Anatomical outcome of laser treatment alone in aggressive retinopathy of prematurity

PURPOSE

The purpose is to study the anatomical outcome of eyes in aggressive retinopathy of prematurity (AROP), treated with laser photocoagulation alone and to evaluate factors affecting outcomes.

METHODS

Records of consecutive babies diagnosed with AROP, undergoing laser photocoagulation treatment in rural tertiary care centers from October 2016 to January 2021 were reviewed retrospectively. Anatomical outcome at 6 months follow-up was grouped as good in eyes with complete regression and poor in those who developed retinal detachment (stage IV a, IV b, and V). Both groups were compared with respect to the period of gestation, birth weight (BW), age at screening, age at treatment, zone of disease, presence of retinal fibrovascular proliferation (FVP), tunica vasculosa lentis, preretinal bleed, need for supplement laser, and associated systemic risk factors.

RESULTS

Of the total of 2468 babies screened, 124 (5.02%) were diagnosed with severe retinopathy of prematurity (ROP), of which 54 (43.5%) lasered AROP babies were analyzed. Mean BW and gestation period of the AROP cohort were 1.43 kg and 31.1 weeks, respectively. Eighty-six eyes (79.6%) had good outcomes with laser photocoagulation alone. Posterior location of disease, presence of FVP, neonatal sepsis, shock, and late screening for ROP were found to be factors associated with poor outcomes.

CONCLUSION

Adequate and timely treatment with laser photocoagulation in AROP can achieve good treatment outcomes in a significant proportion of babies. Although a combined approach using laser, anti-vascular endothelial growth factor and early vitrectomy is better, laser remains a viable treatment option in AROP, especially with limited resources and high risk of loss to follow-up.

Outcomes of early versus deferred laser after intravitreal ranibizumab in aggressive posterior retinopathy of prematurity

Purpose:

The aim of this study was to report the treatment outcomes of early and deferred laser in infants of aggressive posterior retinopathy of prematurity (APROP) after initial treatment with intravitreal Ranibizumab (IVR).

Methods:

In a prospective, randomized, interventional study, infants with APROP received IVR (0.25 mg) and were randomized into two groups prior to laser. Laser was done at 1 week (group 1) or at 6 weeks or earlier if there was a recurrence of plus disease (group 2). The structural outcome, number of laser spots, duration of laser procedure and refractive error at 6 months were compared. Favorable structural outcome was defined as, complete regression of disease at 6 weeks after laser.

Results:

63 eyes of 32 infants with APROP were enrolled. Mean gestational age (GA) and birth weight (BW) were 30.2 ± 2.3 weeks and 1294 ± 372.8 grams respectively. GA, BW, and disease severity were comparable at baseline. 27 (90%) eyes in group 1 and 29 (93.5%) eyes in group 2 had favorable structural outcome (P = 0.61) at 6 weeks after laser. Eyes in group 2 (2149.8 ± 688.7) required lesser number of laser spots than group 1 (2570.8 ± 615) (P = 0.01). At six months, more eyes in group 1 had myopic refractive error (Mean spherical equivalent: –1.0D ± 1.3) than those in group 2 (Mean spherical equivalent: 0.5D ± 1.9) (P = 0.002).

Conclusion:

Infants with APROP receiving IVR have comparable structural outcomes after an early or deferred laser. Moreover, eyes undergoing deferred laser require less number of laser spots and have a less myopia at 6 months after laser.

Ten-year outcomes after initial management with laser photocoagulation versus intravitreal bevacizumab injection in a pair of identical twins with aggressive posterior retinopathy of prematurity

Purpose

To evaluate the long-term clinical outcomes after initial management with retinal laser photocoagulation (RLP) versus intravitreal bevacizumab (IVB) injection in identical twins with zone Ⅰ aggressive posterior retinopathy of prematurity (AP-ROP).

Observations

Identical female twins were born at a gestational age of 28 2/7 weeks, weighing 970 g and 1020 g. The twins were diagnosed with bilateral AP-ROP, referred to a different hospital due to unavilability of a neonatal intensive care unitand received different initial treatments. At a postmenstrual age of 32 6/7 weeks, the first-born infant underwent bilateral IVB (0.313 mg) injection, whereas the second-born infant received bilateral laser photocoagulation on the same day. To treat recurrence, the first-born infant underwent additional bilateral IVB reinjection at 10 weeks post-treatment, while the second-born infant underwent combined bilateral laser photocoagulation and IVB injection at 2 weeks post-treatment.

After 10 years, the first-born infant's best corrected visual acuities (BCVAs) of the right and left eyes were 20/20 and 20/50, respectively. Both eyes showed complete retinal vascularization of the peripheral retina and an anatomically normal foveal contour on swept-source optical coherence tomography (SS-OCT). However, the second-born infant's BCVAs of the right and left eyes were 20/50 and 1-m finger-counting, respectively. Both eyes of the second-born infant showed panretinal chorioretinal atrophy due to laser scars, a flattened foveal contour with thin epiretinal membrane in the right eye, and loss of foveal curvature in the left eye on SS-OCT images, 10 years after the initial treatment. Moreover, severe myopia and astigmatism were observed in both eyes of the second-born infant, compared with those of the first-born infant during follow-up.

Conclusion and importance

These cases involving identical twins indicated that the effect of initial IVB injection for AP-ROP was superior to that of initial RLP in terms of functional and anatomical outcomes during a 10-year follow-up.

Retinopathy of prematurity in a level II neonatal care unit of a district of West Bengal: A retrospective analysis of 5 years

Retinopathy of prematurity (ROP), particularly severe ROP is a health concern. The study is aimed to ascertain the magnitude, profile, and outcome of ROP over 5 years at a level II neonatal unit in a district of West Bengal. From 2012 to 2016, a total of 691 newborns with birth weight (BW) <2000 g and/or gestational age < 35 weeks of a district level II neonatal care unit were screened for ROP. Retrospective analysis of these screened babies was performed using the principles of descriptive and inferential statistics. Overall, 38.5% of newborns had any stage ROP and13.2% severe ROP. Two-thirds of babies with severe ROP were <1250 g of BW. About 16.2% of the ROP cases suffered from aggressive posterior ROP (APROP). Oxygen and prematurity were found as significant risk factors. Substantially high occurrence of severe ROP and APROP warrants appropriate measures. Timely screening and intervention with referral to the neonatal ROP unit can improve the scenario.

Lens-sparing vitrectomy for stage 4A retinopathy of prematurity in infants with aggressive-posterior ROP: Anatomic and functional results

AIM

To assess long-term anatomic and functional outcomes of early lens-sparing vitrectomy (LSV) for stage 4A retinopathy of prematurity (ROP) in infants with aggressive-posterior ROP (AP-ROP) which progressed to retinal detachment despite laser treatment.

METHODS

Chart review of infants who underwent early 25-gage LSV for stage 4A ROP. Outcomes were anatomic success, mean visual acuity (VA), development of postoperative complications, and refractive changes. Follow-up examinations were performed at 1, 3, 6, 12, and then every 6 months.

RESULTS

Ten eyes of seven preterm infants who underwent LSV were included. Mean follow-up was 36 ± 13.4 months and mean postmenstrual age (PMA) at last follow-up was 37 ± 13.7 months. Mean gestational age (GA) and weight at birth was 26 ± 1.4 weeks and 639 ± 180 g. Two eyes had vitreous hemorrhage 4 and 14 days after surgery, respectively. At last follow-up anatomic success was 100%, mean VA was 20/80 and eight eyes (80%) had high myopic refractive correction (mean spherical equivalent -11.25 D).

CONCLUSION

Early LSV for stage 4A ROP with AP-ROP and progression to retinal detachment is efficacious in terms of anatomic and functional outcomes. Anatomic success is associated with visual improvement despite possible myopic refraction changes during follow-up.

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.

Successful treatment of aggressive posterior retinopathy of prematurity with diode laser in ocular albinism: A case report

Oculocutaneous albinism is characterized by partial or complete absence of melanin in retinal pigment epithelium (RPE) and uveal melanocytes. Absence of typical fundal background from RPE and choroid makes it difficult to diagnose retinal disorders in ocular albinism. Lack of melanin in RPE makes the laser photocoagulation very challenging in these cases. This report presents a unique case of preterm infant of oculocutaneous albinism diagnosed as aggressive posterior retinopathy of prematurity (APROP), which was successfully treated with diode laser photocoagulation. The parameters of the laser used in this case were higher than usual, just enough to achieve blanching of retina. This report highlights the fact that the diagnosis of APROP and its treatment with laser is challenging in the presence of oculocutaneous albinism, but it is possible to achieve complete regression using diode laser at higher parameters.

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

OBJECTIVE

To evaluate vascularization end limit of the peripheral retina and describe vascular development patterns of patients at the late period with aggressive posterior retinopathy of prematurity (APROP) who were treated with a single intravitreal injection of bevacizumab.

METHODS

All patients were examined with RetCam III and fluorescein angiography (FA) within 90-100 gestational week. The vascularization end limit according to the zones and vascular structural abnormalities were noted.

RESULTS

A total of 116 eyes of 58 patients were included. The mean gestational age and birth weight were 28.31 ± 2.5 (23-33) weeks and 1156.29 ± 386.38 (360-2300) g, respectively. The mean age at the time of FA was 95.09 ± 3.8 (90-100) weeks. According to the vascular termini, four eyes (3.4%) were in zone II posterior, 30 eyes (25.8%) were in zone II anterior, 22 eyes (18.9%) were in zone III with a distance of > 2 disc diameter (DD) from ora serrata, and 60 eyes (51.7%) were in zone III with a distance of < 2 DD from temporal ora serrata. Abnormal vascular findings were detected in 86.2% of patients (100/116 eyes) including circumferential vessels (43.1%), abnormal vascular branching (25.9%), closely packed vascular shunts (6.8%), and vascular leakage (10.3%).

CONCLUSION

FA gives us quantitative data for treatment decision at late period of APROP patients treated with bevacizumab. Fluorescein leakage and persistent avascular areas still detected at FA at 90-100 gestational weeks increase the risk for late complications. FA can detect the abnormalities that can not be detected via indirect ophthalmoscope and be useful for follow-up and further treatments of APROP.

Favorable outcomes of adequate laser photocoagulation and salvage bevacizumab treatment for aggressive posterior retinopathy of prematurity

Purpose

To evaluate the effect of salvage therapy with bevacizumab after laser photocoagulation for infants with recurrence of zone I aggressive-posterior retinopathy of prematurity (AP-ROP).

Methods

This was a retrospective case series documenting the 2-year outcomes of 8 patients diagnosed with zone I AP-ROP and treated with bevacizumab for recurrence after laser photocoagulation. Prior to intravitreal bevacizumab, additional laser treatment was performed when any skip areas on the avascular retina remained. Anatomical and functional outcomes were evaluated.

Results

The median gestational age at birth was 23.7 weeks and the median birth weight was 541.5 g. The median time of initial laser treatment and intravitreal bevacizumab treatment were 32.1 weeks and 36.7 weeks' postmenstrual age, respectively. All 14 eyes developed a normal macular appearance and all 8 patients had visual responses. Visual acuity was measurable in 13 eyes (92%) between the chronological ages of 12–24 months.

Conclusions

and Importance: Adequate laser treatment and salvage intravitreal bevacizumab achieved favorable anatomical and functional outcomes in AP-ROP patients with recurrence.

Outcomes and prognostic factors for aggressive posterior retinopathy of prematurity following initial treatment with intravitreal ranibizumab

Background

This study sought to identify factors associated with retinal detachment and retreatment of aggressive posterior retinopathy of prematurity (APROP) initially treated with intravitreal ranibizumab (IVR) injection as well as the efficacy of IVR treatment.

Methods

This was a retrospective study. A total of 83 preterm infants (160 eyes) diagnosed with APROP who were primarily treated with IVR were included. The 160 eyes were divided into two groups based on the anatomic outcomes. Group A included 35 eyes that developed retinal detachment, and Group B included 125 eyes without retinal detachment. The following patient factors were retrospectively reviewed: gender, gestational age (GA), birth weight (BW), postmenstrual age (PMA) at first treatment, iris neovascularizations, retinal hemorrhage, neutrophil and lymphocyte counts before the first intravitreal injection, neutrophil-to-lymphocyte ratio (NLR), anatomical outcomes, additional treatment and follow-up time. Three dummy variables were created as dependent variables based on the methods of retreatment. The possible risk factors for APROP were evaluated, and statistical analyses included univariate and multivariate logistic regression.

Results

A total of 160 eyes from 83 preterm infants (56 males and 27 females) underwent initial IVR treatment with a follow-up time of 17.17 ± 10.54 months. Thirty-five of the 160 (21.9%) eyes progressed to retinal detachment, and 82 of the 125 (65.6%) non-retinal detachment eyes needed retreatment, with favorable anatomical outcomes. The disease improved approximately 1.5 ± 1.2 weeks after the first IVR treatment. The mean recurrence period of APROP was approximately 7.5 ± 6.9 weeks after the first IVR treatment. Multiple logistic regression analysis revealed postmenstrual age (P < 0.001) and neutrophil count (P = 0.009) as the most significant factors for retinal detachment in APROP. Retinal hemorrhage (P = 0.007) and BW (P = 0.04) were most significantly associated with APROP recurrence and retreatment.

Conclusions

IVR injection is an effective treatment for APROP. In this study, older postmenstrual age and low neutrophil count were identified as risk factors for retinal detachment in APROP. In addition, retinal hemorrhage and low BW were significantly associated with recurrence and retreatment in non-retinal detachment APROP. Thus, patients with a lower BW, older postmenstrual age, low neutrophil count and retinal hemorrhage should be reexamined in a timely and more frequent manner.

Bevacizumab or laser for aggressive posterior retinopathy of prematurity

PURPOSE

The purpose of this study was to report the rate of reactivation and structural outcome, after the laser or bevacizumab treatment for aggressive posterior retinopathy of prematurity (APROP).

METHODS

Retrospective chart review was conducted on consecutive infants with APROP treated with (1) laser or (2) bevacizumab, followed by fluorescein angiography and prophylactic laser to the persistent avascular retina.

RESULTS

Thirty-six eyes of 19 patients were included in this study. The mean gestational age was 24.5 weeks with a mean birth weight of 632 g in the bevacizumab group and 24.7 weeks and 777 g in the laser group. Unfavorable outcome occurred in 1 of 22 eyes treated with bevacizumab and in 5 of 14 eyes in the laser group (P = 0.002). Reactivation requiring treatment was common in both groups, 9/22 after bevacizumab and 6/14 after laser (ns).

CONCLUSION

Regardless of the initial treatment reactivation requiring retreatment is common in eyes with APROP. The unfavorable structural outcome was significantly more common after initial laser treatment than after initial bevacizumab treatment.

Successful Surgical Management of Retinopathy of Prematurity Showing Rapid Progression despite Extensive Retinal Photocoagulation

The management of retinopathy of prematurity (ROP) can be challenging in preterm babies with a gestational age <30 weeks, those with very low birth weight and multiple risk factors (eg., oxygen therapy for respiratory distress, sepsis, neonatal jaundice). A premature infant presented with “hybrid” zone 1 disease in the right eye and aggressive posterior ROP in the left eye. Both eyes were adequately treated with laser photocoagulation; however, the eyes deteriorated and progressed to stage 4 ROP. Both eyes eventually underwent intravitreal bevacizumab followed by lens sparing vitrectomy with good anatomical and visual outcome. Anticipation of progression despite laser photocoagulation in certain clinical scenarios, frequent follow-up and timely surgical intervention is paramount.

Current understanding and management of aggressive posterior retinopathy of prematurity

Aggressive posterior retinopathy of prematurity (ROP), previously referred to as “Rush disease”, is a rapidly progressive form of ROP. This form of ROP typically presents in very low birth weight babies of early gestational age. Historically, anatomical and functional outcomes have been poor with standard treatment. This review is designed to discuss current knowledge and treatment regarding this aggressive form of ROP. Recommendations regarding management of these difficult cases are detailed.

Capillary-free vascularized retina in patients with aggressive posterior retinopathy of prematurity and late retinal capillary formation

Purpose

To report the clinical features, clinical course, and treatment outcomes after laser photocoagulation in infants with aggressive posterior retinopathy of prematurity (APROP) and capillary-free zones in vascularized retina.

Methods

Six patients (12 eyes) with APROP and capillary-free zones in vascularized retina were retrospectively reviewed. Twelve eyes of six infants were included and were treated with laser photocoagulation for avascular retina and for capillary-free zones in vascularized retina, except for the posterior pole, and fundus findings were photographically-documented in sequence. In addition, anatomic and visual outcomes were evaluated with complications of APROP.

Results

Among all of the consecutive infants with APROP, capillary-free zones in vascularized retina were demonstrated in 24% of the infants. All of the infants were >27 weeks of gestation age and had birth weights >1,000 g. After laser treatment, 7 eyes (58.3%) had favorable outcomes, and late capillary filling in capillary-free zones of vascularized retina were noted, however 4 eyes (33.3%) progressed to retinal detachment and 1 eye (8.3%) was complicated by a retinal fold-distorting posterior pole. The visual outcomes were associated with anatomic outcomes.

Conclusions

The anatomic outcomes in infants with APROP who had capillary-free zones were comparable to previously reported infants with APROP. The late capillary filling of capillary-free zones in vascularized retina was noted, and angiogenesis was considered to be involved. This process toward normal capillary formation or neovascularization in APROP, might determine its outcome.