Twenty-nine infants with advanced ROP were identified from the two referral hospitals and divided into the 5 regions of the country they were born in and referred from to identify the region with the most cases of advanced ROP. Thirty percent of ROP cases were found in the central region of the country while 13% were found in the Western region (Table 2).
Information was extracted from 13 infants. The remaining files of 16 infants from different regions in the country were not obtainable either due to lack of contact information, parents were not reachable by the recorded contact information or lack of information about the hospital where the infant was born.
All patients had one or more pitfall contributing to advanced ROP as follows (Table 3): Failure to follow up by the ophthalmologist was identified in 5 patients. Failure to diagnose by the ophthalmologist due to lack of knowledge or experience was noted in 4 patients. Failure to arrange ophthalmic screening by the neonatologist was identified in 3 patients. Failure to show for follow up appointments due to family negligence was observed in 3 patients. Failure to deliver treatment or refer to higher center for treatment in a timely manner despite correct diagnosis was identified in 2 patients. In one patient, the disease progressed despite timely diagnosis and treatment.
The following presents summaries of all included patients
The neonate was screened at 33 weeks with no ROP seen in both eyes. No follow up appointment was given, and no other ophthalmic examination was found. The child presented to the referral hospital with stage 5 ROP in the right eye and stage 4B ROP in the left eye.
A premature infant was admitted to NICU for 65 days. First screening and first follow-up were done in a timely manner. Follow-up exam at 33- and 34-week postmenstrual age (PMA) revealed poor visualization of both eyes and then no signs of ROP respectively. The ophthalmologist recommended that the child should be assessed by a retina consultant. Two weeks later at 36 weeks, the infant was seen again and showed no signs of ROP in both eyes. There was an undated recommendation to refer the patient to a higher center for further assessment. However, it did not occur for an unknown reason.
One of triplets was admitted suffering from encephalopathy, developmental delay, and asthma. The infant was screened at 36 weeks and documented to have no ROP and no plus disease in both eyes. She was given a 1-week follow up which was not performed. The child was then discharged from the NICU 2 weeks later. No documentation that an appointment was given to the family before discharge. The patient then presented to the referral hospital with Stage 5 ROP in both eyes.
An infant was admitted to the NICU for 7 weeks, mechanically ventilated then on oxygen nasal cannula. She was first screened at 33, 34- and 35-weeks PMA and was found to have no ROP in both eyes. Follow up was given in 2 weeks however, the files showed that the infant was re-examined at 40 weeks and found to have Stage 3 with vitreous hemorrhage in the right eye, and Stage 2 with vitreous opacity in the left eye. The family were given a report and were told to seek care at a tertiary center. She then presented to the referral hospital with bilateral stage 5 ROP.
An infant was admitted to the NICU for 5 weeks. An ophthalmic exam has been ordered but was never performed. The infant was referred for to a general hospital for his medical condition and was screened by the ophthalmologist at 37 weeks PMA and found to have Stage 5 ROP in both eyes. The child was sent to the referral hospital for further management.
An infant was admitted to the NICU for 14 weeks. The infant was on continuous positive airway pressure and oxygen hood. The infant also had a patent ductus arteriosus (PDA), and a grade I intraventricular hemorrhage (IVH). The first ophthalmic screening was at 34 weeks and was found to have Stage 1 in Zone II in both eyes. Follow-up examinations at weeks 36 and 38 weeks revealed the same findings. Examination at 40 weeks revealed Stage 3 in Zone II with plus disease. The infant was treated with laser indirect ophthalmoscopy in both eyes twice over a 2-week period. The infant was discharged from the NICU at 44 weeks. Examination at discharge revealed in the a flat retina with blood vessels bridging anteriorly in the right eye, the left eye was poorly dilated with posterior synechia and a tractional retinal detachment involving the macula with a fibrotic band [Stage 4B]. The infant presented to the referral hospital with bilateral Stage 4B.
Premature male infant was admitted to the NICU for 12 weeks. The infant suffered from chronic lung disease and was ventilated for 8 weeks. The infant was screened once for ROP, but the physician failed to document the date and age of the infant at screening. The exam reported no ROP in both eyes with tortuous vessels, the infant was not followed up. The infant then presented to the referral hospital with bilateral Stage 5 disease.
A premature male infant was admitted to the NICU for 12 weeks, required oxygen for 10 weeks. The infant suffered from respiratory distress syndrome (RDS) and IVH. The infant was screened at 31 weeks and found to have bilateral vitreous hemorrhage with poor view to the fundus in both eyes. The family were informed, but the child was unstable to be transferred to an eye center for management, and the hospital did not have the equipment to deliver treatment. Eight weeks later, once the infant was stabilized, he was referred to a tertiary eye center in the region, he was immediately treated with laser indirect ophthalmoscopy in both eyes. The family then pursued a second opinion, and the infant was found to have bilateral retinal detachment. The patient was directed to the referral center and presented with bilateral Stage 4B ROP.
A premature infant was admitted to the NICU for 52 days, suffered from RDS, pulmonary hemorrhage with a collapsed right upper lobe and required oxygen for 6 weeks. The infant was screened at 31 weeks and was suspected to have advanced ROP. The Patient was referred to a higher center for further screening and management, but the parents refused medical advice, signed the legal forms to be discharged against medical advice and were lost to follow-up. The family then presented to the referral center and the infant was found to have Stage 4B in the right eye and Stage 5 in the left eye.
A premature twin was admitted to the NICU for 25 days. The infant suffered from PDA, neonatal jaundice, chronic anemia requiring multiple blood transfusions and pseudomonas eye infection. First ophthalmic screening was at 35 weeks which revealed no ROP and was given a follow-up in 2 weeks. However, the patient was seen 5 weeks later at 40 weeks of gestation due to missed follow-up by the ophthalmologist. The infant was found to have bilateral retinal detachment (Stage 4). The infant presented to the referral center at 41 weeks and was found to have bilateral stage 5 ROP.
A premature infant was admitted to the NICU for 25 days, suffered from sepsis and RDS. First screening was at 35 weeks post-menstrual age which revealed no ROP in both eyes, and a follow-up 2 weeks later was requested but not done by the ophthalmologist. The infant was discharged from the NICU and a follow-up ophthalmology clinic appointment was given. The clinic appointment was missed. Another follow up appointment was arranged at 39 weeks at which the infant was found to have Stage 5 ROP in both eyes. The infant was referred to our specialized tertiary hospital.
A premature infant was admitted to the NICU for 8 weeks. The first ocular exam was at 36 weeks, which revealed no ROP in both eyes and was given follow-up after 2 weeks. The second exam showed the same picture, and a 3rd follow-up 2 weeks later was requested after discharge from NICU but the patient did not show up. The parents sought another opinion by a retinal specialist in a different clinic and the infant’s examination showed bilateral Stage 5 ROP. At 43 weeks the infant presented to the referral center and the diagnosis was confirmed.
A premature twin was admitted to the NICU for 12 weeks. The infant suffered from RDS and required oxygen for 8 weeks. First screening at 33 weeks of gestation, the general ophthalmologist documented a “normal” retinal exam with normal blood vessels, retina and a healthy disc. No follow-up was given, and no other ophthalmic exam was performed. At 42 weeks of gestation, the family brought the infant to our hospital and was found to have bilateral Stage 5 ROP.