Light of Life
Retinopathy of Prematurity, a silent threat lurking in the fragile world of premature infants, demands enhanced neonatal care, encompassing thorough screening of infants and the provision of necessary treatment to safeguard their vision..
By Dr Mahipal S. Sachdev
Retinopathy of Prematurity (ROP) stands as a significant retinal disorder that primarily affects premature infants and those born with very low birth weights, presenting a condition that holds the potential to cause blindness if left unaddressed, though it remains eminently preventable with the right interventions. The importance of early and appropriate treatment cannot be overstated, as it offers the possibility of preventing blindness entirely and, even in more advanced cases, can equip children with sufficient vision to navigate their surroundings with confidence, marking a critical focus for health planners and implementers who are increasingly prioritising childhood blindness, with ROP at the forefront of their concerns.
Statistical insights reveal that between 20 and 40 percent of preterm infants are likely to develop ROP, with a troubling 3 to 7 percent facing the risk of blindness, a scenario that becomes more pressing as improvements in neonatal care lead to higher survival rates among these vulnerable infants, thereby heightening the urgency to tackle this growing issue head-on. This rising prevalence of ROP blindness is poised to present a major challenge for health planners across the nation, underscoring the essential need to boost awareness about ROP and to establish comprehensive screening programs for all infants who might be susceptible to this condition, ensuring no child is left unprotected.
Why ROP in Premature Babies?
The final 12 weeks of a full-term pregnancy, spanning from 28 to 40 weeks of gestation, represent a particularly active and crucial period for the development of the foetal eye, a process that lays the foundation for healthy vision in later life. However, premature infants find themselves at an elevated risk for developing ROP because they are abruptly removed from the nurturing and protective environment of the mother’s womb, exposing them to a range of external factors including various medications, elevated levels of oxygen, and significant variations in light and temperature that can disrupt normal development.
The blood supply to the retina initiates its formation as early as 16 weeks of gestation, with the retinal vessels gradually extending across the surface of the retina until the time of birth, establishing a critical network. In the case of premature infants, this normal growth process is interrupted, causing the development of retinal vessels to stall, after which abnormal new vessels begin to form in response to specific chemical signals released within the immature eye, potentially leading to damaging retinal changes that could result in vision loss if not carefully managed.
Make ROP Screening Mandatory
The primary objective of implementing ROP screening is to successfully identify and reach all neonates who can benefit from treatment, a goal that underscores the transformative potential of effective screening programs that target every infant deemed to be at risk, with the most optimal setting for such screenings being within the controlled and specialised environment of a neonatal intensive care unit (NICU). The power of good screening lies in its ability to work miracles by ensuring that no vulnerable infant is overlooked, providing a proactive approach to catching ROP in its earliest stages when intervention can be most effective, thereby offering a lifeline to preserve their sight and future quality of life.
Who Should Be Screened?
The screening process must be directed toward specific groups of infants who exhibit the highest risk factors for developing ROP, including those with a birth weight at or below 1,500 grams, a threshold that signals significant vulnerability due to their prematurity. Additionally, infants born at or before 32 weeks’ gestational age are prime candidates for screening, as their early arrival interrupts critical eye development stages, while very sick infants facing high-risk factors such as prolonged mechanical ventilation, the need for blood transfusions, infections, intraventricular haemorrhages, anaemia, and other complicating health conditions also require close monitoring.
The screening schedule must be initiated at 32 weeks’ gestational age or four weeks after birth, whichever occurs earlier, marking the point when ROP typically begins to manifest and become clinically observable, followed by a subsequent screening at 35 to 37 weeks’ gestational age to assess progression, with a final screening conducted between 39 and 42 weeks when ROP often starts to regress naturally. These three critical screening sessions form the backbone of an effective strategy to detect and address ROP promptly, ensuring that every at-risk infant receives the attention they need.
Natural Course of ROP
In the majority of cases, ROP presents as a transient condition that tends to follow a natural course where spontaneous regression occurs in approximately 85 percent of the affected eyes, offering a hopeful outlook for many infants without the need for invasive intervention. However, the data indicates that around 7 percent of infants with a birth weight of less than 1,251 grams will eventually progress to develop significant ROP, necessitating closer scrutiny and potential treatment. Fortunately, most infants diagnosed with mild ROP that resolves either independently or with the assistance of laser treatment will exhibit no remaining scar tissue, preserving their retinal health and visual potential for the future, which highlights the importance of monitoring even mild cases to ensure optimal outcomes.
Treatment of ROP
The approach to treating ROP is highly dependent on the severity of the condition as it presents in each individual case, requiring a tailored strategy to address the specific needs of the infant. For instances of mild involvement, the recommended course of action is often nothing more than careful observation, allowing the condition to resolve naturally in many cases without additional intervention. When moderate involvement is detected, the treatment escalates to include laser or cryotherapy, specialised techniques designed to eliminate the abnormal vessels before they can lead to the serious complication of retinal detachment, a critical step to safeguard the infant’s vision.
In more severe stages, surgical management becomes necessary, with procedures such as scleral buckling performed to address partial retinal detachment and vitreoretinal (V-R) surgery required for cases involving total retinal detachment, offering a chance to restore or preserve vision. For those infants who are left with low vision despite these efforts, a variety of educational adaptations can be implemented, supported by optical aids such as hand magnifiers for close work and distance viewing, closed-circuit television (CCTV) systems to enhance visual access, myopic corrections to address refractive errors, and the provision of high levels of illumination to improve functional vision, all of which contribute to a better quality of life. The most significant aspect of managing ROP lies in the careful and vigilant monitoring of the retinal status in premature infants, a practice that holds the power to save many of these children from the devastating progression to severe ROP, underscoring the value of proactive healthcare measures.
Call to Action
If you happen to come across anyone who has a premature baby in their care, it is imperative to inform them of the importance of arranging for ROP screening at the earliest possible opportunity, a simple yet potentially life-changing step that can make a profound difference. A timely check-up combined with the necessary treatment has the potential to enable the child to better see and appreciate the beauty of the world around them, offering a future filled with visual experiences that might otherwise be lost, emphasising the critical role that awareness and action play in protecting the vision of our youngest and most vulnerable population.
(The author is Chairman & Medical Director, Centre for Sight Group of Eye Hospitals, New Delhi)