Low-dose ranibizumab as primary treatment of posterior type I retinopathy of prematurity

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.

Intestinal perforation after intravitreal low dose ranibizumab injection for the treatment of type 1 retinopathy of prematurity: A case report

PURPOSE

To report a newborn patient with gastrointestinal (GIS) perforation after intravitreal ranibizumab (RBZ) treatment.

CASE REPORT

The patient was born at 31 gestational week and hospitalized with the diagnosis of small for gestational age and prematurity. In the follow up he underwent GIS surgery due to necrotizing enterocolitis (NEC) and was diagnosed with retinopathy of prematurity (ROP). At 43 weeks of postmenstrual age, he developed intestinal perforation after 12 h of the second low-dose RBZ injection. According to our knowledge, this is the first report of GIS perforation due to low-dose intravitreal RBZ treatment in an infant with severe ROP.

CONCLUSION

The risk of GIS perforation should be taken into consideration during the application of intravitreal vascular endothelial growth factor antagonist agents, especially in newborns with previous GIS surgery and a history of NEC, and these patients should be carefully monitored for GIS complications.

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

Purpose:

To report the results of the survey for the role of anti-VEGF in the management of retinopathy of prematurity (ROP) among the members of Indian ROP (iROP) society.

Methods:

A questionnaire was designed in English using Google forms and its link was circulated to the members of the iROP society on their mobile numbers. The survey included questions pertaining to demographics, anti-VEGF agents, injection technique, post-injection follow-up, and documentation pertaining to their ROP practice. Anonymous responses were obtained and analyzed for individual questions.

Results:

226 members of the society were contacted and 157 responded (69.4%) to the survey. 137 (87.2%) respondents used anti-VEGF in the management of ROP. Aggressive posterior ROP (APROP) was the most common indication (78, 52.7%). The procedure was carried out in the main operation room (102, 70.3%) simultaneously for both the eyes (97; 68%) under topical anesthesia (134; 86.4%) by most of the respondents. One-hundred thirteen (77.9%) respondents used half of the adult dose, irrespective of the agent used; however, more than half of them preferred bevacizumab (85, 54%). 53 (36.3%) respondents followed up infants as per disease severity rather than a fixed schedule while only 33 (23%) performed photo documentation. 151 (96.2%) respondents felt the need for guidelines regarding the usage of anti-VEGF in ROP.

Conclusion:

There is an increase in the trend towards the use of anti-VEGF in the management of severe ROP, particularly APROP. However, there are considerable variations among the ROP practitioners regarding the agent, dosage, follow-up schedule, and documentation, suggesting the need for uniform guidelines.

Late visual outcomes in infants treated with primary bevacizumab for type 1 retinopathy of prematurity

PURPOSE

To describe visual acuity findings after 4 years of age in infants treated with primary bevacizumab (IVB) for type 1 retinopathy of prematurity (ROP) and to correlate structural findings on fluorescein angiography (FA) with functional outcomes.

METHODS

Infants born between January 2011 and January 2014 were identified by review of the medical records. Visual acuity was measured in clinic after 4 years of age. As described in the ET-ROP study, normal visual acuity was 20/40 (logMAR 0.3) or better. Examination under anesthesia with FA and prophylactic laser if necessary was recommended for all patients who received primary IVB. Vascular abnormalities were reviewed by 2 experts.

RESULTS

A total of 23 infants (46 eyes) completed visual acuity testing. Median age was 6 years (IQR, 4-7). Median visual acuity was logMAR 0.18 (IQR, 0-0.3). Normal vision was recorded for 39/46 (85%) eyes. Twenty-one patients (42 eyes) completed an examination under anesthesia with FA. All eyes had some peripheral capillary abnormalities (shunts, tangles, or abnormal branching); most had peripheral nonperfusion (90%) and leakage (64%).

CONCLUSIONS

Most eyes treated with IVB for type 1 ROP had normal visual acuity. Our results after IVB in this study compare favorably to 6-year visual outcomes in the ET-ROP study, in which 34.6% of early-treated eyes had normal visual acuity (20/40 or better). Nonetheless, a high percentage of eyes had abnormal vascular patterns on FA, which may be related to underlying ROP or to treatment. Peripheral vascular changes are common in eyes with ROP treated with IVB, but they do not preclude excellent visual acuity.

Laser therapy versus intravitreal injection of anti-VEGF agents in monotherapy of ROP: a Meta-analysis

AIM

To compare the efficacy and safety between laser therapy and anti-vascular endothelial growth factor (VEGF) agents intravitreal injection monotherapy in type-1 retinopathy of prematurity (ROP) and aggressive posterior retinopathy of prematurity (APROP).

METHODS

A systematic literature search was performed in PubMed, Cochrane Library, and Embase for original comparable studies. We included studies that compare laser therapy and intravitreal injections of anti-VEGF agents monotherapy in ROP regardless of languages and publication types.

RESULTS

Complication incidence was significantly higher in laser therapy group (OR: 0.38; 95%CI: 0.19-0.75; P=0.005). Spherical equivalent (SE) was higher in laser therapy [weighted mean difference (WMD): 2.40, 95%CI: 0.88-3.93; P=0.002]. The time between treatment and retreatment was longer in laser therapy group (WMD: 8.45, 95%CI: 5.35-11.55; P<0.00001). Recurrence incidence (OR: 0.97; 95%CI: 0.45-2.09; P=0.93) and retreatment incidence (OR: 1.24; 95%CI: 0.56-2.73; P=0.59) were similar in two approaches. Subgroup analysis between type-1 ROP and APROP was not significant except SE reported in the included studies (P<0.0001).

CONCLUSION

This Meta-analysis outcome indicates anti-VEGF agents are as effective as laser treatment, and safer than laser in type-1 ROP and APROP. The degree of myopia in APROP is higher than type-1 ROP. More randomized controlled trials in large sample size should be conducted in the future.

Neurodevelopmental Outcomes Comparing Bevacizumab to Laser for Type 1 ROP

BACKGROUND AND OBJECTIVE

To evaluate neurodevelopmental outcomes among infants treated for retinopathy of prematurity (ROP) at the authors' institution.

PATIENTS AND METHODS

Before-and-after retrospective chart reviews identified 40 infants treated with laser and 46 treated with primary intravitreal bevacizumab (IVB). Primary outcomes were death, hearing loss, bilateral visual impairment (BVI), and cerebral palsy (CP); odds ratios (ORs) were calculated to determine factors associated with CP. Secondary outcomes were mean Bayley Scales of Infant and Toddler Development, Third Edition (BSID-III) scores.

RESULTS

Overall, there were no significant differences in primary outcome measures by treatment group. However, adjusted odds of BVI were significantly higher with laser compared to IVB (OR = 13.1; P = .038). Although IVB was not associated with CP, both hydrocephalus and BVI were strongly correlated with CP. Mean Bayley-III scores were similar when comparing nine laser-treated infants to 13 IVB-treated infants.

CONCLUSIONS

Visual outcomes are an important aspect of neurodevelopment. IVB was not associated with severe developmental disabilities and may protect against vision loss in this analysis. [Ophthalmic Surg Lasers Imaging Retina. 2019;50:337-343.].

Prethreshold retinopathy of prematurity: VEGF inhibition without VEGF inhibitors

The risk of developing treatment-warranted Type 1 retinopathy of prematurity (ROP) might be reduced in preterm infants by modifying certain systemic factors. There are steps that can be taken both early and late in the course of retinal vascular maturation that may potentially reduce an infant's risk of developing Type 1 ROP. In prethreshold stage 2-3 ROP without plus disease, a combination of supplemental oxygen, correction of severe anemia, and light adaptation to reduce rod photoreceptor oxygen consumption helped us to reduce ROP severity, and encouraged a return to a more physiologic retinal vascular maturation pattern. Thus, it may be possible to reduce the risk of developing Type 1 ROP by making adjustments in certain systemic parameters aimed at reducing retinal hypoxia, thereby gently lowering pathologically elevated levels of vascular endothelial growth factor (VEGF) within the eye.

A lower dose of intravitreal conbercept effectively treats retinopathy of prematurity

Intravitreal Conbercept (IVC) is the latest applied and effective treatment for the management of retinopathy of prematurity (ROP). However, conbercept escapes from the vitreous into the general circulation and reduce systemic VEGF concentrations. Thus, there are concerns about systemic complications, in these premature infants who are developing vital organ systems. This study is to determine whether a low dosage (0.15 mg/0.015 mL) of IVC is effective in the treatment of Zone II Stage 2/3 + ROP. A total of 38 eyes of 20 infants were analyzed retrospectively. We identified treatment effectiveness as complete regression of retinopathy and retinal vascularisation to zone III. The mean gestational age (GA), postmenstrual age (PMA) at treatment and birth weights (BW) were 28.6 ± 2.2 weeks, 39.3 ± 3.0 weeks and 1297.5 ± 429.2 g respectively. Primary effectiveness (react to IVC 0.15 mg alone) was found in 32/38 eyes (84.2%). Secondary effectiveness (a second IVC was required) was found in 6/38 eyes (15.8%). Follow-up continued until 90 weeks’ postmenstrual age and showed no recurrences of plus disease or neovascularization. The study suggests 0.15 mg IVC is effective for Zone II Stage 2/3 + ROP, and there is no adverse ocular outcomes during the follow-up period.

The role of intravitreal ranubizumab in the treatment of familial exudative vitreoretinopathy of stage 2 or greater

AIM

To evaluate the role of intravitreal ranubizumab (IVR) in the treatment of familial exudative vitreoretinopathy (FEVR) of stage 2 or greater either as primary or an ajunct to conventional treatments.

METHODS

Retrospective, non-controlled clinical study. Thirty patients (37 eyes) diagnosed with FEVR were enrolled. Twenty patients (66.67%) were male and 10 patients (33.33%) were female. Age ranged from 0.4 to 35 years old (median 3y). IVR was used either as primary or as a combined therapy according to the retinal neovasuclar activities. The follow up ranged from 1 to 57mo with mean 16.73±15.73 (median 11)mo. The treatment effect of retinal neovasuclar activites were recorded as well as the ocular and systemic side effects.

RESULTS

Among 30 patients (37 eyes), 10 eyes received single IVR, 1 eye received 2 injections. Three eyes were treated with IVR and simutanous laser photocoagulation. Laser indirect ophthalmoscopy (LIO) was applied in 5 eyes 1mo after the primary IVR. Seven eyes were treated surgically following the primary IVR due to persistent retinal neovasuclar activities and retinal traction. IVR was used as combined treatment with vitrectomy in 11 eyes. Retinal neovascular regression was notified 1mo following the primary IVR in all eyes. Neither systemic nor ocular complications were recorded.

CONCLUSION

IVR may be an effective modality in the treatment of FEVR either as primary or as an ajunct to the conventional therapies. The long term effect and safty of IVR still need further research.

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.