AMERICAN ACADEMY OF PEDIATRICS
Screening Examination of Premature Infants
for Retinopathy of Prematurity
A Joint Statement of the American Academy of Pediatrics, the American
Association for Pediatric Ophthalmology and
Strabismus, and the American Academy of Ophthalmology
ROP (Retinopathy of Prematurity)
Progressive retinopathy of prematurity (ROP) was once considered an
untreatable condition leading to blindness. The results of the Cryotherapy for
Retinopathy of Prematurity Trial indicated that treatment was associated with
an approximately 50% reduction in the occurrence of posterior retinal traction
folds and/or detachments. An
accompanying editorial stated that "a new standard of care is evolving
[requiring] careful retinal examination beginning 4 to 6 weeks after birth by
an ophthalmologist experienced in looking at retinas in premature
infants."
This statement outlines the principles upon which a screening program to
detect ROP in infants at risk might be based. It is to be emphasized at the
outset that any screening program set up to implement an evolving standard of
care suffers from inherent defects such as overreferral
or underreferral and cannot, by its very nature,
duplicate the precision and rigor of a scientifically based, randomized,
prospective clinical trial. With that in mind, and based on the information
published thus far, the sponsoring organizations involved in the trial study
suggest the following guidelines:
- Infants
with a birth weight of less than or equal to 1500 g or with a gestational
age of 28 weeks or less as well as those infants more than 1500 g with an
unstable clinical course felt to be at high risk by their attending pediatrician or neonatologist
should have a dilated indirect ophthalmoscopic
examination to detect ROP.
- This
examination should be carried out by an ophthalmologist with experience in
the examination of preterm infants.
- Examination
should be performed between 4 and 6 weeks' chronological age or between 31
and 33 weeks' postconceptional age as determined
by the infant's attending pediatrician or neonatologist. (Postconceptional
age is defined as gestational age at birth plus chronological age.)
- Scheduling
of follow-up examinations are best determined by the findings at the first
examination using the International Classification of Retinopathy of Prematurity, (eg, if the
retinal vasculature is immature and in Zone II but no disease is present,
follow-up examination should be planned at approximately 2- to 4-week
intervals until vascularization proceeds to Zone
III).
- Infants
with ROP or immature vessels detected in Zone I should be seen at least
every 1 to 2 weeks until normal vascularization
proceeds to Zone III or the risk of attaining threshold conditions is
passed.
- Infants
with threshold disease (stage 3 ROP, Zone I, or II in 5 or more continuous
clock hours or 8 cumulative clock hours with the presence of "plus
disease") should be considered candidates for ablative therapy of at
least one eye within 72 hours of diagnosis.
- The
attending pediatrician or neonatologist
should refer the infants who fit the examination criteria for initial
examination to the ophthalmologist and indicate which infants are
medically able to be examined. If a transfer to another neonatal unit or
hospital occurs, the infant's new primary care physician should ascertain
the current ocular examination status of the infant from the record or
through communication with the transferring physician, so that any
necessary ophthalmologic examinations can be arranged.
These recommendations are evolving and, as more long-term ROP outcomes are
known, may have to be modified.
REFERENCES
1. Cryotherapy for Retinopathy of Prematurity
Cooperative Group. Multicenter trial of cryotherapy for retinopathy of prematurity:
preliminary results. Arch Ophthalmol.
1988;106:471-479
2. Tasman W. Multicenter trial
of cryotherapy for retinopathy of prematurity. Arch Ophthalmol. 1988;106:463.
Editorial
3. Cryotherapy for Retinopathy of Prematurity Cooperative Group. Multicenter
trial of cryotherapy for retinopathy of prematurity: three-month outcome. Arch
Ophthalmol. 1990;108:195-204
4. Cryotherapy for Retinopathy of Prematurity Cooperative Group. Multicenter
trial of cryotherapy for retinopathy of prematurity: one-year outcome--structure and function. Arch Ophthalmol. 1990;108:1408-1416
5. Palmer EA, Flynn JT, Hardy RJ, et al. Incidence and early course of
retinopathy of prematurity. Ophthalmology.
1991;98:1628-1640