Toy et al. described 17 infants (33 eyes) who were treated with intravitreal bevacizumab (0.625 mg) injection for type 1 retinopathy of prematurity (ROP) followed by subsequent exam under anesthesia and fluorescein angiography (FA) taken after 50 weeks of gestational age (1). All eyes had a “scalloped regression” pattern of the peripheral retina on FA. Recurrence or chronic vascular arrest based on FA findings were noted in 30 eyes (91%) for which secondary laser was added to areas of persistent non-perfusion.
This paper is not the first or the largest to report on FA findings after anti-vascular endothelial growth factor (anti-VEGF) for ROP. The paper’s novelty is that it makes a strong argument for the practice of combination therapy for type 1 ROP: initial intravitreal anti-VEGF, close follow-up, and subsequent exam under anesthesia and laser. There are three main reasons for this approach:
Another noteworthy observation is the gestational age and birthweights of this US cohort compared with published Chinese cohorts who developed type 1 ROP. In this paper which enrolled patients between 2013 and 2015, the median birthweight was 24.7/24.9 weeks and median birth weight was 645/700 grams (bevacizumab/primary laser). In a paper which published on infants treated for ROP in Beijing, China between 2009 and 2011 the mean BW and GA were 29.4 weeks and 1,241 grams, respectively (4). As China rapidly develops and advances its neonatal care and NICU protocols, the risk factor profile for ROP in China will continue to evolve.
The paper also leads to the question, is FA required for ROP care in the age of anti-VEGF? Although there are typically more ROP findings on FA than noticeable on clinical exam, and it is best to perform FA if available, I would argue that it may not be absolutely necessary to have FA for ROP care. Laser can still be performed to avascular peripheral retina based on clinical exam alone.
What is on the horizon for ROP treatment? Right now, an important question is which anti-VEGF to use for ROP. Although bevacizumab is the most commonly used agent in the United States, it is not available in China and ranibizumab seems to have a safer systemic profile. Studies such as the RAINBOW Study which compares laser to ranibizumab for ROP (5) should help to get US Food and Drug Administration approval for the use of ranibizumab in ROP.
