What are the treatment options for Retinopathy of Prematurity (ROP)?

Treatment Options for Retinopathy of Prematurity (ROP)

Laser photocoagulation is the standard treatment for threshold ROP, particularly in zone II disease, while anti-VEGF agents (bevacizumab preferred over ranibizumab) are increasingly used for zone I disease or as adjunctive therapy. 1

Primary Treatment Modalities

Laser Photocoagulation (Standard of Care)

• Peripheral retinal ablation remains the gold standard for threshold ROP, especially for zone II disease 1
• This treatment has proven effective in reducing blindness from ROP 2
• The major limitation is that laser destroys parts of the retina and can lead to significant eye complications later in life 1

Anti-VEGF Therapy (Emerging Standard)

• Anti-VEGF agents are increasingly used as monotherapy or combined with laser, particularly for zone I ROP 1
• Bevacizumab (0.625 mg/0.025 mL) is strongly preferred over ranibizumab based on clinical outcomes 3
• Ranibizumab (0.25 mg/0.025 mL) carries a significantly higher risk of ROP reactivation: 83% of eyes treated with ranibizumab experienced reactivation (average 5.9 weeks post-treatment) compared to 0% with bevacizumab 3
• The shorter half-life of ranibizumab, while theoretically attractive for reducing systemic toxicity, results in inadequate duration of action 3

Treatment Algorithm by Disease Location

Zone I ROP

• Anti-VEGF agents (specifically bevacizumab) are preferred as first-line therapy 1
• Can be used as monotherapy or combined with laser 1

Zone II ROP

• Laser photocoagulation is the standard treatment 1
• Anti-VEGF may be considered as adjunctive therapy 1

Threshold ROP (Any Zone)

• Requires immediate retinal ablative therapy 4
• Treatment modality chosen based on zone location as above 1

Emerging Preventive Strategies

Oral Propranolol

• Being investigated for prevention and/or treatment of prethreshold ROP with encouraging results 1
• May prevent progression of ROP in earlier stages 1
• Represents a potential treatment option for prethreshold stages that historically had no treatment 1

Critical Management Considerations

Oxygen Management During Active ROP

• Careful oxygen management is essential during the neovascularization and regression phases 5
• High arterial oxygen levels slow normal vascularization, while marginally low oxygen aggravates neovascularization following initial injury 5
• Once past the age of oxygen-induced retinopathy risk, target oxygen saturation of 95% or higher is recommended to prevent pulmonary complications 5

Follow-up After Anti-VEGF Treatment

• Extended close follow-up is mandatory after anti-VEGF therapy, particularly with ranibizumab given the high reactivation rate 3
• Physicians and families must be aware of reactivation risk to ensure appropriate monitoring 3

High-Risk Populations Requiring Intensive Monitoring

• Infants whose vessels and/or ROP remain in zone I or zone II require ophthalmology visits every 1-2 weeks 2
• Infants with chronic lung disease of infancy (CLDI) are at higher risk and require careful coordination of follow-up 2
• Missing follow-up appointments can lead to missed treatment opportunities and preventable vision loss 2

When Treatment Can Be Discontinued

• ROP that is regressing with vessels passed into zone III on at least two sequential examinations is extremely unlikely to progress to threshold 2
• Infants with ROP stage zero zone III do not require continued screening 6
• Complete retinal vascularization indicates screening can be discontinued 2