RETINOPATHY OF PREMATURITY PRACTICES: A NATIONAL SURVEY OF CANADIAN NEONATAL INTENSIVE CARE UNITS

Abstract

BACKGROUND: Retinopathy of prematurity (ROP) accounts for significant morbidity in preterm infants. Early detection and treatment helps prevent adverse sequelae. The objective of this study was to survey the current screening inclusion criteria, treatment options, supportive care and post screening events for ROP in tertiary level Neonatal Intensive Care Units (NICU’s) in Canada. OBJECTIVES: The objective of this study was to survey the current screening inclusion criteria, treatment options, supportive care and post screening events for ROP in tertiary level Neonatal Intensive Care Units (NICUs) in Canada. DESIGN/METHODS: The study was designed as a prospective observational study where a survey was sent out to all 29 level three NICU’s across Canada. Following ethics exemption from the local research ethics board, a cross sectional survey was distributed across all level three NICU’s in Canada from September 1 to December 30, 2015. The tool was designed to elicit information on the screening practices for detection of ROP in tertiary NICU’s. In addition, information on the ROP screening processes, including the timing of screening and grounds for screening infants outside the criteria were collected. The survey also explored the screening process from an organizational standpoint in terms of the person responsible for initiating the screening processes, choice of mydriatics as well as organizing follow up. The practice and use of supportive measures during ROP screening and treatment options provided were also captured.The primary outcome was defined as adherence to the current CPS/COS or AAP guidelines. Specifically, guideline adherence was assessed for the following criteria: inclusion of an infant for ROP screening, age at which first ROP exam was initiated, circumstances where infants outside the screening criteria were deemed eligible for inclusion in the screening process and appropriate follow up processes. Secondary outcomes were defined as the supportive practices in use during the ROP screening examination. This includes the type and dose of mydriatics used, and measures to reduce photophobia and discomfort after ROP related therapeutic interventions. We also assessed healthcare system perspectives related to ROP screening and treatment. This was determined by the availability of dedicated personnel to coordinate the exam, pre-printed order sheets for medication and equipment required, measures to ensure appropriate follow up, use of RetCam (Clarity Medical Systems INC.), ROP treatment options (Anti vascular endothelial growth factor [anti-VEGF] and/or Laser) and treatment location. RESULTS: Twenty two level three nurseries responded to the survey (76 % response rate). Ten different ROP screening inclusion criteria were found to be in use with significant variation in gestational age and birth weight criteria. Reasons for screening babies outside any given unit’s inclusion criteria included unstable clinical course or high oxygen demand as decided by the attending neonatologist. Many other national variations also exist regarding the supportive, procedural and treatment protocols surrounding ROP screening such as Ret Cam use, use of mydriatics and preprinted order sheets. From a treatment standpoint, 50 percent of the centers preferred laser while the remaing 50 percent prefereed Anti VEGF(Vascular Endothelial Growth factor) CONCLUSION: Despite national guidelines, there exists significant variation in ROP screening inclusion criteria practices among neonatal units in Canada. For the many other aspects of ROP screening and treatment, for which there are no national guidelines there also exists significant variations in practice patterns. There is therefore an urgent need for better evidence based screening guidelines as well as a need to standardize supportive measures surrounding ROP screening and treatment, followed by efforts to encourage national uptake of these recommendations.