Retinopathy of Prematurity
What Is Retinopathy of Prematurity
ROP affects the blood vessels that supply your baby's retina, the light-sensitive layer at the back of the eye. When a baby is born early, these vessels have not finished forming, and abnormal growth can occur that puts vision at risk.
In the womb, blood vessels grow outward from the center of the retina toward its edges, completing this process around the time of full-term birth. When a baby arrives early, this process is interrupted. The retina may not receive proper blood supply, triggering abnormal vessel growth that can cause serious problems.
Abnormal vessels can grow in the wrong direction, leak fluid, or form scar tissue that pulls on the retina. In mild cases, the vessels self-correct as the baby matures. In severe cases, the retina can detach from the back of the eye, which threatens your baby's sight and requires prompt treatment.
The greatest risk factors for ROP are early gestational age and low birth weight. Screening is typically recommended for infants born at or before 30 weeks and 6 days of gestational age, or with a birth weight of 1,250 grams or less. Oxygen therapy in the NICU also plays a role, since fluctuating oxygen levels can stimulate abnormal blood vessel growth.
Some hospitals also screen slightly larger premature infants who had an unstable clinical course. Your neonatologist determines whether your baby meets screening criteria based on gestational age, birth weight, and the medical events during the NICU stay.
Doctors classify ROP using a system that describes where the disease is located and how severe it is. The zone (I through III) describes the location of the disease from the center of the retina outward. The stage (1 through 5) describes severity, with stages 4 and 5 involving partial or total retinal detachment. Doctors also note whether 'plus disease' is present, meaning the blood vessels are dilated and twisted, which signals that ROP is active and progressing rapidly.
Zone I disease, which sits closest to the optic nerve and the area responsible for sharp central vision, is the most serious. Your baby's ophthalmologist records the zone, stage, and plus disease status at every exam so changes over time are tracked carefully.
Screening and Diagnosis
Early detection is the cornerstone of preventing vision loss from ROP. Screening exams are performed according to a schedule based on your baby's gestational age at birth.
The initial eye exam generally occurs at 31 weeks postmenstrual age for babies born at or before 26 weeks and 6 days, or at 4 weeks after birth for babies born at 27 weeks or later. The exam is performed at the bedside in the NICU using a specialized light called an indirect ophthalmoscope, after dilating the pupils with eye drops.
Dilating eye drops are given about an hour before the exam to widen the pupils and allow a clear view of the retina. The ophthalmologist uses a bright light and a small lens to examine the inside of the eye. A small instrument called a scleral depressor may gently press on the eye to bring the outer edges of the retina into view.
The exam is brief but may cause temporary discomfort. NICU nurses use comfort measures such as swaddling, pacifiers, and sucrose drops to help your baby through the procedure. Vital signs are monitored throughout and after the exam.
Follow-up exams are scheduled every one to three weeks, depending on the findings of each visit. Babies with more advanced ROP or disease in zone I need more frequent monitoring. Screening continues until the retinal blood vessels have fully matured and the risk period has passed, which generally occurs by 40 to 45 weeks postmenstrual age.
If the ROP is worsening between visits, exams become more frequent. If the retina is maturing as expected, the interval between exams gradually increases until discharge guidelines are met.
Treatment Options for ROP
Not all ROP requires treatment. Mild cases often resolve on their own as the retinal vessels mature. When treatment is needed, the goal is to stop abnormal vessel growth before it causes permanent damage.
Treatment is recommended when ROP reaches what is called Type 1 disease. This includes zone I with any stage and plus disease, zone I stage 3 without plus disease, or zone II stage 2 or 3 with plus disease. At these thresholds, the risk of retinal detachment is high enough that intervening promptly is essential. Your baby's ophthalmologist will explain exactly where your baby falls within this classification at each visit.
Laser treatment is the established standard of care for ROP. The ophthalmologist applies targeted laser burns to the area of the retina that lacks blood vessels. This reduces the signals that drive abnormal vessel growth. The procedure is performed under sedation or general anesthesia, either in the NICU or in an operating room.
Each session takes approximately 30 to 60 minutes per eye. The eyes may appear swollen and red for a few days afterward. A follow-up exam is scheduled within one to two weeks to confirm the treatment worked and to apply additional laser if any areas need further attention.
Anti-VEGF medications work by blocking the growth factor that triggers abnormal blood vessel development. A small amount of medication is injected directly into the eye. This approach is increasingly used as a first-line option, particularly for aggressive disease in zone I, because it allows normal retinal vessels to continue growing rather than destroying peripheral retinal tissue with laser.
Because the effects of anti-VEGF medication can wear off before the retinal vessels fully mature, recurrence of ROP is possible weeks or months after injection. Extended follow-up after anti-VEGF treatment is essential. Your baby's ophthalmologist will discuss which treatment is most appropriate for your baby's specific situation.
Stages 4 and 5 ROP involve retinal detachment and require surgical intervention. Vitrectomy involves removing the vitreous gel and the scar tissue pulling on the retina. Scleral buckling involves placing a supportive band around the eye to push the wall inward toward the detached retina. Both procedures aim to reattach the retina and preserve as much vision as possible.
Visual outcomes for surgery at these advanced stages are less favorable than for treatment at earlier stages. This is why timely screening and early intervention are so important. Most cases of severe ROP can be prevented from reaching detachment when treatment is provided at the right time.
Long-Term Eye Care After ROP
Whether or not your baby required treatment for ROP, ongoing eye care throughout childhood is an important part of their overall development. Premature infants face higher rates of certain eye conditions compared to full-term babies.
Premature infants are at greater risk for myopia (nearsightedness), strabismus (misaligned eyes), and amblyopia (reduced vision in one eye, sometimes called 'lazy eye') regardless of whether they had ROP. Your child's ophthalmologist monitors visual development at regular follow-up visits and recommends glasses, patching, or other interventions as needed. Children treated with laser or anti-VEGF for severe ROP may also have some reduction in peripheral vision, which the ophthalmologist will assess over time.
Myopia is particularly common in children who had ROP, especially those who required laser treatment. Glasses are prescribed when needed to support clear vision during the years when the visual system is still developing. When there is a significant difference in the prescription between the two eyes, one eye may not develop as well as the other, a condition called amblyopia. Patching the stronger eye or using other treatments during the critical window of visual development gives the best chance of improving vision in the weaker eye.
Children with a history of ROP carry a higher risk of retinal detachment later in life, particularly those with high myopia or residual retinal scarring. Annual dilated eye exams allow the ophthalmologist to monitor the retina and detect any early changes. As your child grows, teach them to report warning signs immediately, including sudden floaters, flashing lights, or a shadow or curtain across their vision.
Protective eyewear during sports and activities that carry a risk of eye injury is also strongly recommended, as a retina affected by ROP may be more vulnerable to detachment from trauma.
Frequently Asked Questions
Here are answers to questions we commonly hear from families navigating an ROP diagnosis, with guidance to help you make informed decisions and know when to act quickly.
Most babies with ROP do not lose their vision. The majority of cases are mild and resolve without treatment as the retinal vessels mature. When treatment is needed and provided at the right time, most babies avoid severe vision loss. Vision loss from ROP typically occurs only when the condition is not detected or treated promptly, which is why consistent screening is so critical during your baby's NICU stay.
Screening eligibility is determined by your baby's neonatologist based on gestational age at birth, birth weight, and the clinical course in the NICU. If your baby meets the criteria and has not yet had a screening exam scheduled, ask your neonatology team directly. Timely scheduling is a parent's right to advocate for, and it is appropriate to ask about it.
Laser treatment destroys the peripheral retinal tissue that lacks blood vessels, removing the signal driving abnormal growth. Anti-VEGF injections block that signal chemically, allowing normal vessels to continue developing. Each approach has advantages depending on where and how severe the ROP is. Anti-VEGF carries a higher risk of recurrence, requiring longer follow-up after treatment. Your baby's ophthalmologist will recommend the approach best suited to your baby's specific findings.
ROP treated with laser very rarely recurs. Anti-VEGF treatment carries a meaningful risk of recurrence because the drug effect may wear off before the retinal vessels finish maturing. After anti-VEGF injection, your baby's ophthalmologist will schedule close follow-up and will retreat promptly if the disease returns. Missing follow-up appointments during this window can be dangerous, so maintaining the exam schedule after treatment is essential.
Not necessarily, but the likelihood of needing glasses is higher for children who were born prematurely, especially those who had ROP treated with laser. Refractive errors like myopia can develop as the child grows, and prescriptions may change during the school years. Regular eye exams throughout childhood allow your child's ophthalmologist to update glasses or other corrections as needed and to catch amblyopia early, when it is most treatable.
As your child grows, watch for signs that they may be struggling to see clearly, such as squinting, sitting very close to screens, or difficulty recognizing faces at a distance. More urgently, teach your child to report flashing lights, new floaters, or any shadow across their vision right away, as these can be early signs of retinal detachment, which is a medical emergency requiring same-day evaluation.
Specialized Pediatric Eye Care at Rhode Island Eye Institute
Our Pediatric Ophthalmologist, Dr. John Donahue, brings fellowship-trained expertise in ROP screening, treatment, and long-term management to every family we care for, and is a Clinical Assistant Professor at Brown University with advanced training from Children's National Medical Center. Rhode Island Eye Institute is proud to support premature infants and their families with the comprehensive, compassionate eye care they deserve from the earliest days of life through childhood and beyond. We welcome you to reach out to our team and let us be part of your child's vision journey.