What is the treatment protocol for retinopathy of prematurity (ROP)?

Treatment Protocol for Retinopathy of Prematurity (ROP)

The treatment protocol for retinopathy of prematurity should follow a staged approach based on disease severity, with laser photocoagulation as the gold standard for threshold ROP and anti-VEGF therapy as an emerging alternative for specific cases, particularly zone I disease. 1

Screening and Diagnosis

• Screening criteria:

  • Infants weighing <1500 grams
  • Gestational age ≤34 weeks
  • First examination at 4-6 weeks chronological age or 31-33 weeks postmenstrual age 1

• Follow-up examination frequency:

  • Every 1-2 weeks for infants with vessels/ROP in Zone 1 or Zone 2
  • Less frequent when vessels have reached Zone 3 with regression on two sequential examinations 1

Classification and Treatment Indications

Type I ROP (Treatment Warranted)

• Zone I, any stage with plus disease
• Zone I, stage 3 without plus disease
• Zone II, stage 2 or 3 with plus disease 2

Type II ROP (Observation Recommended)

• Zone I, stage 1 or 2 without plus disease
• Zone II, stage 3 without plus disease 2

Treatment Modalities

1. Laser Photocoagulation

• Gold standard treatment for threshold ROP 1
• Peripheral retinal ablation proven effective in reducing blindness from ROP 3
• Most effective for Zone II disease (64.6% favorable outcome) 4
• Less effective for posterior Zone I disease (0% favorable outcome in one study) 4

2. Anti-VEGF Therapy (Intravitreal Injections)

• Emerging treatment option, particularly for:
  • Zone I disease where laser may be technically challenging
  • Aggressive posterior ROP 1, 5
• Benefits:
  • May allow continued physiologic retinal vascularization 5
  • Ranibizumab shown to be non-inferior to laser photocoagulation for proliferative ROP 3
• Limitations:
  • May not guarantee full retinal vascularization (complete vascularization observed in only 24% of eyes in one study) 6
  • May require additional treatments (76% of eyes in one study) 6
  • Long-term safety and efficacy still being evaluated 1

3. Surgical Intervention

• Indicated for advanced ROP with retinal detachment (Stage 4-5) 7
• Success rates vary by stage:
  • Stage 4: 44.4-74% favorable outcomes
  • Stage 5: 13-33% favorable outcomes 7, 4

Combination Therapy

• Multipronged approach may be necessary for aggressive disease, especially Zone I ROP
• Combinations may include:
  • Laser plus anti-VEGF (10% of cases in one study)
  • Laser plus surgery (10% of cases)
  • Laser plus anti-VEGF plus surgery (10% of cases) 7

Pain Management During ROP Procedures

• Retinal examinations are painful and require appropriate analgesia 3
• Recommended pain management:
  • Topical anesthetics (limited effectiveness alone)
  • Oral sucrose (provides some relief but not complete)
  • Nonpharmacologic methods (swaddling, facilitated tucking)
  • For retinal surgery: adequate anesthesia/analgesia required 3

Follow-up Protocol

• Continue monitoring until retinal vascularization is complete
• Regular vision assessments throughout childhood to monitor for:
  • Refractive errors
  • Strabismus
  • Other ocular complications 1

Special Considerations

• Oxygen Management:

  • Avoid unrestricted supplemental oxygen
  • Current evidence suggests oxygen saturation targets of 95-99% do not increase (and may even decrease) risk of ROP progression in infants with pre-threshold ROP 3, 1
  • Balance oxygen needs with ROP risk

• Fibrotic Component:

  • ROP after 40 weeks postmenstrual age often displays enhanced fibrotic proliferation
  • May influence treatment choice and outcomes 6

Multidisciplinary Approach

• Coordination between neonatologists, ophthalmologists, and pediatricians
• Clear communication about importance of follow-up visits
• Parent education about disease progression and treatment options 1

By following this protocol, approximately 66.6% of treated eyes can achieve favorable outcomes, even in aggressive Zone I disease 7.