Retinopathy of Prematurity

Publication: 07/01/2009  --
Last review: 28/06/2018  
Next review: 28/06/2021  
Clinical Protocol
CURRENT 
ID: 1439 
Approved By:  
Copyright© Leeds Teaching Hospitals NHS Trust 2018  

 

This Clinical Protocol is intended for use by healthcare professionals within Leeds unless otherwise stated.
For healthcare professionals in other trusts, please ensure that you consult relevant local and national guidance.

Retinopathy of Prematurity

Introduction

The new nationally adopted protocol (http://www.rcpch.ac.uk/doc.aspx?id_Resource=3605) prepared jointly by the Royal College of Paediatrics and Child Health, the Royal College of Ophthalmologists and the British Association of Perinatal Medicine has now been published. This provides guidelines for: the selection of infants for screening; timing of initiation of screening; frequency of screening; and timing of surgical intervention when criteria are met. The new protocol has been adopted by the Leeds Teaching Hospitals.

Children with Retinopathy of Prematurity (ROP) often have other complex problems. Screening and treatment demands a high level of multidisciplinary expertise. We are fortunate that we have this immediately available.

These guidelines form a framework for screening for ROP. Infants with developing ROP and those that may require treatment demand an individualised management plan founded on expert assessment.

The UK Retinopathy of Prematurity guideline, 2007, is the basis of protocol. The guideline makes recommendations for which there is firm scientific evidence and others which are examples of good practice points. We have adopted both sets of recommendations.

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Who should be screened?

ROP screening will be carried out for all infants who are:

  • Born before 32 weeks gestation (up to 31 weeks and 6 days)
    OR
  • Born with a birthweight less than 1501g

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When should the first screening be performed?

Babies < 27 weeks gestation - first screen 30/31 weeks (first screening opportunity in the week after baby reaches 30 weeks, and before 31 weeks gestational age

All other babies who need screening - at 4/5 weeks of age (first screening opportunity in the week after the baby reaches 28 days, and before 35 days of age).

In all babies the first screen should be done before discharge home.

If a baby is unable to have screening at the time indicated because of clinical or organisational circumstances, the screening should be rescheduled within one week of the intended examination.

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How often will be babies be screened?

All babies included in the screening programme will be screened at least every two weeks.
Some babies who may be developing ROP will be screened weekly. This is determined by the ophthalmologist and is what occurs now. This includes babies with:

  • The vessels end in zone I or posterior zone II, or
  • There is any plus or pre-plus disease, or
  • There is any stage III disease in any zone.

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When does ROP screening stop?

This decision is made by the ophthalmologist. Screening is stopped when a baby is no longer at risk of sight threatening ROP. This is usually babies that are vascularised into zone 111 AND are 37 weeks gestational age.

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Laser Therapy

Laser treatment can be provided on the neonatal unit at Leeds General Infirmary or in Clarendon Wing Theatres. The decision to go ahead with therapy is made by the ophthalmologist. The general recommendation is that infants with aggressive ROP should receive treatment within 48 hours of the decision and others should normally be treated within 72 hours.

Each infant requires an individual management plan of treatment designed around their needs and the ROP. This will be determined by the ophthalmologist in discussion with the neonatal team. Similarly, a plan will be made for follow-up after treatment.

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Procedures

Screening:

Babies for screening are identified by neonatology staff and entered in the ROP diary. There is a weekly ROP round on both sites.

Parents will be informed of the screening programme and the importance of it to their baby. Written consent is not required for the screening procedure. Information about retinopathy of prematurity should be readily available for parents in infants who are at risk. 

Normal care and feeding is not usually disrupted by the screening procedure. Mydriatic eye drops are given to dilate the pupils. Comfort care techniques such as sucrose solution, nestling, swaddling should be used during or after the procedure. Local anaesthetic (usually proxymetacaine) should be used when a speculum is required.

The opportunity for screening for ROP should not be missed in any infant who is at risk unless there is good reason. If a decision is made not to screen a baby on a certain occasion, the screening should be rearranged within one week.

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Laser treatment

The need for and the timing of laser therapy will be determined by the ophthalmologist. Consideration in each infant is given to their individual needs and the pattern of developing ROP.

During the laser procedure newborn infants will be intubated, ventilated, receiving a paralysing agent and suitable analgesia. After the procedure most infants will be extubated. An individual management plan for all infants receiving laser therapy will be formulated by the multidisciplinary team.

Laser therapy requires full parental information and signed consent. This will be obtained by the Ophthalmology team.

Laser treatment will normally be provided in the operating theatre under the care of the paediatric anaesthetist and the operating theatre team but in certain circumstances may be provided on the neonatal unit under the care of the neonatal team.

In each infant the best place to perform laser therapy will need to be determined individually depending on staff availability and logistics. It is a small number of babies who come to laser therapy each year and the need is not predictable.

We make the following recommendations.

  1. Infants requiring ROP laser therapy are divided into two groups:
    • Those currently receiving mechanical ventilation and those who are unstable on CPAP.
    • Those who are stable on CPAP or breathing spontaneously in supplementary oxygen or room air.
  2. All laser therapy will be done at the LGI site.
  3. The choice of place of therapy will be influenced by staff availability and theatre availability. Clearly, the procedure should only take place on the neonatal unit if during the procedure there is available a member of nursing staff and a doctor who is a consultant in neonatal medicine or one of the registrars who is competent and confident in airway management. In theatre there must be facilities for safe transfer, anaesthetic care and theatre space.
  4. On the neonatal unit the procedure should take place in a side room. At the LGI the side room may safely be made laser safe by occlusion of the windows.
    • Infants on IPPV or unstable on CPAP will in general receive laser therapy in the operating theatre but if this presents difficulties and treatment become urgent, arrangements may be made for treatment on the neonatal unit.
    • Infants stable on CPAP or breathing spontaneously in supplementary oxygen or room air will receive laser therapy in the operating theatre unless there are special circumstances.
  5. A small number of infants each year come to the Leeds Teaching Hospitals for laser therapy. These infants receive laser therapy at the LGI. The procedure will be performed in the operating theatre. After the procedure infants will return to LGI surgical newborn unit

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Other Treatments

Anti-VEGF Injections:
Intravitreal injections have been given to babies to treat ROP. This has been done as a primary (only) treatment or as rescue treatment (when laser has not worked). LTH has given clinical ethics approval for treatment with Bevacizumab injections for cases that are progressing despite previous laser. The injection may be administered in the Neonatal unit or in theatre. It can be administered under topical anaesthesia unless further laser is planned as well.

These guidelines form a framework for care. Screening and treatment of ROP is vitally important in protecting the newborn infant from sight loss. The importance of individual management plans formulated by the multidisciplinary team is emphasised.

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Provenance

Record: 1439
Objective:

These guidelines form a framework for screening for ROP. Infants with developing ROP and those that may require treatment demand an individualised management plan founded on expert assessment.

Clinical condition:

Retinopathy of prematurity

Target patient group: Premature infants
Target professional group(s): Secondary Care Doctors
Secondary Care Nurses
Adapted from:

The new nationally adopted protocol prepared jointly by the Royal College of Paediatrics and Child Health, the Royal College of Ophthalmologists and the British Association of Perinatal Medicine.This provides guidelines for: the selection of infants for screening; timing of initiation of screening; frequency of screening; and timing of surgical intervention when criteria are met.


Evidence base

Not supplied

Document history

LHP version 1.0

Related information

Appendix 1: Diary note for NICU

ROP SCREENING Sept 2010

UK ROP Guidelines May 2008

www.rcpch.ac.uk or www.rcophth.ac.uk

WHO: We will screen all babies who:

  • are born before 32 completed weeks of gestation (up to 316 weeks)
    OR
  • have a birthweight less than 1501g

WHEN: The first screening examination will be performed:

  • Babies < 27 weeks gestation - between 30 and 31 weeks
    (first screening opportunity in the week after baby reaches 30 weeks, and before 31 weeks gestational age)
  • All other babies who need screening - between 4 and 5 weeks of age
    (first screening opportunity in the week after the baby reaches 28 days, and before 35 days of age).

All babies should have their first ROP check prior to discharge.

Dilating regime: 1/2 hour before eye examination

Drops: Phenylephrine 2.5%
Cyclopentolate 0.5%

METHOD
Date of screening to be entered in the diary chart at the front of each infant’s notes and entered in the Eye Book for the 1st available day closest to screening (usually Tuesday LGI / Friday SJUH).

Following screening, results to be documented in the notes and/or on Badger.

Discharge letters must include results of ROP screening or if no screening occurred during stay, notification to the effect “at risk but not screened”.

Patients discharged home before completion of programme must have Ophthalmic O/P appointment made for follow - up.

Patients discharge to another Neonatal Unit need to be referred to a local Ophthalmologist by a local Paediatrician.

IF A BABY IS CROSSED OUT - PLEASE STATE WHY AND SIGN.

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