Strengthening retinopathy of prematurity screening and treatment services in Nigeria: a case study of activities, challenges and outcomes 2017-2020

A Narrative Review on Managing Retinopathy of Prematurity: Insights Into Pathogenesis, Screening, and Treatment Strategies

Retinopathy of prematurity (ROP) is a rare proliferative ocular condition that can happen in premature babies (born preterm <36 weeks) or who weigh <1.5 kg at birth (low birth weight babies). ROP is a major cause of childhood blindness. It is a premature disease since retina vascularization is completed only by 40 weeks of life. The survivability for preterm infants has increased owing to recent improvements in neonatal care during the past decade. As a result, the prevalence of ROP has risen concurrently. The abnormal development of blood vessels in the retina is the cause of this illness. It occurs in two phases, phases 1 and 2. Most preterm infants weighing <1.5 kg need supplemental oxygen for respiratory support at birth. This leads to the initiation of phase 1 (vasoconstrictive phase). Phase 1 is characterized by loss of maternal-fetal connection and hyperoxia due to supplemental oxygen therapy. Oxygen's vasoconstrictive and obliterative action is primarily observed in developing retinal vessels. The inhibition of vascular endothelial growth factor follows from this. Phase 2 (vasoproliferative phase) shows the dilatation and tortuosity of the bigger existing vessels together with neovascularization and proliferation of new vessels into the vitreous when the baby is shifted from respiratory support to room air. Now, the retina gets hypoxic, where the retina becomes more metabolically active but is yet minimally vascularized, leading to VEGF-induced vasoproliferation, which might result in retinal detachment. Patients with ROP face the danger of loss of vision. If correct and quick treatment is not provided, they might land into permanent blindness. Yet, ROP remains one of the most preventable causes of childhood blindness worldwide. Blindness caused by ROP can only be avoided if screening programs are readily available, pertinent, and appropriate. The initial stage in the therapy of ROP is the screening of premature neonates. Timely screening and management for ROP is important to avoid this irreversible loss of vision. The treatment is based on the severity of the disease. Management may include pharmacological interventions like intravitreal and anti-vascular endothelial growth factor and non-pharmacological interventions like laser surgery, vitrectomy, and scleral buckling. We conducted a thorough literature search of studies on pathogenesis, risk factors, classification, and various treatment options for retinopathy of prematurity in infants, using a mixture of pertinent keywords. Only those studies published in peer-reviewed journals between 2010 and 2023 and written in English were included. Duplicate studies, unavailable in full-text for free, or studies unrelated to our subject matter were excluded. After thoroughly evaluating the selected studies, the results were synthesized and presented narratively. This article sheds light on the pathogenesis of ROP, particularly its relation to oxygen use, screening, and potential therapeutic management of ROP. Today advances in screening techniques have improved the outcomes for infants with ROP. Still, ongoing research is needed to optimize management strategies and reduce the burden of this condition.

Impact of COVID-19 pandemic on retinopathy of prematurity services in low resource settings

BACKGROUND AND OBJECTIVES

Retinopathy of prematurity is an increasingly important cause of blindness in children in low- and middle-income countries. Timely screening and treatment greatly reduce blindness. This study assessed the impact of the COVID-19 pandemic on ROP services in low- and middle-income countries.

METHODS

An online survey with closed and open-ended questions in Microsoft Teams was sent to 304 ophthalmologists providing screening, treatment and/or vitreoretinal services (January 15 to March 12 2021). Categories were used to report impact on services. 28 participants were purposively selected for interview.

RESULTS

184/201 completed forms from 32 countries were received. Two thirds of participants worked in government facilities and 45.6% were paediatric ophthalmologists. A moderate to severe impact was reported by 13% for screening, 9% for treatment and 16% for vitreoretinal surgery with some variation between government, private and not-for-profit sectors. 22% thought services would take a year to recover. Fifteen ophthalmologists from 12 countries were interviewed. Many reported fewer neonatal admissions, and several reported more ROP blind infants once restrictions lifted. Themes associated with services continuing included limited lockdown, autonomy and flexibility, commitment, advocacy and technology. Themes associated with a negative impact include fear and panic, closure of facilities, COVID infection or quarantining of health workers and parents, lack of transport and exacerbation of poverty.

CONCLUSIONS

The COVID pandemic had a very variable impact on the provision of ROP services. In some countries where the impact was great, more infants may have become blind from ROP. Lessons can be learnt for planning pandemic preparedness.

Retinopathy of prematurity among infants admitted to two neonatal intensive care units in Ethiopia

OBJECTIVE

This study was conducted to determine the prevalence and risk factors for retinopathy of prematurity (ROP) in two neonatal intensive care units (NICUs) in Addis Ababa, Ethiopia.

METHODS AND ANALYSIS

A prospective screening survey was conducted from June 2019 to June 2020 in two level 3 public NICUs. Infants with a birth weight (BW) of ≤1500 g or gestational age (GA) of ≤32 weeks and those with a BW of >1500 g and GA of >32 weeks with an unstable clinical course were included. Data on demographic and neonatal characteristics, neonatal and maternal comorbidities, and therapeutic interventions were collected. Logistic regression analysis was used to identify predictors of ROP.

RESULTS

Two hundred and two infants were included: mean BW: 1658g (range: 700-2400 g) and mean GA: 32.4 weeks (range: 26-34 weeks). 32.2% had any stage of ROP, and 6.4% had Type 1 ROP. Lower BW, smaller GA and total days on oxygen were independent risk factors for severe ROP (Type 1 or worse). All 13 neonates with severe ROP were treated.

CONCLUSION

ROP is emerging as a concern in Ethiopia. ROP screening should include neonates with BW of <1800 g or GAs of ≤33 weeks, but further studies are needed in level 2 and private NICUs. Screening guidelines need to be developed and implemented in all hospitals with NICUs.

Blindness in infants presenting with advanced and untreated ROP: a single-centre study in Pakistan

To describe the ocular features and characteristics of young children presenting with advanced, untreated retinopathy of prematurity and to determine appropriate screening guidelines for retinopathy of prematurity (ROP) in Pakistan.

Material and methods

A retrospective case series of young children with stage5A or 5B or cicatricial changes (4B or 4A ROP) was undertaken in the Department of Ophthalmology, Lahore General Hospital, Lahore, Pakistan, from August 2017 to July 2019. Information was obtained from interviewing parents and from neonatal care discharge summaries, if available. An assessment of visual function and a dilated fundus examination were performed.

Results

51 children presented at mean age of 9.7 (1.5–36) months. Their mean gestational age (GA) was 28.84 (26–38) weeks, and mean birth weight (BW) was 1229 (800–2100) g. Four children (7.8%) had a GA of >31 weeks plus a BW of >1501 g. 40 (76.4%) children were blind and 11 (23.6%) had impaired vision. Sixty-five eyes (63.7%) had stage 5B; 13 (12.7%) eyes had stage 5A; 18 (17.6%) had falciform macular folds (4B ROP) and 6 eyes (5.9%) had macular dragging (4A ROP). 39 (76.5%) children had bilateral stage 5A/5B. Half (47%) of the children lived outside the capital city of Lahore, and 15 came from small cities (population <1 million).

Conclusion

The third epidemic of blindness due to ROP has arrived in Pakistan, and premature babies are going blind even in smaller cities. Initial screening guidelines of a GA of ≤35 weeks and BW of ≤2000 g seem reasonable. There is an urgent need to improve the quality of neonatal care and to increase the coverage of ROP screening and treatment services across the country.

Systematic review of the guidelines for retinopathy of prematurity

As the characteristics of preterm infants with retinopathy of prematurity (ROP) vary, depending on the quality of neonatal care they received, universal screening criteria for ROP are not possible. The purpose of this study was to compare ROP guidelines for those planning to develop guidelines, particularly in resource-poor settings.A systematic review was undertaken of PubMed, Embase and guidelines registers to identify national or international policy statements or guidelines in English, issued or operational in 2010-2021. Bibliographies of two publications were also reviewed. The searches identified 633, 1081 and 317 records, respectively, and 157 records were retrieved from other sources. 23 publications were included in the analysis.Most included documents defined cut-offs for screening as <32 weeks gestational age (GA) or ≤1500g birth weight (BW). The highest values were in the Philippines (<35 weeks GA; <2000g) and India (≤34 weeks GA; <2000g). The lowest were in high-income countries, i.e. the United States of America (≤32 weeks for GA) and New Zealand (<1250g for BW). Most guidelines included additional risk factors to consider. The most frequent indication for when screening should start was a combination of GA and chronological age. All but one document defined when screening could stop. There was general consensus on the indications, timing and methods of treatment. Indications for anti-VEGF therapy varied between countries.Guidelines were identified for a limited number of countries with none from low-income settings. Variation in the indications for screening reflects the varying exposure to risk factors in different settings.

Respiratory distress syndrome management in resource limited settings-Current evidence and opportunities in 2022

The complications of prematurity are the leading cause of neonatal mortality worldwide, with the highest burden in the low- and middle-income countries of South Asia and Sub-Saharan Africa. A major driver of this prematurity-related neonatal mortality is respiratory distress syndrome due to immature lungs and surfactant deficiency. The World Health Organization's Every Newborn Action Plan target is for 80% of districts to have resources available to care for small and sick newborns, including premature infants with respiratory distress syndrome. Evidence-based interventions for respiratory distress syndrome management exist for the peripartum, delivery and neonatal intensive care period- however, cost, resources, and infrastructure limit their availability in low- and middle-income countries. Existing research and implementation gaps include the safe use of antenatal corticosteroid in non-tertiary settings, establishing emergency transportation services from low to high level care facilities, optimized delivery room resuscitation, provision of affordable caffeine and surfactant as well as implementing non-traditional methods of surfactant administration. There is also a need to optimize affordable continuous positive airway pressure devices able to blend oxygen, provide humidity and deliver reliable pressure. If the high prematurity-related neonatal mortality experienced in low- and middle-income countries is to be mitigated, a concerted effort by researchers, implementers and policy developers is required to address these key modalities.

Analysis of a two-year independent screening effort for retinopathy of prematurity in rural Egypt

BACKGROUND

The third epidemic of retinopathy of prematurity (ROP) has majorly involved middle income countries in which tailored screening and local guidelines require development. The data regarding ROP prevalence and cutoff numbers for screening in Egypt are lacking.

METHODS

Retrospective analysis of an independent screening effort spanning 2 years (February 2019 to February 2021) and involving 32 neonatal care units within Sharkia governorate, Egypt. Infants of gestational age (GA) ≤ 34 weeks and/or birth weight (BW) ≤ 2000 g were included, as well as those with unstable clinical course. Two eyecare centers located in Sharkia and Cairo governorates served as referral centers for any required interventions.

RESULTS

Of the 276 screened infants, 133 (48.2%) had some form of ROP that was bilateral in 127 (95.5%) of them. Aggressive posterior ROP (AP-ROP) was detected in both eyes of 24 infants (8.7%). The median (IQR) GA of infants with ROP was 32 (30-34) weeks, and the median (IQR) BW was 1600 (1350-2000) g. Sixty-three infants (47.4%) required treatment. Of the total 84 eyes that primarily were treated, 73 (86.9%) received intravitreal ranibizumab, 8 (9.5%) underwent laser ablation therapy, and 3 eyes (3.6%) underwent surgery. Recurrence rate was 16.7% (14 eyes). Final outcome was favorable in 83 eyes (98.8%). Applying the American Academy criteria would have led to the missing of 36.8% of infants with ROP and 28.6% of those requiring treatment in our sample.

CONCLUSION

The incidence of both ROP and AP-ROP in the Egyptian rural setting appears to be in the high end of global reported rates. Prevention measures should urgently be planned and implemented.

Retinopathy of prematurity in the University of Calabar Teaching Hospital, Calabar, Nigeria: An early report of a screening service

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