Screening of Premature Infants for Retinopathy of Prematurity

Publication Date: November 30, 2018
Last Updated: March 14, 2022


  1. All infants with a birth weight of ≤1500 g or a gestational age of 30 weeks or less (as defined by the attending neonatologist) and selected infants with a birth weight between 1500 and 2000 g or a gestational age of 30 weeks who are believed by their attending pediatrician or neonatologist to be at risk for ROP (such as 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) should be screened for ROP. Retinal screening examinations should be performed after pupillary dilation by using binocular indirect ophthalmoscopy with a lid speculum and scleral depression (as needed) to detect ROP. Dilating drops should be sufficient to allow adequate examination of the fundi, but care should be taken in using multiple drops if the pupil fails to dilate because poor pupillary dilation can occur in advanced ROP, and administering multiple doses of dilating drops can adversely affect the cardiorespiratory and gastrointestinal status of the infant. Separate sterile instruments or instruments cleaned in accord with the anti-infective protocol for metal instruments for each NICU should be used to examine each infant to avoid possible cross contamination by infectious agents. One examination is sufficient only if it unequivocally reveals the retina to be fully vascularized in both eyes. Effort should be made to minimize the discomfort and systemic effect of this examination. In recent literature, authors suggest that a carefully organized program of remotely interpreted wide-angle fundus camera ROP screening may initially be used in place of binocular indirect ophthalmoscope examinations up to the point at which treatment of ROP is believed to be indicated; at this point, indirect ophthalmoscopy is required. This possibility is further discussed in recommendation 6.
  2. Retinal examinations in preterm infants should be performed by an ophthalmologist who has sufficient knowledge and experience to accurately identify the location and sequential retinal changes of ROP. The International Classification of Retinopathy of Prematurity Revisited (ICROP)10 should be used to classify, diagram, and record these retinal findings at the time of examination. The initiation of acute-phase ROP screening should be based on the infant’s postmenstrual age because the onset of serious ROP correlates better with postmenstrual age (gestational age at birth plus chronologic age) than with postnatal age. That is, the more preterm an infant is at birth, the longer the time to develop serious ROP. This knowledge has been used previously in developing a screening schedule. Although there is little evidence that initiating earlier screening is beneficial, some practitioners have advocated for earlier screening on the basis of speculation that treatable aggressive posterior retinopathy of prematurity (AP-ROP) (a severe form of ROP that is characterized by rapid progression to advanced stages in posterior ROP) could occur before 31 weeks’ postmenstrual age. Because there is no significant body of evidence to support either practice, each practitioner and NICU will have to rely on clinical judgment as to the initiation of screening in preterm infants of 22 and 23 weeks’ gestational age.
  3. Authors of recent reports of neonatal algorithms, such as WINROP, Co-ROP, and CHOP-ROP, take factors into account other than birth weight, postmenstrual age, or gestational age. These factors include rapid postnatal weight gain and may be helpful in selecting infants at risk for ROP who should be screened and in eliminating some infants from the need for screening despite their meeting the previously mentioned screening criteria. Substitution of these algorithms for the screening measures described in this article is not justified by current literature, and it is not clear that these criteria apply to international populations.
  4. Follow-up examinations should be recommended by the examining ophthalmologist on the basis of retinal findings classified according to the “International classification of retinopathy of prematurity revisited.”



Screening of Premature Infants for Retinopathy of Prematurity

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