The third epidemic of ROP mostly involves middle-income countries, where wider NICU availability is increasingly supporting the survival of infants, but suboptimal care and improper oxygen administration and monitoring are resulting in higher rates of ROP among older and heavier infants [18, 19]. This is especially true in rural settings where higher rates of more severe forms of the disease are reported [20, 21]. In this work, we have attempted to explore the incidence and behavior of ROP in a cohort of Egyptian premature infants within a rural setting, highlighting the sample’s characteristics and challenges in evaluation and management.
The incidence of ROP in our sample (48.19%) is higher than rates reported in studies from other middle income countries like India (Eastern India 33.2% [22], Northern India 26.6% [23], and rural outreach centers 22.39%[24]), Turkey (30% [25] and 27% [26]), South Africa (29.6% [27]), Iran (23.5% [28]), Palestine (23.5% [29]), and Botswana (11% [30]). The incidence of AP-ROP (8.7%) is also beyond the high end of the spectrum of rates reported in the literature that range from 0.11–5% [6]. Both findings reflect on the iceberg burden of ROP in Egypt, the suboptimal quality of maternal and neonatal healthcare in the country’s rural setting, and the dire need for a national prevention program.
The delay in initial screening in our sample (IQR: 29 - 60 days) could have contributed to the higher rate of severe disease. In our setting, the burden of meeting the screening schedule rested solely on the parents. A study in an Indian population [31] reported that the main barriers to early screening consisted of a triad of unavailability of sufficient trained ophthalmologists, lack of awareness among parents and healthcare personnel, and distance from point of care. Another study [32] even reported that, in a rural setting, initiating screening on first contact with the infant in the NICU before the recommended time of conventional screening (21 - 28 days) ensured a better yield of screened infants, better pre-counselling of mothers, and higher rates of enrollment in and compliance to screening schedules. This highlights our setting’s need for more specialized, trained ophthalmologists and for comprehensive awareness campaigns to ensure wider, timely coverage of the screening process.
Four independent studies on ROP incidence in an Egyptian setting exist to date in the literature. Abdel Hakeem et al. [14] and Nassar [16] screened for ROP in a single NICU setting within a university hospital in upper Egypt and found the incidence of the condition to be 19.2% and 36.5%, respectively. Ezz El Din et al. [33] and Hadi et al. [15] examined the incidence in the more urban settings of a Cairo university hospital and 3 Alexandrian private hospitals and found it to be 18.9% and 34.4%, respectively. It is imperative to mention that all the aforementioned studies utilized the lower cutoff GA of 32 weeks and BW of 1500 g (except Hadi et al. [15] who used 1250 g as the cutoff) for screening, and none reported on AP-ROP incidence. Screening cutoffs should be tailored to each setting [8], and it has previously been established that ROP in developing countries could affect older and heavier infants, such that in these settings it would be rational to adopt more inclusive screening criteria [34]. In our sample, applying the lower cutoffs of the AAP/AAO criteria would have led to the missing of 36.84% of infants with ROP and 28.57% of those requiring treatment.
IVR was widely offered for patients requiring treatment in our sample due to the convenience of availability and easier technicality of administration. This is in line with the reported overreliance of developing nations on anti-VEGF to treat ROP [8]. To date, the largest randomized trial by Stahl et al. [35] reported that IVR (0.2 mg) might be superior to laser therapy when it comes to unfavorable ocular outcomes, and that it processed a good 24-week safety profile. Furthermore, Barry et al. [36] have recently reported that IVR administered to infants using bedside sedation results in faster return to pre-procedure respiratory baseline than laser ablation therapy under GA.
Limitations to our work include the relatively small sample size, especially when considering the large, estimated burden of premature births in the country. Being specific to the rural settings, our results may also be non-generalizable to a national level, and future well-designed studies in different settings are needed to complement our work. Nevertheless, we have intended for the work to serve as a preliminary report, ushering organized efforts for screening and prevention of a condition of national and global public health relevance.