Combined Vitrectomy and Anti-VEGF Treatment for Stage 4 Retinopathy of Prematurity With Extensive Neovascular Proliferation

Surgical outcomes in aggressive retinopathy of prematurity (AROP)-related retinal detachments

Introduction

Aggressive retinopathy of prematurity (AROP) is a severe and progressive variant of retinopathy of prematurity (ROP) rapidly forming fibrous tissue extending from the disc toward the posterior lens surface progressing to Stage 5 disease without traversing the classical course that includes Stages 1 to 3. Since AROP behaves differently from type 1 ROP, this study was undertaken to evaluate the surgical outcome of AROP-related detachments.

Methods

Retrospective analysis of data from electronic medical records of babies diagnosed with AROP-related detachments who underwent micro-incision vitrectomy surgery (MIVS) was included. The demographic data, details of primary intervention (laser and/or intravitreal bevacizumab), and surgery were noted. In a subset of patients, surgical intervention was planned early at the onset of fibrovascular tissue.

Results

43 eyes of 26 babies with median birth weight 1175 g and median gestational age of 29 weeks were analyzed. 42/43 eyes underwent primary intervention in form of laser and/or anti-VEGF injection before surgery. 41.8%, 25.5%, and 32.5% eyes progressed to stages 4A, 4B, and 5, respectively, requiring surgical intervention. 66% eyes underwent lensectomy and vitrectomy (LV), and 44% eyes underwent lens sparring vitrectomy (LSV). 58% eyes had attached macula. 44% eyes that had a relatively less vascular diseases had better anatomical outcome (P = 0.019). At final follow-up, 53.4% eyes followed or at least had light fixation, and 77.7% eyes undergoing LSV fixated and/or followed light compared to 33% for LV (P = 0.04).

Conclusion

Challenges in AROP include rapid progression to advanced stages of ROP requiring close monitoring and multiple interventions. Surgeries for AROP have a favorable anatomical and functional outcome in 58% and 53%, respectively. Eyes undergoing lens sparing vitrectomy had better visual outcomes.

Clinical profile and management outcomes of posterior zone 1 retinopathy of prematurity

BACKGROUND

To analyse the varied clinical profile and treatment outcomes of posterior zone 1 retinopathy of prematurity (ROP).

METHODS

This retrospective case-series included 54 eyes of 27 infants of posterior zone 1 ROP treated at our centre from January 2018 to June 2019. Three clinical patterns were observed at presentation - Posterior zone 1 ROP without detachment (group 1), with subtotal detachment (group 2) and total detachment (group 3) of the vascularised retina. Their profile, treatment options and outcomes were studied.

RESULTS

The mean birth weight was 1204 ± 262 gm and mean gestational age was 28.8 ± 2 weeks. Clinical presentation as per group 1, 2 and 3 was seen in 33/54 (61.1%), 9/54 (16.6%) and 12/54 (22.2%) eyes, respectively. All the eyes received intravitreal ranibizumab as primary intervention. In group 1, 25/33 (75.7%) eyes had laser and 8/33 (24.2%) had surgery whereas, in group 2, 2/9 (22.2%) eyes had laser and 7/9 (77.7%) underwent surgery as a second intervention. In group 3, only 3 /12 (25%) eyes had second intervention (surgery). Surgical outcomes of group 1 and 2 were better than group 3. At last follow-up, macular vascularisation was noted in 33/54 (61.1%) eyes.

CONCLUSION

A customised and multifaceted treatment approach is required to treat posterior zone 1 ROP.

The role of anti-vascular endothelial growth factor in treatment of retinopathy of prematurity-a current review

The review aims to evaluate the uses of conventional laser therapy and intravitreal injection of various anti-VEGF in terms of efficacy and side effects for the treatment of retinopathy of prematurity. A literature search of the publication, concerning conventional laser treatment and intravitreal injection of anti-VEGF for ROP. A total of 40 articles were reviewed after curation by the authors for relevance. Intravitreal anti-VEGF showed better ocular efficacy in zone I ROP while laser therapy had a lower recurrence rate in zone II. Comparing the two mainstay anti-VEGF agents, bevacizumab showed lower ROP recurrence rate than ranibizumab. Anti-VEGF has a higher chance in developing persistent peripheral avascularisation compared to conventional laser therapy, but a lower chance of developing high myopia. Ranibizumab has a lower systemic absorption than bevacizumab, despite having no difference in the incidence of persistent peripheral avascularisation. In conclusion, it is advised that intravitreal anti-VEGF should be used as the first-line treatment for zone I ROP while laser therapy should be the mainstay for zone II ROP owing to the different pathogenetic mechanisms. In patients with recurrence after initial anti-VEGF injection, that given ranibizumab may opt to repeat the injection while that given bevacizumab should consider supplement laser ablative treatment.

An Observational Study of Different Treatment Practices for Aggressive Posterior Retinopathy of Prematurity

PURPOSE

To evaluate risk factors and outcomes of preferred practice for infants with aggressive posterior retinopathy of prematurity (APROP) at a tertiary eye center in India.

METHODS

This was an observational study of infants with APROP where patients were divided into three groups after 2 weeks of initial treatment depending on the treatment received: anti-VEGF only, laser only, and combination of anti-VEGF injection followed by laser within 2 weeks of anti-VEGF injection (combined group). All infants were evaluated for risk factors and followed up at 1, 2, 4, 8, and 12 weeks to determine treatment outcomes in terms of regression, vascular re-growth, progression, and recurrence of the disease.

RESULTS

Sixty eyes of 31 infants were included in the study, with 26 eyes in the anti-VEGF only group, 19 eyes in the laser-only group, and 15 eyes in the combined group. Infants in the combined group presented late with lower birth weight (BW), smaller gestational age (GA), and a history of longer duration of ventilatory support. After 3 months of follow-up, regression occurred in 73.08% in the anti-VEGF only group, 89.5% in the laser-only group, and 86.66% in the combined group (P = .07). Zone of vascularization was greater in the anti-VEGF only group and the combined group compared to the laser-only group. Disease recurrence was seen in 27% in the anti-VEGF group, none in the laser-only group, and 13.33% in the combined group (P < .001). However, progression to stage 4 ROP requiring surgery was noted in 2 eyes in the laser-only group.

CONCLUSIONS

Infants with APROP who have a lower GA or BW or require longer ventilatory support are possibly a subset best suited for planned combination therapy. A combination of anti-VEGF therapy followed by laser treatment within 2 weeks allows for early regression, a stable course, lower recurrence, and a larger area of retinal vascularization. [J Pediatr Ophthalmol Strabismus. 2021;58(6):370-376.].