Selection of a laser photocoagulation method based on clinico-vascular risk in preterm infants

Objective. To justify and validate a risk-oriented selection of laser ablation for retinopathy of prematurity (ROP) using an integrated model that combines neonatal predictors with angiographic markers of vascular activity on fluorescein angiography (FA).

Materials and methods. A three-component angiographic index, the V-Score (fraction of avascular retina, number of sectors with active leakage, composite arteriolar tortuosity/caliber index), and an integrated scale Neo-ROP-V that merges the V-Score with the clinical Neo-ROP-8 score were developed.

Results. The impact of FA on ROP staging and on treatment selection was evaluated among three strategies: selective pre-threshold transpupillary laser photocoagulation (s-PTLPC), classical near-total ablation, and a combined approach. Results: FA upgraded disease stage in 10 % of eyes at stage I, 30 % at stage II, 75 % at stage III, and 60 % in aggressive posterior ROP (AP-ROP) (p < 0.05). Diagnostic performance was AUC = 0.94 for Neo-ROP-8 (cut-off ≥ 7), AUC = 0.88 for the V-Score (cut-off ≥ 5; κ = 0.82), and AUC = 0.96 for Neo-ROP-V (cut-off ≥ 13) with 89 % sensitivity and 92 % specificity.

Conclusion. Integrating Neo-ROP-8 and the V-Score into Neo-ROP-V standardizes the choice of intervention radicality: scores 6-9 indicate s-PTLPC; 10-12 favour classical retinal ablation; ≥ 13 support a combined tactic (classical laser plus cryotherapy or administration of anti-VEGF agents).

1. Early Treatment For Retinopathy Of Prematurity Cooperative Group. Revised indications for the treatment of retinopathy of prematurity: results of the early treatment for retinopathy of prematurity randomized trial. Arch Ophthalmol. 2003; 121(12): 1684–1694.

2. International Committee for the Classification of Retinopathy of Prematurity. The international classification of retinopathy of prematurity revisited. Arch Ophthalmol. 2005; 123(7): 991–999.

3. Fierson W.M., American academy of pediatrics section on ophthalmology, American academy of ophthalmology, et al. Screening examination of premature infants for retinopathy of prematurity. Pediatrics. 2018; 142(6). doi: 10.1542/peds.2018-3061.

4. Mintz-Hittner H.A., Kennedy K.A, Chuang A.Z., BEAT-ROP cooperative group. Efficacy of intravitreal bevacizumab for stage 3+ retinopathy of prematurity. N Engl J Med. 2011; 364(7): 603–615.

5. Yucel O.E., Eraydin B., Niyaz L., O. Terzi. Incidence and risk factors for retinopathy of prematurity in premature, extremely low birth weight and extremely low gestational age infants. BMC Ophthalmol. 2022; 22(1): 1–8. doi: 10.1186/s12886-022-02591-9.

6. Wu P.Y., Fu Y.K., Lien R.I., et al. Systemic cytokines in retinopathy of prematurity. J Pers Med. 2023; 13(2). doi:10.3390/jpm13020291.

7. Heo J.I., Ryu J. Natural products in the treatment of retinopathy of prematurity: exploring therapeutic potentials. Int J Mol Sci. 2024; 25(15). doi: 10.3390/ijms25158461.

8. Yang C.S., Wang A.G., Sung C.S., et al. Long-term visual outcomes of laser-treated threshold retinopathy of prematurity: a study of refractive status at 7 years. Eye. 2010; 24(1): 14–20.

9. Klufas M.A., Patel S.N., Ryan M.C., et al. Influence of fluorescein angiography on the diagnosis and management of retinopathy of prematurity. Ophthalmology. 2015; 122(8): 1601–1608.

10. Lepore D., Quinn G.E., Molle F., et al. Atlas of fluorescein angiography findings in eyes undergoing laser photocoagulation for retinopathy of prematurity. Ophthalmology. 2011; 118(1): 168–175.

11. Velia D., Di Digitulo M., Campanella C., et al. Fluorescein angiography in preterm infants: retinal vascular development and pathological findings. Br J Ophthalmol. 2013; 97(6): 734–739.