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Retinopathy of prematurity - information on screening

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Which babies are screened?

All babies who are:

  • <31 weeks gestation, or
  • < 1250 g (only one criterion needs to be met) or
  •  Selected infants >1250 g and>31 weeks with an unstable clinical course who are believed to be at high risk by their attending neonatologist. 

In the joint guidelines published by the American Academy of Paediatrics Annual report data on the incidence of ROP in Starship NICU has shown that the frequency of significant ROP in infants > 1250 g and > 31 weeks is sufficiently low that these infants are not routinely examined.

Consistently reported risk factors for the development of ROP include:

  • Affected twin to twin transfusion infants.
  • Treatment with Nitric Oxide for PPHN.
  • Intrauterine Hydrops.
  • Severe sepsis.
  • Grade3/4 IVH, Post haemorrhagic hydrocephalus.
  • Prolonged period in high inspired oxygen.

Assessment / ROP screening

First ROP examination schedule
< 26 weeks gestation 30 - 31 weeks PMA
26 - 29 weeks 4 weeks postnatal
> 30 weeks 4 weeks postnatal
ROP follow up examination schedules
Timing of follow up (weeks)  Retinal findings
< 1 week Early features of possible AP - ROP
1 week Any ROP in zone 1
Regressing ROP zone 1

Immature vascularization in zone 1
Stage 3 in zone 2
Pre - plus disease in any zone
Hazy view of retina
2 weeks Any stage ROP except stage 3 in zone 2
Regressing ROP zone 2
Stage 1 or 2 ROP in zone 3
Regressing ROP zone 3
Less than 1 week follow up is recommended for babies with retinal features indicative of Aggressive Posterior ROP ( AP- ROP) posterior location of ROP, increased dilatation and tortuosity of retinal vessels in all 4 quadrants out of proportion to the peripheral retinopathy development of shunting vessels within the vascularized retina.


Recommended drops to facilitate eye examination

At ADHB we use Phenylephrine 2.5% x2 at 10 min intervals, Tropicamide 1% x2 at 10 min intervals.

Pain control

Local anaesthetic eg. 1% Amethocaine (Tetracaine) x2 at 10 min intervals all given 30 - 60 mins pre exam.
Oral sucrose immediately prior to exam.

It is the responsibility of the medical staff NS-ANPs to ensure that the examinations are scheduled according to the above guidelines.

Treatment criteria

Treatment for ROP should be undertaken if any of the following retinal features are present:

  • Zone 1 any ROP with plus
  • Zone 1 stage 3 without plus
  • Zone 2 stage 2 or 3 with plus

Treatment should generally be completed when possible within 48 -72 hours of diagnosis of treatable disease.

Babies with Aggressive Posterior ROP should be treated as soon as possible and preferably within 24 hours, not later than 48 hours from diagnosis.

Classification System

  

  

  

  

  

     

   

   

Referrals

ROP treatment occurs in 5 of the level 3 Neonatal Intensive Care Units: Auckland, Counties, Hamilton, Wellington and Christchurch.

Severe ROP requiring laser treatment is relatively rare and should only be carried out by appropriately trained practitioners. It should be restricted to centers where such expertise is available to ensure optimum treatment outcomes.

Termination of ROP screening

  • Examinations should not stop prior to 36 weeks.
  • Expect to go to PMA 38/39 weeks for infants < 28 weeks.
  • ROP screening can be discontinued if:
    • Retinal vascularization reached zone 3 without previous ROP.
    • ROP regressed either spontaneously or after treatment indicated by development of dry white ridges/ line from active pink ridges, development of laser induces scar tissue and transgression of vessels across the demarcation line.
    • Infant reaches PMA 45 weeks and there is no pre threshold ROP present (any zone 1 disease or stage 3 in zone 2)
    • If Bevacizumab (Avastin) is used ROP screening should continue to 54 weeks corrected age.

Transfer to another hospital

Details of eye examinations and recommendations for further examinations MUST be included in transfer letters. The transfer letter should specify the stage of ROP (if present) and the zone to which the retina is vascularized as this will influence follow up arrangements.

Follow up post discharge from NICU

Long term clinical follow up for babies at risk of ROP as below.

Premature babies who qualified for ROP screening irrespective of having ROP are at higher risk of developing other ocular morbidities such as strabismus, amblyopia.

For infants without ROP treatment a six months outpatient review after discharge from acute ROP screening should be offered and future follow up can be discontinued if there is no ocular abnormality seen.

For infants who have ROP laser treatment, a three months outpatient review should be offered and thereafter 9 - 12 monthly until Ophthalmologist transfers to a community optometrist.

Infants who have had ROP requiring treatment are at higher risk of neurodevelopmental delay and long term follow up by a paediatrician should occur.

ROP screening service organization & responsibility

Each NICU should have a ROP nurse coordinator, or neonatal associate clinical nurse manager responsible for ROP screening.

A record system eg electronic data base must be in place to trigger and schedule the initial ROP examination for those infants at risk this is done at the time of admission in NICU and will book the date of the first exam.

It is the responsibility of the neonatologist to ensure that infants who are eligible for screening are scheduled on time for initial and follow up ROP eye examinations.

It is the responsibility of the screening ophthalmologist to ensure the initial ROP examination takes place at the time mutually agreed between the neonatologist and ophthalmologist.

The examining ophthalmologist must record a follow up screening plan in the infants medical record and communicate this to the neonatology service coordinator on the day as well as the outcome of the current examination.

For babies transferred from a level 3 to a level 2 unit it is the responsibility of the transferring NICU neonatologist to inform the neonatologist/ paedriatrician in the receiving DHB the requirement and the timing of initial or follow up ROP examination.

Each unit should have a system follow up ROP examination booking for those babies discharged home before completion of their ROP screening examination.

References

  1. Darlow B A Arch Dis Child 1988; 63: 1083-6.
  2. Darlow B A, Clement R S, Retinopathy of Prematurity: screening and optimal use of ophthalmologist's time. Australia and New Zealand Journal of Ophthalmology 1990; 18 (1) : 41 -46.
  3. International Committee for the Classification of Retinopathy of Prematurity. The international classification of retinopathy of prematurity revisited. Arch Ophthalmol2005; 123 (70: 991-9
  4. Chiang et al, Detection of clinically significant retinopathy of prematurity using wide angled digital retinal photography: a report by the American Academy of Ophthalmology. Ophthalmology 2012 June; 119 (6) : 1270 - 80.
  5. Trese M What is the real gold standard for ROP screening? Retina 2008; 28 (3 Suppl): S1-2
  6. Dai, Shuan, Darlow, Brian, Austin, Nicola. Retinopathy of Prematurity: New Zealand recommendations for case detection and treatment. Journal of Paediatrics and Child Health 2015 (accepted press ).

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Document Control

  • Date last published: 25 September 2018
  • Document type: Clinical Guideline
  • Services responsible: Neonatology
  • Owner: Newborn Services Clinical Practice Committee
  • Editor: Sarah Bellhouse
  • Review frequency: 2 years