Bevacizumab versus diode laser in stage 3 posterior retinopathy of prematurity.

Editor, A nti-VEGF agents, primarily bevacizumab, are emerging as a successful therapy for retinopathy of prematurity (ROP), particularly in aggressive posterior disease (Spandau et al. 2013). Concerns exist however regarding dosage, timing, duration of follow-up and long-term visual function. We conducted a prospective case– control study in 14 infants with symmetrical zone 1 or posterior zone 2 Stage 3 + ROP; comparing intravitreal bevacizumab in one eye to laser therapy in the fellow eye. The purpose was to evaluate anatomic outcomes (regression or recurrence of ROP), and functional visual outcomes in the bevacizumab-treated eyes compared with laser-treated eyes, at oneand 2year follow-up. We also evaluated ocular, systemic and developmental outcomes at oneand 2-year followup. Four infants had symmetrical Zone 1 Stage 3 + disease and 10 infants had Zone 2 Stage 3 + disease (Fig. 1). We randomized the eyes into intravitreal bevacizumab (Avastin; Genentech Inc., South San Francisco, CA, USA) versus conventional laser therapy. All procedures were performed in the special-care baby unit (SCBU) under morphine sedation. Intravitreal injection with bevacizumab was performed under aseptic technique using a dose of 1.25 mg in 0.1 ml. After injection of bevacizumab, conventional 360° laser treatment was applied to the fellow eye. The eyes were monitored weekly for 8 weeks, 3 monthly for a further 12 months, and 3–6 monthly thereafter. At 1and 2-year follow-up, a full ocular examination was performed. Electrophysiology testing, visual evoked potential (VEP) and electroretinography (ERG), was performed on each eye where possible. All of the babies had a paediatric examination and magnetic resonance (MR) brain scan. We observed rapid regression of ROP in all eyes injected with bevacizumab, as well as resolution of plus disease and flattening of the ridge by 48 hr postinjection in all eyes. Further vascularization was noted with complete regression taking up to sixty weeks in some eyes. In our study, four of 14 eyes (28.6%) had recurrence of ROP; three eyes (21.42%) which had bevacizumab treatment and one eye (7.14%) with conventional laser therapy. There was a significant time delay to recurrence in the bevacizumab group compared with laser, with a mean age of 51 weeks PMA at time of recurrence in bevacizumab-treated eyes compared with 37 weeks PMA in the laser-treated eye. This delay in recurrence has also been reported by other studies including the BEAT-ROP trial. (Mintz-Hittner et al. 2011). Of the 3 bevacizumab-treated eyes with recurrence, two eyes received laser treatment where the ROP was peripheral. One eye with more posterior recurrence received a further intravitreal bevacizumab injection. In the eyes that received laser treatment, one eye (7.14%) demonstrated recurrent