In the neonatal eye, the pars plana region is incompletely developed and almost not existent. The axial length of a newborn eye is 16 mm in the 34th gestational week and 17 mm in the 40th gestational week. The anterior retina lies just behind the pars plicata. The site of sclerotomy is therefore much closer to the limbus. The sclerotomy should be performed 1.0 mm behind the limbus. See Table 17.1. The newborn eye has a huge lens compared to the globe. A big lens and a short sclerotomy site allow only a small canal to insert and manoeuvre the instruments. Utmost care is needed in inserting a vitreoretinal instrument or in administering an injection, because it may cause inadvertent lens touching, traction on the vitreous base and retinal damage. The vitreous body is completely intact; there is no degeneration of the vitreous body present. The vitreous body is very firmly attached to the retina; a PVD is virtually not possible. If you try to induce a PVD, you risk creating a retinal tear.

ROP is a tractive retinal detachment and not a rhegmatogenous retinal detachment. Due to the fact that a retinal break is not present, there is no need for a tamponade or even postoperative posture. The aim of surgery is to remove the vitreous body in order to relieve retinal traction. The retina will reattach in a few days after surgery. In addition, an anti-VEGF injection is needed to reduce the vascular activity and remove the pathologic reason of the tractive detachment. We use ranibizumab (Lucentis^®) because the half-life in serum is lower compared to bevacizumab (Avastin^®).

In a 4A and 4B detachment, the state-of-the-art method may be to use the sutureless 27G technique, to perform a lens-sparing vitrectomy and to inject intravitreal Lucentis.

Timing of surgery is of utmost importance. We only operate ROP stage 4A (retinal detachment and attached macula) and 4B (retinal detachment and detached macula). See Fig. 17.1. We do not operate stage 5 ROP. Do not operate too late. The risk that you will not succeed is high, and the risk that you will have complications is even higher. Try to operate in stage 4A.

The surgery is easy but you have to operate absolutely without complications: No lens touch, no retina touch and no retinal tear. A lens touch will result in a lensectomy and amblyopia. A retinal touch with retinal tear will result in retinal detachment and blindness. Be careful when inserting the trocars and instruments. Aim towards the optic nerve. Perform a central and peripheral vitrectomy. Do not induce a PVD; it is almost impossible in newborn. Do not remove membranes; you may induce a retinal tear. A tamponade is not necessary.