Author Affiliations: Department of Ophthalmology and Visual Sciences, University of Illinois at Chicago (Drs Hoang, Kiernan, Chau, Shapiro, and Blair); and Retina Consultants, Ltd, Des Plaines, Illinois (Dr Shapiro).
Standard treatment for type 1 prethreshold retinopathy of prematurity (ROP) is laser ablation.1 A number of recent reports describe regression of ROP with intravitreous injection of the anti–vascular endothelial growth factor (VEGF) agent bevacizumab.2- 6 We describe a premature boy diagnosed with type 1 prethreshold ROP who received bilateral intravitreous bevacizumab injections and demonstrated initial resolution. Two months later, clinical examination and fluorescein angiography demonstrated a circumferential vascular anastomotic pattern at the location of the initial stage 3 complex with radial vessels that continued peripherally toward a second, more anterior stage 3 complex. This was then successfully treated with laser photocoagulation.
A 26-week-gestation boy weighing 675 g at birth and with multiple medical problems was transferred to our institution for treatment of presumed type 1 prethreshold ROP in the setting of prominent tunica vasculosa lentis. Although initial examination disclosed immature vessels in zone 2, he quickly progressed to stage 3 with plus disease by age 34 weeks. Given the patient's critically ill health, the neonatology service recommended against prolonged sedation for laser therapy. Therefore, after an informed discussion with his parents, light intravenous sedation was administered to the infant and his eyelashes and conjunctival surfaces were prepared with 10% povidone-iodine topical solution. Intravitreous injections of bevacizumab (0.75 mg/0.025 mL) were administered bilaterally using a separate, sterile eyelid speculum for each eye. The infant was examined on postinjection day 1 and then weekly for 2 months. Within 2 weeks, examination identified regression of the lens-associated vessels, disappearance of extraretinal fibrovascular proliferation, and marked regression of plus disease. Subsequently, radial vessels grew anteriorly within the retina.
Two months after treatment, a second stage 3 complex developed anterior to the original stage 3 complex that had regressed, leaving a circumferential vascular anastomosis (Figure 1). Fluorescein angiography demonstrated anterior extraretinal fibrovascular proliferation with leakage and a more posterior circumferential vascular ring with associated telangiectasis but without leakage (Figure 2). Because the patient had become systemically stable enough for adequate sedation, conventional peripheral laser photocoagulation was administered to both eyes. Subsequent examination demonstrated bilateral cicatricial changes of the stage 3 complex over the next 3 weeks, with stabilization by 1 month after laser treatment without further vascular changes on follow-up.
A second stage 3 complex (arrowheads) associated with plus disease developed anterior to the initial complex, which developed into a circumferential vascular anastomosis (arrows) with associated telangiectasis, evident on a RetCam color photograph (A) and a fluorescein angiogram (B).
A wide-field RetCam fluorescein angiogram demonstrates a new stage 3 complex (arrowheads) anterior to the former complex, which has developed into a nonleaking, circumferential vascular anastomosis (arrows).
Evidence indicates that ROP may be a biphasic disease with an initial oxygen-induced vascular obliteration phase, followed by hypoxia-induced vessel proliferation.7 Anti-VEGF therapy may be effective in the second phase2 and as a single dose because there is theoretically only 1 burst of VEGF.8 This is in contrast to other ocular neovascular conditions, such as age-related macular degeneration and diabetic retinopathy, where aberrant VEGF production often recurs as a result of long-standing disease.
Supporting this, Mintz-Hittner and Kuffel3 reported that a single bilateral injection of bevacizumab in 22 eyes of 11 infants induced regression of acute ROP and allowed vascularization of the peripheral retina to resume. In contrast, another report5 described a 41-week-old boy with zone 1, stage 2 plus disease that initially responded to bevacizumab treatment, but recurrence developed 11 weeks later. This recurrence responded to a second bevacizumab injection, but the patient died soon afterward of systemic illness.
In our case, zone 2, stage 3 plus disease treated on day 64 of life responded markedly to intravitreous bevacizumab, but 2 months later a second, more anterior stage 3 complex developed. Although the occurrence of multiple ridges is well documented, it is a rare event compared with other patterns of ROP regression. To our knowledge, this is the first angiographic documentation of circumferential anastomosis at the bevacizumab-induced regression site with radial vessels progressing anteriorly to form a second stage 3 complex. The time course seems to indicate quiescence due to bevacizumab followed by reactivation from its waning effect. Although this case provides further evidence of the efficacy of bevacizumab as a treatment option for patients with ROP when laser treatment is not feasible, it also emphasizes that the angiogenic stimulus potentiating the sight-threatening complications of ROP may recur or persist after a single injection of an anti-VEGF agent. This case also provides further support that intravitreous bevacizumab does not necessarily inhibit subsequent retinal vascular development.3
Correspondence: Dr Blair, Department of Ophthalmology and Visual Sciences, University of Illinois at Chicago, 1855 W Taylor Street, M/C 648, Chicago, IL 60612 (email@example.com).
Author Contributions: Dr Blair had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.
Financial Disclosure: None reported.
Funding/Support: This work was supported by an unrestricted grant from Research to Prevent Blindness, New York, New York (Dr Blair).
Thank you for submitting a comment on this article. It will be reviewed by JAMA Ophthalmology editors. You will be notified when your comment has been published. Comments should not exceed 500 words of text and 10 references.
Do not submit personal medical questions or information that could identify a specific patient, questions about a particular case, or general inquiries to an author. Only content that has not been published, posted, or submitted elsewhere should be submitted. By submitting this Comment, you and any coauthors transfer copyright to the journal if your Comment is posted.
* = Required Field
Disclosure of Any Conflicts of Interest*
Indicate all relevant conflicts of interest of each author below, including all relevant financial interests, activities, and relationships within the past 3 years including, but not limited to, employment, affiliation, grants or funding, consultancies, honoraria or payment, speakers’ bureaus, stock ownership or options, expert testimony, royalties, donation of medical equipment, or patents planned, pending, or issued. If all authors have none, check "No potential conflicts or relevant financial interests" in the box below. Please also indicate any funding received in support of this work. The information will be posted with your response.
Some tools below are only available to our subscribers or users with an online account.
Download citation file:
Web of Science® Times Cited: 13
Customize your page view by dragging & repositioning the boxes below.
Enter your username and email address. We'll send you a link to reset your password.
Enter your username and email address. We'll send instructions on how to reset your password to the email address we have on record.
Athens and Shibboleth are access management services that provide single sign-on to protected resources. They replace the multiple user names and passwords necessary to access subscription-based content with a single user name and password that can be entered once per session. It operates independently of a user's location or IP address. If your institution uses Athens or Shibboleth authentication, please contact your site administrator to receive your user name and password.