Evidence based management of retinopathy of prematurity: More than meets the eye

Problem under investigation: Retinopathy of prematurity (ROP) is a potentially blinding disorder of infants born preterm. With increased survival of preterm infants, ROP is on the rise especially in the developing world. An international classification is used to classify ROP. Based on a randomized control trial, well defined guidelines for laser treatment exist. Although randomized trials for new age anti-vascular endothelial growth factor (antiVEGF) drugs in ROP exist, their role is less well defined. Study eligibility criteria: The current review includes studies that report the newer variations in disease presentation, treatment indications outside current guidelines and the unanswered controversies surrounding the use of anti -VEGF agents in ROP. Evidence and flaws from major randomized trials and meta-analysis is presented. Types of participants: Data from randomized trials, real world studies and perspective from practicing ROP physicians is collated. Results: Disease classification needs to expand to include certain subtypes like posterior zone 1 ROP and hybrid ROP. Objective criterion need to be defined for plus disease.Treatment indications need to be revisited for gray areas like persistent non resolving ROP or Stage 3 ROP in zone 2 without plus disease, which constitute a fair number of eyes being treated outside treatment criteria. Practical guidelines need to be developed for indications and rational use of anti-VEGF drugs in ROP. These also need to address management of disease reactivation and persistent avascular retina (PAR), after anti-VEGF treatment. Conclusion: Further evidence based studies and guidelines are required to address real world dilemmas in managing ROP.