Scientific Online Resource System

Scripta Scientifica Salutis Publicae

Retinopathy of Prematurity - a Bulgarian perspective of a global epidemic

Elena Grozeva, Jana Simova, Desislava Vankova, Zlatina Naneva, Christina Grupcheva


Retinopathy of Prematurity (ROP) is in the focus of public health interest as far as it is one of the most common potentially avoidable causes of visual loss in childhood and can lead to vision impairment and blindness. Therefore, it has lifelong implications for the affected children, their families, but also for the whole society. In Bulgaria, the processes of continuous health care transformations have led to lower quality control over ROP- screening processes. The aim of the presented study is to make a horizon scanning research, which includes: 1) introduction of some ROP-related definitions; 2) a clinical and public health overview of ROP from an international and Bulgarian perspective; 3) presentation of the organizational structure of screening, the early diagnosis and therapy of ROP in Bulgaria. Themethodsused are: meta-analysis of global and national data on ROP; sociological method - questionnaire distributed amongst the ophthalmologists who diagnose and treat ROP and participatory research method e.g. follow up of the patients` path and the clinical and public health procedures. Globally, the three waves of the ROP-epidemic are described. Nationally, the Bulgarian ROP-related picture is drawn, summarizing and analyzing the results from the interviews with ophthalmologists engaged with ROP-screening from all 28 administrative regions of Bulgaria (Period: April-September, 2015). Finally, after an extensive drill-down of the Bulgarian context and the global developments, locally relevant health policy strategies are proposed like development of a National Consensus on ROP and Registry database of ROP in Bulgaria. Further, a three-level ROP-screening procedure is outlined and the telemedicine application grounded.


retinopathy of prematurity, epidemiology, Bulgaria

Full Text


Gilbert, C., Retinopathy of prematurity: a global perspective of the epidemics, population of babies at risk and implications for control, Early Hum Dev., 2008: Feb; 84(2):77-82. doi: 10.1016/j.earlhumdev.2007.11.009.

Azad, R., Trese, M., Textbook of Retinopathy of Prematurity, 2011, Lippincott Williams & Wilkins: India.

Flynn, J.T. and Tasman, W.S., (eds.), Retinopathy of Prematurity: A Clinician`s Guide, 1992: Springer-Verlag New York Inc.& New York.

WHO, Born Too Soon: The Global Action Report on Preterm Birth , 2012: WHO& Geneva.

National Eye Institute, National Institutes of Health, The Telemedicine Approaches to Evaluating Acute-phase ROP (e-ROP) study, available at , 2014; accessed on 01. 2016.

MOH, Ordinance No. 19 from 22 of Dec. 2014. On the New Standards `Obstetrics and Gynecology`, State Gazette (official edition of the National Assembly), issue 106, on 23.12.2014 (Bulgarian).

Frederick M. Wilson, II, MD. Practical ophthalmology: A manual for beginning residents., San Francisco, American Academy of Ophthalmology, 1996, 415

Sekeroglu MA, Hekimoglu E, Sekeroglu HT, Arslan U. Alternative methods for the screening of retinopathy of prematurity: binocular indirect ophthalmoscopy vs wide-field digital retinal imaging. Eye. 2013;27(9):1053-1057. doi:10.1038/eye.2013.128

Castillo-Riquelme M.C., J. Lord, M.J. Moseley, A.R. Fielder, L. Haines. Cost-effectiveness of digital photographic screening for retinopathy of prematurity in the United Kingdom. Int J Technol Assess Health Care. 2004 Spring;20(2):201-13.

Seiberth V., C. Woldt. Wide angle fundus documentation in ROP. Ophthalmology, 2001, 98(10): 960-3.

Yen KG, D. Hess, B. Burke, R.A. Johnson, W.J. Feuer, J.T. Flynn.Telephotoscreening to detect retinopathy of prematurity: preliminary study of the optimum time to employ digital fundus camera imaging to detectROP. J AAPOS. 2002 Apr;6(2):64-70.

Fierson W.M., A. Jr. Capone; AAP, AAO, AACO;Telemedicine for evaluation of retinopathy of prematurity. Pediatrics. 2015 Jan;135(1):e238-54.

Field M. Telemedicine: A Guide to Assessing Telecommunications in Health Care. Washington, DC: National Academies Press; 1996

Lorenz B, Spasovska K, Elflein H, Schneider N. Wide-field digital imaging based telemedicine for screening for acute retinopathy of prematurity (ROP). Six-year results of a multicentre field study. Graefes Arch Clin Exp Ophthalmol. 2009;247(9):1251-1262pmid:19462177

Institute of Medicine, Preterm Birth: Causes, Consequences, and Prevention. Washington, D.C.: National Academy Press, 2007.

Zin A, Gole GA., Retinopathy of prematurity-incidence today, 2013: Clin Perinatol., 40:185-200.

Gilbert C, Foster A., Childhood blindness in the context of Vision 2020-the right to sight. Bulletin of World Health Organisation, 2001;79:227-32.

Terry TL., Extreme prematurity and fibroplastic overgrowth of persistent vascular sheath behind each crystalline lens. American Journal of Ophthalmology , 1942;25:203-4.

Campbell K. Intensive oxygen therapy as a possible cause of retrolental fibroplasia: a clinical approach. Med J Aust., 1951;2:48-50.

Hatfield EM. Blindness in infants and young children. Sight Sav Rev 1972; 42:69-89.

Avery ME, Oppenheimer EH., Recent increase in mortality from hyaline membrane disease. Journal of Pediatrics, 1960;57:553-9.

Gibson DL, Sheps SB, Schechter MT, et al., Retinopathy of prematurity: a new epidemic? Pediatrics 1989; 83:486-92.

Phelps DL., Retinopathy of prematurity: an estimate of vision loss in the United States-1979. Pediatrics, 1981: 67:924-6.

Keith CG, Doyle LW, Kitchen WH, et al., Retinopathy of prematurity in infants of 24-30 weeks` gestational age. Med J Aust 1989; 150:293-6.

Wheatley, C. M., Dickinson, J. L., Mackey, D. A., Craig, J. E. , Sale M. M., Retinopathy of prematurity: recent advances in our understanding, Br J Ophthalmol., 2002;86:696-701.

American Academy of Ophthalmology, Retinopathy of Prematurity- Epidemiology, 2015:, accessed on 6-01-2015.

RCPCH (Expert group of Royal College of Paediatrics and Child Health, Royal College of Ophthalmologists British Association of Perinatal Medicine & BLISS), UK Retinopathy of Prematurity Guideline, 2008: Royal College of Paediatrics and Child Health: UK

Pandova, M., Feschieva, N., Mircheva, I., Methodological Considerations in Population-based studies of Blindness and Low Vision, Vol. 10, Suppl. 3, 12-17, 2012.

Nikolova, S., Kontrova, E., Zlatarova, Z et al., Retinopatia na nedonosenoto- rezultati ot screening I lechenie za 12 godishen period. Referativen Buletin N 6; 2009: 27-32.

Marinov, V., Sivkova,N., Boeva, J., Retinoaptia na nedonosenoto v Plovdiv I regiona- parvonachalni nabljudenia, Referativen Buletin po oftalmologia, N 4; 2011: 34-41.

National Center of Public Health and Analyses, Data provided by NCPHA especially for a PhD-project “Prichini za namaleno zrenie I za slepota sred decata, rodeni nedonoseni v Starozagorski region” Department of Ophthalmology, MU-Varna, 12 Nov.2015, Sofia.

Lee SK, Normand C, McMillan D, et al. Evidence for changing guidelines for routine screening for retinopathy of prematurity. Arch Pediatr Adolesc Med 2001;155:387–95.

Whitfill CR, Drack AV. Avoidance and treatment of retinopathy of prematurity. Sem Pediatr Surg 2000;9:103–5.

IAPB, the International Agency for the Prevention of Blindness, Leading Blindness Prevention Efforts Worldwide, accessed on 08.2015,

Council of Ministers, Национална програма за подобряване на майчиното и детското здраве 2014-2020 г. Национална здравна стратегия 2014-2020 на Министерския съвет на Република България.

Nencheva, B., Zrenie 20/20 mit ili realnost, 2015, Mu-Varna, Steno: Varna.



About The Authors

Elena Grozeva
Medical Center - Galabovo

Jana Simova
Medical University of Varna

Desislava Vankova
Medical University of Varna

Zlatina Naneva
Regional Health Inspectorate - Stara Zagora

Christina Grupcheva
Medical University of Varna

Font Size