Intravitreal injection of bevacizumab for retinopathy of prematurity

Delayed resolution of retinopathy of prematurity

PURPOSE

To compare the characteristics of infants whose retinopathy of prematurity (ROP) resolves in <50 weeks with those of infants whose ROP resolves in >50 weeks' postmenstrual age (PMA) in order to identify which infants are at risk for delayed resolution and to evaluate whether severe ROP developed after 50 weeks' PMA.

METHODS

The medical records of infants screened for ROP from January 2008 to December 2016 at a tertiary care facility were reviewed retrospectively. Infants without follow-up prior to ROP resolution or complete retinal vascularization and those with retinal detachment were excluded. Delayed resolution of ROP was defined as presence of immature retinal vasculature at ≥50 weeks' PMA. The birth characteristics, neonatal complications, and ROP characteristics of infants with and without delayed resolution were compared.

RESULTS

A total of 996 infants were included, of whom 136 (13.6%) showed delayed resolution. Increasing severity of ROP (higher stage, lower zone, plus/pre-plus disease) and type 2 ROP was associated with delayed resolution (P < 0.05). Other variables associated with delayed resolution included <28 weeks gestational age, ≤3rd percentile birth weight, positive blood culture sepsis, necrotizing enterocolitis, intraventricular hemorrhage, and bronchopulmonary dysplasia (P < 0.05). No infants developed type 1 after 50 weeks' PMA. After a prolonged follow-up course consistent with AAP guidelines, a single patient in our study cohort was treated at 81 weeks' PMA for persistent type 2 ROP.

CONCLUSIONS

In our cohort, delayed resolution of ROP was more likely in infants with more severe ROP or a complex neonatal course. No patient with delayed resolution developed type 1 ROP after 50 weeks' PMA, supporting AAP guidelines.

Hot Topics in Retinopathy of Prematurity

Retinopathy of prematurity (ROP) is a condition seen in premature infants that is characterized by abnormal retinal blood vessel growth incited by relative hyperoxia and followed by hypoxia. It can have severe consequences ranging from high myopia to blindness. This article reviews recent "hot" topics related to ROP, specifically the changing incidence of ROP worldwide, the advent of predictive algorithms for screening for ROP, the emerging data behind efficacy of anti-vascular endothelial growth factor treatments for ROP, and advanced retinal imaging in children who were born premature. [Pediatr Ann. 2017;46(11):e415-e422.].

RETINAL VASCULAR DEVELOPMENT WITH 0.312 MG INTRAVITREAL BEVACIZUMAB TO TREAT SEVERE POSTERIOR RETINOPATHY OF PREMATURITY: A Longitudinal Fluorescein Angiographic Study

PURPOSE

To report the outcome of intravitreal 0.312 mg bevacizumab (IVB) monotherapy in acute retinopathy of prematurity (ROP) and to describe the vascular development over time.

METHODS

Seventeen prematurely born infants were treated with IVB (0.312 mg in 0.025 mL per eye) because of acute ROP in posterior Zone II or Zone I, including aggressive posterior ROP. Infants were examined by fluorescein angiography (FA) using RetCam II or III (Clarity Medical Systems Inc) before IVB (n = 21 eyes), within 6 weeks (n = 23 eyes), 8 to 13 weeks (n = 22 eyes), and up to 45 months (n = 10 eyes).

RESULTS

Acute ROP regressed in 19 out of 27 analyzed eyes (70%), including 100% and 80% of posterior Zone II and Zone I eyes, respectively, but only 25% of aggressive posterior ROP eyes. Early recurrences (11%, all aggressive posterior ROP) and late reactivations (18%) were observed within 1 week and at 9 to 12 weeks, respectively. All eyes showed leakage at the junction of the vascularized zone and capillary malformation on FA before treatment. Vessel branching abnormalities and circumferential vessel formation were typical FA features after treatment. Vascular outgrowth after one IVB became complete in 87.5% of eyes for which FA was available up to at least 9 weeks after IVB.

CONCLUSION

A single dose of 0.312 mg bevacizumab was efficient to induce regression of ROP in posterior Zone II and most of Zone I cases, but not in aggressive posterior ROP. FA describes vascular abnormalities, the importance of which warrants further investigation.

Usefulness of Intravitreal Bevacizumab for Retinopathy of Prematurity with Severely Dilated Tunica Vasculosa Lentis and Poor Mydriasis

Background

Laser therapy has been the gold standard treatment for retinopathy of prematurity (ROP), while intravitreal bevacizumab (IVB) is reported to be of significant benefit for zone I ROP. A problem with laser therapy is that it is difficult to administer in ROP patients with severely dilated tunica vasculosa lentis and poor mydriasis. However, although IVB treatment has been performed in such severe ROP cases, only 1 report has discussed its usefulness.

Case 1

A male infant was born with a birth weight of 382 g at 23 weeks’ gestation. As visualization was poor and laser therapy could not be performed due to dilated tunica vasculosa lentis and poor mydriasis, IVB (0.625 mg/0.025 mL) was administered to both eyes. Following treatment, the ROP gradually improved, with regression of the dilated tunica vasculosa lentis and improvement of the mydriasis in both eyes.

Case 2

A male infant was born with a birth weight of 698 g at 25 weeks’ gestation. As laser therapy could not be performed due to severely dilated tunica vasculosa lentis and poor mydriasis, IVB (0.625 mg/0.025 mL) was administered to both eyes. Following treatment, the ROP gradually improved, with regression of the dilated tunica vasculosa lentis and improvement of the mydriasis in both eyes.

Conclusions

IVB is potentially more useful than laser therapy for the treatment of severe ROP with dilated tunica vasculosa lentis and poor mydriasis.

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.

Chronic Vascular Arrest as a Predictor of Bevacizumab Treatment Failure in Retinopathy of Prematurity

PURPOSE

To describe a pattern of retinopathy of prematurity (ROP) disease regression and chronic vascular arrest after intravitreal bevacizumab treatment that is not observed after peripheral laser ablation.

DESIGN

Single-institution retrospective cohort study.

PARTICIPANTS

Consecutive sample of 58 eyes in 30 patients treated for type 1 ROP.

METHODS

Initial treatment with either a single intravitreal injection of bevacizumab in off-label use (n = 33 eyes) or peripheral laser ablation (n = 25 eyes) as part of standard clinical care. There was bias in recommending off-label bevacizumab for smaller infants with type 1 ROP.

MAIN OUTCOME AND MEASURES

Reactivation or persistence of ROP, as determined by clinical examination, fundus photography, and fluorescein angiography.

RESULTS

All eyes treated initially with bevacizumab demonstrated irregular progression of the leading vascular edge in a stereotyped pattern, suggestive of scalloped regression. Recurrence, based on angiographic demonstration of leakage, or chronic vascular arrest, confirmed based on angiographic demonstration of peripheral ischemia, was noted in 30 eyes (91%) in the bevacizumab group, at a median interval of 14.9 weeks after injection (corrected gestational age, 49.3 weeks). Univariate logistic regression indicated that the need for rescue treatment was associated with decreased birth weight (odds ratio [OR], -0.007; P = 0.04) and age of initial treatment (OR, -0.35; P = 0.05), but not gender, race, or gestational age. Multivariate logistic regression indicated that only decreased birth weight (OR, -0.018; P = 0.04) was associated with need for rescue treatment.

CONCLUSIONS

Treating ROP with intravitreal bevacizumab results in a characteristic scalloped regression pattern that is highly associated with treatment using biologic anti-vascular endothelial growth factor agents. The presence of this pattern in conjunction with chronic vascular arrest and peripheral retinal ischemia persisting beyond standard screening timelines has significant implications for the management of ROP. Fluorescein angiography is important in assessing vascular maturation in these infants.

Occurrence of intraocular air bubbles during intravitreal injections for retinopathy of prematurity

This study aims to present five cases with retinopathy of prematurity (ROP) who were found to have intraocular air bubbles after intravitreal injection (IVI) treatment. The medical records of 148 infants who underwent IVI for ROP were retrospectively reviewed and the ones who demonstrated post-injection intraocular air bubble formation were recruited. Of the 148 patients (31 babies received ranibizumab, 20 babies received aflibercept, 97 babies received bevacizumab), five were found to have intraocular air bubbles right after the IVI. Two infants received intravitreal ranibizumab and three received intravitreal bevacizumab injections. Although intraocular pressure increased temporarily, no intraocular sterile or infective reactions were observed in the postoperative period. The air bubble was found to resorb spontaneously within 72 h. The occurrence rate of the intravitreal air bubbles in our series was 3.37 % despite previously not been reported in the literature. Due to the intravitreal air injection risk, it is important to be more careful while preparing the intravitreal medication before treatment in premature babies.

Intravitreal bevacizumab for retinopathy of prematurity in infants ineligible for laser therapy

BACKGROUND/AIM

To evaluate refractive and strabismic results and the efficacy of intravitreal bevacizumab in retinopathy of prematurity (ROP) ineligible for laser therapy.

MATERIALS AND METHODS

Thirty-nine eyes of 20 consecutive infants with high-risk prethreshold ROP (11 infants with Zone I and 9 infants with Zone II disease) who were ineligible for laser therapy due to systemic and/or ocular conditions were treated with intravitreal bevacizumab. Recurrent retinopathy was treated with laser ablation. The final follow-up examination was performed at 29.8 ± 6.0 months of corrected age.

RESULTS

All eyes responded to the initial treatment with intravitreal bevacizumab. ROP recurred in 8 eyes (36%) with initial Zone I disease and in only 2 eyes (11%) with initial Zone II disease, which were successfully treated with laser ablation. No eye developed myopia higher than 5.0 diopters. At 2.5 years, the Zone I eyes that had received laser treatment appeared to be more myopic than the Zone I eyes treated only with intravitreal bevacizumab (P = 0.038). A tendency for a higher incidence of strabismus after additional laser therapy was also noted, but was not significant (P = 0.22).

CONCLUSION

Avoidance or even deferral of laser ablation with intravitreal bevacizumab may lead to less myopization in ROP compared with conventional laser treatment.

Regression Rates Following the Treatment of Aggressive Posterior Retinopathy of Prematurity with Bevacizumab Versus Laser: 8-Year Retrospective Analysis

Background

Retinopathy is a serious complication related to prematurity and a leading cause of childhood blindness. The aggressive posterior form of retinopathy of prematurity (APROP) has a worse anatomical and functional outcome following laser therapy, as compared with the classic form of the disease. The main outcome measures are the APROP regression rate, structural outcomes, and complications associated with intravitreal bevacizumab (IVB) versus laser photocoagulation in APROP.

Material/Methods

This is a retrospective case series that includes infants with APROP who received either IVB or laser photocoagulation and had a follow-up of at least 60 weeks (for the laser photocoagulation group) and 80 weeks (for the IVB group). In the first group, laser photocoagulation of the retina was carried out and in the second group, 1 bevacizumab injection was administered intravitreally. The following parameters were analyzed in each group: sex, gestational age, birth weight, postnatal age and postmenstrual age at treatment, APROP regression, sequelae, and complications. Statistical analysis was performed using Microsoft Excel and IBM SPSS (version 23.0).

Results

The laser photocoagulation group consisted of 6 premature infants (12 eyes) and the IVB group consisted of 17 premature infants (34 eyes). Within the laser photocoagulation group, the evolution was favorable in 9 eyes (75%) and unfavorable in 3 eyes (25%). Within the IVB group, APROP regressed in 29 eyes (85.29%) and failed to regress in 5 eyes (14.71%). These differences are statistically significant, as proved by the McNemar test (P<0.001).

Conclusions

The IVB group had a statistically significant better outcome compared with the laser photocoagulation group, in APROP in our series.

Serial evaluation of retinal vascular changes in infants treated with intravitreal bevacizumab for aggressive posterior retinopathy of prematurity in zone I

PURPOSE

To evaluate the serial changes in retinal vasculature in infants treated with intravitreal bevacizumab (IVB) for aggressive posterior retinopathy of prematurity (APROP) in zone I.

METHODS

Retrospective analysis of serial changes in retinal vasculature after IVB in the seven eyes of four babies with APROP in zone I.

RESULTS

The initial regression, following IVB, was dramatic with reduction in vessel caliber and marked thinning and invisibility of the bridging shunts. Resurgent vascular development was very slow radially though there was continued abnormal vascular growth circumferentially. Common findings in all eyes were tangled vasculature and fine saw-toothed shunts. The variable findings were (1) new closely packed multilayered bridging shunts, long arching mature looking vessels, and finally a ridge at the periphery (n=3 eyes) at 52 weeks of postmenstrual age (PMA); (2) status quo at the stage of saw-toothed shunt and ridge in both eyes for a long time (n=2 eyes); and (3) multiple retinal hemorrhages within the vascularized retina and thick preretinal hemorrhage overlying the saw-toothed shunts and ridge that persisted for another 3 weeks and regressed 2 weeks after laser (n=1). The eyes that received bevacizumab alone (3) did not show any abnormal vascularization at 56 weeks of PMA or beyond.

CONCLUSIONS

The retinal vascularization following IVB was different than normal in terms of its time, speed, and morphology; few of these changes are first to be reported in the literature (Medline search) and warrants further studies.

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.

Treatment of type 1 retinopathy of prematurity with bevacizumab versus laser

PURPOSE

To compare structural outcomes, visual function, refraction, and frequency of follow-up for infants with type 1 retinopathy of prematurity in zone I or zone II posterior treated with intravitreal bevacizumab (IVB) versus laser.

METHODS

The medical records of infants treated with IVB or laser photocoagulation at our institution from January 2009 to May 2013 were retrospectively reviewed. Only infants with a minimum of 6 months' follow-up were included. Outcome measures were structural outcome, visual acuity, and spherical equivalent (SE) at corrected age of 1 year. The frequency of follow-up visits during 9 months after treatment was evaluated.

RESULTS

A total of 23 eyes of 13 infants were treated with IVB and 22 eyes of 12 infants were treated with laser. There was no statistically significant difference in gestational age or birth weight between groups. None developed unfavorable structural outcome. Mean visual acuity was 0.99 ± 0.38 logMAR for the IVB group and 0.71 ± 0.36 logMAR for the laser group (P = 0.34; 95% CI, -0.52 to 0.19). Mean spherical equivalent was -3.57 ± 6.19 D for the IVB group and -6.39 ± 4.41 D for the laser group (P = 0.33; 95% CI, -7.19 to 2.49). In the IVB group, infants had an average of 16.00 ± 6.00 follow-up visits; in the laser group, 6.00 ± 3.00 (P < 0.0001).

CONCLUSIONS

Both treatments resulted in good structural outcome, and no difference in visual acuity or refraction. However, more frequent follow-up was observed in the IVB group.

Intravitreal anti-VEGF therapy as a treatment for retinopathy of prematurity: what we know after 7 years

The authors review published clinical case reports, case series, and clinical trials evaluating the use of anti-vascular endothelial growth factor (VEGF) medications for the primary or adjunctive treatment of retinopathy of prematurity (ROP). A literature search of peer reviewed reports on PubMed was performed. More than 50 pertinent peer-reviewed publications between 2006 and 2014 were selected to be included in this review and are summarized in this report. There is a growing body of literature on the use of anti-VEGF therapy as a treatment for ROP, predominately in the form of case reports and small case series. Adverse effects from anti-VEGF treatment for ROP have been reported, but with limited follow-up time. The use of anti-VEGF as a treatment for ROP remains off-label.

[Off-label use of intravitreal bevacizumab for severe retinopathy of prematurity]

OBJECTIVE

To examine the quality of evidence and the variability in the off-label use of intravitreal bevacizumab for retinopathy of prematurity (ROP).

METHODS

A wide review of the literature was performed using Pubmed, Medline, and Cochrane database, using the words vascular endothelial growth factor (VEGF), retinopathy of prematurity, treatment and bevacizumab.

RESULTS

Case reports, case series, reviews, one sistematic review and one randomized controlled trial were found on the use of intravitreal bevacizumab in severe ROP, as monotherapy or combined with láser and/or vitrectomy.

CONCLUSIONS

The results shown on the use of intravitreal bevacizumab in ROP stage 3+ in zone I or in aggressive posterior ROP are promising. However, uncertainty remains regarding its maximum tolerable dose in the neonatal group, its ocular and systemic safety profile, or its efficacy and bioactivity in a developing child. This report found no significant differences in the recurrence rates of ROP stage 3+ in zone II in patients treated with intravitreal bevacizumab monotherapy in comparison to láser, although the latter is the best option due to long-term safety and efficacy. The use of intravitreal bevacizumab is not indicated in stages 1 and 2 of ROP as the risk of severe visual loss is low and VEFG is necessary for normal retinal vessel development. On the other hand, the use of intravitreal bevacizumab would be contraindicated in stages 4 and 5 because the retinal detachment is accelerated.

Intravitreal injection of bevacizumab for retinopathy of prematurity in an infant with peters anomaly

Purpose

To report our findings in an infant with Peters anomaly type II whose retinopathy of prematurity (ROP) was treated with an anti-VEGF agent and surgeries.

Case Report

A male infant weighing 548 g was born prematurely at 23 weeks and 1 day with corneal opacity and shallow anterior chambers in both eyes. At the postmenstrual age of 35 weeks and 3 days, the infant was tentatively diagnosed with stage 3 ROP because of a dilated tunica vasculosa lentis and ultrasonographic findings. The boy was treated with bilateral intravitreal injections of bevacizumab (IVB) because laser photocoagulation of the retina could not be performed due to the corneal opacity. The retina in the right eye detached 3 times, namely 5 days, 16 days, and 7 months after the IVB; encircling the scleral buckle and a vitrectomy with endolaser photocoagulation were therefore required. In his left eye, the retina was reattached after the initial IVB, and no additional treatment was required. ROP was not reactivated in both eyes until the last examination at the age of 2 years and 6 months.

Conclusions

Our results showed that IVB is a useful treatment for ROP in patients with Peters anomaly. However, a retinal detachment can be a complication after IVB. The optimal timing of IVB for ROP in infants with hazy media needs to be determined.