Retinopathy of prematurity: Still more to do

Retinopathy of prematurity (ROP) is a complex eye disorder in premature infants, requiring coordinated care between neonatologists and ophthalmologists. To prevent blindness, a fail-safe protocol for neonatal oxygen management, along with timely screening and treatment, must be established. Recently, there has been a rise in the prevalence of aggressive ROP (A-ROP), a severe disease type characterized by a featureless appearance to the retina, tortuous vessels, and minimal staging signs.[1] A-ROP resembles the findings in the first historical reports of retrolental fibroplasia[2] and may be found in settings where there is excessive use of 100% oxygen or poor monitoring of saturation levels. The natural history of ROP progresses through two distinct phases. Initial hyperoxia-driven vasoconstriction leads to cessation of retinal vessel growth, followed by pathological neovascularization in response to retinal hypoxia, producing the classical appearances of ROP. Although regression, or “die-back,” of previously formed vessels in the initial phase has been shown, it has only been documented in A-ROP among more mature preterm infants with severe disease [Fig. 1].[3] While classic ROP onset is predictable by postmenstrual age, A-ROP may have a compressed clinical course, demanding earlier and more frequent screening in more mature infants.Figure 1: Retinal images of a preterm child taken during telescreening in a semi-urban neonatal unit. Infant born at 32 weeks’ GA with 1700 g BW. (a) Right eye image taken at 2 weeks postnatal age showing blood vessels in posterior zone II (black arrows). (b) Same eye image taken at 4 weeks postnatal age showing regression (die-back) of these formed vessels from posterior zone II to zone I (black arrows). A large ischemic is seen in inferotemporal quadrant (white arrow) at 4 weeks postnatal age, which was absent 2 weeks earlier. (c and d) Left eye images of the same baby taken at a similar timeline showing die-back of formed vessels from zone II to zone I (black arrows). The infant had respiratory distress and was on continuous positive airway pressure for 5 days, followed by unblended high-flow oxygen for another 5 daysPrevention and neonatal care Preventing ROP begins with quality neonatal care. Antenatal corticosteroids for imminent preterm delivery (<35 weeks) and optimal delivery room management, e.g., delayed cord clamping and prevention of hypothermia, are vital. Oxygen, a critical drug in neonatal care, must be carefully regulated. The World Health Organization recommends a saturation target of 88%–94%, with alarms set at 86% and 95%.[4] In situations without air-oxygen blenders, simple blending methods using Y-connectors can provide safer oxygen delivery [Fig. 2]. Using a low-flow meter (with a maximum flow rate of 3 L/min and a minimum 0.1 or 0.25 L/min), inspired oxygen concentrations can be reduced by reducing the flow rate, but must be titrated using target oxygen saturations.Figure 2: Y-connector to blend oxygen and air from (a) cylinders and (b) central supplyAvoiding fluctuations in oxygenation is equally important and can be difficult when using continuous positive airway pressure; both caffeine therapy and kangaroo care can help stabilize oxygen levels. Adequate nutrition, including early parenteral support and mother’s milk, is essential for maintaining insulin-like growth factor levels and reducing ROP risk. Additional strategies include measures to prevent sepsis and careful antibiotic stewardship. Screening and programmatic needs Indian guidelines recommend ROP screening for infants <34 weeks’ gestation or <2000 g, and for selected older preterm infants needing respiratory support.[5] Screening should ideally start at 2–3 weeks postnatal age, given the faster progression seen in more mature babies. Delays in ophthalmologist availability, poor coordination with neonatology services, and lack of parental awareness can all hinder timely diagnosis and treatment. The appearance of A-ROP should prompt the ophthalmologist to provide feedback concerns about oxygen management to the neonatal team. Conclusion ROP-induced blindness is largely preventable with consistent implementation of oxygen protocols, enhanced screening coverage, and early intervention. With most forms of ROP progressing within a narrow age window, coordinated care between neonatologists and ophthalmologists remains the cornerstone of effective prevention and treatment.