POLICY STATEMENT

Organizational Principles to Guide and Define the Child Health Care System and/or Improve the Health of all Children

Walter M. Fierson, MD, FAAP, AMERICAN ACADEMY OF PEDIATRICS Section on Ophthalmology, ScreeningAMERICAN ACADEMY OF OPHTHALMOLOGY, Examination AMERICAN ASSOCIATION FOR PEDIATRIC of OPHTHALMOLOGYPremature InfantsAND STRABISMUS, AMERICAN for ASSOCIATION Retinopathy OF CERTIFIED ORTHOPTISTS of Prematurity

This policy statement revises a previous statement on screening of preterm abstract infants for retinopathy of prematurity (ROP) that was published in 2013. ROP is a pathologic process that occurs in immature retinal tissue and can progress to a tractional retinal detachment, which may then result in visual loss or blindness. For more than 3 decades, treatment of severe Dr Fierson was responsible for writing and revising the policy statement and responding to reviewers’ concerns and has approved ROP that markedly decreases the incidence of this poor visual outcome the final manuscript as submitted. has been available. However, severe, treatment-requiring ROP must be This document is copyrighted and is property of the American diagnosed in a timely fashion to be treated effectively. The sequential nature Academy of Pediatrics and its Board of Directors. All authors have filed conflict of interest statements with the American Academy of ROP requires that infants who are at-risk and preterm be examined of Pediatrics. Any conflicts have been resolved through a process at proper times and intervals to detect the changes of ROP before they approved by the Board of Directors. The American Academy of Pediatrics has neither solicited nor accepted any commercial become destructive. This statement presents the attributes of an effective involvement in the development of the content of this publication. program to detect and treat ROP, including the timing of initial and follow-up Policy statements from the American Academy of Pediatrics benefit examinations. from expertise and resources of liaisons and internal (AAP) and external reviewers. However, policy statements from the American Academy of Pediatrics may not reflect the views of the liaisons or the organizations or government agencies that they represent.

The guidance in this statement does not indicate an exclusive course of treatment or serve as a standard of medical care. Variations, taking INTRODUCTION into account individual circumstances, may be appropriate.

All policy statements from the American Academy of Pediatrics automatically expire 5 years after publication unless reaffirmed, revised, or retired at or before that time. Retinopathy of prematurity (ROP) is a disorder of the developing retinal blood vessels in preterm infants who are low birth weight and is a leading DOI: https://​doi.​org/​10.​1542/​peds.​2018-​3061 cause of childhood blindness. In almost all term infants, the retina and Address correspondence to Walter M. Fierson, MD, FAAP. E-mail: [email protected] retinal vasculature are fully developed, and, therefore, ROP cannot occur; however, in preterm infants, the development of the retina, which PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275). proceeds peripherally from the optic nerve head during the course of Copyright © 2018 by the American Academy of Pediatrics gestation, is incomplete, with the extent of the immaturity of the retina depending mainly on the degree of prematurity at birth, thus creating the To cite: Fierson WM, AAP AMERICAN ACADEMY OF PEDIATRICS possibility for abnormal development. Section on Ophthalmology, AAP AMERICAN ACADEMY OF OPHTHALMOLOGY, AAP AMERICAN ASSOCIATION FOR PEDIATRIC In the Multicenter Trial of Cryotherapy for Retinopathy of Prematurity, OPHTHALMOLOGY AND STRABISMUS, AAP AMERICAN ASSOCIATION researchers demonstrated the efficacy of peripheral retinal cryotherapy OF CERTIFIED ORTHOPTISTS. Screening Examination of (ie, cryoablation of the immature, avascular peripheral retina) in reducing Premature Infants for Retinopathy of Prematurity. Pediatrics. unfavorable outcomes for threshold ROP, defined as morphologic changes 2018;142(6):e20183061 ’ 1 beyond which the incidence of unfavorable2 outcome was >50%. In the study s 15-year follow-up report,​ authors confirmed the following Downloaded from www.aappublications.org/news by guest on September 27, 2021 PEDIATRICS Volume 142, number 6, December 2018:e20183061 FROM THE AMERICAN ACADEMY OF PEDIATRICS lasting benefits: unfavorable This statement outlines the a lid speculum and scleral structural outcomes were reduced principles on which a program to depression (as needed) to detect from 48% to 27%, and unfavorable detect, follow, and treat ROP in ROP. Dilating drops should be visual outcomes (ie, best corrected infants who are at risk might be sufficient to allow adequate visual acuity worse than 20/200) based. The goal of an effective ROP examination of the fundi, but care were reduced from 62% to 44%. screening program is to identify should be taken in using multiple Subsequently, laser photocoagulation infants who could benefit from drops if the pupil fails to dilate has been used for peripheral retinal treatment and make appropriate because poor pupillary dilation ablation with– at least equal success recommendations on the timing can occur in advanced ROP, and of future screening and treatment administering multiple doses and is now 3the6 preferred method of ablation. ‍‍ More recently, in the interventions. Because undiagnosed of dilating drops can adversely Early Treatment of Retinopathy or treatment-delayed ROP can affect the cardiorespiratory of Prematurity Randomized Trial lead to permanent blindness, it and gastrointestinal status (ETROP), researchers confirmed the is important that all infants who of the infant. Separate sterile efficacy of treatment of high-risk are at risk be screened in a timely instruments or instruments prethreshold ROP (recategorized fashion, recognizing that not all cleaned in accord with the anti- as type 1 ROP), redefined the infants require treatment. On the infective protocol for metal “ indications for treatment, and basis of information published thus instruments for each NICU ” “ ” replaced the terms prethreshold far, the sponsoring organizations of should be used to examine each “ ” ROP and threshold ROP with this statement suggest the following infant to avoid possible cross- “ ” type 1 ROP (aggressive, treatment- recommendations for the United contamination by infectious requiring) and type 2 ROP States. It is important to recognize agents. One examination is (more indolent, less aggressive), that other locations around the sufficient only if it unequivocally 7 world could have different screening reveals the retina to be fully respectively. 8,9​ parameters. ‍ It is also important to vascularized in both eyes. Effort note that despite appropriate timing should be made to minimize the Because of the usually predictable of examinations and treatment, a– discomfort and systemic effect and sequential nature of ROP small number of at-risk infants 3with6 of this examination. In recent progression and the proven benefits ROP still progress to blindness. ‍ ‍ literature, authors suggest that of timely treatment in reducing a carefully organized program the risk of visual loss, efficacious RECOMMENDATIONS of remotely interpreted wide- care now requires that infants who angle fundus camera ROP are at risk receive carefully timed screening may initially be used ≤ retinal examinations to identify 1. All infants with a birth weight in place of binocular indirect treatment-requiring ROP in time for of 1500 g or a gestational age ophthalmoscope examinations that treatment to be effective. These of 30 weeks or less (as defined up to the point at which examinations should be performed by the attending neonatologist) treatment of ROP is believed to be by an ophthalmologist who is and selected infants with a indicated; at this point, indirect experienced in the examination of birth weight between 1500 and ophthalmoscopy is required. This preterm infants for ROP using a 2000 g or a gestational age of possibility is further discussed in binocular indirect ophthalmoscope. >30 weeks who are believed recommendation 6. The examinations should be ’ by their attending pediatrician scheduled according to the preterm or neonatologist to be at risk 2. Retinal examinations in preterm infant s gestational age at birth for ROP (such as infants with infants should be performed and subsequent disease presence hypotension requiring inotropic by an ophthalmologist who and severity, with all pediatricians support, infants who received has sufficient knowledge and or other primary care providers oxygen supplementation for experience to accurately identify who care for the at-risk preterm more than a few days, or infants the location and sequential retinal infant aware of this schedule. When who received oxygen without changes of ROP. The International implemented properly, telemedicine saturation monitoring) should Classification of Retinopathy of10 systems using wide-angle retinal be screened for ROP. Retinal Prematurity Revisited (ICROP) images and clinical data may be used screening examinations should should be used to classify, for preliminary ROP screening or be performed after pupillary diagram, and record these as an adjunct to binocular indirect dilation by using binocular retinal findings at the time of ophthalmoscopy for ROP screening. indirect ophthalmoscopy with examination. Downloaded from www.aappublications.org/news by guest on September 27, 2021 2 FROM THE AMERICAN ACADEMY OF PEDIATRICS TABLE 1 Timing of First Eye Examination Based on Gestational Age at Birth Gestational Age at Birth, wk Age at Initial Examination, wk The initiation of acute-phase ’ Postmenstrual Chronologic ROP screening should be based on the infant s postmenstrual 22a 31 9 a age because the onset of serious 23 31 8 24 31 7 ROP correlates better with 25 31 6 postmenstrual age (gestational 26 31 5 27 31 4 age at birth plus chronologic 11 age) than with postnatal age. 28 32 4 29 33 4 That is, the more preterm an 30 34 4 infant is at birth, the longer Older gestational age, high-risk factorsb — 4 the time to develop serious Shown is a schedule for detecting prethreshold ROP with 99% confidence, usually before any required treatment.— , not ROP. This knowledge has been applicable. a This guideline should be considered tentative rather than evidence based for infants with a gestational age of 22 to 23 used previously in developing12,13​ wk because of the small number of survivors in these postmenstrual age categories. a screening schedule. ‍ b Consider timing on the basis of the severity of comorbidities. ‍Table 1 was developed from an evidence-based analysis of the Multicenter Trial of Cryotherapy for Retinopathy of Prematurity judgment as to the initiation offer treatment at the time when it ’ natural history data and confirmed of screening in preterm infants One-Week-or-Lessis most likely to succeed. Follow-up by the Light Reduction in ROP of 22 and 23 weeks gestational •• Study, which14 was conducted a age. decade later. It represents a Zone I: immature suggested schedule for the timing 3. Authors of recent reports of •• vascularization, no ROP; of the initial eye examinations neonatal16 algorithms,17 such as WIN- •• based on postmenstrual age and ROP,18 ​ Co-ROP,​ and CHOP-ROP,​ Zone I: stage 1 or stage 2 ROP; ‍ take factors into account other chronologic (postnatal) age to Immature retina extending than birth weight, postmenstrual – detect ROP before it becomes into posterior zone II, near the age, or gestational age. These severe enough to result in retinal •• boundary of zone I zone II; detachment while minimizing the factors include rapid postnatal Suspected presence of AP-ROP; number of potentially traumatic weight gain and may be helpful in 15 •• and examinations. In Table 1, a selecting infants at risk for ROP rigorously tested schedule is who should be screened and in Stage 3 ROP, zone I requires provided for detecting treatable eliminating some infants from the One-treatment, to 2-Week not Follow-up observation. need for screening despite their ROP with high confidence in •• infants with gestational ages meeting the previously mentioned of 24 to 30 weeks. However, screening criteria. Substitution Posterior zone II: immature its recommendations are of these algorithms for the •• vascularization; screening measures described extrapolated for gestational ages •• Zone II: stage 2 ROP; and of 22 and 23 weeks. Although in this article is not justified by Zone I: unequivocally regressing there is little evidence that current literature, and it is not Two-WeekROP. Follow-up initiating earlier screening is clear that these criteria apply to beneficial, some practitioners have international populations. •• advocated for earlier screening 4. Follow-up examinations should be •• on the basis of speculation that recommended by the examining Zone II: stage 1 ROP; treatable aggressive posterior ophthalmologist on the basis Zone II: no ROP, immature “ retinopathy of prematurity of retinal findings classified •• vascularization; and (AP-ROP) (a severe form of ROP according to the International ” Zone II: unequivocally that is characterized by rapid classification of retinopathy of Two-regressing to 3-Week ROP. Follow-up progression to advanced stages prematurity revisited (see ’ 8 in posterior ROP) could occur Fig‍ 1). The following schedule is •• before 31 weeks postmenstrual suggested as an acceptable one for •• Zone III: stage 1 or 2 ROP; and age. Because there is no significant most infants, but certain infants body of evidence to support either may require an altered frequency Zone III: regressing ROP. practice, each practitioner and of examinations, remembering 5. The termination of acute retinal NICU will have to rely on clinical that the goal of examinations is to screening examinations should Downloaded from www.aappublications.org/news by guest on September 27, 2021 PEDIATRICS Volume 142, number 6, December 2018 3 large-scale operational digital- imaging systems with remote interpretation versus binocular

indirect ophthalmoscopy25 have been published. Nevertheless, some neonatal centers are

conducting remote ROP screening23,24​ for infants still in the hospital. At a minimum, programs that use this method should comply with the timing and other recommendations outlined in the preceding guidelines as FIGURE 1 well as have capacity for timely Scheme of retina of the right and left eyes showing zone borders and clock hours used to describe the location and extent of ROP. Diagrammatic representation of the potential total area of the bedside examinations if images premature retina, with zone I (the most posterior) symmetrically surrounding the optic nerve head are ambiguous or be able to (the earliest to develop) is shown. A larger retinal area is present temporally (laterally) rather than promptly transfer to a hospital nasally (medially) (zone III). Only zones I and II are present nasally. The retinal changes discussed in that can provide this examination. recommendation 4 are usually recorded on a diagram such as this one. Protocol modifications may be required to allow for additional •• time for communication,

processing, transportation,26,27​ or be based on age and retinal13 If anti-VEGF injectable ophthalmoscopic findings. medications were used to other logistical issues,​ ‍ with Findings in which is it suggested cause regression of the ROP, no time added to the timing noted that examinations can be postmenstrual age of at least 65 below for treatment. Captured terminated include the weeks, because this treatment images and their interpretations •following:• alters the natural history of this should be incorporated into the disease. Very late recurrences permanent medical record. It is Full retinal vascularization – ° of proliferative ROP have also recommended that indirect in close proximity to the ora 19 21 been reported,​ ‍ ‍ so caution ophthalmoscopy be performed serrata for 360 , that is, the and clinical judgment are at least once by a qualified normal distance found in required to determine when ophthalmologist before treatment mature retina between the surveillance can be safely or termination of acute-phase end of vascularization and terminated in individual cases. screening of ROP for infants at the ora serrata. This criterion Infants treated with anti-VEGF risk for ROP. A technical report in should also be used for all – medications need particularly which authors have outlined the cases treated for ROP solely close follow-up during the requirements for a safe program with anti vascular endothelial time of highest risk for of remote photo screening for growth factor (VEGF) injectable disease reactivation, between ROP has been published by the •• medications. postmenstrual age 45 to 55 sponsoring organizations23 of this policy statement. Zone III retinal vascularization •• weeks. 22 attained without previous Regression of ROP (care Digital image capture (taking zone I or II ROP (if there is must be taken to be sure that of retinal photographs) examiner doubt about the there is no abnormal vascular requires skill, experience, broad zone or if the postmenstrual tissue present that is capable of understanding of the infant eye, age is less than 35 weeks, reactivation and progression in and knowledge of ROP (zone, confirmatory examinations may zone II or III). stage, and plus). Ophthalmologists •• be warranted). 6. The use of digital photographic who perform remote Postmenstrual age of 45 weeks retinal images that are captured interpretation of screening photos “ ” and no type 1 ROP (previously and sent for remote interpretation for ROP should have the same called prethreshold ) disease is a developing alternative training requirements as bedside

(defined as stage 3 ROP in zone approach to ophthalmoscopic23,24​ examiners as well as experience in II, any ROP in zone I) or worse ROP screening ‍ ; however, few the interpretation of digital images ROP is present. outcome comparisons between for ROP. Interpretation requires Downloaded from www.aappublications.org/news by guest on September 27, 2021 4 FROM THE AMERICAN ACADEMY OF PEDIATRICS ⚬⚬

not only expert knowledge about that treatment, rather than 7,13​ As noted previously, the ROP but also understanding of ⚬observation,⚬ is appropriate. ‍ presence of plus disease, the limitations of interpreting Treatment should be initiated rather than the number of static images and the special care for the following retinal findings clock hours of disease, is the that must be taken to schedule that· characterize Type 1 ROP: better determining factor more frequent imaging sessions in recommending ablative that may be required because Zone I ROP: any stage with plus ⚬⚬treatment; · of those limitations. Remote disease; Treatment should generally ophthalmologist interpreters must Zone I ROP: stage 3, no plus be accomplished as soon as provide timely clinical input on · disease; and the timing of follow-up imaging possible, at least within 72 hours Zone II: stage 2 or 3 with plus sessions and ophthalmoscopic of determination of the presence •• disease. examinations using appropriate of treatable disease, in order methodology. These findings must Practitioners involved in the to minimize the risk of retinal be communicated in a manner ophthalmologic care of preterm ⚬⚬detachment; and infants should be aware that the that is compliant with rules of Follow-up is recommended presence of the retinal findings the Health Insurance Portability in 3 to 7 days after laser requiring strong consideration of and Accountability Act (HIPAA) photocoagulation or anti-VEGF ablative treatment were revised and other federal and state legal injection to ensure that there according to the Early Treatment requirements. is no need for additional laser of Retinopathy of Prematurity 7 treatment in areas where Digital retinal imaging may also Randomized Trial study. This ablative treatment was not be a useful tool for objective recommendation is based on complete or additional anti-VEGF documentation of retinal findings the findings of improved visual injection. and for teaching NICU staff and outcomes with earlier treatment •• parents about examination results, recommended by the Final Anti-VEGF treatment may hold even if it is not the primary Visual Acuity Results in the Early “ great promise in the treatment of method used28 for ROP screening in Treatment of Retinopathy29 of ” type30 1 ROP. Recently published the NICU. Prematurity Study. Threshold data indicate that intravitreal ROP,​ a term that refers to ROP care that includes off-site bevacizumab monotherapy, as specific morphologic features compared with conventional image interpretation by defined in the Multicenter Trial of ophthalmologists requires laser therapy, in infants with Cryotherapy for Retinopathy of stage 3+ ROP is effective in and close collaboration among Prematurity, is no longer the least “ may offer significantly improved neonatologists, imaging staff, and severe ROP for which intervention examining ophthalmologists. As ” structural results compared with should be considered. Threshold laser ablation for zone I but not with all ROP screening programs, ROP,​ as defined in the Multicenter specific responsibilities of each for zone II disease. Development Trial of Cryotherapy for of peripheral retinal vessels individual must be carefully Retinopathy of Prematurity study, delineated in a protocol written continues after treatment with is now included in type 1 ROP, intravitreal bevacizumab, whereas in advance so that repeat imaging as are certain levels of what was and/or confirmatory examinations conventional laser therapy led previously known as prethreshold to permanent ablation of the and required treatments can be disease that also respond better performed without delay. peripheral retina, although authors Treatment to ablative treatment7 than to of published studies indicate ⚬⚬ observation. that this apparent destruction •• Special care must be used was associated with only a in determining the zone of modest visual field loss. This The presence of plus disease “ 30 (defined as abnormal dilation disease. The authors of the trial was too small to assess International classification the safety and effects on future and tortuosity of the posterior ” retinal blood vessels in 2 or of retinopathy of prematurity development of the brain and more quadrants of the retina revisited provide specific other tissues. Additional studies meeting or exceeding the degree examples on how to identify are also currently being conducted

of abnormality represented1,8​ in zone I and zone II disease with other anti-VEGF agents, reference photographs ‍ ; see by using binocular indirect including ranibizumab (Lucentis). below) in zones I or II indicates ophthalmoscopy; Consideration may be given to Downloaded from www.aappublications.org/news by guest on September 27, 2021 PEDIATRICS Volume 142, number 6, December 2018 5 treatment of infants with zone until the examiner can be assured Parents should be aware of I, stage 3+ ROP with intravitreal that reactivation of proliferative ROP examinations and should

injection of bevacizumab. However, ROP will not30 occur. In the BEAT- be informed if their child has practitioners using this therapy ROP study,​ recurrence of ROP ROP, with subsequent updates should be aware that neither after bevacizumab injection tended on ROP progression, and should bevacizumab nor other anti- to occur considerably later than be aware of the possibility of ± VEGF substances is currently after conventional laser peripheral blindness if they do not adhere ± approved by the US Food and Drug retinal ablative treatment (16 4.6 to the examination schedule Administration for the treatment vs 6.2 5.7 weeks); therefore, after discharge. The possible of ROP. longer follow-up is required for consequences of serious ROP ⚬⚬ infants treated with bevacizumab should be discussed at the If intravitreal injection of to ensure that ROP requiring time that a significant risk of bevacizumab or other anti-VEGF treatment does not recur. Long- poor visual outcome develops. agents for zone I stage 3+ ROP term follow-up of the BEAT-ROP Documentation of such cohort revealed the time frame conversations with parents in the is contemplated, it is essential ’ that treatment be administered of highest disease reactivation nurse or physician notes is highly was between 45 and 55 weeks recommended, as is the use of only after obtaining a detailed ’ informed consent because postmenstrual age, with 1 AP-ROP standardized parental educational •• there remain unanswered case reactivating at31, 6437​ weeks materials. postmenstrual age. ‍ There are questions involving dosage, 25,31,​ 35,​ 36,​ 38​ Responsibility for examination additional reports ‍ ‍ ‍ of timing, safety, and visual and ’ and follow-up of infants at risk recurrence requiring retreatment systemic outcomes. Whether for ROP must be carefully defined as late as 65 to 70 weeks there are neurodevelopmental by the staff and consultants of postmenstrual⚬⚬ age. complications related to this each NICU. Unit-specific criteria treatment remains to be seen. Infants treated with intravitreal with respect to birth weight and To date, studies– have yielded injection of bevacizumab or gestational age for examination contrary findings,31 33 with 1 ranibizumab alone, therefore, for ROP should be established for publication ‍‍ reporting require special caution in the each NICU by consultation and increased incidence of decision to conclude regular agreement between neonatology neurodevelopmental problems, retinal examinations. Because and ophthalmology services. including severe cerebral palsy, of the propensity for late These criteria should be recorded hearing loss, and bilateral reactivation of significant and should automatically trigger blindness, in preterm infants proliferative disease, one cannot ophthalmologic examinations or treated with bevacizumab rely on the findings of initial ROP photographic documentation with ’ compared with infants whose regression or the achievement transmission for reading if remote ROP was treated with laser of 45 weeks postmenstrual age. digital camera screening for ROP peripheral ablation alone, but is used. Full retinal vascularization is Follow-up and Transition of Care another publication34 revealed no the only criterion listed above such effect. In addition, reports that can be relied on as a valid •• indicate that there might be less conclusion point. However, If hospital discharge or transfer myopic progression in infants full retinal vascularization is to another neonatal unit or treated with bevacizumab not always achieved in infants hospital is contemplated before compared with infants treated treated with these agents alone. retinal development into anterior with laser ablation, although Under these circumstances, the zone III has taken place, or if the long-term comparisons between examiner will have to rely on infant has been treated for ROP laser and bevacizumab35,36​ therapy prolonged observation, clinical and there is either incomplete •• are lacking. ‍ judgment, and evolving criteria regression or incomplete in the literature for termination Infants treated with bevacizumab retinal healing or maturation, of examinations or a need for ’ injection should be monitored 3 follow-up must be arranged •• further treatment. closely after injection by using before the infant s departure techniques in accord with these Communication with parents from the hospital, including ROP examination guidelines by members of the care team is ensuring the availability of until retinal vascularization is important, as is documentation appropriate ophthalmologic completed or, if not completed, of those communications. follow-up; specific arrangement Downloaded from www.aappublications.org/news by guest on September 27, 2021 6 FROM THE AMERICAN ACADEMY OF PEDIATRICS for that examination must be the hospital. If responsibility modified as additional data about made before such discharge or for arranging follow-up ROP risk factors, treatments, and transfer occurs. The transferring ophthalmologic care after LEADlong-term AUTHOR outcomes are published. or discharging pediatrician, discharge is delegated to the Walter M. Fierson, MD, FAAP after consultation with the parents, they must be made to examining ophthalmologist, understand the potential for SUBCOMMITTEE ON RETINOPATHY OF has the responsibility for severe visual loss, including PREMATURITY, 2015–2018 communicating to the receiving blindness; that there is a critical Walter M. Fierson, MD, FAAP, Chairperson physician what eye examinations examination time schedule Michael F. Chiang, MD, FAAP are needed and their required to be met if treatment is to William Good, MD, FAAP timing. By review of the medical be successful; and that timely Dale Phelps, MD, FAAP James Reynolds, MD, FAAP record and communication follow-up examination is Shira L. Robbins, MD, FAAP with the transferring and/ essential to successful treatment. or discharging pediatrician, This information should be SECTION ON OPHTHALMOLOGY EXECUTIVE as appropriate, the receiving communicated both verbally COMMITTEE, 2017–2018 physician should ascertain the and in writing and should be ’ Daniel J. Karr, MD, FAAP, Chairperson current ocular examination carefully documented in the Geoffrey E. Bradford, MD, FAAP, Chairperson-Elect status of the infant. This period infant s medical record. If such Kanwal Nischal, MD, FAAP of review and communication arrangements for communication John Roarty, MD, FAAP Steven E. Rubin, MD, FAAP before discharge or transfer and follow-up after transfer or Donny Won Suh, MD, FAAP provides the opportunity for any discharge cannot be made, the Sharon S. Lehman, MD, FAAP, Immediate Past necessary examinations by an infant should not be discharged Chair ophthalmologist with ongoing until appropriate follow-up George S. Ellis, Jr, MD, FAAP, Section Historian experience and expertise in examination can be arranged by LIAISONS examination of preterm infants the unit staff who are discharging for ROP to be arranged at the ••the infant. Pamela Erskine Williams, MD, FAAP – American Academy of Ophthalmology appropriate time at the receiving Regardless of whether infants Gregg T. Lueder, MD, FAAP – American Academy of facility or on an outpatient basis Ophthalmology Council at risk develop treatment- if discharge is contemplated Christie L. Morse, MD, FAAP – American requiring ROP, pediatricians before the need for continued Association for Pediatric Ophthalmology and and other physicians who care examination has ceased, as Strabismus for infants who have had ROP Sarah MacKinnon, MSc, OC(C), COMT – American outlined in recommendation should be aware that these Association of Certified Orthoptists 5 and in the section above infants are at increased risk for on treatment with anti-VEGF STAFF other seemingly unrelated visual agents. For infants managed by Jennifer G. Riefe, MEd disorders, such as strabismus, using remote photo screening, amblyopia, high refractive especially those treated with errors, cataracts, and glaucoma. ABBREVIATIONS anti-VEGF agents, outpatient Ophthalmologic follow-up for remote photo screening is not these potential problems after currently available. In these discharge from the NICU is AP-ROP: aggressive posterior cases, examination with indirect indicated within 4 to 6 months retinopathy of ophthalmoscopy is the only after discharge. prematurity option available, and these HIPAA: Health Insurance follow-up examinations must be This statement replaces the Portability and arranged before discharge. previous statement on ROP •• Accountability Act from the American Academy of ICROP: International It is strongly recommended that Pediatrics, American Academy Classification of the hospital staff arrange and of Ophthalmology, American Retinopathy of schedule the first postdischarge Association for Pediatric Prematurity Revisited outpatient ophthalmology Ophthalmology and Strabismus, and ROP: retinopathy of prematurity appointment with a physician American Association of Certified ’ 39 VEGF: vascular endothelial trained in ROP care before Orthoptists ; ROP care is evolving, growth factor the infant s discharge from and recommendations may be

Downloaded from www.aappublications.org/news by guest on September 27, 2021 PEDIATRICS Volume 142, number 6, December 2018 7 FINANCIAL DISCLOSURE: The lead author has indicated he has no financial relationships relevant to this article to disclose. Committee member Dr Chiang has disclosed the following: a research relationship with the National Institutes of Health, a research relationship with the National Science Foundation, a consulting relationship with Novartis (member of the Steering Committee for the RAINBOW study, which is an international, multicenter, Novartis-sponsored trial involving anti–vascular endothelial growth factor for retinopathy of prematurity treatment), and stock ownership relationship with Inteleretina, a company that is beginning to provide telemedicine services for diabetic retinopathy in Hawaii.

FUNDING: No external funding.

POTENTIAL CONFLICT OF INTEREST: The lead author has indicated he has no potential conflicts of interest to disclose. Committee member Dr Chiang has disclosed the following: an advisory board relationship with Clarity Medical Systems (unpaid).

REFERENCES 1. Cryotherapy for Retinopathy of 2005;115(5). Available at: www.​ 16. Löfqvist C, Andersson E, Sigurdsson Prematurity Cooperative Group. pediatrics.​org/​cgi/​content/​full/​115/​5/​ J, et al. Longitudinal postnatal weight Multicenter trial of cryotherapy e518 and insulin-like growth factor I for retinopathy of prematurity. measurements in the prediction of 9. Gilber t C. Retinopathy of prematurity: Preliminary results. Arch Ophthalmol. retinopathy of prematurity. Arch a global perspective of the epidemics, 1988;106(4):471 479 Ophthalmol. 2006;124(12):1711–1718 – population of babies at risk and 2. Palmer EA, Hardy RJ, Dobson V, et al; implications for control. Early Hum 17. Cao JH, Wagner BD, Cerda A, et al. Cryotherapy for Retinopathy of Dev. 2008;84(2):77–82 Colorado retinopathy of prematurity Prematurity Cooperative Group. model: a multi-institutional validation 10. International Committee for the 15-year outcomes following threshold study. J AAPOS. 2016;20(3):220–225 retinopathy of prematurity: final Classification of Retinopathy of Prematurity. The international 18. Binenbaum G, Ying GS, Quinn GE, results from the multicenter trial et al. The CHOP postnatal weight of cryotherapy for retinopathy of classification of retinopathy of prematurity revisited. Arch gain, birth weight, and gestational prematurity. Arch Ophthalmol. age retinopathy of prematurity Ophthalmol. 2005;123(7):991–999 2005;123(3):311–318 risk model. Arch Ophthalmol. 3. McNamara JA, Tasman W, Brown GC, 11. Palmer EA, Flynn JT, Hardy RJ, et al; 2012;130(12):1560–1565 The Cryotherapy for Retinopathy Federman JL. Laser photocoagulation 19. Snyder LL, Garcia-Gonzalez JM, Shapiro of Prematurity Cooperative Group. for stage 3+ retinopathy of MJ, Blair MP. Very late reactivation Incidence and early course of prematurity. Ophthalmology. of retinopathy of prematurity after retinopathy of prematurity. 1991;98(5):576–580 monotherapy with intravitreal Ophthalmology. 1991;98(11):1628–1640 4. Hunter DG, Repka MX. Diode laser bevacizumab. Ophthalmic Surg Lasers photocoagulation for threshold 12. LIGHT -ROP Cooperative Group. The Imaging Retina. 2016;47(3):280–283 design of the multicenter study of light retinopathy of prematurity. A 20. Mehta S, Hubbard GB III. Delayed reduction in retinopathy of prematurity randomized study. Ophthalmology. recurrent neovascularization (LIGHT-ROP). J Pediatr Ophthalmol 1993;100(2):238–244 and persistent avascular retina Strabismus. 1999;36(5):257 263 5. Laser ROP Study Group. Laser therapy – following intravitreal bevacizumab for retinopathy of prematurity. Arch 13. Hutchinson AK, Saunders RA, O’Neil for retinopathy of prematurity. Retin Ophthalmol. 1994;112(2):154–156 JW, Lovering A, Wilson ME. Timing of Cases Brief Rep. 2013;7(3):206–209 6. Iverson DA, Trese MT, Orgel IK, initial screening examinations for 21. Hajrasouliha AR, Garcia-Gonzales Williams GA. Laser photocoagulation retinopathy of prematurity. Arch JM, Shapiro MJ, Yoon H, Blair for threshold retinopathy of Ophthalmol. 1998;116(5):608–612 MP. Reactivation of retinopathy prematurity. Arch Ophthalmol. 14. Reynolds JD, Hardy RJ, Kennedy KA, of prematurity three years after 1991;109(10):1342–1343 Spencer R, van Heuven WA, Fielder treatment with bevacizumab. Ophthalmic Surg Lasers Imaging 7. Early Treatment for Retinopathy AR; Light Reduction in Retinopathy of Retina. 2017;48(3):255 259 of Prematurity Cooperative Group. Prematurity (LIGHT-ROP) Cooperative – Revised indications for the treatment Group. Lack of efficacy of light 22. Repka MX, Palmer EA, Tung B; of retinopathy of prematurity: results reduction in preventing retinopathy Cryotherapy for Retinopathy of of the early treatment for retinopathy of prematurity. N Engl J Med. Prematurity Cooperative Group. of prematurity randomized trial. Arch 1998;338(22):1572–1576 Involution of retinopathy of Ophthalmol. 2003;121(12):1684 1694 prematurity. Arch Ophthalmol. – 15. Reynolds JD, Dobson V, Quinn GE, 2000;118(5):645 649 8. Gilber t C, Fielder A, Gordillo L, et al; et al; CRYO-ROP and LIGHT-ROP – International NO-ROP Group. Cooperative Study Groups. Evidence- 23. Fierson WM, Capone A Jr; American Characteristics of infants with severe based screening criteria for Academy of Pediatrics Section on retinopathy of prematurity in countries retinopathy of prematurity: natural Ophthalmology; American Academy of with low, moderate, and high levels history data from the CRYO-ROP and Ophthalmology, American Association of development: implications for LIGHT-ROP studies. Arch Ophthalmol. of Certified Orthoptists. Telemedicine screening programs. Pediatrics. 2002;120(11):1470–1476 for evaluation of retinopathy of

Downloaded from www.aappublications.org/news by guest on September 27, 2021 8 FROM THE AMERICAN ACADEMY OF PEDIATRICS prematurity. Pediatrics. 2015;135(1). of Prematurity Cooperative Group. 35. Geloneck MM, Chuang AZ, Clark WL, Available at: www.​pediatrics.​org/​cgi/​ Final visual acuity results in the et al; BEAT-ROP Cooperative Group. content/​full/​135/​1/​e238 early treatment for retinopathy of Refractive outcomes following 24. Lorenz B, Spasovska K, Elflein H, prematurity study. Arch Ophthalmol. bevacizumab monotherapy compared Schneider N. Wide-field digital imaging 2010;128(6):663–671 with conventional laser treatment: a randomized clinical trial. JAMA based telemedicine for screening 30. Mintz-Hittner HA, Kennedy KA, Chuang Ophthalmol. 2014;132(11):1327–1333 for acute retinopathy of prematurity AZ; BEAT-ROP Cooperative Group. (ROP). Six-year results of a multicentre Efficacy of intravitreal bevacizumab for 36. Hu J, Blair MP, Shapiro MJ, Lichtenstein field study. Graefes Arch Clin Exp stage 3+ retinopathy of prematurity. N SJ, Galasso JM, Kapur R. Reactivation Ophthalmol. 2009;247(9):1251 1262 – Engl J Med. 2011;364(7):603–615 of retinopathy of prematurity 25. Quinn GE, Ying GS, Daniel E, et al; after bevacizumab injection. Arch 31. Honda S, Hirabayashi H, Tsukahara e-ROP Cooperative Group. Validity Ophthalmol. 2012;130(8):1000 1006 Y, Negi A. Acute contraction of the – of a telemedicine system for the proliferative membrane after an evaluation of acute-phase retinopathy 37. Mintz-Hittner HA, Geloneck MM, Chuang intravitreal injection of bevacizumab of prematurity. JAMA Ophthalmol. AZ. Clinical management of recurrent for advanced retinopathy of 2014;132(10):1178–1184 retinopathy of prematurity after prematurity. Graefes Arch Clin Exp intravitreal bevacizumab monotherapy. 26. Silva RA, Murakami Y, Lad EM, Ophthalmol. 2008;246(7):1061–1063 Ophthalmology. 2016;123(9):1845 1855 Moshfeghi DM. Stanford University – 32. Morin J, Luu TM, Superstein R, et al; network for diagnosis of retinopathy 38. Zepeda-Romero LC, Liera-Garcia Canadian Neonatal Network of prematurity (SUNDROP): 36-month JA, Guti rrez-Padilla JA, Valtierra- and the Canadian Neonatal é experience with telemedicine Santiago CI, Avila-G mez CD. Follow-Up Network Investigators. ó screening. Ophthalmic Surg Lasers Paradoxical vascular-fibrotic reaction Neurodevelopmental outcomes Imaging. 2011;42(1):12–19 after intravitreal bevacizumab following bevacizumab injections for 27. Chiang MF, Wang L, Busuioc M, et al. for retinopathy of prematurity retinopathy of prematurity. Pediatrics. Telemedical retinopathy of prematurity [published correction appears in Eye 2016;137(4):e20153218 diagnosis: accuracy, reliability, and (Lond). 2010;24(1):202]. Eye (Lond). image quality. Arch Ophthalmol. 33. Quinn GE, Darlow BA. Concerns for 2010;24(5):931–933 2007;125(11):1531–1538 development after bevacizumab 39. Fierson WM; American Academy of 28. Scott KE, Kim DY, Wang L, et al. treatment of ROP. Pediatrics. 2016;137(4):e20160057 Pediatrics Section on Ophthalmology; Telemedical diagnosis of retinopathy of American Academy of Ophthalmology; prematurity intraphysician agreement 34. Araz-Ersan B, Kir N, Tuncer S, et al. American Association for Pediatric between ophthalmoscopic examination Preliminary anatomical and Ophthalmology and Strabismus; and image-based interpretation. neurodevelopmental outcomes American Association of Certified Ophthalmology. 2008;115(7):1222–1228. of intravitreal bevacizumab as Orthoptists. Screening examination e3 adjunctive treatment for retinopathy of premature infants for retinopathy 29. Good WV, Hardy RJ, Dobson V, et al; of prematurity. Curr Eye Res. of prematurity. Pediatrics. Early Treatment for Retinopathy 2015;40(6):585–591 2013;131(1):189–195

Downloaded from www.aappublications.org/news by guest on September 27, 2021 PEDIATRICS Volume 142, number 6, December 2018 9 Screening Examination of Premature Infants for Retinopathy of Prematurity Walter M. Fierson, AMERICAN ACADEMY OF PEDIATRICS Section on Ophthalmology, AMERICAN ACADEMY OF OPHTHALMOLOGY, AMERICAN ASSOCIATION FOR PEDIATRIC OPHTHALMOLOGY AND STRABISMUS and AMERICAN ASSOCIATION OF CERTIFIED ORTHOPTISTS Pediatrics 2018;142; DOI: 10.1542/peds.2018-3061 originally published online November 26, 2018;

Updated Information & including high resolution figures, can be found at: Services http://pediatrics.aappublications.org/content/142/6/e20183061 References This article cites 39 articles, 5 of which you can access for free at: http://pediatrics.aappublications.org/content/142/6/e20183061#BIBL Subspecialty Collections This article, along with others on similar topics, appears in the following collection(s): Ophthalmology http://www.aappublications.org/cgi/collection/ophthalmology_sub Permissions & Licensing Information about reproducing this article in parts (figures, tables) or in its entirety can be found online at: http://www.aappublications.org/site/misc/Permissions.xhtml Reprints Information about ordering reprints can be found online: http://www.aappublications.org/site/misc/reprints.xhtml

Downloaded from www.aappublications.org/news by guest on September 27, 2021 Screening Examination of Premature Infants for Retinopathy of Prematurity Walter M. Fierson, AMERICAN ACADEMY OF PEDIATRICS Section on Ophthalmology, AMERICAN ACADEMY OF OPHTHALMOLOGY, AMERICAN ASSOCIATION FOR PEDIATRIC OPHTHALMOLOGY AND STRABISMUS and AMERICAN ASSOCIATION OF CERTIFIED ORTHOPTISTS Pediatrics 2018;142; DOI: 10.1542/peds.2018-3061 originally published online November 26, 2018;

The online version of this article, along with updated information and services, is located on the World Wide Web at: http://pediatrics.aappublications.org/content/142/6/e20183061

Pediatrics is the official journal of the American Academy of Pediatrics. A monthly publication, it has been published continuously since 1948. Pediatrics is owned, published, and trademarked by the American Academy of Pediatrics, 345 Park Avenue, Itasca, Illinois, 60143. Copyright © 2018 by the American Academy of Pediatrics. All rights reserved. Print ISSN: 1073-0397.

Downloaded from www.aappublications.org/news by guest on September 27, 2021