RETINOPATHY OF PREMATURITY

WHAT IS RETINOPATHY OF PREMATURITY?

Babies born at a very early gestation can develop Retinopathy of Prematurity where blood vessels grow abnormally and uncontrollably causing damage to the light sensitive layer of the retina.

In the worst case scenario this can lead to bleeding and scarring that can pull the retina away from the wall of the eye (retinal detachment) putting the baby at risk of becoming blind. 

WHAT HAPPENS IN RETINOPATHY OF PREMATURITY?

Retinopathy (ret-in-AH-puh-thee) of prematurity makes blood vessels grow abnormally in the eye that can leak or bleed. This causes scarring of the retina, the layer of nerve tissue in the eye that sends messages about light to the brain.

HOW DO YOU KNOW IF YOUR BABY HAS ROP?

Your baby gets an eye exam for ROP if he:

•  Is born before 30 weeks
•  Weighs less than 1500 grams at birth
•  Is born after 30 weeks or weighs 1500 grams at birth and has risk factors for ROP

For the eye exam, a pediatric ophthalmologist checks your baby’s vision. This is a doctor who identifies and treats eye problems in babies and children. Your baby gets her first eye exam 4 to 9 weeks after birth. She may be in the newborn intensive care unit (also called NICU), or she may be home by this time. Babies born at 27 weeks or later usually have their first eye exam when they’re 4 weeks old. Babies born before 27 weeks usually have the exam later. This is because the more premature a baby is, the longer it takes to develop serious ROP. This is why it’s important to take your baby to every eye exam, even after you take your baby home from the NICU.

If your baby’s first eye exam shows that the blood vessels in both retinas have developed normally, she doesn’t need a follow-up exam. If your baby’s eye exam shows that she has ROP and her provider thinks she needs treatment, she starts treatment within 72 hours. Early treatment gives your baby the best chance of having healthy vision. 

RISK FACTORS AND SYMPTOMS:

Risk factors for ROP include:

•  Anemia.        This is when the body doesn’t have enough healthy red blood cells to carry oxygen to the rest of the body.

•  Birthweight. Babies who weigh less than 1500 grams at birth are more likely to have ROP than babies who weigh more at birth.  

•  Breathing problems, including apnea and respiratory distress syndrome (also called RDS). These problems are common in premature babies because the lungs and the part of the central nervous system (brain and spinal cord) that controls breathing may not be full developed. Apnea is when a baby’s breathing stops for 15 to 20 seconds or more. Apnea may lead to a drop in a baby’s oxygen level (also called oxygen desaturation) and a slow heart rate (also called bradycardia). RDS is a breathing problem that’s common in premature babies. It’s caused by a lack of surfactant, a slippery substance that keeps small air sacs in a baby's lungs from collapsing. 

•  Heart disease or slow heart rate. Heart disease includes conditions that affect the heart and blood vessels. 

  
•  Infection and sepsis. Sepsis is the body’s extreme response to infection.
•  Premature birth. All premature babies are at risk for ROP. Premature babies born before 30 weeks of pregnancy are most likely to have it.
•  Blood problems, including low blood oxygen, high carbon dioxide levels in the blood, low blood acidity or having a blood transfusion. Your baby’s provider measures.
 blood oxygen, carbon dioxide and blood acidity in your baby’s blood with a blood oxygen level test. If the levels in the blood are out of balance (not in the right amounts), it can mean your baby’s lungs aren’t working well. A blood transfusion is when new blood is put in in the body. Low blood oxygen, high carbon dioxide levels and low blood acidity may be signs of RDS. 

Severe and untreated Retinopathy of Prematurity can present some of the following symptoms:

•  White pupils, called leukocoria
•  Abnormal eye movements, called nystagmus
•  Crossed eyes, called strabismus
•  Severe nearsightedness, called myopia

 

STAGES OF ROP:

• Stage 1. Mildly abnormal blood vessel growth. Many babies at stage 1 get better without treatment and go on to have healthy vision.  
• Stage 2. Moderately abnormal blood vessel growth. Many babies at stage 2 don’t need treatment and go on to have healthy vision.
• Stage 3. Severely abnormal blood vessel growth. Some babies at stage 3 get better without treatment. Others may develop a condition called plus disease. This is when the retina’s blood vessels get big and twisted. Plus disease is a sign that ROP is getting worse, but treatment can help prevent retinal detachment.  
• Stage 4. Partially detached retina. Babies with stage 4 ROP need treatment because part of the retina pulls away from the inside wall of the eye.
• Stage 5. Completely detached retina. In stage 5, the retina is completely pulled away from the inside wall of the eye. Without treatment, a baby can have severe vision problems or blindness. 

Most babies with ROP have stage 1 or 2 and get better on their own without treatment. Take your baby to all his checkups and eye exams so his provider can make sure he’s getting any treatment he needs for ROP.

DIAGNOSIS:

The only way to determine if babies have ROP is to examine the inside of their eyes for abnormalities in the retina. Ophthalmologists trained in the diagnosis and treatment of ROP will? examine your baby's eyes. During this exam, your baby's pupils will be dilated with eye drops so the retina can be studied.

TREATMENT:

Babies who need treatment for ROP usually have Laser or surgery. The most common types of ROP are:

• Laser surgery (also called laser therapy or photocoagulation). Your baby’s provider uses laser beams of light to burn and scar the sides of the retina. This is the most common surgery.

• Cryotherapy (also called freezing). Your baby’s doctor uses a metal probe to freeze and scar the sides of the retina. 

These surgeries can slow down or stop the growth of abnormal blood vessels and help prevent pulling on the retina. They can cause some loss of side vision (also called peripheral vision), but they can help save a baby’s central vision. Central vision is when you can see what’s straight ahead of you.

If your baby has stage 4 or 5 ROP and his retina is partially or completely detached, he may get these types of surgery:

• Scleral buckle. Your baby’s provider puts a silicone band around the white of your baby’s eye (called the sclera). This band helps push the eye in so that the retina stays along the wall of the eye. The buckle is removed later as the eye grows. If it isn’t removed, a child can become nearsighted. This means he has trouble seeing things that are far away.

• Vitrectomy. Your baby’s provider removes the clear gel in the center of your baby’s eye (called the vitreous) and puts saline (salt) solution in its place. Your baby’s provider can then take out scar tissue, so that the retina can relax and doesn’t pull. Only babies with stage 5 ROP have this surgery.

LONG -TERM FOLLOW UP:

Many babies with ROP don’t need treatment. Even with treatment, some babies with ROP may have vision loss. And even if treatment works, babies with ROP are more likely than other babies to have some eye problems later in life including:

   
•  Nearsightedness (also called myopia)
•  Crossed eyes (also called strabismus)
•  Lazy eye (also called amblyopia)

•  Glaucoma. This is a group of diseases that damage the eye’s optic nerve. The optic nerve connects the retina to the brain. Glaucoma can lead to vision loss and blindness.

This is why it’s so important to make sure your baby gets all his checkups and eye exams. Ask your baby’s provider about eye exams at every checkup to help make sure ROP and other vision problems related to premature birth are diagnosed and treated as early as possible.

RETINOPATHY OF PREMATURITY PREVENTION:

PREVENTING PRE-TERM BIRTH:

Preventing premature births will reduce the incidence of babies developing Retinopathy of Prematurity.

EARLY DETECTION:

Having specialist ophthalmologists carefully monitoring and examining at-risk babies during the weeks after birth and before hospital discharge. The only way to determine if babies have Retinopathy of Prematurity is to examine the inside of their eyes for abnormalities in the retina.

A paediatric ophthalmologist can detect changes in a baby's retina through proper examination using special instruments.

DELIVERY OF NEONATAL CARE:

Providing better resources and equipment in low-to-middle income countries to manage the care of babies in neonatal units - especially in relation to monitoring the oxygen levels a pre-term baby is exposed to after birth. High levels of oxygen are damaging to blood vessels and linked to development of Retinopathy of Prematurity.

QUESTIONS AND ANSWER

Is my child at risk of blindness because of Retinopathy of Prematurity?

Retinopathy of Prematurity has 5 stages. The mild growth of abnormal blood vessels is stage 1, while a completely detached retina is stage 5. Children in stages 1, 2, and sometimes stage 3 usually improve with no treatment at all. Children in the later stages of Retinopathy of Prematurity need treatment to preserve their eyesight.
The National Eye Institute reports that about 28,000 babies are born weighing 2.75 pounds or less each year. Nearly half of them have some form of Retinopathy of Prematurity, but it is almost always the milder forms. Each year, between 1,100 and 1,500 babies are born with Retinopathy of Prematurity that is advanced enough they need medical treatment. Out of that group, on average, 400 to 600 will become legally blind.

Is Retinopathy of Prematurity Treatable?

Yes, you can treat Retinopathy of Prematurity. Often, the issue resolves itself. If your child needs treatment, your doctor will choose the best option based on your baby’s condition. Options include:
•  Laser surgery to stop the abnormal blood vessels that are growing on the edge of the retina.
•  Injections of medicine to cause the blood vessels to grow more normally.
•  Flexible silicone band around the eye that helps push the retina back in place.
•  Removal of the clear gel inside in the eye and scar tissue that is pulling the retina away from the back of the eye.

How will I know if my baby has Retinopathy of Prematurity?

There are no warning signs of this condition. An ophthalmologist or pediatric-trained optometrist must conduct an eye exam to determine if the condition is present.
If you suspect your baby has retinopathy of prematurity, schedule an appointment with one of our pediatric specialists at Grand Rapids Ophthalmology. Dr. Laura Piipppo, fellowship-trained pediatric ophthalmologist, with a vast amount of experience with children, and Dr. Abby Veldkamp, optometrist, who specializes in complete eye care for pediatric patients.