The authors report a case of late retinal detachment after bevacizumab monotherapy for ROP, illustrating the need for extra caution when using this treatment in infants.
A 560-g neonate, born prematurely at 23 weeks postmenstrual age, was noted to have stage 3 ROP in zone 1 at 34 weeks postmenstrual age. Following informed consent, off-label intravitreous bevacizumab (0.625 mg) was injected into each eye. The patient was then examined every one to two weeks.
Posterior fibrotic tissue was noted first at 48 weeks, and fine vascularity appeared at 50 weeks. Retinal detachment (stage 4a ROP) in the right eye was present at 52 weeks, and the patient was referred by the original clinician to our service for surgical intervention. The patient did not appear for treatment and state department of family services intervention was required to bring the patient to the authors’ service, which occurred at 57 weeks. At that time, both retinas were completely detached (stage 5) with fibrovascular tissue immediately posterior to the lens.
Despite some promising results with intravitreous bevacizumab monotherapy, the authors believe this case demonstrates that caution must be taken. Clearly the progression of ROP is altered, with initial regression but possible recurrence as the effect declines over time. Unfortunately, the timing and rapidity of onset are not well characterized. Moreover, the location and pattern of recurrence may also be altered.
The authors note that lapses in parental compliance with an extended burden of follow-up may play an important role in the outcome and therefore the treatment choice. They believe that laser, despite causing less rapid regression of disease, induces a more permanent response because it destroys the source of vascular endothelial growth factor. Additionally, laser induces some retinal adhesion that may slow the effect of contracting fibrovascular tissue, and the recurrence pattern is more clearly defined and thus easier to detect.
“Clearly laser has its deficiencies,” they write, “but we are concerned that the dramatic early effects of bevacizumab may lead to an under-appreciation of its own limitations.”
They believe treatment success can be considered final not after the early response but only after there is complete retinal vascularization.
They conclude that this case serves as a warning to clinicians that extensive, long-term, careful follow-up and prompt subsequent intervention are needed in infants treated with intravitreous bevacizumab.