What is the recommended treatment for a premature infant with retinopathy of prematurity?

Treatment of Retinopathy of Prematurity

For premature infants with threshold ROP, peripheral retinal ablation using laser photocoagulation is the definitive treatment that has proven effective in reducing blindness. 1

Treatment Modalities by Disease Severity

Threshold ROP (Treatment-Requiring Disease)

• Laser photocoagulation is the standard treatment, particularly for disease located in Zone II 2
• Peripheral ablation (cryotherapy or laser therapy) destroys avascular retinal tissue to prevent progression to blindness 3, 1
• Anti-vascular endothelial growth factor (anti-VEGF) agents are increasingly used as monotherapy or adjunct to laser, especially for Zone I disease 2
• The choice between laser alone versus anti-VEGF depends on disease location, with Zone I disease favoring anti-VEGF consideration 2

Pre-threshold ROP

• Oral propranolol shows encouraging results for prevention and treatment of pre-threshold disease, though this represents emerging evidence 2
• Close monitoring with ophthalmology visits every 1-2 weeks is required for infants whose vessels or ROP remain in Zone I or Zone II 1

Advanced Disease (Stages 4-5)

• Retinal detachment repair may be attempted, though visual outcomes are disappointing with 93.6% of eyes achieving visual acuity of 3/60 or less 4
• Surgical intervention is often required for complications including cataract (54.8% of advanced cases), glaucoma (22.6%), and microphthalmos (48.4%) 4

Critical Oxygen Management During Treatment

Oxygen control differs based on the infant's retinal vascular status and disease phase:

For Infants with Incomplete Retinal Vascularization

• Avoid sustained hyperoxemia, as high arterial oxygen levels slow normal vascularization during the vaso-obliteration phase 5
• Marginally low oxygen aggravates neovascularization during Phase II, requiring careful balance 5, 1
• The STOP-ROP trial demonstrated that oxygen saturation targets of 96-99% do not increase risk of ROP progression in infants with pre-threshold disease 3, 6

For Infants with Complete Retinal Vascularization

• Once retinal vessels have grown to the ora serrata (fully vascularized), the retina is considered "safe" from mildly elevated arterial oxygen levels 3
• Target oxygen saturation of 95% or higher is recommended to prevent pulmonary complications 6, 1
• This applies to infants who have undergone peripheral retinal ablation, as they have no residual avascular retina 3

Follow-Up Requirements

Missing follow-up appointments represents the greatest risk for preventable vision loss 6, 1

High-Risk Infants Requiring Frequent Monitoring

• Infants with vessels or ROP still in Zone I or Zone II need ophthalmology visits every 1-2 weeks 6, 1
• Infants with chronic lung disease of infancy require careful coordination of follow-up appointments, as parents cannot usually provide close oxygen control at home without extensive support 3, 6

Safe to Discontinue Screening

• ROP that is regressing with vessels passed into Zone III on at least two sequential examinations is extremely unlikely to progress to threshold 6, 1
• Complete retinal vascularization indicates screening can be discontinued 6, 1

Common Pitfalls to Avoid

• Delayed transfer for treatment: Infants transferred from other facilities often present beyond threshold ROP (80% in one series), missing the optimal treatment window 4
• Inadequate home oxygen monitoring: Parents cannot be expected to provide close oxygen control without extensive support, potentially leading to ROP worsening 3
• Screening infants >37 weeks gestation: These infants do not require screening unless they have chronic lung disease 6
• Using general ophthalmologists for screening: Only pediatric ophthalmologists skilled in evaluating the premature infant retina should perform examinations 6