Retinopathy of Prematurity Stages and How it Affects Vision

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What Is Retinopathy of Prematurity (ROP)

Premature newborns may develop retinopathy of prematurity (ROP), which is a potentially blinding condition caused by faulty retinal blood vessel formation. The retina is the eye’s inner layer, which takes light and converts it into visual data for transmission to the brain. The retinal blood vessels might develop abnormally when a kid is born prematurely. The majority of ROP improves without causing retinal damage. When ROP is severe, the retina may tear away or detach from the eye’s wall, potentially resulting in blindness. Babies weighing less than 1250 grams and born before 31 weeks of pregnancy are at the greatest danger.

What causes ROP

In comparison to after delivery, the fetus is hypoxic in pregnancy. Even though oxygenation is at ambient level, when newborns are delivered preterm, the relative oxygen level is occasionally raised. Capillaries may be damaged by excessive supplementary oxygen.

Premature birth and other causes induce a mismatch between normal retinal vascularization and the oxygen needs of the growing retina, resulting in ROP.

What are the potential risk factors?

Some factors make a newborn more susceptible to developing ROP than others. These are referred to as risk factors. Having a risk factor does not guarantee that your child will get ROP. However, it may improve his prospects. We know that ROP is more likely in the tiniest and sickest newborns than in the bigger, healthier babies. ROP may be caused by a number of reasons, including:

  • This occurs when the body’s supply of healthy red blood cells is insufficient to transport oxygen to the rest of the body.
  • Low fetal weight. ROP is more common in newborns who weigh less than approximately 3 pounds at birth than in babies who weigh more.
  • Short gestational age (premature babies)
  • Variations in oxygenation due to high, uncontrolled oxygen levels during birth
  • Poor postnatal development

Other possible risk factors

  • Multiple births
  • intraventricular hemorrhage
  • Respiratory Distress Syndrome and Apnea are examples of breathing issues (also called RDS). Because the lungs and the component of the CNS (brain and spinal cord) that governs breathing are not fully matured in preterm newborns, these issues are prevalent. When a baby’s breathing pauses for 15 to 20 seconds or longer, this is called apnea. Apnea may cause a decrease in a baby’s oxygen level (also known as oxygen desaturation) as well as a sluggish heart rate (also called bradycardia). RDS is a frequent respiratory condition in premature babies. A lack of surfactant, a slick material that prevents little air sacs in a baby’s lungs from collapsing, causes it.
  • Sepsis
  • White race
  • Blood transfusion
  • Prenatal steroid usage
  • Mechanical ventilation duration

Signs and Symptoms of Retinopathy of Prematurity

Many of the symptoms of retinopathy of prematurity occur deep inside the eye, making them difficult to detect just by glancing at your kid. Only an ophthalmologist (a doctor who specializes in eye care) who has been trained to diagnose and treat ROP can detect these symptoms by examining your child’s retina with sophisticated tools.

The American Academy of Pediatrics has established ROP screening criteria for all neonatal critical care units, and these screenings identify the great majority of newborns with ROP.

Visual problems such as nystagmus (abnormal eye movements) and leukocoria may occur in a newborn with severe ROP (white pupils). These are, nevertheless, common symptoms of visual problems, and if your kid exhibits any of them, you should consult an ophthalmologist as soon as possible.

What Effects Does ROP Have On My Baby?

The majority of newborns with ROP have normal vision for their age. Only after ROP has progressed to its most severe stages does vision become a concern. Fortunately, most cases of ROP go away without causing visual loss. The difficulty is that no one can tell which infants will thrive and which will struggle. The most essential variables in avoiding ROP-related vision loss are effective screening and prompt treatment.

Is there a progression of Retinopathy of Prematurity?

Yes. ROP is divided into five phases, ranging from moderate to severe (stages I to V):

Retinopathy of Prematurity Stage I

Blood vessel development is somewhat irregular. Many children with stage I vision recover without therapy and go on to have normal vision. Without further advancement, the illness resolves on its own.

Retinopathy of Prematurity Stage I

The demarcation line is the first stage of  ROP. Between the typically vascularized retina and the peripheral retina with no blood vessels, a whitish line may be seen.

Retinopathy of Prematurity Stage II

Blood vessel development is somewhat irregular. Many children with stage II vision problems recover without therapy and go on to have normal vision. Without further advancement, the illness resolves on its own.

Retinopathy of Prematurity Stage II

ROP Stage II: Visible ridge Between the vascular and peripheral retinas.

Retinopathy of Prematurity Stage III

Significantly irregular blood vessel growth. Instead of following their typical development pattern along the surface of the retina, the irregular blood vessels expand into the center of the eye. Some babies with stage III visual problems recover without therapy and go on to have normal eyesight. Some require medical treatment when babies have a considerable degree of Stage III and “plus disease” develops. The term “plus disease” refers to the enlargement and twisting of the retina’s blood vessels, signifying a worsening of the disorder. Treatment at this stage is likely to avoid retinal detachment.

Retinopathy of Prematurity Stage III

Retinopathy of Prematurity Stage III

Retinopathy of Prematurity Stage IV

Partial retinal detachment. The retina is pulled away from the eyewall by the scar caused by bleeding, irregular arteries.

Retinopathy of Prematurity Stage IV

Retinopathy of Prematurity Stage V

The ultimate stage of the disorder, with a completely detached retina, involves central vision (macula). If the baby’s eye is left alone at this point, he or she may suffer from serious vision impairment, if not blindness.

Retinopathy of Prematurity Stage V

Retinopathy of Prematurity Treatments

Photocoagulation is a technique that involves the use of light (laser therapy)

The first way to protect against worsening retinopathy of prematurity is photocoagulation. The procedure is similar to that of a retinal exam, with the exception that your baby will be given a local or general anesthetic. To inhibit the future formation of irregular blood vessels, the ophthalmologist uses a diode laser placed on an indirect ophthalmoscope to generate small “burns” in the periphery of the retina.

Your child’s doctor will schedule follow-ups— generally every couple of weeks — to assess how the laser therapy is working. If your child’s retinopathy of prematurity worsens, he or she may need more laser treatments or perhaps eye surgery.

Cryopexy (a kind of cryotherapy)

Cryopexy, once the treatment of choice for Retinopathy of prematurity, involves freezing sections of the retina’s periphery through the outer wall of the eye using a pen-like tool called a cryoprobe. Cryopexy is effective when the retina can’t be completely viewed, even though laser treatment has mostly replaced it. Like when trying to view through a hemorrhage.

Photocoagulation and cryopexy both damage a portion of the retina’s periphery, so your baby may lose partial side vision as a result of these procedures. The surgery, on the other hand, is designed to preserve their “central vision,” or the most crucial area of their eyesight, which is required for tasks such as reading and driving.

Surgical Options

If your child’s retina is partially or fully detached (Stages 4 or 5), your doctor may send them to a retinal surgeon for surgery, which typically involves scleral buckling or vitrectomy.

Scleral buckling entails tightening a silicone band around the eyeball until the retina is near enough to the wall to reconnect. The band, known as a scleral buckle, maybe in place for months or even years to protect the eye.

The vitreous (the gel-like material that makes up the bulk of the inside. of the eye) is removed and replaced with saline solution or oil during a vitrectomy. The scar tissue on the retina may then be peeled or sliced away, enabling the retina to flatten against the eye’s wall.

If the retina touches the backside of the lens, it must be removed since it would make it difficult to enter the eye. The success rate of retinal reattachment is 70% when scleral buckling is regarded as a suitable treatment.

Prognosis After Retinopathy of Prematurity Treatment

Following these operations, the child’s eyesight ranged from:

  • 15 percent of eyes have a vision range of 20/60 to 20/300.
  • For 30% of eyes, the vision ranges from 20/60 to 20/800.
  • For 48 percent of people, 20/60 to 20/1900 is the range (ambulatory vision)
  • 72 percent of eyes only regained light perception

The ability to perceive things and walk around a room without tripping or bumping against objects is known as ambulatory vision. Sadly, even with proper care and vitreous surgery, 28 percent of youngsters still had severe vision problems and lose their ability to see light.

Vitreous surgery has recently been done earlier, at stage 4A, when the macula (the central vision part of the retina) remains connected, with success rates of up to 90%. Visual outcomes in this group are yet unavailable, however, they are thought to be better than when surgery is conducted at stage 4B or 5.

Avastin Therapy for Retinopathy of Prematurity

A paper on the use of Avastin in retinopathy of prematurity treatment was recently published in the New England Journal of Medicine. This research indicated that Avastin was superior to laser therapy in zone 1 retinopathy of prematurity (more serious posterior retinopathy of prematurity). For more peripheral retinopathy of prematurity, however, this was not the case. A number of people in the ophthalmological community have expressed concerns about this study, claiming that it does not accurately represent effective laser treatment, does not present data correctly, and describes treatment in a population that is two-thirds Hispanic, rather than a balanced population.. The research has sparked such controversy that editorials have been prepared for the journals Ophthalmology and Pediatrics, and multiple letters and editorials have been sent to the New England Journal of Medicine.

The pharmacological dangers of Avastin, an anti-VEGF (vascular endothelial growth factor) medicine, to growing youngsters are also not covered in this article with any considerable discussion. In addition, this medicine is administered through intraocular injection, which has its own set of dangers. If a serious infection develops after intraocular injection, the eyes may need to be removed. In several studies, 33% of those eyes go completely blind as a result of this illness. Laser surgery has a one in ten thousand chance of causing anterior segment ischemia which could result in a similar outcome.

When Is Treatment Required?

Usually when a premature baby has stage 3 retinopathy of prematurity is when treatment may be considered to slow the formation of additional abnormal blood vessel growth. Treatment for stages 4 and 5 is almost always initiated.

Many ROP newborns may not need therapy. Some newborns with ROP may have visual loss despite therapy. Even if therapy is successful, kids with ROP are more prone than other babies to have a variety of vision impairments later in life, including:

  • Nearsightedness is a condition that occurs when a person can’t see up close (also called myopia)
  • Eyes crossed (also called strabismus)
  • Amblyopia or ( Lazy eye)
  • Glaucoma – This is a category of disorders that affect the optic nerve of the eye. The retina and the brain are linked through the optic nerve. Glaucoma may cause visual loss and eventually blindness.
  • This is why it’s critical that your child has all of their follow-ups and eye examinations. To ensure that ROP and other visual disorders due to preterm delivery are recognized and treated as soon as possible, ask your baby’s provider about eye examinations at every appointment.
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Preventing Retinopathy of Prematurity

The biggest risk factors according to the National Eye Institute seem to be gestational age, maternal nutrition, and the oxygen supply to premature infants.  Medical treatment can be avoided if the premature babies’ lungs are developed enough to not need additional oxygen after birth. Severely premature babies are at the highest risk of being legally blind due to the amount of time they may be required to be on oxygen and the effects it has on producing abnormal blood vessels.  Therefore preventing Retinopathy of Prematurity should be focused on caring for the baby to term. Keeping the mother healthy with vital nutrients, not smoking, and plenty of rest.  Early detection by a pediatric ophthalmologist or Low vision specialist and early treatment will help prevent severe vision loss.

About the Author:
Dr. Shaun Larsen

Dr. Shaun Larsen

Dr. Shaun Larsen is an optometrist who specializes in low vision services and enhancing vision with contact lenses. He has a passion for making people's lives better by helping them see well enough to read, write, or drive again. He always keeps up with the latest technology so he can help people regain their independence.

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