Asymmetric Reactivation of Aggressive Retinopathy of Prematurity Following Bilateral Intravitreal Bevacizumab in an Extremely Low Birth Weight Infant: A Case Report

Abstract

Background: Aggressive retinopathy of prematurity (A-ROP) in Zone I carries a high risk of blindness in extremely low birth weight infants. Anti-vascular endothelial growth factor treatment induces rapid regression, but persistent avascular retina may cause delayed reactivation.

Objective: To describe interocular asymmetry, longitudinal retinal changes, and the response to rescue laser photocoagulation after bilateral intravitreal bevacizumab.

Methods: This CARE-guided longitudinal case report followed a female infant born at 26 weeks (birth weight, 930 g) across eight clinical epochs from postmenstrual age (PMA) 31 to 55 weeks. Serial RetCam imaging and quantitative vascular tortuosity measurements were reviewed.

Results: Bilateral intravitreal bevacizumab (0.625 mg/0.025 mL) was administered at PMA 34 weeks for Zone I stage 2 ROP with plus disease in the right eye and A-ROP in the left eye. Bilateral regression occurred within 1 week. At 7 weeks after injection (PMA 41 weeks), the left eye alone developed recurrent hemorrhages and a 1,700% increase in arterial tortuosity index (0.2 to 3.6); the right eye remained quiescent. Rescue diode laser photocoagulation (100 mW, 153 spots) was applied to the anterior avascular retina. By PMA 55 weeks, both eyes remained anatomically quiescent.

Conclusion: Early regression after anti-VEGF therapy does not preclude delayed, asymmetric reactivation. Extended eye-specific surveillance and timely laser treatment of persistent avascular retina may achieve durable anatomical stability.