The prevalence of Retinopathy of Prematurity (ROP), a critical eye disease observed in premature infants, has been substantially influenced by advancements in neonatal care since the 1940s. This study elucidates various factors influencing the incidence and management of ROP in neonates, drawing upon a rich pool of data from German hospitals and paralleling international studies and guidelines.

Global and regional perspectives on ROP

ROP has been recognised as a significant challenge in neonatal healthcare, with its incidence being intimately tied to the improved survival rates of preterm babies due to enhanced neonatal care practices. Despite the significant strides made globally in reducing ROP-induced blindness, disparities exist, with some regions witnessing a surge in ROP cases concomitant with rising neonatal survival rates [16]. This scenario emphasises the necessity for optimised screening protocols and interventions, particularly in regions grappling with this increasing burden.

Screening protocols and guidelines

Understanding the variability in screening protocols internationally is essential in delineating a comprehensive approach to ROP management. Infants with a weight under 1.5 kg are commonly the target group for ROP screening, though the exact criteria can differ based on several factors, including the level of development in a country and the specifics of individual neonatal courses [17,18,19].

The American Academy of Pediatrics (AAP), the American Association for Pediatric Ophthalmology and Strabismus (AAPOS), and the American Academy of Ophthalmology (AAO) propose stringent guidelines for ROP screening, particularly emphasising the necessity to screen infants with certain risk factors, such as low birth weight and prolonged oxygen support [19]. Concurrently, German guidelines rely heavily on the ETROP study's recommendations, emphasising a more nuanced approach based on gestational age and oxygen administration duration [20,21,22,23].

Incidence and associated risk factors

Reaching the actual incidence rates, it is discerned that the previously reported rates often stem from collaborative efforts of expert centers, and not from an epidemiological background, potentially portraying a skewed representation of the disease spectrum. Our study, which covered the whole German population, delineated specific associated factors, underlining the critical role of birth weight and unveiling the near-universal incidence of ROP in neonates with a weight less than 750 g. This observation hints at potential underreporting or overlooking of ROP in certain NICUs, a prospect warranting further investigation to uncover other contributing factors possibly dampening the reported incidence rates.

Gender disparities in ROP incidence

An intriguing facet of our study was the exploration of gender-specific variations in ROP occurrence. Despite the majority of literature concurring on the non-significant role of gender in ROP development, our study highlighted an increasing trend of ROP in larger birth weight females. This observation necessitates a deeper analysis, considering the potential influence of sex hormones on vascular development and the differential responses to stressful perinatal conditions exhibited by different genders [24, 25].

Technological advancements and network integration

In the face of mounting challenges, including the scarcity of specialised ophthalmologists and the proliferation of neonatal centers, a shift towards telemedicine approaches seems not only viable but indispensable. Incorporating non-invasive ocular imaging techniques and developing remote consultation platforms are paving the way for a more integrated and efficient approach towards ROP management [26,27,28,29,30,31,32,33].

Moreover, ROP management’s success is increasingly attributed to cohesive networks involving various healthcare professionals. These networks foster adherence to established guidelines, promoting quality and consistency in ROP care [34].

Current treatment modalities

The treatment landscape for ROP has witnessed significant transformations, with the advent of anti-VEGF therapy marking a significant milestone. Our study emphasised the efficacy of this intervention, echoing the promising results demonstrated in recent studies [35,36,37]. However, the pursuit for more robust evidence continues, necessitating further studies with a comprehensive design to substantiate the preliminary findings.

Generalizability

The findings of this study, based on an extensive analysis of data from the German DRG database, primarily offer insights into neonatal ROP cases within the German healthcare context between January and December 2019. While the results showcase notable trends and relationships, the generalizability may be limited due to the study’s geographical and temporal scope. Therefore, caution should be exercised when attempting to apply these findings to different healthcare systems, time frames, or broader populations. Future research should aim to expand the scope to include multi-national datasets for a more comprehensive understanding and global applicability of the results.

Study limitations and future directions

While our study offers a significant contribution to the analysis of ROP incidence in Germany, it has several constraints that must be considered. First, the lack of detailed clinical data impedes the possibility of performing a multivariate analysis, potentially affecting the depth and breadth of our findings. This limitation highlights a significant gap, as a more comprehensive dataset would permit nuanced insights into the underlying trends and relationships in ROP cases.

Second, the statistical tools employed in this research did not sufficiently address the data’s heterogeneity. Specifically, the absence of measures such as the Gini coefficient (GSI) hindered a fuller understanding of population distribution and risk factors associated with ROP, limiting the depth of the analysis.

Recognising these constraints, future research should prioritise incorporating a broader spectrum of statistical methods capable of facilitating a multi-variable analysis, fostering a more detailed examination of data heterogeneity. Additionally, merging robust clinical data with statistical analysis is paramount. This integration would not only fill the existing gaps in the current study but also forge pathways to developing data-driven, context-specific interventions that could significantly enhance ROP prevention and management strategies. By addressing these areas, we can aim to provide a more comprehensive and nuanced understanding of ROP incidence globally, thereby improving the precision and effectiveness of future preventative strategies.