Aggressive retinopathy of prematurity in a twin with twin-to-twin transfusion syndrome: a case report from a district hospital in Ghana

Retinopathy of prematurity (ROP) is a leading cause of preventable childhood blindness. The condition is particularly unpredictable in monochorionic twin pregnancies complicated by twin-to-twin transfusion syndrome (TTTS). Previous studies have reported either no significant difference in the incidence of ROP between donor and recipient twins, or a higher incidence among donor twins than among recipient twins. In contrast, the findings in this case differ from these previous reports, underscoring the need for equal vigilance when monitoring both donor and recipient twins. This case report describes a moderate preterm infant who was a recipient twin in a monochorionic pregnancy complicated by twin-to-twin transfusion syndrome (TTTS). The infant was delivered at 32 weeks and 6 days of gestation with a birth weight of 2000 g. The recipient twin required oxygen therapy for 6 days via improvised continuous positive airway pressure (CPAP), with a positive end-expiratory pressure (PEEP) of 7 cmH₂O, before being stepped down to intranasal oxygen at 1 L/min. The infant was successfully weaned off oxygen on day 8 of life. Initial retinal screening of the recipient twin revealed aggressive ROP (Zone I, Incomplete Vascularization, Plus disease; TeleROP-SS score, 60). The infant was subsequently treated with intravitreal anti-vascular endothelial growth factor (anti-VEGF) therapy, with gradual regression of ROP over 11 weeks. The donor twin had a birth weight of 1,490 g and received the same oxygen therapy as the recipient twin. The donor underwent ROP screening but did not develop ROP requiring treatment. This case highlights the importance of early retinal screening and vigilant follow-up of both recipient and donor twins from pregnancies complicated by twin-to-twin transfusion syndrome (TTTS). Timely detection and appropriate treatment of ROP are essential to prevent avoidable lifelong visual impairment and blindness.