What are the guidelines for treating retinopathy of prematurity (ROP)?

Guidelines for Treatment of Retinopathy of Prematurity (ROP)

The current standard treatment for retinopathy of prematurity includes laser photocoagulation and/or intravitreal anti-vascular endothelial growth factor (anti-VEGF) injections, with treatment selection based on disease severity, zone involvement, and presence of plus disease.

Screening and Classification

• Screening should be performed in all preterm infants at risk for developing ROP
• Classification is based on:
  • Zone of involvement (posterior Zone I, anterior Zone II, or Zone III)
  • Stage of disease (1-5)
  • Presence or absence of plus disease (vascular dilation and tortuosity)
  • Extent of disease (clock hours)

Treatment Indications

Treatment is indicated for:

• Type 1 ROP:
  • Zone I, any stage with plus disease
  • Zone I, stage 3 without plus disease
  • Zone II, stage 2 or 3 with plus disease
• Aggressive posterior ROP (AP-ROP)
• Threshold disease (at least 5 contiguous or 8 cumulative clock hours of stage 3 ROP in zone I or II with plus disease)

Treatment Options

1. Laser Photocoagulation

• Primary indication: Standard treatment for threshold and prethreshold disease (type 1 ROP) 1
• Technique: Panretinal photocoagulation to avascular retina
• Benefits: Well-established efficacy with decades of follow-up data
• Limitations:
  • Permanent destruction of peripheral retina
  • Requires sedation or general anesthesia
  • Associated with higher rates of myopia
  • May be difficult to perform in cases with poor pupillary dilation or media opacity

2. Anti-VEGF Therapy

• Primary indication: Increasingly used for posterior disease (Zone I or posterior Zone II)
• Agents:
  • Bevacizumab (Avastin) 0.625mg
  • Ranibizumab (Lucentis) 0.2mg
  • Aflibercept (Eylea)
• Benefits:
  • Rapid regression of neovascularization (within 48 hours) 2
  • Allows continued vascularization of peripheral retina
  • Less myopia compared to laser
  • Avoids need for sedation/intubation required for laser
  • Particularly useful when media opacity prevents adequate laser treatment
• Limitations:
  • Risk of late recurrence (8-11 weeks after injection) requiring vigilant monitoring 2
  • Concerns about systemic absorption and potential effects on developing organs
  • Limited long-term safety data

Treatment Algorithm

1. For Zone I or posterior Zone II disease with plus disease:

   • Consider anti-VEGF as primary therapy, especially in cases with:
     • Media opacity preventing adequate laser
     • Very posterior disease where laser would destroy significant functional retina
     • Systemic instability making prolonged laser procedure risky

2. For anterior Zone II disease with plus disease:

   • Laser photocoagulation remains first-line treatment

3. For aggressive posterior ROP (AP-ROP):

   • Anti-VEGF therapy often preferred due to rapid progression and poor response to laser

4. For recurrent disease after anti-VEGF:

   • Consider supplemental laser to avascular retina, which may spare the posterior retina from photocoagulation effects 2

5. For stage 4 or 5 ROP (partial or total retinal detachment):

   • Surgical intervention with vitrectomy or scleral buckling

Post-Treatment Monitoring

• After anti-VEGF therapy:

  • Examine within 1 week to confirm initial response
  • Continue weekly examinations for first month
  • Then every 1-2 weeks until complete vascularization
  • Critical: Monitor for late recurrence (8-11 weeks after injection) 2

• After laser therapy:

  • Examine within 1 week
  • Continue examinations every 1-2 weeks until regression of neovascularization

Important Considerations

• Anti-VEGF therapy induces rapid regression of ROP with continued peripheral retinal growth, but requires vigilant monitoring for recurrence 2
• Combined therapy (anti-VEGF plus selective laser) may be beneficial in certain cases 3
• Anti-VEGF therapy is associated with fewer adverse events compared to laser therapy, though mortality rates show no significant difference 4
• The potential for recurrent ROP after anti-VEGF injection requires careful follow-up for at least 3-4 months

Treatment Complications

• Laser: Anterior segment inflammation, cataract, intraocular pressure elevation, visual field constriction
• Anti-VEGF: Endophthalmitis, cataract, vitreous hemorrhage, potential systemic effects
• Both: Progression to retinal detachment if treatment is inadequate or delayed

By following these guidelines and selecting the appropriate treatment based on disease characteristics, the risk of blindness from ROP can be significantly reduced while maximizing visual potential.