Aggressive Posterior Retinopathy of Prematurity Treated with Intravitreal Bevacizumab: Late Period Fluorescein Angiographic Findings

Vascular imaging findings in retinopathy of prematurity

Retinopathy of prematurity (ROP) is a vascular disease among preterm infants involving incomplete or abnormal retinal vascularization and is a leading cause of preventable blindness globally. Measurements of ocular blood flow originating from a variety of imaging modalities, including colour Doppler imaging (CDI), fluorescein angiography (FA) and ocular coherence tomography angiography (OCTA), have been associated with changes in ROP patients. Herein, we discuss and summarize the relevant current literature on vascular imaging and ROP reviewed through December 2022. Differences in vascular imaging parameters between ROP patients and healthy controls are reviewed and summarized. The available data identify significantly increased peak systolic velocity (PSV) in the central retinal artery and ophthalmic artery as measured by CDI, increased vascular tortuosity as measured by FA, smaller foveal avascular zone (FAZ) as measured by FA and OCTA, and increased foveal vessel density (VD) and reduced parafoveal VD as measured by OCTA in ROP patients compared with controls. None of the above findings appear to reliably correlate with visual acuity. The studies currently available, however, are inconclusive and lack robust longitudinal data. Vascular imaging demonstrates the potential to aid in the diagnosis, management and monitoring of ROP, alongside retinal examination via indirect ophthalmoscopy and fundus photography.

Visual field after anti-vascular endothelial growth factor therapy and laser treatment for retinopathy of prematurity

PURPOSE

To evaluate the visual field after anti-vascular endothelial growth factor (VEGF) therapy and laser treatment for retinopathy of prematurity.

METHOD

Retrospective cohort study. Infants with retinopathy of prematurity treated by anti-VEGF therapy or laser treatment were included in the study. Degrees of visual field in eight directions examined by Goldmann perimeter (intensity, 1000 apostilb; size, V4e = 64 mm2) were compared between the anti-VEGF therapy and laser treatment groups. The visual acuity (VA) and spherical equivalent refraction were also compared between the two groups.

RESULTS

Nine eyes with anti-VEGF therapy and 12 eyes with laser treatment were enrolled in the analysis. The total, upper, nasal upper, nasal, nasal lower, temporal lower, and temporal upper visual fields were significantly wider in the eyes with anti-VEGF therapy than in those with laser treatment (496 vs 416, P = .002; 53 vs 45, P = .008; 56 vs 43, P = .003; 58 vs 39, P < .001; 55 vs 44, P = .01; 72 vs 65, P = .01; and 62 vs 56, P = .03, respectively). The logarithm of the minimum angle of resolution VA tended to be better in the eyes with anti-VEGF therapy than in those with laser treatment (0.01 vs 0.15, P = .06). Eyes with anti-VEGF therapy had significantly lower myopia than those with laser treatment (spherical equivalent refraction: -0.72 vs -5.7, P = .001).

CONCLUSION

Anti-VEGF therapy may provide a wider visual field, better VA, and less myopia compared with laser treatment.

Aggressive posterior retinopathy of prematurity: a review on current understanding

A review of literature was performed, focused on the etiopathogenesis of aggressive posterior retinopathy of prematurity (APROP), the characteristic and atypical clinical features, management strategies, anatomical and visual outcomes. Characteristically APROP has zone I/posterior zone II involvement with prominent plus disease, featureless junction, large vascular loops, flat extra-retinal fibrovascular proliferation, and a rapidly progressive course. The risk factors for APROP are extreme prematurity (birth weight ≤1000 gram and/or gestational age ≤28 weeks), dysregulated oxygen supplementation, intrauterine growth retardation, sepsis, and thrombocytopenia. The uncommon presentations include small zone I disease, a hybrid disease with additional ridge tissue, and APROP in bigger babies with birth weight greater than 1500 g. Laser photocoagulation role is limited by the resultant visual field loss and high refractive error. Although anti-vascular endothelial growth factor injection allows peripheral retinal vascularization; reactivation of disease, systemic absorption of the drug and long-term safety are the chief concerns. Early vitrectomy is required when tractional retinal detachment develops. The visual outcome depends upon the morphology and vascular development of the macula. With the limited yet emerging new understanding of the pathophysiology, a multifaceted rational and individualized treatment strategy is suggested for APROP. Best practices in neonatal intensive care may prevent the occurrence of APROP. Further studies need to be performed for the prevention and safe, effective management of APROP.

The results of intravitreal bevacizumab monotherapy for treating aggressive posterior retinopathy of prematurity and Type 1 retinopathy of prematurity

OBJECTIVES

This study evaluated the efficacy of intravitreal bevacizumab (IVB) monotherapy for aggressive posterior retinopathy of prematurity (APROP) and Type 1 retinopathy of prematurity (ROP), along with recurrence rates and treatment outcomes for recurrences.

METHODS

This retrospective cohort study reviewed the records of infants with ROP (Type 1 and APROP), who received IVB treatment between March 2013 and February 2018.

RESULTS

A total of 257 eyes from 130 cases (unilateral eyes in three cases) were included. Cases were followed for 121.7 ± 45.7 weeks (range: 70-260 weeks). Recurrence requiring treatment was determined in 14.8% of all eyes at a mean of 9.6 ± 2.7 weeks (range: 6-15 weeks) after initial treatment and a mean of 42.3 ± 2.2 weeks (range: 38-48 weeks) postmenstrual age. Recurrence requiring treatment was observed in 20.8% of APROP and 5.8% of Type 1 ROP eyes at a statistically significant difference (p = 0.001). Persistent avascular areas were found in 54 eyes (25.8%) at the corrected age of 1 year, and prophylactic laser treatment was applied. This was statistically significantly higher in APROP (38.6%) than in Type 1 ROP (10.5%) (p < 0.001). An unfavourable structural outcome (progression to retinal detachment) occurred in one eye (0.4%), which developed insufficient regression and progression.

CONCLUSIONS

IVB monotherapy is effective for APROP and Type 1 ROP with Zone 1 and posterior Zone 2 localisation. However, because of recurrences requiring treatment and persistent peripheral avascular areas, severe, late complications must be considered, and follow-up examinations must be made. Prophylactic laser treatment for persistent avascular areas seems effective for minimising long-term complications.

Red cell distribution width and its association with retinopathy of prematurity

OBJECTIVE

The aim of this study was to evaluate whether there is a relationship between red cell distribution width (RDW) values and the development of retinopathy of prematurity (ROP) in premature infants.

METHODS

This retrospective study was conducted on a total of 159 infants with gestational age (GA) < 35 weeks including 77 infants diagnosed as ROP (patients' group) and 82 infants without ROP (control group) between September 2015 and January 2018. RDW values of the preterm infants were obtained from their medical records (routine postpartum cord blood sample and follow-up venous blood samples taken at first week, second week and first month). The possible relationship between RDW values and clinical features of ROP development was evaluated.

RESULTS

The mean GA of all infants was 29.2 ± 2.4 (24-35) weeks, and the mean birth weight was 1268 ± 419 (550-2500) g. The RDW values measured in the first and the second weeks were significantly higher in infants with ROP compared with those wihout ROP (p < .001 for both). There was no statistically significant difference between the groups in terms of cord blood and first month RDW values (p = .719, p = .108, respectively). The first and second week's RDW values of infants with ROP requiring treatment (severe ROP) were significantly higher than those of infants with ROP not requiring treatment (mild ROP) (p = .005, p = .031, respectively), but no statistically significant difference was observed between the groups in terms of cord blood and first month values (p = .114 and p = .371, respectively).

CONCLUSION

RDW is an easily accessible and inexpensive marker that may reflect the clinical risk factors for ROP. Follow-up measures of RDW have the potential to help clinicians for the prediction of ROP development in the first 2 weeks postnatally.

Characteristics of 'sawtooth shunt' following anti-vascular endothelial growth factor for aggressive posterior retinopathy of prematurity

OBJECTIVE

To explore the characteristics of 'sawtooth shunts (STS)' following intravitreal anti-vascular endothelial growth factors (anti-VEGF) for aggressive posterior retinopathy of prematurity (AP-ROP).

DESIGN

Prospective observational study.

METHODS

In a prospective observational study, 45 eyes of 24 babies receiving intravitreal anti-VEGF for AP-ROP or hybrid ROP were analyzed. Anti-VEGF molecule and doses: bevacizumab (0.62 mg or ½ IVB, n = 30 eyes; 0.25 mg or 1/5IVB, n = 9 eyes; 0.12 mg or 1/10 IVB, n = 1 eye); or ranibizumab (0.25 mg or ½IVR, n = 3 eyes; 0.1 mg or 1/5IVR, n = 2 eyes). They were followed every 1-2 week till disease regression with or without laser treatment. Development of STS, its variants, characteristics, timeline, and final outcomes was analyzed.

RESULTS

STS occurred in 26 (57.7%) eyes at 1-6 weeks following anti-VEGF injections and persisted for 1-14 weeks. While the shunt regressed spontaneously in half of the treated eyes (n = 13) with anti-VEGF alone, the other half (n = 13) required additional laser because of either non-compliance (n = 9) or recurrence (n = 4).

CONCLUSION

The STS was observed to be an important retinal vascular change seen in infants treated with intravitreal anti-VEGF at half adult doses. It warrants further studies to explore the association between STS and its association with disease recurrence or regression.