Chronic Vascular Arrest as a Predictor of Bevacizumab Treatment Failure in Retinopathy of Prematurity

Abstract

To describe a pattern of retinopathy of prematurity (ROP) disease regression and chronic vascular arrest after intravitreal bevacizumab treatment that is not observed after peripheral laser ablation. Single-institution retrospective cohort study. Consecutive sample of 58 eyes in 30 patients treated for type 1 ROP. Initial treatment with either a single intravitreal injection of bevacizumab in off-label use (n= 33 eyes) or peripheral laser ablation (n= 25 eyes) as part of standard clinical care. There was bias in recommending off-label bevacizumab for smaller infants with type 1 ROP. Reactivation or persistence of ROP, as determined by clinical examination, fundus photography, and fluorescein angiography. All eyes treated initially with bevacizumab demonstrated irregular progression of the leading vascular edge in a stereotyped pattern, suggestive of scalloped regression. Recurrence, based on angiographic demonstration of leakage, or chronic vascular arrest, confirmed based on angiographic demonstration of peripheral ischemia, was noted in 30 eyes (91%) in the bevacizumab group, at a median interval of 14.9 weeks after injection (corrected gestational age, 49.3 weeks). Univariate logistic regression indicated that the need for rescue treatment was associated with decreased birth weight (odds ratio [OR],-0.007; P= 0.04) and age of initial treatment (OR,-0.35; P= 0.05), but not gender, race, or gestational age. Multivariate logistic regression indicated that only decreased birth weight (OR,-0.018; P= 0.04) was associated with need for rescue treatment. Treating ROP with intravitreal bevacizumab results in a characteristic scalloped regression pattern that is highly associated with treatment using biologic anti-vascular endothelial growth factor agents. The presence of this pattern in conjunction with chronic vascular arrest and peripheral retinal ischemia persisting beyond standard screening timelines has significant implications for the management of ROP. Fluorescein angiography is important in assessing vascular maturation in these infants.