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