Study Finds Shifting ROP Burden as Neonatal Survival Improves

Neonatal gains expose a growing blind spot in ROP care.

Retinopathy of prematurity–related blindness is declining worldwide, but a new global analysis shows a less reassuring countertrend: moderate and severe visual impairment are rising in regions where neonatal survival has improved faster than screening and follow-up systems.

The findings suggest that while more preterm infants are surviving, many are doing so with avoidable, lifelong visual consequences—shifting ROP from a problem of mortality to one of long-term visual morbidity.

Published in JAMA Ophthalmology, the study analyzed ROP-related visual outcomes across 204 countries between 1990 and 2021, integrating socioeconomic indicators and health system metrics with machine-learning forecasting models.¹

The results point to persistent inequities in where and how ROP-related vision loss occurs and raise concerns that gains in neonatal survival are outpacing the systems needed to protect visual outcomes.¹

Global trends mask regional divergence

Globally, an estimated 8.79 million cases of ROP-related visual loss were reported during the study period. Although the age-standardized prevalence rate declined from 113.49 to 101.92 cases per 100,000 people—reflecting gradual improvements in neonatal care and ROP management—this overall progress masks substantial regional divergence.¹

Countries with low and low-middle sociodemographic index (SDI) continue to account for the largest absolute number of ROP-related visual loss cases, including blindness. At the same time, high-middle SDI regions have experienced a steady increase in prevalence across all grades of visual impairment since the mid-2000s.¹

By 2021, South Asia and sub-Saharan Africa recorded the highest prevalence rates for all-grade ROP-related visual loss, with Pakistan, India and Bangladesh among the most affected countries. Europe and Central Asia showed the lowest prevalence rates.¹

Moderate impairment drives future burden

The most consequential shift, however, is developmental rather than geographic. As neonatal survival improves, the study found that moderate visual loss—rather than blindness—is increasingly driving the ROP burden in middle and high-middle SDI regions.¹

While blindness prevalence has declined in many low-SDI settings since the early 2000s, moderate and severe visual impairment have risen in regions with expanding neonatal intensive care capacity but incomplete screening and follow-up systems.¹

Forecasting models suggest that without targeted intervention, ROP-related visual loss will continue to increase in middle and high-middle SDI regions through 2050, particularly for moderate visual impairment. Pakistan, India and parts of the Middle East and North America are projected to carry the highest future prevalence.¹

These projections underscore that preventing blindness alone is no longer sufficient. Children who survive prematurity but develop untreated or undertreated ROP may live with lifelong visual impairment affecting education, employment and quality of life.¹

Health systems shape visual outcomes

Beyond clinical risk factors such as prematurity and low birth weight, the analysis identified health system and socioeconomic drivers strongly associated with ROP-related visual loss.¹

Higher prevalence was linked to lower prenatal care coverage, reduced social insurance coverage, higher out-of-pocket health care costs, and lower densities of trained physicians and nursing staff.¹

Regions with stronger health financing, broader insurance coverage, and higher workforce density showed lower rates of severe visual impairment and blindness.¹

A “fourth epidemic” and a window for action

In an accompanying invited commentary, Dr. Thanitsara Rittiphairoj (USA) placed these findings within a broader health-system framework, describing the current transition as a potential “fourth epidemic” of ROP, a phase in which survival gains outpace the development of screening, treatment and rehabilitation.²

Dr. Rittiphairoj emphasized the stakes, stating, “As neonatal care continues to advance, the imperative is not only to help infants survive but also to ensure they can see—a reminder that the true measure of progress in neonatal care is not merely how many lives are saved, but how fully those lives can be lived.²

Projections signal opportunity, not inevitability

The authors stressed that these trends are not fixed outcomes. The machine-learning models assumed relatively stable conditions and cannot fully account for future policy shifts, investment or technological advances, but they highlight where intervention could have the greatest impact.¹

Expanding universal ROP screening, strengthening follow-up pathways, and investing in neonatal and ophthalmic workforce capacity remain central priorities. Teleophthalmology and AI-assisted screening may help address access gaps in resource-limited settings, but they are not substitutes for sustained system-level investment.¹

LKC’s RETeval offers new solutions for infants with ROP at PAAO 2023

ROP as a marker of neonatal equity

Taken together, the findings position ROP as a marker of neonatal health equity. As preterm survival improves worldwide, the challenge for eye care and neonatal systems alike is ensuring that survival gains are matched by effective screening, timely treatment and long-term visual care.

Editor’s Note: This content is intended exclusively for healthcare professionals. It is not intended for the general public. Products or therapies discussed may not be registered or approved in all jurisdictions, including Singapore.

References

Wong ES, Choy RW, Zhang Y, et al. Global and regional trends in retinopathy of prematurity. JAMA Ophthalmol. 2025;ePub ahead of print.
Rittiphairoj T. The global epidemiologic transition of retinopathy of prematurity: Interpreting forecasts through a health-system lens. JAMA Ophthalmol. 2025;ePub ahead of print.