Transcript Document 609604

Management of ROP: Our experience
while addressing this iceberg
disease in Eastern India
Tapas Ranjan Padhi
Faculty
L.V Prasad Eye Institute
Bhubaneswar
Broad outline
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Introduction to ROP
Evolution of our screening net over years
ROP statistics in Eastern India
District wise analysis of treatment naïve advanced ROP at
presentation
Outcome of treatment
Hurdles peculiar to our state
Our stand today and how we look at the future
Core issues
Twin -1 :normal
Twin -2 :Blind
Twin-1,GA-29 wk,BW-1.070 kg,had h/o respiratory
distress and was on O2 therapy for 1 month
Age at presentation to us-10 month
Well regressed ROP.Child is normal
Twin-2,GA-29 wk,BW-0.670 kg,had h/o
septicemia,blood transfusion(twice) and was on O2
therapy for 1 month
Age at presentation to us-10 month
(OU)Stage 4B (cicatricial) ROP
(Parents neglected despite the advice by the
pediatrician for ROP screening)
1st child 3 yr….GA 30 wk...severely visually impaired
2nd child 6 m……GA 29 wks…….blind
Never screened, never told, not aware of ROP
OD Stage 5 ROP
OS Stage 4B ROP
Never screened, never told despite stay at two NICUs for 2m
Parents in tears
IVF pregnancy after 15 yrs
Twin pregnancy
GA 29 wks
BW 700 and 750 gm
Stage 5 ROP OU in both babies
Bw – 750 gm,GA-30 wk,Age at presentation – 7 months,
OU-Leucocoria,Stage V ROP with Irreversible blindness
Late presentation
RE - Blind
LE - Normal
Bw – 1.2 kg,GA-32 Wk
RDS, Age at presentation – 1 year
OD – Regressed ROP
OS-Stage V cicatricial ROP
Management of ROP
• Screening (active/passive,air tight & aggressive) of at risk
babies
• Diagnosis
• Decision to treat or not
• Treatment
- Tt. of ROP itself ... Observation/laser/surgery
- Correction of systemic factors
- Rx of ROP related complications
• Post treatment follow up
• Rehabilitation
OUR DREAM FOR ROP
Elimination of ROP Related Blindness from Odisha
lessons from the journey
Our screening protocol
<2000 gms and/or ≤35 weeks.
All preterms whose gestational age is not
well known
Any preterm/LBW baby whom the
Pediatrician has high index of
suspicion
Existing screening net
NICUs
Medical colleges,
Private Multi specialty Hospitals,
Civil Hospitals
Adopted Strategies
Ophthalmologists
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Referral from
Paediatricians
Babies for
screening
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General practitioners
Weekly screening at
NICUs
Discussion with
Ophthalmologists /
Pediatrician/Child
health care providers
Spreading the message
via parents of affected
babies
CME/Workshops on
ROP
Educated/Motivated
parents
Premature babies brought for
some other ocular complaint
(Opportunistic Screening)
For an airtight screening net screener has to go to the street
Team ROP
LVPEI-Capital
hosp.
collaboration
Laser
Set up
Laser protocol :ETROP guidelines
Treatment within 48 hrs x
Timing for laser: at the earliest possible
√
Requires:4H
Head, Hand
Hours &Heart
Can be done at NICU, OPD, OR, topical anesthesia/GA,very safe
Back up by a Pediatric internist…must and can ensure complete safety
Result
• Babies screened for ROP: n= 2112
(1596 off campus and 516 at institute)
• Babies detected with ROP:526
Babies treated :118
24 babies - cicatricial ROP
Left alone
95% cases lasered had favorable outcome
49% had APROP
Eyes saved: 206
Happy patients ….60 % treated free of cost
Baby is our only VIP in ROP care !!!
No baby under our screening net has progressed to
stage 4B or 5 over last 4 yrs
Timely laser and good compliance can ensure
success rate as high as > 98%
Baby 1 hr after laser
2 among the triplets treated for laser….timely tt,
good compliance……regressed completely
Highly reluctant to tt.,image based counseling helped
Retinopathy regressed well after laser
Multiple sittings of laser….common in our laser protocol
under topical anesthesia : Be prepared for repeat tt. for a sure success
Extremely stormy
postnatal course
Neonatologist
support
tremendous for
timely laser
Results obvious
Alert! APROP is on rise in district SNCUs
APROP
Untreated
Stage 5
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Our strategy for APROP :Catch them early by 20 day strategy
ROP is a race against time and adverse situations
Our experience with
APROP
• Out of 226 eyes treated :49% of them had APROP
• The trend towards APROP is increasing day by day
• APROP is seen even in larger and older infants than
western population
• APROP with GA > 28 wk 45%
Bw > 1200 gm 22%
• The success rate with treatment 91%
Aggressive Posterior ROP
(APROP)
Reason for Avastin popularity in ROP
Brief ,easy, less stressful, very quick
and dramatic effect within days
IVT Avastin:n = 13 babies (23 eyes)
• Only Avastin : none
• Avastin+ laser : 10 babies
18 eyes
• Avastin+surgery: 3 babies
5 eyes
• Babies who did very well:8
• Babies who did well after
surgery :2
Surgery:11 eyes
• Stage 5: 6 eyes
(PPL+PPV+FAE)
Post pole attached -2
Fully attached :1
Failed :3
• Stage 4 : All case LSVS
Stage 4A : 1
Stage 4 b :5
All LSVS cases had excellent anatomical
and functional outcome
Surgery
Sutureless lens sparing vitrectomy
very good outcome in stage 4 ROP
At presentation
Remarkable improvement
Progression
despite laser
Post LSVS
Surgery for Stage 5
• Outcome usually poor
• Aim :Not let the eye enter into stage 5 by early intervention at
stage 4 itself
• Surgery worth trying if feasible for babies who have no vision
• ANY vision is better than NO VISION
Stage 5 ROP
Stage 5 ROP before surgery
After 23G PPL+PPV+FAE
Posterior pole getting attached
but
Outcome not that encouraging
Treatment naïve advanced stage 4 B and 5
Cicatricial ROP with blindness
Total : 56 (6 yrs)
Actual load: too high
(Tip of iceberg)
Age at presntn:15 m
(1.3 m to 14 yrs)
77% were at NICU
at the due time for
screening
> 90% could have been saved
Pediatrician factor 64.5%
Ophthalmologist 20.8%
Parental factor 6.9%
Others-rest
Pediatrician factors
• No referral
• Tardy referrals (referral after the recommended time for
screening)
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• Poor quality of referral
• Wrong belief
Only babies on O2 get ROP
ROP exam and tt. risky to life ….can be delayed
GA 27 wk, BW 900 gm
Stormy neonatal course
We were not allowed to examine because
the baby was too small/too sick
2 wks later… Stage 4B ROP OD
Stage 4A ROP OS
Laser (excellent outcome)
Inj.+ laser + surgery
but ambulatory vision
Ophthalmologist related factors
• Unavailability of trained ophthalmologist
• Inaccurate/missed diagnosis
• Poor communication with parents
• Inadequate expertise
(Three babies were refused examination because of poor
co-operation!!)
Parent related factors
• Lack of adequate counseling
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• Inadequate understanding
• Unaddressed concerns regarding ophthalmic examinations
• Neglect on the part of parents
• Inadequate boost by the child health care providers
Screening with RetCam
Excellent documentation
Telescreening possible
Easy & can be done by a technician
Easy to analyze treatment outcome
Computer based ROP analysis
(CAIAR,RISA,ROP tool etc) feasible
Is there any mother who will
refuse follow up ?
Pediatrician will think twice
before refusing tt.?
Image based counseling crucial for compliance and timely tt.
In absence of
photographic
documentation
Counseling in mass
helps
Our stand today and how do we like to see the
future
• Strengthening of ROP care at Bhubaneswar √
• Replication of this ROP model in 5 ROP hot districts
• Replication of ROP model in other districts
• Decentralize the ROP care and create self sufficient leaders in
medical colleges/districts
• ……So that no baby from Odisha would go blind because of
ROP…….
From no disease at birth
to sight/blindness
You can make a difference
…..and it is a team effort
Core messages
• ROP scenario at Bhubaneswar
Babies screened for ROP……25 out of 100 have disease
06 out of 100 require treatment
• District SNCUs…ROP blindness 1/month
• APROP on rise : some NICUs….APROP factory!!
• Advanced cicatricial ROP…increasing burden from peripheral
SNCUs
• Compulsory/repeated ROP awareness CMEs for Pediatrician
• Law enforcement to make ROP care mandatory
• Increase the number of Ophthalmologists trained in ROP
• Ensure referral to a ROP trained ophthalmologist
• ROP is a time bound disease
Do not delay screening/treatment…just because baby is sick
In ROP TIME Means VISION….
ROP
SLOGANS
‘Do bund jindegike
Tees din ROP ke’
‘Ek mahine me
check up karo
Kaho ki ROP
Bharat Chhodo’
Acknowledgement
- Lingaraj Pradhan and their team
- Subhadra Jalali
- All the Paediatricians of the City
- Taraprasad Das, LVPEI staff and my colleagues
- Samir, Gopal, Vijay, Transporting staff
- all the premature babies and their parents
- MHMT
- IIPH for taking it forward for a great cause
for their support and co-operation to fulfill our mission of
eliminating ROP related blindness from this part of the
world.
Be aware!
APROP
Vs
Staged
or
Classical
ROP
They differ in appearance, progression, pace,
treatment & treatment response:
Pre laser
Post laser
Anti VEGF
• Wonder drug
• No long term safety data available.
• Reserve drug to
- assist or supplement laser in severe cases
- buy time till laser shows its effect
- only modality when laser not feasible
- prepare the eye for surgery
• Dramatic dampening of the disease momentum
• Requires long follow up after treatment (late recurrence)
NVI & marked plus
Disease remained stand still for 6 weeks
Regressed within
a week after laser
Be vigilant for late
recurrences
We see ROP as a Vitreoretinopathy
& Intervene early
GRADE OF SEVERITY OF VITREOUS
ORGANIZATION
• Grade 0
• Grade 1
• Grade 2
None visible
Minimal to mild (view of underlying retina
not significantly reduced
Moderate to marked (view of underlying retina
significantly obscured )
Stage 4B ROP
Before surgery
1 month Post LSVS
Ambulatory vision
So the message stops
But our mission continues …..
Thanks for joining us
in the race against ROP
….and it’s a team approach
Eye
Care
Parents
Premature
Neonatal
Care
Baby
Social
workers
Anaesthesi
a Care
Optical &
Rehab
Care
Regressed ROP with very good outcome after
treatment with laser