A Report by the American Academy of Ophthalmology Ophthalmic Technology Assessment Committee Pediatric Ophthalmology/Strabismus Panel: Deborah K. VanderVeen, MD,1 Michele Melia, ScM,2 Michael B. Yang, MD,3 Amy K. Hutchinson, MD,4 Lorri B. Wilson, MD,5 Scott R. Lambert, MD6
Ophthalmology, May 2017, Vol 124, 619-633 © 2017 by the American Academy of Ophthalmology. Click here for free access to the OTA.
Purpose: To review the available evidence on the ocular safety and efficacy of anti-vascular endothelial growth factor (VEGF) agents for the treatment of retinopathy of prematurity (ROP) compared with laser photocoagulation therapy.
Methods: A literature search of the PubMed and Cochrane Library databases was conducted last on September 6, 2016 with no date restrictions and limited to articles published in English. This search yielded 311 citations, of which 37 were deemed clinically relevant for full-text review. Thirteen of these were selected for inclusion in this assessment. The panel methodologist assigned ratings to the selected articles according to the level of evidence.
Results: Of the 13 citations, 6 articles on 5 randomized clinical trials provided level II evidence supporting the use of anti-VEGF agents, either as monotherapy or in combination with laser therapy. The primary outcome for these articles included recurrence of ROP and the need for retreatment (3 articles), retinal structure (2 articles), and refractive outcome (1 article). Seven articles were comparative case series that provided level III evidence. The primary outcomes included the effects of anti-VEGF treatment on development of peripheral retinal vessels (1 article), refractive outcomes (1 article), or both structural and refractive or visual outcomes (5 articles).
Conclusions: Current level II and III evidence indicates that intravitreal anti-VEGF therapy is as effective as laser photocoagulation for achieving regression of acute ROP. Although there are distinct ocular advantages to anti-VEGF pharmacotherapy for some cases (such as eyes with zone I disease or aggressive posterior ROP), the disadvantages are that the ROP recurrence rate is higher, and vigilant and extended follow-up is needed because retinal vascularization is usually incomplete. After intravitreal injection, bevacizumab can be detected in serum within 1 day, and serum VEGF levels are suppressed for at least 8 to 12 weeks. The effects of lowering systemic VEGF levels on the developing organ systems of premature infants are unknown, and there are limited long-term data on potential systemic and neurodevelopmental effects after anti-VEGF use for ROP treatment. Anti-VEGF agents should be used judiciously and with awareness of the known and unknown or potential side effects.
1Department of Ophthalmology, Boston Children's Hospital, Harvard Medical School, Boston Massachusetts
2Jaeb Center for Health Research, Tampa, Florida
3Department of Ophthalmology, Abrahamson Pediatric Eye Institute, Cincinnati Children's Hospital Medical Center, University of Cincinnati, College of Medicine, Cincinnati, Ohio
4Department of Ophthalmology, Emory University School of Medicine, Atlanta, Georgia
5Casey Eye Institute, Oregon Health & Science University, Portland, Oregon
6Department of Ophthalmology, Stanford University School of Medicine, Stanford, California