Evidence-Based ROP Surveillance
Given the availability of effective therapy for Type I pre-threshold ROP and Stage 4 ROP, routine surveillance is likely the most critical aspect of ROP care.
Natural history data from the CRYO-ROP and LIGHT-ROP studies were combined to speak to the question of when to begin and conclude surveillance for acute ROP. The study included 4099 infants with birth weights less than 1251 grams prospectively screened in 23 study centers between January 1, 1986 and November 30, 1987 (CRYO-ROP study group), and 361 infants with birth weights less than 1251 grams and gestational ages less than 31 weeks screened in 3 study centers between July 1, 1995 and March 31, 1997 (LIGHT-ROP study group). Retinal findings indicative of poor outcome (namely, prethreshold ROP, threshold ROP, plus disease, or stage 3+ disease) were seen in only 1% of infants before 31 weeks post-menstrual age (PMA) and in only 1% of infants after 46.3 weeks PMA. Therefore, for the vast majority of eyes in the CRYO-ROP and LIGHT-ROP Studies, the time window for development of serious ROP (prethreshold or worse) was between 30.9 weeks and 46.3 weeks PMA. Retinal findings indicative of minimal risk of poor outcome (namely, vascularization into zone 3 without prior ROP or full retinal vascularization) were seen in 99% of infants by 45.9 weeks post-menstrual age.
Many neonatal intensive care units (NICUs) have higher birth-weight criteria (i.e., > 1251 grams), based on the concern that at-risk infants may be missed. The current consensus document of the American Academy Of Pediatrics Section On Ophthalmology, American Academy Of Ophthalmology, American Association For Pediatric Ophthalmology And Strabismus and American Association Of Certified Orthoptists recommends that “…[i]nfants with a birth weight of less than 1500 g or gestational age of 30 weeks or less (as defined by the attending neonatologist) and selected infants with a birth weight between 1500 and 2000 g or gestational age of >30 weeks with an unstable clinical course, including those requiring cardiorespiratory support and who are believed by their attending pediatrician or neonatologist to be at high risk, should have retinal surveillance examinations performed after pupillary dilation using binocular indirect ophthalmoscopy to detect ROP…[I]nfants born before 25 weeks’ gestational age should be considered for earlier surveillance on the basis of severity of comorbidities.” Exams are continued until 50 weeks PMA.
Summary guidelines for surveillance of premature infants are presented below.
- All infants with a birth weight <1,500 g (3 lbs, 4 oz)
- All infants born at postmenstrual age of 30 weeks or earlier
- All infants weighing between 1,500 and 2,000 g (4 lbs, 6 oz) requiring supplemental oxygen, or with an unstable clinical course and who are thought to be at high risk
- Initial exam by 31 weeks’ postmenstrual age or 4 weeks’ chronological age, whichever is later
- Weekly: Retinal vessel immaturity with vessels ending in zone I but no ROP in that zone or Low risk prethreshold ROP*
- Every 2 weeks: less than prethreshold ROP in zone II
- Treat: High risk prethreshold ROP
How long to examine
- Attainment of 50 weeks’ postmenstrual age without the development of prethreshold ROP or worse
- Progression of retinal vascularization into zone III without previous zone II ROP
- Full vascularization (to or within 1 disk diameter of the ora serrata) on 2 occasions
Risk management considerations are addressed in detail in the “ROP Risk Management” section. Of particular note, missed exams following discharge may require efforts beyond those expended for adult patients to ensure follow-up, including sending a letter to parents/caregivers by certified mail, notifying the pediatrician, and considering contacting Child Welfare Services.
Reynolds JD, Dobson V, Quinn GE et al. CRYO-ROP and LIGHT-ROP Cooperative Study Groups. Evidence-based screening criteria for retinopathy of prematurity: natural history data from the CRYO-ROP and LIGHT-ROP Studies. Arch Ophthalmol 2002;120:1470-1476
Hutchinson AK, O'Neil JW, Morgan EN, Cervenak MA, Saunders RA. Retinopathy of prematurity in infants with birth weights greater than 1250 grams. J AAPOS 2003;7(3):190-4.
American Academy Of Pediatrics Section On Ophthalmology, American Academy Of Ophthalmology, American Association For Pediatric Ophthalmology And Strabismus And American Association Of Certified Orthoptists. POLICY STATEMENT: Screening Examination Of Premature Infants For Retinopathy Of Prematurity. Pediatrics 2013;131;189; Originally Published Online December 31, 2012; DOI: 10.1542/Peds.2012-2996