Early clinical characteristics of bacterial endophthalmitis in retinopathy of prematurity after intravitreal bevacizumab injection: A case report

The Long-Term Observation of the Beneficial Effects of Treatment: 0.12 mg Anti-VEGF Monotherapy or Anti-VEGF Combined Therapy and Diode-Laser in Various Stages of Retinopathy of Prematurity-Series of Cases

Background 2-year observations of ranibizumab monotherapy and combined therapy with diode laser for severe ROP in extremely prematures. Materials and methods: In a group of 18 prematures (n = 36 eyes; 5 study groups); 25.8 ± 1.5 Hbd, birth weight 796.5 ± 166.1 g. Apgar 4.62 ± 1.88) with A-ROP (n = 22; 61%) and 3 ROP (plus) (n = 14; 39%), ranibizumab monotherapy (n = 4 eyes) in dose 0.12 mg/0.12 mL or with diode laser (n = 32 eyes) were applied. The first intervention was carried out in PMA of 33 (gr. 4 and 5) and 34 in (gr. 1, 2, 3), mean follow-up time 21.44 ± 8.7 months. One-way analysis of variance (ANOVA) with Welch's correction, non-parametric Kruskal-Wallis test, Chi square test of independence were used. A retrospective observational study based on a case series. Results Retinal attachment was achieved in 92.3% of the studied eyes. Bilateral retinal detachment was noted in 1 infant (2 eyes). Myopization (-0.75 to -7.5 D) was observed in 5 infants (45%); mild hyperopia (+0.5 to +4.5 D) was observed in the rest infants (55%). Conclusions Individualization strategies in severe ROP with lower dose 0.12 mg Ranibizumab or combined laser-therapy resulted in effective outcomes. Myopia has not been reported in patients where Ranibizumab was the first drug administered in the ROP treatment strategy.

Practice Patterns and Outcomes of Intravitreal Anti-VEGF Injection for Retinopathy of Prematurity: An International Multicenter Study

PURPOSE

To report practice patterns of intravitreal injections of anti-VEGF for retinopathy of prematurity (ROP) and outcomes data with a focus on retreatments and complications.

DESIGN

Multicenter, international, retrospective, consecutive series.

SUBJECTS

Patients with ROP treated with anti-VEGF injections from 2007 to 2021.

METHODS

Twenfty-three sites (16 United States [US] and 7 non-US) participated. Data collected included demographics, birth characteristics, examination findings, and methods of injections. Comparisons between US and non-US sites were made.

MAIN OUTCOME MEASURES

Primary outcomes included number and types of retreatments as well as complications. Secondary outcomes included specifics of the injection protocols, including types of medication, doses, distance from limbus, use of antibiotics, and quadrants where injections were delivered.

RESULTS

A total of 1677 eyes of 918 patients (43% female, 57% male) were included. Mean gestational age was 25.7 weeks (range, 21.2-41.5 weeks), and mean birth weight was 787 g (range, 300-2700 g). Overall, a 30-gauge needle was most commonly used (51%), and the quadrant injected was most frequently the inferior-temporal (51.3%). The distance from the limbus ranged from 0.75 to 2 mm, with 1 mm being the most common (65%). Bevacizumab was the most common anti-VEGF (71.4%), with a dose of 0.625 mg in 64% of cases. Overall, 604 (36%) eyes required retreatment. Of those, 79.8% were retreated with laser alone, 10.6% with anti-VEGF injection alone, and 9.6% with combined laser and injection. Complications after anti-VEGF injections occurred in 15 (0.9%) eyes, and no cases of endophthalmitis were reported. Patients in the United States had lower birth weights and gestational ages (665.6 g and 24.5 weeks, respectively) compared with non-US patients (912.7 g and 26.9 weeks, respectively) (P < 0.0001). Retreatment with reinjection and laser was significantly more common in the US compared with the non-US group (8.5% vs. 4.7% [P = 0.0016] and 55% vs. 7.2% [P < 0.001], respectively). There was no difference in the incidence of complications between the 2 geographic subgroups.

CONCLUSIONS

Anti-VEGF injections for ROP were safe and well tolerated despite a variance in practice patterns. Infants with ROP receiving injections in the US tended to be younger and smaller, and they were treated earlier with more retreatments than non-US neonates with ROP.

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.

Endophthalmitis in Retinopathy of Prematurity after Intravitreal Aflibercept Injection

We report the case of a male infant who had an intravitreal anti-VEGF (aflibercept) injection for the treatment of retinopathy of prematurity at 35-week postmenstrual age. Four days following the injection, retinal imaging demonstrated a yellowish gray blurred mass that extended into the vitreous in the right eye, and the vitreous body was blurred. After two days, despite starting endophthalmitis treatment, there was still no improvement in the retinal lesion. Due to the worsening of the clinical signs, we decided to perform 25-gauge lens-sparing pars plana vitrectomy.

Retinopathy of Prematurity: How to Prevent the Third Epidemics in Developing Countries

Retinopathy of prematurity (ROP) is vasoproliferative disease affecting preterm infants and is a leading cause of avoidable childhood blindness worldwide. The world is currently experiencing the third epidemic of ROP, where majority of the cases are from middle-income countries. Over 40% of the world's premature infants were born in India, China, Bangladesh, Pakistan, and Indonesia. Together with other neighboring nations, this region has unique challenges in ROP management. Key aspects of the challenges including heavier and more mature infants developing severe ROP. Current strategies include adoption of national screening guidelines, telemedicine, integrating vision rehabilitation and software innovations in the form of artificial intelligence. This review overviews some of these aspects.

Post-Ranibizumab injection endophthalmitis in aggressive posterior retinopathy of prematurity

A preterm infant with zone 1 aggressive posterior retinopathy of prematurity developed infectious endophthalmitis after intravitreal injection of ranibizumab. Urgent empirical intravitreal therapy with vancomycin, ceftazidime, and dexamethasone along with intravenous therapy with amikacin and meropenem helped in early resolution. Vascularization/activity of disease subsided on follow-up, media cleared, and laser photocoagulation was completed. Later the disease reactivated, developed vitreous membranes and central retinal traction, for which 25-gauge lens-sparing vitrectomy was performed. Emergent treatment helped in salvaging the eye from both aggressive ROP disease and devastating endophthalmitis. Rationale approach to such a case is being discussed.

The use of bevacizumab in pediatric retinal and choroidal disease: A review

The use of intravitreal bevacizumab in pediatric retinal and uveitic disease has become more widespread over the past decade. This article serves to outline the rationale underlying the use of intravitreal bevacizumab, and which disease entities it should be appropriately thought of as a primary or solo therapy, as opposed to an adjuvant one. Also presented is the relevant literature regarding each of these retinopathies.

Intravitreal ranibizumab versus laser photocoagulation for retinopathy of prematurity: efficacy, anatomical outcomes and safety

Background/Aims

To compare the efficacy, anatomical outcomes and complications of intravitreal ranibizumab with those of laser photocoagulation for retinopathy of prematurity (ROP).

Methods

This is a retrospective case series of 314 eyes from 165 infants diagnosed with type I ROP and treated with either laser photocoagulation (161 eyes) or intravitreal ranibizumab (0.25 mg/0.025 mL) injection (153 eyes) between January 2006 and December 2016 in a tertiary referral-based hospital. The main outcome was the rate of recurrence requiring additional treatment. Secondary outcomes included the incidence of major complications and final refractive error.

Results

The mean follow-up was 36.3±31.9 months. Recurrences requiring further intervention were noted in 22 (13.7%) laser-treated and 15 (9.8%) ranibizumab-treated eyes (p=0.196). Retinal detachment (8 vs 1, p=0.037) and macular dragging (7 vs 1, p=0.039) were observed in the laser-treated and injection-treated groups, respectively, but no systemic or neurodevelopmental adverse events were reported. In the ranibizumab group, 95.6% showed fully vascularised retinas. Multivariate analyses revealed that birth weight (OR 0.993, p=0.023) and higher ROP stage (OR 11.222, p=0.008) influenced the incidence of major complications.

Conclusion

Intravitreal ranibizumab for ROP appears to achieve similar therapeutic effects than did laser photocoagulation, but with fewer surgical complications such as retinal detachment or macular dragging.

Anti-vascular Endothelial Growth Factor Treatment of Retinopathy of Prematurity: Efficacy, Safety, and Anatomical Outcomes

PURPOSE

To investigate the efficacy, safety, and anatomical outcomes associated with intravitreal anti-vascular endothelial growth factor (VEGF) treatment of retinopathy of prematurity (ROP).

METHODS

We performed a retrospective review of intravitreal anti-VEGF (bevacizumab or ranibizumab) treatment of 153 eyes (83 infants) diagnosed with ROP at two tertiary hospitals from June 2011 to January 2017. The primary outcome was the rate of recurrence requiring additional treatment; secondary outcomes included incidence of major complications and final refractive error.

RESULTS

A total of 101 eyes were treated with bevacizumab, and 52 with ranibizumab. The bevacizumab and ranibizumab groups were characterized by mean birthweights of 941.8 ± 296.1 and 1,257.7 ± 514.5 g, gestational ages at birth of 26.9 ± 1.9 and 28.1 ± 3.2 weeks, and postmenstrual ages at treatment of 40.4 ± 2.4 and 39.2 ± 2.3 weeks, respectively. The two groups differed significantly in birthweights and gestational ages at birth, but not in postmenstrual ages at treatment. The mean follow-up duration was 30.9 ± 18.4 months for the bevacizumab group, and 13.9 ± 12.5 months for ranibizumab. More cases were classified as zone 1 ROP in the ranibizumab group (44.2% vs. 11.9%, p < 0.001). Major surgical interventions included scleral encircling and vitrectomy (one and two eyes, respectively, both in the bevacizumab group). Retinal detachment was noted in one eye treated with bevacizumab. There was no significant difference in the most recent spherical equivalence for the two groups (+0.10 ± 3.66 and +0.22 ± 3.00 diopters for bevacizumab and ranibizumab, respectively). Univariable analysis revealed that only ROP stage influenced the occurrence of major complications (odds ratio, 9.046; p = 0.012).

CONCLUSIONS

Intravitreal anti-VEGF treatment of ROP with both bevacizumab and ranibizumab achieved stable retinal vascularization with a low rate of complications and recurrence. Ranibizumab achieved similar anatomical outcomes as bevacizumab, without additional risk for major complications.