PEDIATRIC OPHTHALMOLOGY AND STRABISMUS
Retinopathy of Prematurity: Injection or Laser
Amit R. Bhatt, MD; Catherine O. Jordan, MD; Rudolph S. Wagner, MD
Abstract
Wagner: Our topic today is retinopathy of prematurity (ROP): injection or laser treatment. This is a typical case of a 23-week-old premature infant who developed stage 3 ROP at the margin of zones I and II with plus disease and a few small scattered hemorrhages at the demarcation ridge. He is now 34 weeks’ gestational age and he is still intubated and requires high oxygen therapy for pulmonary issues. What would be your thought process in deciding if you would treat right now and what factors would you consider?
Bhatt: Based on that history and the age, I would lean toward intravitreal anti-vascular endothelial growth factor (VEGF) treatments over laser in this case. The reason for favoring intravitreal treatment would be the really posterior disease. It’s still at the zone I/zone II border, so I think that’s a lot of retina to laser. Giving the patient a chance to vascularize further would be beneficial and decrease myopia in the future. The Bevacizumab Eliminates the Angiogenic Threat for Retinopathy of Prematurity (BEAT-ROP) study and some of the more recent studies have given us good data that bevacizumab is at least as good as, if not superior to, laser in these really posterior eyes.
Wagner: For general anesthesia, do you take the patient into the operating room or do you do it in the neonatal intensive care unit (NICU)?
Bhatt: The patient is already intubated, but at my hospital we would do general anesthesia for laser treatment. Our hospital requires the laser treatment to be done in the operating room due to safety concerns and they want a very controlled environment. But I would prefer to treat in the NICU.
Wagner: For an injection, do you have to go to the operating room?
Bhatt: We can administer an injection in the NICU. I use a hospital gown and a mask and sterile gloves, and I try to use a sterile set of instruments for each eye and prep with povidone-iodine. We don’t use any sedation, just topical anesthetic on the eye. The patients tolerate it well and we’ve had good success with no infections so far.
Jordan: I would definitely do intravitreal treatment for this patient. We use bevacizumab 0.125 mg in a 0.1-mL syringe at our institution and that’s worked well for us so far. We’re waiting for results on the next phase of the Pediatric Eye Disease Investigator Group (PEDIG) study to consider a lower dose. We would do this in the NICU and the neonatologists usually prefer some sedation to make the patients more comfortable, such as midazolam and fentanyl. I also use povidone-iodine before and after the injection and a semi-sterile set-up for each eye, using a totally different set of instruments. Our institution also requires double gloves because it’s technically a chemotherapy agent.For laser treatment, we also have to do it in the operating room due to safety issues. In this case, I agree that this disease is too posterior to warrant laser treatment at this time. But these patients need to be monitored closely and generally we do have to do laser treatment at some point, depending on whether or not they fully vascularize, if they’re being discharged and there’s risk of follow-up concerns, or if there’s recurrence of the ROP.