Ranibizumab, Laser Photocoagulation Protocol Protects Against Detachment in ROP

Patients who qualify as neonates with type 1 retinopathy of prematurity (ROP) treated with the anti-vascular endothelial growth factor (anti-VEGF) ranibizumab and subsequent laser photocoagulation can have good structural outcomes, with no progression to retinal detachment, according to research published in the Journal of American Association for Pediatric Ophthalmology and Strabismus.

Researchers retrospectively reviewed the medical records of patients treated for type 1 ROP with intravitreal anti-VEGF injections of ranibizumab followed by delayed laser photocoagulation between January 2015 and March 2020 to evaluate refractive and structural outcomes. 

Infants with type 1 ROP (based on the third revision to the International Classification for Retinopathy of Prematurity [ICROP-3]) were treated with intravitreal ranibizumab (0.25 mg) followed by delayed laser photocoagulation (at least 2 weeks and <1 year after initial anti-VEGF injection). The timing of the delayed laser treatment was dependent upon ROP reactivation (defined as any observation of ROP progression, even mild disease).

The study’s primary outcomes were spherical equivalent (SE), macular dragging, macular scarring, and retinal detachment. The secondary outcomes included the presence of strabismus, amblyopia, optic atrophy, and nystagmus at last follow up. All patients had a minimum follow-up duration of 6 months. 

A total of 68 eyes of 34 neonates (56% boys and 44% girls), with median gestational age of 24 weeks and birthweight of 657 g, were included in the study. Most eyes (71%) underwent 1 injection and 1 laser treatment; 18% of eyes received 2 injections and 1 laser treatment; 10% of eyes received 1 injection and 2 laser treatments; and 1% of eyes received 2 injections and 2 laser treatments. The mean follow-up duration was 2.7±1.02 years. At last follow up, the patients were aged 0.9 to 4.4 years.

The researchers observed no progression to stage 4 or 5 ROP or macular dragging following treatment during the study period. At 2-year follow up (mean age, 2.41±0.23 years), they found the median SE was -0.13 diopters (D) (interquartile range, 4.20). 

At most recent examination (mean age, 2.70±1.02 years), the team reported the most common ocular findings were strabismus (32%), optic atrophy (24%), amblyopia (21%), high myopia (7%), and nystagmus (4%). They also found that 39% of eyes had emmetropia (+1.00 D ≥ SE >-1.00 D); 33% of eyes had low myopia (-5.00 D < SE ≤-1.00 D); 13% of eyes had low hyperopia (+1.00 D < SE ≤+4.00 D); 9% of eyes had high hyperopia (SE >+4.00 D); and 7% of eyes high myopia (SE ≤-5.00 D). 

“Treating infants with delayed laser after initial anti-VEGF treatment could be protective against ROP reactivation and decrease the need for intensive follow-up, particularly relevant in resource-limited settings,” researchers report.

Limitations of the study included the small sample size, relatively short and variable follow-up durations, and analysis of the frequency of high myopia only.