eMedicine Specialties > Pediatrics: Cardiac Disease and Critical Care Medicine > Neonatology

Retinopathy of Prematurity

Author: KN Siva Subramanian, MD, Professor of Pediatrics and Obstetrics/Gynecology, Chief of Neonatal Perinatal Medicine, Director of Nurseries, Georgetown University Hospital
Coauthor(s): Monisha Bahri, MBBS, MD, Fellow in Neonatal/Perinatal Medicine, Department of Neonatology, Georgetown University Hospital; Gonzalo (Vike) Vicente, MD, FAAP, Consulting Ophthalmologist, Eye Doctors of Washington
Contributor Information and Disclosures

Updated: Jun 29, 2009

Introduction

Background

Retinopathy of prematurity (ROP) is a serious vasoproliferative disorder that affects extremely premature infants. Retinopathy of prematurity often regresses or heals but can lead to severe visual impairment or blindness. Significant retinopathy of prematurity can lead to lifelong disabilities for the smallest survivors of neonatal ICUs (NICUs). It remains a serious problem despite striking advances in neonatology.

Pathophysiology

Retinopathy of prematurity primarily occurs in extremely low birth weight (ELBW) infants. Most research suggests that a low birth weight, a young gestational age (GA), and the severity of illness (eg, respiratory distress syndrome [RDS], bronchopulmonary dysplasia [BPD], sepsis) are associated factors. Recently, other associations have been described. However, the severity of the illness appears to be a major predictor of severe disease. The smallest, sickest, and most immature infants are at the highest risk for serious disease. Black infants appear to have less severe retinopathy of prematurity.

Retinal vasculature begins to develop around 16 weeks' gestation. It grows circumferentially and becomes fully mature at term. Premature birth results in the cessation of normal retinal vascular maturation. Exposure of newborn premature infants to hyperoxia downregulates retinal vascular endothelial growth factor (VEGF). Blood vessels constrict and can become obliterated, resulting in delays of normal retinal vascular development. This hyperoxia-vasocessation is known as stage I of retinopathy of prematurity.

Stage I retinopathy of prematurity.

Stage I retinopathy of prematurity.

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Stage I retinopathy of prematurity.

Stage I retinopathy of prematurity.


Early on, oxygen and nutrients can be delivered to the retina by means of diffusion from the underlying choroid capillary bed. The retina continues to grow in thickness and eventually outgrows its vascular supply. Over time, retinal hypoxia occurs and results in an overgrowth of vessels; this hypoxia-vasoproliferation is stage II of retinopathy of prematurity.

Stage II retinopathy of prematurity.

Stage II retinopathy of prematurity.

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Stage II retinopathy of prematurity.

Stage II retinopathy of prematurity.


This process is mediated, in part, by VEGF and is affected by insulinlike growth factor-1 (IGF-1) and other cytokines. These changes in the retina result in retinopathy of prematurity.

Dhaliwal et al found that retinopathy of prematurity occurred with significantly greater frequency and severity in small-for-GA (SGA) infants compared with appropriate-for-GA (AGA) infants.1 In a review of 1413 infants with birth weight less than 1500 g and/or GA of 26-31 weeks, infants with a birth weight below the tenth percentile for GA were more likely to develop any stage of retinopathy of prematurity than their AGA peers (p<0.01) and were more likely to develop severe retinopathy of prematurity (GA of 26-27 weeks, p<0.01; GA of 28-31 weeks, p = 0.01).

Frequency

United States

The incidence varies with birth weight but is reported to be approximately 50-70% in infants whose weight is less than 1250 g at birth.

Hussain et al reviewed the incidence and the need for surgery in neonates with retinopathy of prematurity who were born at 22-36 weeks' gestation between July 1989 and June 30, 1997.2 The incidences were 21.3% (202 of 950 patients) for retinopathy of prematurity of any stage and 4.6% (44 of 950 patients) for retinopathy of prematurity at stage III or worse. No retinopathy of prematurity was noted in infants born after 32 weeks' gestation. No infant born after 28 weeks' gestation needed retinal surgery in this study. Despite the increased survival of ELBW infants, they found a considerable reduction in the incidence and severity of retinopathy of prematurity compared with reports from an earlier period. However, infants born before 28 weeks' gestation and those with birth weights less than 1000 g were at risk to need retinal surgical treatment for retinopathy of prematurity.

Investigators from the Supplemental Therapeutic Oxygen for Prethreshold Retinopathy of Prematurity (STOP-ROP) multicenter trial concluded that maintaining oxygen saturation in the high-90% range did not reduce the severity of the retinopathy when compared with the saturations in the low-90% range.3 However, it did result in more adverse pulmonary events. In a subanalysis of infants who did not have plus disease (ie, tortuosity of vessels) at the time of study entry, the progression to threshold was significantly decreased when compared with the progression in infants with plus disease. Thus, a critical window for oxygen administration may be determined.

International

Retinopathy of prematurity is prevalent worldwide and several reports have detailed the incidence and risk factors associated with the disease. 

A Korean study reported a 20.7% incidence (88 of 425 premature babies) and reported that a GA of 28 weeks or less and a birth weight of 1000 g or less were the most significant risk factors.4 Another study from Singapore reported a 29.2% incidence (165 of 564 ELBW infants).5 The median age of onset of retinopathy of prematurity was 35 weeks (range, 31-40 wk) postmenstrual age. The risk factors for development of threshold retinopathy of prematurity by regression analysis were maternal preeclampsia, birth weight, pulmonary hemorrhage, duration of ventilation, and duration of continuous positive airway pressure (CPAP).

An observational study from United Kingdom designed to compare the characteristics of infants with severe retinopathy of prematurity in countries with low, moderate, and high levels of development found that the mean birth weights of infants from highly developed countries was 737-763 g compared with 903-1527 g in less-developed countries.6 Mean GAs of infants from highly developed countries were 25.3-25.6 weeks compared with 26.3-33.5 weeks in less-developed countries. Thus, larger and more mature infants seemed to be developing severe retinopathy of prematurity in less-developed nations. This suggests that individual countries need to develop their own screening programs with criteria suited to their local population.

Mortality/Morbidity

Long-term outcomes for serious disease include severe visual impairment and blindness. In addition, myopia, amblyopia, and strabismus may occur. Repka et al described the need for subsequent ophthalmic intervention in patients with retinopathy of prematurity.7

Race

Some reports indicate a decreased incidence of progression to threshold disease in black infants. Most evidence comes from the Cryotherapy for Retinopathy of Prematurity (CRYO-ROP) study.8 Further evidence that black infants are less likely to develop severe retinopathy of prematurity has been reported in studies of candidemia in ELBW infants.9 The exact mechanism for the decreased incidence of progression to surgery in black infants has not been described. Bizzaro et al showed a strong genetic predisposition to retinopathy of prematurity when comparing monozygotic twins with dizygotic twins.10

Sex

Although some reports indicate a male predilection, the CRYO-ROP study revealed no differences based on sex.8

Age

Retinopathy of prematurity is a disease of the immature retina, and the occurrence of retinopathy of prematurity is inversely related to GA. The more premature the infant, the more likely retinopathy of prematurity is to develop.

Clinical

History

  • Infants at highest risk for retinopathy of prematurity (ROP) are those with the lowest birth weights and youngest gestational ages (GAs).
  • Prolonged exposure to supplemental oxygen is also a risk factor.
  • The severity of illness (including sepsis), blood transfusions, days receiving mechanical ventilation, a patent ductus arteriosus, and intraventricular hemorrhage are also associated with retinopathy of prematurity.
  • The effect of blood transfusion on retinopathy of prematurity is controversial. The smallest, sickest infants receive more transfusions than their healthy counterparts and may have more frequent or severe retinopathy of prematurity. However, theoretical risks associated with factors such as volume and iron load may place infants who receive more transfusions at higher risk for retinopathy of prematurity.
  • Recent studies by Lofqvist et al have shown that infants whose postnatal gain weight is less than expected are at increased risk.11

Physical

  • Screening: An ophthalmologist experienced in evaluating infants for retinopathy of prematurity should perform a screening examination.
  • International classification
    • To standardize examinations, a group of physicians organized an international classification of ROP (ICROP) in 1984 and updated the classification in 1987 and again in 2005.12
    • ROP is characterized by 3 parameters: stage, zone, and plus disease (ie, tortuosity of vessels).
  • Examination recommendations: The American Academy of Pediatrics (AAP) and the American Academy of Ophthalmology have joint recommendations for infants who should be screened for retinopathy of prematurity.13
    • Screening should include those infants with a birth weight of less than 1500 g or a GA of 31 weeks or less and selected infants with a birth weight of 1500-2000 g or a GA of more than 31 weeks with an unstable clinical course, including those who require cardiorespiratory support and those who are believed by their attending pediatrician or neonatologist to be at high risk.
    • The retinal screening examinations should be performed by an experienced ophthalmologist after pupillary dilation using binocular indirect ophthalmoscopy to detect retinopathy of prematurity. 
    • The time of initiation of retinopathy of prematurity screening should be based on the infant's age. The onset of serious retinopathy of prematurity correlates better with postmenstrual age (gestational age at birth plus chronologic age) than with postnatal age; this means that the youngest infants at birth take the longest time to develop serious retinopathy of prematurity.
    • Screening guidelines have been the focus of recent studies. The issue of cost-effectiveness versus missing cases is controversial. In addition, Subhani et al suggested that infants should be examined by age 4-6 weeks, contrary to the standard postmenstrual age criteria.14 The AAP guidelines for retinopathy of prematurity screening suggested a schedule for detecting prethreshold retinopathy of prematurity (99% confidence), usually well before any required treatment. See the table below.
    • Timing of First Eye Examination Based on Gestational Age at Birth

      Open table in new window

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      Table
      Gestational Age at Birth (wk)Chronologic Age (wk)Postmenstrual Age (wk)
      22 * 931
      23 * 831
      24731
      25631
      26531
      27431
      28432
      29433
      30434
      31†435
      32†436
      Gestational Age at Birth (wk)Chronologic Age (wk)Postmenstrual Age (wk)
      22 * 931
      23 * 831
      24731
      25631
      26531
      27431
      28432
      29433
      30434
      31†435
      32†436
    • * This guideline should be considered tentative rather than evidence-based for infants with a GA of 22-23 weeks because of the small number of survivors in these categories. † If necessary.
    • Follow-up examinations are based on initial examination findings. Most infants are screened every 2 weeks. More frequent (once a week or less) follow-up is recommended in stage I or II retinopathy of prematurity in zone I  and in stage III retinopathy of prematurity in zone II. The presence of plus disease requires careful evaluation because, in these cases, peripheral ablation is more appropriate rather that observation alone.
    • Screening examinations are continued until the blood vessels reach the anterior edge of the retina (complete retinal vascularization around 40 weeks' gestation) or until postmenstrual age of 45 weeks with no prethreshold disease (defined as stage III retinopathy of prematurity in zone II, any retinopathy of prematurity in zone I) or no worse retinopathy of prematurity is present.

More on Retinopathy of Prematurity

Overview: Retinopathy of Prematurity
Differential Diagnoses & Workup: Retinopathy of Prematurity
Treatment & Medication: Retinopathy of Prematurity
Follow-up: Retinopathy of Prematurity
Multimedia: Retinopathy of Prematurity
References
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References

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Further Reading

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Keywords

retinopathy of prematurity, ROP, retrolental fibroplasia, retinal neovascularization, extremely low birth weight infants, ELBW, respiratory distress syndrome, RSD, bronchopulmonary dysplasia, BPD, sepsis, retinal hypoxia, tortuosity of vessels, maternal preeclampsia, pulmonary hemorrhage, visual impairment, blindness, myopia, amblyopia, strabismus, patent ductus arteriosus, intraventricular hemorrhage, visual impairment, blindness, supplemental oxygen, treatment, diagnosis

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Contributor Information and Disclosures

Author

KN Siva Subramanian, MD, Professor of Pediatrics and Obstetrics/Gynecology, Chief of Neonatal Perinatal Medicine, Director of Nurseries, Georgetown University Hospital
KN Siva Subramanian, MD is a member of the following medical societies: American Academy of Pediatrics, American Association for the Advancement of Science, American College of Nutrition, American Society for Parenteral and Enteral Nutrition, American Society of Law Medicine and Ethics, New York Academy of Sciences, and Southern Society for Pediatric Research
Disclosure: Nothing to disclose.

Coauthor(s)

Monisha Bahri, MBBS, MD, Fellow in Neonatal/Perinatal Medicine, Department of Neonatology, Georgetown University Hospital
Monisha Bahri, MBBS, MD is a member of the following medical societies: American Academy of Pediatrics, Indian Academy of Pediatrics, and Medical Council of India
Disclosure: Nothing to disclose.

Gonzalo (Vike) Vicente, MD, FAAP, Consulting Ophthalmologist, Eye Doctors of Washington
Gonzalo (Vike) Vicente, MD, FAAP is a member of the following medical societies: American Academy of Ophthalmology, American Academy of Pediatrics, American Association for Pediatric Ophthalmology and Strabismus, and American Medical Association
Disclosure: Nothing to disclose.

Medical Editor

Oussama Itani, MD, FAAP, FACN, Clinical Associate Professor of Pediatrics and Human Development, Michigan State University; Medical Director, Department of Neonatology, Borgess Medical Center
Oussama Itani, MD, FAAP, FACN is a member of the following medical societies: American Academy of Pediatrics, American College of Nutrition, American College of Physician Executives, and American Heart Association
Disclosure: Nothing to disclose.

Pharmacy Editor

Mary L Windle, PharmD, Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy, Pharmacy Editor, eMedicine
Disclosure: Pfizer Inc Stock Investment from financial planner; Avanir Pharma Stock Investment from financial planner ; WebMD Salary and stock Employment and investment from financial planner

Managing Editor

Arun K Pramanik, MD, MBBS, Professor of Pediatrics, Director of Neonatal Fellowship, Louisiana State University Health Sciences Center
Arun K Pramanik, MD, MBBS is a member of the following medical societies: American Academy of Pediatrics, American Thoracic Society, National Perinatal Association, and Southern Society for Pediatric Research
Disclosure: Nothing to disclose.

CME Editor

Carol L Wagner, MD, Professor of Pediatrics, Medical University of South Carolina
Carol L Wagner, MD is a member of the following medical societies: American Academy of Pediatrics, American Chemical Society, American Medical Women's Association, American Public Health Association, American Society for Bone and Mineral Research, American Society for Clinical Nutrition, Massachusetts Medical Society, National Perinatal Association, and Society for Pediatric Research
Disclosure: Nothing to disclose.

Chief Editor

Ted Rosenkrantz, MD, Professor, Departments of Pediatrics and Obstetrics/Gynecology, Division of Neonatal-Perinatal Medicine, University of Connecticut School of Medicine
Ted Rosenkrantz, MD is a member of the following medical societies: American Academy of Pediatrics, American Medical Association, American Pediatric Society, Connecticut State Medical Society, Eastern Society for Pediatric Research, and Society for Pediatric Research
Disclosure: Nothing to disclose.

 
 
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