Understanding Retinopathy of Prematurity (ROP)

Retinopathy of prematurity is an eye condition that can affect premature babies while the blood vessels in the retina are still developing. This page is here to help your family understand the diagnosis, how ROP is monitored and treated, and when it may be appropriate to ask whether missed screening or delayed care contributed to vision loss.

What is retinopathy of prematurity?

The retina is the light-sensitive tissue at the back of the eye that sends visual information to the brain. Its blood vessels begin developing during pregnancy and normally continue growing until around a baby’s due date. When a baby is born very early, that development must continue outside the womb.

In retinopathy of prematurity, retinal blood vessels do not develop normally. Abnormal vessels may grow in the wrong direction and can lead to bleeding or scar tissue. In more advanced cases, the scar tissue may pull the retina away from the back of the eye, causing a partial or complete retinal detachment.

Many babies develop only mild ROP, which can improve as the retinal blood vessels mature. Other babies develop diseases that require treatment to protect their vision. ROP does not mean that a provider caused the condition, but timely screening and follow-up are important because the early stages cannot be seen by looking at a baby’s eyes.

Signs and symptoms of retinopathy of prematurity

ROP usually has no visible symptoms while it is developing, which is why at-risk babies need scheduled dilated retinal examinations. If the disease progresses and affects vision, a family may later notice signs such as:

• Eyes that wander, shake, cross, or make other unusual movements
• Difficulty following faces, lights, or objects with the eyes
• A white appearance in one or both pupils
• Difficulty recognizing faces or responding to visual information
• Reduced vision or other signs that a child is not seeing as expected

These signs can have causes other than ROP and may not appear until significant damage has occurred. An ophthalmologist diagnoses and monitors ROP through a dilated examination of the retina, not through symptoms alone.

What causes retinopathy of prematurity?

ROP develops because a premature baby’s retinal blood vessels are still immature at birth. Prematurity and low birth weight are the strongest risk factors, but the condition is multifactorial and cannot always be traced to one event. Factors associated with a higher risk include:

• Birth at an early gestational age, especially before retinal blood vessels have had time to mature
• A very low birth weight
• Respiratory distress, apnea, or a need for prolonged breathing support
• Supplemental oxygen exposure, particularly when oxygen levels are not carefully monitored and managed
• Infection or other serious medical problems affecting the heart, lungs, or brain
• An unstable neonatal course that places added stress on a premature baby

Oxygen can be lifesaving for a premature baby and should not be withheld when it is medically needed. The goal is to monitor oxygen saturation closely and balance the risks of too little oxygen with the risks of excessive exposure. Even with careful neonatal care, some babies still develop ROP.

When retinopathy of prematurity may be a sign of medical malpractice

Not every case of retinopathy of prematurity is the result of medical negligence. ROP can develop because a baby was born very early, and some cases progress despite appropriate screening, monitoring, and treatment. At the same time, medical teams are expected to identify babies who need screening, follow the required examination schedule, communicate findings, and arrange prompt treatment when the disease becomes vision-threatening. When those steps are missed and a child is harmed, a family may have reason to ask whether the vision loss could have been avoided.

The following situations may point to negligence:

• Failing to identify an eligible baby or arrange timely ROP screening
• Using an inexperienced examiner or misclassifying retinal changes
• Failing to schedule repeat exams or ophthalmology follow-up after discharge or transfer
• Delaying treatment or follow-up after laser therapy or anti-VEGF injections
• Failing to properly monitor oxygen levels or manage supplemental oxygen

Determining whether any of this happened in a particular case takes a careful review of the medical records. Wais, Vogelstein, Forman, Koch & Norman, LLC works with medical experts to examine the care a mother and baby received and to help families understand whether it met the standards they had a right to expect.

Treatment and long-term outlook

Treatment depends on the stage and location of the disease, whether the retinal vessels show signs of severe stress known as plus disease, and how quickly the ROP is changing. Mild ROP is often monitored with repeat dilated eye examinations because it may improve without treatment as the retina matures.

When ROP reaches a treatment-requiring level, treatment should be arranged promptly. Laser therapy treats the undeveloped peripheral retina to reduce signals that drive abnormal blood vessel growth. In selected cases, an ophthalmologist may inject an anti-VEGF medicine into the eye to block abnormal vessel growth. Babies treated with an injection need extended follow-up because ROP can reactivate later.

If the retina has partially or completely detached, surgery may be needed. A scleral buckle supports the outside of the eye, while a vitrectomy removes the gel and scar tissue that are pulling on the retina. Surgery may preserve some vision, but advanced retinal detachment can cause lasting visual impairment even when appropriate treatment is provided.

The long-term outlook varies widely. Many babies with mild ROP retain healthy vision, while others may experience nearsightedness, crossed eyes, amblyopia, glaucoma, cataracts, retinal detachment, or vision loss. Children who had ROP should continue to receive eye care after the acute disease resolves so later vision problems can be identified and treated as early as possible.