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What do you do about ROP screening in “big” babies?
1. G E Quinn
1. Pediatric Ophthalmology, Wood Center, 1st Floor, The Children’s Hospital of Philadelphia, Philadelphia, PA, USA; quinn{at}email.chop.edu

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Screening guidelines should not be considered generalisable to all nursery populations . . . regional differences must be taken into account

World Health Organization guidelines for effective screening programmes1 demand several conditions be met, but these conditions are still being understood for retinopathy of prematurity (ROP) screening. There is little doubt that ROP is an important health problem in the premature infant population and that peripheral retinal ablation is an accepted treatment for patients with recognised disease. In addition, much is known about the natural history of the condition and the disorder can readily be detected by indirect ophthalmoscopy. However, as Andruscavage and Weissgold point out in their article in this issue of the BJO (1127), there is not yet an agreed policy on whom to treat as patients, in particular what should the criteria be for ROP screening in children with birth weights larger than 1250 g? Society must also address the cost of finding cases that only rarely occur in higher birthweight, but still preterm, babies.

Results of the randomised Multicenter Trial of Cryotherapy for Retinopathy of Prematurity (CRYO-ROP)2 have shown that, for 10 year old children with birth weights of <1251 g born in the United States in 1986 and 1987, treatment within 72 hours of the diagnosis of threshold disease resulted in a 28.5% reduction in the number of treated eyes with visual acuity of 20/200 or worse (p<0.001) compared to control eyes. There was also a 43.2% reduction of treated eyes with retinal folds involving the fovea or total retinal detachment, compared to eyes in the control group (p<0.001). The cohort of children that constitutes the CRYO-ROP study population accounted for approximately 15% of the <1251 g birthweight children born in the United States during the enrolment period,3 and 291 children were enrolled in the treatment arm of the study, representing 6% of the study population.

We do not know the prevalence of severe ROP in the larger birthweight preterm infants, though retinopathy of this severity does occur in children with birth weights of greater than 1250 g.4 The two cases reported by Andruscavage and Weissgold represent 1.2% of the 162 children screened and only 0.65% of the survivors with birth weights greater than 1500 g eligible for ROP screening according to their nursery criteria. There are two interesting aspects to the ocular findings in these children: (1) the four eyes that required treatment reached threshold severity nearly at term, somewhat later than most threshold disease in <1251 g birthweight children,5 and (2) all four eyes had good structural and functional outcomes with no significant refractive error. Though little can be made of the findings in such a small sample, it is in agreement with my clinical impression that threshold ROP is less virulent in larger birthweight babies.

The recent screening guidelines for ROP from the American Academy of Pediatrics, the American Academy of Ophthalmology, and the American Association of Pediatric Ophthalmology and Strabismus6 provide little guidance in determining which preterm infants with higher birth weights should be examined. The statement recommends that ROP screening should be performed at least twice in “selected infants between 1500 g and 2000 g with an unstable clinical course who are believed to be at high risk by their attending pediatrician or neonatologist.” The risk factors that identify “unstable clinical course” are left to the individual clinician to define.

The cost effectiveness of treatment for threshold ROP for infants <1251 g has been demonstrated in two studies. Javitt et al,7 using data from the CRYO-ROP study, predicted a cost per quality adjusted life year gained was from $2488 to$6045 (£1583–£3845), depending on how frequently the eyes were examined. The overall cost savings in the cohort of infants born annually in the United States ranged up to \$64.9 million (£41.3 million). In addition, they suggested that blindness could be avoided in 320 children per year if a timely intervention strategy for severe ROP were used. More recently, Brown et al8 calculated cost effectiveness of laser therapy or cryotherapy for threshold ROP and suggested that the cost effectiveness is somewhat higher for laser treatment, but that both were “excellent values” since they had long term benefit for those children who were prevented from going blind by the treatment. At our present level of understanding, the cost effectiveness of screening for higher birthweight infants cannot be calculated for a number of reasons: (1) we have not defined the population at risk; (2) we have not described the natural history of severe ROP in infants with birth weights of >1251 g; and (3) we have not developed an effective strategy for examining these children who are most likely to be discharged from the hospital before development of threshold disease.

The current database that has provided much of our knowledge of the natural history of ROP has been collected in tertiary care nurseries in the industrialised world. The prevalence of blinding disease in the newly industrialising countries is largely unknown and older, larger babies may be at risk in these areas.9 Therefore, screening guidelines for ROP should not be considered generalisable to all nursery populations, but regional differences must be taken into account.

In summary, Andruscavage and Weissgold have begun to help us unravel the complex question of what to do about detecting and treating blinding disease in higher birthweight preterm infants, but much remains to be done. Certainly missing the opportunity to treat threshold ROP and to prevent blindness in an infant is recognised by all as tragic, but we have yet to grapple with issue of staff levels to accomplish the necessary screening examinations and we are still trying to identify those children at risk. Perhaps, when there is an adequate understanding of the ROP in these children we will be able to develop an algorithm similar to that being used in the Early Treatment for ROP (ET-ROP) study10 currently under way in the United States to determine which infants to examine and when to treat their retinopathy.

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Screening guidelines should not be considered generalisable to all nursery populations . . . regional differences must be taken into account

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