Presentation of Retinopathy of Prematurity and Associated Risk Factor in a Referral Center in Iraq

Dear Editor, We read the interesting article by Abdulsahib et al.[1] published in the September–December 2023 issue of the Arab Board Medical Journal. On using the early treatment for retinopathy of prematurity (ETROP) classification, Abdulsahib et al.[1] found that type 1 ROP, type 2 ROP, zone 3 (stages I and II), and stage IV were found in 7.1%, 16%, 2.2%, and 0.7% of the patients, respectively. Moreover, type-1 ROP had a statistically significant correlation with low birth weight, respiratory distress syndrome, and low gestational age. The multivariate regression analysis showed a statistically significant correlation between poor weight gain and type 1 ROP.[1] Abdulsahib et al.[1] mentioned the study limitations of the single-center enrollment and the retrospective nature of the work. We hereby present the following limitation. The ETROP classification of ROP employed in the study is old and launched approximately two decades ago.[2] The ETROP classification includes type 1 ROP and type 2 ROP, while the groups that don’t fulfill the criteria for ETROP are categorized into zone III, stages I and II, without plus disease. The international classification of retinopathy of prematurity (ICROP) is an assent statement that constructs a standard nomenclature for ROP classification. The third edition (ICROP3) has been developed to forestall the following challenges: concerns regarding the subjectivity in essential elements of ROP classification; advancements in ophthalmic imaging; innovations in novel pharmacological treatments such as antivascular endothelial growth factor that have a greater rate of regression and reactivation processes posttherapy in comparison with ablative treatments; and finally the notice that patterns of ROP in some areas of the world do not fulfill completely into the current classification system.[3] The ICROP3 kept the current definitions such as stage (view of the disease at a vascular-avascular junction), zone (site of disease), and the circumferential extent of disease. The following are among the ICROP3 updates: essential classification elements such as notch, posterior zone II, stage V subcategorization, and the notice that a continuing scope of vascular abnormality presents ranging from normal to plus disease; and the use of “aggressive ROP” instead of “aggressive-posterior ROP” due to growing notice that aggressive disease might take place in bigger preterm neonates and beyond the posterior retina, especially in areas of the world where resources are constrained. These innovations in ICROP3 classification are solicited to raise the standards and quality of ROP care globally and provide a framework to hasten clinical care and research.[3] Referring to the study methodology to the new ICROP3 classification,[3] rather than the old ETROP classification[2] could make the study findings more validated. As a result, this methodological limitation could further put under question the study results stated by Abdulsahib et al.[1]