Q&A: ROP treatment challenges
Treatment of ROP can be carried out for both the proliferative vascularisation phase (Stage 3) and cicatricial (scaring with vitro-retinal traction, Stages 4 and 5) phase of ROP.
Treatment during the proliferative vascularisation stages for ROP: Ablation using transpupillary laser has replaced cryotherapy but it requires expensive equipment, can require 30 to 40 minutes per eye to administer and is stressful for infants. Laser treatment is also associated with induced myopia and astigmatism.
Vasoproliferation in ROP is driven by VEGF and blocking it with anti-VEGF agents is logical. Anti-VEGF is administered as an intravitreal injection; it takes 2 to 3 minutes per eye. No special equipment is needed except for the medication, but drawing up the very small doses needed can be challenging. In settings where lasers and trained ophthalmologists who can operate them are not available, anti-VEGF treatment is potentially useful although it requires careful and sustained follow up to monitor recurrence of disease. In addition there are concerns about long-term systemic complications and whether failure of the retina to completely vascularise causes problems in the long term.
Some ophthalmologists use a combination of laser and anti-VEGF agents, such as anti-VEGF first for very active disease followed by laser to reduce the risk of recurrence, or laser first followed by anti-VEGF injection, if laser fails. However, there is no evidence from clinical trials on the indications for, and outcomes of, these approaches.
Treatment for the cicatricial stage is surgery which is much more complex and, once retinal detachment occurs even peripherally, the visual results are usually poor. There may be a role for intravitreal anti-VEGF prior to surgery to reduce vascular activity as this allows the surgery to be carried out earlier with shorter operative times.
In our live Q&A session this week, an international panel of experts came together to tackle some of these complex questions surrounding ROP treatment, sharing their perspectives on the pros and cons of anti-VEGF treatment and its use in combination with lasers or as a rescue treatment when laser has failed.
Experts who took part:
- (Chair) Professor Clare Gilbert, Professor of International Eye Health
- Dr Pramod S Bhende, Director, Shri Bhagawan Mahavir Vitreo-Retinal Services, Medical Research Foundation, (Sankara Nethralaya)
- Graham Quinn, Children’s Hospital of Philadelphia and the University of Pennsylvania.
- Umar K. Mian. M.D., Director Retina Service, Department of Ophthalmology and Visual Sciences, Montefiore Medical Center
- Professor Brian Darlow, Clinical Neonatologist
- Dr Linda Visser, Academic Head – Department of Ophthalmology, UKZN
- Dr Andrea Zin, Ophthalmologist and ROP expert, Brazil
Thanks to everyone who participated and posted questions to our experts.
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