Impact of improved neonatal care on the profile of retinopathy of prematurity in rural neonatal centers in India over a 4-year period

Figures & data

Table 1 Demographics of the study zone

Parameter	Value
Zone	North Karnataka
Number of districts	Six
Number of neonatal intensive care units (NICUs)	17 (six public and eleven private NICUs)
Total babies screened	4,167 babies (2,172 public and 1,995 private)
Study period	January 2011 to July 2015
Imaging sessions	11,390
Images	158,406

Table 2 Birth weight and gestational age distribution of the study cohort

Parameter	Value
Number of babies	4,167
Sex distribution (M:F)	2,292:1,875
Birth weight distribution (N, % of total)
≤1,000 g	175 (4.2)
1,001–1,500 g	1,683 (40.4)
1,501–1,750 g	1,009 (24.2)
1,751–2,000 g	867 (20.8)
22652,001 g	433 (10.4)
Gestational age distribution (N, % of total)
≤30 weeks	1,179 (28.3)
31–32 weeks	979 (23.5)
33–34 weeks	1,042 (25.0)
≥35 weeks	967 (23.2)

Abbreviations: M, male; F, female.

Table 3 ROP distribution in the study cohort

Parameter	Value, N (%)
No ROP	3,146 (75.5)
Any stage ROP	1,021 (24.5)
Treatment-requiring ROP	185 (4.4)
Stage of ROP distribution (n=1,021)	N (% proportion of disease)
Stage 1	401 (39.3)
Stage 2	435 (42.6)
Stage 2 with Plus	21 (2.1)
Stage 3	132 (12.9)
Stage 4	0 (0)
Stage 5	0 (0)
APROP	32 (3.1)

Abbreviations: ROP, retinopathy of prematurity; APROP, aggressive posterior ROP.

Table 4 ROP distribution compared during the two study periods

Parameter	2011–2013	2013–2015	Total/P-value
Number of babies screened	1,825	2,342	4,167/P<0.001
Number of imaging sessions	5,566	5,824	11,390
Number of babies with any stage ROP	489 (26.8%)	525 (22.4%)	P<0.001
Incidence of type 2 ROP	388 (79.3%)	441 (84%)
Number of babies requiring treatment	101 (20.7%)	84 (16%)	P=0.06
Number of babies with APROP	21 (20.8%)	11 (13.1%)	P=0.23

Abbreviations: ROP, retinopathy of prematurity; APROP, aggressive posterior ROP.

Figure 1 The graph depicts the trend of decline in the disease profile over the first 2 years and the latter 2-year period following the introduction of better neonatal care practices.

Notes: There was a decline in the incidence of any stage ROP, treatment-requiring ROP, and APROP but only the first category was statistically significant.
Abbreviations: ROP, retinopathy of prematurity; APROP, aggressive posterior ROP.

Figure 2 Left eye of a female infant born at 33 weeks weighing 1,750 g in a private rural neonatal center showing aggressive posterior retinopathy of prematurity with neovascularization in zone 1 (blue arrows), severe plus disease, and closed capillary loops.

Figure 3 Left eye of a male infant born at 32 weeks weighing 1,300 g in a rural center showing occluded and closed loops of vessels abruptly stopping in posterior zone 1.

Note: The anterior extent of these loops ends before the temporal border of zone 1 (blue arrows).

Figure 4 Left eye of a female infant born at 32 weeks weighing 1,400 g shows aggressive posterior ROP.

Notes: There are capillaries only in the posterior pole (blue arrows). The anterior extensions of the dilated vasculature beyond contain ischemic, “bald” capillary devoid zones (blue asterisks) and extend into zone 2.
Abbreviation: ROP, retinopathy of prematurity.

Figure 5 (A) Left eye nasal quadrant of a male baby born at 33 weeks weighing 1,500 g shows ischemic loops enclosing areas of capillary drop out extending until the anterior edge of zone 2. (B) The angiogram on the same eye confirms the capillary non-perfusion within these loops. Leaking neovascularization adjacent to the optic disc is also noted.

Table 5 Incidence of ROP in upper and lower middle-income countries

Country	Study	Period	Number of NICUs	Number of babies	Severe ROP incidence (%)
Upper middle-income countries
Argentina	Tavosnanska^Citation12	2008–2010	1	1,169	13
Brazil	Zin et al^Citation13	2004–2006	7	3,437	3.4
People’s Republic of China	Li et al^Citation14	2009–2010	1	2,185	1.3
Colombia	Zuluaga et al^Citation15	2001–2005	1	1,138	8.0
Iran	Saeidi et al^Citation16	2005–2006	1	45	8.5
Lithuania	Jakuskiene et al^Citation17	2003–2005	1	338	4.2
Romania	Vătavu et al^Citation18	2002–2007	1	1,783	15.2
Serbia	Knezevic et al^Citation19	2006–2009	1	478	21.3
South Africa	Delport et al^Citation20	1999	1	94	4.3
Turkey	Akkoyun et al^Citation21	2002–2004	1	88	29.5
Lower middle-income countries
India	Charan et al^Citation22	1993	1	165	12.8
India	Gopal et al^Citation23	1992–1994	1	50	16.0
India	Vinekar et al^Citation24	1993–2003	1	138	44.9
India	Varughese et al^Citation25	1999–2000	1	79	6.3
India	Jalali et al^Citation26	1999–2002	2	1,083	11.0
India	Hungi et al^Citation27	2008–2010	1	118	10.2
Pakistan	Taqui et al^Citation28	2003–2006	1	68	20.6
Vietnam	Phan et al^Citation29	2001	1	225	9.3
Bangladesh (low income)	Ahmed et al^Citation30	1998–2003	1	114	4.4

Abbreviations: ROP, retinopathy of prematurity; NICUs, neonatal intensive care units.

TavosnanskaJMorbimortalidad de recién nacidos con menos de 1500 gramos asistidos en hospitales públicos de la ciudad de Buenos Aires. [Mortality and morbidity of very low birth weight newborn infants assisted in Buenos Aires public hospitals]Arch Argent Pediatr20121105394403 Spanish23070181

 PubMed Web of Science ®Google Scholar

ZinAAMoreiraMELBunceCDarlowBAGilbertCERetinopathy of prematurity in 7 neonatal units in Rio de Janeiro: screening criteria and workload implicationsPediatrics20101262e410e41720660549

 PubMed Web of Science ®Google Scholar

LiQWangZLiYRetinopathy of prematurity screening in 2185 premature infantsZhonghua Yan Ke Za Zhi2012481090390723302245

 PubMedGoogle Scholar

ZuluagaCLlanosGTorresJEffects of the screening program on ROP in Cali, ColumbiaActa Med Litu2006133176178

 Google Scholar

SaeidiRAhmadHAhmadiSRahmaniSPrevalence and predisposing factors of ROP in very low-birth-weight infants discharged from NICUIran J Pediatr20091915963

 Web of Science ®Google Scholar

JakuskieneRVollmerBSaferisVDaugelieneDNeonatal outcomes of very preterm infants admitted to a tertiary center in Lithuania between the years 2003 and 2005Eur J Pediatr2011170101293130321404102

 PubMed Web of Science ®Google Scholar

VǎtavuINascutzyCCiomârtanTBrezanFAncaIStoicescuSRetinopathy of prematurity–screening resultsOftalmologia2010541110117

 Google Scholar

KnezevicSStojanovicNOrosASavicDSimovicAKnezeviJAnalysis of risk factors in the development of retinopathy of prematuritySrp Arh Celok Lek20111397–843343821980650

 PubMed Web of Science ®Google Scholar

DelportSDSwanepoelJCOdendaalPJLRouxPIncidence of retinopathy of prematurity in very-low-birth-weight infants born at Kalafong Hospital, PretoriaS Afr Med J2002921298699012561416

 PubMed Web of Science ®Google Scholar

AkkoyunIOtoSYilmazGRisk factors in the development of mild and severe retinopathy of prematurityJ AAPOS200610544945317070481

 PubMed Web of Science ®Google Scholar

CharanRDograMRGuptaANarangAThe incidence of retinopathy of prematurity in a neonatal care unitIndian J Ophthalmol19954331231268822486

 PubMedGoogle Scholar

GopalLSharmaTRamachandranSShanmugasundaramRAshaVRetinopathy of prematurity: a studyIndian J Ophthalmol199543259618818311

 PubMedGoogle Scholar

VinekarADograMRSangtamTNarangAGuptaARetinopathy of prematurity in Asian Indian babies weighing greater than 1250 grams at birth: ten year data from a tertiary care center in a developing countryIndian J Ophthalmol200755533133617699940

 PubMedGoogle Scholar

VarugheseSJainSGuptaNSinghSTyagiVPuliyelJMMagnitude of the problem of retinopathy of prematurity. Experience in a large maternity unit with a medium size level-3 nurseryIndian J Ophthalmol200149318718815887728

 PubMedGoogle Scholar

JalaliSMataliaJHussainAAnandRModification of screening criteria for retinopathy of prematurity in India and other middle-income countriesAm J Ophthalmol2006141596696816678524

 PubMed Web of Science ®Google Scholar

HungiBVinekarADattiNRetinopathy of prematurity in a rural neonatal intensive care unit in south India-a prospective studyIndian J Pediatr201279791191522359197

 PubMed Web of Science ®Google Scholar

TaquiAMSyedRChaudhryTAAhmadKSalatMSRetinopathy of prematurity: frequency and risk factors in a tertiary care hospital in Karachi, PakistanJ Pak Med Assoc200858418619018655427

 PubMedGoogle Scholar

PhanMHNguyenPNReynoldsJDIncidence and severity of retinopathy of prematurity in Vietnam, a developing middle-income countryJ Pediatr Ophthalmol Strabismus200340420821212908532

 PubMed Web of Science ®Google Scholar

AhmedASMuslimaHAnwarKSRetinopathy of prematurity in Bangladeshi neonatesJ Trop Pediatr200854533333918503093

 PubMed Web of Science ®Google Scholar