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We read with great interest the article by Kello et al.1 The authors have to be congratulated for the hard hitting and well written article. A current concern for people involved in paediatric eye care is the emergence of what is probably the third epidemic of retinopathy of prematurity (ROP) in developing countries.2,3 It is therefore significant that no case of ROP was found in the population screened in this study. Several factors could account for this.
The very low or nil prevalence of ROP in countries such as Ethiopia, where the study was carried out, is most probably because of lack of intensive care facilities for premature infants and their low survival rates.
The variation in the incidence of ROP between ethnic groups could also account for this, with the available evidence suggesting that African-American infants are less prone to severe outcome ROP than white infants.4,5
However, it is also important to note that the article mentions that children with mental retardation were not examined owing to the admission criteria of the blind schools that preclude their admission. This too could have accounted for the gross underestimation of the prevalence of ROP as suggested by Jacobson et al.6 In addition, these children with mental handicap could be suffering from cerebral palsy and would have been at high risk for ROP because of the higher incidence of retinal vascular anomalies associated with both cerebral ischaemia and prematurity.7
A large number of infants had phthisis bulbi (51 cases). In children with bilateral phthisis bulbi, there is a possibility that an unknown proportion developed the condition secondary to end stage ROP.
In conclusion, if improvement in perinatal care occurs in Ethiopia, the overall numbers of children with ROP would increase as is seen in other developing countries like India with infant mortality rates (IMRs) between 10–60 per 1000 live births.3 Lack of ophthalmologists experienced in the management of ROP could be effectively circumvented by introduction of digital retina camera technology to improve access to subspecialty care8 for cases requiring treatment. As a lower cost option, screening infants under 1200 g alone might be more cost effective9 and could be the first step, with modification of the screening guidelines made later, consequent to research undertaken within the country itself.
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