

bull Gestational age gt 32 weeks

bull Unstable clinical course (at discretion of

neonatologists)

582019

10

ESTABLISHING THE ROP PROJECT

Coordinated effort between

bull Ophthalmologists

bull Pediatricians

bull Parents

bull Nursing Staff

bull Social Workers

bull Administration

Distribution of ResponsibilitiesPediatrics

1 Primary Prevention

2 Notification

to ophthalmologist

baby meets

ldquoscreening criteriardquo

582019

11

Distribution of ResponsibilitiesOphthalmology

1 Who will do the screeningtrained residents FellowsConsultants Retina Pediatrics

2 Who will do the treatment3 Local regional will you need to

transport baby

ihabsaadhotmailcom

How do we Screen Premature

Babies

582019

12

ihabsaadhotmailcom

In Incubators Outreach Program

ndash Mydriaticsbull Phenylephrine 25

bull Cyclopentolate 01 (cyclomydril)

bull Topical anesthesia

ndash How much

bull 1-2 drops could maintain mydriasis for 120 min

bull Examine at 90 min

ndash Complications of mydriatics

bull Oculocardiac reactions (resuscitation)

bull Corneal clouding

bull Transient cataract

bull Postpartum intraretinal hemorrhage

bull Poor visualization persistant tunica vasculosa lentis

bull Cyclopentolate 1 rarrvomiting or ileus

Vicente GV et al JAAPOS Aug 2013

ihabsaadhotmailcom

Who Does the Screening

Expert Ophthalmologist

582019

10

ESTABLISHING THE ROP PROJECT

Coordinated effort between

bull Ophthalmologists

bull Pediatricians

bull Parents

bull Nursing Staff

bull Social Workers

bull Administration

Distribution of ResponsibilitiesPediatrics

1 Primary Prevention

2 Notification

to ophthalmologist

baby meets

ldquoscreening criteriardquo

582019

11

Distribution of ResponsibilitiesOphthalmology

1 Who will do the screeningtrained residents FellowsConsultants Retina Pediatrics

2 Who will do the treatment3 Local regional will you need to

transport baby

ihabsaadhotmailcom

How do we Screen Premature

Babies

582019

12

ihabsaadhotmailcom

In Incubators Outreach Program

ndash Mydriaticsbull Phenylephrine 25

bull Cyclopentolate 01 (cyclomydril)

bull Topical anesthesia

ndash How much

bull 1-2 drops could maintain mydriasis for 120 min

bull Examine at 90 min

ndash Complications of mydriatics

bull Oculocardiac reactions (resuscitation)

bull Corneal clouding

bull Transient cataract

bull Postpartum intraretinal hemorrhage

bull Poor visualization persistant tunica vasculosa lentis

bull Cyclopentolate 1 rarrvomiting or ileus

Vicente GV et al JAAPOS Aug 2013

ihabsaadhotmailcom

Who Does the Screening

Expert Ophthalmologist

582019

11

Distribution of ResponsibilitiesOphthalmology

1 Who will do the screeningtrained residents FellowsConsultants Retina Pediatrics

2 Who will do the treatment3 Local regional will you need to

transport baby

ihabsaadhotmailcom

How do we Screen Premature

Babies

582019

12

ihabsaadhotmailcom

In Incubators Outreach Program

ndash Mydriaticsbull Phenylephrine 25

bull Cyclopentolate 01 (cyclomydril)

bull Topical anesthesia

ndash How much

bull 1-2 drops could maintain mydriasis for 120 min

bull Examine at 90 min

ndash Complications of mydriatics

bull Oculocardiac reactions (resuscitation)

bull Corneal clouding

bull Transient cataract

bull Postpartum intraretinal hemorrhage

bull Poor visualization persistant tunica vasculosa lentis

bull Cyclopentolate 1 rarrvomiting or ileus

Vicente GV et al JAAPOS Aug 2013

ihabsaadhotmailcom

Who Does the Screening

Expert Ophthalmologist

582019

12

ihabsaadhotmailcom

In Incubators Outreach Program

ndash Mydriaticsbull Phenylephrine 25

bull Cyclopentolate 01 (cyclomydril)

bull Topical anesthesia

ndash How much

bull 1-2 drops could maintain mydriasis for 120 min

bull Examine at 90 min

ndash Complications of mydriatics

bull Oculocardiac reactions (resuscitation)

bull Corneal clouding

bull Transient cataract

bull Postpartum intraretinal hemorrhage

bull Poor visualization persistant tunica vasculosa lentis

bull Cyclopentolate 1 rarrvomiting or ileus

Vicente GV et al JAAPOS Aug 2013

ihabsaadhotmailcom

Who Does the Screening

Expert Ophthalmologist

582019

13

ihabsaadhotmailcom

NICU Screening

bull Indirect

Ophthalmoscopy with

scleral depression

ndash Topical anesthetic

ndash Speculum application

ndash Learning curve

ndash Difficult in advanced

stages ROP

ndash Fundus sketches are

objective

ihabsaadhotmailcom

Digital Screening

bull Examination is done

using Retcam and

fundus examination

for concordance

582019

14

ihabsaadhotmailcom

RetCam the first wide-field real-time pediatric retinal

camera

ihabsaadhotmailcom

582019

15

Classification of ROP (Old)

bull Stage

ndash Related to neovascular development and

progression

bull Zone

ndash Related to degree of avascular retina

bull Plus disease

ndash Vascular incompetence

ihabsaadhotmailcom

ICROP (1985 amp 2005 Revisited)International Classification of ROP

Zones

Stages

ExtentPlus

Disease

582019

16

ihabsaadhotmailcom

Stage 1 demarcation line

ihabsaadhotmailcom

Stage 2 Demarcation ridge

582019

17

ihabsaadhotmailcom

Stage 3 Ridge with extraretinal

fibrovascular proliferation

ihabsaadhotmailcom

Stage 4 Tractional Retinal

Detachment

4A Macula

on

4B Macula

off

582019

18

ihabsaadhotmailcom

Stage 5 Total funnel RD

ihabsaadhotmailcom

Bilateral Stage 5b in infancy =

bilateral blindness

582019

19

Retinopathy of Prematurity

Zone 1 centered around macula

Zone 2 mid-periphery and to edge closest to nose

Zone 3 crescent shaped

temporally

ihabsaadhotmailcom

Zones= Defines degree of

ischemia

6 mm

582019

20

ihabsaadhotmailcomSevere plus disease with stage 1 in zone 2

Zone 1 Zone 2

2x discfovea distance

ihabsaadhotmailcom

avascular retina

shunt vessel

Early stage 1

zone 1 zone 2

582019

21

ihabsaadhotmailcom

Plus disease = Vascular

Incompetence

The posterior veins are enlarged and

the arterioles are tortuous in ge 2

Threshold disease

bull Five contiguous or

eight cumulative clock

hours of stage 3

disease in zones I or

II in the presence of

plus disease

bull Increased likelihood

of developing a retinal

detachment by 50

ihabsaadhotmailcom

582019

22

1930

1980 1970 1960

19501940

1990 2000 2010

Retrolental

Fibroplasia

First

described

by Terry

Modern

incubators

first

prototype Oxygen

Restrictions

New name

ROP

By Heath

ICROP

CRYO-ROP

ET-ROPBEAT-

ROP

ICROP

Revisite

d

Landmark Studies

bull ICROP (1985 amp 2005)

bull CRYO-ROP (1986-1987)

bull ET-ROP (1999-2001)

bull BEAT-ROP (2008-2010)

582019

23

CRYO-ROP(1986 - 1987)

bull Why ndash To assess the efficacy of treating THRESHOLD

ROP using trans-scleral Cryotherapy instead of observation

bull Study design ndash RCT Cryotherapy vs Observation

bull Main Results ndash Cryotherapy had better functional and Structural

outcomes as compared to observed infants

ET-ROP(1999-2002)

bull Why

ndash To assess the efficacy of treating PRETHRESHOLD (type 1)

ROP using laser retinal ablation

The study introduced the concept of Type 1 and Type 2

ROP

bull Study design

ndash RCT Laser at Threshold Vs Prethreshold )

bull Main Results

ndash Treatment at prethreshold had better functional and

Structural outcomes as compared to later treatment at

threshold

582019

24

BEAT-ROP(2008-2010)bull Why

ndash To assess the efficacy of treating ROP using Intravitreal Anti-VEGF instead of Laser

bull Study design ndash RCT Anti-VEGF vs Laser

bull Main Results ndash Injection was superior to laser in Stage 3

disease especially zone 1

ndash No difference in zone 2 disease

ihabsaadhotmailcom

bull Peripheral Retinal

Ablationndash Indirect diode laser

ophthalmoscopy

ndash Done for stage 3 threshold plus disease

ndash We use confluent burns

582019

25

ihabsaadhotmailcom

ihabsaadhotmailcom

UPDATES Early Treatment

ROP trial bull Type 1 ROP high-risk

prethreshold ROP

ndash Zone I any stage ROP with

plus disease

ndash Zone I stage 3 ROP

without plus disease

ndash Zone II stage 2 or 3 ROP

with plus disease

582019

26

ihabsaadhotmailcom

bull Wait and Watch Policy

ndash Type 2 ROP

bull Zone I stage 1 or 2 ROP without plus disease

bull Zone II stage 3 ROP without plus disease

bull These eyes should be considered for treatment

only if they progress to type 1 or threshold ROP

ET ROP

Zone 1 Zone 2 Stage 1 Stage 2 Plus Stage 3

Type 1 + Y Y +

Type 1 + +

Type 1 + + + +

Type 2 + Y Y -

Type 2 + - +

ihabsaadhotmailcom

582019

27

ihabsaadhotmailcom

Prognosisbull Natural History

ndash Spontaneous regression

ihabsaadhotmailcom

1 week mild reduction

in plus

582019

28

ihabsaadhotmailcom

bull Progression to stages 4 and 5

bull Changes with Stage 3ndash Myopia Age 6-8 months

ndash Amblyopia

bull Arrest of normal postnatal dvpt of central macula

bull Occult hyperoxic retinal necrosis

bull Progressive RPERetinal atrophy

ndash Strabismus

ndash dragging

ndash Equatorial NVE

bull Dragging

ihabsaadhotmailcom

582019

29

ihabsaadhotmailcom

Need for long term follow up

bull Peripheral retinal changesndash Incomplete vascularization

ndash Abnormal straight retinal vessels

ndash Circumferential interconnecting vascular arcades

ndash Retinal pigmentation

ndash Vitreous membranes

ndash Equatorial folds

ndash Lattice-like degeneration

ndash Retinal breaks

ndash Exudative TRD RRD

When a baby needs treatment

bull Refer to treatment center

bull Coordination between units

bull Transport

bull Risks for baby

bull Who goes with

the baby

Or travel to the

baby

582019

30

When a baby needs treatment

Operating theater or neonatal unit

Treat in unit if possible

Portable Diode laser

Pediatric anesthesiologist

neonatologist

Anti-VEGF

bull Ranibuzimab

(Lucentis)

ndash Least effective

ndash Less profound

systemic VEGF

depletion

bull Bevacizumab

(Avastin) Eylea

ndash More effective

ndash Systemic VEGF

depletion (3 months) ihabsaadhotmailcom

582019

31

Case 2

bull Bilateral plus disease S3 zone 1

bull Male

bull Single

bull 30 weeks

bull 1780

bull Mode of delivery CS

First Visit

582019

32

One week post-injection

Six months post injection

582019

33

Pars Plana Vitrectomy in

Stage 4 and 5 ROP

Use of Densiron and trypan

blue Ihab Saad Othman MD FRCS

Professor of Ophthalmology

Cairo University

Director EyeWorld Hospital

Egypt

ihabsaadhotmailcom

ihabsaadhotmailcom

Stage 4 Tractional Retinal

Detachment

4A Macula

on

4B Macula

off

582019

34

ihabsaadhotmailcom

Stage 4 ROP

Dragging of

the macular

area

ihabsaadhotmailcom

High myopia

VA 04

Lens sparing vitrectomy

582019

35

ihabsaadhotmailcom

Stage 5 ROP

A STAGE WE HATE TO SEE

ihabsaadhotmailcom

Stage 5 Total funnel RD

582019

36

ihabsaadhotmailcom

Bilateral Stage 5b in infancy =

bilateral blindness

ihabsaadhotmailcom

Management

bull Pars PlicataLensectomyVitrectomy

ndash Closed PPV

582019

37

ihabsaadhotmailcom

ihabsaadhotmailcom

Visual Rehabilitation-F up

582019

38

Localization of Pars plicata

ihabsaadhotmailcom

Avoid the fold

Where to place infusion

bull Infants distance from

limbus

bull 0-6 months 15 mm

6-12 months 25 mm

bull 12-24 months 3 mm

582019

14

ihabsaadhotmailcom

RetCam the first wide-field real-time pediatric retinal

camera

ihabsaadhotmailcom

582019

15

Classification of ROP (Old)

bull Stage

ndash Related to neovascular development and

progression

bull Zone

ndash Related to degree of avascular retina

bull Plus disease

ndash Vascular incompetence

ihabsaadhotmailcom

ICROP (1985 amp 2005 Revisited)International Classification of ROP

Zones

Stages

ExtentPlus

Disease

582019

16

ihabsaadhotmailcom

Stage 1 demarcation line

ihabsaadhotmailcom

Stage 2 Demarcation ridge

582019

17

ihabsaadhotmailcom

Stage 3 Ridge with extraretinal

fibrovascular proliferation

ihabsaadhotmailcom

Stage 4 Tractional Retinal

Detachment

4A Macula

on

4B Macula

off

582019

18

ihabsaadhotmailcom

Stage 5 Total funnel RD

ihabsaadhotmailcom

Bilateral Stage 5b in infancy =

bilateral blindness

582019

19

Retinopathy of Prematurity

Zone 1 centered around macula

Zone 2 mid-periphery and to edge closest to nose

Zone 3 crescent shaped

temporally

ihabsaadhotmailcom

Zones= Defines degree of

ischemia

6 mm

582019

20

ihabsaadhotmailcomSevere plus disease with stage 1 in zone 2

Zone 1 Zone 2

2x discfovea distance

ihabsaadhotmailcom

avascular retina

shunt vessel

Early stage 1

zone 1 zone 2

582019

21

ihabsaadhotmailcom

Plus disease = Vascular

Incompetence

The posterior veins are enlarged and

the arterioles are tortuous in ge 2

Threshold disease

bull Five contiguous or

eight cumulative clock

hours of stage 3

disease in zones I or

II in the presence of

plus disease

bull Increased likelihood

of developing a retinal

detachment by 50

ihabsaadhotmailcom

582019

22

1930

1980 1970 1960

19501940

1990 2000 2010

Retrolental

Fibroplasia

First

described

by Terry

Modern

incubators

first

prototype Oxygen

Restrictions

New name

ROP

By Heath

ICROP

CRYO-ROP

ET-ROPBEAT-

ROP

ICROP

Revisite

d

Landmark Studies

bull ICROP (1985 amp 2005)

bull CRYO-ROP (1986-1987)

bull ET-ROP (1999-2001)

bull BEAT-ROP (2008-2010)

582019

23

CRYO-ROP(1986 - 1987)

bull Why ndash To assess the efficacy of treating THRESHOLD

ROP using trans-scleral Cryotherapy instead of observation

bull Study design ndash RCT Cryotherapy vs Observation

bull Main Results ndash Cryotherapy had better functional and Structural

outcomes as compared to observed infants

ET-ROP(1999-2002)

bull Why

ndash To assess the efficacy of treating PRETHRESHOLD (type 1)

ROP using laser retinal ablation

The study introduced the concept of Type 1 and Type 2

ROP

bull Study design

ndash RCT Laser at Threshold Vs Prethreshold )

bull Main Results

ndash Treatment at prethreshold had better functional and

Structural outcomes as compared to later treatment at

threshold

582019

24

BEAT-ROP(2008-2010)bull Why

ndash To assess the efficacy of treating ROP using Intravitreal Anti-VEGF instead of Laser

bull Study design ndash RCT Anti-VEGF vs Laser

bull Main Results ndash Injection was superior to laser in Stage 3

disease especially zone 1

ndash No difference in zone 2 disease

ihabsaadhotmailcom

bull Peripheral Retinal

Ablationndash Indirect diode laser

ophthalmoscopy

ndash Done for stage 3 threshold plus disease

ndash We use confluent burns

582019

25

ihabsaadhotmailcom

ihabsaadhotmailcom

UPDATES Early Treatment

ROP trial bull Type 1 ROP high-risk

prethreshold ROP

ndash Zone I any stage ROP with

plus disease

ndash Zone I stage 3 ROP

without plus disease

ndash Zone II stage 2 or 3 ROP

with plus disease

582019

26

ihabsaadhotmailcom

bull Wait and Watch Policy

ndash Type 2 ROP

bull Zone I stage 1 or 2 ROP without plus disease

bull Zone II stage 3 ROP without plus disease

bull These eyes should be considered for treatment

only if they progress to type 1 or threshold ROP

ET ROP

Zone 1 Zone 2 Stage 1 Stage 2 Plus Stage 3

Type 1 + Y Y +

Type 1 + +

Type 1 + + + +

Type 2 + Y Y -

Type 2 + - +

ihabsaadhotmailcom

582019

27

ihabsaadhotmailcom

Prognosisbull Natural History

ndash Spontaneous regression

ihabsaadhotmailcom

1 week mild reduction

in plus

582019

28

ihabsaadhotmailcom

bull Progression to stages 4 and 5

bull Changes with Stage 3ndash Myopia Age 6-8 months

ndash Amblyopia

bull Arrest of normal postnatal dvpt of central macula

bull Occult hyperoxic retinal necrosis

bull Progressive RPERetinal atrophy

ndash Strabismus

ndash dragging

ndash Equatorial NVE

bull Dragging

ihabsaadhotmailcom

582019

29

ihabsaadhotmailcom

Need for long term follow up

bull Peripheral retinal changesndash Incomplete vascularization

ndash Abnormal straight retinal vessels

ndash Circumferential interconnecting vascular arcades

ndash Retinal pigmentation

ndash Vitreous membranes

ndash Equatorial folds

ndash Lattice-like degeneration

ndash Retinal breaks

ndash Exudative TRD RRD

When a baby needs treatment

bull Refer to treatment center

bull Coordination between units

bull Transport

bull Risks for baby

bull Who goes with

the baby

Or travel to the

baby

582019

30

When a baby needs treatment

Operating theater or neonatal unit

Treat in unit if possible

Portable Diode laser

Pediatric anesthesiologist

neonatologist

Anti-VEGF

bull Ranibuzimab

(Lucentis)

ndash Least effective

ndash Less profound

systemic VEGF

depletion

bull Bevacizumab

(Avastin) Eylea

ndash More effective

ndash Systemic VEGF

depletion (3 months) ihabsaadhotmailcom

582019

31

Case 2

bull Bilateral plus disease S3 zone 1

bull Male

bull Single

bull 30 weeks

bull 1780

bull Mode of delivery CS

First Visit

582019

32

One week post-injection

Six months post injection

582019

33

Pars Plana Vitrectomy in

Stage 4 and 5 ROP

Use of Densiron and trypan

blue Ihab Saad Othman MD FRCS

Professor of Ophthalmology

Cairo University

Director EyeWorld Hospital

Egypt

ihabsaadhotmailcom

ihabsaadhotmailcom

Stage 4 Tractional Retinal

Detachment

4A Macula

on

4B Macula

off

582019

34

ihabsaadhotmailcom

Stage 4 ROP

Dragging of

the macular

area

ihabsaadhotmailcom

High myopia

VA 04

Lens sparing vitrectomy

582019

35

ihabsaadhotmailcom

Stage 5 ROP

A STAGE WE HATE TO SEE

ihabsaadhotmailcom

Stage 5 Total funnel RD

582019

36

ihabsaadhotmailcom

Bilateral Stage 5b in infancy =

bilateral blindness

ihabsaadhotmailcom

Management

bull Pars PlicataLensectomyVitrectomy

ndash Closed PPV

582019

37

ihabsaadhotmailcom

ihabsaadhotmailcom

Visual Rehabilitation-F up

582019

38

Localization of Pars plicata

ihabsaadhotmailcom

Avoid the fold

Where to place infusion

bull Infants distance from

limbus

bull 0-6 months 15 mm

6-12 months 25 mm

bull 12-24 months 3 mm

582019

15

Classification of ROP (Old)

bull Stage

ndash Related to neovascular development and

progression

bull Zone

ndash Related to degree of avascular retina

bull Plus disease

ndash Vascular incompetence

ihabsaadhotmailcom

ICROP (1985 amp 2005 Revisited)International Classification of ROP

Zones

Stages

ExtentPlus

Disease

582019

16

ihabsaadhotmailcom

Stage 1 demarcation line

ihabsaadhotmailcom

Stage 2 Demarcation ridge

582019

17

ihabsaadhotmailcom

Stage 3 Ridge with extraretinal

fibrovascular proliferation

ihabsaadhotmailcom

Stage 4 Tractional Retinal

Detachment

4A Macula

on

4B Macula

off

582019

18

ihabsaadhotmailcom

Stage 5 Total funnel RD

ihabsaadhotmailcom

Bilateral Stage 5b in infancy =

bilateral blindness

582019

19

Retinopathy of Prematurity

Zone 1 centered around macula

Zone 2 mid-periphery and to edge closest to nose

Zone 3 crescent shaped

temporally

ihabsaadhotmailcom

Zones= Defines degree of

ischemia

6 mm

582019

20

ihabsaadhotmailcomSevere plus disease with stage 1 in zone 2

Zone 1 Zone 2

2x discfovea distance

ihabsaadhotmailcom

avascular retina

shunt vessel

Early stage 1

zone 1 zone 2

582019

21

ihabsaadhotmailcom

Plus disease = Vascular

Incompetence

The posterior veins are enlarged and

the arterioles are tortuous in ge 2

Threshold disease

bull Five contiguous or

eight cumulative clock

hours of stage 3

disease in zones I or

II in the presence of

plus disease

bull Increased likelihood

of developing a retinal

detachment by 50

ihabsaadhotmailcom

582019

22

1930

1980 1970 1960

19501940

1990 2000 2010

Retrolental

Fibroplasia

First

described

by Terry

Modern

incubators

first

prototype Oxygen

Restrictions

New name

ROP

By Heath

ICROP

CRYO-ROP

ET-ROPBEAT-

ROP

ICROP

Revisite

d

Landmark Studies

bull ICROP (1985 amp 2005)

bull CRYO-ROP (1986-1987)

bull ET-ROP (1999-2001)

bull BEAT-ROP (2008-2010)

582019

23

CRYO-ROP(1986 - 1987)

bull Why ndash To assess the efficacy of treating THRESHOLD

ROP using trans-scleral Cryotherapy instead of observation

bull Study design ndash RCT Cryotherapy vs Observation

bull Main Results ndash Cryotherapy had better functional and Structural

outcomes as compared to observed infants

ET-ROP(1999-2002)

bull Why

ndash To assess the efficacy of treating PRETHRESHOLD (type 1)

ROP using laser retinal ablation

The study introduced the concept of Type 1 and Type 2

ROP

bull Study design

ndash RCT Laser at Threshold Vs Prethreshold )

bull Main Results

ndash Treatment at prethreshold had better functional and

Structural outcomes as compared to later treatment at

threshold

582019

24

BEAT-ROP(2008-2010)bull Why

ndash To assess the efficacy of treating ROP using Intravitreal Anti-VEGF instead of Laser

bull Study design ndash RCT Anti-VEGF vs Laser

bull Main Results ndash Injection was superior to laser in Stage 3

disease especially zone 1

ndash No difference in zone 2 disease

ihabsaadhotmailcom

bull Peripheral Retinal

Ablationndash Indirect diode laser

ophthalmoscopy

ndash Done for stage 3 threshold plus disease

ndash We use confluent burns

582019

25

ihabsaadhotmailcom

ihabsaadhotmailcom

UPDATES Early Treatment

ROP trial bull Type 1 ROP high-risk

prethreshold ROP

ndash Zone I any stage ROP with

plus disease

ndash Zone I stage 3 ROP

without plus disease

ndash Zone II stage 2 or 3 ROP

with plus disease

582019

26

ihabsaadhotmailcom

bull Wait and Watch Policy

ndash Type 2 ROP

bull Zone I stage 1 or 2 ROP without plus disease

bull Zone II stage 3 ROP without plus disease

bull These eyes should be considered for treatment

only if they progress to type 1 or threshold ROP

ET ROP

Zone 1 Zone 2 Stage 1 Stage 2 Plus Stage 3

Type 1 + Y Y +

Type 1 + +

Type 1 + + + +

Type 2 + Y Y -

Type 2 + - +

ihabsaadhotmailcom

582019

27

ihabsaadhotmailcom

Prognosisbull Natural History

ndash Spontaneous regression

ihabsaadhotmailcom

1 week mild reduction

in plus

582019

28

ihabsaadhotmailcom

bull Progression to stages 4 and 5

bull Changes with Stage 3ndash Myopia Age 6-8 months

ndash Amblyopia

bull Arrest of normal postnatal dvpt of central macula

bull Occult hyperoxic retinal necrosis

bull Progressive RPERetinal atrophy

ndash Strabismus

ndash dragging

ndash Equatorial NVE

bull Dragging

ihabsaadhotmailcom

582019

29

ihabsaadhotmailcom

Need for long term follow up

bull Peripheral retinal changesndash Incomplete vascularization

ndash Abnormal straight retinal vessels

ndash Circumferential interconnecting vascular arcades

ndash Retinal pigmentation

ndash Vitreous membranes

ndash Equatorial folds

ndash Lattice-like degeneration

ndash Retinal breaks

ndash Exudative TRD RRD

When a baby needs treatment

bull Refer to treatment center

bull Coordination between units

bull Transport

bull Risks for baby

bull Who goes with

the baby

Or travel to the

baby

582019

30

When a baby needs treatment

Operating theater or neonatal unit

Treat in unit if possible

Portable Diode laser

Pediatric anesthesiologist

neonatologist

Anti-VEGF

bull Ranibuzimab

(Lucentis)

ndash Least effective

ndash Less profound

systemic VEGF

depletion

bull Bevacizumab

(Avastin) Eylea

ndash More effective

ndash Systemic VEGF

depletion (3 months) ihabsaadhotmailcom

582019

31

Case 2

bull Bilateral plus disease S3 zone 1

bull Male

bull Single

bull 30 weeks

bull 1780

bull Mode of delivery CS

First Visit

582019

32

One week post-injection

Six months post injection

582019

33

Pars Plana Vitrectomy in

Stage 4 and 5 ROP

Use of Densiron and trypan

blue Ihab Saad Othman MD FRCS

Professor of Ophthalmology

Cairo University

Director EyeWorld Hospital

Egypt

ihabsaadhotmailcom

ihabsaadhotmailcom

Stage 4 Tractional Retinal

Detachment

4A Macula

on

4B Macula

off

582019

34

ihabsaadhotmailcom

Stage 4 ROP

Dragging of

the macular

area

ihabsaadhotmailcom

High myopia

VA 04

Lens sparing vitrectomy

582019

35

ihabsaadhotmailcom

Stage 5 ROP

A STAGE WE HATE TO SEE

ihabsaadhotmailcom

Stage 5 Total funnel RD

582019

36

ihabsaadhotmailcom

Bilateral Stage 5b in infancy =

bilateral blindness

ihabsaadhotmailcom

Management

bull Pars PlicataLensectomyVitrectomy

ndash Closed PPV

582019

37

ihabsaadhotmailcom

ihabsaadhotmailcom

Visual Rehabilitation-F up

582019

38

Localization of Pars plicata

ihabsaadhotmailcom

Avoid the fold

Where to place infusion

bull Infants distance from

limbus

bull 0-6 months 15 mm

6-12 months 25 mm

bull 12-24 months 3 mm

582019

16

ihabsaadhotmailcom

Stage 1 demarcation line

ihabsaadhotmailcom

Stage 2 Demarcation ridge

582019

17

ihabsaadhotmailcom

Stage 3 Ridge with extraretinal

fibrovascular proliferation

ihabsaadhotmailcom

Stage 4 Tractional Retinal

Detachment

4A Macula

on

4B Macula

off

582019

18

ihabsaadhotmailcom

Stage 5 Total funnel RD

ihabsaadhotmailcom

Bilateral Stage 5b in infancy =

bilateral blindness

582019

19

Retinopathy of Prematurity

Zone 1 centered around macula

Zone 2 mid-periphery and to edge closest to nose

Zone 3 crescent shaped

temporally

ihabsaadhotmailcom

Zones= Defines degree of

ischemia

6 mm

582019

20

ihabsaadhotmailcomSevere plus disease with stage 1 in zone 2

Zone 1 Zone 2

2x discfovea distance

ihabsaadhotmailcom

avascular retina

shunt vessel

Early stage 1

zone 1 zone 2

582019

21

ihabsaadhotmailcom

Plus disease = Vascular

Incompetence

The posterior veins are enlarged and

the arterioles are tortuous in ge 2

Threshold disease

bull Five contiguous or

eight cumulative clock

hours of stage 3

disease in zones I or

II in the presence of

plus disease

bull Increased likelihood

of developing a retinal

detachment by 50

ihabsaadhotmailcom

582019

22

1930

1980 1970 1960

19501940

1990 2000 2010

Retrolental

Fibroplasia

First

described

by Terry

Modern

incubators

first

prototype Oxygen

Restrictions

New name

ROP

By Heath

ICROP

CRYO-ROP

ET-ROPBEAT-

ROP

ICROP

Revisite

d

Landmark Studies

bull ICROP (1985 amp 2005)

bull CRYO-ROP (1986-1987)

bull ET-ROP (1999-2001)

bull BEAT-ROP (2008-2010)

582019

23

CRYO-ROP(1986 - 1987)

bull Why ndash To assess the efficacy of treating THRESHOLD

ROP using trans-scleral Cryotherapy instead of observation

bull Study design ndash RCT Cryotherapy vs Observation

bull Main Results ndash Cryotherapy had better functional and Structural

outcomes as compared to observed infants

ET-ROP(1999-2002)

bull Why

ndash To assess the efficacy of treating PRETHRESHOLD (type 1)

ROP using laser retinal ablation

The study introduced the concept of Type 1 and Type 2

ROP

bull Study design

ndash RCT Laser at Threshold Vs Prethreshold )

bull Main Results

ndash Treatment at prethreshold had better functional and

Structural outcomes as compared to later treatment at

threshold

582019

24

BEAT-ROP(2008-2010)bull Why

ndash To assess the efficacy of treating ROP using Intravitreal Anti-VEGF instead of Laser

bull Study design ndash RCT Anti-VEGF vs Laser

bull Main Results ndash Injection was superior to laser in Stage 3

disease especially zone 1

ndash No difference in zone 2 disease

ihabsaadhotmailcom

bull Peripheral Retinal

Ablationndash Indirect diode laser

ophthalmoscopy

ndash Done for stage 3 threshold plus disease

ndash We use confluent burns

582019

25

ihabsaadhotmailcom

ihabsaadhotmailcom

UPDATES Early Treatment

ROP trial bull Type 1 ROP high-risk

prethreshold ROP

ndash Zone I any stage ROP with

plus disease

ndash Zone I stage 3 ROP

without plus disease

ndash Zone II stage 2 or 3 ROP

with plus disease

582019

26

ihabsaadhotmailcom

bull Wait and Watch Policy

ndash Type 2 ROP

bull Zone I stage 1 or 2 ROP without plus disease

bull Zone II stage 3 ROP without plus disease

bull These eyes should be considered for treatment

only if they progress to type 1 or threshold ROP

ET ROP

Zone 1 Zone 2 Stage 1 Stage 2 Plus Stage 3

Type 1 + Y Y +

Type 1 + +

Type 1 + + + +

Type 2 + Y Y -

Type 2 + - +

ihabsaadhotmailcom

582019

27

ihabsaadhotmailcom

Prognosisbull Natural History

ndash Spontaneous regression

ihabsaadhotmailcom

1 week mild reduction

in plus

582019

28

ihabsaadhotmailcom

bull Progression to stages 4 and 5

bull Changes with Stage 3ndash Myopia Age 6-8 months

ndash Amblyopia

bull Arrest of normal postnatal dvpt of central macula

bull Occult hyperoxic retinal necrosis

bull Progressive RPERetinal atrophy

ndash Strabismus

ndash dragging

ndash Equatorial NVE

bull Dragging

ihabsaadhotmailcom

582019

29

ihabsaadhotmailcom

Need for long term follow up

bull Peripheral retinal changesndash Incomplete vascularization

ndash Abnormal straight retinal vessels

ndash Circumferential interconnecting vascular arcades

ndash Retinal pigmentation

ndash Vitreous membranes

ndash Equatorial folds

ndash Lattice-like degeneration

ndash Retinal breaks

ndash Exudative TRD RRD

When a baby needs treatment

bull Refer to treatment center

bull Coordination between units

bull Transport

bull Risks for baby

bull Who goes with

the baby

Or travel to the

baby

582019

30

When a baby needs treatment

Operating theater or neonatal unit

Treat in unit if possible

Portable Diode laser

Pediatric anesthesiologist

neonatologist

Anti-VEGF

bull Ranibuzimab

(Lucentis)

ndash Least effective

ndash Less profound

systemic VEGF

depletion

bull Bevacizumab

(Avastin) Eylea

ndash More effective

ndash Systemic VEGF

depletion (3 months) ihabsaadhotmailcom

582019

31

Case 2

bull Bilateral plus disease S3 zone 1

bull Male

bull Single

bull 30 weeks

bull 1780

bull Mode of delivery CS

First Visit

582019

32

One week post-injection

Six months post injection

582019

33

Pars Plana Vitrectomy in

Stage 4 and 5 ROP

Use of Densiron and trypan

blue Ihab Saad Othman MD FRCS

Professor of Ophthalmology

Cairo University

Director EyeWorld Hospital

Egypt

ihabsaadhotmailcom

ihabsaadhotmailcom

Stage 4 Tractional Retinal

Detachment

4A Macula

on

4B Macula

off

582019

34

ihabsaadhotmailcom

Stage 4 ROP

Dragging of

the macular

area

ihabsaadhotmailcom

High myopia

VA 04

Lens sparing vitrectomy

582019

35

ihabsaadhotmailcom

Stage 5 ROP

A STAGE WE HATE TO SEE

ihabsaadhotmailcom

Stage 5 Total funnel RD

582019

36

ihabsaadhotmailcom

Bilateral Stage 5b in infancy =

bilateral blindness

ihabsaadhotmailcom

Management

bull Pars PlicataLensectomyVitrectomy

ndash Closed PPV

582019

37

ihabsaadhotmailcom

ihabsaadhotmailcom

Visual Rehabilitation-F up

582019

38

Localization of Pars plicata

ihabsaadhotmailcom

Avoid the fold

Where to place infusion

bull Infants distance from

limbus

bull 0-6 months 15 mm

6-12 months 25 mm

bull 12-24 months 3 mm

582019

17

ihabsaadhotmailcom

Stage 3 Ridge with extraretinal

fibrovascular proliferation

ihabsaadhotmailcom

Stage 4 Tractional Retinal

Detachment

4A Macula

on

4B Macula

off

582019

18

ihabsaadhotmailcom

Stage 5 Total funnel RD

ihabsaadhotmailcom

Bilateral Stage 5b in infancy =

bilateral blindness

582019

19

Retinopathy of Prematurity

Zone 1 centered around macula

Zone 2 mid-periphery and to edge closest to nose

Zone 3 crescent shaped

temporally

ihabsaadhotmailcom

Zones= Defines degree of

ischemia

6 mm

582019

20

ihabsaadhotmailcomSevere plus disease with stage 1 in zone 2

Zone 1 Zone 2

2x discfovea distance

ihabsaadhotmailcom

avascular retina

shunt vessel

Early stage 1

zone 1 zone 2

582019

21

ihabsaadhotmailcom

Plus disease = Vascular

Incompetence

The posterior veins are enlarged and

the arterioles are tortuous in ge 2

Threshold disease

bull Five contiguous or

eight cumulative clock

hours of stage 3

disease in zones I or

II in the presence of

plus disease

bull Increased likelihood

of developing a retinal

detachment by 50

ihabsaadhotmailcom

582019

22

1930

1980 1970 1960

19501940

1990 2000 2010

Retrolental

Fibroplasia

First

described

by Terry

Modern

incubators

first

prototype Oxygen

Restrictions

New name

ROP

By Heath

ICROP

CRYO-ROP

ET-ROPBEAT-

ROP

ICROP

Revisite

d

Landmark Studies

bull ICROP (1985 amp 2005)

bull CRYO-ROP (1986-1987)

bull ET-ROP (1999-2001)

bull BEAT-ROP (2008-2010)

582019

23

CRYO-ROP(1986 - 1987)

bull Why ndash To assess the efficacy of treating THRESHOLD

ROP using trans-scleral Cryotherapy instead of observation

bull Study design ndash RCT Cryotherapy vs Observation

bull Main Results ndash Cryotherapy had better functional and Structural

outcomes as compared to observed infants

ET-ROP(1999-2002)

bull Why

ndash To assess the efficacy of treating PRETHRESHOLD (type 1)

ROP using laser retinal ablation

The study introduced the concept of Type 1 and Type 2

ROP

bull Study design

ndash RCT Laser at Threshold Vs Prethreshold )

bull Main Results

ndash Treatment at prethreshold had better functional and

Structural outcomes as compared to later treatment at

threshold

582019

24

BEAT-ROP(2008-2010)bull Why

ndash To assess the efficacy of treating ROP using Intravitreal Anti-VEGF instead of Laser

bull Study design ndash RCT Anti-VEGF vs Laser

bull Main Results ndash Injection was superior to laser in Stage 3

disease especially zone 1

ndash No difference in zone 2 disease

ihabsaadhotmailcom

bull Peripheral Retinal

Ablationndash Indirect diode laser

ophthalmoscopy

ndash Done for stage 3 threshold plus disease

ndash We use confluent burns

582019

25

ihabsaadhotmailcom

ihabsaadhotmailcom

UPDATES Early Treatment

ROP trial bull Type 1 ROP high-risk

prethreshold ROP

ndash Zone I any stage ROP with

plus disease

ndash Zone I stage 3 ROP

without plus disease

ndash Zone II stage 2 or 3 ROP

with plus disease

582019

26

ihabsaadhotmailcom

bull Wait and Watch Policy

ndash Type 2 ROP

bull Zone I stage 1 or 2 ROP without plus disease

bull Zone II stage 3 ROP without plus disease

bull These eyes should be considered for treatment

only if they progress to type 1 or threshold ROP

ET ROP

Zone 1 Zone 2 Stage 1 Stage 2 Plus Stage 3

Type 1 + Y Y +

Type 1 + +

Type 1 + + + +

Type 2 + Y Y -

Type 2 + - +

ihabsaadhotmailcom

582019

27

ihabsaadhotmailcom

Prognosisbull Natural History

ndash Spontaneous regression

ihabsaadhotmailcom

1 week mild reduction

in plus

582019

28

ihabsaadhotmailcom

bull Progression to stages 4 and 5

bull Changes with Stage 3ndash Myopia Age 6-8 months

ndash Amblyopia

bull Arrest of normal postnatal dvpt of central macula

bull Occult hyperoxic retinal necrosis

bull Progressive RPERetinal atrophy

ndash Strabismus

ndash dragging

ndash Equatorial NVE

bull Dragging

ihabsaadhotmailcom

582019

29

ihabsaadhotmailcom

Need for long term follow up

bull Peripheral retinal changesndash Incomplete vascularization

ndash Abnormal straight retinal vessels

ndash Circumferential interconnecting vascular arcades

ndash Retinal pigmentation

ndash Vitreous membranes

ndash Equatorial folds

ndash Lattice-like degeneration

ndash Retinal breaks

ndash Exudative TRD RRD

When a baby needs treatment

bull Refer to treatment center

bull Coordination between units

bull Transport

bull Risks for baby

bull Who goes with

the baby

Or travel to the

baby

582019

30

When a baby needs treatment

Operating theater or neonatal unit

Treat in unit if possible

Portable Diode laser

Pediatric anesthesiologist

neonatologist

Anti-VEGF

bull Ranibuzimab

(Lucentis)

ndash Least effective

ndash Less profound

systemic VEGF

depletion

bull Bevacizumab

(Avastin) Eylea

ndash More effective

ndash Systemic VEGF

depletion (3 months) ihabsaadhotmailcom

582019

31

Case 2

bull Bilateral plus disease S3 zone 1

bull Male

bull Single

bull 30 weeks

bull 1780

bull Mode of delivery CS

First Visit

582019

32

One week post-injection

Six months post injection

582019

33

Pars Plana Vitrectomy in

Stage 4 and 5 ROP

Use of Densiron and trypan

blue Ihab Saad Othman MD FRCS

Professor of Ophthalmology

Cairo University

Director EyeWorld Hospital

Egypt

ihabsaadhotmailcom

ihabsaadhotmailcom

Stage 4 Tractional Retinal

Detachment

4A Macula

on

4B Macula

off

582019

34

ihabsaadhotmailcom

Stage 4 ROP

Dragging of

the macular

area

ihabsaadhotmailcom

High myopia

VA 04

Lens sparing vitrectomy

582019

35

ihabsaadhotmailcom

Stage 5 ROP

A STAGE WE HATE TO SEE

ihabsaadhotmailcom

Stage 5 Total funnel RD

582019

36

ihabsaadhotmailcom

Bilateral Stage 5b in infancy =

bilateral blindness

ihabsaadhotmailcom

Management

bull Pars PlicataLensectomyVitrectomy

ndash Closed PPV

582019

37

ihabsaadhotmailcom

ihabsaadhotmailcom

Visual Rehabilitation-F up

582019

38

Localization of Pars plicata

ihabsaadhotmailcom

Avoid the fold

Where to place infusion

bull Infants distance from

limbus

bull 0-6 months 15 mm

6-12 months 25 mm

bull 12-24 months 3 mm

582019

18

ihabsaadhotmailcom

Stage 5 Total funnel RD

ihabsaadhotmailcom

Bilateral Stage 5b in infancy =

bilateral blindness

582019

19

Retinopathy of Prematurity

Zone 1 centered around macula

Zone 2 mid-periphery and to edge closest to nose

Zone 3 crescent shaped

temporally

ihabsaadhotmailcom

Zones= Defines degree of

ischemia

6 mm

582019

20

ihabsaadhotmailcomSevere plus disease with stage 1 in zone 2

Zone 1 Zone 2

2x discfovea distance

ihabsaadhotmailcom

avascular retina

shunt vessel

Early stage 1

zone 1 zone 2

582019

21

ihabsaadhotmailcom

Plus disease = Vascular

Incompetence

The posterior veins are enlarged and

the arterioles are tortuous in ge 2

Threshold disease

bull Five contiguous or

eight cumulative clock

hours of stage 3

disease in zones I or

II in the presence of

plus disease

bull Increased likelihood

of developing a retinal

detachment by 50

ihabsaadhotmailcom

582019

22

1930

1980 1970 1960

19501940

1990 2000 2010

Retrolental

Fibroplasia

First

described

by Terry

Modern

incubators

first

prototype Oxygen

Restrictions

New name

ROP

By Heath

ICROP

CRYO-ROP

ET-ROPBEAT-

ROP

ICROP

Revisite

d

Landmark Studies

bull ICROP (1985 amp 2005)

bull CRYO-ROP (1986-1987)

bull ET-ROP (1999-2001)

bull BEAT-ROP (2008-2010)

582019

23

CRYO-ROP(1986 - 1987)

bull Why ndash To assess the efficacy of treating THRESHOLD

ROP using trans-scleral Cryotherapy instead of observation

bull Study design ndash RCT Cryotherapy vs Observation

bull Main Results ndash Cryotherapy had better functional and Structural

outcomes as compared to observed infants

ET-ROP(1999-2002)

bull Why

ndash To assess the efficacy of treating PRETHRESHOLD (type 1)

ROP using laser retinal ablation

The study introduced the concept of Type 1 and Type 2

ROP

bull Study design

ndash RCT Laser at Threshold Vs Prethreshold )

bull Main Results

ndash Treatment at prethreshold had better functional and

Structural outcomes as compared to later treatment at

threshold

582019

24

BEAT-ROP(2008-2010)bull Why

ndash To assess the efficacy of treating ROP using Intravitreal Anti-VEGF instead of Laser

bull Study design ndash RCT Anti-VEGF vs Laser

bull Main Results ndash Injection was superior to laser in Stage 3

disease especially zone 1

ndash No difference in zone 2 disease

ihabsaadhotmailcom

bull Peripheral Retinal

Ablationndash Indirect diode laser

ophthalmoscopy

ndash Done for stage 3 threshold plus disease

ndash We use confluent burns

582019

25

ihabsaadhotmailcom

ihabsaadhotmailcom

UPDATES Early Treatment

ROP trial bull Type 1 ROP high-risk

prethreshold ROP

ndash Zone I any stage ROP with

plus disease

ndash Zone I stage 3 ROP

without plus disease

ndash Zone II stage 2 or 3 ROP

with plus disease

582019

26

ihabsaadhotmailcom

bull Wait and Watch Policy

ndash Type 2 ROP

bull Zone I stage 1 or 2 ROP without plus disease

bull Zone II stage 3 ROP without plus disease

bull These eyes should be considered for treatment

only if they progress to type 1 or threshold ROP

ET ROP

Zone 1 Zone 2 Stage 1 Stage 2 Plus Stage 3

Type 1 + Y Y +

Type 1 + +

Type 1 + + + +

Type 2 + Y Y -

Type 2 + - +

ihabsaadhotmailcom

582019

27

ihabsaadhotmailcom

Prognosisbull Natural History

ndash Spontaneous regression

ihabsaadhotmailcom

1 week mild reduction

in plus

582019

28

ihabsaadhotmailcom

bull Progression to stages 4 and 5

bull Changes with Stage 3ndash Myopia Age 6-8 months

ndash Amblyopia

bull Arrest of normal postnatal dvpt of central macula

bull Occult hyperoxic retinal necrosis

bull Progressive RPERetinal atrophy

ndash Strabismus

ndash dragging

ndash Equatorial NVE

bull Dragging

ihabsaadhotmailcom

582019

29

ihabsaadhotmailcom

Need for long term follow up

bull Peripheral retinal changesndash Incomplete vascularization

ndash Abnormal straight retinal vessels

ndash Circumferential interconnecting vascular arcades

ndash Retinal pigmentation

ndash Vitreous membranes

ndash Equatorial folds

ndash Lattice-like degeneration

ndash Retinal breaks

ndash Exudative TRD RRD

When a baby needs treatment

bull Refer to treatment center

bull Coordination between units

bull Transport

bull Risks for baby

bull Who goes with

the baby

Or travel to the

baby

582019

30

When a baby needs treatment

Operating theater or neonatal unit

Treat in unit if possible

Portable Diode laser

Pediatric anesthesiologist

neonatologist

Anti-VEGF

bull Ranibuzimab

(Lucentis)

ndash Least effective

ndash Less profound

systemic VEGF

depletion

bull Bevacizumab

(Avastin) Eylea

ndash More effective

ndash Systemic VEGF

depletion (3 months) ihabsaadhotmailcom

582019

31

Case 2

bull Bilateral plus disease S3 zone 1

bull Male

bull Single

bull 30 weeks

bull 1780

bull Mode of delivery CS

First Visit

582019

32

One week post-injection

Six months post injection

582019

33

Pars Plana Vitrectomy in

Stage 4 and 5 ROP

Use of Densiron and trypan

blue Ihab Saad Othman MD FRCS

Professor of Ophthalmology

Cairo University

Director EyeWorld Hospital

Egypt

ihabsaadhotmailcom

ihabsaadhotmailcom

Stage 4 Tractional Retinal

Detachment

4A Macula

on

4B Macula

off

582019

34

ihabsaadhotmailcom

Stage 4 ROP

Dragging of

the macular

area

ihabsaadhotmailcom

High myopia

VA 04

Lens sparing vitrectomy

582019

35

ihabsaadhotmailcom

Stage 5 ROP

A STAGE WE HATE TO SEE

ihabsaadhotmailcom

Stage 5 Total funnel RD

582019

36

ihabsaadhotmailcom

Bilateral Stage 5b in infancy =

bilateral blindness

ihabsaadhotmailcom

Management

bull Pars PlicataLensectomyVitrectomy

ndash Closed PPV

582019

37

ihabsaadhotmailcom

ihabsaadhotmailcom

Visual Rehabilitation-F up

582019

38

Localization of Pars plicata

ihabsaadhotmailcom

Avoid the fold

Where to place infusion

bull Infants distance from

limbus

bull 0-6 months 15 mm

6-12 months 25 mm

bull 12-24 months 3 mm

582019

19

Retinopathy of Prematurity

Zone 1 centered around macula

Zone 2 mid-periphery and to edge closest to nose

Zone 3 crescent shaped

temporally

ihabsaadhotmailcom

Zones= Defines degree of

ischemia

6 mm

582019

20

ihabsaadhotmailcomSevere plus disease with stage 1 in zone 2

Zone 1 Zone 2

2x discfovea distance

ihabsaadhotmailcom

avascular retina

shunt vessel

Early stage 1

zone 1 zone 2

582019

21

ihabsaadhotmailcom

Plus disease = Vascular

Incompetence

The posterior veins are enlarged and

the arterioles are tortuous in ge 2

Threshold disease

bull Five contiguous or

eight cumulative clock

hours of stage 3

disease in zones I or

II in the presence of

plus disease

bull Increased likelihood

of developing a retinal

detachment by 50

ihabsaadhotmailcom

582019

22

1930

1980 1970 1960

19501940

1990 2000 2010

Retrolental

Fibroplasia

First

described

by Terry

Modern

incubators

first

prototype Oxygen

Restrictions

New name

ROP

By Heath

ICROP

CRYO-ROP

ET-ROPBEAT-

ROP

ICROP

Revisite

d

Landmark Studies

bull ICROP (1985 amp 2005)

bull CRYO-ROP (1986-1987)

bull ET-ROP (1999-2001)

bull BEAT-ROP (2008-2010)

582019

23

CRYO-ROP(1986 - 1987)

bull Why ndash To assess the efficacy of treating THRESHOLD

ROP using trans-scleral Cryotherapy instead of observation

bull Study design ndash RCT Cryotherapy vs Observation

bull Main Results ndash Cryotherapy had better functional and Structural

outcomes as compared to observed infants

ET-ROP(1999-2002)

bull Why

ndash To assess the efficacy of treating PRETHRESHOLD (type 1)

ROP using laser retinal ablation

The study introduced the concept of Type 1 and Type 2

ROP

bull Study design

ndash RCT Laser at Threshold Vs Prethreshold )

bull Main Results

ndash Treatment at prethreshold had better functional and

Structural outcomes as compared to later treatment at

threshold

582019

24

BEAT-ROP(2008-2010)bull Why

ndash To assess the efficacy of treating ROP using Intravitreal Anti-VEGF instead of Laser

bull Study design ndash RCT Anti-VEGF vs Laser

bull Main Results ndash Injection was superior to laser in Stage 3

disease especially zone 1

ndash No difference in zone 2 disease

ihabsaadhotmailcom

bull Peripheral Retinal

Ablationndash Indirect diode laser

ophthalmoscopy

ndash Done for stage 3 threshold plus disease

ndash We use confluent burns

582019

25

ihabsaadhotmailcom

ihabsaadhotmailcom

UPDATES Early Treatment

ROP trial bull Type 1 ROP high-risk

prethreshold ROP

ndash Zone I any stage ROP with

plus disease

ndash Zone I stage 3 ROP

without plus disease

ndash Zone II stage 2 or 3 ROP

with plus disease

582019

26

ihabsaadhotmailcom

bull Wait and Watch Policy

ndash Type 2 ROP

bull Zone I stage 1 or 2 ROP without plus disease

bull Zone II stage 3 ROP without plus disease

bull These eyes should be considered for treatment

only if they progress to type 1 or threshold ROP

ET ROP

Zone 1 Zone 2 Stage 1 Stage 2 Plus Stage 3

Type 1 + Y Y +

Type 1 + +

Type 1 + + + +

Type 2 + Y Y -

Type 2 + - +

ihabsaadhotmailcom

582019

27

ihabsaadhotmailcom

Prognosisbull Natural History

ndash Spontaneous regression

ihabsaadhotmailcom

1 week mild reduction

in plus

582019

28

ihabsaadhotmailcom

bull Progression to stages 4 and 5

bull Changes with Stage 3ndash Myopia Age 6-8 months

ndash Amblyopia

bull Arrest of normal postnatal dvpt of central macula

bull Occult hyperoxic retinal necrosis

bull Progressive RPERetinal atrophy

ndash Strabismus

ndash dragging

ndash Equatorial NVE

bull Dragging

ihabsaadhotmailcom

582019

29

ihabsaadhotmailcom

Need for long term follow up

bull Peripheral retinal changesndash Incomplete vascularization

ndash Abnormal straight retinal vessels

ndash Circumferential interconnecting vascular arcades

ndash Retinal pigmentation

ndash Vitreous membranes

ndash Equatorial folds

ndash Lattice-like degeneration

ndash Retinal breaks

ndash Exudative TRD RRD

When a baby needs treatment

bull Refer to treatment center

bull Coordination between units

bull Transport

bull Risks for baby

bull Who goes with

the baby

Or travel to the

baby

582019

30

When a baby needs treatment

Operating theater or neonatal unit

Treat in unit if possible

Portable Diode laser

Pediatric anesthesiologist

neonatologist

Anti-VEGF

bull Ranibuzimab

(Lucentis)

ndash Least effective

ndash Less profound

systemic VEGF

depletion

bull Bevacizumab

(Avastin) Eylea

ndash More effective

ndash Systemic VEGF

depletion (3 months) ihabsaadhotmailcom

582019

31

Case 2

bull Bilateral plus disease S3 zone 1

bull Male

bull Single

bull 30 weeks

bull 1780

bull Mode of delivery CS

First Visit

582019

32

One week post-injection

Six months post injection

582019

33

Pars Plana Vitrectomy in

Stage 4 and 5 ROP

Use of Densiron and trypan

blue Ihab Saad Othman MD FRCS

Professor of Ophthalmology

Cairo University

Director EyeWorld Hospital

Egypt

ihabsaadhotmailcom

ihabsaadhotmailcom

Stage 4 Tractional Retinal

Detachment

4A Macula

on

4B Macula

off

582019

34

ihabsaadhotmailcom

Stage 4 ROP

Dragging of

the macular

area

ihabsaadhotmailcom

High myopia

VA 04

Lens sparing vitrectomy

582019

35

ihabsaadhotmailcom

Stage 5 ROP

A STAGE WE HATE TO SEE

ihabsaadhotmailcom

Stage 5 Total funnel RD

582019

36

ihabsaadhotmailcom

Bilateral Stage 5b in infancy =

bilateral blindness

ihabsaadhotmailcom

Management

bull Pars PlicataLensectomyVitrectomy

ndash Closed PPV

582019

37

ihabsaadhotmailcom

ihabsaadhotmailcom

Visual Rehabilitation-F up

582019

38

Localization of Pars plicata

ihabsaadhotmailcom

Avoid the fold

Where to place infusion

bull Infants distance from

limbus

bull 0-6 months 15 mm

6-12 months 25 mm

bull 12-24 months 3 mm

582019

20

ihabsaadhotmailcomSevere plus disease with stage 1 in zone 2

Zone 1 Zone 2

2x discfovea distance

ihabsaadhotmailcom

avascular retina

shunt vessel

Early stage 1

zone 1 zone 2

582019

21

ihabsaadhotmailcom

Plus disease = Vascular

Incompetence

The posterior veins are enlarged and

the arterioles are tortuous in ge 2

Threshold disease

bull Five contiguous or

eight cumulative clock

hours of stage 3

disease in zones I or

II in the presence of

plus disease

bull Increased likelihood

of developing a retinal

detachment by 50

ihabsaadhotmailcom

582019

22

1930

1980 1970 1960

19501940

1990 2000 2010

Retrolental

Fibroplasia

First

described

by Terry

Modern

incubators

first

prototype Oxygen

Restrictions

New name

ROP

By Heath

ICROP

CRYO-ROP

ET-ROPBEAT-

ROP

ICROP

Revisite

d

Landmark Studies

bull ICROP (1985 amp 2005)

bull CRYO-ROP (1986-1987)

bull ET-ROP (1999-2001)

bull BEAT-ROP (2008-2010)

582019

23

CRYO-ROP(1986 - 1987)

bull Why ndash To assess the efficacy of treating THRESHOLD

ROP using trans-scleral Cryotherapy instead of observation

bull Study design ndash RCT Cryotherapy vs Observation

bull Main Results ndash Cryotherapy had better functional and Structural

outcomes as compared to observed infants

ET-ROP(1999-2002)

bull Why

ndash To assess the efficacy of treating PRETHRESHOLD (type 1)

ROP using laser retinal ablation

The study introduced the concept of Type 1 and Type 2

ROP

bull Study design

ndash RCT Laser at Threshold Vs Prethreshold )

bull Main Results

ndash Treatment at prethreshold had better functional and

Structural outcomes as compared to later treatment at

threshold

582019

24

BEAT-ROP(2008-2010)bull Why

ndash To assess the efficacy of treating ROP using Intravitreal Anti-VEGF instead of Laser

bull Study design ndash RCT Anti-VEGF vs Laser

bull Main Results ndash Injection was superior to laser in Stage 3

disease especially zone 1

ndash No difference in zone 2 disease

ihabsaadhotmailcom

bull Peripheral Retinal

Ablationndash Indirect diode laser

ophthalmoscopy

ndash Done for stage 3 threshold plus disease

ndash We use confluent burns

582019

25

ihabsaadhotmailcom

ihabsaadhotmailcom

UPDATES Early Treatment

ROP trial bull Type 1 ROP high-risk

prethreshold ROP

ndash Zone I any stage ROP with

plus disease

ndash Zone I stage 3 ROP

without plus disease

ndash Zone II stage 2 or 3 ROP

with plus disease

582019

26

ihabsaadhotmailcom

bull Wait and Watch Policy

ndash Type 2 ROP

bull Zone I stage 1 or 2 ROP without plus disease

bull Zone II stage 3 ROP without plus disease

bull These eyes should be considered for treatment

only if they progress to type 1 or threshold ROP

ET ROP

Zone 1 Zone 2 Stage 1 Stage 2 Plus Stage 3

Type 1 + Y Y +

Type 1 + +

Type 1 + + + +

Type 2 + Y Y -

Type 2 + - +

ihabsaadhotmailcom

582019

27

ihabsaadhotmailcom

Prognosisbull Natural History

ndash Spontaneous regression

ihabsaadhotmailcom

1 week mild reduction

in plus

582019

28

ihabsaadhotmailcom

bull Progression to stages 4 and 5

bull Changes with Stage 3ndash Myopia Age 6-8 months

ndash Amblyopia

bull Arrest of normal postnatal dvpt of central macula

bull Occult hyperoxic retinal necrosis

bull Progressive RPERetinal atrophy

ndash Strabismus

ndash dragging

ndash Equatorial NVE

bull Dragging

ihabsaadhotmailcom

582019

29

ihabsaadhotmailcom

Need for long term follow up

bull Peripheral retinal changesndash Incomplete vascularization

ndash Abnormal straight retinal vessels

ndash Circumferential interconnecting vascular arcades

ndash Retinal pigmentation

ndash Vitreous membranes

ndash Equatorial folds

ndash Lattice-like degeneration

ndash Retinal breaks

ndash Exudative TRD RRD

When a baby needs treatment

bull Refer to treatment center

bull Coordination between units

bull Transport

bull Risks for baby

bull Who goes with

the baby

Or travel to the

baby

582019

30

When a baby needs treatment

Operating theater or neonatal unit

Treat in unit if possible

Portable Diode laser

Pediatric anesthesiologist

neonatologist

Anti-VEGF

bull Ranibuzimab

(Lucentis)

ndash Least effective

ndash Less profound

systemic VEGF

depletion

bull Bevacizumab

(Avastin) Eylea

ndash More effective

ndash Systemic VEGF

depletion (3 months) ihabsaadhotmailcom

582019

31

Case 2

bull Bilateral plus disease S3 zone 1

bull Male

bull Single

bull 30 weeks

bull 1780

bull Mode of delivery CS

First Visit

582019

32

One week post-injection

Six months post injection

582019

33

Pars Plana Vitrectomy in

Stage 4 and 5 ROP

Use of Densiron and trypan

blue Ihab Saad Othman MD FRCS

Professor of Ophthalmology

Cairo University

Director EyeWorld Hospital

Egypt

ihabsaadhotmailcom

ihabsaadhotmailcom

Stage 4 Tractional Retinal

Detachment

4A Macula

on

4B Macula

off

582019

34

ihabsaadhotmailcom

Stage 4 ROP

Dragging of

the macular

area

ihabsaadhotmailcom

High myopia

VA 04

Lens sparing vitrectomy

582019

35

ihabsaadhotmailcom

Stage 5 ROP

A STAGE WE HATE TO SEE

ihabsaadhotmailcom

Stage 5 Total funnel RD

582019

36

ihabsaadhotmailcom

Bilateral Stage 5b in infancy =

bilateral blindness

ihabsaadhotmailcom

Management

bull Pars PlicataLensectomyVitrectomy

ndash Closed PPV

582019

37

ihabsaadhotmailcom

ihabsaadhotmailcom

Visual Rehabilitation-F up

582019

38

Localization of Pars plicata

ihabsaadhotmailcom

Avoid the fold

Where to place infusion

bull Infants distance from

limbus

bull 0-6 months 15 mm

6-12 months 25 mm

bull 12-24 months 3 mm

582019

21

ihabsaadhotmailcom

Plus disease = Vascular

Incompetence

The posterior veins are enlarged and

the arterioles are tortuous in ge 2

Threshold disease

bull Five contiguous or

eight cumulative clock

hours of stage 3

disease in zones I or

II in the presence of

plus disease

bull Increased likelihood

of developing a retinal

detachment by 50

ihabsaadhotmailcom

582019

22

1930

1980 1970 1960

19501940

1990 2000 2010

Retrolental

Fibroplasia

First

described

by Terry

Modern

incubators

first

prototype Oxygen

Restrictions

New name

ROP

By Heath

ICROP

CRYO-ROP

ET-ROPBEAT-

ROP

ICROP

Revisite

d

Landmark Studies

bull ICROP (1985 amp 2005)

bull CRYO-ROP (1986-1987)

bull ET-ROP (1999-2001)

bull BEAT-ROP (2008-2010)

582019

23

CRYO-ROP(1986 - 1987)

bull Why ndash To assess the efficacy of treating THRESHOLD

ROP using trans-scleral Cryotherapy instead of observation

bull Study design ndash RCT Cryotherapy vs Observation

bull Main Results ndash Cryotherapy had better functional and Structural

outcomes as compared to observed infants

ET-ROP(1999-2002)

bull Why

ndash To assess the efficacy of treating PRETHRESHOLD (type 1)

ROP using laser retinal ablation

The study introduced the concept of Type 1 and Type 2

ROP

bull Study design

ndash RCT Laser at Threshold Vs Prethreshold )

bull Main Results

ndash Treatment at prethreshold had better functional and

Structural outcomes as compared to later treatment at

threshold

582019

24

BEAT-ROP(2008-2010)bull Why

ndash To assess the efficacy of treating ROP using Intravitreal Anti-VEGF instead of Laser

bull Study design ndash RCT Anti-VEGF vs Laser

bull Main Results ndash Injection was superior to laser in Stage 3

disease especially zone 1

ndash No difference in zone 2 disease

ihabsaadhotmailcom

bull Peripheral Retinal

Ablationndash Indirect diode laser

ophthalmoscopy

ndash Done for stage 3 threshold plus disease

ndash We use confluent burns

582019

25

ihabsaadhotmailcom

ihabsaadhotmailcom

UPDATES Early Treatment

ROP trial bull Type 1 ROP high-risk

prethreshold ROP

ndash Zone I any stage ROP with

plus disease

ndash Zone I stage 3 ROP

without plus disease

ndash Zone II stage 2 or 3 ROP

with plus disease

582019

26

ihabsaadhotmailcom

bull Wait and Watch Policy

ndash Type 2 ROP

bull Zone I stage 1 or 2 ROP without plus disease

bull Zone II stage 3 ROP without plus disease

bull These eyes should be considered for treatment

only if they progress to type 1 or threshold ROP

ET ROP

Zone 1 Zone 2 Stage 1 Stage 2 Plus Stage 3

Type 1 + Y Y +

Type 1 + +

Type 1 + + + +

Type 2 + Y Y -

Type 2 + - +

ihabsaadhotmailcom

582019

27

ihabsaadhotmailcom

Prognosisbull Natural History

ndash Spontaneous regression

ihabsaadhotmailcom

1 week mild reduction

in plus

582019

28

ihabsaadhotmailcom

bull Progression to stages 4 and 5

bull Changes with Stage 3ndash Myopia Age 6-8 months

ndash Amblyopia

bull Arrest of normal postnatal dvpt of central macula

bull Occult hyperoxic retinal necrosis

bull Progressive RPERetinal atrophy

ndash Strabismus

ndash dragging

ndash Equatorial NVE

bull Dragging

ihabsaadhotmailcom

582019

29

ihabsaadhotmailcom

Need for long term follow up

bull Peripheral retinal changesndash Incomplete vascularization

ndash Abnormal straight retinal vessels

ndash Circumferential interconnecting vascular arcades

ndash Retinal pigmentation

ndash Vitreous membranes

ndash Equatorial folds

ndash Lattice-like degeneration

ndash Retinal breaks

ndash Exudative TRD RRD

When a baby needs treatment

bull Refer to treatment center

bull Coordination between units

bull Transport

bull Risks for baby

bull Who goes with

the baby

Or travel to the

baby

582019

30

When a baby needs treatment

Operating theater or neonatal unit

Treat in unit if possible

Portable Diode laser

Pediatric anesthesiologist

neonatologist

Anti-VEGF

bull Ranibuzimab

(Lucentis)

ndash Least effective

ndash Less profound

systemic VEGF

depletion

bull Bevacizumab

(Avastin) Eylea

ndash More effective

ndash Systemic VEGF

depletion (3 months) ihabsaadhotmailcom

582019

31

Case 2

bull Bilateral plus disease S3 zone 1

bull Male

bull Single

bull 30 weeks

bull 1780

bull Mode of delivery CS

First Visit

582019

32

One week post-injection

Six months post injection

582019

33

Pars Plana Vitrectomy in

Stage 4 and 5 ROP

Use of Densiron and trypan

blue Ihab Saad Othman MD FRCS

Professor of Ophthalmology

Cairo University

Director EyeWorld Hospital

Egypt

ihabsaadhotmailcom

ihabsaadhotmailcom

Stage 4 Tractional Retinal

Detachment

4A Macula

on

4B Macula

off

582019

34

ihabsaadhotmailcom

Stage 4 ROP

Dragging of

the macular

area

ihabsaadhotmailcom

High myopia

VA 04

Lens sparing vitrectomy

582019

35

ihabsaadhotmailcom

Stage 5 ROP

A STAGE WE HATE TO SEE

ihabsaadhotmailcom

Stage 5 Total funnel RD

582019

36

ihabsaadhotmailcom

Bilateral Stage 5b in infancy =

bilateral blindness

ihabsaadhotmailcom

Management

bull Pars PlicataLensectomyVitrectomy

ndash Closed PPV

582019

37

ihabsaadhotmailcom

ihabsaadhotmailcom

Visual Rehabilitation-F up

582019

38

Localization of Pars plicata

ihabsaadhotmailcom

Avoid the fold

Where to place infusion

bull Infants distance from

limbus

bull 0-6 months 15 mm

6-12 months 25 mm

bull 12-24 months 3 mm

582019

22

1930

1980 1970 1960

19501940

1990 2000 2010

Retrolental

Fibroplasia

First

described

by Terry

Modern

incubators

first

prototype Oxygen

Restrictions

New name

ROP

By Heath

ICROP

CRYO-ROP

ET-ROPBEAT-

ROP

ICROP

Revisite

d

Landmark Studies

bull ICROP (1985 amp 2005)

bull CRYO-ROP (1986-1987)

bull ET-ROP (1999-2001)

bull BEAT-ROP (2008-2010)

582019

23

CRYO-ROP(1986 - 1987)

bull Why ndash To assess the efficacy of treating THRESHOLD

ROP using trans-scleral Cryotherapy instead of observation

bull Study design ndash RCT Cryotherapy vs Observation

bull Main Results ndash Cryotherapy had better functional and Structural

outcomes as compared to observed infants

ET-ROP(1999-2002)

bull Why

ndash To assess the efficacy of treating PRETHRESHOLD (type 1)

ROP using laser retinal ablation

The study introduced the concept of Type 1 and Type 2

ROP

bull Study design

ndash RCT Laser at Threshold Vs Prethreshold )

bull Main Results

ndash Treatment at prethreshold had better functional and

Structural outcomes as compared to later treatment at

threshold

582019

24

BEAT-ROP(2008-2010)bull Why

ndash To assess the efficacy of treating ROP using Intravitreal Anti-VEGF instead of Laser

bull Study design ndash RCT Anti-VEGF vs Laser

bull Main Results ndash Injection was superior to laser in Stage 3

disease especially zone 1

ndash No difference in zone 2 disease

ihabsaadhotmailcom

bull Peripheral Retinal

Ablationndash Indirect diode laser

ophthalmoscopy

ndash Done for stage 3 threshold plus disease

ndash We use confluent burns

582019

25

ihabsaadhotmailcom

ihabsaadhotmailcom

UPDATES Early Treatment

ROP trial bull Type 1 ROP high-risk

prethreshold ROP

ndash Zone I any stage ROP with

plus disease

ndash Zone I stage 3 ROP

without plus disease

ndash Zone II stage 2 or 3 ROP

with plus disease

582019

26

ihabsaadhotmailcom

bull Wait and Watch Policy

ndash Type 2 ROP

bull Zone I stage 1 or 2 ROP without plus disease

bull Zone II stage 3 ROP without plus disease

bull These eyes should be considered for treatment

only if they progress to type 1 or threshold ROP

ET ROP

Zone 1 Zone 2 Stage 1 Stage 2 Plus Stage 3

Type 1 + Y Y +

Type 1 + +

Type 1 + + + +

Type 2 + Y Y -

Type 2 + - +

ihabsaadhotmailcom

582019

27

ihabsaadhotmailcom

Prognosisbull Natural History

ndash Spontaneous regression

ihabsaadhotmailcom

1 week mild reduction

in plus

582019

28

ihabsaadhotmailcom

bull Progression to stages 4 and 5

bull Changes with Stage 3ndash Myopia Age 6-8 months

ndash Amblyopia

bull Arrest of normal postnatal dvpt of central macula

bull Occult hyperoxic retinal necrosis

bull Progressive RPERetinal atrophy

ndash Strabismus

ndash dragging

ndash Equatorial NVE

bull Dragging

ihabsaadhotmailcom

582019

29

ihabsaadhotmailcom

Need for long term follow up

bull Peripheral retinal changesndash Incomplete vascularization

ndash Abnormal straight retinal vessels

ndash Circumferential interconnecting vascular arcades

ndash Retinal pigmentation

ndash Vitreous membranes

ndash Equatorial folds

ndash Lattice-like degeneration

ndash Retinal breaks

ndash Exudative TRD RRD

When a baby needs treatment

bull Refer to treatment center

bull Coordination between units

bull Transport

bull Risks for baby

bull Who goes with

the baby

Or travel to the

baby

582019

30

When a baby needs treatment

Operating theater or neonatal unit

Treat in unit if possible

Portable Diode laser

Pediatric anesthesiologist

neonatologist

Anti-VEGF

bull Ranibuzimab

(Lucentis)

ndash Least effective

ndash Less profound

systemic VEGF

depletion

bull Bevacizumab

(Avastin) Eylea

ndash More effective

ndash Systemic VEGF

depletion (3 months) ihabsaadhotmailcom

582019

31

Case 2

bull Bilateral plus disease S3 zone 1

bull Male

bull Single

bull 30 weeks

bull 1780

bull Mode of delivery CS

First Visit

582019

32

One week post-injection

Six months post injection

582019

33

Pars Plana Vitrectomy in

Stage 4 and 5 ROP

Use of Densiron and trypan

blue Ihab Saad Othman MD FRCS

Professor of Ophthalmology

Cairo University

Director EyeWorld Hospital

Egypt

ihabsaadhotmailcom

ihabsaadhotmailcom

Stage 4 Tractional Retinal

Detachment

4A Macula

on

4B Macula

off

582019

34

ihabsaadhotmailcom

Stage 4 ROP

Dragging of

the macular

area

ihabsaadhotmailcom

High myopia

VA 04

Lens sparing vitrectomy

582019

35

ihabsaadhotmailcom

Stage 5 ROP

A STAGE WE HATE TO SEE

ihabsaadhotmailcom

Stage 5 Total funnel RD

582019

36

ihabsaadhotmailcom

Bilateral Stage 5b in infancy =

bilateral blindness

ihabsaadhotmailcom

Management

bull Pars PlicataLensectomyVitrectomy

ndash Closed PPV

582019

37

ihabsaadhotmailcom

ihabsaadhotmailcom

Visual Rehabilitation-F up

582019

38

Localization of Pars plicata

ihabsaadhotmailcom

Avoid the fold

Where to place infusion

bull Infants distance from

limbus

bull 0-6 months 15 mm

6-12 months 25 mm

bull 12-24 months 3 mm

582019

23

CRYO-ROP(1986 - 1987)

bull Why ndash To assess the efficacy of treating THRESHOLD

ROP using trans-scleral Cryotherapy instead of observation

bull Study design ndash RCT Cryotherapy vs Observation

bull Main Results ndash Cryotherapy had better functional and Structural

outcomes as compared to observed infants

ET-ROP(1999-2002)

bull Why

ndash To assess the efficacy of treating PRETHRESHOLD (type 1)

ROP using laser retinal ablation

The study introduced the concept of Type 1 and Type 2

ROP

bull Study design

ndash RCT Laser at Threshold Vs Prethreshold )

bull Main Results

ndash Treatment at prethreshold had better functional and

Structural outcomes as compared to later treatment at

threshold

582019

24

BEAT-ROP(2008-2010)bull Why

ndash To assess the efficacy of treating ROP using Intravitreal Anti-VEGF instead of Laser

bull Study design ndash RCT Anti-VEGF vs Laser

bull Main Results ndash Injection was superior to laser in Stage 3

disease especially zone 1

ndash No difference in zone 2 disease

ihabsaadhotmailcom

bull Peripheral Retinal

Ablationndash Indirect diode laser

ophthalmoscopy

ndash Done for stage 3 threshold plus disease

ndash We use confluent burns

582019

25

ihabsaadhotmailcom

ihabsaadhotmailcom

UPDATES Early Treatment

ROP trial bull Type 1 ROP high-risk

prethreshold ROP

ndash Zone I any stage ROP with

plus disease

ndash Zone I stage 3 ROP

without plus disease

ndash Zone II stage 2 or 3 ROP

with plus disease

582019

26

ihabsaadhotmailcom

bull Wait and Watch Policy

ndash Type 2 ROP

bull Zone I stage 1 or 2 ROP without plus disease

bull Zone II stage 3 ROP without plus disease

bull These eyes should be considered for treatment

only if they progress to type 1 or threshold ROP

ET ROP

Zone 1 Zone 2 Stage 1 Stage 2 Plus Stage 3

Type 1 + Y Y +

Type 1 + +

Type 1 + + + +

Type 2 + Y Y -

Type 2 + - +

ihabsaadhotmailcom

582019

27

ihabsaadhotmailcom

Prognosisbull Natural History

ndash Spontaneous regression

ihabsaadhotmailcom

1 week mild reduction

in plus

582019

28

ihabsaadhotmailcom

bull Progression to stages 4 and 5

bull Changes with Stage 3ndash Myopia Age 6-8 months

ndash Amblyopia

bull Arrest of normal postnatal dvpt of central macula

bull Occult hyperoxic retinal necrosis

bull Progressive RPERetinal atrophy

ndash Strabismus

ndash dragging

ndash Equatorial NVE

bull Dragging

ihabsaadhotmailcom

582019

29

ihabsaadhotmailcom

Need for long term follow up

bull Peripheral retinal changesndash Incomplete vascularization

ndash Abnormal straight retinal vessels

ndash Circumferential interconnecting vascular arcades

ndash Retinal pigmentation

ndash Vitreous membranes

ndash Equatorial folds

ndash Lattice-like degeneration

ndash Retinal breaks

ndash Exudative TRD RRD

When a baby needs treatment

bull Refer to treatment center

bull Coordination between units

bull Transport

bull Risks for baby

bull Who goes with

the baby

Or travel to the

baby

582019

30

When a baby needs treatment

Operating theater or neonatal unit

Treat in unit if possible

Portable Diode laser

Pediatric anesthesiologist

neonatologist

Anti-VEGF

bull Ranibuzimab

(Lucentis)

ndash Least effective

ndash Less profound

systemic VEGF

depletion

bull Bevacizumab

(Avastin) Eylea

ndash More effective

ndash Systemic VEGF

depletion (3 months) ihabsaadhotmailcom

582019

31

Case 2

bull Bilateral plus disease S3 zone 1

bull Male

bull Single

bull 30 weeks

bull 1780

bull Mode of delivery CS

First Visit

582019

32

One week post-injection

Six months post injection

582019

33

Pars Plana Vitrectomy in

Stage 4 and 5 ROP

Use of Densiron and trypan

blue Ihab Saad Othman MD FRCS

Professor of Ophthalmology

Cairo University

Director EyeWorld Hospital

Egypt

ihabsaadhotmailcom

ihabsaadhotmailcom

Stage 4 Tractional Retinal

Detachment

4A Macula

on

4B Macula

off

582019

34

ihabsaadhotmailcom

Stage 4 ROP

Dragging of

the macular

area

ihabsaadhotmailcom

High myopia

VA 04

Lens sparing vitrectomy

582019

35

ihabsaadhotmailcom

Stage 5 ROP

A STAGE WE HATE TO SEE

ihabsaadhotmailcom

Stage 5 Total funnel RD

582019

36

ihabsaadhotmailcom

Bilateral Stage 5b in infancy =

bilateral blindness

ihabsaadhotmailcom

Management

bull Pars PlicataLensectomyVitrectomy

ndash Closed PPV

582019

37

ihabsaadhotmailcom

ihabsaadhotmailcom

Visual Rehabilitation-F up

582019

38

Localization of Pars plicata

ihabsaadhotmailcom

Avoid the fold

Where to place infusion

bull Infants distance from

limbus

bull 0-6 months 15 mm

6-12 months 25 mm

bull 12-24 months 3 mm

582019

24

BEAT-ROP(2008-2010)bull Why

ndash To assess the efficacy of treating ROP using Intravitreal Anti-VEGF instead of Laser

bull Study design ndash RCT Anti-VEGF vs Laser

bull Main Results ndash Injection was superior to laser in Stage 3

disease especially zone 1

ndash No difference in zone 2 disease

ihabsaadhotmailcom

bull Peripheral Retinal

Ablationndash Indirect diode laser

ophthalmoscopy

ndash Done for stage 3 threshold plus disease

ndash We use confluent burns

582019

25

ihabsaadhotmailcom

ihabsaadhotmailcom

UPDATES Early Treatment

ROP trial bull Type 1 ROP high-risk

prethreshold ROP

ndash Zone I any stage ROP with

plus disease

ndash Zone I stage 3 ROP

without plus disease

ndash Zone II stage 2 or 3 ROP

with plus disease

582019

26

ihabsaadhotmailcom

bull Wait and Watch Policy

ndash Type 2 ROP

bull Zone I stage 1 or 2 ROP without plus disease

bull Zone II stage 3 ROP without plus disease

bull These eyes should be considered for treatment

only if they progress to type 1 or threshold ROP

ET ROP

Zone 1 Zone 2 Stage 1 Stage 2 Plus Stage 3

Type 1 + Y Y +

Type 1 + +

Type 1 + + + +

Type 2 + Y Y -

Type 2 + - +

ihabsaadhotmailcom

582019

27

ihabsaadhotmailcom

Prognosisbull Natural History

ndash Spontaneous regression

ihabsaadhotmailcom

1 week mild reduction

in plus

582019

28

ihabsaadhotmailcom

bull Progression to stages 4 and 5

bull Changes with Stage 3ndash Myopia Age 6-8 months

ndash Amblyopia

bull Arrest of normal postnatal dvpt of central macula

bull Occult hyperoxic retinal necrosis

bull Progressive RPERetinal atrophy

ndash Strabismus

ndash dragging

ndash Equatorial NVE

bull Dragging

ihabsaadhotmailcom

582019

29

ihabsaadhotmailcom

Need for long term follow up

bull Peripheral retinal changesndash Incomplete vascularization

ndash Abnormal straight retinal vessels

ndash Circumferential interconnecting vascular arcades

ndash Retinal pigmentation

ndash Vitreous membranes

ndash Equatorial folds

ndash Lattice-like degeneration

ndash Retinal breaks

ndash Exudative TRD RRD

When a baby needs treatment

bull Refer to treatment center

bull Coordination between units

bull Transport

bull Risks for baby

bull Who goes with

the baby

Or travel to the

baby

582019

30

When a baby needs treatment

Operating theater or neonatal unit

Treat in unit if possible

Portable Diode laser

Pediatric anesthesiologist

neonatologist

Anti-VEGF

bull Ranibuzimab

(Lucentis)

ndash Least effective

ndash Less profound

systemic VEGF

depletion

bull Bevacizumab

(Avastin) Eylea

ndash More effective

ndash Systemic VEGF

depletion (3 months) ihabsaadhotmailcom

582019

31

Case 2

bull Bilateral plus disease S3 zone 1

bull Male

bull Single

bull 30 weeks

bull 1780

bull Mode of delivery CS

First Visit

582019

32

One week post-injection

Six months post injection

582019

33

Pars Plana Vitrectomy in

Stage 4 and 5 ROP

Use of Densiron and trypan

blue Ihab Saad Othman MD FRCS

Professor of Ophthalmology

Cairo University

Director EyeWorld Hospital

Egypt

ihabsaadhotmailcom

ihabsaadhotmailcom

Stage 4 Tractional Retinal

Detachment

4A Macula

on

4B Macula

off

582019

34

ihabsaadhotmailcom

Stage 4 ROP

Dragging of

the macular

area

ihabsaadhotmailcom

High myopia

VA 04

Lens sparing vitrectomy

582019

35

ihabsaadhotmailcom

Stage 5 ROP

A STAGE WE HATE TO SEE

ihabsaadhotmailcom

Stage 5 Total funnel RD

582019

36

ihabsaadhotmailcom

Bilateral Stage 5b in infancy =

bilateral blindness

ihabsaadhotmailcom

Management

bull Pars PlicataLensectomyVitrectomy

ndash Closed PPV

582019

37

ihabsaadhotmailcom

ihabsaadhotmailcom

Visual Rehabilitation-F up

582019

38

Localization of Pars plicata

ihabsaadhotmailcom

Avoid the fold

Where to place infusion

bull Infants distance from

limbus

bull 0-6 months 15 mm

6-12 months 25 mm

bull 12-24 months 3 mm

582019

25

ihabsaadhotmailcom

ihabsaadhotmailcom

UPDATES Early Treatment

ROP trial bull Type 1 ROP high-risk

prethreshold ROP

ndash Zone I any stage ROP with

plus disease

ndash Zone I stage 3 ROP

without plus disease

ndash Zone II stage 2 or 3 ROP

with plus disease

582019

26

ihabsaadhotmailcom

bull Wait and Watch Policy

ndash Type 2 ROP

bull Zone I stage 1 or 2 ROP without plus disease

bull Zone II stage 3 ROP without plus disease

bull These eyes should be considered for treatment

only if they progress to type 1 or threshold ROP

ET ROP

Zone 1 Zone 2 Stage 1 Stage 2 Plus Stage 3

Type 1 + Y Y +

Type 1 + +

Type 1 + + + +

Type 2 + Y Y -

Type 2 + - +

ihabsaadhotmailcom

582019

27

ihabsaadhotmailcom

Prognosisbull Natural History

ndash Spontaneous regression

ihabsaadhotmailcom

1 week mild reduction

in plus

582019

28

ihabsaadhotmailcom

bull Progression to stages 4 and 5

bull Changes with Stage 3ndash Myopia Age 6-8 months

ndash Amblyopia

bull Arrest of normal postnatal dvpt of central macula

bull Occult hyperoxic retinal necrosis

bull Progressive RPERetinal atrophy

ndash Strabismus

ndash dragging

ndash Equatorial NVE

bull Dragging

ihabsaadhotmailcom

582019

29

ihabsaadhotmailcom

Need for long term follow up

bull Peripheral retinal changesndash Incomplete vascularization

ndash Abnormal straight retinal vessels

ndash Circumferential interconnecting vascular arcades

ndash Retinal pigmentation

ndash Vitreous membranes

ndash Equatorial folds

ndash Lattice-like degeneration

ndash Retinal breaks

ndash Exudative TRD RRD

When a baby needs treatment

bull Refer to treatment center

bull Coordination between units

bull Transport

bull Risks for baby

bull Who goes with

the baby

Or travel to the

baby

582019

30

When a baby needs treatment

Operating theater or neonatal unit

Treat in unit if possible

Portable Diode laser

Pediatric anesthesiologist

neonatologist

Anti-VEGF

bull Ranibuzimab

(Lucentis)

ndash Least effective

ndash Less profound

systemic VEGF

depletion

bull Bevacizumab

(Avastin) Eylea

ndash More effective

ndash Systemic VEGF

depletion (3 months) ihabsaadhotmailcom

582019

31

Case 2

bull Bilateral plus disease S3 zone 1

bull Male

bull Single

bull 30 weeks

bull 1780

bull Mode of delivery CS

First Visit

582019

32

One week post-injection

Six months post injection

582019

33

Pars Plana Vitrectomy in

Stage 4 and 5 ROP

Use of Densiron and trypan

blue Ihab Saad Othman MD FRCS

Professor of Ophthalmology

Cairo University

Director EyeWorld Hospital

Egypt

ihabsaadhotmailcom

ihabsaadhotmailcom

Stage 4 Tractional Retinal

Detachment

4A Macula

on

4B Macula

off

582019

34

ihabsaadhotmailcom

Stage 4 ROP

Dragging of

the macular

area

ihabsaadhotmailcom

High myopia

VA 04

Lens sparing vitrectomy

582019

35

ihabsaadhotmailcom

Stage 5 ROP

A STAGE WE HATE TO SEE

ihabsaadhotmailcom

Stage 5 Total funnel RD

582019

36

ihabsaadhotmailcom

Bilateral Stage 5b in infancy =

bilateral blindness

ihabsaadhotmailcom

Management

bull Pars PlicataLensectomyVitrectomy

ndash Closed PPV

582019

37

ihabsaadhotmailcom

ihabsaadhotmailcom

Visual Rehabilitation-F up

582019

38

Localization of Pars plicata

ihabsaadhotmailcom

Avoid the fold

Where to place infusion

bull Infants distance from

limbus

bull 0-6 months 15 mm

6-12 months 25 mm

bull 12-24 months 3 mm

582019

26

ihabsaadhotmailcom

bull Wait and Watch Policy

ndash Type 2 ROP

bull Zone I stage 1 or 2 ROP without plus disease

bull Zone II stage 3 ROP without plus disease

bull These eyes should be considered for treatment

only if they progress to type 1 or threshold ROP

ET ROP

Zone 1 Zone 2 Stage 1 Stage 2 Plus Stage 3

Type 1 + Y Y +

Type 1 + +

Type 1 + + + +

Type 2 + Y Y -

Type 2 + - +

ihabsaadhotmailcom

582019

27

ihabsaadhotmailcom

Prognosisbull Natural History

ndash Spontaneous regression

ihabsaadhotmailcom

1 week mild reduction

in plus

582019

28

ihabsaadhotmailcom

bull Progression to stages 4 and 5

bull Changes with Stage 3ndash Myopia Age 6-8 months

ndash Amblyopia

bull Arrest of normal postnatal dvpt of central macula

bull Occult hyperoxic retinal necrosis

bull Progressive RPERetinal atrophy

ndash Strabismus

ndash dragging

ndash Equatorial NVE

bull Dragging

ihabsaadhotmailcom

582019

29

ihabsaadhotmailcom

Need for long term follow up

bull Peripheral retinal changesndash Incomplete vascularization

ndash Abnormal straight retinal vessels

ndash Circumferential interconnecting vascular arcades

ndash Retinal pigmentation

ndash Vitreous membranes

ndash Equatorial folds

ndash Lattice-like degeneration

ndash Retinal breaks

ndash Exudative TRD RRD

When a baby needs treatment

bull Refer to treatment center

bull Coordination between units

bull Transport

bull Risks for baby

bull Who goes with

the baby

Or travel to the

baby

582019

30

When a baby needs treatment

Operating theater or neonatal unit

Treat in unit if possible

Portable Diode laser

Pediatric anesthesiologist

neonatologist

Anti-VEGF

bull Ranibuzimab

(Lucentis)

ndash Least effective

ndash Less profound

systemic VEGF

depletion

bull Bevacizumab

(Avastin) Eylea

ndash More effective

ndash Systemic VEGF

depletion (3 months) ihabsaadhotmailcom

582019

31

Case 2

bull Bilateral plus disease S3 zone 1

bull Male

bull Single

bull 30 weeks

bull 1780

bull Mode of delivery CS

First Visit

582019

32

One week post-injection

Six months post injection

582019

33

Pars Plana Vitrectomy in

Stage 4 and 5 ROP

Use of Densiron and trypan

blue Ihab Saad Othman MD FRCS

Professor of Ophthalmology

Cairo University

Director EyeWorld Hospital

Egypt

ihabsaadhotmailcom

ihabsaadhotmailcom

Stage 4 Tractional Retinal

Detachment

4A Macula

on

4B Macula

off

582019

34

ihabsaadhotmailcom

Stage 4 ROP

Dragging of

the macular

area

ihabsaadhotmailcom

High myopia

VA 04

Lens sparing vitrectomy

582019

35

ihabsaadhotmailcom

Stage 5 ROP

A STAGE WE HATE TO SEE

ihabsaadhotmailcom

Stage 5 Total funnel RD

582019

36

ihabsaadhotmailcom

Bilateral Stage 5b in infancy =

bilateral blindness

ihabsaadhotmailcom

Management

bull Pars PlicataLensectomyVitrectomy

ndash Closed PPV

582019

37

ihabsaadhotmailcom

ihabsaadhotmailcom

Visual Rehabilitation-F up

582019

38

Localization of Pars plicata

ihabsaadhotmailcom

Avoid the fold

Where to place infusion

bull Infants distance from

limbus

bull 0-6 months 15 mm

6-12 months 25 mm

bull 12-24 months 3 mm

582019

27

ihabsaadhotmailcom

Prognosisbull Natural History

ndash Spontaneous regression

ihabsaadhotmailcom

1 week mild reduction

in plus

582019

28

ihabsaadhotmailcom

bull Progression to stages 4 and 5

bull Changes with Stage 3ndash Myopia Age 6-8 months

ndash Amblyopia

bull Arrest of normal postnatal dvpt of central macula

bull Occult hyperoxic retinal necrosis

bull Progressive RPERetinal atrophy

ndash Strabismus

ndash dragging

ndash Equatorial NVE

bull Dragging

ihabsaadhotmailcom

582019

29

ihabsaadhotmailcom

Need for long term follow up

bull Peripheral retinal changesndash Incomplete vascularization

ndash Abnormal straight retinal vessels

ndash Circumferential interconnecting vascular arcades

ndash Retinal pigmentation

ndash Vitreous membranes

ndash Equatorial folds

ndash Lattice-like degeneration

ndash Retinal breaks

ndash Exudative TRD RRD

When a baby needs treatment

bull Refer to treatment center

bull Coordination between units

bull Transport

bull Risks for baby

bull Who goes with

the baby

Or travel to the

baby

582019

30

When a baby needs treatment

Operating theater or neonatal unit

Treat in unit if possible

Portable Diode laser

Pediatric anesthesiologist

neonatologist

Anti-VEGF

bull Ranibuzimab

(Lucentis)

ndash Least effective

ndash Less profound

systemic VEGF

depletion

bull Bevacizumab

(Avastin) Eylea

ndash More effective

ndash Systemic VEGF

depletion (3 months) ihabsaadhotmailcom

582019

31

Case 2

bull Bilateral plus disease S3 zone 1

bull Male

bull Single

bull 30 weeks

bull 1780

bull Mode of delivery CS

First Visit

582019

32

One week post-injection

Six months post injection

582019

33

Pars Plana Vitrectomy in

Stage 4 and 5 ROP

Use of Densiron and trypan

blue Ihab Saad Othman MD FRCS

Professor of Ophthalmology

Cairo University

Director EyeWorld Hospital

Egypt

ihabsaadhotmailcom

ihabsaadhotmailcom

Stage 4 Tractional Retinal

Detachment

4A Macula

on

4B Macula

off

582019

34

ihabsaadhotmailcom

Stage 4 ROP

Dragging of

the macular

area

ihabsaadhotmailcom

High myopia

VA 04

Lens sparing vitrectomy

582019

35

ihabsaadhotmailcom

Stage 5 ROP

A STAGE WE HATE TO SEE

ihabsaadhotmailcom

Stage 5 Total funnel RD

582019

36

ihabsaadhotmailcom

Bilateral Stage 5b in infancy =

bilateral blindness

ihabsaadhotmailcom

Management

bull Pars PlicataLensectomyVitrectomy

ndash Closed PPV

582019

37

ihabsaadhotmailcom

ihabsaadhotmailcom

Visual Rehabilitation-F up

582019

38

Localization of Pars plicata

ihabsaadhotmailcom

Avoid the fold

Where to place infusion

bull Infants distance from

limbus

bull 0-6 months 15 mm

6-12 months 25 mm

bull 12-24 months 3 mm

582019

28

ihabsaadhotmailcom

bull Progression to stages 4 and 5

bull Changes with Stage 3ndash Myopia Age 6-8 months

ndash Amblyopia

bull Arrest of normal postnatal dvpt of central macula

bull Occult hyperoxic retinal necrosis

bull Progressive RPERetinal atrophy

ndash Strabismus

ndash dragging

ndash Equatorial NVE

bull Dragging

ihabsaadhotmailcom

582019

29

ihabsaadhotmailcom

Need for long term follow up

bull Peripheral retinal changesndash Incomplete vascularization

ndash Abnormal straight retinal vessels

ndash Circumferential interconnecting vascular arcades

ndash Retinal pigmentation

ndash Vitreous membranes

ndash Equatorial folds

ndash Lattice-like degeneration

ndash Retinal breaks

ndash Exudative TRD RRD

When a baby needs treatment

bull Refer to treatment center

bull Coordination between units

bull Transport

bull Risks for baby

bull Who goes with

the baby

Or travel to the

baby

582019

30

When a baby needs treatment

Operating theater or neonatal unit

Treat in unit if possible

Portable Diode laser

Pediatric anesthesiologist

neonatologist

Anti-VEGF

bull Ranibuzimab

(Lucentis)

ndash Least effective

ndash Less profound

systemic VEGF

depletion

bull Bevacizumab

(Avastin) Eylea

ndash More effective

ndash Systemic VEGF

depletion (3 months) ihabsaadhotmailcom

582019

31

Case 2

bull Bilateral plus disease S3 zone 1

bull Male

bull Single

bull 30 weeks

bull 1780

bull Mode of delivery CS

First Visit

582019

32

One week post-injection

Six months post injection

582019

33

Pars Plana Vitrectomy in

Stage 4 and 5 ROP

Use of Densiron and trypan

blue Ihab Saad Othman MD FRCS

Professor of Ophthalmology

Cairo University

Director EyeWorld Hospital

Egypt

ihabsaadhotmailcom

ihabsaadhotmailcom

Stage 4 Tractional Retinal

Detachment

4A Macula

on

4B Macula

off

582019

34

ihabsaadhotmailcom

Stage 4 ROP

Dragging of

the macular

area

ihabsaadhotmailcom

High myopia

VA 04

Lens sparing vitrectomy

582019

35

ihabsaadhotmailcom

Stage 5 ROP

A STAGE WE HATE TO SEE

ihabsaadhotmailcom

Stage 5 Total funnel RD

582019

36

ihabsaadhotmailcom

Bilateral Stage 5b in infancy =

bilateral blindness

ihabsaadhotmailcom

Management

bull Pars PlicataLensectomyVitrectomy

ndash Closed PPV

582019

37

ihabsaadhotmailcom

ihabsaadhotmailcom

Visual Rehabilitation-F up

582019

38

Localization of Pars plicata

ihabsaadhotmailcom

Avoid the fold

Where to place infusion

bull Infants distance from

limbus

bull 0-6 months 15 mm

6-12 months 25 mm

bull 12-24 months 3 mm

582019

29

ihabsaadhotmailcom

Need for long term follow up

bull Peripheral retinal changesndash Incomplete vascularization

ndash Abnormal straight retinal vessels

ndash Circumferential interconnecting vascular arcades

ndash Retinal pigmentation

ndash Vitreous membranes

ndash Equatorial folds

ndash Lattice-like degeneration

ndash Retinal breaks

ndash Exudative TRD RRD

When a baby needs treatment

bull Refer to treatment center

bull Coordination between units

bull Transport

bull Risks for baby

bull Who goes with

the baby

Or travel to the

baby

582019

30

When a baby needs treatment

Operating theater or neonatal unit

Treat in unit if possible

Portable Diode laser

Pediatric anesthesiologist

neonatologist

Anti-VEGF

bull Ranibuzimab

(Lucentis)

ndash Least effective

ndash Less profound

systemic VEGF

depletion

bull Bevacizumab

(Avastin) Eylea

ndash More effective

ndash Systemic VEGF

depletion (3 months) ihabsaadhotmailcom

582019

31

Case 2

bull Bilateral plus disease S3 zone 1

bull Male

bull Single

bull 30 weeks

bull 1780

bull Mode of delivery CS

First Visit

582019

32

One week post-injection

Six months post injection

582019

33

Pars Plana Vitrectomy in

Stage 4 and 5 ROP

Use of Densiron and trypan

blue Ihab Saad Othman MD FRCS

Professor of Ophthalmology

Cairo University

Director EyeWorld Hospital

Egypt

ihabsaadhotmailcom

ihabsaadhotmailcom

Stage 4 Tractional Retinal

Detachment

4A Macula

on

4B Macula

off

582019

34

ihabsaadhotmailcom

Stage 4 ROP

Dragging of

the macular

area

ihabsaadhotmailcom

High myopia

VA 04

Lens sparing vitrectomy

582019

35

ihabsaadhotmailcom

Stage 5 ROP

A STAGE WE HATE TO SEE

ihabsaadhotmailcom

Stage 5 Total funnel RD

582019

36

ihabsaadhotmailcom

Bilateral Stage 5b in infancy =

bilateral blindness

ihabsaadhotmailcom

Management

bull Pars PlicataLensectomyVitrectomy

ndash Closed PPV

582019

37

ihabsaadhotmailcom

ihabsaadhotmailcom

Visual Rehabilitation-F up

582019

38

Localization of Pars plicata

ihabsaadhotmailcom

Avoid the fold

Where to place infusion

bull Infants distance from

limbus

bull 0-6 months 15 mm

6-12 months 25 mm

bull 12-24 months 3 mm

582019

30

When a baby needs treatment

Operating theater or neonatal unit

Treat in unit if possible

Portable Diode laser

Pediatric anesthesiologist

neonatologist

Anti-VEGF

bull Ranibuzimab

(Lucentis)

ndash Least effective

ndash Less profound

systemic VEGF

depletion

bull Bevacizumab

(Avastin) Eylea

ndash More effective

ndash Systemic VEGF

depletion (3 months) ihabsaadhotmailcom

582019

31

Case 2

bull Bilateral plus disease S3 zone 1

bull Male

bull Single

bull 30 weeks

bull 1780

bull Mode of delivery CS

First Visit

582019

32

One week post-injection

Six months post injection

582019

33

Pars Plana Vitrectomy in

Stage 4 and 5 ROP

Use of Densiron and trypan

blue Ihab Saad Othman MD FRCS

Professor of Ophthalmology

Cairo University

Director EyeWorld Hospital

Egypt

ihabsaadhotmailcom

ihabsaadhotmailcom

Stage 4 Tractional Retinal

Detachment

4A Macula

on

4B Macula

off

582019

34

ihabsaadhotmailcom

Stage 4 ROP

Dragging of

the macular

area

ihabsaadhotmailcom

High myopia

VA 04

Lens sparing vitrectomy

582019

35

ihabsaadhotmailcom

Stage 5 ROP

A STAGE WE HATE TO SEE

ihabsaadhotmailcom

Stage 5 Total funnel RD

582019

36

ihabsaadhotmailcom

Bilateral Stage 5b in infancy =

bilateral blindness

ihabsaadhotmailcom

Management

bull Pars PlicataLensectomyVitrectomy

ndash Closed PPV

582019

37

ihabsaadhotmailcom

ihabsaadhotmailcom

Visual Rehabilitation-F up

582019

38

Localization of Pars plicata

ihabsaadhotmailcom

Avoid the fold

Where to place infusion

bull Infants distance from

limbus

bull 0-6 months 15 mm

6-12 months 25 mm

bull 12-24 months 3 mm

582019

31

Case 2

bull Bilateral plus disease S3 zone 1

bull Male

bull Single

bull 30 weeks

bull 1780

bull Mode of delivery CS

First Visit

582019

32

One week post-injection

Six months post injection

582019

33

Pars Plana Vitrectomy in

Stage 4 and 5 ROP

Use of Densiron and trypan

blue Ihab Saad Othman MD FRCS

Professor of Ophthalmology

Cairo University

Director EyeWorld Hospital

Egypt

ihabsaadhotmailcom

ihabsaadhotmailcom

Stage 4 Tractional Retinal

Detachment

4A Macula

on

4B Macula

off

582019

34

ihabsaadhotmailcom

Stage 4 ROP

Dragging of

the macular

area

ihabsaadhotmailcom

High myopia

VA 04

Lens sparing vitrectomy

582019

35

ihabsaadhotmailcom

Stage 5 ROP

A STAGE WE HATE TO SEE

ihabsaadhotmailcom

Stage 5 Total funnel RD

582019

36

ihabsaadhotmailcom

Bilateral Stage 5b in infancy =

bilateral blindness

ihabsaadhotmailcom

Management

bull Pars PlicataLensectomyVitrectomy

ndash Closed PPV

582019

37

ihabsaadhotmailcom

ihabsaadhotmailcom

Visual Rehabilitation-F up

582019

38

Localization of Pars plicata

ihabsaadhotmailcom

Avoid the fold

Where to place infusion

bull Infants distance from

limbus

bull 0-6 months 15 mm

6-12 months 25 mm

bull 12-24 months 3 mm

582019

32

One week post-injection

Six months post injection

582019

33

Pars Plana Vitrectomy in

Stage 4 and 5 ROP

Use of Densiron and trypan

blue Ihab Saad Othman MD FRCS

Professor of Ophthalmology

Cairo University

Director EyeWorld Hospital

Egypt

ihabsaadhotmailcom

ihabsaadhotmailcom

Stage 4 Tractional Retinal

Detachment

4A Macula

on

4B Macula

off

582019

34

ihabsaadhotmailcom

Stage 4 ROP

Dragging of

the macular

area

ihabsaadhotmailcom

High myopia

VA 04

Lens sparing vitrectomy

582019

35

ihabsaadhotmailcom

Stage 5 ROP

A STAGE WE HATE TO SEE

ihabsaadhotmailcom

Stage 5 Total funnel RD

582019

36

ihabsaadhotmailcom

Bilateral Stage 5b in infancy =

bilateral blindness

ihabsaadhotmailcom

Management

bull Pars PlicataLensectomyVitrectomy

ndash Closed PPV

582019

37

ihabsaadhotmailcom

ihabsaadhotmailcom

Visual Rehabilitation-F up

582019

38

Localization of Pars plicata

ihabsaadhotmailcom

Avoid the fold

Where to place infusion

bull Infants distance from

limbus

bull 0-6 months 15 mm

6-12 months 25 mm

bull 12-24 months 3 mm

582019

33

Pars Plana Vitrectomy in

Stage 4 and 5 ROP

Use of Densiron and trypan

blue Ihab Saad Othman MD FRCS

Professor of Ophthalmology

Cairo University

Director EyeWorld Hospital

Egypt

ihabsaadhotmailcom

ihabsaadhotmailcom

Stage 4 Tractional Retinal

Detachment

4A Macula

on

4B Macula

off

582019

34

ihabsaadhotmailcom

Stage 4 ROP

Dragging of

the macular

area

ihabsaadhotmailcom

High myopia

VA 04

Lens sparing vitrectomy

582019

35

ihabsaadhotmailcom

Stage 5 ROP

A STAGE WE HATE TO SEE

ihabsaadhotmailcom

Stage 5 Total funnel RD

582019

36

ihabsaadhotmailcom

Bilateral Stage 5b in infancy =

bilateral blindness

ihabsaadhotmailcom

Management

bull Pars PlicataLensectomyVitrectomy

ndash Closed PPV

582019

37

ihabsaadhotmailcom

ihabsaadhotmailcom

Visual Rehabilitation-F up

582019

38

Localization of Pars plicata

ihabsaadhotmailcom

Avoid the fold

Where to place infusion

bull Infants distance from

limbus

bull 0-6 months 15 mm

6-12 months 25 mm

bull 12-24 months 3 mm

582019

34

ihabsaadhotmailcom

Stage 4 ROP

Dragging of

the macular

area

ihabsaadhotmailcom

High myopia

VA 04

Lens sparing vitrectomy

582019

35

ihabsaadhotmailcom

Stage 5 ROP

A STAGE WE HATE TO SEE

ihabsaadhotmailcom

Stage 5 Total funnel RD

582019

36

ihabsaadhotmailcom

Bilateral Stage 5b in infancy =

bilateral blindness

ihabsaadhotmailcom

Management

bull Pars PlicataLensectomyVitrectomy

ndash Closed PPV

582019

37

ihabsaadhotmailcom

ihabsaadhotmailcom

Visual Rehabilitation-F up

582019

38

Localization of Pars plicata

ihabsaadhotmailcom

Avoid the fold

Where to place infusion

bull Infants distance from

limbus

bull 0-6 months 15 mm

6-12 months 25 mm

bull 12-24 months 3 mm

582019

35

ihabsaadhotmailcom

Stage 5 ROP

A STAGE WE HATE TO SEE

ihabsaadhotmailcom

Stage 5 Total funnel RD

582019

36

ihabsaadhotmailcom

Bilateral Stage 5b in infancy =

bilateral blindness

ihabsaadhotmailcom

Management

bull Pars PlicataLensectomyVitrectomy

ndash Closed PPV

582019

37

ihabsaadhotmailcom

ihabsaadhotmailcom

Visual Rehabilitation-F up

582019

38

Localization of Pars plicata

ihabsaadhotmailcom

Avoid the fold

Where to place infusion

bull Infants distance from

limbus

bull 0-6 months 15 mm

6-12 months 25 mm

bull 12-24 months 3 mm

582019

36

ihabsaadhotmailcom

Bilateral Stage 5b in infancy =

bilateral blindness

ihabsaadhotmailcom

Management

bull Pars PlicataLensectomyVitrectomy

ndash Closed PPV

582019

37

ihabsaadhotmailcom

ihabsaadhotmailcom

Visual Rehabilitation-F up

582019

38

Localization of Pars plicata

ihabsaadhotmailcom

Avoid the fold

Where to place infusion

bull Infants distance from

limbus

bull 0-6 months 15 mm

6-12 months 25 mm

bull 12-24 months 3 mm

582019

37

ihabsaadhotmailcom

ihabsaadhotmailcom

Visual Rehabilitation-F up

582019

38

Localization of Pars plicata

ihabsaadhotmailcom

Avoid the fold

Where to place infusion

bull Infants distance from

limbus

bull 0-6 months 15 mm

6-12 months 25 mm

bull 12-24 months 3 mm

582019

38

Localization of Pars plicata

ihabsaadhotmailcom

Avoid the fold

Where to place infusion

bull Infants distance from

limbus

bull 0-6 months 15 mm

6-12 months 25 mm

bull 12-24 months 3 mm

582019

39

Stage 5 ROP

ihabsaadhotmailcom

ihabsaadhotmailcom

582019

40

2 months

6 Months

Ambulatory vision

6 month

old male

5 month-old male

582019

41

8 Months

Ambulatory vision

ihabsaadhotmailcom

582019

42

ihabsaadhotmailcom

Removal of Densiron

ihabsaadhotmailcom

582019

43

ihabsaadhotmailcom

OD OS

ihabsaadhotmailcom

582019

44

ihabsaadhotmailcom

ihabsaadhotmailcom

582019

45

ihabsaadhotmailcom

ihabsaadhotmailcom

582019

46

ihabsaadhotmailcom

ihabsaadhotmailcom

582019

47

bull 120 operated cases (2006-2012)

bull Stage 4 ROP

ndash 80 cases

ndash Lens sparing technique 60 cases

ndash Anatomic success 80

ndash Silicone oil use 10

ndash Failures 10

ihabsaadhotmailcom

bull Stage 5 ROP

ndash 48 cases

ndash Success 15 cases (30)

ihabsaadhotmailcom

582019

48

Neurologic ComplicationsAssociated with Prematurity

Global Delays

Motor disability Cerebral Palsy 7-30

Cognitive disability

Autism spectrum

Cortical visual impairment

Discussion

bull Functional and structural visual impairments from ocular and neurological conditions associated with prematurity can be improved by appropriate interventions

582019

49

Interventions

bull Optical correct refractive errors patching (amblyopia) specs (strabismus anisometropia)

bull Surgical ROP strabismus NLD probing

bull Medicalglaucoma strabismus amblyopia

wwwsolobambinicom

Interventions

Trans-disciplinary

bull child with multiple impairments

bull cortical visual impairment delayed visual maturation

bull low vision from

structural defects

582019

50

Conclusion

bull Children born prematurely should have ophthalmologic evaluation and intervention at frequent intervals during first 3 years of life regardless of presence of ROP and amount of prematurity

ihabsaadhotmailcom

httpwwwjmsregnet on Thursday January 10 2019 IP 102327427]

582019

51

ihabsaadhotmailcom

bull IN 2019 IS IT TIME FOR NO MORE BLINDNESS FROM ROP IN EGYPT

582019

52

ihabsaadhotmailcom

582019

40

2 months

6 Months

Ambulatory vision

6 month

old male

5 month-old male

582019

41

8 Months

Ambulatory vision

ihabsaadhotmailcom

582019

42

ihabsaadhotmailcom

Removal of Densiron

ihabsaadhotmailcom

582019

43

ihabsaadhotmailcom

OD OS

ihabsaadhotmailcom

582019

44

ihabsaadhotmailcom

ihabsaadhotmailcom

582019

45

ihabsaadhotmailcom

ihabsaadhotmailcom

582019

46

ihabsaadhotmailcom

ihabsaadhotmailcom

582019

47

bull 120 operated cases (2006-2012)

bull Stage 4 ROP

ndash 80 cases

ndash Lens sparing technique 60 cases

ndash Anatomic success 80

ndash Silicone oil use 10

ndash Failures 10

ihabsaadhotmailcom

bull Stage 5 ROP

ndash 48 cases

ndash Success 15 cases (30)

ihabsaadhotmailcom

582019

48

Neurologic ComplicationsAssociated with Prematurity

Global Delays

Motor disability Cerebral Palsy 7-30

Cognitive disability

Autism spectrum

Cortical visual impairment

Discussion

bull Functional and structural visual impairments from ocular and neurological conditions associated with prematurity can be improved by appropriate interventions

582019

49

Interventions

bull Optical correct refractive errors patching (amblyopia) specs (strabismus anisometropia)

bull Surgical ROP strabismus NLD probing

bull Medicalglaucoma strabismus amblyopia

wwwsolobambinicom

Interventions

Trans-disciplinary

bull child with multiple impairments

bull cortical visual impairment delayed visual maturation

bull low vision from

structural defects

582019

50

Conclusion

bull Children born prematurely should have ophthalmologic evaluation and intervention at frequent intervals during first 3 years of life regardless of presence of ROP and amount of prematurity

ihabsaadhotmailcom

httpwwwjmsregnet on Thursday January 10 2019 IP 102327427]

582019

51

ihabsaadhotmailcom

bull IN 2019 IS IT TIME FOR NO MORE BLINDNESS FROM ROP IN EGYPT

582019

52

ihabsaadhotmailcom

582019

41

8 Months

Ambulatory vision

ihabsaadhotmailcom

582019

42

ihabsaadhotmailcom

Removal of Densiron

ihabsaadhotmailcom

582019

43

ihabsaadhotmailcom

OD OS

ihabsaadhotmailcom

582019

44

ihabsaadhotmailcom

ihabsaadhotmailcom

582019

45

ihabsaadhotmailcom

ihabsaadhotmailcom

582019

46

ihabsaadhotmailcom

ihabsaadhotmailcom

582019

47

bull 120 operated cases (2006-2012)

bull Stage 4 ROP

ndash 80 cases

ndash Lens sparing technique 60 cases

ndash Anatomic success 80

ndash Silicone oil use 10

ndash Failures 10

ihabsaadhotmailcom

bull Stage 5 ROP

ndash 48 cases

ndash Success 15 cases (30)

ihabsaadhotmailcom

582019

48

Neurologic ComplicationsAssociated with Prematurity

Global Delays

Motor disability Cerebral Palsy 7-30

Cognitive disability

Autism spectrum

Cortical visual impairment

Discussion

bull Functional and structural visual impairments from ocular and neurological conditions associated with prematurity can be improved by appropriate interventions

582019

49

Interventions

bull Optical correct refractive errors patching (amblyopia) specs (strabismus anisometropia)

bull Surgical ROP strabismus NLD probing

bull Medicalglaucoma strabismus amblyopia

wwwsolobambinicom

Interventions

Trans-disciplinary

bull child with multiple impairments

bull cortical visual impairment delayed visual maturation

bull low vision from

structural defects

582019

50

Conclusion

bull Children born prematurely should have ophthalmologic evaluation and intervention at frequent intervals during first 3 years of life regardless of presence of ROP and amount of prematurity

ihabsaadhotmailcom

httpwwwjmsregnet on Thursday January 10 2019 IP 102327427]

582019

51

ihabsaadhotmailcom

bull IN 2019 IS IT TIME FOR NO MORE BLINDNESS FROM ROP IN EGYPT

582019

52

ihabsaadhotmailcom

582019

42

ihabsaadhotmailcom

Removal of Densiron

ihabsaadhotmailcom

582019

43

ihabsaadhotmailcom

OD OS

ihabsaadhotmailcom

582019

44

ihabsaadhotmailcom

ihabsaadhotmailcom

582019

45

ihabsaadhotmailcom

ihabsaadhotmailcom

582019

46

ihabsaadhotmailcom

ihabsaadhotmailcom

582019

47

bull 120 operated cases (2006-2012)

bull Stage 4 ROP

ndash 80 cases

ndash Lens sparing technique 60 cases

ndash Anatomic success 80

ndash Silicone oil use 10

ndash Failures 10

ihabsaadhotmailcom

bull Stage 5 ROP

ndash 48 cases

ndash Success 15 cases (30)

ihabsaadhotmailcom

582019

48

Neurologic ComplicationsAssociated with Prematurity

Global Delays

Motor disability Cerebral Palsy 7-30

Cognitive disability

Autism spectrum

Cortical visual impairment

Discussion

bull Functional and structural visual impairments from ocular and neurological conditions associated with prematurity can be improved by appropriate interventions

582019

49

Interventions

bull Optical correct refractive errors patching (amblyopia) specs (strabismus anisometropia)

bull Surgical ROP strabismus NLD probing

bull Medicalglaucoma strabismus amblyopia

wwwsolobambinicom

Interventions

Trans-disciplinary

bull child with multiple impairments

bull cortical visual impairment delayed visual maturation

bull low vision from

structural defects

582019

50

Conclusion

bull Children born prematurely should have ophthalmologic evaluation and intervention at frequent intervals during first 3 years of life regardless of presence of ROP and amount of prematurity

ihabsaadhotmailcom

httpwwwjmsregnet on Thursday January 10 2019 IP 102327427]

582019

51

ihabsaadhotmailcom

bull IN 2019 IS IT TIME FOR NO MORE BLINDNESS FROM ROP IN EGYPT

582019

52

ihabsaadhotmailcom

582019

43

ihabsaadhotmailcom

OD OS

ihabsaadhotmailcom

582019

44

ihabsaadhotmailcom

ihabsaadhotmailcom

582019

45

ihabsaadhotmailcom

ihabsaadhotmailcom

582019

46

ihabsaadhotmailcom

ihabsaadhotmailcom

582019

47

bull 120 operated cases (2006-2012)

bull Stage 4 ROP

ndash 80 cases

ndash Lens sparing technique 60 cases

ndash Anatomic success 80

ndash Silicone oil use 10

ndash Failures 10

ihabsaadhotmailcom

bull Stage 5 ROP

ndash 48 cases

ndash Success 15 cases (30)

ihabsaadhotmailcom

582019

48

Neurologic ComplicationsAssociated with Prematurity

Global Delays

Motor disability Cerebral Palsy 7-30

Cognitive disability

Autism spectrum

Cortical visual impairment

Discussion

bull Functional and structural visual impairments from ocular and neurological conditions associated with prematurity can be improved by appropriate interventions

582019

49

Interventions

bull Optical correct refractive errors patching (amblyopia) specs (strabismus anisometropia)

bull Surgical ROP strabismus NLD probing

bull Medicalglaucoma strabismus amblyopia

wwwsolobambinicom

Interventions

Trans-disciplinary

bull child with multiple impairments

bull cortical visual impairment delayed visual maturation

bull low vision from

structural defects

582019

50

Conclusion

bull Children born prematurely should have ophthalmologic evaluation and intervention at frequent intervals during first 3 years of life regardless of presence of ROP and amount of prematurity

ihabsaadhotmailcom

httpwwwjmsregnet on Thursday January 10 2019 IP 102327427]

582019

51

ihabsaadhotmailcom

bull IN 2019 IS IT TIME FOR NO MORE BLINDNESS FROM ROP IN EGYPT

582019

52

ihabsaadhotmailcom

582019

44

ihabsaadhotmailcom

ihabsaadhotmailcom

582019

45

ihabsaadhotmailcom

ihabsaadhotmailcom

582019

46

ihabsaadhotmailcom

ihabsaadhotmailcom

582019

47

bull 120 operated cases (2006-2012)

bull Stage 4 ROP

ndash 80 cases

ndash Lens sparing technique 60 cases

ndash Anatomic success 80

ndash Silicone oil use 10

ndash Failures 10

ihabsaadhotmailcom

bull Stage 5 ROP

ndash 48 cases

ndash Success 15 cases (30)

ihabsaadhotmailcom

582019

48

Neurologic ComplicationsAssociated with Prematurity

Global Delays

Motor disability Cerebral Palsy 7-30

Cognitive disability

Autism spectrum

Cortical visual impairment

Discussion

bull Functional and structural visual impairments from ocular and neurological conditions associated with prematurity can be improved by appropriate interventions

582019

49

Interventions

bull Optical correct refractive errors patching (amblyopia) specs (strabismus anisometropia)

bull Surgical ROP strabismus NLD probing

bull Medicalglaucoma strabismus amblyopia

wwwsolobambinicom

Interventions

Trans-disciplinary

bull child with multiple impairments

bull cortical visual impairment delayed visual maturation

bull low vision from

structural defects

582019

50

Conclusion

bull Children born prematurely should have ophthalmologic evaluation and intervention at frequent intervals during first 3 years of life regardless of presence of ROP and amount of prematurity

ihabsaadhotmailcom

httpwwwjmsregnet on Thursday January 10 2019 IP 102327427]

582019

51

ihabsaadhotmailcom

bull IN 2019 IS IT TIME FOR NO MORE BLINDNESS FROM ROP IN EGYPT

582019

52

ihabsaadhotmailcom

582019

45

ihabsaadhotmailcom

ihabsaadhotmailcom

582019

46

ihabsaadhotmailcom

ihabsaadhotmailcom

582019

47

bull 120 operated cases (2006-2012)

bull Stage 4 ROP

ndash 80 cases

ndash Lens sparing technique 60 cases

ndash Anatomic success 80

ndash Silicone oil use 10

ndash Failures 10

ihabsaadhotmailcom

bull Stage 5 ROP

ndash 48 cases

ndash Success 15 cases (30)

ihabsaadhotmailcom

582019

48

Neurologic ComplicationsAssociated with Prematurity

Global Delays

Motor disability Cerebral Palsy 7-30

Cognitive disability

Autism spectrum

Cortical visual impairment

Discussion

bull Functional and structural visual impairments from ocular and neurological conditions associated with prematurity can be improved by appropriate interventions

582019

49

Interventions

bull Optical correct refractive errors patching (amblyopia) specs (strabismus anisometropia)

bull Surgical ROP strabismus NLD probing

bull Medicalglaucoma strabismus amblyopia

wwwsolobambinicom

Interventions

Trans-disciplinary

bull child with multiple impairments

bull cortical visual impairment delayed visual maturation

bull low vision from

structural defects

582019

50

Conclusion

bull Children born prematurely should have ophthalmologic evaluation and intervention at frequent intervals during first 3 years of life regardless of presence of ROP and amount of prematurity

ihabsaadhotmailcom

httpwwwjmsregnet on Thursday January 10 2019 IP 102327427]

582019

51

ihabsaadhotmailcom

bull IN 2019 IS IT TIME FOR NO MORE BLINDNESS FROM ROP IN EGYPT

582019

52

ihabsaadhotmailcom

582019

46

ihabsaadhotmailcom

ihabsaadhotmailcom

582019

47

bull 120 operated cases (2006-2012)

bull Stage 4 ROP

ndash 80 cases

ndash Lens sparing technique 60 cases

ndash Anatomic success 80

ndash Silicone oil use 10

ndash Failures 10

ihabsaadhotmailcom

bull Stage 5 ROP

ndash 48 cases

ndash Success 15 cases (30)

ihabsaadhotmailcom

582019

48

Neurologic ComplicationsAssociated with Prematurity

Global Delays

Motor disability Cerebral Palsy 7-30

Cognitive disability

Autism spectrum

Cortical visual impairment

Discussion

bull Functional and structural visual impairments from ocular and neurological conditions associated with prematurity can be improved by appropriate interventions

582019

49

Interventions

bull Optical correct refractive errors patching (amblyopia) specs (strabismus anisometropia)

bull Surgical ROP strabismus NLD probing

bull Medicalglaucoma strabismus amblyopia

wwwsolobambinicom

Interventions

Trans-disciplinary

bull child with multiple impairments

bull cortical visual impairment delayed visual maturation

bull low vision from

structural defects

582019

50

Conclusion

bull Children born prematurely should have ophthalmologic evaluation and intervention at frequent intervals during first 3 years of life regardless of presence of ROP and amount of prematurity

ihabsaadhotmailcom

httpwwwjmsregnet on Thursday January 10 2019 IP 102327427]

582019

51

ihabsaadhotmailcom

bull IN 2019 IS IT TIME FOR NO MORE BLINDNESS FROM ROP IN EGYPT

582019

52

ihabsaadhotmailcom

582019

47

bull 120 operated cases (2006-2012)

bull Stage 4 ROP

ndash 80 cases

ndash Lens sparing technique 60 cases

ndash Anatomic success 80

ndash Silicone oil use 10

ndash Failures 10

ihabsaadhotmailcom

bull Stage 5 ROP

ndash 48 cases

ndash Success 15 cases (30)

ihabsaadhotmailcom

582019

48

Neurologic ComplicationsAssociated with Prematurity

Global Delays

Motor disability Cerebral Palsy 7-30

Cognitive disability

Autism spectrum

Cortical visual impairment

Discussion

bull Functional and structural visual impairments from ocular and neurological conditions associated with prematurity can be improved by appropriate interventions

582019

49

Interventions

bull Optical correct refractive errors patching (amblyopia) specs (strabismus anisometropia)

bull Surgical ROP strabismus NLD probing

bull Medicalglaucoma strabismus amblyopia

wwwsolobambinicom

Interventions

Trans-disciplinary

bull child with multiple impairments

bull cortical visual impairment delayed visual maturation

bull low vision from

structural defects

582019

50

Conclusion

bull Children born prematurely should have ophthalmologic evaluation and intervention at frequent intervals during first 3 years of life regardless of presence of ROP and amount of prematurity

ihabsaadhotmailcom

httpwwwjmsregnet on Thursday January 10 2019 IP 102327427]

582019

51

ihabsaadhotmailcom

bull IN 2019 IS IT TIME FOR NO MORE BLINDNESS FROM ROP IN EGYPT

582019

52

ihabsaadhotmailcom

582019

48

Neurologic ComplicationsAssociated with Prematurity

Global Delays

Motor disability Cerebral Palsy 7-30

Cognitive disability

Autism spectrum

Cortical visual impairment

Discussion

bull Functional and structural visual impairments from ocular and neurological conditions associated with prematurity can be improved by appropriate interventions

582019

49

Interventions

bull Optical correct refractive errors patching (amblyopia) specs (strabismus anisometropia)

bull Surgical ROP strabismus NLD probing

bull Medicalglaucoma strabismus amblyopia

wwwsolobambinicom

Interventions

Trans-disciplinary

bull child with multiple impairments

bull cortical visual impairment delayed visual maturation

bull low vision from

structural defects

582019

50

Conclusion

bull Children born prematurely should have ophthalmologic evaluation and intervention at frequent intervals during first 3 years of life regardless of presence of ROP and amount of prematurity

ihabsaadhotmailcom

httpwwwjmsregnet on Thursday January 10 2019 IP 102327427]

582019

51

ihabsaadhotmailcom

bull IN 2019 IS IT TIME FOR NO MORE BLINDNESS FROM ROP IN EGYPT

582019

52

ihabsaadhotmailcom

582019

49

Interventions

bull Optical correct refractive errors patching (amblyopia) specs (strabismus anisometropia)

bull Surgical ROP strabismus NLD probing

bull Medicalglaucoma strabismus amblyopia

wwwsolobambinicom

Interventions

Trans-disciplinary

bull child with multiple impairments

bull cortical visual impairment delayed visual maturation

bull low vision from

structural defects

582019

50

Conclusion

bull Children born prematurely should have ophthalmologic evaluation and intervention at frequent intervals during first 3 years of life regardless of presence of ROP and amount of prematurity

ihabsaadhotmailcom

httpwwwjmsregnet on Thursday January 10 2019 IP 102327427]

582019

51

ihabsaadhotmailcom

bull IN 2019 IS IT TIME FOR NO MORE BLINDNESS FROM ROP IN EGYPT

582019

52

ihabsaadhotmailcom

582019

50

Conclusion

bull Children born prematurely should have ophthalmologic evaluation and intervention at frequent intervals during first 3 years of life regardless of presence of ROP and amount of prematurity

ihabsaadhotmailcom

httpwwwjmsregnet on Thursday January 10 2019 IP 102327427]

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bull IN 2019 IS IT TIME FOR NO MORE BLINDNESS FROM ROP IN EGYPT

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bull IN 2019 IS IT TIME FOR NO MORE BLINDNESS FROM ROP IN EGYPT

582019

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582019

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