Preterm infants at risk of severe retinopathy of prematurity (ROP) defined by national guidelines and their parents
User group
Healthcare professionals, eye units, neonatal units, hospitals, and health services
Statement of standard
Programmes for preventive measures such as control of oxygen supplementation and promotion of optimal nutrition are established as well as screening programmes for detection, documentation, and treatment of sight threatening retinopathy of prematurity (ROP) in all units caring for very preterm infants.
Rationale
The goal is to prevent visual impairment and blindness due to retinopathy of prematurity (ROP), which is a major cause of childhood blindness and mainly affects extremely preterm infants. (1,2)Uncontrolled oxygen supplementation and poor neonatal monitoring are important factors contributing to increased ROP risk, even in more mature infants. (3)
Hospitals caring for very preterm infants need programmes promoting adherence to oxygen saturation targets and avoidance of hyperoxia, through implementation of appropriate alarm levels, education of healthcare professionals, oxygen titration guidelines, and sufficient number of skilled attendants. Automated oxygen control can improve SpO2 targeting and may be an alternative. (4) Prevention and management of ROP require close inter-disciplinary collaboration.
Hospitals caring for very preterm infants should adhere to screening and treatment programmes for ROP, based on existing evidence.
These programmes define:
screening inclusion criteria,
timing of eye examination
choice of dilating drops and information on how to avoid systemic absorption
pain and stress control at screening examinations (5)
indication for treatment
anaesthesia/analgesia during laser treatment (5)
follow-up of treated infants following appropriate protocols based on the treatment
Currently, most hospitals adhere to the US recommendations for screening (6) and for treatment, the recommendations of the Early Treatment for Retinopathy of Prematurity Group (7) are followed in many countries.
Benefits
Short-term benefits
Reduced occurrence of severe retinopathy of prematurity (ROP) needing treatment (8–10)
Improved identification of infants needing treatment for ROP (6)
Increased percentage of infants treated timely (6,11)
Reduced stress for parents (12)
Long-term benefits
Reduced occurrence of visual impairment and blindness caused by ROP (8–10)
Components of the standard
Component
Grading of evidence
Indicator of meeting the standard
For parents and family
Parents are informed by healthcare professionals about retinopathy of prematurity (ROP), screening, treatment, and outcomes including the importance of provision of mother’s own milk for the prevention of ROP (see Care procedures). (12, 13)
A (Low quality) B (High quality)
Patient information sheet1
For healthcare professionals
Available guidelines on prevention and management of ROP are adhered to by all involved healthcare professionals.
B (High quality)
Guideline
Training on oxygen saturation targets is attended by all responsible healthcare professionals. (13)
A (High quality) B (High quality)
Training documentation
For neonatal unit
Unit guidelines on prevention of ROP are available and regularly updated. (6,7,13)
A (High quality) B (High quality)
Guideline
Unit guidelines for control of oxygen supplementation and promotion of maternal milk feeding are available and regularly updated. (14,15)
A (Moderate quality) B (High quality)
Audit report2, guideline
For eye unit
Guidelines on screening, documentation and management of ROP are available and regularly updated. (2)
A (High quality)
B (High quality)
Guideline
For hospital
Training on prevention and management of ROP is ensured.
B (High quality)
Training documentation
Availability of expert personnel for fail-safe system of ophthalmological screening and treatment is ensured. (6)
A (Moderate quality) B (High quality)
Audit report2
For health service
National guidelines on prevention and management of ROP are available and regularly updated.
B (High quality)
Guideline
Rate of blindness and impaired vision due to ROP is monitored nationally.
B (High quality)
Audit report2
1The indicator ‘patient information sheet’ is an example for written, detailed information, in which digital solutions are included, such as web-based systems, apps, brochures, information leaflets, and booklets.
2The indicator ‘audit report’ can also be defined as a benchmarking report.
Where to go
Further development
Grading of evidence
For parents and family
N/A
For healthcare professionals
Initiate seamless information transfer systems between clinics and hospitals and measures to improve patient adherence to ophthalmological follow-up during screening and after treatment (see Follow-up & continuing care). (16–18)
B (Moderate quality)
For neonatal unit
N/A
For hospital
N/A
For health service
Consider telemedicine support for screening for retinopathy of prematurity ( ROP). (11,19)
A (Moderate quality)
Support research into causes and treatment of ROP. (20)
B (Moderate quality)
Getting started
Initial steps
For parents and family
Parents are verbally informed by healthcare professionals about retinopathy of prematurity (ROP), screening, treatment and outcomes including the importance of provision of maternal milk for the prevention of ROP.
For healthcare professionals
Attend training on prevention and management of ROP.
For neonatal unit
Develop and implement a unit guideline on prevention of ROP.
Develop formalised programmes for education in oxygen saturation targets.
Develop formalised programmes for promotion of mother’s own milk feeding.
For eye unit
Develop and implement a unit guideline for management of ROP.
Develop information material on ROP for parents.
Develop fail-safe systems for the identification of infants at risk of ROP.
Ensure fail safe systems for referral and continuous cover by ophthalmologist.
For hospital
Support healthcare professionals to participate in training on prevention and management of ROP.
Identify pathways for infants with progressive ROP to receive expert assessment and treatment.
For health service
Develop and implement a national guideline on prevention and management of ROP.
Despite the success of retinopathy of prematurity (ROP) screening and treatment much is unknown about the progression and response to treatment.
There is controversy over the precise oxygen saturation targets but current evidence suggests that, whereas ROP is less frequent when saturations are targeted at 85-89%, mortality is increased. Thus, most units maintain targets of 91-95%. (21) However, recent European consensus guidelines recommend a target range of 90-94% with alarm limits set at 89% and 95%. (22) It is important to avoid higher saturations and research is ongoing into whether these targets can be refined further. Most importantly better adherence to saturation targets is associated with lower rates of ROP. (14)
Furthermore, early provision of mother’s own milk is associated with a reduced risk of ROP. (13,23)
If treated at the appropriate stage, vision of infants with severe ROP can be preserved by laser therapy or anti-VEGF therapy where indicated. (20) The long-term safety of anti-VEGF treatment needs further research. (24) If left untreated, severe ROP may lead to irreversible blindness – often in both eyes. (25) Importantly, even less severe ROP affects vision (26) and infants treated for ROP have an increased risk of retinal detachment, myopia, and other complications throughout life. (27,28)
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September 2022 / 2nd edition / previous edition reviewed by Krohne TU / next revision 2025
Recommended citation
EFCNI, Hellström A, Hellström-Westas L et al., European Standards of Care for Newborn Health: Prevention, detection, documentation, and treatment of retinopathy of prematurity (ROP). 2022.
