Report on the Controversy over Retinopathy of Prematurity
by Ronnie Londner, Twins Magazine
Earnest and angry debate is raging over the causes of retinopathy of prematurity. One side, led primarily by Peter Aleff, the father of a child blinded by ROP, accuses doctors of deliberately allowing premature babies to be exposed to harmful lights. On the other side, most neonatologists and ophthalmologists say that lights have little or nothing to do with ROP.
Here is a look at both sides of the controversy, and excerpts from recent media coverage.
Peter Aleff, a father with a mission
Peter Aleff, a New Jersey father of two, is convinced his son, David, was blinded, at least in part, by the treatment he received shortly after his 24-week gestation birth.
"My son, David, is five years old," said Mr. Aleff. "He cannot see and is somewhat delayed. When you have a premature baby, at first you are so full of gratitude that NICUs [neonatal intensive care units] exist, you do not question what they do there. Later you may realize that not all those procedures may be necessary. I think many doctors practice 'Mercedes medicine.'
"Industrial safety is taken more seriously than hospital safety. Newborn babies, with their clear lenses, are not protected against ultra-violet light. Even if they close their eyes, their eyelids are so thin and transparent the lids block only about 10% of the light. Those first few hours of exposure can damage eyes for life."
In an essay headlined Blinding Ignorance, (New York Times, August 9, 1989) Mr. Aleff wrote:
"...The epidemic of blinding could easily have been ended long before David and thousands of other now blind children were born, if doctors had applied the medical research described in their own journals. When I tried to bring this to the attention of various physicians and asked them to help eradicate ROP, I found mostly medical ignorance and indifference. ...
The fluorescent lamps in the nurseries emit high- energy blue wavelength in a laser-like concentration even more intense than that from the sun. ... Instead of developing in darkness as nature intended, a preemies retinas receive, in less than three hours, more than eleven times the amount of irradiation recognized as the industrial danger limit for adult workers. In 1986 I wrote to the American Academy of Pediatrics and asked to change its specifications on nursery lighting to less dangerous levels. It sent me a brush-off reply...
I alerted the New York State Department of Health in 1987 about the mountain of evidence incriminating nursery lights. The people there promised to review the situation and then promptly lost my papers.... The group is still 'studying the matter' and the department has not done anything to end the blinding."
Penny Glass, a developmental psychologist at the George Washington University Medical School, has produced evidence indicating that light can cause ROP. Her study, published in 1985 in the New England Journal of Medicine, shows a "significant relation between the intensity of light exposure and the incidence of retinopathy of prematurity." Unprotected prematures had 20 percent more ROP than those in shaded incubators.
However, there is general agreement that ROP cannot be eliminated just by turning down the lights. "The primary cause of ROP is prematurity," said Penny Glass. "To prevent it, you would have to prevent prematurity."
To people who say the only way to prevent ROP is to prevent prematurity, Mr. Aleff says, "Blaming ROP on prematurity is like blaming plane crashes on gravity." He and Dr. Gerald B. Merenstein, Chairman of the Committee of Fetus and Newborn of the American Academy of Pediatrics, debated the lights question on Good Morning America on August 30, 1989. During the program. Peter Aleff explained how he came to conclude that the lights in the NICU blinded his son:
"A year after his birth, I was running a factory where we were curing inks and paints with ultraviolet light, and I studied the occupational safety aspects of the lighting at the time to make sure that everything was OK for the workers; and at the same time I discovered that the same problem applied also to the blue light emitted by the fluorescent lamps in the intensive care nurseries and that the eye damage there would be the same as to the workers."
Dr. Merenstein replied:
"The thought that light might be involved in ROP is not a new one. [fluorescent lights] were studied in several studies then that showed no correlation, and a study just published in June  again looked at it and could find no direct cause ...."
Mr. Aleff countered that the studies showing lights were safe all suffered from the same basic flaw: that the babies were protected only after the first day of their life, and it is sufficient to expose them to fluorescent lights for less than three hours to give them more than 19 times the dose of light that is considered as the danger limit for industrial workers.
Asked what he would have hospitals do, Mr. Aleff said,
"Replace fluorescent lights with incandescent light. ... whenever there is no need for bright lighting to do an examination, then turn them down with a dimmer switch."
Dr. Merenstein then cautioned,
"Anytime we do anything different in the nursery we have to be very careful. ... Premature babies are very, very complex, and simple changes should not be introduced without studying them very carefully. Even something as simple as keeping the lights very low may have an adverse effect that we are not aware of."
Replied Mr. Aleff,
"I do not understand why Dr. Merenstein feels there is a great need for study for switching off the lights when there was no study whatsoever for putting the lights in there in the first place."
A Pediatric Ophthalmologist Comments
Anne Ballen, M.D., is a pediatric ophthalmologist in private practice in Miami, Florida. She is also the mother of two young children. Dr. Ballen had this to say about the lights controversy:
"I'd be interested to see the work Mr. Aleff has done. If limits to fluorescent light exposure by adults have been exceeded in the NICU then he certainly has a valid point."
But Dr. Ballen still questions why so many premature babies do well despite the lights.
"Why do so many prematures at high risk for ROP survive without damage? Oxygen does not seem to be a issue, but we can't be sure. We monitor blood levels from many parts of the circulation, such as central arterial, or radial from heel sticks, but we can't do retina-blood levels. There may be variabilities at the retinal level we can't see."
When asked what she would do about lighting if she had a premature baby in an NICU, Dr. Ballen sighed.
"I like to think I'd do whatever the doctors told me," she said. "But you think differently as a mother than as a physician. I might try to fashion some kind of sunglasses for my baby or other type of protection. I would ask for lights to be turned down at nighttime."
Apparently other doctors feel the same way, although they don't say it aloud.
"I know a neonatologist who says he doesnt believe light has anything to do with ROP," said Dr. Ballen. "But despite his philosophy, on a gut level he must believe there may be a connection, because I've seen him put a towel over babies' eyes."
But what of babies who have no one to protect them from the possibly harmful lights? Dr. Ballen paused, and then said,
"I have no answer except to hang my head in shame. At this point, having looked at the information, I will start to agitate in NICUs about the issue. I'll talk to neonatologists I know and see what can be done."
Peter Aleff has a final comment on the controversy:
"How many doctors will it take to change the lightbulbs in the intensive care nurseries? If they continue so irrationally to deny the evidence that the present lighting hurts the babies, it will probably take a lawyer to tell them to change those lightbulbs."
The above article by Ronnie Londner was published in the Prematurity Column of Twins Magazine, Spring 1990.
Read more press coverage:
Newsweek ¦ Parade Magazine ¦ Aesclepius
People's Medical Society ¦ New York Times
The Catholic Herald
View also the transcripts of TV shows:
a discussion on "Good Morning America" about "Blinding preemies by excess nursery light"
the Canadian Broadcasting Corporation's
"Market Place" program on
"Babies and Blindness"
a "USA Today" show on "Preemies going blind"