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Retinopathy of Prematurity

Feb 24 | 1:30 PM

In its more severe forms, Retinopathy of prematurity (ROP), can result in severe visual impairment or blindness. India like other middle income countries is currently facing the third epidemic of ROP. The poor quality of neonatal care, lack of timely screening, and higher rates of premature births have been implicated for the difference in the spectrum of ROP in India compared to the rest of the world. Join us live, in conversation with Dr. Jitendra Jethani to understand how to tackle the ROP health problem in India and how to approach a case of ROP..

[Music] so good evening everyone i'm dr nivedata and i um welcome you all to this evening session on behalf of metric we have with us our speaker for this evening dr jatendra jaitani he's a senior consultant ophthalmologist and uh to moderate this session we have dr arnab saroya his graduation from bj medical college ahmedabad in 1999 and then did his uh due in 2001 calling which he completed his msn of thermology from mng institute of thermology mdhabad in 2002. he did his dnb in 2003 senior residency in strabismus followed by he's a fellow of the national board in pediatric ophthalmology at arvindai hospital madurai and later joined the hospital as a medical officer he did a short-term fellowship in pediatric ophthalmology and strabismus from university of wisconsin madison and was awarded by the international council of thermology he also worked as an assistant professor at region institute of ophthalmology for about one and a half years my pleasure completely thank you thank you so much for the kind words and uh believe me the reason i was asking whether you are into pediatrics or into rops because i just wanted to interact more uh as to because this is something which is uh truly speaking a very a very niche subject of prematurity happens only in premature kids because the name of the disease itself is uh prematurity and it so it's very important for post graduates also to know about it because it is a public health problem and uh still you know even after so many years so it was way back in 1949 when uh terry was the first person who found out that there is something known as uh retinopathy of prematurity or rather he called it as retro entered fibroplastia because he found that premature children came back once they were around a month or two month old these children came back and were having problems in vision the whole retina was detached and there was a white uh you know reflects just behind the lens and so he called it as detrimental fibroblastia so yeah so essentially uh it was it was then that all this started and gradually we came to know more and more about retinopathy of prematurity and with oxygen and low birth weight and hemodynamic i mean other risk factors also came up gradually and so basically what do we know at this point of time about retinopathy of prematurely that is what i will be talking about what are the classifications of retinopathy of prematurity and what and how and when we should you know refer the patients or we should do the evaluation of these premature babies who are admitted in nxus what is the need for newer classification so there has been a new classification which came up only three months back and then we would be finally partying or will be concluding with about rop and what can be done so regarding rop at this point of time we all know that you know pregnancy and child but we know that normal pregnancy ranges between 38 to 42 weeks of pregnancy and a full term infant would weigh around 2500 to 4000 grams so this isn't this is just about normative and what do we call uh preterm is uh defined as babies who are born alive but before 37 weeks of freedom uh and after 37 weeks we call them as normal uh pregnancy range so extremely preterm uh very preterm moderately preterm and rate free term that is what is the that is how we have subdivided our preterm babies and before 28 weeks of pregnancy is extreme freedom so between extreme freedom and very preterm it is very common and so not only rop is common but treatable rop is seen mainly between extreme freedom and very brittle and sometimes in moderately freedom and occasionally in late freedom we do see retinopathy of prematurity so basically any child who is born preterm before 36 weeks of pregnancy was admitted in an isu or not admitted in an icu whether he needed oxygen or not needed oxygen should be referred to a pediatric ophthalmologist or to a retina specialist who does uh rop work so we all know uh this whole gamut of problems that a preterm baby can have and one of this most important the whole the whole syndrome complex or the whole problems that do occur with preterm infants one of the most common or one of the most treatable parts see most important thing in medicine is also that which are the diseases which can be prevented and which can be completely treated so rop is one of those uh one of those diseases that occurs in preterm infants and is 100 treatable if seen at an appropriate time and that is why rop screening is done by the ophthalmologists who are doing rop work so so these are some of the reasons or the major risk factors for the most common risk factor obviously a high oxygen uh eye high oxygen that we have to give and nowadays uh there are you know there are uh nhu's would give titrated oxygen because we we don't want to give them 100 oxygen but we just want to give them oxygen which is sufficient for them to maintain a good oxygen level and more oxygen inhibits vascular growth and so there is legit secretion at 31 weeks of gestation causes neovascularization other complications now what are the risk factors respect most common is obviously the preterm part the fetal growth restriction hypoxia post poor postnatal growth and how do we how do we prevent this by preventing the need for oxygen it gives steroids maintain oxygen saturation targets and cause circulation stability so how common it is it is one of the most common avoidable causes see the most important thing is avoidable causes of blindness in children so 15 to 20 percent are affected among the 15 million babies which have borne freedom every year so in india the prevalence is a good see this is a very variable prevalence of 38 to 47 the reason why this variability is that because it depends from a nicu to nicu what kind of care they give and not only on preterm but it also depends on lot of other factors the sickness or whether the baby had other problems like uh you know lung disease or pneumonia whether the baby had anemia whether the baby needed uh blood transfusion uh how bad was his like whether he had any seizures convergence so there are a lot of other factors also with responsibility this is just a broad timeline as what are the major things that occurred so way back in late 40s in 1949 i think it was terrier diagnosed or who said that it was return under fibroplastia and gradually in 50s and 60s late 50s and 60s it came to be known as retinopathy of prematurity there was a re-emergence in 80s because because of again because of the advent of an icu then more and more babies were now were being saved so more and more babies were saved means more and more chances of ropi would occur and then there were there was a icrop was established which is international classification for rop and renault fibroblastia was now displaced and was known as retinopathy of prematurity because it has absolutely nothing to do with lengths and there's nothing like reproductive fibroblasts but it is actually the retinopathy of prematurity and so they define zones and stages and we will see all those things but uh yeah first and foremost question is who are children like who should be screened like which are the children who are these children who should be screened because you know the obvious question of always is that should we screen all the babies and that is a public health problem because every checkup that we do causes the financial burden to the patient to the nhu and society at large so these are questions very pertinent questions which are asked mainly in western countries where all this is insured and these these put financial pressures so there are guidelines as to who should be screened and this is very important because all the pediatricians all the health care workers who work in an ico should be should be knowing that you know this child needs a retirement prematurity screening so screening all premature babies obviously would be a waste of time but that but at this point of time we do tell everybody to scream to screen as many as possible but there are three crucial parameters which is birth weight gestational age and total number of days the oxygen was given however there are other criteria as well like sickness score like whether blood transfusion was given or not given and so there are multiple ways where you know younger the baby is born more premature the baby is more are the chances that he would end up into having rop so we have to screen babies at least once if the baby is premature born before 36 weeks of pregnancy within 30 days of arrival i mean within his first 30 days and that is how it has been promoted as teased in zindagi like the first 30 days of life we should go and get a screening done for rot if the baby is premature and these are all potential risk factors multiple births of parent blood transfusion radius sepsis phototherapy intraventricular hemorrhage vitamin e deficiency anemia seizures so there are a lot of risk factors and pediatricians do have to you know pediatricians do have to find out uh and refer these patients uh there have been uh you know multiple multiple guidelines and at the end of the day it is the neutral neurologist or pediatrician who has to be aware of these things so initial examination as i said of rop must be carried out at 32 weeks post conceptual age which is the earliest age at which early significant rop may occur some children are born at 32 weeks so they can be seen within a week but at least by first 30 weeks of birth once the the patient should be screened there are multiple guidelines like you know less than 30 weeks less than 32 weeks less than for 34 weeks but any child will bond premature and have risk factors should be screened as i said 30 weeks or 32 weeks post consumption whichever is earlier but wait actually there is no cut off but yes any any child less than 1750 grams of 1.75 kgs should be screened for rop and any preterm kid who who has an unstable clinical court or a stormy nicu admission are believed to have these problems or if the neonatologist feels that this particular kid should be seen should be screened and when they should be screened so uh a large number of nurseries throughout the world would carry out routine screening at this point of time like i'm i'm based in baroda there are around 18 isus and we routinely go to all our icos and screen them every week solely on the basis of postnatal age or even birth weight or if the neonatologist feels that this particular child should be screened so ideally infants should be examined at an icu itself because at least one examination if done at an icu creates a rapport between parents and the eye surgeon and it becomes easier to see the babies in an icu because because if there is excessive vehicle stimulation or if there is uh there is uh breath holding spasm or breath holding apnea cases then they could be dealt with easily and it should it should be very very important that at least once we should see the baby at an icu itself and how to screen is basically meant mainly for people who are doing rop screening but this is how we do it we use half the concentration of tropical plus or we can use cyclobacterium and phenylalanine half like point five percent with two point five percent a pediatric speculum and a sterile depressor so normally we use a vector for this and the indirect ophthalmoscope with scleral depression is the gold standard for screening these babies and we sterilize the speculum and scleral depressor uh and if the disinfectant is used it should be washed in betadine and then we use the rim of the indirect lenses also cleaned by alcohol and we have to keep all the septic precautions in place we have to clean our hands and then examine these babies because these babies are prone at having uh you know at acquiring infections because they are free term already they are weak and have a lower immunity so once the initial examination is carried out with application of speculum so we get a good knowledge if we see the initial posterior pole examination is done to know whether there is any plus disease or not it is very very important because plus disease is also known as rush disease which means that the disease will progress without going through its normal conventional stage one two three four it would directly jump from disease stage 1 to stage 5. so it is very very important that you know whether there is any presence of plus disease we should be seeing that and then we just see the periphery and we try to notify the whole things we have to see the nasal character of the retina and then we rotate the child and see the temporal retina and then this is how we draw it just to show whether there is a ridge which means stage two whether there is any demarcation line or whether there is any interactional vascularization whether there is a raised ridge or not so these are some of the problems which can crop up when we are doing rop examination because uh because of the mainly because of the vehicle stimulation uh and we have to be in that icu to deal with these problems so this has to be kept in mind and this is how we tend to follow these up if the child has mature retina absolutely normal westernization till periphery will see the child again after one year this has now been modified to six months because we want to check the reflective error also that is one of the major frequency of preterm babies because they do end up into having reflective errors much you know much earlier and much commoner compared to full term term infants immature retina stage one or two in zone two two weeks immature retina zone one every week close follow free threshold three to seven days and threshold disease will be taking up free threshold and threshold disease within 72 hours so what are the pros and cons it uh i mean the the most important thing of doing it is that indirect i mean this is pros and cons of doing the indirect ophthalmoscopy versus doing and imaging the pros and cons of course are that you need an experienced ophthalmologist but that is a that is a better thing also because an experienced ophthalmologist can immediately take a decision what has to be done the problem is that you have to visit nicu's uh every time and we i will be showing the imaging these are some of the imaging systems there are more imaging systems these are just two imaging systems and now redcam was manufactured by clarity now it is almost uh they don't they don't market it anymore uh three based company so they give a wide you know this is this is one of the images of red cam and it provides color digital images and so so it's a good uh you know this is a good way of getting the images acquired because it helps medical legally also and so there is no ambiguity there is no subjective difference between what i think and what uh another doctor think that it is on paper it's a print so directly you know you can just discuss uh directly but this does not give you a a stereoscopic vision has to be seen by an experienced ophthalmologist doing rop work but it can be used by telemedicine so that's a big advantage over visiting the nhus and these are the this is about how do we classify rop it is very important to understand that also so what do we already know we know that icrp was formed in way back in 1984 and then it was expanded icrop was expanded the classification was changed or slightly more expanded in 87 and then there was uh the the major revision came in 2005 and then now last year uh it just came to have icrop3 basically like rop is classified or characterized into zones stages and type and a combination of all this would describe the severity of rop so so what is zone one so zone one contains basically the macula optic nerve at the center and it extends twice the distance from optic nerve to macular in a circle any portion of optic nerve in the same view as that of the ridge of rop and zone 2 is surrounds the circle of zone 1 and then the ridge shows vascular branching but this is mainly about zone two and zone three this is basically zone three it is basically an outer crescent that zone two did not encompass and was limited by the aura so zone two touches the nasal aura and zone three touches the temporal aura so that is regarding zone two and zone three and then comes to staging stage one to stage five so stage five is basically the end stage where the retina has completely detached now here you can see this is stage five where total regular detachment has occurred this whole retina has detect this orange color thing is the retinal detachment stage one basically state 0 means there is no rop stage 1 means there is a small demarcation line between the vastula retina and the avascular antenna stage 2 is a rich so it is slightly more slightly more vascularized and slightly more elevated and state three is extra retinal fibromuscular proliferation slightly more elevated and stage four is basically partial retinal detachment so basically what happens is that the the a vascular antenna and the vascular retina there is a demarcation line and gradually there is there are new vessels neo vascularization occurs at this this particular part and gradually there is fibrosis and there is extra retinal fibrous proliferation which gradually starts pulling the retina gradually starts detaching the neurosensory layer of the eye which is retina so once there is stage 2 3 that is pre threshold and then there is threshold disease uh once there is stage three we have to do some intervention like laser or in some cases there is plus disease we may go for injecting anti veget we will be taking that up also so this is just to show clinical pictures of red chem this shows stage one and this is stage two and you can see state three there is very large you can see that there is a big fibrous proliferation and slightly more elevated compared to stage one and stage two now uh that was regarding the stages we already took zones and zone one is the most posterior zone close to the disc and macula zone two is outer to zone one and zone three is the outermost touching the temporal aura now characterization by types type one and type two now type two is basically uh any so this is this requires any so basically we have to differentiate like this one is a plus disease and another is a uh traditional i mean normal uh stage one two three four five so so the plus disease uh no this is oh i'm sorry so we will be taking up plus disease here also uh but we will be taking the whole icrop3 so it becomes much easier to understand uh what was the need for ic rop3 uh i i mean there have been multiple advances and so there are a lot of subjective components in iso arrow p2 so they decided to make icrop3 the key components of icrop3 are these uh the first and fourth so there are nine points which they have included in icrop3 classification they have included first immature vessels to be labeled as incomplete vascularization accompanied by their zone new posterior zone 2 was added so now there is a zone one which is absolute posterior on the disc and macula surrounding that there is posterior zone two and surrounding that is anterior zone two and then there is zone three so there is a new posterior zone 2 which is added i will be showing you a photograph of that the term notch has been introduced and so basically to reduce the subjectivity the group included sample images to demonstrate the spectrum of 3 plus and plus because more and more babies now come up with plus disease and a precursor of plus is free plus disease so more and more babies are coming with pre plus and plus disease and aggressive posterior rop which was basically very similar to plus disease but basically it is a very aggressive form of rop type 2 rop rush disease which progresses very quickly and then there is regression with introduction of the term persistent avascular retina which has come up mainly because of the introduction of anti vegets which causes a vascular persistent avascular retina and then there are reactivation of stages and then thunderstorms and geography which is not very commonly available but they have tried to include that keeping future in mind so this we can skip how so this is this is what i was talking about when i was talking about zone one uh posterior zone two zone two anterior and zone three and then there are clock eyes so what i want to draw the attention of audience is that the center point is the optic disc and this is the macula so if you make a circle of two distance so basically if you make a circle the distance between disc and macula if you make a circle out of that double of that that will be zone two zone one just outside that is zone two so what is zone two so zone two is two disc diameters peripheral to zone one so that this diameter if you this is the disk diameter so if you take to this diameter and make a circle that is posterior zone two and outside that is anterior zone two which touches the nasal aura the temporal crescent is zone three so that that much for zones there is another unique uh thing which used to occur and which we used to frequently uh frequently encounter was that there used to be a tongue like you know tongue like excursion which used to travel from zone two to zone 1 and it used to become very difficult to label it whether it was in zone 2 or it was actually a zone 1 disease and so now they have added this particular so in this photograph what they have done is they have tried to show that this hole is a vascular retina and this is all vascular retina you can see that blood vessels are going here and you can see this tongue like structure is the a vascular part which is now known as the notch now this is just a spectrum of images from pre plus to plus disease so you see the green and then you go towards the red and red is a hotter color or a more aggressive color and shows a very very strong plus disease whereas this this particular first photograph does not show that strong a plus disease and that would be termed as normal or pre starting of pre plus normal two plus disease and then this is the aggressive rop which progresses very rapidly it is the rapid form of progression starts from zone 1 and very quickly progresses so we have to be very very cautious with aggressive rop and then this is known as the persistent a vascular retina mainly because and you know with the advent of antivegef treatment of rop we will be taking that up there used to be uh you know the the vagina level will go down immediately and then gradually it will start vascularizing so a lot of area and periphery would remain avascular and that that was not included in icrop2 because at that point of time antivirus were not very common they just started in 2007 and reactivation with stages because once you have a persistent avascular retina there is a chance that the stages may reactivate and then this is uh you know this is not available very routinely we can skip that so uh uh icrop3 this is regarding iso rp3 conclusion now we come back to when to treat so this is the guideline from early treatment rop study a little very old guideline but for the sake of our discussion we can take this as free threshold and threshold disease nowadays we do not quantify it straight forward like free threshold threshold but for the sake of understanding we can go with free threshold and threshold disease so pre-threshold disease would be any stage of roping zone one is free threshold state three state in zone one stage two or three with plus disease zone two stage one so this is just a classification of free threshold and threshold disease as to when the disease should be treated so this is this is a straightforward indication for treatment of treatment and what are the treatment levels available treatment levels available are laser treatment so there is a diode laser with an indirect oxaloscope uh around 1800 to 2500 spots of 100 micron size are placed one half one width apart and they are applied to entire muscular retina up to aura avoiding any measles ridge so you have to do this is the way laser is done this is the peripheral retina which is a vascular and laser has to be applied there and so i do i whenever i have to laser i do some laser anterior to this switch also at least one one line or one row of lasers i do anterior to that particular ridge also so this is just to to tell you about the laser nobody nobody is doing cry online nowadays so cry was almost completely out of uh question which nowadays uh more and more people going for uh you know antivirus so cryo is completely out of question nowadays so there are these are the three things which you have to see you have to see whether there is any plus disease or whether there are any skip areas if there are any skip areas we have to re-laser it and then we come to the sequelae of rop what happens like so secretly of rop would include biopia cataracts late retinal detachments glaucoma and dragging off retinal optic discs so these are the sequelae of ropi myopia is very very important because uh almost uh you know the almost 20 to 30 percent of children who are you know who need lasers or almost 45 of the patients after laser so kids who require laser uh develop myopia almost 45 that's a huge huge number of patients so there are a lot of patients who develop glasses and therefore it is very imperative that we should also advise the child to have early checkup for glasses so that we can intervene in terms of glasses also very very early now although laser is a gold standard for rop management at this point of time but we know that it is destructive it limits visual field and induces significant refractive error so anti-vegf can be a treatment of choice or rather it is the treatment of choice for very posterior zone one plus disease and areas in where we we think that it is aggressive rop there have been multiple trials that have proved its severity later especially in zone one or aggressive rop we know there are multiple antivirus available like devices device um eliminates the angiogenic threat for b therapy trial this was b therapy trial and another was rainbow trap where ranibizumab was used for rop and all these did suggest that you know introverted running visual map or zoom app both the both the drugs do help and they are they are superior to laser especially in zone one it is very very important to understand that in zone one and aggressive rop antivirgif is a god gift antivirup would help tremendously because the effect of nt ygf is almost instantaneous it reduces the wedges level within 24 to 36 hours whereas laser will take some time and so antivirgin is a choice modality when it comes to aggressive rop or zone one rop because if we are doing lasers in zone mineralogy we are removing a lot of peripheral visual field so it is very very important to understand that you know antivirus is the treatment of choice in these particular babies but there have been some concerns about using antivirus in all the babies and so there is there is uh you know there are options of using either anti-vengeance or laser depending on the severity of the disease so that's all uh regarding retinopathy of prematurity we have one question uh after anti-vegf or even laser uh what are the recurrence chances so normally uh so so i will try to explain what what is the difference between laser and antivirus so antivirus basically what it does is it reduces the vascular endothelial growth factor level inside the eye so gradually uh the antivirus of the effect of antimatter would last for four to six weeks and we have to keep following up the patient and antivirus would so in essentially antivirus is not treating the disease it is just making uh getting the levels of veggies back to normal where the vascularization starts becoming normal here we have to understand that actually vascularization occurs because of vegf so when we are giving antivirus we are just reducing the overwhelmingly high vegeta which is inside the eye and which is causing neovascularization so once we give antiverges the level of vegf goes down and gradually the vascularization picks up so the chances of persistent a vascular retina after anti-vegf after one injection of antivirus is quite high and there are lot of patients who will need laser even after intervention well after laser basically laser is a completely so laser is a destructive procedure the photo the photo coagulation basically what it does is it creates a bond between retina by you know by burning the because the laser is absorbed by rp layer so basically it creates a bond between retina and rp layer and it basically destructs the peripheral retina so the chances of failure of our failure of laser is less but possible if there are any skip areas if we were not very you know if the burns are not very close there are chances that there are there are skip areas and there is still a vascularity which is causing the wedgef level to go up and causing neo-oscarization but the chances are pretty low with antiversif we may have to do laser but the amount of laser to be done after anti-widget will go down significantly and that is the most important advantage of antibiotics so it would help in preserving the pilot killer or even monocular visual field so visual field loss will be less with anti-wedges i think there is a question what and making knowledge what an amazing knowledge i think these are trying to ask about what kind of imaging can be done we probably answered that in the talk itself that there are fundus cameras which are wide field view furnace cameras which capture around 120 degrees of risky so you can see the disc and almost 60 degrees on each side so you can see a very large amount of retina in single shot and then you can tilt the camera and see in periphery also so the the imaging system helps a lot uh you know where doctors cannot travel and the technician can take images in peripheral areas and they can do a telemedicine and they can ask the doctor whether this particular baby would require any treatment or can be kept in an icu and can be observed till you know something is available so that that is a wonderful tool especially if we want to cover more areas because you know huma as a as a manpower person you have to travel to all and i feel personally to see the patients how high oxygen level causes premature retinopathy so what happens there are multiple there are multiple theories there's a spindle theory so basically in uh if we go by uh for the sake of understanding what happens is that oxygen levels what they do is when there is high oxygen level it causes value constriction in the periphery and that further causes ischemia and causes the vegeta level to go up now once this vegf level is up this causes neo-oscarization and so high oxygen level also cause release of free radicals and that also increases the chances of neo-oscarization basically all these things uh coupled with high oxygen level if there's a low oxygen level the water constriction the peripheral vessels will not uh vasoconstrict they will not shrink and then the antivir the vegeta will not rise once the vegetable rises it causes new vessels which are unstable and they bleed and they cause fibrovascular proliferation and that is what pulls the retina so that is how the oxygen level uh causes the the rop there is a question um by dr paris agarwad is the no not really because you know cryotherapy we need to give general anesthesia to the child for cryotherapy and the chances of developing myopia are very high so cryotherapy nowadays is uh and cryotherapy also covers very very very large areas so cryotherapy um at least in last couple of years has been very i mean very very rare cases where laser and everything has worked and still if there is uh you know still if there is persistent uh uh vascularization or neo-oscarization cryo can be used but at this point of time cryo is like almost not being used for retinopathy of prematurity yeah because if the pupil is small they we would directly go and give antivengef earlier if the pupil was small we would do a cryo and not laser but now if the pupil is not dilating which is a soft sign that a child may be having three plus or plus disease we go ahead and give antivengef rather than uh do a cryo okay uh liquid like what are the actual practical uses of insulin-like growth factors or drugs like filgrastim and gene therapy in in the indian scenario per se in the management of rop you see to be honest these things have not really percolated to india at this point of time so the most recent uh i would say in rop is use of propranolol use of beta blockers which there were a couple of articles one was from turkey and another was from mumbai where they started using propranolol or beta blockers and they found that you know by giving them systemically they could reduce the progression uh from zone uh you know from stage two or state three to stage one and they also use proper beta blockers for plus disease but again see the problem is that whenever we talk about very uh like gene therapy or things like that the problem with these things is that we are dealing here with premature babies where we are also thinking about their growth and development of brain and a lot of organ systems so it is very uh you know we have to be very very cautious because the reason why antivirgin has not still become gold standard is because of the fear that this may uh you know this may uh sort of interfere with the growth or with the brain development because it can it can go through blood brain barrier and so once it goes systemic we don't know whether it is going to create havoc or not and these are things are very far-reaching like you know only after 10 or 15 years people can say that okay 10 years back so first antivirgin was given in 2007. so we are we are here how uh how it would behave over a long term or over a very long period of 8 to 10 years or 15 years in perspective so when we are talking about infants it becomes very difficult uh to talk about drugs uh and that is that is the only reason why uh laser is still so popular compared with uh anti-vegf although we know that you know it is more physiological to give antivirgin when the vegetable levels are high we have to inject antivirus but we are not we have all of all the people who practice rop would still say that you know in most of the cases lasers would still remain the gold standard thank you for answering the comment uh can that can be used for retinal images without any other ocd type diagnostic instrument at least for written image so yes so there are very few machines of oct which can be used for a handheld oct uh at a typical ocd machine you cannot carry it in an ico and the best part of redcam was that at least in the western countries it used to be in an icu uh in the in our ophthalmology department we would have red camp and we will have the babies and you know we can put the camera and check whether how much is the vascularity or whatever the zone where the vascularization has reached but oct is basically about the macular thickness and the cross section of the retina it will not give much information about the peripheral retina moreover we do not have handheld octs very commonly available in the country the third thing is that thunderstorms and geography would help again for thunderstorms and geography we have to inject fluorescent dye with premature kids we really do not take uh that much chances but in some of the patients we can dilute the drug and uh give fluency angiography again these systems are very high-end systems very few setups in the country like in bangalore or madurai or some of the setups in coimbatore do have these systems but they require a handheld thunderstorm and geographic camera which moves as for the kid the kid is supine most of the after examinations are done with you know sitting up upright and facing towards the doctor so it is red cam is a very good instrument which can be used for retinal images unfortunately the company which was manufacturing red cam has stopped the production the three years back and they would be supporting it uh the maintenance for another four years but there is an indian company trinitra which started making uh similar not similar but almost similar cameras which are portable uh can be used uh instead of red cam and it is very popular at this point of time a lot of people do uh screening with the help of those cameras uh basically there's a technician uh they travel with the camera they go to uh nicu's uh capture the images send it back to the rop specialist or pediatric retinal specialist or pediatric ophthalmologist and then get the feedback what is to be done with those babies so yes it is a very good uh it's a very good instrument to be used thank you for that uh thank you so much sir thank you so much for such an elaborative talk starting from the history to the pathogenesis to staging to the prevention diagnosis treatment everything was beautifully covered and i think it will be very helpful for all everyone that has attended or can it end the video later thank you so much thank you for the opportunity and i hope uh we keep meeting on this platform so thank you thanks again and have a great evening

BEING ATTENDED BY

Dr. Murtuza Zozwala & 673 others

SPEAKERS

dr. Jitendra Jethani

Dr. Jitendra Jethani

Senior Consultant Ophthalmologist

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dr. Jitendra Jethani

Dr. Jitendra Jethani

Senior Consultant Ophthalmologist

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