Anti-vascular endothelial growth factor in the management of retinopathy of prematurity: A survey among the members of Indian Retinopathy of Prematurity Society

Bilateral Anti-VEGF on Same-Day-Investigation on Safety in Retinopathy of Prematurity: A Multicenter Retrospective Study

PURPOSE

To report an incidence of procedure-related complications in preterm infants with retinopathy of prematurity (ROP) treated with intravitreal anti-VEGFs injection in both eyes on the same day.

DESIGN

Retrospective, multicenter case series.

SUBJECTS

Preterm infants with ROP treated with anti-VEGF bilaterally on the same day.

METHODS

All included infants underwent intravitreal anti-VEGF injection in both eyes under aseptic precautions in an ophthalmic operation theater (OT) or neonatal intensive care unit (NICU). A postoperative examination was performed to look for procedure-related complications.

MAIN OUTCOME MEASURES

Incidence of procedure-related complication (presumed endophthalmitis, intraocular inflammation, lens injury, vitreous hemorrhage, and retinal tear) in the study cohort. To study the association of indication, type of anti-VEGF, type of needle used, setting of procedure, site of injection (distance from limbus), and experience of the treating ophthalmologist with the complications.

RESULTS

Nine thousand nine hundred and eighty-four eyes of 4992 infants were analyzed. The procedure was most commonly performed in ophthalmic OT (8258, 82.7%) using a 29G (4514, 45.2%) needle between 1 and 1.5 mm (9984, 100%) from limbus. Aggressive ROP was the most common indication for anti-VEGF use (4866, 48.7%), whereas Bevacizumab was the most commonly used anti-VEGF agent (8642, 86.6%). Overall, 26 eyes (0.3%) had procedure-related complications. Lens injury (15, 0.15%) and presumed endophthalmitis (7, 0.07%) were the most common complications. One eye had culture-proven endophthalmitis with Pseudomonas aeruginosa. No case of bilateral endophthalmitis was noted. Endophthalmitis was not associated with the setting of a procedure or type of anti-VEGF used, whereas the risk of lens injury was 7 times higher when performed in NICU and 30 times higher when performed by an ophthalmologist with <1 year of experience in injecting anti-VEGF in preterm infants.

CONCLUSIONS

The incidence of presumed endophthalmitis after bilateral same-day anti-VEGF in infants with ROP is 0.07%. These infants can be treated in both eyes on the same day with the anti-VEGFs and needles (29-32G) evaluated in this study, with emphasis on the direction of needle parallel to the visual axis. Extra precaution is advocated if the procedure is planned in the NICU or by an ophthalmologist with limited experience.

FINANCIAL DISCLOSURE(S)

The authors have no proprietary or commercial interest in any materials discussed in this article.

Bedside bilateral sequential intravitreal anti-VEGF injections for retinopathy of prematurity

PURPOSE

To evaluate the outcome and ocular adverse events of bedside bilateral sequential intravitreal anti-vascular endothelial growth factor injections for retinopathy of prematurity (ROP) (BBSIR).

METHODS

This retrospective interventional study included infants who received BBSIR with a follow-up of at least 1 month. Clinical history, intravitreal injection details, indications, intraoperative and postoperative ocular adverse events, and outcomes were analyzed.

RESULTS

The study cohort included 192 babies (384 eyes) spread over 9 years. The mean gestational age was 30.2 ± 2.6 weeks (28.8-34.1), and the birth weight was 1098.11 ± 271.65 g (650-2000). The indications for BBSIR were as follows: 73.4% (n = 141 infants) were too sick to transfer to an ophthalmic unit, 10.9% (n = 21 infants) due to the parents' inconvenience of traveling to the ophthalmic center, and 15. 6% (n = 30 infants) due to both reasons. The injections were given by an ROP specialist/ROP-trained ophthalmologist after due parental consent, considering each eye as a fresh eye with separate scrubbing and draping. Light from the head-worn indirect ophthalmoscope served as the source of illumination. The retinopathy was regressing/regressed in 92.4% of babies until the last follow-up. The major ocular complication was cataract in 2 eyes (0.5%). There was no incidence of endophthalmitis till last follow-up (median 5.7 months).

CONCLUSIONS

As per this study, BBSIR was observed to be effective and safe if given by those fully trained in the management of ROP. Though the rate of complications like cataract is small, they can pose management challenges and impact vision in a growing child.

Comparison of reactivation between ranibizumab and bevacizumab in aggressive retinopathy of prematurity: A retrospective case series

PURPOSE

To compare the incidence, type, interval for reactivation, and structural outcomes in infants with aggressive retinopathy of prematurity (A-ROP) treated with ranibizumab or bevacizumab.

METHOD

It is a single-center, retrospective, consecutive, case series. We included infants with A-ROP which were initially treated with either intravitreal ranibizumab (IVR, 0.25 mg) or intravitreal bevacizumab (IVB, 0.625 mg) between January 2017 and December 2023. The infants were followed up for reactivation. The demographic and clinical data were collected. The time, zone, type of reactivation, its treatment, type of final structural outcome, and factors associated with reactivation were analyzed.

RESULTS

One hundred eight among the 322 infants with A-ROP were included in the study. Fifty-five received IVR, while 53 received IVB. Infants treated with IVR had higher incidence of reactivation (92.7% vs 52.8%, P < 0.001) at an earlier interval than IVB (7.7 weeks vs 12.8 weeks, P < 0.001). Infants treated with IVR had approximately 3.3 times higher possibility of reactivation than those treated with IVB. Three infants (5.9%) in the IVR group and five (9.4%) in the IVB group attained complete vascularization of the retina ( P = 0.72). More infants treated with IVB had regression with a persistent avascular retina (PAR) than IVR (52.8% vs 15.7%, P < 0.001). Infants in the IVB group had 10 times higher possibility of regression with PAR.

CONCLUSION

Infants of A-ROP treated with IVR have a higher incidence and earlier reactivation, while those treated with IVB have less incidence and delayed reactivation, albeit with a higher possibility of regression with a PAR.

Anti-Vascular Endothelial Growth Factor (Anti-VEGF) for the Treatment of Type I ROP

This retrospective study evaluated the trends in the use of anti-vascular endothelial growth factor (anti-VEGF) for the treatment of type-1 retinopathy of prematurity (ROP) during two periods - 2016-2019 (epoch A) and 2020-2022 (epoch B) in a neonatal unit of India. The study also compared the efficacy of anti-VEGF and laser therapies. Anti-VEGF was used in 8 (12.2%) out of 66 eyes treated during epoch A and 54 (75%) out of 72 eyes during epoch B (P = 0.001). The proportion of eyes in which ROP regressed with a single attempt of laser and anti-VEGF therapies was 8/20 (40%) and 7/15 (46.6%) respectively for the disease in zone 1 and aggressive-posterior ROP (P = 0.70) and 46/66 (69.6%) and 17/37 (45.9%) respectively for the disease in zone 2 (P = 0.018). There was a trend towards an increase in the use of anti-VEGF for ROP management over time. Anti-VEGF showed equal efficacy as laser for zone 1 ROP and AP-ROP, but laser therapy was better for zone 2 ROP.

Ranibizumab versus laser therapy for the treatment of very low birthweight infants with retinopathy of prematurity (RAINBOW): five-year outcomes of a randomised trial

Background

Concerns remain over the long-term safety of vascular endothelial growth factor (VEGF) inhibitors to treat retinopathy of prematurity (ROP). RAINBOW is an open label randomised trial comparing intravitreal ranibizumab (in 0.2 mg and 0.1 mg doses) with laser therapy in very low birthweight infants (<1500 g) with ROP.

Methods

Of 201 infants completing RAINBOW, 180 were enrolled in the RAINBOW Extension Study. At 5 years, children underwent ophthalmic, development and health assessments. The primary outcome was visual acuity in the better-seeing eye. The study is registered with ClinicalTrial.gov, NCT02640664.

Findings

Between 16-6-2016 and 21-4-2022, 156 children (87%) were evaluated at 5 years. Of 32 children with no acuity test result, 25 had a preferential looking test, for 4 children investigators reported low vision for each eye, and in 3 further children no vision measurement was obtained. 124 children completed the acuity assessment, the least square mean (95% CI) letter score in the better seeing eye was similar in the three trial arms-66.8 (62.9-70.7) following ranibizumab 0.2 mg, 64.6 (60.6-68.5) following ranibizumab 0.1 mg and 62.1 (57.8-66.4) following laser therapy; differences in means: ranibizumab 0.2 mg v laser: 4.7 (95% CI: -1.1, 10.5); 0.1 mg v laser: 2.5 (-3.4, 8.3); 0.2 mg v 0.1 mg: 2.2 (-3.3, 7.8). High myopia (worse than -5 dioptres) in at least one eye occurred in 4/52 (8%) children following ranibizumab 0.2 mg, 8/55 (15%) following ranibizumab 0.1 mg and 11/45 (24%) following laser therapy (0.2 mg versus laser: odds ratio: 3.99 (1.16-13.72)). Ocular and systemic secondary outcomes and adverse events were distributed similarly in each trial arm.

Interpretation

5-year outcomes confirm the findings of the original RAINBOW trial and a planned interim analysis at 2 years, including a reduced frequency of high myopia following ranibizumab treatment. No effects of treatment on non-ocular outcomes were detected.

Funding

Novartis Pharma AG.

Retinopathy of prematurity in India - what can we learn from the polio legacy?

Retinopathy of prematurity (ROP) is a vasoproliferative disease of the preterm retina that has the potential to cause vision impairment and blindness. Timely screening and treatment are hence critical for infants at risk for ROP. Screening for ROP is challenging in India owing to the limited resources, a vast at-risk population and lack of awareness among paediatricians and the public. Addressing ROP in India requires a comprehensive approach involving multiple sectors, considering the magnitude of the problem and the expected increase in need for ROP services due to the increased survival of preterm infants following improvements in neonatal care. The success of the Global Polio Eradication Initiative (GPEI) offers valuable lessons for improving ROP services in developing nations by applying its strategies. An approach for primary and secondary prevention of ROP is proposed, and the current challenges and a neonatal-led care model for ROP are discussed.

Role of Anti-Vascular Endothelial Growth Factor (Anti-VEGF) in the Treatment of Retinopathy of Prematurity: A Narrative Review in the Context of Middle-Income Countries

The rise in preterm births and higher survival rates of premature infants have led to a global increase in retinopathy of prematurity (ROP), a vasoproliferative retinal disorder common in premature infants. ROP is one of the leading causes of childhood blindness. Clinical manifestation of ROP ranges from mild abnormal retinal neovascularization to bilateral retinal detachment and vision loss. The incidence of ROP is higher in middle income countries, including India, which has the highest number of global preterm births. Low birth weight and low gestational age are the primary risk factors for ROP; however, anemia, cardiac defects, blood transfusion, apnea, sepsis, respiratory distress syndrome, high exposure to oxygen and poor postnatal weight gain may also contribute to its development. India has stringent ROP screening guidelines revised in 2018, and screening of infants with either birth weight <2000 grams or gestational age <34 weeks is mandated. With an improved understanding of the pathogenesis of ROP in the past decades and advances in clinical research, treatment for ROP has evolved from cryotherapy to laser retinal ablation. Most recently, anti-vascular endothelial growth factor (anti-VEGF) drugs have emerged as a favorable treatment option for zone-I and II ROP. This article reviews the current approaches for ROP treatment in India with a particular focus on anti-VEGF drugs. The article also integrates the understanding of safety and risk-benefit evaluation of the current approaches in ROP management. The review concluded that there is a need to increase the ROP screening not only for preterm and low birth weight but also for optimal gestational age infants with healthy birth weight. Anti-VEGF therapies have shown improved efficacy, although studies are required to establish the long-term safety.