Fig. 4.38  High myopia vs. ROP stage (Courtesy of

V. Dobson)

EYES WITH HIGH MYOPIA:

STAGE 1,2, OR 3 ROP, ZONE 2

surgical intervention may be best postponed until the early, variable period closes after 1 year.

Cataract and glaucoma are much less frequent (Fig. 4.39). They can occur as a complication of the disease or the treatment. Mild ROP has a negligible incidence. Even serious ROP has a low incidence. However, the worst disease i.e., stage 5 ROP has such a dramatically altered physiology that these are much more common, as is phthisis, the most extreme complication. Management of cataract will be dependent on visual potential or secondary benefit. Management of glaucoma will also depend on visual potential but also the potential need to mitigate pain or disfigurement. The particular approach will depend on which form of glaucoma supervenes [157].

The management of visual impairment from ROP or indirect neurologic problems is the final component of mitigating the disability with which some of these infants must contend. It is not enough to manage the ocular concerns. The ophthalmologist must be a patient advocate in this circumstance. He or she is often uniquely situated to arrange referrals to low vision specialists, early intervention programs, social service agencies, and support groups. And education and reassuring support is a role that should not be underestimated

It is readily apparent that the ROP story does not end with acute ROP. Regression of serious ROP, whether posttreatment or natural, is followed by many potential medical problems. This is truly a disease for life. Longterm vigilance is necessary to minimize complications and maximize function [158, 159].

retinas as screening. There is now zero tolerance for any pretreatment error in disease management. Treatment and posttreatment care does not have the same liability risk attached to it. Why? Because treatment properly provided in a timely manner can still result in a poor outcome. This is true of most of medical treatment. Natural treatment response is a mix of good and bad outcomes independent of the quality of care. But unlike almost every other disease, the failure to detect treatable ROP associated with an unfavorable outcome is both grossly obvious to all and completely unforgiven. It is therefore possible to maintain that involvement in ROP “screening” imparts a level of liability unmatched in any other disease. Couple this with a time-consuming, unprofitable, and relatively thankless job performed by a relatively small number of appropriately trained and experienced examiners and one has the making of a potential crisis in access to care.

It is not malpractice actions alone that are responsible for this. Such actions can have at least a potential positive impact by illuminating problem areas that can be successfully addressed. The true inherent problem is elevating a screening process to a standard demanding 100% accuracy in eliminating false negatives or compliance deficiencies. Such a standard simply cannot be achieved. However, one cannot simply bemoan

Table 4.10  Neonatology/pediatric ROP screening lessons

No infant can be allowed to “fall through the cracks.” Eligible infants must be referred

Appropriate referral is the responsibility of the admitting nursery, the transferring nursery, the receiving nursery, the discharging staff, and the receiving pediatricians, as well as the parents themselves

No care giver should provide care for these infants or accept such infants into their practice unless they are familiar with the ROP screening eligibility requirements. Ignorance of these by ordinary pediatricians who accept such at risk infants is no excuse or defense

Assuming appropriate knowledge is present and appropriate actions are taken, proper documentation of that knowledge and effort is critical. Knowing a baby needs an exam and informing a parent of this is little defense without solid documentation

Parents must be appropriately informed of the necessary actions and potential consequences

Recognize that human error can occur. Develop a system that includes all parties and various checks and balances to insure proper tracking and referral. Eliminate sources of human error when possible by the use of such a systems approach

Table 4.11  Ophthalmology ROP screening lessons

The duties of all involved parties should be clear

The examining ophthalmologist should not be responsible for ensuring initial outpatient appointments

The ophthalmologist is responsible for ensuring outpatient visits subsequent to the initial visit

Ophthalmologists should participate in a screening eligibility protocol which should be present in every nursery

Residents can participate in ROP care only under appropriate supervision

Examiner error occurs. Ophthalmologists should keep this in mind and prudently reexamine if elements of the case seem atypical

Zone III ROP cannot be routinely considered safe. If preexisting zone II ROP was present, reexamination is prudent

Examining ophthalmologists must be familiar and current with normal and abnormal retinal development, classification and nomenclature of ROP, and document and act accordingly

this fact. Appropriate analysis can suggest ways to minimize screening program failures.

Reynolds analyzed a national series of ROP malpractice cases [40]. He found a limited number of repetitive errors that produced malpractice negligence. This analysis led to the suggestions for screening programs as follows in Tables 4.10 and 4.11. These lessons from malpractice actions cannot eliminate inherent screening error, but can go a long way in reducing them and defending them.

4.14  Conclusion

This chapter has presented a snapshot of our current level of knowledge and care of ROP. From history through classification, incidence, natural history, pathogenesis, screening, management, and medico legal concerns, a picture of the disease as a whole has been built. No section is meant to be exhaustive. That would require its own complete text. Each section is its own overview and can serve as a springboard for further inquiry or as a ready reference, especially utilizing the tabular material. Clearly there is author bias in selecting the approach, the facts utilized, and the choice of presentations. As a frequent author on ROP, I like to end where we began, with Dr. Terry. His plea for further investigation into the “cause and full nature” of ROP still echoes across 65 years [7].

Acknowledgement  Supported by an unrestricted award from Research to Prevent Blindness, New York, NY.

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