Intravitreal anti-vascular endothelial growth factor treatment for retinopathy of prematurity: comparison between Ranibizumab and Bevacizumab. Retina. 2015;35:667-674. [PMID: 25462435 DOI: 10.1097/iae.0000000000000380]

Intravitreal Ranibizumab Injection for the Treatment of Retinopathy of Prematurity

OBJECTIVES

To evaluate the efficacy of a single injection of 0.3 mg intravitreal ranibizumab for the treatment of retinopathy of prematurity (ROP).

METHODS

We conducted this retrospective case series study at King Abdul Aziz Medical City, Riyadh, Saudi Arabia. Seventy-four eyes of 37 preterm infants with ROP stage III with plus disease in zone I, posterior zone II, and aggressive posterior ROP received a single injection of 0.3 mg intravitreal ranibizumab. The favorable outcome measure was complete regression of the disease with normal vascularization of the retina of those infants.

RESULTS

The gestational age of the 37 included cases was in the range of 23-28 weeks and their body weight at birth was between 510 and 1,235 g except for one case with 2,550 g under oxygen therapy <7days with severe hypoglycemia. All eyes showed a favorable response in terms of regression of plus disease from the first day after treatment, followed by regression of stage III retinopathy. All patients developed complete vascularization over variable periods of time.

CONCLUSION

One injection of 0.3 mg intravitreal ranibizumab is effective in treating ROP stage III mainly in zones I and II.

Anti-vascular Endothelial Growth Factor Treatment of Retinopathy of Prematurity: Efficacy, Safety, and Anatomical Outcomes

PURPOSE

To investigate the efficacy, safety, and anatomical outcomes associated with intravitreal anti-vascular endothelial growth factor (VEGF) treatment of retinopathy of prematurity (ROP).

METHODS

We performed a retrospective review of intravitreal anti-VEGF (bevacizumab or ranibizumab) treatment of 153 eyes (83 infants) diagnosed with ROP at two tertiary hospitals from June 2011 to January 2017. The primary outcome was the rate of recurrence requiring additional treatment; secondary outcomes included incidence of major complications and final refractive error.

RESULTS

A total of 101 eyes were treated with bevacizumab, and 52 with ranibizumab. The bevacizumab and ranibizumab groups were characterized by mean birthweights of 941.8 ± 296.1 and 1,257.7 ± 514.5 g, gestational ages at birth of 26.9 ± 1.9 and 28.1 ± 3.2 weeks, and postmenstrual ages at treatment of 40.4 ± 2.4 and 39.2 ± 2.3 weeks, respectively. The two groups differed significantly in birthweights and gestational ages at birth, but not in postmenstrual ages at treatment. The mean follow-up duration was 30.9 ± 18.4 months for the bevacizumab group, and 13.9 ± 12.5 months for ranibizumab. More cases were classified as zone 1 ROP in the ranibizumab group (44.2% vs. 11.9%, p < 0.001). Major surgical interventions included scleral encircling and vitrectomy (one and two eyes, respectively, both in the bevacizumab group). Retinal detachment was noted in one eye treated with bevacizumab. There was no significant difference in the most recent spherical equivalence for the two groups (+0.10 ± 3.66 and +0.22 ± 3.00 diopters for bevacizumab and ranibizumab, respectively). Univariable analysis revealed that only ROP stage influenced the occurrence of major complications (odds ratio, 9.046; p = 0.012).

CONCLUSIONS

Intravitreal anti-VEGF treatment of ROP with both bevacizumab and ranibizumab achieved stable retinal vascularization with a low rate of complications and recurrence. Ranibizumab achieved similar anatomical outcomes as bevacizumab, without additional risk for major complications.

Comparison of intravitreal bevacizumab injection and laser photocoagulation for type 1 zone II retinopathy of prematurity

Purpose

To compare the efficacy of intravitreal bevacizumab (IVB) injection with conventional laser photocoagulation in eyes with type 1 zone II retinopathy of prematurity (ROP).

Methods

Preterm infants with type 1 ROP in zone II (stage 2 or 3 ROP with plus disease) were randomly assigned to intravitreal injection of 0.625 mg/0.025 ml bevacizumab (Group 1) or laser photocoagulation (Group 2). Patients were followed weekly for 4 weeks and then biweekly till 90 weeks gestational age. Also, spherical and cylindrical refractive errors were compared at 90 weeks postmenstrual age (PMA).

Results

A total of 116 preterm infants (232 eyes) were treated and completed the follow-up period. IVB injection was done in 154 eyes (77 cases), and laser photocoagulation was done in 78 eyes (39 cases). ROP regressed after single IVB injection in 149 eyes (96.8%) and in 5 eyes (3.2%) after the second injection. Cataract developed in one eye (0.63%) after IVB injection. ROP regressed in 94.7% of treated eyes (76 eyes) in the laser photocoagulation group; however, retinal fold and traction developed in 2 eyes. Spherical and also cylindrical refractive errors had no significant difference.

Conclusions

Both IVB injection and laser photocoagulation are effective methods for the treatment of type 1 zone II ROP. However, re-treatment requirement may be higher in the IVB injection group. IVB re-injection is an effective option for re-treatment in persistent cases.

Aqueous cytokine levels associated with severity of type 1 retinopathy of prematurity and treatment response to ranibizumab

PURPOSE

To determine the aqueous humor levels of cytokines in eyes with type 1 retinopathy of prematurity (ROP) before primary intravitreal injection of ranibizumab (IVR).

METHODS

Forty-nine infants with type 1 ROP (56 eyes of 28 infants in the threshold ROP group and 42 eyes of 21 infants in the type 1 pre-threshold ROP group) received primary IVR and 49 aqueous humor samples were obtained preoperatively. Aqueous humor samples from 15 infants (15 eyes) undergoing congenital cataract surgery were used as controls. The concentrations of 27 cytokines were measured by a multiplex bead assay. Infants with persistent, recurrent, or progressive ROP after IVR were retreated.

RESULTS

The preoperative aqueous levels of 16 cytokines were significantly different among type 1 pre-threshold, threshold ROP, and control groups (P < 0.05). The concentrations of vascular endothelial growth factor (VEGF) (P < 0.001), interferon-γ (P < 0.001), interleukin (IL)-10 (P < 0.001), and IL-12 (P < 0.001) were the highest in the threshold ROP group, less in the type 1 pre-threshold ROP group, and the lowest in the control group. Retreatment was given to 55% of infants with ROP within a 48-week follow-up period after primary IVR. Higher VEGF (hazard ratio [HR] = 1.001, P = 0.001) and macrophage inflammatory protein-1β (HR = 1.085, P = 0.022) levels were independently correlated with ROP retreatment.

CONCLUSIONS

Higher aqueous levels of VEGF and inflammatory cytokines were associated with more severe type 1 ROP and ROP retreatment after primary IVR.

Gene therapy knockdown of VEGFR2 in retinal endothelial cells to treat retinopathy

Inhibition of vascular endothelial growth factor (VEGF) in retinopathy of prematurity (ROP) raises concerns for premature infants because VEGF is essential for retinovascular development as well as neuronal and glial health. This study tested the hypothesis that endothelial cell-specific knockdown of VEGF receptor 2 (VEGFR2), or downstream STAT3, would inhibit VEGF-induced retinopathy without delaying physiologic retinal vascular development. We developed an endothelial cell-specific lentiviral vector that delivered shRNAs to VEGFR2 or STAT3 and a green fluorescent protein reporter under control of the VE-cadherin promoter. The specificity and efficacy of the lentiviral vector-driven shRNAs were validated in vitro and in vivo. In the rat oxygen-induced retinopathy model highly representative of human ROP, the effects of endothelial cell knockdown of VEGFR2 or STAT3 were determined on intravitreal neovascularization (IVNV), physiologic retinal vascular development [assessed as area of peripheral avascular/total retina (AVA)], retinal structure, and retinal function. Targeted knockdown of VEGFR2 or STAT3 specifically in retinal endothelial cells by subretinal injection of lentiviral vectors into postnatal day 8 rat pup eyes efficiently inhibited IVNV, and knockdown of VEGFR2 also reduced AVA and increased retinal thickness without altering retinal function. Taken together, our results support specific knockdown of VEGFR2 in retinal endothelial cells as a novel therapeutic method to treat retinopathy.

Anti-VEGF for ROP and Pediatric Retinal Diseases

Vascular endothelial growth factor (VEGF) is an important mediator of the pathological neovascularization and vascular permeability of the eye. The increasing use of intravitreal therapies targeting VEGF has revolutionized the treatment of pediatric vitreoretinal diseases. In retinopathy of prematurity (ROP), the role of VEGF in pathogenesis has been well recognized and the use of anti-VEGF treatment in phase 2 ROP has demonstrated promising results, particularly in severe cases of posterior disease. This has made VEGF an established target in the treatment of pediatric retinal diseases known to have abnormal vascular activity. However, questions remain about late systemic and neurodevelopmental effects after anti-VEGF therapy for children because intravitreal injection of anti-VEGF may result in systemic circulation of anti-VEGF agent and a corresponding suppression of systemic VEGF. We do not currently know whether the short-term suppression of systemic VEGF affects long-term neurodevelopmental outcomes because VEGF is a vital supporting factor during neurodevelopment. This review article focuses on the evidence for the use of anti-VEGF treatment in certain pediatric ocular diseases, including ROP, Coats disease, and retinoblastoma. More extensive and prospective studies are warranted to further elucidate the role of anti-VEGF therapy in these diseases and illustrate how we can optimally use these agents in pediatric patients.

Refractive and Biometric Outcomes in Patients with Retinopathy of Prematurity Treated with Intravitreal Injection of Ranibizumab as Compared with Bevacizumab: A Clinical Study of Correction at Three Years of Age

Purpose

To compare refractive and biometric outcomes in patients with type 1 retinopathy of prematurity (ROP) treated with intravitreal injection of ranibizumab (IVR) versus bevacizumab (IVB), at a corrected age of 3 years.

Methods

A retrospective case series compared cycloplegic refractive statuses and biometric statuses in patients who received either IVR or IVB for type 1 ROP, from April 2011 to April 2014.

Results

A total of 62 eyes (33 patients) with type 1 ROP were evaluated (26 eyes in 13 IVR patients and 36 eyes in 20 IVB patients). There were no differences in birth statuses including gestational age and birth body weight between the two groups. The prevalence of refractive error greater than 1 D was higher in the IVB group (p = 0.03), and there was a higher prevalence of high myopia (<-5.0 D, p = 0.03) in the IVB group. Comparisons in biometric finding showed that IVB patients had shallower anterior chamber depth (p = 0.01).

Conclusion

Both IVR and IVB showed low refractive errors, even followed at the corrected age of 3 years. No difference was noted between the two groups in refractive statuses. However, IVB was associated with shallower anterior chamber and higher prevalence of refractive error at the corrected age of 3 years. This trial is registered with NCT03334513.

Comparison of efficacy between anti-vascular endothelial growth factor (VEGF) and laser treatment in Type-1 and threshold retinopathy of prematurity (ROP)

Background

Retinopathy of Prematurity (ROP) is one of the most common causes of childhood blindness worldwide. Comparisons of anti-VEGF and laser treatments in ROP are relatively lacking, and the data are scattered and limited. The objective of this meta-analysis is to compare the efficacy of both treatments in type-1 and threshold ROP.

Methods

A comprehensive literature search on ROP treatment was conducted using PubMed and Embase up to March 2017 in all languages. Major evaluation indexes were extracted from the included studies by two authors. The fixed-effects and random-effects models were used to measure the pooled estimates. The test of heterogeneity was performed using the Q statistic.

Results

Ten studies were included in this meta-analysis. Retreatment incidence was significantly increased for anti-VEGF (OR 2.52; 95% CI 1.37 to 4.66; P = 0.003) compared to the laser treatment, while the incidences of eye complications (OR 0.29; 95% CI 0.10 to 0.82; P = 0.02) and myopia were significantly decreased with anti-VEGF compared to the laser treatment. However, there was no difference in the recurrence incidence (OR 1.86; 95% CI 0.37 to 9.40; P = 0.45) and time between treatment and retreatment (WMD 7.54 weeks; 95% CI 2.00 to 17.08; P = 0.12).

Conclusion

This meta-analysis indicates that laser treatment may be more efficacious than anti-VEGF treatment. However, the results of this meta-analysis also suggest that laser treatment may cause more eye complications and increase myopia. Large-scale prospective RCTs should be performed to assess the efficacy and safety of anti-VEGF versus laser treatment in the future.

Electronic supplementary material

The online version of this article (10.1186/s12886-018-0685-6) contains supplementary material, which is available to authorized users.

Anti-vascular endothelial growth factor (VEGF) drugs for treatment of retinopathy of prematurity

BACKGROUND

Vascular endothelial growth factor (VEGF) plays a key role in angiogenesis in foetal life. Researchers have recently attempted to use anti-VEGF agents for the treatment of retinopathy of prematurity (ROP), a vasoproliferative disorder. The safety and efficacy of these agents in preterm infants with ROP is currently uncertain.

OBJECTIVES

To evaluate the efficacy and safety of anti-VEGF drugs when used either as monotherapy, that is without concomitant cryotherapy or laser therapy, or in combination with planned cryo/laser therapy in preterm infants with type 1 ROP (defined as zone I any stage with plus disease, zone I stage 3 with or without plus disease, or zone II stage 2 or 3 with plus disease).

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL 2016, Issue 11), MEDLINE (1966 to 11 December 2016), Embase (1980 to 11 December 2016), CINAHL (1982 to 11 December 2016), and conference proceedings.

SELECTION CRITERIA

Randomised or quasi-randomised controlled trials that evaluated the efficacy or safety of administration, or both, of anti-VEGF agents compared with conventional therapy in preterm infants with ROP.

DATA COLLECTION AND ANALYSIS

We used standard Cochrane and Cochrane Neonatal methods for data collection and analysis. We used the GRADE approach to assess the quality of the evidence.

MAIN RESULTS

Six trials involving a total of 383 infants fulfilled the inclusion criteria. Five trials compared intravitreal bevacizumab (n = 4) or ranibizumab (n = 1) with conventional laser therapy (monotherapy), while the sixth study compared intravitreal pegaptanib plus conventional laser therapy with laser/cryotherapy (combination therapy).When used as monotherapy, bevacizumab/ranibizumab did not reduce the risk of complete or partial retinal detachment (3 studies; 272 infants; risk ratio (RR) 1.04, 95% confidence interval (CI) 0.21 to 5.13; risk difference (RD) 0.00, 95% CI -0.04 to 0.04; very low-quality evidence), mortality before discharge (2 studies; 229 infants; RR 1.50, 95% CI 0.26 to 8.75), corneal opacity requiring corneal transplant (1 study; 286 eyes; RR 0.34, 95% CI 0.01 to 8.26), or lens opacity requiring cataract removal (3 studies; 544 eyes; RR 0.15, 95% CI 0.01 to 2.79). The risk of recurrence of ROP requiring retreatment also did not differ between groups (2 studies; 193 infants; RR 0.88, 95% CI 0.47 to 1.63; RD -0.02, 95% CI -0.12 to 0.07; very low-quality evidence). Subgroup analysis showed a significant reduction in the risk of recurrence in infants with zone I ROP (RR 0.15, 95% CI 0.04 to 0.62), but an increased risk of recurrence in infants with zone II ROP (RR 2.53, 95% CI 1.01 to 6.32). Pooled analysis of studies that reported eye-level outcomes also revealed significant increase in the risk of recurrence of ROP in the eyes that received bevacizumab (RR 5.36, 95% CI 1.22 to 23.50; RD 0.10, 95% CI 0.03 to 0.17). Infants who received intravitreal bevacizumab had a significantly lower risk of refractive errors (very high myopia) at 30 months of age (1 study; 211 eyes; RR 0.06, 95% CI 0.02 to 0.20; RD -0.40, 95% CI -0.50 to -0.30; low-quality evidence).When used in combination with laser therapy, intravitreal pegaptanib was found to reduce the risk of retinal detachment when compared to laser/cryotherapy alone (152 eyes; RR 0.26, 95% CI 0.12 to 0.55; RD -0.29, 95% CI -0.42 to -0.16; low-quality evidence). The incidence of recurrence of ROP by 55 weeks' postmenstrual age was also lower in the pegaptanib + laser therapy group (76 infants; RR 0.29, 95% CI 0.12 to 0.7; RD -0.35, 95% CI -0.55 to -0.16; low-quality evidence). There was no difference in the risk of perioperative retinal haemorrhages between the two groups (152 eyes; RR 0.62, 95% CI 0.24 to 1.56; RD -0.05, 95% CI -0.16 to 0.05; very low-quality evidence). However, the risk of delayed systemic adverse effects with any of the three anti-VEGF drugs is not known.

AUTHORS' CONCLUSIONS

Implications for practice: Intravitreal bevacizumab/ranibizumab, when used as monotherapy, reduces the risk of refractive errors during childhood but does not reduce the risk of retinal detachment or recurrence of ROP in infants with type 1 ROP. While the intervention might reduce the risk of recurrence of ROP in infants with zone I ROP, it can potentially result in higher risk of recurrence requiring retreatment in those with zone II ROP. Intravitreal pegaptanib, when used in conjunction with laser therapy, reduces the risk of retinal detachment as well as the recurrence of ROP in infants with type 1 ROP. However, the quality of the evidence was very low to low for most outcomes due to risk of detection bias and other biases. The effects on other critical outcomes and, more importantly, the long-term systemic adverse effects of the drugs are not known. Insufficient data precludes strong conclusions favouring routine use of intravitreal anti-VEGF agents - either as monotherapy or in conjunction with laser therapy - in preterm infants with type 1 ROP.

IMPLICATIONS FOR RESEARCH

Further studies are needed to evaluate the effect of anti-VEGF agents on structural and functional outcomes in childhood and delayed systemic effects including adverse neurodevelopmental outcomes.

Management of Retinopathy of Prematurity--Use of Anti-VEGF Therapy

Retinopathy of prematurity (ROP) is a leading cause of childhood blindness worldwide. Although laser photocoagulation re-mains the gold standard for treating threshold and prethreshold disease (type 1 ROP), the off-label use of anti‒vascular endothelial growth factor (anti-VEGF) therapy to treat ROP is increasing. Benefits include acute regression of ROP, growth of retinal vasculature beyond the demarcation line, lesser degree of myopia and peripheral visual field loss, and avoidance of sedation and intubation required for laser. However, controversies regarding anti-VEGF in this vulnerable population persist including choice of anti-VEGF agent, dosing, systemic absorption, safety, and late recurrence. This review updates recent evidence regarding the use of anti-VEGF therapy in the management of ROP.

SERUM VASCULAR ENDOTHELIAL GROWTH FACTOR AFTER BEVACIZUMAB OR RANIBIZUMAB TREATMENT FOR RETINOPATHY OF PREMATURITY

PURPOSE

To investigate vascular endothelial growth factor (VEGF) levels in the systemic circulation after intravitreal injections of bevacizumab (IVB) or ranibizumab (IVR) in patients with Type 1 retinopathy of prematurity (ROP).

METHODS

Patients who had Type 1 ROP and received IVB or IVR were enrolled. Serum samples were collected before and up to 12 weeks after IVB or IVR treatment. The main outcome measurements were serum levels of VEGF up to 12 weeks after anti-VEGF treatment.

RESULTS

In total, 10 patients with Type 1 ROP were enrolled in this study. All the eyes had complete resolution of abnormal neovascularization of ROP after IVB or IVR. In the direct comparison of IVB with IVR, serum VEGF was found to be suppressed more in patients with Type 1 ROP who received IVB treatment, compared with those who received IVR treatment (P = 0.01, P = 0.03, and P = 0.03, respectively, 2, 4, and 8 weeks after intravitreal injection).

CONCLUSION

Serum VEGF levels in patients with Type 1 ROP were suppressed for 2 months after treatment with IVB, and VEGF levels were less affected after IVR treatment. Further studies are warranted to investigate the long-term effects of VEGF changes in ROP patients.

Ranibizumab after laser photocoagulation failure in retinopathy of prematurity (ROP) treatment

The purpose of this study was to investigate the anatomical and functional outcomes of the two-stage treatment of severe retinopathy of prematurity (ROP) using laser photocoagulation and intravitreal ranibizumab injection. The medical records of 53 eyes of 28 infants treated by conventional laser photocoagulation with deferred intravitreal 0.25 mg/0.025 mL ranibizumab injection were analysed. All patients had at least 11 months of follow-up. In the analysed group, the mean gestational age at birth was 25 weeks and mean birthweight was 790 g. The mean time of laser photocoagulation was 34 weeks of postmenstrual age (PMA). Ranibizumab injection was performed on average at 37 weeks of PMA. The mean time between interventions was 19 days. Retinal detachment occurred in 12 eyes (22.6%), in three children bilaterally. Visual responses were obtained in 23 of 28 treated children. Our results indicate that ranibizumab injection can be taken into consideration in the selected cases of laser photocoagulation failure. The unsatisfactory results of this study elicited a change in the ROP treatment protocol in our medical centre. The study gives an insight into anatomical and functional outcomes of ROP treatment in the Central and Eastern European population.

Low-dose ranibizumab as primary treatment of posterior type I retinopathy of prematurity

OBJECTIVE

The aim of this study was to evaluate the visual and structural outcomes of eyes that received ranibizumab as treatment for retinopathy of prematurity (ROP).

METHODS

This was a retrospective case series of infants who received a 0.2 mg (0.02 mL) intravitreal injection of ranibizumab as the primary treatment for type 1 ROP. Outcome measures included regression or recurrence of ROP, complications of treatment, and assessment of visual acuity and refractive error.

RESULTS

Forty-two eyes of 21 infants (13 male) were included. Mean gestational age and birth weight were 24.6 ± 1.3 weeks and 613 ± 91 g, respectively. Mean age at injection was 37.4 ± 2.2 weeks postmenstrual age, and mean follow-up period was 10.1 ± 7 months. Active neovascularization regressed rapidly, and anatomical outcomes were favourable in all eyes. Twelve eyes of 6 infants received supplemental laser photocoagulation at a mean post-menstrual age (PMA) of 72.0 ± 27.3 weeks when vascularization had not advanced beyond zone II. Visual acuity was measurable in 28 of 42 eyes. Mean visual acuity was 0.94 ± 0.36 logMAR. Mean spherical equivalent was +1.00. There were no ocular or systemic complications in these patients and no cicatricial complications were observed with no progression to stage 4 or 5 disease.

CONCLUSIONS

A single intravitreal dose of 0.2 mg (0.02 mL) ranibizumab showed favourable anatomical and functional outcomes in eyes with type 1 ROP.

Advances in understanding and management of retinopathy of prematurity

The understanding, diagnosis, and treatment of retinopathy of prematurity have changed in the 70 years since the original description of retrolental fibroplasia associated with high oxygenation. It is now recognized that retinopathy of prematurity differs in appearance worldwide and as ever smaller and younger premature infants survive. New methods are being evaluated to image the retina, diagnose severe retinopathy of prematurity, and determine windows of time for treatment to save eyes and improve visual and neural outcomes. New treatments to promote physiologic retinal vascular development, vascular repair, and inhibit vasoproliferation by regulating proteins involved in vascular endothelial growth factor, insulin-like growth factor, or erythropoietin signaling. Reducing excessive oxidative/nitrosative stress and understanding progenitor cells and neurovascular and glial vascular interactions are being studied.

Ranibizumab Injection as Primary Treatment in Patients with Retinopathy of Prematurity: Anatomic Outcomes and Influencing Factors

PURPOSE

To investigate the anatomic outcomes and influencing factors of ranibizumab in the treatment of retinopathy of prematurity (ROP).

DESIGN

Retrospective case series.

PARTICIPANTS

A total of 283 eyes of 145 patients with type 1 ROP treated with intravitreal injection of ranibizumab (IVR) as primary treatment.

METHODS

Retrospective review of infants who were diagnosed with type 1 ROP and accepted IVR (0.25 mg/0.025 ml) as primary treatment from January 2012 to August 2015. The anatomic outcomes and the influencing factors were analyzed.

MAIN OUTCOME MEASURES

Anatomic outcomes of ROP eyes after IVR and the influencing factors.

RESULTS

A total of 283 eyes of 145 patients were included in this study. There were a total of 266 eyes (94.0%) in the positive response group and 17 eyes (6.0%) in the negative/no response group after IVR. Within the positive response group, 139 eyes (48.6%) were in the regression without reactivation subgroup, and 127 eyes (44.9%) were in the regression with reactivation subgroup. A total of 152 eyes received additional laser or surgical treatment. At the last visit, 278 eyes (98.2%) had attached retinas, and 5 eyes (1.8%) had retinal detachment. A classification tree model showed that for patients with gestational age (GA) ≤29.5 weeks, the possibility of experiencing reactivation after IVR is higher than that of those with GA >29.5 weeks (61.6% vs. 29.6%). Moreover, for patients with GA ≤29.5 weeks, those diagnosed with zone II stage 2+ ROP have a lower possibility of experiencing reactivation than other patients (37.9% vs. 80%).

CONCLUSIONS

Intravitreal injection of ranibizumab seemed to be effective in treating patients with ROP. After treatment, there were primarily 3 different outcomes. Our predictive tree model is helpful for ophthalmologists to evaluate the risk of reactivation.

Recurrence of Retinopathy of Prematurity in Zone II Stage 3+ after Ranibizumab Treatment: A Retrospective Study

Objective. To determine the prevalence and risk factors for the recurrence of retinopathy of prematurity (ROP) in Zone II Stage 3+ after ranibizumab treatment. Methods. This was a retrospective, nonrandomized, noncontrolled study that excluded Zone I and aggressive posterior ROP (APROP) cases. Infants who developed Zone II Stage 3 ROP with plus disease and underwent initial intravitreal injection of ranibizumab (IVR) were recruited. Patients were divided into 2 groups based on the outcome after initial ranibizumab treatment: recurrence of ROP or favorable outcome. Data was collected and analyzed by SPSS 16.0. Results. Forty-two patients were included, and 80 eyes with Zone II Stage 3+ were subjected to IVR treatment. Eleven of 42 patients (26.2%, 18 eyes) had a recurrence of ROP after the initial treatment. On univariate analysis, preretinal hemorrhage before treatment was significantly different between the two groups (P = 0.000). Multivariate analysis found that preretinal hemorrhage before treatment was the only factor associated with the recurrence of ROP in our study (P = 0.004). Conclusions. The recurrence rate of ROP in Zone II Stage 3+ after initial ranibizumab treatment was notable and preretinal hemorrhage before treatment was associated with the recurrence of ROP in our study.

Results of intravitreal ranibizumab treatment for retinopathy of prematurity in infants

PURPOSE

To assess the results of intravitreal ranibizumab treatment for retinopathy of prematurity (ROP) in infants.

METHODS

A single-institution, retrospective consecutive case series.

RESULTS

Thirty-one patients who received ranibizumab treatment for ROP were evaluated in this study. The mean follow-up time was 14 ± 1.37 months. Vascularization of the peripheral retina had completed with delay in the majority of cases and also avascular areas were present in the peripheral retinas of five infants at one year of age. Although recurrence of ROP developed in 14 infants after single-dose ranibizumab treatment, only four infants received additional treatment due to recurrence of ROP requiring treatment. No serious ocular complications were reported, but, two infants died in this series.

CONCLUSION

Even so ranibizumab treatment is an effective therapy for ROP in early period, close monitoring after injection is necessary due to the high incidence of recurrence. In addition, questions remain regarding the systemic safety of ranibizumab. Further studies are needed to study the systemic and ocular side effects of ranibizumab.

Genetic analysis and clinical features of X-linked retinoschisis in Chinese patients

Many mutations in the retinoschisis (RS1) gene have been identified, but there are limited clinical data relating to the different genotypes. This study investigated the genotype, clinical phenotype and therapies for X-linked juvenile retinoschisis (XLRS) patients in China to evaluate the effects of gene mutations and therapies on the prognosis of the disease. Thirty patients were recruited in the study. Genetic examination identified 8 novel RS1 gene mutations. Twenty-four patients were identified as missense mutation, which was the most common gene mutation in XLRS patients. Amino acids 102 and 209 were the most common mutation areas, accounting for a total 35.7% of all patients. Mutations affecting amino acid 102 were associated with poor results on the flash electroretinogram (ERG). Sixteen patients had various complications. Anti-vascular endothelial growth factor (VEGF) drugs were given to four patients with hemorrhage or other complications, and serious adverse events did not occur. Our outcome demonstrates that missense mutation was the leading cause of XLRS and more than half of the patients with this missense had various complications. Anti-VEGF drugs may be an effective and safe way to prevent deterioration of XLRS with certain complications. There is wide genotypic and phenotypic variability in Chinese patients with XLRS.

Comparison of Intravitreal Bevacizumab, Intravitreal Ranibizumab and Laser Photocoagulation for Treatment of Type 1 Retinopathy of Prematurity in Turkish Preterm Children

PURPOSE

To evaluate effectiveness of treatment modalities, major complications and refractive errors in children who were treated with intravitreal bevacizumab (IVB), intravitreal ranibizumab (IVR) or laser photocoagulation (LP) for type 1 retinopathy of prematurity (ROP).

METHODS

Premature infants who underwent IVB monotherapy (Group 1), IVR monotherapy (Group 2) or LP (Group 3) for type 1 ROP and infants with spontaneously regressed ROP (Group 4) were included for the study. Major complications, recurrence rate, recurrence time, total retinal vascularization time and refractive errors at 18 months of corrected age (CA) were determined.

RESULTS

Groups 1, 2, 3 and 4 included 24 eyes of 12 patients, 12 eyes of six patients, 72 eyes of 36 patients and 148 eyes of 74 patients, respectively. Recurrence of the disease occurred in two eyes of one patient in Group 1 at 52 weeks of postmenstrual age (PMA) and two eyes of one patient at 48 weeks of PMA in Group 2. In Group 3, disease did not regress after the first treatment in 10 eyes of five patients. The mean vascularization time in Group 1 was 73 ± 10.1 weeks of PMA and 61.8 ± 6.6 weeks of PMA in Group 2 (p = 0.027). Macular ectopia was seen in two eyes of one patient and exudative retinal detachment (ERD) occurred in two eyes of one patient in Group 3. Mean spherical equivalent was 1.49 ± 3.04 diopters (D) in Group 1, -1.79 ± 2.87D in Group 2, -1.27 ± 2.8 D in Group 3 and 1.52 ± 1.07 D in Group 4 at 18 months of CA. There was no significant difference in astigmatism values in all groups.

CONCLUSION

IVB, IVR and LP are options that can successfully treat ROP. Myopia was observed to be the main refractive error in all treatment groups. Vascularization of the retina was completed later in the IVB group than in the IVR group.

Antivascular endothelial growth factor in the treatment of retinopathy of prematurity

PURPOSE OF REVIEW

To review the most recent literature regarding the clinical experience of antivascular endothelial growth factor (anti-VEGF) therapies in the treatment of retinopathy of prematurity (ROP).

RECENT FINDINGS

Anti-VEGF agents in stage 3+ and aggressive posterior ROP have been shown to induce rapid ROP regression. However, significant reoccurrence rates can require repeat injections and thus longer term and more frequent follow-up. Initial studies reflect conflicting evidence regarding significant systemic side effects of these treatments, and outcomes in these patients past the first few years of life are yet to be definitively determined.

SUMMARY

Although anti-VEGF therapies show promise in the treatment of ROP, frequent reoccurrences and lack of thorough data about long-term side effects of pharmacologic intervention necessitate further research before anti-VEGF agents become the mainstay of ROP management.

Combination of Intravitreal Injection of Ranibizumab and Photocoagulation for the Treatment of Aggressive Posterior Retinopathy of Prematurity with Vitreous Hemorrhage

To investigate the efficacy of intravitreal ranibizumab (IVR) combined with laser photocoagulation for aggressive posterior retinopathy of prematurity (AP-ROP) patients with vitreous hemorrhage, we conducted a retrospective observational case series study. A total of 37 eyes of 20 patients' medical records were reviewed. Patients first received IVR (0.25 mg/0.025 mL) and later photocoagulation. The mean postconceptual age of injection was 34.6 ± 1.4 weeks, and the mean follow-up period was 39.3 ± 8.3 weeks. During the follow-up, 96.6% eyes had various degree of rapid absorption of vitreous hemorrhage after IVR. The mean time of received first photocoagulation after IVR was 4.8 ± 2.9 weeks. Ten (27.0%) eyes received second laser therapy and the mean time of second laser therapy after IVR was 3.2 ± 0.8 weeks. All eyes exhibited adequate regression of ROP and were stable with attached retina. Fibrosis membrane was observed in seven eyes (18.9%) and three of them demonstrated mild ectopic macula. No significant side effects related to IVR were observed. So IVR could be conducted as primary treatment of AP-ROP associated with vitreous hemorrhage, which can improve the fundus visibility, followed by conventional photocoagulation. Further randomized controlled trials are necessary to compare the clinical efficacy and safety with conventional interventions.

A lower dose of intravitreal bevacizumab effectively treats retinopathy of prematurity

PURPOSE

To determine whether a low dose (0.25 mg/0.01 mL) of intravitreal bevacizumab is effective in the treatment of type 1 retinopathy of prematurity (ROP).

METHODS

This prospective, noncomparative, interventional case series included all consecutive infants who received 0.25 mg/0.01 mL of intravitreal bevacizumab for type 1 ROP. Infants were followed for ROP persistence/recurrence until 90 weeks' postmenstrual age.

RESULTS

A total of 49 eyes of 25 infants (24 bilateral and 1 unilateral) underwent intravitreal injection of a reduced dose (0.25 mg/0.01 mL) of intravitreal bevacizumab. ROP regressed in all eyes. Follow-up continued until 90 weeks' postmenstrual age and showed no recurrences of plus disease or neovascularization.

CONCLUSIONS

All eyes treated with 0.25mg/0.01ml intravitreal bevacizumab showed complete regression, with no recurrence of plus disease or neovascularization. No safety issues were attributable to bevacizumab during the study period.

Smouldering retinopathy of prematurity: a case treated by multiple antivascular endothelial growth factor therapy

A 13 months old female baby born at 24 weeks of gestational age (GA) presented with stage 4A retinopathy of prematurity (ROP) with plus disease in the right eye and stage 3 with plus disease in the left eye. The baby was diagnosed with stage 3 zone 2 ROP in both eyes with plus disease at 32 weeks of GA and received intravitreal bevacizumab in both eyes. The baby received intravitreal bevacizumab and ranibizumab injections at 39 and 57 weeks of postmenstrual age (PMA), respectively for recurrence. Laser treatment to peripheral avascular retina was carried out at 67 weeks of PMA. The right eye progressed to stage 4A and left eye developed pre-retinal haemorrhages. This case reports late recurrence treated with initial multiple antivascular endothelial growth factor (VEGF) injections alone. One should be cautious in using anti-VEGF agents as a monotherapy in cases of ROP that appear different from the current understanding of the natural course of the disease.

Comparison of Bevacizumab, Ranibizumab, and Laser Photocoagulation in the Treatment of Retinopathy of Prematurity in Turkey

PURPOSE

To evaluate the efficacies and treatment outcomes following intravitreal bevacizumab (IVB), intravitreal ranibizumab (IVR), and laser photocoagulation (LPC) in retinopathy of prematurity (ROP).

METHODS

This was a retrospective interventional case series study including the data of 134 infants (264 eyes) who were treated with IVB, IVR, or LPC for ROP. The data were collected from two major ROP treatment centers in Turkey without any randomization or masking. Regression of ROP, recurrence profile, complications after each treatment modality, and indications for retreatment were evaluated. The main outcome measures included the total inactivation of ROP with anatomic and refractive outcomes at 1.5 years of adjusted age.

RESULTS

There were 55 infants (41.1%) in the IVB group, 22 infants (16.4%) in the IVR group, and 57 infants (42.5%) in the LPC group. All but 3 infants (5.5%) in the IVB group and 11 infants (50%) in the IVR group showed recurrence to stage 1 and 2 ROP following IVB and IVR (p < 0.001). Retreatment was performed in three infants in both IVB and IVR groups (p = 0.098). At 1.5 years of adjusted age, all infants showed favorable anatomic outcome except one infant in the LPC group. No significant difference of the mean spherical equivalent (SE) was observed between the groups (p = 0.131). In Zone I ROP, laser treated infants had significantly higher rates of myopia and high myopia than IVB and IVR treated infants (p = 0.040 and p = 0.019, respectively).

CONCLUSIONS

Both IVB and IVR treated infants had significantly better refractive outcomes in Zone I ROP as compared to LPC treated infants at 1.5 years of adjusted age. The higher rate of disease recurrence was associated with IVR. Gestational age (GA) and the zone of ROP were also predictive factors for recurrence of ROP in the study.

Review of effects of anti-VEGF treatment on refractive error

To examine the effect of anti-vascular endothelial growth factor (anti-VEGF) agents on refractive error in the setting of retinopathy of prematurity (ROP) through a review of the literature, a PubMed search was performed of appropriate search terms, and the results of all relevant studies were extracted and compiled. Eleven relevant articles were identified in the literature, totaling 466 eyes, treated with varied anti-VEGF agents (bevacizumab, ranibizumab, and aflibercept) with mean spherical equivalent refractions ranging from +0.75 D to −3.57 D, with prevalence of high myopia ranging from 0 to 35%. Anti-VEGF monotherapy for ROP leads to low levels of myopia, and there may be a differential effect of specific anti-VEGF agents utilized on refractive outcomes.

Risk of recurrence of retinopathy of prematurity after initial intravitreal ranibizumab therapy

We report our experience with the use of intravitreal ranibizumab for the treatment of retinopathy of prematurity (ROP). A retrospective review was performed on 138 consecutive infants screened at a single centre over 18 months. Intravitreal ranibizumab was offered in selected cases requiring treatment, such as aggressive posterior ROP or poor mydriasis. 2 eyes of 1 infant received intravitreal ranibizumab alone and 8 eyes of 5 infants received combined intravitreal ranibizumab and laser therapy. 3 out of 8 eyes treated initially with intravitreal ranibizumab monotherapy had persistent disease requiring laser therapy, and 3 out of 5 eyes with initial regression suffered disease recurrence at a mean of 7.6 weeks post-injection. 2 eyes treated first with laser followed by intravitreal ranibizumab had disease regression without recurrence. Our cohort demonstrate a significant rate of persistent disease and recurrence in ROP eyes treated initially with intravitreal ranibizumab monotherapy, which is greater and earlier than that reported for intravitreal bevacizumab in the BEAT-ROP study. Intravitreal ranibizumab may be useful as an initial treatment in selected cases of ROP when laser therapy as first line is suboptimal. However, close monitoring is important and adjunctive laser therapy may subsequently be needed in a majority of cases.

Pharmacologic interventions for the prevention and treatment of retinopathy of prematurity

Retinopathy of prematurity (ROP), a significant morbidity in prematurely born infants, is the most common cause of visual impairment and blindness in children and persists till adulthood. Strict control of oxygen therapy and prevention of intermittent hypoxia are the keys in the prevention of ROP, but pharmacologic interventions have decreased risk of ROP. Various drug classes such as methylxanthines (caffeine), VEGF inhibitors, antioxidants, and others have decreased ROP occurrence. The timing of pharmacologic intervention remains unsettled, but early prevention rather than controlling disease progression may be preferred. These drugs act through different mechanisms, and synergistic approaches should be considered to maximize efficacy and safety.

Retinopathy of prematurity: Past, present and future

Retinopathy of prematurity (ROP) is a vasoproliferative disorder of the retina occurring principally in new born preterm infants. It is an avoidable cause of childhood blindness. With the increase in the survival of preterm babies, ROP has become the leading cause of preventable childhood blindness throughout the world. A simple screening test done within a few weeks after birth by an ophthalmologist can avoid this preventable blindness. Although screening guidelines and protocols are strictly followed in the developed nations, it lacks in developing economies like India and China, which have the highest number of preterm deliveries in the world. The burden of this blindness in these countries is set to increase tremendously in the future, if corrective steps are not taken immediately. ROP first emerged in 1940s and 1950s, when it was called retrolental fibroplasia. Several epidemics of this disease were and are still occurring in different regions of the world and since then a lot of research has been done on this disease. However, till date very few comprehensive review articles covering all the aspects of ROP are published. This review highlights the past, present and future strategies in managing this disease. It would help the pediatricians to update their current knowledge on ROP.

Intravitreal ranibizumab as a primary or a combined treatment for severe retinopathy of prematurity

PURPOSE

The aim of the study was to assess the outcomes of severe retinopathy of prematurity (ROP) in zone I or posterior zone II treated with intravitreal ranibizumab (IVR) as monotherapy or combined treatment with laser photocoagulation.

METHODS

This is a retrospective study analyzing clinical records of the included patients. Patients were divided into two groups: group 1 included patients who received only IVR treatment; and group 2 was subdivided into group 2A - including patients with IVR as initial treatment and complementary laser photocoagulation if retinal neovascularization or plus disease did not regress, and group 2B - including patients with initial laser photocoagulation and IVR as rescue therapy. Favorable outcomes were regression of the retinal neovascularization and plus disease, meaning control of the disease. Unfavorable outcomes were progression to stages 4 and 5 of ROP.

RESULTS

Fifty-seven eyes were included in the study. Mean birth weight and gestational age were 1,281±254 g and 29.5±2.1 weeks, respectively. Group 1 comprised of 16 eyes, with favorable outcomes in 14 eyes (87.5%). Group 2 comprised of 41 eyes, with favorable outcomes in 29 eyes (70.7%), in a mean follow-up period of 12.8 months.

CONCLUSION

IVR was effective to treat severe cases of ROP as a primary or a combined treatment. Forty-three of the 57 treated eyes (75.4%) achieved regression of ROP and favorable outcomes.

Ultrasonographic demonstration of the superior ophthalmic vein in the orbit of premature infants with and without retinopathy of prematurity

Retinopathy of prematurity (ROP), which develops due to abnormal retinal vascularization in premature babies, can lead to irreversible vision loss. B-scan ocular ultrasonography is a noninvasive examination which makes it possible to image the eye and orbit. Our purpose was to echographically assess the orbit of premature babies with and without retinopathy of prematurity (ROP), with a focus on the superior ophthalmic vein (SOV) which is normally not detected by orbital ultrasound. A prospective study design was used after approved by the local institutional review board. ROP was diagnosed by routine ophthalmoscopic exam. Orbital ultrasound was performed by a single experienced ophthalmologist and ultra-sonographer who was masked to the routine ROP screening results. The results of the ophthalmoscopic exam were compared to the orbital ultrasound findings. The study group was divided into those diagnosed with ROP and those not diagnosed with ROP and were found to be comparable by age and weight at the time of the US examination. The SOV was dilated in 21 of 22 eyes (95.4%) with ROP and in only 5 of 32 eyes (15.6%) without ROP. The present study suggests an association between ROP and dilatation of the SOV.

A Systematic Review and Meta-Analysis on the Safety of Vascular Endothelial Growth Factor (VEGF) Inhibitors for the Treatment of Retinopathy of Prematurity

INTRODUCTION

Laser photocoagulation is the current gold standard treatment for proliferative retinopathy of prematurity (ROP). However, it permanently reduces the visual field and might induce myopia. Vascular endothelial growth factor (VEGF) inhibitors for the treatment of ROP may enable continuing vascularization of the retina, potentially allowing the preservation of the visual field. However, for their use in infants concern remains. This meta-analysis explores the safety of VEGF inhibitors.

METHODS

The Ovid Interface was used to perform a systematic review of the literature in the databases PubMed, EMBASE and the Cochrane Library.

RESULTS

This meta-analysis included 24 original reports (including 1.457 eyes) on VEGF inhibitor treatment for ROP. The trials were solely observational except for one randomized and two case-control studies. We estimated a 6-month risk of retreatment per eye of 2.8%, and a 6-month risk of ocular complication without the need of retreatment of 1.6% per eye. Systemic complications were only reported as isolated incidents.

DISCUSSION

VEGF inhibitors seem to be associated with low recurrence rates and ocular complication rates. They may have the benefit of potentially allowing the preservation of visual field and lower rates of myopia. Due to the lack of data, the risk of systemic side effects cannot be assessed.