Retinopathy of Prematurity (ROP) is a potentially blinding eye condition affecting premature infants. It occurs when abnormal blood vessels develop in the retina, the light-sensitive tissue at the back of the eye. This abnormal growth can lead to retinal detachment and permanent blindness if untreated. Globally, ROP is responsible for blindness in approximately 50,000 children annually, particularly in regions with improving neonatal care but insufficient safeguards for preterm infants.
In Uganda, with a preterm birth rate of 14 per 1,000 live births, the burden of ROP is significant. Yet, routine ROP screening is not standard in most Neonatal Intensive Care Units (NICUs), putting thousands of vulnerable infants at risk. Advocacy for widespread ROP screening and improved neonatal care is vital to prevent blindness in this vulnerable population.

Major Risk Factors for ROP: ROP develops primarily in preterm infants due to the incomplete development of retinal blood vessels at birth. Key risk factors include:
1. Prematurity: Infants born before 32 weeks of gestation are at the highest risk.
2. Low Birth Weight: Birth weights below 1,500 grams increase the likelihood of developing ROP.
3. Oxygen Therapy: Improper oxygen administration can exacerbate abnormal blood vessel growth, particularly if saturation levels exceed 95%.
4. Sepsis and Infections: Neonatal infections contribute to systemic stress, heightening ROP risk.
5. Poor Nutrition: Deficiencies in essential nutrients critical for retinal development may also play a role.
 

Findings from Uganda’s First ROP Study: In 2022, we conducted the first Ugandan study on ROP at Mulago Specialized Women and Neonatal Hospital (MSWNH) and Kawempe Hospital. Our findings underscored the need for routine screening:
 Combined ROP prevalence: 6% across both facilities.
 Prevalence of treatment-requiring ROP at MSWNH: 18%, the highest in our analysis.
 

These figures reflect the urgent need for early detection and timely intervention to prevent blindness. Calculations of ROP Prevalence from Screening Efforts. Since 2022, we have expanded ROP screening efforts to multiple facilities, generating valuable data on prevalence rates:
1. Mulago Specialized Women and Neonatal Hospital (2023):
o 250 infants screened, 115 had treatment-requiring ROP.
o Prevalence of treatment-requiring ROP: 46%.
2. Kawempe Hospital (January–October 2024):
o 705 infants screened, 37 had treatment-requiring ROP.
o Prevalence of treatment-requiring ROP: approx 5.2%3. Kiwoko Hospital (April 2023–May 2024)o 328 infants screened, 30 had treatment-requiring ROP.
o Prevalence of treatment-requiring ROP: approx 9.1%.
4. Hoima Hospital (May–November 2024):
o 124 infants screened, 6 had treatment-requiring ROP.
o Prevalence of treatment-requiring ROP: approx 4.8%.
5. ROP Screening Camps (2024):
o Bwera Hospital: 15%.
o Jinja Hospital: 16.7%.
 

Preventing ROP; Prevention of ROP hinges on mitigating the risk factors:
1. Appropriate Oxygen Management: Ensuring oxygen saturation levels remain between 90–95% using blended oxygen systems is critical.
2. Timely Screening: All infants born at ≤34 weeks gestation or weighing ≤2000 grams should undergo ROP screening starting at 31 weeks post-menstrual age.
3. Optimal Neonatal Care: Addressing infections, improving nutrition, and maintaining overall health stability in NICU settings are essential.
4. Parental Awareness: Educating caregivers about ROP and its risks ensures timely follow-up and treatment compliance.
 

Treating ROP;Treatment of ROP depends on its severity:
1. Laser Therapy: ablates the peripheral retina to stop abnormal blood vessel growth.
2. Anti-VEGF Injections: These are increasingly used to inhibit abnormal vascular growth in severe cases. This is the one we use most in Uganda. Works well for Stages two (2) and three (3) ROP
3. Surgery: Advanced ROP may require vitrectomy or scleral buckling to address retinal detachment. Works on Stage 4 ROP.
 

Impact of ROP Screening Efforts in Uganda; Our screening initiatives have provided critical insights into ROP prevalence while saving the vision of numerous preterm infants:
 Mulago Specialized Women and Neonatal Hospital: Timely treatment for 115 infants in 2023 resulted in successful ROP regression in all cases.
 Kawempe Hospital: With support from Mama Tulia Organization, 37 cases of treatment-requiring ROP were identified and treated between January and October 2024.
 Kiwoko Hospital: ADARA Development facilitated the treatment of 30 infants with ROP, ensuring a positive outcome for all.
 Hoima Hospital: Six infants received timely treatment through support from Ubora Foundation and Eye Health Africa.
 ROP Camps: Screening camps at Bwera and Jinja Hospitals identified and treated six cases of treatment-requiring ROP.
 

Challenges and Advocacy; Despite progress, challenges persist in scaling ROP screening services:
1. Limited Access to Blended Oxygen: Kiwoko Hospital remains the only facility with this critical equipment among those mentioned in this article in which we have done the ROP screening.
2. Financial Barriers: Many parents struggle to cover treatment costs, limiting access to care.
3. Lack of Awareness: Many healthcare providers and caregivers are unaware of ROP’s risks and the importance of timely intervention.
4. Policy Gaps: Oxygen therapy is poorly regulated in public hospitals, increasing ROP risk.
 

Call to Action; To address these challenges, we recommend:
1. Nationwide ROP Screening Programs: All NICUs must implement routine ROP screening for at-risk infants. First ROP screening to be done between 4-6 weeks from birth. All discharge forms of preterm babies must indicate a recommendation for ROP screening
2. Blended Oxygen Systems: Public hospitals need access to this technology to ensure safe oxygen management.
3. Awareness: Healthcare providers should be educated on ROP and how to prevent it by pushing for timely screening, and awareness campaigns should target caregivers.
4. Policy Reform: Strict regulations for oxygen therapy must be established to ensure safe practice.
 

Conclusion; ROP screening and treatment save sight and transform lives. With partnerships from organizations like Mama Tulia, ADARA Development, and Eye Health Africa, significant strides have been made. However, much remains to be done to scale these efforts across Uganda.
By prioritizing ROP screening and prevention, we can protect thousands of preterm infants from a lifetime of blindness. Together, we can ensure every child has the opportunity to see the world clearly and live to their full potential. Let us take this critical step toward a brighter future.
 

By Dr. Iddi Ndyabawe (Kiwoko Hospital) and Dr. Anne Ampaire Musika (Makerere University College of Health Sciences) Date: 25/11/2024