Retinopathy of Prematurity

Aka: Retinopathy of Prematurity

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II. Pathophysiology

  1. Retinal vessels develop over a long period of time
    1. Onset at 22 weeks
    2. Starts from Optic Nerve and slowly vascularizes
  2. Vessels are very reactive
    1. Increased carbon dioxide leads to vasodilation
    2. Increased oxygen exposure leads to Vasoconstriction
      1. Results in tissue necrosis
      2. Retrolental fibroplasia
      3. Results in vessel proliferation

III. Risk Factors

  1. Very Premature Infants are at high risk (Gestational Age <=30 weeks or birth weight <1500 g)
    1. Difficult to prevent Retinopathy
    2. Retinopathy of Prematurity occurs in 95% at 25 weeks
  2. Moderately Premature Infants (>30 weeks or birth weight 1500 to 2000 g)
    1. Retinopathy may occur if risk factors present (e.g. Supplemental Oxygen)
  3. Risk is very low for older Gestational Ages (unless hyperoxia)

IV. Anatomy

  1. Zone 1
    1. Circumferential around Optic Nerve area
    2. Zone 1 changes are predictive of severe Retinopathy
  2. Zone 2
    1. Middle region
  3. Zone 3
    1. Peripheral circumference on Retina

V. Exam: Indications for Dilated Eye Exam by Ophthalmology

  1. Infant birth weight <1500g (or Gestational Age <30 weeks)
    1. Perform initial dilated Eye Exam in NICU or by 5 weeks of age
  2. Infant birth weight 1500 to 2000g (Gestational Age 30 to 36 weeks) AND prolonged Supplemental Oxygen
    1. Perform initial dilated Eye Exam in NICU or by 5-8 weeks of age

VI. Signs

  1. Dilated Eye Exam performed by experienced Ophthalmologist
  2. Dilate eyes 30 minutes before exam
    1. Cyclomydril 1 drop each eye
    2. Apply drop twice, 5 minutes apart
  3. Funduscopic Staging of Retinopathy
    1. Stage 1: Demarcation Line
    2. Stage 2: Ridge
    3. Stage 3: Extraretinal fibrovascular proliferation
    4. Stage 4: Retinal Detachment

VII. Associated Conditions

  1. Strabismus
  2. Refractive Error
  3. Cortical-Visual Impairment

VIII. Management

  1. Prevent premature births
  2. Prevent Hyperoxia
  3. Eye Exams every 1-2 weeks (assess for Stage 3)
  4. Laser ablation (or Cryotherapy) indications
    1. Stage 3 Retinopathy of Prematurity
    2. Prevents vessel proliferation and progression

IX. Prognosis

  1. Infant >38 weeks (corrected) without Retinopathy
    1. Will not develop Retinopathy of Prematurity
  2. Future Risks
    1. Strabismus
    2. Myopia
    3. Retinal Detachment

X. References

  1. Bybel (2025) Am Fam Physician 112(2): 153-61 [PubMed]

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