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Editorial

Do we need India‑specific retinopathy of prematurity screening guidelines?

Retinopathy of prematurity (ROP) is a major cause of preventable blindness in children.[1] It is estimated that of about 15 million
children born preterm worldwide, about 53,000 develop sight‑threatening ROP requiring treatment, and 20,000 suffer blindness
or severe visual impairment.[2] More than 60% of preterm births occur in Africa and South Asia.[3] India accounts for the most
preterm births in the world (3.5 million).[3] United Nations Children’s Fund estimates that 21 million newborns (15% of all births)
have low birth weight (LBW).[4] India has the third highest incidence of LBW, with about 1.7 million weighing <2500 g and about
0.4 million <1500 g.[4] Crucially, premature birth and LBW predispose a newborn to develop ROP, for which India is evidently
the hotbed.
The occurrence of severe ROP is related to the level of neonatal and ophthalmologic care and the socioeconomic status of a
country. Of 15 million infants born prematurely each year, 1.2 million are born in high‑income countries with access to optimal
neonatal intensive care, another 8.2 million are born in middle‑  or low‑income countries with access to hospital births but
with variable and limited infrastructure and expertise, and 5.6 million are born in low‑income countries with home care.[5,6] In
high‑income countries, where the level of neonatal care is optimal, ROP‑associated blindness is relatively uncommon.[6‑9] However,
in middle‑ and low‑income countries with regional variations in technology and capacity, ROP blindness may be substantially
high, contributing to about 40% of childhood blindness.[6,9]
Unfortunately, there is no hard data on the incidence of ROP in India. Of 3.5 million premature births in India, approximately
one in six (about 600,000) children are born at <32 weeks gestational age (GA).[10,11] Estimating that about 40% of these receive
neonatal care and 80% of them survive, about 200,000 children are at risk of developing ROP in India every year. If about
10% of them develop treatable ROP, the number of newborns needing ROP management is at least 20,000 every year.[11] In
addition, children with GA 32–36 weeks who receive suboptimal postnatal care and have comorbidities may also be at the
risk of developing ROP.
The dynamic and time‑bound development of ROP and effectiveness of treatment at an appropriate stage make it
amenable for systematic screening. Screening guidelines, however, vary from region to region. The 2019 American Academy
of Pediatrics (AAP) guidelines recommend screening of all infants with a BW ≤1500 g or a GA ≤30 weeks and selected infants
with a BW between 1500 and 2000 g or GA >30 weeks who are believed to be at risk for ROP (infants with hypotension requiring
inotropic support, infants who received oxygen supplementation for more than a few days, or infants who received oxygen
without saturation monitoring).[12] United Kingdom guidelines developed by the Royal College of Ophthalmologists (RCO) and
Royal College of Pediatrics and Child Health stipulate that babies <32 weeks GA or <1501 g birthweight should be screened
for ROP.[13]
It is known that ROP can develop in bigger and more mature babies in India, which may be attributed to the variable and often
suboptimal quality of neonatal care.[14‑16] Studies from India have shown that children with BW of 2000 g can develop ROP.[14‑16] A
prospective study from South India confirmed that severe ROP does occur in babies who lie outside the conventional American
or British screening criteria.[15] About 6.7% and 13.3% of severe ROP would have been missed using the RCO or AAP screening
criteria, respectively.[15] The authors suggested that broader screening criteria of GA of <34 weeks and birth weight (BW) of <1750 g
would be an ideal starting point for the region.[15] Another study from South India noted that 17.7% and 22.6% of children with
threshold ROP or worse would have been missed if they were to use the AAP or RCO screening criteria, respectively.[16] A study
from India found the mean BW in the group with severe ROP was 1554 g (range 850–2290) and the mean GA was 31.75 weeks (range
28–34).[17] A report from China showed that 30.4% and 16.2% of infants with ROP Stages 3, 4, and 5 outlied the AAP and RCO
screening criteria, respectively.[18]
There have been attempts in the past to customize ROP screening criteria to India.[19] Jalali et al. initially suggested screening of
all children with BW <1500 g or GA <34–35 weeks and children exposed to oxygen for >30 days and BW <2000 g or GA <37 weeks
with high‑risk factors.[20] They later proposed a modified screening criteria of BW <1750 g and GA of <34 weeks.[15] Screening
guidelines published by the National Neonatology Forum recommends first screening between 2 and 3 weeks for infants born
before 28 weeks GA or with a BW <1200 g and not later than 4 weeks after birth for infants born between GA of 28 and 34 weeks
or BW ≤2000 g.[21] The latest ROP guidelines (published by a collaborative of neonatal care and ROP experts in India, London
School of Hygiene and Tropical Medicine, led by the Indian Institute of Public Health – Public health Foundation of India and
supported by the Queen Elizabeth Diamond Jubilee Trust) are an attempt to standardize the screening and management of ROP
in India and integrate it with the existing public health delivery system.[11] It proposes screening of all children born ≤34 weeks
and those >34 weeks with risk factors if the GA is known, or all infants ≤2000 g BW if GA is unknown [Fig. 1]. It includes
an elaborate set of follow‑up screening  [Fig.  2], treatment  [Fig. 3], and long‑term follow‑up  (based on cortical and ocular
morbidity) [Figs. 4 and 5] guidelines. In a significant move, it also proposes the use of wide‑field fundus imaging and screening
by nonophthalmologists.

© 2019 Indian Journal of Ophthalmology | Published by Wolters Kluwer - Medknow

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712 Indian Journal of Ophthalmology Volume 67 Issue 6

Figure 1: Retinopathy of prematurity screening guidelines. (Reproduced with permission from “Project operational guidelines. Prevention of Blindness
from Retinopathy of Prematurity in Neonatal Care Units, https://phfi.org/wp‑content/uploads/2019/05/2018‑ROP‑operational‑guidelines.pdf”)
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June 2019 Honavar: ROP Screening

in India 713

Figure 2: Algorithm for the follow‑up and management of retinopathy of prematurity. (Reproduced with permission from “Project
operational guidelines. Prevention of Blindness from Retinopathy of Prematurity in Neonatal Care Units, https://phfi.org/wp‑content/
uploads/2019/05/2018‑ROP‑operational‑guidelines.pdf”)
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714 Indian Journal of Ophthalmology Volume 67 Issue 6

Figure 3: Retinopathy of prematurity treatment guidelines. (Reproduced with permission from “Project operational guidelines. Prevention of Blindness
from Retinopathy of Prematurity in Neonatal Care Units, https://phfi.org/wp‑content/uploads/2019/05/2018‑ROP‑operational‑guidelines.pdf”)
[Downloaded free from http://www.ijo.in on Thursday, June 25, 2020, IP: 200.107.21.120]

June 2019 Honavar: ROP Screening

in India 715

Figure 4: Ophthalmic evaluation guidelines for preterm infants. (Reproduced with permission from “Project operational guidelines. Prevention of
Blindness from Retinopathy of Prematurity in Neonatal Care Units, https://phfi.org/wp‑content/uploads/2019/05/2018‑ROP‑operational‑guidelines.pdf”)

Figure 5: Ocular and cortical morbidity in preterm infants  –  follow‑up evaluation guidelines. (Reproduced with permission from “Project
operational guidelines. Prevention of Blindness from Retinopathy of Prematurity in Neonatal Care Units, https://phfi.org/wp‑content/
uploads/2019/05/2018‑ROP‑operational‑guidelines.pdf”)
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716 Indian Journal of Ophthalmology Volume 67 Issue 6

In the absence of large epidemiological studies and mapping of nation‑wide ROP data, we may have to agree that the current
ROP screening and management guidelines are only a good starting point. Wider screening criteria, no doubt, will increase the
rate of pick‑up of ROP. It is estimated that approximately 19 hours of ophthalmologists’ time is required to detect one threshold
ROP.[22] Although screening workload per child relatively decreases with increasing GA and BW, the overall stress on the healthcare
system due to the increased number of children under screening needs an astute evaluation. Screening by nonophthalmologists and
tele‑screening by wide‑field fundus imaging are paradigm changes in concept but need to be validated for agreement with the gold
standard (screening by a trained retina specialist) in varied real‑life situations before these measures can be widely implemented.
This issue of the Indian Journal of Ophthalmology is a tribute to concerted efforts by several dedicated individuals, institutions, and
organizations to the cause of ROP and pediatric retinal diseases. Prof. Mangat Ram Dogra, who retires this month as the Head of the
Department, Advanced Eye Centre, Postgraduate Institute of Medical Education and Research, Chandigarh, India, needs a special
mention for having inspired generations of Indian ophthalmologists to take up the crying cause of ROP and pursue it as their passion.

Santosh G Honavar
Editor, Indian Journal of Ophthalmology,
Editorial Office: Centre for Sight, Road No. 2, Banjara Hills, Hyderabad ‑ 500 034, Telangana, India.
E‑mail: editorjournal@aios.org
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PMID: Cite this article as: Honavar SG. Do we need India‑specific retinopathy of
*** prematurity screening guidelines? Indian J Ophthalmol 2019;67:711-6.