 Central Florida Retina Institute, Specializing
in diseases and surgery of the retina, macula, and vitreous,
 877-245-2020
Retina FAQs | Glossary
of Ophthalmologic Terms | Description
of a Retina | Diabetic
Retinopathy | Epiretinal
Membranes | Flashers &
Floaters | Macular Degeneration
| Macular Holes | Retinal
Detachment | Retinopathy
Of Prematurity | Clinical Trials
Q: Description of retinopathy of prematurity
(ROP)?
A: Babies who are born prematurely
still have a growing retina. The retina usually finishes growing
a few weeks to a month after birth in full term babies, but in
premature babies the retina is still growing. During the course
of this growth, the blood vessels that bring blood to the retina
can begin to develop abnormally. This abnormal growth is called
retinopathy of prematurity. Many factors interact to cause retinopathy
of prematurity. We do not understand all of the causes at present.
A number of research studies are taking place that will help
us better understand this problem.
Q: Symptoms of ROP?
A: It does not seem that all
babies born prematurely are at risk of developing ROP. The general
rule is that those born earlier (more premature) and those weighing
the least at birth are the most likely to develop ROP. In the
hospitals we are affiliated with, all babies weighing less than
1500 grams (3 pounds, 5 ounces) or born at or before 34 weeks
of gestation have eye examinations, since these babies are at
risk of developing ROP. Any babies weighing less than 1250 grams
(2 pounds, 12 ounces) or born at less than 30 weeks of gestation
are at greater risk of developing ROP. It is also thought that
babies who are very sick at birth and who require oxygen might
be at risk of developing ROP even if they weigh more than the
above-mentioned limits and if they are older than noted above.
These babies are also examined for ROP.
Q: Why are eye exams performed on premature
babies?
A: The only way to determine
if ROP is present is by examining the inside of the eye. The
retina is examined and changes and abnormalities in the retina
can be noted.
Q: When are the first eye exams performed?
A: In the hospitals we are affiliated
with, the nurses and neonatologists are extremely careful and
knowledgeable about the problems of premature babies. They keep
track of all babies born in the neonatal intensive care unit
(NICU) who meet the age and weight criteria for ROP susceptibility
and schedule eye exams for these babies at 4-6 weeks after birth.
Babies who are discharged from the hospital are also examined
at 4-6 weeks after birth. The timing of the first examination
does not depend on the babies' gestational age (how long they
were in the womb).
Q: Who performs the eye exams?
A: Ophthalmologists trained
in the care of ROP; therefore retina specialists or pediatric
ophthalmologists usually perform this examination.
Q: Where are the eye exams performed?
A: If the baby has been discharged
from the hospital before the age of 4-6 weeks, the exams are
performed in the ophthalmologist's office. In general, most of
the premature babies are still in the hospital at the time of
the first exam and the exam is performed at the bedside in the
neonatal intensive care unit.
Q: How are the eye exams performed?
A: The doctor performs the exam
with the help of an assistant. The assistant helps hold the baby
during the examination. The baby's eyes are dilated with eye
drops prior to the examination. The doctor may use an instrument
called an "eyelid speculum" to hold the eyelids open
and another instrument called a "scleral depressor"
to help hold and move the eye into different positions so that
all of the retina can be inspected. An instrument called an "indirect
ophthalmoscope" is used; it has a special lens that sends
a bright light into the eye, enabling the doctor to examine the
retina.
Q: Is the eye exam uncomfortable for a
premature baby?
A: A premature baby is very
sensitive to any type of examination. An eye exam can be stressful
to a premature baby, but the extreme importance of such an exam
in preventing blindness has to be kept in mind. A well-trained
doctor should be able to perform this exam quickly and with minimal
discomfort to the baby. As with almost any exam, the baby will
cry, but this is not an indication that the examination is causing
pain, particularly since the baby usually calms down very quickly
after the exam and returns to sleep or to feeding almost immediately.
(The baby should not be fed just before the examination). After
the exam, the baby's eyelids may be red or slightly swollen.
The white part of the eyes can also appear red and, occasionally,
there can be small dots of blood on the white part of the eyes.
These are not signs of injury or damage. The eyes will return
to the way they were before the exam; however, blood may take
several weeks to disappear completely.
Q: How often are the follow-up eye exams
performed?
A: The follow-up exams are scheduled
depending on the stage and the extent of ROP. Usually exams are
performed every 1-2 weeks while the baby is in the hospital and
then every 1-4 weeks once the baby leaves the hospital. Occasionally
some babies' retinas grow slowly, and if no ROP is present they
can be followed at longer intervals. Generally the eye exams
are performed until the retina has fully developed. This can
sometimes take several months.
Q: What are the different stages of ROP?
A: Retinopathy Of Prematurity
is classified according to the severity of the changes of the
blood vessels and the region of the retina into which the vessels
have grown. The severity is referred to as the "Stage"
and the retinal regions as "Zones."
Stages are as follow:
Immature Vessels Normal but
incomplete growth
Stage 1 Mildly abnormal growth
Stage 2 Moderately abnormal growth
Stage 3 Severely abnormal growth
Stage 4 Partially detached retina
Stage 5 Completely detached retina
Zones are as follow:
Zone I Earliest growth of the
central retina which includes the macula
Zone II Middle region of growth in which most ROP occurs
Zone III Last region of growth
The "immature vessels"
stage actually occurs in all infants, and does not necessarily
lead to ROP. Also, when ROP regresses (goes away), the vessels
may go through this stage again until they complete their growth.
Stage 1 is a mild abnormality
of the retinal vessel growth and does not require treatment.
Stage 2 is a moderate abnormality
of the retinal vessel growth and also does not require treatment.
Stage 3 is a severe abnormality
of the retinal vessel growth in which the blood vessels grow
toward the center of the eye instead of following their normal
growth pattern along the surface of the retina. When a certain
degree of Stage 3 is present and when "plus disease"
develops, treatment is considered. "Plus disease" indicates
that the blood vessels of the retina have become enlarged and
twisted. This is an indication of worsening of the disease. Plus
disease can occur with almost any stage and its presence alone
is not sufficient to require treatment.
Stage 4 involves a partial detachment
of the retina. Stage 4A indicates that the macula is still attached.
No surgery is generally required for these cases. Stage 4B indicates
that the macula is detached and surgery is suggested in some
cases.
Stage 5 involves a complete
detachment of the retina and these cases should not be operated
on. The decision against surgery in stage 5 babies is based on
Dr. Charles' vast experience with these in a 23 year study of
over 1300 cases.
Q: What happens if the ROP does not go
away?
A: Most of the time, Stages
1, 2, and even some Stage 3 cases may go away without treatment.
In a small number of babies, for reasons not well understood
as yet, ROP worsens and can develop into a sight-threatening
condition. This occurs only about 10% of the time, in which case
treatment is usually recommended by the doctor.
Q: What treatments are there for ROP?
A: Starting in the late 1980's,
treatments became available for ROP. The first treatments for
ROP were "cryotherapy" or freezing treatments. A freezing
probe was held onto the outside of the eye to freeze the peripheral
retina (side of the retina). This caused the ROP to go away in
many cases, and reduced the chances of retinal detachments and
blindness by about 50% as compared to babies who had no treatment.
Not all babies responded favorably to this treatment.
More recently, lasers have been
used for treatment of ROP, which appears to work better, but
not all babies respond to this treatment either. Laser treatment
is less painful, and causes fewer problems than the freezing
treatments, but both treatments are accepted, and are still in
use today.
Our treatment of choice is laser.
The purpose of the treatment is to create scar tissue on the
peripheral retina. This has been shown to eliminate ROP progression
in many cases. The treated part of the retina will be scarred
and will no longer work. The goal of the treatments is to save
as much as possible of the central retina, where the best vision
is located. Some of the peripheral retina and, therefore, some
of the side vision will likely be lost after these treatments.
It is important to keep in mind that the central retina, where
the reading vision, straight ahead vision, and most of the color
vision are located, is the most important part of the retina
to save.
Q: How is the laser treatment done?
A: The laser treatment can be
performed with the baby in the crib in the neonatal intensive
care unit (NICU). The baby may be given medication to make it
sleepy and comfortable. The baby's heart rate and breathing is
monitored during the entire procedure. The laser beam is directed
through the pupil to treat the side part of the retina. The procedure
is similar to the examination with the addition of laser. The
treatment usually takes 30-45 minutes per eye. Afterwards, the
baby's eye may be red, and the eyelids may be red and a little
swollen. Eyedrops are used for about one week. The redness and
swelling usually goes away in a few days but may take a few weeks
to completely disappear. A follow-up exam is usually performed
2-3 weeks after the laser treatment.
Q: What complications are there?
A: Not all babies respond to
the treatment, and the ROP may continue to worsen. Further treatments
may be offered, either by more laser or, in some cases, surgery
inside the eye. Bleeding inside the eye (vitreous hemorrhage),
which is a potential complication of ROP, may occasionally follow
the laser treatment. Vitreous hemorrhages do not cause damage
to the eye, and usually clear up after several weeks. Scar tissue
inside the eye, resulting from the disease process and/or treatment,
may cause pulling on the retina that can lead to distortion or
even detachments of the retina. Cataracts may form. Rarely, the
baby may get tired during the treatment and have to be aided
with a ventilator to breathe more easily. This is temporary,
and as soon as the baby recovers the ventilator is removed.
Q: What happens if the laser treatment
does not work?
A: The biggest concern, if the
ROP laser treatments do not work to halt the scar tissue growth,
is the development of retinal detachment.
Often, only part of the retina
detaches. If only the peripheral retina detaches, no further
treatments should be performed, since these peripheral detachments
may remain the same or go away without treatment.
If the center part of the retina
or the entire retina detaches, then surgery is recommended to
try to reattach the retina. This surgery involves removing the
scar tissue inside the eye to help the retina to reattach.
Surgery is not recommended for
distortion of the retina or for scar tissue that is not causing
a detachment affecting the central vision. These cases are referred
to as Stage 4A if the macula is not detached. Cases in which
the center of the retina becomes detached are referred to as
Stage 4B. Many Stage 4B cases have a thin fold through the macula
and do not need surgery. Some Stage 4B cases that do not have
a thin fold through the macula may benefit from surgery.
Q: What has to be done for the baby after
the laser treatments are performed?
A: Eye drops are used for about
1 week. No further eye medications are usually required. Surgery
inside the eye requires other medication regimens that depend
on the type of surgery and on the individual surgeon.
Q: What is the follow-up care after laser
treatments?
A: Usually the eyes are examined
after 2-3 weeks to see if they have responded to the treatment.
If the eyes have responded to the laser treatment, no further
treatments are required. The eyes may be examined at intervals
of 4 weeks and then several months later to ensure that no further
changes are occurring. If the eyes did not respond, further treatments
might be suggested. These might include more laser or possibly
surgery. It is important to keep in mind that any baby who has
had ROP may develop retinal detachments later in life also. This
is more likely if any scar tissue is present. Routine eye exams
should be continued at regular intervals, usually yearly.
Q: What is the long-term care?
A: Any premature baby, whether
it has had ROP or not, has a higher chance of being nearsighted
or farsighted, or of having "strabismus", which means
that the eyes turn in or out. Eyes with strabismus may develop
amblyopia, also called lazy eye.
Some of these problems can be
corrected with glasses. Even a very small baby may require glasses.
If it needs glasses it is important that these be obtained, so
that the visual part of the brain develops normally.
In general, any premature baby
should be taken to a pediatric eye doctor, to possibly fit for
glasses and to make sure that the eyes are straight, at about
4 months after the baby's due date. If glasses do not straighten
the eyes, surgery on the eye muscles may be considered. It is
important for the eyes to be straight during the early development
periods so that normal growth of the visual part of the brain
can occur and the best vision can be achieved.
Many premature babies have limited
vision for reasons other than ROP. Limited brain development
or damage to the brain from other causes can limit vision.
ROP, even if it becomes inactive
and does not require treatment, can leave scar tissue inside
the eye. This scar tissue can cause some problems, including
pulling (traction) on the retina, which could result in a distorted
retina or even a detachment of the retina.
Q: Does oxygen administered to babies cause
ROP?
A: This is a complicated question
that does not have a definite answer yet. A number of studies
are being undertaken to evaluate the possible association of
oxygen and ROP. It was thought at one time that too much oxygen
caused ROP. However, many very premature babies would not survive
or would be retarded without oxygen. Now there are many advances
in neonatal medicine which help immature lungs develop and work
better, so less oxygen can be used for the premature babies.
It is also thought that not enough oxygen could cause ROP. The
answer is probably that a combination of factors, all of which
are not yet understood, and oxygen being only one factor, cause
ROP. These days, neonatalogists are trained to not use excessive
oxygen, and chances are that with better understanding of ROP
in the future, we will reduce the number of babies with this
problem.
Q: Do neonatal intensive care unit (NICU)
lights worsen ROP?
A: Studies have shown no correlation
between light exposure and the development of ROP. At present
there does not seem to be a connection.
Q: Do vitamins help ROP?
A: Several years ago, studies
were done showing that large doses of vitamin E reduced the chances
of worsening ROP. However, babies who received large doses of
Vitamin E had many more medical problems, some of which were
life-threatening. Thus, vitamin therapy is not currently recommended
for ROP.
If you have
any further questions about the service provided by Central Florida
Retina Institute or if you would like to make an appointment,
please call (863) 682-7474 or call toll-free at 877-245-2020.
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