Retinopathy of Prematurity (ROP) Treatment Program

Retinopathy of Prematurity (ROP) is a serious ophthalmologic condition that affects premature infants, particularly those born with very low birth weights. It involves the abnormal development of retinal blood vessels, which can lead to retinal scarring, detachment, and in severe cases, permanent vision loss or blindness. ROP is one of the leading causes of preventable childhood blindness worldwide and requires timely screening and early intervention to preserve vision.

With significant advancements in neonatal care, more preterm infants are surviving—yet with that comes an increased risk of ROP. Early detection, close monitoring, and specialized treatment are essential for managing this potentially blinding condition.

Why Cuba

In Cuba, Retinopathy of Prematurity (ROP) is managed by paediatric ophthalmologists who are highly experienced in neonatal retinal care. Given the profound impact ROP can have on long-term visual function and neurological development, Cuban medical teams perform rigorous screening and in-depth retinal evaluations to identify at-risk infants early and initiate timely intervention. These assessments ensure that treatment is specifically adapted to the stage and severity of the condition, whether the goal is to halt disease progression or preserve visual potential.

Post-treatment care is carefully structured to monitor retinal development, reduce complications, and support visual maturation. Follow-up protocols are individualized to track progress and make timely adjustments.

Causes of ROP

In a healthy full-term infant, retinal blood vessels develop fully in the final weeks of gestation. In premature babies, especially those born before 31 weeks of gestation or weighing less than 1500 grams, the retinal vasculature is incomplete. After birth, abnormal oxygen levels or systemic instability can trigger disordered vascular proliferation in the retina.

This abnormal vessel growth can lead to fibrous tissue formation and traction, which may pull the retina away from the back of the eye (retinal detachment), a condition that, if left untreated, causes irreversible vision loss.

The exact cause of ROP is multifactorial, involving both systemic and environmental factors:

• Premature birth
• Low birth weight
• Fluctuating oxygen levels in neonatal intensive care
• Mechanical ventilation or oxygen therapy
• Sepsis and other neonatal infections
• Anaemia and poor postnatal growth
• Genetic predisposition and inflammatory markers

Although oxygen therapy is essential for preterm infants, imbalanced oxygen exposure is a known trigger for abnormal retinal vessel growth in susceptible infants.

Symptoms of ROP

If untreated or diagnosed late, ROP can lead to serious and irreversible damage to the eye and vision. Potential consequences include:

• Retinal detachment and scarring
• Amblyopia (lazy eye)
• Strabismus (eye misalignment)
• Refractive errors, such as myopia (nearsightedness)
• Nystagmus, or involuntary eye movement
• Blindness, especially in advanced stages
• Even in mild cases that resolve spontaneously, children may have an increased risk of long-term vision problems, which necessitates regular ophthalmologic monitoring through childhood.

ROP often progresses without visible symptoms in its early stages, which is why routine retinal screening is essential in at-risk infants. In more advanced stages or later life, the following symptoms may emerge:

• Poor visual tracking
• Delayed visual responses
• White pupillary reflex (leukocoria)
• Nystagmus (rapid eye movement)
• Strabismus (misaligned eyes)
• Apparent vision loss or difficulty focusing

Types and Classification of ROP

ROP is classified based on zone (location), stage (severity), and presence of plus disease (vascular dilation and tortuosity):

Zones (anatomical location)

• Zone I: Closest to the optic nerve (most severe)
• Zone II: Intermediate zone
• Zone III: Outermost peripheral retina (least severe)

Stages (severity)

• Stage 1: Mild demarcation line between vascular and avascular retina
• Stage 2: Ridge formation
• Stage 3: Abnormal blood vessel growth (neovascularization)
• Stage 4: Partial retinal detachment
• Stage 5: Total retinal detachment (most severe)

Plus Disease

• Characterized by increased venous dilation and arterial tortuosity, signaling more aggressive disease requiring immediate intervention

Diagnosis of ROP

ROP is diagnosed through a dilated retinal examination using an indirect ophthalmoscope by a trained paediatric ophthalmologist or retina specialist.

Diagnostic procedures may include:

• Fundus photography or digital retinal imaging (e.g., RetCam)
• Fluorescein angiography to evaluate retinal vasculature in selected cases
• Serial monitoring, as the disease can progress rapidly over days or weeks

Screening is typically initiated between 4–6 weeks after birth, depending on gestational age and weight.

Types of Procedures of ROP

ROP treatment includes both minimally invasive therapies and traditional surgical approaches, depending on the stage and progression of the disease.

Surgery may be recommended for:

• ROP progresses to Stage 3 with plus disease
• There is retinal detachment (Stage 4 or 5)
• The disease is not responsive to laser or pharmacologic therapy
• There is a need to preserve visual potential in the affected eye

Surgery may be recommended for:

• The disease is in its early, spontaneously regressing stages
• The infant is medically unstable or not fit for anaesthesia
• Advanced retinal detachment with no visual prognosis is present
• Parents opt for conservative management based on prognosis and co-existing conditions

Treatment procedures for ROP include:

The treatment of Retinopathy of Prematurity depends on the stage, location, and progression of the disease. Early stages may resolve spontaneously with careful monitoring, but threshold or advanced ROP requires prompt intervention to prevent permanent vision loss. In Cuba, ophthalmic specialists use a combination of minimally invasive and traditional surgical techniques, tailored to the individual infant’s condition and overall health.

Laser Photocoagulation (Minimally Invasive)

• Laser photocoagulation remains the gold standard for treating threshold ROP, particularly in preterm infants with disease in Zone II or III and with active neovascularization (Stage 3 with plus disease).
• The procedure involves applying a precise laser beam to the avascular peripheral retina, targeting areas where abnormal blood vessels are forming due to hypoxia. By ablating these ischemic regions, the treatment reduces the stimulus for further abnormal vessel growth and halts disease progression.
• The procedure is performed under local or general anaesthesia, depending on the infant’s age, weight, and medical stability.
• Recovery is typically fast, and although it may reduce peripheral vision, laser therapy is effective in preserving central vision and preventing retinal detachment.

Intravitreal Anti-VEGF Injections (Minimally Invasive)

• Intravitreal injections of anti-VEGF agents (such as bevacizumab or ranibizumab) are used as an alternative or adjunct to laser therapy, especially for Zone I or aggressive posterior ROP, where laser treatment may be less effective or potentially harmful to central vision.
• These medications block vascular endothelial growth factor (VEGF)—a key driver of abnormal vessel proliferation—thereby stabilizing the retina and allowing for more normal vascular development over time.
• The injection is administered in a sterile setting under local or general anaesthesia, using specialized instruments.
• The procedure is minimally invasive and typically well-tolerated, but it may require additional doses or prolonged follow-up due to the possibility of disease reactivation.
• While it spares peripheral retina tissue, unlike laser therapy, long-term safety data is still being studied.

Vitrectomy (Traditional Surgery)

• For advanced stages of ROP—namely Stage 4 and Stage 5, where partial or total retinal detachment has occurred—vitrectomy is the primary surgical option.
• This procedure is more complex and involves the removal of the vitreous gel from the eye and the relief of traction on the retina caused by fibrous tissue.
• The goal is to allow the retina to reattach or remain attached, thereby preserving or restoring whatever vision may still be possible.
• Vitrectomy is performed under general anaesthesia.
• It is considered a traditional surgical technique due to its invasive nature and longer recovery time compared to laser or anti-VEGF treatments. However, it remains a crucial sight-saving procedure for infants with advanced retinal damage and can significantly improve long-term visual outcomes when performed promptly.