Role of Pediatricians in ROP :

The responsibility of getting the baby to the ophthalmologist for screening at the appropriate time rests with the pediatrician. A well organized screening strategy and timely intervention can to a large extent prevent blindness due to ROP.

Who should be screened?

The indications recommended by the Indian ROP working group are given in table 5. 24

Table 5: The screening criteria for ROP

Birth Weight	<1700 gms
Gestational age	< 34-35 weeks
Exposure to Oxygen	> 30 days
Other Risk Factors (in babies , 37 weeks or > 2000 gms)	Respiratory distress     Syndrome  Blood Transfusions  Sepsis  Multiple Births (twins/triplets     etc)  Apnoeic episodes  Intracranial Hemorrhage  Pediatrician has an index of     suspicion

When should the screening begin?

There is an optimal time when the screening should take place. An earlier date would result in high false negatives and a later date would result in missing the treatable cases until it is too late. The sequence of events leading to ROP usually takes about 4 weeks except in a small subset of premature infants who develop fulminate or type 2 ROP in 2 weeks. Therefore routine screening should begin at no later than four weeks after the birth and possibly even earlier for infants at higher risk (2 weeks). 25 One session of retinal screening should be carried out before day 30 of the life of any premature baby 'THE DAY 30 STRATEGY'.

How frequently a premature baby should be examined?

The answer depends on the presence or absence of the disease and its severity. This will be decided by the ophthalmologist by assessing the stage of the disease, zone of involvement and the presence or absence of plus disease.
Nevertheless, even after the ROP has resolved a premature child is at a high risk of developing other vision threatening ocular morbidity (Table 1) that require a follow up at 4 months of age to assess the refractive status and ocular alignment followed by next check up at one year to assess the functional vision.

Based on the results of the HOPE ROP study 25 (High Oxygen Percentage in retinopathy of prematurity study) and STOP ROP study 26 (Supplemental Therapeutic Oxygen for Prethreshold Retinopathy of Prematurity study 26 ) following recommendations can be made :

• Supplemental oxygen is not found to have any additional benefit in Prethreshold or threshold ROP
• The risk of adverse event including pneumonia and/or exacerbation of chronic lung disease is high in children who receive the supplemental oxygen
• The clinician should individually assess the risk/benefit ratio of oxygen supplementation or curtailing the oxygen without worrying about the risk of exacerbating an active disease (ROP)
• Avoid repeated large fluctuations in SpO 2 levels

Treatment of Babies with ROP :

It is known that spontaneous regression occur in 48% of those babies with Threshold disease giving rise to good visual and functional outcome. Out of remaining 52% children 35% are likely to develop severe vision threatening complication if not treated. The incidence of the unfavorable out come can be reduced to 9% if the LASER or CRYO is performed at prethreshold stage. However, lowering the limit from Prethreshold stage would mean treating 3 children when only one child required treatment. Ophthalmologists apply the criteria to treat or not to treat based on the individual risk/benefit ratio. LASER photocoagulation is performed in one or more sittings within 72 hours of decision to treat. The peripheral, nonvascular retina is ablated with the LASER and the sign of regression is visible within 5-7 days.
In advanced cases (Stage 4 or 5) retinal surgery is indicated which has limited success rates.