Retinopathy of prematurity occurs due to the growth of abnormal new vessels in the retina, affecting premature babies or those born with less than 1,500 g, which, if treated in time, prevents blindness.⁽¹⁾ It is classified according to the affected areas, stage, and extent of the pathology. The acute stage includes stages 1 to 3, in which the development of the retina is incompletely vascularized. For retinal detachment, we will see included stages 4 and 5, in which stage 4 is partial detachment and stage 5 is complete detachment of the retina.⁽²⁾

A baby is considered premature when they are born alive before reaching 37 weeks of gestation. Premature babies will be divided according to gestational age ranges into extremely premature babies (< 28 weeks), very premature babies (29 to 32 weeks), and moderate to late premature babies (33 to 37 weeks).⁽³⁾ Eight per cent of newborns in the Dominican Republic are born prematurely.⁽⁴⁾

Premature babies must comply with a protocol at the time of birth; usually, they must be taken to the neonatal intensive care unit (NICU), where they are usually administered a series of medications, blood transfusions, and oxygen therapy, depending on their needs, to improve their survival rate.⁽⁵⁾

The treatment of Retinopathy of prematurity (ROP) will depend on the case or the patient's stage; certain cases are mild enough and improve without treatment.⁽¹⁾ Among the treatments we can find are laser photocoagulation, anti-vascular endothelial growth factor (anti-VEGF) therapy, and cryotherapy. In some stages, the patient might need a vitrectomy, and cerclage can also be used in cases of retinal detachment.⁽⁶⁾

Anti-VEGF is an intravitreal injected medication that blocks vascular endothelial growth proteins. It is used to block the formation of new abnormal vessels, thus preventing vision loss. Currently, we can find three types: aflibercept, ranibizumab, and bevacizumab, the latter being the most used treatment in ROP, commercially known as Avastin.⁽⁷⁾ Among the unfavorable effects that anti-VEGF treatment may present are retinoschisis, persistent avascular retina, and long-term macula abnormalities.⁽²⁾

It has been shown that treatment with anti-VEGF was associated with higher retreatment compared to the use of laser photocoagulation; among the anti-VEGFs studied, ranibizumab was found to have a higher rate of recurrence and retreatment than bevacizumab, aflibercept, and conbercept.⁽⁸⁾ In another study conducted by Patel et al. in 2024,⁽⁹⁾ the higher the dose of bevacizumab, the lower the amount of retreatment.⁽⁹⁾ The patients seen in this study were treated with 0.025 mL of bevacizumab.

It was also observed that the use of anti-VEGF has fewer complications than laser photocoagulation therapy, among which the incidence of myopia, retinal detachment, and retinal detachment.⁽⁸⁾

The purpose of this research is to determine the evolution of retinopathy of prematurity in patients treated with intravitreal antiangiogenics in the retina private practice at an Ophthalmology Center from January 2020 to January 2023.

A retrospective, descriptive, observational, case series-type study was conducted. The sampling is non-experimental and non-probabilistic. Using a population of 61 newborns, a confidence interval of 99%, and a margin of error of 1%, the sample to be used was 61 newborns.

Our selection criteria were based on premature babies who attended the retinopathy of prematurity appointment at the Ophthalmology Center in the period from January 2020 to January 2023, who received 1 or more doses of anti-VEFG in one or both eyes, and who continued their consultations at the center.

Two of our four specific objectives were to correlate the stage of ROP with the efficacy of anti-VEGF treatment and to contrast the relationship between the stage of ROP and the degree of prematurity, so we took into account the stages of ROP, degree of prematurity, and the amount of anti-VEGF doses applied in our inclusion criteria.

The researchers completed a questionnaire for the medical records. Subsequently, the data was extrapolated from Google Sheets to CVS and then Statistical Package for the Social Sciences (SPSS) for data analysis. Microsoft Word and Google Docs were used as data processors.

In 2010, according to estimates, approximately 184,700 babies out of 14.9 million were born prematurely and developed some stage of ROP, for which they received intravitreal antiangiogenic therapy.⁽¹⁶⁾ In a prospective comparative study, 174 eyes of 87 premature babies were examined, all of whom were diagnosed with grade 3 ROP and randomly assigned to receive anti-VEGF therapy.⁽¹⁷⁾ Of the 122 eyes included in our research, 120 eyes used intravitreal antiangiogenic therapy (Figure 1).

A study conducted in 2015 involving 80 premature infants found that most patients had a gestational age of 26.4±1.5 weeks, with 6.2% having an active form of ROP.⁽¹⁸⁾ We determined that all of our patients had active ROP and that 52.5% of our patients were between 29 and 32 weeks of gestational age (Figure 2).

In a study conducted by Curbelo in 2015,⁽¹⁹⁾ 88.2% of premature infants who used oxygen developed ROP. 60.7% of our patients used oxygen therapy. Patients with active ROP required a longer duration of oxygen therapy (20 ± 3.4 days) compared to those without ROP, who had a shorter duration of oxygen therapy. Twenty-eight percent of our patients remained on oxygen therapy for more than 5 days (Figure 3). A study by Kim et al. in 2015⁽²⁰⁾ revealed that the use of mechanical ventilation and CPAP is a risk factor and a guaranteed referral to an ophthalmologist. Of our patients, 54% used CPAP, 25% used an oxyhood, and the remaining 21% used mechanical ventilation (Figure 4).

Other risk factors include neonatal sepsis and blood transfusions, which accelerate oxidative damage, causing ROP.⁽²⁰⁾ Twenty-three percent of our patients developed neonatal sepsis (Figure 5), and 18% of our patients received red blood cell transfusions (Figure 5).

The study by Autrata et al. in 2012⁽¹⁷⁾ showed stable regression of ROP in 90.2% of patients treated with anti-VEGF therapy who had stage 3 disease in zones 1 and/or 2. Our patients with stage 1 to 4 ROP post-tx had a regression of 77.14%, with a p-value of 0.312 (Table 1, Figure 6).

Anti-VEGF therapy demonstrated high efficacy in inducing regression of retinopathy of prematurity across stages I to IV, with particularly favorable outcomes in early disease. The majority of affected eyes were observed in very preterm neonates. Although regression rates were consistently high, statistical analysis did not reveal a significant correlation between ROP stage and treatment response (p = 0.312), suggesting that therapeutic benefit is broadly applicable across disease stages.

Beyond gestational age, several neonatal risk factors were identified. A substantial proportion of patients (72%) required oxygen therapy for more than five days, with varying modalities including CPAP (54%), oxyhood (25%), and mechanical ventilation (21%). Additional factors included red blood cell transfusions (18%) and sepsis (23%), both of which were present in a minority of cases. No cases were observed in stage V, which highlights that early treatment and diagnosis helps prevent the progression to advanced disease.