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

Treatment Guidelines for Retinopathy of Prematurity (ROP)

Screening and early intervention are the cornerstones of ROP management, with laser photocoagulation remaining the gold standard treatment for most cases, while anti-VEGF therapy serves as an emerging alternative particularly for Zone I disease. 1

Screening Recommendations

• Screening Criteria:

  • Infants with birth weight ≤1500g OR gestational age ≤34 weeks 1
  • First examination at 4-6 weeks chronological age or 31-33 weeks postmenstrual age 1

• Follow-up Schedule:

  • Zone I or Zone II ROP: Every 1-2 weeks 1
  • Zone III with regression on two sequential examinations: Less frequent 1
  • Continue examinations until retinal vascularization is complete 1

Treatment Indications

Treatment is indicated for:

• Zone I, any stage ROP with plus disease (Type 1 ROP) 1, 2
• Zone I, stage 3 ROP with or without plus disease (Type 1 ROP) 2
• Zone II, stage 2+ or 3+ ROP 1
• Aggressive posterior ROP (AP-ROP) 1, 3

Treatment Options

1. Laser Photocoagulation

• Gold standard treatment for threshold ROP, particularly for Zone II disease 1
• Favorable outcome in 64.6% of Zone II disease cases 1
• Protocol for Zone I aggressive ROP:
  • Multiple sessions of laser at any sign of plus disease with abnormal shunt vessels 3
  • Immediate treatment when Zone I ROP is diagnosed 2
  • Complete and adequate laser ablation of avascular retina 3, 4
• Favorable outcomes in 87.5% of Zone I aggressive ROP cases with protocol-based approach 3

2. Anti-VEGF Therapy

• Emerging alternative, particularly for Zone I disease 1
• Advantages:
  • May allow continued physiologic retinal vascularization 1
  • Less destructive to retina than laser
• Limitations:
  • May not guarantee full retinal vascularization 1
  • May require additional treatments 1
  • Recent trial with intravitreal aflibercept did not meet criteria for noninferiority compared to laser photocoagulation 5

3. Surgical Intervention

• Indicated for advanced ROP with retinal detachment (Stage 4-5) 1
• Success rates vary by stage:
  • Stage 4: 44.4-74% 1
  • Stage 5: 13-33% 1

Management Algorithm

1. Diagnosis and Staging:

   • Determine zone, stage, and presence of plus disease
   • Identify if aggressive posterior ROP is present

2. Treatment Decision:

   • For Type 1 ROP (Zone I any stage with plus, Zone I stage 3, Zone II stage 2+ or 3+):

     • Proceed to immediate treatment 1, 2

   • For Type 2 ROP (Zone I stage 1-2 without plus, Zone II stage 3 without plus):

     • Close observation with examinations every 1-2 weeks 1
     • Treat if progression to Type 1 ROP occurs

3. Treatment Selection:

   • Zone II disease: Laser photocoagulation as first-line 1
   • Zone I disease: Consider either laser photocoagulation or anti-VEGF therapy 1
   • Aggressive posterior ROP: Consider aggressive laser photocoagulation or combination therapy 1, 3

4. Post-treatment Follow-up:

   • Weekly examinations until regression is observed 1
   • Continue examinations until complete vascularization 1
   • Long-term follow-up for refractive errors, strabismus, and other complications 1

Pain Management During Treatment

• Topical anesthetics, oral sucrose, and nonpharmacologic methods recommended 1, 4
• Laser under topical anesthesia is practiced in many settings due to logistics and risks of general anesthesia in pre-term infants 4

Special Considerations

• Oxygen Management:

  • Oxygen saturation targets of 95-99% do not increase (and may decrease) risk of ROP progression 1
  • Lowering target oxygen saturation from 90-99% to 85-93% in infants ≤1,000g may decrease ROP incidence 1

• Combination Approaches:

  • For aggressive disease, especially Zone I ROP, consider combinations of:
    • Laser plus anti-VEGF
    • Laser plus surgery
    • Laser plus anti-VEGF plus surgery 1

Treatment Outcomes and Prognosis

• Protocol-based aggressive laser approach for Zone I ROP shows 87.5% favorable outcomes 3
• Disease progression can be rapid, with mean period between stage 1 and stage 3 being only 1-1.7 weeks 2
• Regular vision assessments throughout childhood are necessary to monitor for complications 1

Key Pitfalls to Avoid

1. Delayed treatment: Zone I ROP can progress rapidly, requiring immediate intervention when diagnosed 2
2. Inadequate laser: Complete ablation of avascular retina is essential for successful outcomes 3, 4
3. Poor follow-up: Clear communication about importance of follow-up visits is critical 1
4. Overlooking hazy media: Zone I ROP may need to be diagnosed and treated despite persistent hazy media such as corneal opacity, miotic pupil, or hazy vitreous 2