Download BOOSTII Ophthalmic Examination Form - NPEU

Ophthalmic Examination Report
Please complete all of the information in this box
Baby’s name:
BOOST study number:
/
D D
Date of examination:
M M
/
Y Y
D D
Date of birth:
/
M M
/
Y Y
This box can be completed, if necessary, to form part of your clinical record
Gestation at birth:
Baby’s hospital number:
Postmenstrual age at examination:
wks
Please see back of this form for ICROP definitions
12
1
11
12
1
10
2
2
10
3
9
3
9
8
4
4
8
Right Eye
days
days Birth weight (g):
NOTE: Completion of the retinal diagram is optional
11
wks
7
5
7
6
5
6
Left Eye
Question
Is ROP present?
Please circle
Right Eye
Left Eye
Yes No
Yes No
If yes:
What is the highest ROP stage in any zone?
Use key from box below
What is the lowest zone of ROP?
Use key from box below
Record number of clock hours involved, highest stage only
Use numbers 1-12
Was surgery done or recommended at this examination?
Use key & give details below
If no:
What is the lowest zone of vascularisation?
Use key from box below
Is pre-plus or plus disease present?
Use key from box below
Is follow-up required? Tick one
No
Yes in
weeks with*
at*
(*if different from this examination)
Were any RetCam images obtained? Yes
No
Other comments on examination and/or details of
surgery not included elsewhere
Print Name:
Highest stage
0
1
2
3
4
5
A
=
=
=
=
=
=
=
No ROP
Stage 1
Stage 2
Stage 3
Stage 4
Stage 5
AP-ROP
Zone
1 = Zone I
2 = Zone II
3 = Zone III
Plus disease
0 = None
1 = Pre-plus
2 = Plus
disease
Surgery
0
1
2
3
=
=
=
=
No Surgery
Laser therapy
Cryotherapy
Transferred for
treatment
Signature:
Hospital:
Version 2 November 2008
Please see back of this form for ICROP definitions
International Classification of ROP Revisited
Arch Ophthalmol 2005; 123: 991-99
Location
Each zone is centred on the optic disc.
Zone I. A circle of radius - twice the distance from the disc centre to the centre of the macula.
Zone II. Extends from the edge of zone I to the nasal ora serrata.
Zone III. The residual crescent of retina anterior to zone II.
Practically: the extent of zone I is determined by its temporal border. Through a 25 or 28 dioptre lens with the nasal
border of the optic disc at one edge of the field, the temporal limit of zone I is the other edge. The outer extent of zone II
is determined by its nasal border so that if the vessels reach the ora serrata nasally the eye is defined as a zone III eye.
If this cannot be fully ascertained, the eye should be considered a zone II eye.
ROP Staging
Stage 1: Demarcation line - A thin relatively flat line separating the vascular and avascular retina. Abnormal
branching or arcading of vessels may lead up to the demarcation line.
Stage 2: Ridge - The ridge has height and width extending above the retina. lsolated tufts of neovascular
tissue - “popcorn” - may be seen posterior to the ridge.
Stage 3: Extraretinal Fibrovascular Proliferation - In this stage extraretinal fibrovascular proliferation or
neovascularisation extends from the ridge into the vitreous.
Stage 4: Partial Retinal Detachment - Stage 4 partial retinal detachment: sparing macula (stage 4a) and involving
macula (stage 4b).
Stage 5: Total Retinal Detachment
Extent
Recorded in clock hours.
Aggressive posterior ROP (AP-ROP)
An uncommon, but rapidly progressive, form of ROP previously known as rush disease. AP-ROP is observed most
commonly in zone I, but can also be located in posterior zone II. Critically, AP-ROP is deceptively featureless and
may appear as a flat network of neovascularisation which can be easily ignored. Shunts are common but the most
prominent feature of AP-ROP is plus disease which is out of all proportion to the appearance of the ROP. AP-ROP does
not have the appearance of classic ROP and does not usually progress through the stages 1-3.
Pre-plus & Plus disease
Signs indicative of ROP activity including increased venous dilation and arteriolar tortuosity of the posterior retinal
vessels which may later increase in severity to include iris vascular engorgement, poor pupillary dilation (rigid pupil),
and vitreous haze. Changes in at least 2 vessel quadrants equivalent to the standard photograph (see website) are
required for the diagnosis of plus. Pre-plus changes are vascular abnormalities of the posterior pole that are insufficient
for the diagnosis of plus disease, but that cannot be considered normal.
What to do now
When this form is complete the WHITE copy should be returned to BOOST-II UK Co-ordinating Centre in the
FREEPOST envelope provided; YELLOW copy should be retained by the ophthalmologist; PINK copy should be
filed in the baby’s notes. Thank you for completing this form.
Freepost RLSL-SBZK-HTAT, BOOST-II UK Co-ordinating Centre, NPEU Clinical Trials Unit (University of
Oxford), Old Road Campus, Headington, OXFORD OX3 7LF
Version 2 November 2008