Retina Society 2026: Timing matters: Early stage 2 ROP signals higher risk of treatment

At the Retina Society 59th Annual Scientific Meeting, Nimesh Patel, MD, presented research on how the timing of stage 2 retinopathy of prematurity (ROP) relates to the risk of eventual treatment.

Current treatment criteria rely on stage, zone, and plus disease. Patel noted that as infants survive at earlier gestational ages, some develop ROP earlier, and those cases tend to be more severe. Such patients were less represented in the clinical trials that shaped current guidelines.

Early stage 2 predicts treatment

The investigators compared patients who reached stage 2 before 34 weeks, after 38 weeks, and in between. The treatment rate was significantly higher when stage 2 appeared before 34 weeks. These patients tended to be younger and smaller and to have more risk factors for treatment-warranted ROP.

Among patients with stage 2 and type 2 disease, which does not meet treatment guidelines, 66% ultimately required treatment. Patel said the findings support considering earlier, more preventive treatment, as in diabetic retinopathy.

Refer early

"ROP blindness is largely preventable," Patel said. He attributed persistent poor outcomes partly to delayed referral, when referring centers wait until treatment criteria are met. His advice to referring physicians: "if you see any ROP, just refer it."

Risk-tailored screening

Patel proposed moving from a one-size-fits-all approach toward risk-tailored management, with earlier treatment for high-risk infants with early disease and potentially later screening for low-risk infants. Infants who are intubated or on continuous positive airway pressure (CPAP), and those with hazy views, are harder to examine and more likely to be caught late.

Anti-VEGF first

Patel usually treats with anti-VEGF injection first. It is fast, avoids reintubation, and, he said, is more effective when given before disease progresses to stage 3. In a review of 1,600 injections, his group found no infections. A separate study found more retreatment with laser than with injection, which he attributed to laser taking days to weeks to reduce VEGF drive.

His center typically lasers avascular retina on an outpatient basis at 55 weeks to prevent reactivation. Patel said the center has had no detachments, unfavorable outcomes, or macular folds in 6 years using this approach.

Expanding access with telemedicine

Patel described a telemedicine screening program at a satellite hospital that lets infants stay in their local neonatal intensive care unit; only 1 patient was transferred for treatment in 2 years. To sustain the ROP workforce, he called for reducing unnecessary screening, expanding photographic screening by nurses, ensuring adequate reimbursement, and securing government investment. He noted that ROP screening is highly valuable in terms of cost per quality-adjusted life-year.