Retinopathy of prematurity (ROP) is rapidly becoming a common and alarming cause of neonatal blindness in the developing world. Significant improvements in neonatal care are leading to an increase in survival rates of premature and extremely premature neonates with ROP. The World Health Organization (WHO) defines blindness as a best-corrected visual acuity in the better eye of less than 20/400 and low vision as best-corrected visual acuity in the better eye of worse than 20/60 but equal to or better than 20/400. Using this definition, the prevalence of blindness in children (0–15 years) worldwide is estimated to be 1.4 million. Data suggest that in highly industrialized countries (ie, ranked by the United Nations Development Programme on the basis of their Human Development Index), the infant mortality rate is very low at <9/1000 live births, with the rate of ROP blindness in this population at 10%. In countries with high infant mortality rates (above 60/1000), the rate of ROP-related blindness is extremely low, likely because of the lack of neonatal facilities and a higher mortality rate. On the other hand, countries with infant mortality rates between 9/1000 and 60/1000 have a very high and concerning rate of ROP-related blindness. This demographic of increasingly at-risk neonates is being referred to as the “third epidemic” of ROP. The majority of countries classified as middle-income are areas in Latin America, Eastern Europe, Southeast Asia, and the Caribbean. In Latin America, approximately 24% of childhood blindness occurs secondary to ROP, with an estimated 24 000 affected children. In 2002, a multicenter study was published using data from 11 neonatal intensive care units in Latin America. The authors identified a 42% rate of ROP in very low-birthweight infants, with only 68% of the babies receiving adequate screening.

Peru, a middle-income country, has a population of 29 million and a childhood blindness prevalence of 0.062%, with approximately 17 000 blind persons <15 years old. A survey in 2003 conducted at 4 schools for the blind in Lima determined that the frequency of ROP-related blindness was 16%. The same survey performed 2 years later in 2005 reported an increased frequency of ROP-related blindness, to 25% (L Gordillo, personal communication, Lima, Peru, September 19, 2010).

This increasing frequency of ROP deserves further investigation, with consideration of improved public policy support for clinical activities, because few ophthalmologists are available to screen and treat ROP. In 2002 there were only 800 ophthalmologists in Peru, but the number was expected to grow by 50 per year. At present, there are few primary ophthalmologists who conduct ROP screening examinations; therefore, imaging and fundus photographic screening technologies are currently being implemented as these forms of screening improve and begin to gain acceptance.

Based on ROP studies conducted in the United States, significant reductions in the rate of blindness from ROP have been demonstrated, initially with the use of cryotherapy and later with the indirect diode laser–delivered panretinal photocoagulation (current standard treatment). The long-term outcome data from the Cryotherapy for Retinopathy of Prematurity study demonstrated that 15 years after treatment, the number of unfavorable structural outcomes was 52% in the control group in comparison to 30% in the treatment group.

In Peru, current treatment uses the diode laser. The solid-state diode lasers are easy to transport and allow access for treatment into more rural areas. In a series of consecutive eyes with threshold ROP treated using diode laser photocoagulation, the reported rate of regression among 8 studies ranged from 71% to 100%. In addition, the Early Treatment of Retinopathy of Prematurity study reported that laser treatment for high-risk prethreshold ROP reduced the rate of unfavorable structural outcomes from 15.6% to 9.0%. Effective evidence-based reduction in the incidence of blindness from ROP emphasizes the importance of early detection, screening, and laser treatment of prethreshold ROP.

The medical infrastructure and neonatal care continues to improve in Peru and other middle-income nations. Along with such improvements, a greater burden of ROP is expected. The societal impact of ROP and subsequent childhood blindness must be considered in order to appropriately allocate scarce healthcare resources in the most cost-effective manner. Traditionally, a cost-of-illness study is used to address such conditions. These studies take into account both the direct and indirect costs, including productivity loss secondary to morbidity or premature mortality. Direct costs include the cost of screening, medical staff, treatment, and follow-up examinations. Indirect cost includes the individual’s lost productivity plus that of the caretaker. Caretakers of blind adults are estimated to lose at least 10% of their productivity, clearly an additional burden on society. To the best of our knowledge, there are no current estimates for the lost productivity for caretakers of blind children. Overestimates of cost may include future tax revenue, a cost that is not included in this study and may falsely overestimate the impact. Instead, we propose that a more fact-based analysis should be used.

The purpose of this work is to demonstrate that evidence-based ROP care is cost-effective in Peru, reduces the societal burden of blindness, and substantially improves the quality of life for those directly and indirectly affected. Furthermore, this analysis will also help the political entities in such countries to best determine appropriate and cost-effective allocation of scarce healthcare resources. The financial and societal analysis taken from this study may also be applicable to other developing countries. This dataset will demonstrate and highlight the magnitude and cost-effectiveness of aggressive screening and prevention strategies for management of treatable neonatal blindness from ROP. Such a model analysis could be applied to many developing nations.