Indian Journal of Clinical and Experimental Ophthalmology

Print ISSN: 2395-1443

Online ISSN: 2395-1451

CODEN : IJCEKF

Indian Journal of Clinical and Experimental Ophthalmology (IJCEO) is open access, a peer-reviewed medical journal, published quarterly, online, and in print, by the Innovative Education and Scientific Research Foundation (IESRF) since 2015. To fulfill our aim of rapid dissemination of knowledge, we publish articles ‘Ahead of Print’ on acceptance. In addition, the journal allows free access (Open Access) of its content, which is likely to attract more readers and citations of articles more...


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Gour, Shende, Melwani, Singh, and Kumar: Pattern and risk factors of retinopathy of prematurity in tertiary care centre


Introduction

Retinopathy of prematurity is one of the commonest cause of blindness in sick neonates exposed to excessive oxygen following NICU admissions. Retinopathy of prematurity (ROP) also called retrolental fibroplasia is categorized as unique condition as it occurs only in premature infants with incompletely vascularized retinas characterized by retinal ischaemia leading to neovascularization.1 Though occurrence of ROP has been on rise in developed and developing countries, but the clinical profile of ROP is very different among them.2, 3 Also significant variation in the incidence of ROP have been observed even in urban and rural centers of India.4 With the medical and technological advancement, survival of neonates associated with critical illness have increased, thus prevalence of ROP is expected to rise.

In 1942, retrolental fibroplasia was first described by Terry and the oxygen therapy was the only attributed cause associated with this pathology.5 However, with further advancements in research, ROP have been observed even without oxygen therapy and even after oxygen therapy. Also the fact that not all premature infants develop ROP indicate toward other possible risk factors.6 There are various risk factors associated with ROP but three factors have shown consistent and significant association with ROP. These include- low gestational age, low birth weight and prolonged exposure to supplementary oxygen following delivery.7 Other probable risk factors include mechanical ventilation, sepsis, intraventricular hemorrhage, surfactant therapy, anemia, frequent blood transfusions, and apnea.8 The present study was thus conducted to assess the pattern and risk factors associated with incidence of retinopathy of prematurity.

Objectives

  1. To estimate the proportion of ROP at tertiary centre

  2. To study the risk factors associated with ROP

  3. To study the patterns of ROP

Materials and Methods

The present study was conducted as a retrospective record based study at tertiary care centre, Bhopal. Being a tertiary care centre, the services are utilized by population from inside as well as nearby Districts. Thus the study area act as a referral centre for various nearby districts. All the records of babies between 1st July 2017 to 30th May 2020 were screened for ROP. Baseline characteristics as obtained from the records were noted such as mother's name, sex, gestational age, birth weight.Risk factors analyzed in the study included gestational age, birth weight, oxygen supplementation, respiratory distress syndrome (RDS), neonatal hyperbilirubinemia (NNH), multiple pregnancy, congenital heart disease, neonatal sepsis (NNS), birth asphyxia, necrotizing enterocolitis (NEC), hypoglycemia, hypocalcemia, hypothermia and need for mechanical ventillation. The zone and stage of ROP were categorized as per the International classification of ROP9 along with iris neovascularisation and plus disease as per the revised international classification of retinopathy of prematurity (ICROP) preplus disease criteria.10

Statistical analysis

Data was entered in excel sheet and analysed using SPSS software version 20. Data was grouped and their frequency and percentage were calculated.

Observations

Retrospective analysis of eyes of 289 neonates was conducted for presence of retinopathy of prematurity. The mean gestational age of neonates was 32.2±7.2 weeks and mean birth weight was 1.47±0.8 kg. All neonates presented late for screening with mean age at first screening 10.38 weeks (range 6–18 weeks).

Table 1

Distribution according to sociodemographic variables

Sociodemographic variables

Frequency

Percentage

Gestationaage (weeks)

<28

28

9.7

28-31

170

58.8

32-34

74

25.6

>34

17

5.9

Birth weight (kg)

<1

21

7.3

1-1.49

97

33.6

1.5-2

148

51.2

>2

23

7.95

Gender

Male

184

63.7

Female

105

36.3

Majority of neonates belonged to gestational age of 28 to 31 weeks (58.8%) and 51.2% neonates had birthweight of 1.5 to 2 kg. The present study documented 63.7% males and 36.3% females. Thus male preponderance was observed with male: female ratio of 1.75:1. (Table 1)

Out of 289 neonates, avascular retina was observed in 148 (51.2%) whereas ROP was observed in remaining 141 (48.8%). Of them, type I and type II ROP was observed in 27 (19.1%) and 114 (80.9%). Thus the proportions of ROP in present study was documented as 48.8%.

Table 2

Distribution according to risk factor

Risk factor

Total

TYPE I (n=27)

Type II (n=114)

No ROP (n=148)

P value

Gender

Male

184

16 (59.3)

76 (66.7)

92 (62.2)

0.66

Female

105

11 (40.7)

38 (33.3)

56 (37.8)

GA

<28

28

9 (33.3)

7 (6.1)

12 (8.1)

0.001

28 -31

170

5 (18.5)

74 (64.9)

90 (60.8)

32– 34

74

7 (25.9)

29 (25.4)

38 (25.7)

>34

17

6 (22.2)

3 (2.6)

8 (5.4)

Birth weight

<1

21

9 (33.3)

7 (6.1)

5 (3.4)

0.001

1-1.49

97

9 (33.2)

33 (28.9)

55 (37.2)

1.5-2

148

6 (22.2)

68 (59.6)

74 (50)

>2

23

3 (11.1)

4 (3.5)

14 (9.4)

Oxygen supplementation

Yes

72

9 (33.3)

29 (25.4)

34 (23)

0.51

No

217

18 (66.7)

85 (74.6)

114 (77.0)

RDS

Yes

59

2 (7.4)

28 (23.7)

29 (19.6)

0.13

No

230

25 (92.6)

86 (76.3)

119 (80.4)

Hyperbilirubinemia

Yes

74

7 (25.9)

29 (25.4)

38 (25.7)

0.99

No

215

20 (74.1)

85 (74.6)

110 (74.3)

Multiple pregnancy

Yes

70

4 (14.8)

27 (23.7)

39 (26.4)

0.43

No

219

23 (85.2

87 (76.3)

109 (73.6)

CHD

Yes

61

3 (14.8)

29 (25.4)

29 (19.6)

0.21

No

228

24 (85.2)

85 (74.6)

119 (80.4)

Septicaemia

Yes

92

6 (22.2)

31 (27.2)

55 (37.2)

0.12

No

197

21 (77.8)

83 (72.8)

93 (62.8)

Asphaxia

Yes

71

4 (14.8)

32 (28.1)

35 (23.6)

0.33

No

218

23 (85.2

82 (71.9)

113 (76.4)

NEC

Yes

64

4 (14.8

26 (22.8)

34 (23)

0.63

No

225

23 (85.2)

88 (77.2)

114 (77)

Hypoglycemia

Yes

77

4 (14.8)

27 (23.7)

46 (31.1)

0.14

No

212

23 (85.2)

87 (76.3)

102 (68.9)

Hypocalcemia

Yes

81

5 (18.5)

32 (28.1)

44 (29.7)

0.49

No

208

22 (81.5)

82 (71.9)

104 (70.3)

Hypothermia

Yes

102

5 (18.5)

44 (33.6)

53 (35.8)

0.14

No

187

22 (81.5)

70 (61.4)

95 (64.2)

Mechanical ventilation

Yes

64

2 (7.4)

22 (19.3)

40 (27)

0.06

No

225

25 (92.6)

92 (80.7)

108 (73)

Amongst the various risk factors, the occurrence of ROP was highly significantly associated with gestational age and birthweight (p<0.01). (Table 2)

Subgroup analysis revealed that aggressive posterior ROP (APROP) contributed significantly to Type I ROP in 11.1% (3) cases. Also the mean gestational age of neonates with APROP was 30.1 weeks whereas mean birth weight was 1.2 kg. And the observed difference in gestational age and birthweight between APROP and other cases of ROP were statistically highly significant (p<0.01).

Discussion

The present study was conducted with aim to study the proportions of ROP through a retrospective analysis of records. The proportions of ROP in this study was 48.8%, which was comparatively higher as reported by Dwivedi A et al (30%).11 The findings of present study were omparable with studies from various other parts of India which reported an incidence between 42.27-51.89%.12, 13

However, the 11.1% APROP was comparatively less as reported by Dwivedi A et al.11 These findings were similar to study by Hungi B et alwherereported APROP cases were reported to be 13.2% in a rural neonatal intensive care unit.4 The mean gestational age of neonates with APROP was 30.1 weeks whereas mean birth weight was 1.2 kg. These findings were similar to study by Dwivedi A et al in which mean gestational age and birth weight of APROP babies were 30.9 weeks and 1359.9 gm respectively.1 Sanghi et al documented mean gestational age of 29.75 weeks and birth weight of 1259.66 gm. 14

The major risk factors associated with occurrence of ROP in present study were birth weight and gestational age (p<0.01). These findings were in concordance to a study by Dwivedi A et al.11 Jothi S et al alo observed significant association of ROP with gestational age and birthweight similar to present study. Mean birth weight of babies having ROP was 1.34 kg and mean gestational age was 31.56 weeks, which was lower than the babies without ROP. RDS and LBW were the risk factors for development of ROP in mature (>32 weeks) babies.15 Gawai D et al also documented similar findings i.e. highest percentage of retinopathy of prematurity was seen in infants with gestational age < 28 weeks and extremely low birth weight (<1000 g) infants.16

The study has certain limitations, retrospective nature lack of the details regarding Oxygen supplementation i.e., dose and duration of O2 therapy are major limitations.

Conclusion

Based upon the findings of present study, the proportions of ROP are higher among neonates in presence of various prenatal/postnatal risk factors especially low birth weight and neonates with small gestational age. Hence, early and timely screening of ROP for all high risk neonates should be mandatory among neonates and uniform screening protocol must be developed at national level which must be incorporated in National Programs all over India.

Source of Funding

None.

Conflict of Interest

The authors declare no conflict of interest.

References

1 

A Patz Role of oxygen in retrolental fibroplasiaTrans Am Ophthalmolsoc19686694085

2 

C Gilbert J Rahi M Eckstein J O'sullivan A Foster Retinopathy of prematurity in middle-income countriesLancet19973509070124

3 

GE Quinn What do you do about ROP screening in “big” babies?Br J Ophthalmol2002861010723

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B Hungi A Vinekar N Datti P Kariyappa S Braganza S Chinnaiah Retinopathy of prematurity in a rural eonatal Intensive Care Unit in South India--A prospective studyIndian J Pediatr2012799115

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TL Terry Extreme prematurity and fibroblastic overgrowth of persistent vascular sheath behind each crystalline lensAm J Ophthalmol1942252034

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D Chawla R Agarwal A Deorari Retinopathy of prematurityIndian J Pediatr Paul VK. Indian J Pediatr200875736

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T Kim J Sohn YH Yoon Postnatal risk factors of retinopathy of prematurityPaediatr Perinat Epidemiol2004181304

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AH Hakeem GB Mohamed MF Othman Retinopathy of prematurity: a study of prevalence and risk factorsMiddle East AfrJ Ophthalmol2012193289

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Cryotherapy for Retinopathy of PrematurityCooperative group: Multicentre trial of cryotherapy for retinopathy of prematurity: preliminary resultsArch Ophthalmol19881064719

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Committee for the Classification of Retinopathy of Prematurity. An international classification of retinopathy of prematurityArch Ophthalmol1984102811304

11 

A Dwivedi D Dwivedi S Lakhtakia C Chalisgaonkar JS Prevalence Risk factors and pattern of severe retinopathy of prematurity in eastern Madhya PradeshIndian J Ophthalmol20196781923

12 

R Charan MR Dogra A Gupta A Narang The incidence of retinopathy of prematurity in a neonatal care unitIndian J Ophthalmol19954331236

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S Varughese S Jain N Gupta S Singh V Tyagi JM Puliyel Experience in a large maternity unit with a medium size level-3 nurseryIndian J Ophthalmol2001491878

14 

G Sanghi MR Dogra P Das A Vinekar A Gupta S Dutta Aggressive posterior retinopathy of prematurity in Asian Indian babies: Spectrum of disease and outcome after laser treatmentRetina200929913359

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S Jothi H Mangalanathan M Kamatchi V Viswanathan S Karicheri Study of incidence and risk factors of retinopathy of prematurity in tertiary care centreKerala J Ophthalmol2016281236

16 

D Gawai V Une B Khaire Incidence and Risk factors of Retinopathy of Prematurity in Tertiary Care Centre of Western IndiaJ Med Sci Clin Res20164710.18535/jmscr/v4i7.48



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Article type

Original Article


Article page

695-698


Authors Details

Richa Gour, Snehal Shende*, Veena Melwani, Priti Singh, Kavita Kumar


Article History

Received : 17-06-2021

Accepted : 09-08-2021

Available online : 03-01-2022


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