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 Table of Contents  
Year : 2021  |  Volume : 1  |  Issue : 3  |  Page : 542-544

Primary exudative retinal detachment in stage 4b retinopathy of prematurity managed nonsurgically – A case report

1 Shree Netralaya Super-Speciality Eye Care and Retina Centre, Vadodara, Gujarat, India
2 Baroda Children Eyecare and Squint Clinic, Vadodara, Gujarat, India

Date of Submission31-May-2020
Date of Acceptance07-Feb-2021
Date of Web Publication02-Jul-2021

Correspondence Address:
Dr. Vishal R Dedhia
Shree Netralaya Super-Speciality Eye Care and Retina Centre, Rubellite Building 204.205, Urmi Char Rasta, Akota, Vadodara, Gujarat - 390020
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ijo.IJO_1752_20

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Preterm baby born at 30 weeks of gestation presented at 3 weeks with zone 1 stage 3 retinopathy of prematurity (ROP) with plus disease in the right eye and zone 1 stage 4b ROP with plus disease in the left eye. We report this rare primary presentation of exudative retinal detachment in ROP in the left eye managed by concurrent laser photocoagulation and intravitreal injection anti-VEGF. ROP regressed completely in 6 weeks. The right eye was managed similarly. Stage 4b ROP usually requires surgical intervention. We report this rare presentation managed nonsurgically with good prognosis.

Keywords: Anti-VEGF, exudative retinal detachment, laser photocoagulation, retinopathy of prematurity, stage 4b ROP

How to cite this article:
Dedhia VR, Jethani J. Primary exudative retinal detachment in stage 4b retinopathy of prematurity managed nonsurgically – A case report. Indian J Ophthalmol Case Rep 2021;1:542-4

How to cite this URL:
Dedhia VR, Jethani J. Primary exudative retinal detachment in stage 4b retinopathy of prematurity managed nonsurgically – A case report. Indian J Ophthalmol Case Rep [serial online] 2021 [cited 2021 Jul 28];1:542-4. Available from: https://www.ijoreports.in/text.asp?2021/1/3/542/319984

Retinopathy of prematurity (ROP) is a retinal vascular disease commonly seen in premature infants. Aggressive posterior ROP and ROP in Zone 1 are less responsive to laser and the disease may progress despite a confluent laser.

Advanced stages of ROP (4 and 5) usually require surgical intervention. Several procedures have been described to treat ROP-associated RDs, including open-sky vitrectomy, scleral buckling, closed vitrectomy and lensectomy with or without scleral buckling, and lens sparing vitrectomy without scleral buckling.[1]

We report a case of zone 1 stage 4b ROP (fovea-involving sub-total exudative retinal detachment) with plus disease managed successfully nonsurgically with concurrent laser photocoagulation and intravitreal anti-VEGF injection bevacizumab.

  Case Report Top

A preterm female child of twin pregnancy of 30 weeks of gestational age and 1100 g of birth weight was screened for retinopathy of prematurity (ROP) at 33 weeks of postmenstrual age. Baby had history of sepsis and anemia with prolonged oxygen therapy. On ocular examination, anterior segment of both the eyes was normal apart from a moderately dilating pupil. Fundus examination of the left eye [Figure 1]a and [Figure 1]b revealed a localized bullous and smooth band of sub-retinal fluid involving the fovea and extending till the temporal periphery whereas the rest of the retina was attached suggestive of exudative retinal detachment. Also the blood vessels over the posterior pole showed venous dilatation and arterial tortuosity suggestive of plus disease. The left eye was classified as zone 1 stage 4b ROP with plus disease. Fundus examination of the right eye [Figure 2]a, [Figure 2]b, [Figure 2]c revealed zone 1 stage 3 ROP with plus disease. The other baby boy of twin pregnancy also had zone 1 stage 3 ROP, managed similarly. Family history was not significant.
Figure 1: (a and b) Fundus photographs of the left eye showing localized bullous and smooth band of sub-retinal fluid involving the fovea (a) and extending till the temporal periphery (b) suggestive of exudative retinal detachment in ROP. Note the venous dilatation and arterial tortuosity over the posterior pole suggestive of plus disease. The baby was classified as Zone 1 Stage 4b ROP with plus disease in the left eye

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Figure 2: (a-c) Fundus photographs of the right eye showing zone 1 stage 3 ROP with plus disease. Note the venous dilatation and arterial tortuosity over the posterior pole suggestive of plus disease

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We planned concurrent laser photo-coagulation and intravitreal injection Anti-VEGF Bevacizumab (IVB) for both the eyes.

Laser treatment was done under topical anesthesia (0.5% proparacaine) in the operation theater in the presence of an anesthetist with continuous monitoring of the heart rate and respiration of the child. Laser guidelines followed the protocols of Jalali et al.[2] Pale white laser burns were applied in the areas of avascular retina extending from the ridge of extra-retinal fibrovascular proliferation to the ora serrata, half burn width apart.

Temporal quadrant did not take laser burns with the routine power in the left eye due to the retinal detachment. Laser power was increased upto 400 milliwatts to get a very faint laser burn to as much temporal periphery as possible.

After the laser photo-coagulation, eyes were prepared and draped for IVB. IVB (0.625 mg in 0.025 mL of solution) injection was performed under topical anesthesia. Topical prednisolone acetate 1% four times a day and homatropine hydrobromide 2% twice daily were prescribed for both the eyes for a week.

The procedure was uneventful. No skip areas were noted and no repeat laser treatment was needed. Patient was examined one day after treatment. Follow-up visits were scheduled weekly for 4 weeks, and then biweekly until postmenstrual age of 90 weeks.

ROP regressed completely by 6 weeks of follow-up in both the eyes [Figure 3]a, [Figure 3]b, [Figure 3]c, [Figure 3]d, [Figure 3]e and [Figure 4]a and [Figure 4]b. Fovea-involving subtotal exudative retinal detachment in the left eye resolved completely with few residual exudates over the macula. Cycloplegic refraction using atropine at 6 months showed +2.0 D sphere in each eye.
Figure 3: (a-e) Fundus photographs of the left eye showing complete resolution of exudative retinal detachment with few residual exudates over the macula (a), completely regressed ROP with laser marks seen in the temporal (b), inferior (c), nasal (d), and superior (e) quadrants

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Figure 4: (a and b) Fundus photographs of the right eye showing completely regressed ROP (a) with laser marks seen in the temporal quadrant (b)

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  Discussion Top

Retinal detachment in ROP is frequently seen in stages 4 and 5 of the disease. This RD is usually tractional in nature. Exudative RD in ROP has so far been reported mainly after laser photocoagulation[3] or as a late sequelae.[4]

Exudative RD in ROP without laser has been rarely described.[5] A hyperoxia-induced proliferative retinopathy (HIPR) model was shown in a retinal phenotype of murine model by Lajko et al.[6] with neovascularization and fibrinogen within the retina, which triggers an inflammatory process leading to exudative RD. A similar pathogenesis could explain the development of exudative RD in our case as well since this baby also had prolonged oxygen therapy with labile oxygen saturations.

Other causes of exudative RD in this age group include Coats disease and Familial exudative vitreoretinopathy (FEVR) and were differentiated from our case.

Whereas Coats disease is usually unilateral and has a strong male predominance, FEVR is usually seen in full-term babies with normal birth weight and there is no related oxygen therapy in the postnatal period. In our case, there is prematurity with low birth weight along with prolonged oxygen therapy. Also, there was no significant family history. Genetic analysis of the family members for FEVR would have helped to rule out FEVR.[7]

Images were taken by a hand-held fundus camera (Smartscope, Optomed, Oulu, Finland) and we do not have ultra-wide-field imaging systems and hence peripheral fundus photos and fundus fluorescein angiography (FFA) was not performed which would have helped to rule out the other differential diagnosis. But the typical features of ROP with plus disease in both the eyes along with similar disease in the other twin support our diagnosis.

The intravitreal concentration of VEGF is highly elevated in advanced ROP and this factor plays a major role in the development of retinal neovascularization in ROP.[8] Decreasing the intravitreal VEGF level may be a good therapeutic option for the treatment of ROP. Mintz-Hittner et al. showed that IVB provided a significant benefit in the treatment of eyes with zone I ROP as compared to laser.[9] Armada-Maresca et al.[10] have used IVB in ROP for exudative RD after laser with good resolution.

Problems with anti-VEGF monotherapy include late recurrences[11] and tractional retinal detachment.[12] Our case already had stage 4b ROP and chances of traction increasing postanti-VEGF alone would have been more. Hence concurrent IVB along with zone 1 sparing laser ablation was done and this approach was shown to be effective in zone 1 ROP by Kim et al.[13] Also Yoon JM et al. have shown favorable outcomes without recurrences with IVB and concomitant or deferred laser for type 1 ROP in zone 1.[14]

Possible advantages of combined approach include single treatment session especially in sick babies due to anesthesia or other systemic reasons, lesser follow-ups, early regression of ROP, and lesser chances of recurrences.

Laser was difficult in the temporal peripheral but faintly possible most probably due to increase in the power settings and shallow sub-retinal fluid in the periphery.

Diagnosis of such rare primary presentation of fovea-involving exudative retinal detachment in ROP is important since it can be managed nonsurgically with good prognosis.

Also concurrent treatment of laser photocoagulation and Anti-VEGF injection for stage 4b ROP has not be described to the best of our knowledge.

  Conclusion Top

It is important to recognize such rare presentation as treatment can be nonsurgical and outcome after timely intravitreal anti-VEGF and laser is excellent.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Hubbard GB 3rd, Cherwick DH, Burian G. Lens sparing vitrectomy for stage 4 retinopathy of prematurity. Ophthalmology 2004;111:2274-7.  Back to cited text no. 1
Jalali S, Azad R, Trehan HS, Dogra MR, Gopal L, Narendran V, et al. Technical aspects of laser treatment for acute retinopathy of prematurity under topical anesthesia. Indian J Ophthalmol 2010;58:509-15.  Back to cited text no. 2
[PUBMED]  [Full text]  
Moshfeghi D, Silva R, Berrocal A. Exudative retinal detachment following photocoagulation in older premature infants for retinopathy of prematurity: Description and management. Retina 2014;34:83-6.  Back to cited text no. 3
Brown MM, Brown GC, Duker JS, Tasman WS, Augsburger JJ. Exudative retinopathy of adults: A late sequelae of retinopathy of prematurity. Int Ophthalmol 1994;18:281-5.  Back to cited text no. 4
Sen P, Yusufali H, Khetan V, Rao C, Banerjee A. Exudative retinal detachment, a primary presentation in retinopathy of prematurity. Can J Ophthalmol 2018;53:e74-7.  Back to cited text no. 5
Lajko M, Cardona HJ, Taylor JM, Shah RS, Farrow KN, Fawzi AA. Hyperoxia-induced proliferative retinopathy: Early interruption of retinal vascular development with severe and irreversible neurovascular disruption. PLoS One 2016;11:e0166886.  Back to cited text no. 6
Peng J, Zhang Q, Chen C, Huang Q, Li Y, Zhao P. Early onset coats' disease initially treated as unilateral ROP at 39 weeks postmenstrual age: A case report. BMC Ophthalmol 2017;17:145.  Back to cited text no. 7
Sato T, Kusaka S, Shimojo H, Fujikado T. Vitreous levels of erythropoietin and vascular endothelial growth factor in eyes with retinopathy of prematurity. Ophthalmology 2009;116:1599-603.  Back to cited text no. 8
Mintz-Hittner HA, Kennedy KA, Chuang AZ; BEAT-ROP Cooperative Group. Efficacy of intravitreal bevacizumab for stage 3+retinopathy of prematurity. N Engl J Med 2011;364:603-15.  Back to cited text no. 9
Armada-Maresca F, Peralta-Calvo J, Pastora-Salvador N, Grabowska A, Vallejo-Garcia J. External subretinal drainage, bevacizumab, and scleral buckling for complete exudative retinal detachment after photocoagulation in retinopathy of prematurity. Retina Cases Brief Rep 2014;8:33-6.  Back to cited text no. 10
Hajrasouliha AR, Garcia-Gonzales JM, Shapiro MJ, Yoon H, Blair MP. Reactivation of retinopathy of prematurity three years after treatment with bevacizumab. Ophthalmic Surg Lasers Imaging Retina 2017;48:255-9.  Back to cited text no. 11
Yonekawa Y, Wu W-C, Nitulescu CE, Chan RVP, Thanos A, Thomas BJ, et al. Progressive retinal detachment in infants with retinopathy of prematurity treated with intravitreal bevacizumab or ranibizumab. Retina 2018;38:1079-83.  Back to cited text no. 12
Kim J, Kim S, Chang Y, Park W. Combined intravitreal bevacizumab injection and Zone I sparing laser photocoagulation in patients with Zone I retinopathy of prematurity. Retina 2014;34:77-82.  Back to cited text no. 13
Yoon JM, Shin DH, Kim SJ, Ham D, Kang SW, Chang YS, et al. Outcomes after laser versus combined laser and bevacizumab treatment for type 1 retinopathy of prematurity in Zone I. Retina 2017;37:88-96  Back to cited text no. 14


  [Figure 1], [Figure 2], [Figure 3], [Figure 4]


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