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Rop case series- DR AJAY DUDANI
1. Management of ROP and case
series
Dr. Ajay Dudani
Mumbai retina centre
Zen Eye Centre
Bombay Hospital
2. Retinopathy of prematurity
Potentially blinding disorder of premature infants
Association between extreme prematurity and
“fibroblastic overgrowth of persistent avascular
sheath behind each crystalline lens” was first
described by Terry in 1942
Vasculogenesis
Angiogenesis
Requires VEGF
4. Treatment of ROP
CRYO-ROP trial1
Beneficial effect of peripheral cryo-ablation on
avascular retina
STOP-ROP trial2
No difference in conventional vs supplemental
Oxygen therapy
ETROP trial3
Led to ICROP to identify eyes at high risk
1. Arch Ophthalmol. 2001;119:1110-1118.
2. PEDIATRICS Vol. 105 No. 2 February 2000, pp. 295-310
3. PEDIATRICS Vol. 114 No. 2 August 2004, pp. 490-491
5. Treatment of ROP
Ablation of retina
Cryo- extremely destructive
Laser- lesser destructive
Anti-VEGF injection1,2,3
Pathogenesis
Biochemical analysis of the vitreous of
stage 4 ROP eyes shows significantly
elevated VEGF and TGF-beta
concentrations, and normal levels of other
angiogenic factors.
Various case reports
1. Curr Opin Pediatr. 2009 Apr;21(2):182-7
2. Early Hum Dev. 2008 Feb;84(2):95-9.
3. Dev Ophthalmol. 2009;44:89-97. Epub 2009 Jun 3
6. Anti-VEGF in Retinopathy Of Prematurity
Promising treatment for advanced ROP
Severe stage 3 ROP
Aggressive posterior ROP (AP-ROP)
Anecdotal series with all three anti-VEGF1,2,3,4
Quiroz et al have published their series of 18 eyes injected with Avastin2
Neovascular regression in all but one eye
Mintz-Hittner et al from Texas studied 22 eyes treated with Avastin (no
laser)3
Single low dose of Avstin of IVT Avastin for zone I or posterior zone
II ROP stage 3
Michael Trese studied Pegaptanib for stage IV ROP
1. British Journal of Ophthalmology 2008;92:1450-1455
2. Retina 2008; 28:S19-S25.
3. Retina 2008; 28:831-838
4. http://www.osnsupersite.com/view.aspx?rid=20862
7. Anti-VEGF in Retinopathy Of Prematurity
BLOCK ROP trial:
Phase I, prospective multicentric
Bevacizumab one injection, rescue therapy for one
eye of patients with bilateral ROP refractory to
conventional therapy
Stage IV ROP
Endpoint:
Ability of Avastin to stop progression of
ROP to RD
Ophthalmology Times, Apr 1 2008
8. Anti-VEGF in Retinopathy Of Prematurity
Ongoing trial:
BEAT ROP (Bevacizumab Eliminates the Angiogenic Threat of ROP)
Phase II anti VEGF vs Laser
Stage 3 ROP in zone I or posterior zone II with plus disease
Sponsored by: The University of Texas Health Science Center,
Houston
Current status presented at the World ROP Congress in New Delhi
Recurrence rate in zone I greater than in zone II
29 eyes have had recurrences- mostly in laser arm
Intravitreal Bevacizumab monotherapy may prove to have
favorable risk-benefit ratio
http://clinicaltrials.gov/ct2/show/NCT00622726
9. Selective anti-VEGF in ROP
Why selectivity?
VEGF 165 blockade inhibits pathological
angiogenesis at margin of vascular and
avascular retina
Normal retinal angiogenesis continues at the
periphery
Systemic safety
Paramount in premature infants
10. Selective anti-VEGF in ROP
Pioneering use of Pegaptanib sodium to treat ROP unveils many
issues for future studies- Michael Trese, ARVO 2007
Five eyes were given half dose (0.15mg) of Macugen intravitreally
Macugen treatment resulted in reduction of the tunica vasculosa
lentis and improved pupil dilation that allowed laser treatment to be
performed more easily
All of the Macugen-treated eyes appeared more vascularly quiet
than the controls
http://www.escrs.org/PUBLICATIONS/EUROTIMES/06Sept/pdf/Pioneeringuseof.pdf
12. Anti-VEGF for ROP
Our series of 8 premature children, 17 eyes treated with
anti-VEGF
Anti-VEGF agents used:
6 patients (12 eyes) given Pegaptanib Sodium
One each Avastin (one eye) and Lucentis (four eyes)
13. Anti-VEGF for ROP: our series
Age ranged from 27 weeks to 30 weeks
Stage III or IV, zone I or II cases
15 eyes had undergone at least 5000 shots of
laser before considering anti-VEGF
Two eyes were administered anti-VEGF therapy
without initial laser shots
4 eyes underwent lens sparing vitrectomy
Regression of neovascularisation and vitreous
hemorrhage was observed in all the eyes
14. Case-1- ROP
27 weeks infant presented with ROP stage IV A Zone 2
Areas of TRD with Fibro Vascular Proliferation
Laser - 5000 shots
Both eyes pegaptanib sodium (3/4th dose) at one week
interval
Good regression of NV and TRD
18. Case 2
27 weeks baby
Sudden progression to rush disease, zone I and
II
Laser sittings
BE Lucentis
RE developed TRD
19. Case-3
27 weeks infant presented with bilateral ROP stage III Zone 1 with
new vessels around macula : persistent
Bilateral Laser 4000- 5000 shots
RE pegaptanib sodium (3/4th dose)
LE pegaptanib sodium delayed by one week
NV increased with Vitreous Hemorrhage
Do not delay
No Side Effects noted
25. Case-3
After 6 weeks, BE developed vitreous hemorrhage
BE underwent lens sparing vitrectomy
BE bleeding less due to prior anti-VEGF
Suggestion
Pre-vitrectomy Inj. Pegaptanib followed by surgery
after 2 days
Prevent intraop bleeding
26. Case 4
Both eyes ROP stage III zone II with plus
disease
BE inj Lucentis
No laser
FU after 3 weeks
BE stage I zone III with no plus disease
BUT peripheral retina remained avascular
? Does pan-VEGF blockade prevent
normal vasculogenesis of avascular retina?
34. Summary
Though some have used as primary therapy, we have tried
maximum laser f/b anti-VEGF if required
Our case series showed good response in terms of regression of
neovascularisation
Early treatment is the key
No systemic side effects were noted
Potential use anti-VEGF in ROP
Laser failed
Pre-operative to reduce bleeding
Primary
