Retinopathy of Prematurity ( ROP ) - Protocol for Laser Treatment on the Neonatal Unit

Publication: 08/02/2017  --
Last review: 17/04/2020  
Next review: 03/04/2023  
Standard Operating Procedure
ID: 4899 
Approved By: Trust Clinical Guidelines Group 
Copyright© Leeds Teaching Hospitals NHS Trust 2020  


This Standard Operating Procedure 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 (ROP) – Protocol for Laser Treatment on the Neonatal Unit

Background and indications for standard operating procedure/protocol

Retinopathy of Prematurity (ROP) is a well-recognized complication in premature babies1. The abnormal proliferation of blood vessels in the retina can cause retinal detachment and blindness in severe cases2. Current recommendations for screening at risk infants sets a strict timeline for when screening should be carried out, to allow for early identification of high risk pre-threshold, early posterior aggressive or threshold ROP, which would require treatment3. The principle treatment for ROP is peripheral retinal ablation with a laser photocoagulation device4. Treatment for ROP performed in a timely manner can have improved outcomes in visual acuity in later childhood5.

The majority of Laser treatments are carried out in the Operating Theatres. However, there are rare occasions where the treatment would need to be performed on the neonatal unit, such as the unavailability of theatre, ventilated babies or babies on continuous positive airway pressure (CPAP), in order to commence treatment within 48-72 hours of detecting threshold disease. This target standard was set by the latest UK ROP Guidelines6. Providing safe and effective sedation and ventilation by neonatal staff during laser treatment on the Neonatal Unit will prevent delays7,8. Observations are taken in line with theatre. Babies may also sometimes be treated awake on the unit or in theatre with an intra- vitreal, anti-VEGF injection (e.g. Bevacizumab). This is for failure of laser treatment or for babies unfit for general anaesthetic or laser treatment.

This SOP has been developed to ensure a safe and standardized approach to manage our babies before and after the procedure on the Neonatal Unit9.

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Procedure method (step by step)


  • Ensure a clean side room on the neonatal unit is available
  • Confirm the time of treatment with the operating Opthalmologist
  • Ensure a senior nurse is available for the duration of the treatment
  • Ensure a neonatal doctor is available for the duration of the treatment
  • Prescribe Proxymetacaine 0.5%, Cyclopentolate 0.5% and Phenylephrine hydrochloride 2.5% eye drops (to be given as below)
  • Prescribe analgesia and paralyzing agent (see below)

1 hour before treatment:

  • Intubate and ventilate the baby
  • Request Chest X-Ray to confirm the endotracheal (ET) tube position
  • Give eye drops: Proxymetacaine 0.5% first, followed by Cyclopentolate 0.5% and Phenylephrine 2.5%

30 minutes before treatment:

  • Repeat eye drops: Proxymetacaine 0.5% first, followed by Cyclopentolate 0.5% and Phenylephrine 2.5%
  • Blood gas to confirm adequate ventilation

5 minutes before treatment:

  • Full set of observations
  • Give Morphine 100 micrograms/kg IV bolus
  • Give Pancuronium 100 micrograms/kg IV bolus
  • Draw up (and label) a further dose of Pancuronium, which may be needed during the procedure
  • Consider ongoing analgesia either as:
    • Continuous Morphine infusion at a rate of 20 micrograms/kg/hour
    • Or, a further bolus of Morphine at 100 micrograms/kg IV

During Treatment:

  • Regular observations every 10 minutes, paying particular attention to signs that the baby may be in pain (e.g. tachycardia, raised blood pressure)
  • If the baby is on a Morphine infusion, titrate the rate according to pain response
  • Consider a further dose of Pancuronium if the paralysis is starting to wear off

After treatment:

  • If the baby is on a Morphine infusion, continue the infusion for 1 hour
  • If the baby is stable and has adequate respiratory drive, aim to extubate the baby as soon as possible
  • If ventilation needs to be continued:
    • Check blood gas
    • Consider repeat chest X-Ray if appropriate
  • Observations every 30 minutes until baby is extubated

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Record: 4899

To standardize and optimize the process of laser treatment for Retinopathy of Prematurity (ROP) on the neonatal unit

Clinical condition:
Target patient group:
Target professional group(s): Secondary Care Doctors
Secondary Care Nurses
Adapted from:

Evidence base

  1. Neonatal Outcomes of Extremely Preterm Infants from the NICHD Neonatal Research Network. Pediatrics 2010;126:443–456
  2. Section on Ophthalmology American Academy of Pediatrics. "Screening examination of premature infants for retinopathy of prematurity." Pediatrics 117.2 (2006): 572.
  3. Screening Examination of Premature Infants for Retinopathy of Prematurity. American Academy of Pediatrics Section on Ophthalmology, American Academy of Ophthalmology, American Association for Pediatric Ophthalmology and Strabismus, American Association of Certified Orthoptists. Pediatrics Jan 2013, 131 (1) 189-195; DOI: 10.1542/peds.2012-2996
  4. Hunter, David G., and Michael X. Repka. "Diode laser photocoagulation for threshold retinopathy of prematurity: a randomized study." Ophthalmology100.2 (1993): 238-244.
  5. Good WV, Hardy RJ, Dobson V, et al., Early Treatment for Retinopathy of Prematurity Cooperative Group. Final visual acuity results in the early treatment for retinopathy of prematurity study. Arch Ophthalmol. 2010;128(6):663–671
  6. UK Retinopathy of Prematurity Guideline May 2008. Royal College of Paediatrics and Child Health, Royal College of Opthalmologists, British Association of Perinatal Medicine, Bliss. 2008
  7. Anand, D et al. Anaesthesia for Treatment of Retinopathy of Prematurity. Archives of Disease in Childhood. Fetal and Neonatal Edition 92.2 (2007): F154–F155
  8. Retinopathy of Prematurity Laser Treatment. Newborn Services Clinical Guideline. Aukland District Health Board.
  9. Bristol Neonatal Unit ROP Treatment Consensus

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Approved By

Trust Clinical Guidelines Group

Document history

LHP version 1.0

Related information

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