Retinopathy of Prematurity Clinical Presentation

Updated: Feb 28, 2015
  • Author: KN Siva Subramanian, MD; Chief Editor: Ted Rosenkrantz, MD  more...
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Infants at highest risk for retinopathy of prematurity (ROP) are those with the lowest birth weights and youngest gestational ages (GAs). See the Gestational Age from Estimated Date of Delivery calculator.

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. [13]




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. [14]

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. [15]

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. [16] 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.

Table. Timing of First Eye Examination Based on Gestational Age at Birth (Open Table in a new window)

Gestational Age at Birth (wk) Chronologic Age (wk) Postmenstrual Age (wk)
22 * 9 31
23 * 8 31
24 7 31
25 6 31
26 5 31
27 4 31
28 4 32
29 4 33
30 4 34
31 (if necessary) 4 35
32 (if necessary) 4 36


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.

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.