Refractive outcomes comparing primary laser to primary bevacizumab with delayed laser for type 1 ROP

Ophthalmic sequelae of prematurity in late childhood and adulthood: A review

Advances in the care of premature infants have resulted in unprecedented rates of survival of these infants into adulthood, including those born at very low gestational ages. Ophthalmologists have historically followed premature infants to assess for the presence of and potential need for treatment of retinopathy of prematurity. However, a growing body of literature suggests that the ophthalmic consequences of prematurity extended beyond retinopathy of prematurity and that ophthalmic sequelae of prematurity can endure through adulthood even among formerly preterm adults who were never diagnosed with retinopathy of prematurity. These abnormalities can include a range of both anterior segment and posterior segment sequelae, including higher rates of corneal aberrations, ocular hypertension, strabismus, foveal anomalies, and retinal tears and detachments. This review aims to summarise this literature, underscoring the importance of lifelong examinations and regular monitoring for these complications among adults who were born prematurely.

Long-term outcomes of type 1 retinopathy of prematurity following monotherapy with bevacizumab: a Canadian experience

OBJECTIVE

To report long-term structural, visual, and refractive outcomes after monotherapy with intravitreal bevacizumab injection.

DESIGN

Cohort retrospective chart review.

PARTICIPANTS

A total of 56 premature infants with type 1 retinopathy of prematurity.

METHODS

This is a chart review at 2 Canadian institutions. Inclusion criteria were single injection of 0.625 mg  intravitreal bevacizumab and minimum age at last follow-up of 3 years. Primary outcome was retinal structure. Secondary outcomes were refractive error in spherical equivalent, monocular visual acuity, strabismus, and amblyopia.

RESULTS

Fifty-six infants (101 eyes) met inclusion criteria. Mean birth weight was 707 ± 178 g (range, 420-1520 g). Mean gestational age was 25.0 ± 1.3 weeks (range, 22.9-29.7 weeks). Twenty-four eyes were in zone I (24%) and 77 in zone II (76%). Mean postmenstrual age at treatment was 36.9 ± 2.1 weeks (range, 32.8-42.0 weeks). At a mean age of 5.4 ± 1.6 years (range, 3.0-8.0 years), all eyes had a favourable structural outcome with no reactivation requiring treatment. Mean monocular visual acuity was 0.29 ± 0.27 logMAR (range, 0.0-1.3 logMAR; 89 of 101 eyes). Mean spherical equivalent was -1.98 ± 4.91 D (range, -16.63 to +5.38 D; 101 of 101 eyes). Prevalence of emmetropia (>-1.0 to ≤1 D) was 43.6%; low myopia (≥1.0 to <5 D) was 17.8%; high myopia (≥5 to <8 D) was 8.9 %; very high myopia (≥8.0 D) was 12.9%; and hyperopia (>1 D) was 16.8%. Twelve children (23%) had amblyopia, and 17 (32%) developed strabismus.

CONCLUSIONS

All patients demonstrated a favourable structural outcome with a single bevacizumab injection without the need for additional laser. We suggest regular monitoring following regression of acute retinopathy of prematurity as an alternative to universal, preplanned delayed prophylactic laser treatment. Future studies to evaluate other aspects of visual function are needed.

Retinopathy of Prematurity in the 21st Century and the Complex Impact of Supplemental Oxygen

Retinopathy of prematurity (ROP) is a leading cause of childhood blindness. Not only do the epidemiologic determinants and distributions of patients with ROP vary worldwide, but clinical differences have also been described. The Third Edition of the International Classification of ROP (ICROP3) acknowledges that aggressive ROP (AROP) can occur in larger preterm infants and involve areas of the more anterior retina, particularly in low-resource settings with unmonitored oxygen supplementation. As sub-specialty training programs are underway to address an epidemic of ROP in sub-Saharan Africa, recognizing characteristic retinal pathology in preterm infants exposed to unmonitored supplemental oxygen is important to proper diagnosis and treatment. This paper describes specific features associated with various ROP presentations: oxygen-induced retinopathy in animal models, traditional ROP seen in high-income countries with modern oxygen management, and ROP related to excessive oxygen supplementation in low- and middle-income countries: oxygen-associated ROP (OA-ROP).

Refractive status, biometric components, and functional outcomes of patients with threshold retinopathy of prematurity: systemic review and a 17-year longitudinal study

OBJECTIVE

To assess the long-term refractive status, visual outcome, astigmatism, and the change in biometric optic components in older adolescents up to age 17 years with threshold retinopathy of prematurity (ROP) treated with diode laser.

METHODS

A retrospective, longitudinal study in which cycloplegic refraction, keratometry, and the biometric measurement of optic components were performed on 28 consecutive preterm eyes with laser-treated threshold ROP at age 17 years. The study results were statistically analysed and compared with age-matched full-term control.

RESULTS

All patients with ROP had myopia (average spherical equivalent of - 6.35 D, ranges from - 1.25 to - 12.38 D), and 12 eyes (43%) were highly myopic (spherical equivalent <  - 6.0 D). Threshold ROP eyes exhibited a significantly poorer visual acuity (P < 0.001), greater cylinder refractive error (P < 0.001), higher corneal astigmatism (P < 0.001), and flatter horizontal corneal curvature (P = 0.01) compared with age-matched controls. Biometric optic components analysis revealed a significant shallower anterior chamber depth (P < 0.001), thicker lens (P < 0.001), and shorter axial length (P = 0.021) in laser-treated ROP eyes compared with age-matched controls.

CONCLUSIONS

In this 17-year longitudinal study, a higher prevalence of myopia and astigmatism was observed in laser-treated threshold ROP eyes compared with age-matched control eyes. Myopia and astigmatism in laser-treated ROP eyes typically progress through adolescence after school age. Therefore, we recommend that preterm patients with laser-treated threshold ROP should attend regular follow-up not only for refractive status but also for structural change of anterior segment until their adolescence.

Relationship between refractive outcomes and quantitative retinal vascularization and severity of plus disease in eyes treated with intravitreal bevacizumab

Purpose

The study aimed to investigate the relationship between refractive outcomes with the extent of retinal vascularization and severity of the plus disease in infants treated with intravitreal bevacizumab (IVB).

Methods

Pre-IVB fundus images (PFIs), final fundus images (FFIs), and refractive outcomes of the 93 infants who underwent IVB monotherapy for type 1 and aggressive retinopathy of prematurity (A-ROP) were retrospectively evaluated. Quantitative measurements were performed on PFIs and FFIs. Pre-IVB plus severity was scored on a five-leveled scale. Correlation between spherical equivalent (SE) with pre-treatment and final extent of the temporal retinal vascularization and pre-treatment severity of plus disease was analyzed.

Results

There was a linear and low positive correlation between the extent of pre-IVB and final temporal retinal vascularization with final SE (p = 0.000, r = 0.267; P = 0.002, r = 0.274, respectively). There was a low negative correlation between the pre-IVB plus severity score with final SE (p = 0.012, r = -0.192). Gestational age (GA), birth weight (BW), IVB dose, presence of additional IVB, or laser treatments were not correlated with refractive outcome. Out of 171 eyes, 38 eyes had >1 D myopia. In the univariate logistic analyses, pre-IVB retinal zone and pre-IVB and final extent of the temporal retinal vascularization were found to be related to the development of >1 D myopia (p = 0.002, odds ratio (OR) = 0.298; P = 0.000, OR = 0.281; P = 0.001, OR = 0.317; respectively).

Conclusion

Our study indicates that the pre-treatment and final extent of retinal vascularization were the main parameters that were related to final refractive outcomes in IVB-treated eyes for type 1 and A-ROP.

Factors associated with refractive outcome in children treated with bevacizumab for retinopathy of prematurity: the importance of retinal vascularization

PURPOSE

To evaluate the factors that may be associated with refractive outcome in eyes treated with intravitreal bevacizumab (IVB) injection for retinopathy of prematurity (ROP).

METHODS

Retrospective case series. Refractive outcomes of 181 infants who were treated with primary IVB for Type I ROP or aggressive ROP, were retrospectively evaluated. According to the pretreatment retinal vascularization, eyes were classified into zone I, zone I-zone II, and zone II groups. The first year, third year, and final refractive error were analyzed. Univariate logistic regression test was performed to evaluate the effect of factors on the development of ≥ 1 diopter (D) myopia.

RESULTS

At the final examination, the mean age was 22.9 ± 10.9 months. The zone II group was more hyperopic than the zone I-zone II and zone I zone groups (P = 0.001). Of the 331 eyes, 17 eyes (5.1%) had high myopia, 50 eyes (15.1%) had low myopia, and 83 eyes (25.1%) had emmetropia. During follow-up, 110 (33.2%) eyes underwent laser treatment. Gestational age, birth weight, neonatal intensive care unit type, the presence of additional laser treatment, number of injections, the type of ROP, and the dose of IVB were not associated with the development of ≥ 1 D myopia. The pretreatment and prelaser retinal zones were associated with the development of ≥ 1 D myopia.

CONCLUSION

The most important factors affecting the refractive outcome in infants who underwent primary IVB treatment was the extent of pretreatment and prelaser retinal vascularization.

CLINICAL FEATURES AND OUTCOMES OF INFANTS WITH RETINOPATHY OF PREMATURITY WHO FAIL ANTIVASCULAR ENDOTHELIAL GROWTH FACTOR THERAPY

PURPOSE

To describe characteristics and outcomes of patients with retinopathy of prematurity who failed intravitreal antivascular endothelial growth factor.

METHODS

A retrospective case series of 211 eyes (112 patients) treated with antivascular endothelial growth factor as initial therapy for retinopathy of prematurity at a single academic institution between 2011 and 2019 and an additional 6 eyes (3 patients) referred to us for management of failed antivascular endothelial growth factor.

RESULTS

Among the 211 eyes receiving initial treatment at our institution, 17 eyes (11%) failed. Of the 23 total eyes managed by us for failure, 3 eyes (13%) failed after 50-week postmenstrual age. Failure manifested as recurrent plus in 14 eyes (58%), recurrent Stage 3 in 13 eyes (54%) and retinal detachment in 5 eyes (21%). Treatment failures were managed with laser (13 eyes), repeat injection (4 eyes), vitrectomy (2 eyes), or a combination of modalities (4 eyes). Follow-up of ≥6 months was available for 18 of the 23 eyes. The retina was fully attached in 17 eyes, and fixation behavior was present in 10 eyes.

CONCLUSION

The most common manifestations of treatment failure were recurrent plus and Stage 3. The failure rate at our institution was 11.0%. A significant proportion of failures occurred after 50-week postmenstrual age. Most failed eyes had favorable anatomical outcomes and over half demonstrated fixation behavior.

Complications of retinopathy of prematurity treatment

PURPOSE OF REVIEW

The purpose of this review is to summarize complications of treatment for retinopathy of prematurity (ROP) and to compare complications of laser and intravitreal antivascular endothelial growth factor (VEGF) injections.

RECENT FINDINGS

Poor structural outcomes and myopia are more common with laser for severe ROP than with anti-VEGF. Clinical trial data show unfavourable outcomes in 9.1-9.5% of laser treated, and 1.4-3.6% of anti-VEGF treated eyes. Additional randomized trial data show risk for very high myopia (≥-8.00D) to be 3.8 and 51.4% for zone I eyes treated with bevacizumab and laser, respectively. However, anti-VEGF may be complicated by late recurrence and is more likely to require retreatment than laser. Laser often necessitates general anaesthesia with its attendant risks, including worse short-term respiratory outcomes. Neurodevelopmental complications have been reported with anti-VEGF, but existing studies are subject to bias.

SUMMARY

Treatment complications are substantially different for the two modalities in common use today. In more severe cases, risk of poor structural outcome and myopia favour treatment with anti-VEGF. In less severe ROP, risk of recurrence and the need for additional treatments may favour laser. Additional data are needed to establish comparative risks of neurodevelopmental complications.

Neurodevelopmental outcomes following bevacizumab treatment for retinopathy of prematurity: a systematic review and meta-analysis

OBJECTIVE

To systematically review the studies exploring the association between bevacizumab and neurodevelopmental outcomes.

METHODS

Embase, Medline, CINAHL, and Cochrane Library databases were searched for studies examining neurodevelopmental outcomes of preterm infants treated with bevacizumab compared to laser ablation or cryotherapy for severe retinopathy of prematurity (ROP).

RESULTS

Thirteen studies (clinical trial = 1; cohort studies = 12) were included. Random-effects model meta-analysis showed significant increased odds of cognitive impairment associated with bevacizumab treatment on both unadjusted (unadjusted odds ratio (OR) 1.61; 95% confidence interval (CI) 1.12, 2.30) and adjusted analyses (adjusted OR 1.90; 95% CI 1.22, 2.97). Infants treated with bevacizumab for severe ROP had significantly lower Bayley-III cognitive (mean difference (MD) -1.66; 95% CI -3.21, -0.12), and language composite scores (MD -5.50; 95% CI -8.24, -2.76) compared to infants treated with laser ablation or cryotherapy.

CONCLUSION

Bevacizumab treatment for severe ROP is associated with increased risk of cognitive impairment and lower cognitive and language scores in preterm infants.