Long-term peripheral retinal vascular behavior in retinopathy of prematurity patients treated with ranibizumab intravitreal injection as monotherapy using fluorescein angiography

Abstract

Background Few challenges are faced with the introduction of anti-VEGF agents as a modality of treatment for retinopathy of prematurity. The clinical behavior and time course of regression post injection differ compared to post laser ablation. This study aims to evaluate the long-term peripheral retinal vascularization outcome of Ranibizumab intravitreal injections monotherapy in the treatment of retinopathy of prematurity. Method Hospital-based quasi-experimental study. Include ROP patients who received intravitreal ranibizumab (IVR), as primary treatment for type 1 ROP. Patients were examined under general anaesthesia to ensure documentation of all junctions of vascular and avascular zones. Images were taken by RetCam III, Phoenix ICON and fluorescein angiography was performed to describe vascular behaviors. Results The mean gestational age was 24.67 weeks and the mean postmenstrual age at the time of intravitreal ranibizumab treatment was 36.3 weeks. Fluorescein angiography was performed at 155–288 weeks; most eyes showed two disk diameters of avascular peripheral retina. Only eyes with original aggressive ROP who required a second injection (six eyes) showed extensive peripheral avascular retina reaching zone I (13.64%). Neovascularization was evident in five eyes (11.36%), all with an original aggressive ROP and received multiple injections. Conclusions Ranibizumab treated babies with incomplete retinal vascularization require close and long-term follow-up visits to assess post injection vascular behavior. Peripheral retinal avascular zone of more than two-disc diameters was present in most of the patients evidenced by fluorescein angiography. Babies with initial diagnosis of aggressive ROP are more likely to have persistent peripheral neovascularization.

Vascular imaging findings in retinopathy of prematurity

“…Many studies have utilized this imaging modality to better qualify the retinal vasculature and understand the disease pathogenesis. Specifically, studies have found that after treatment, FA shows vascular extension more temporally than nasally, a continuous circumferential line of demarcation separating the vascular and avascular retina, arteriovenous shunting, tortuosity without dilatation, vascular dilation, leakage, vascular loops, nonhomogeneous capillary dropout through the vascular retina including in the posterior pole, abnormal branching at the capillary level and diffuse flat neovascularization (Al Rasheed et al., 2022; Azad et al., 2008; Bayramoglu & Sayın, 2022; Cheng et al., 2019; Henaine‐Berra et al., 2014; Jin et al., 2019; Lepore et al., 2014, 2021; Mansukhani et al., 2019; Ng et al., 2006; Perente et al., 2019; Vural et al., 2022; Vural, Ekinci, et al., 2019; Vural, Perente, et al., 2019; Yokoi et al., 2009). Several studies have also found that these vascular abnormalities may prevail long after treatment with long‐term progression of the vascularization process (Al Rasheed et al., 2022; Perente et al., 2019; Sternfeld et al., 2022), although they may be reduced with photocoagulation (Gonzalez & Agarwal‐Sinha, 2020).…”

Retinal Blood Vessel Formation in the Macula Following Intravitreal Ranibizumab Injection for Aggressive Retinopathy of Prematurity

“…After anti-VEGF therapy, vascular changes could occur in the posterior pole, as well as peripheral vascular abnormalities such as PAR. Indeed, Rasheed et al observed capillaries intruding into the macula after IVR in patients exhibiting severe ROP [ 19 ]. Further studies are needed to understand the incidence of these vascular abnormalities and their impact on visual prognosis in ROP patients treated with anti-VEGF drugs.…”

Role of Anti-Vascular Endothelial Growth Factor (Anti-VEGF) in the Treatment of Retinopathy of Prematurity: A Narrative Review in the Context of Middle-Income Countries

“…Reports have shown its utility by describing different patterns of regression, reactivation and response after anti-VEGF, aiding the clinician in the decision to retreat or follow. [91][92][93] However, angiography is not readily available in most centers, and the specialist may rely on clinical examination and to treat the persistent peripheral avascular retina (PPAR), if any. 25 The avascular retina might lead to recurrent ROP.…”