New zones, new tools, new thinking. ROP care gets a refresh.
Retinopathy of prematurity (ROP) may affect the smallest patients in the room, but the decisions around it are anything but small. On Day 3 of the 18th Congress of the Asia-Pacific Vitreo-Retina Society (APVRS 2025), a dedicated symposium took a fresh (and occasionally provocative) look at how we screen, stage, image, treat and ultimately try to prevent ROP.
With perspectives spanning classification updates, diagnostic innovations, prevention strategies, national programs and global trends, the session offered a timely reminder that ROP care is less a fixed pathway and more a constantly evolving playbook.
Updated classifications and emerging risk factors
If ROP classification feels like a living, breathing entity rather than a static rulebook, that’s because it is—and it’s been quietly evolving to keep up with real-world disease patterns. Dr. Nawazish Shaikh (India) opened the session with a clear-eyed walkthrough of ROP classification systems, homing in on the third edition of the International Classification of ROP (ICROP-3), published in 2021.
“What was the need for this classification to come about again? We already had the first edition and the second edition. Why was the third edition required?” Dr. Shaikh asked rhetorically, before answering her own question. “The crux of this lies in the subjectivity of critical elements for disease classification, plus disease.”
Among the key updates in ICROP-3 is the introduction of “posterior zone 2,” a refinement that allows for more accurate prognostication. The classification also formally defined a “notch,” described as an “incursion of the ROP lesion 1 to 2 clock hours into a more posterior zone,” a subtle shift that can meaningfully alter disease staging and, potentially, management decisions.
Another notable change was the rebranding of APROP (Aggressive Posterior ROP) to AROP (Aggressive ROP). “This was because larger preterm infants were developing these changes in zones beyond the posterior zone,” Dr. Shaikh explained, underscoring how clinical reality has outgrown earlier terminology.
Beyond classification tweaks, Dr. Shaikh drew attention to a growing list of risk factors that extend well past the traditional cornerstones of gestational age and birth weight. These include poor postnatal weight gain, low insulin-like growth factor levels, proteinuria, repeated blood transfusions, corticosteroid use for bronchopulmonary dysplasia, low total bilirubin and genetic factors linked to familial exudative vitreoretinopathy, reminding clinicians that ROP risk assessment is becoming increasingly nuanced and decidedly more multifactorial.
READ MORE: New Horizons in ROP Treatment, Tailoring Care for Premature Infants
Advances in ROP diagnostics
If ROP diagnosis once relied almost entirely on what the clinician could see in the moment, today’s toolkit is far more visual, data-rich and—dare we say—camera-friendly. In a pre-recorded lecture, Prof. Dr. Sengul Ozdek (Turkey) walked the audience through how imaging technologies have reshaped the way clinicians diagnose and monitor ROP, while still keeping indirect ophthalmoscopy firmly in its starring role.
“Imaging is very helpful to compare images to see progression and the tempo of the disease. And it gives us a better determination of zone and plus disease,” she noted, highlighting imaging’s strength as both a diagnostic and longitudinal tool.
Dr. Ozdek reviewed several imaging modalities, with a focus on wide-field systems. The ideal setup, she explained, should be “non-contact, non-mydriatic, affordable, with wide field of view cameras and a short image acquisition time,” a wish list that will sound familiar to anyone who has ever tried to image a squirming preterm infant.
She placed particular emphasis on fluorescein angiography (FA), calling it indispensable in modern ROP care. “It’s a perfect tool to demonstrate vascular pathologies. It can be used both in acute disease or in follow-up of regression or reactivation.” FA, she added, improves detection of stage 3 disease, plus disease and persistent avascular retina following anti-vascular endothelial growth factor (anti-VEGF) treatment.
Optical coherence tomography (OCT) also earned a spotlight for its ability to reveal macular pathology that may slip past the clinical exam. “This was a stage 4A case with a basal shallow retinal detachment. But when we took the OCT pictures, we saw that even in the macula there was retinal detachment, so it was actually stage 4B,” Dr. Ozdek shared—an example of how a deeper look can sometimes rewrite the diagnosis.
READ MORE: LKC’s RETeval Offers New Solutions for Infants with ROP
An innovative diagnostic approach
When IV access, anesthesia and logistics start to feel like the real barriers to good imaging, it may be time to rethink the route altogether. Dr. Akash Belenje (India) introduced a novel—and decidedly more outpatient department (OPD)-friendly—approach to detecting reactivation after anti-VEGF therapy using oral fundus fluorescein angiography.
“Conventionally, we have been using intravenous fundus fluorescein angiography [IV FFA] under general anesthesia to detect reactivation or persistent avascular retina to have a targeted treatment. But the challenges are this can be performed in an ophthalmic institute where you have a pediatric neonatologist or an anesthetist. Whereas it is difficult to perform IV FFA in an OPD setting,” Dr. Belenje explained.
To sidestep these hurdles, his team developed a protocol using oral fluorescein dye at 7.5 mg per kilogram body weight, mixed with expressed mother’s milk. Imaging is then performed with ultra-widefield systems, starting five minutes after ingestion—a setup that trades IV lines for patience and good timing.
“Oral fundus fluorescein dye angiography is safe and effective in diagnosing reactivation post anti-VEGF. It helped in early detection of neovascularization, prevented overtreatment of cases and helped us in targeted, judicious laser treatment,” Dr. Belenje concluded, adding that the pilot study supporting this approach has been published in Eye (London).*
READ MORE: Haag-Streit Launches Eyesi Laser Simulation Module for ROP Treatment
Emerging therapies and clinical trials
If ROP management were a chess game, this session was all about thinking several moves ahead. Not just how to treat disease, but how to stop it from escalating (or appearing) in the first place. Dr. J. Peter Campbell (USA) offered a sharp and structured tour of current and emerging therapeutic strategies for ROP, neatly organizing them into three levels of prevention.
“Tertiary prevention is when you have treatment—requiring disease and you treat it. Secondary prevention is when you have the disease but do something to reduce the chance of developing treatment—requiring ROP. Primary prevention is preventing the incidence of disease to begin with,” he explained.
Laser and anti-VEGF therapies continue to anchor tertiary prevention, but Dr. Campbell focused much of his attention on secondary prevention, where the field is getting increasingly creative. Strategies under investigation include oxygen modulation during phase 2 ROP and the use of topical dexamethasone.
“I’m probably most excited about this study coming out of Sweden looking at topical dexamethasone drops once a baby gets to a certain level of disease, reducing the incidence of type 1 ROP,” he said, pointing to the eagerly awaited DROPROP study, with results expected soon.
When it comes to primary prevention, Dr. Campbell highlighted nutritional interventions, including specialized formulas supplemented with specific fatty acids that have demonstrated reductions in severe ROP. He also touched on experimental pharmacologic approaches targeting the hypoxia-inducible factor (HIF) pathway and lipid peroxidase pathways—early-stage clinical trials that hint at a future where preventing ROP may start well before the retina raises any red flags.
READ MORE: New Retinal Frontiers Unveiled at APAO 2025
National ROP programs
Building a national ROP program is less about a single breakthrough and more about persistence, coordination and a lot of unglamorous groundwork done right. Dr. Rachelle Anzures shared how the Philippines has been steadily assembling the pieces of a nationwide ROP strategy: one system, one guideline and one region at a time.
The Philippine ROP Working Group was formed in 2012 to address what she described as “persistent gaps in screening, treatment and follow-up access across the regions in the Philippines.” From the outset, the program was designed around five core pillars: policy and guidelines development, capacity building, service delivery models, data monitoring systems, and advocacy and communication.
“In 2013, we launched ROP screening guidelines for the Philippines. And then seven years after that, we made another study looking into if we could adjust the screening criteria,” Dr. Anzures explained. That reassessment led to the updated 2020 guidelines and the introduction of the easy-to-remember “STOP” risk factors: Sepsis, Transfusion history, Oxygen use (especially without blender) and other Prematurity complications.
To improve coordination on the ground, the group developed an ROP network website (phropnetwork.com) that maps screening providers and treatment centers nationwide, making referrals less of a guessing game. Just as critically, ROP screening has now been successfully integrated into the country’s national health insurance coverage.
“National ROP programs will succeed when they are multidisciplinary, standardized, data-driven and sustained,” Dr. Anzures concluded, rallying the audience with the group’s unmistakable call to action: “One child blind from ROP is one child too many.”
READ MORE: Round Up on ROP: Experts Share Strategies to Prevent ROP in Asia-Pacific
Global strategies and future directions
If the earlier talks zoomed in on the details, the final speaker pulled the lens all the way back to the global stage…and the picture was both sobering and forward-looking. Dr. Peiquan Zhao (China) closed the session with a wide-angle view of ROP management worldwide, spanning prevention, acute treatment and the long road of advanced disease care.
“We are now in the third epidemic of ROP, mainly in low- and middle-income countries. Today, Asia accounts for about half of preterm births and ROP-related blindness,” Dr. Zhao noted, setting the context for why global strategy matters now more than ever.
On the prevention front, he stressed the fundamentals that still make the biggest difference: meticulous oxygen control in neonatal intensive care units (NICUs) and screening guidelines tailored to each country’s resources and realities. He also pointed to telemedicine and artificial intelligence (AI)-assisted screening as promising tools to close access gaps, particularly in remote and underserved regions.
Turning to acute ROP, Dr. Zhao traced the therapeutic evolution from cryotherapy to laser to anti-VEGF agents. He shared his team’s experience with faricimab, which “achieved 100% initial regression with a relatively low reactivation rate and no adverse events,” suggesting a potential new chapter in medical management.
Advanced ROP (stages 4–5) brought a look at surgical innovation, including viscoelastic-assisted delamination of retrolental plaques while preserving the lens, as well as alternative anti-VEGF delivery routes in stage 5 disease, such as subretinal and intra–anterior chamber injections.
“Even after successful treatment, many children have anatomical sequelae such as persistent avascular retina or macular dragging. Functional problems like amblyopia, strabismus and refractive errors are also common. Early and ongoing visual rehabilitation is essential for these patients,” Dr. Zhao concluded, reminding the audience that success in ROP is measured not just in regression, but in long-term visual outcomes.
READ MORE: The Last Miles of Retinal Care at APVRS 2025 Put Systems on the Retina Map
*Jalali S, Belenje A, Reddy R. et al. Oral fundus fluorescein angiogram detects reactivation post anti-VEGF in retinopathy of prematurity. Eye (London). April 9, 2025. [ePub ahead of print.]
Editor’s Note: This content is intended exclusively for healthcare professionals. It is not intended for the general public. Products or therapies discussed may not be registered or approved in all jurisdictions, including Singapore. Reporting for this story took place during the 18th Congress of the Asia-Pacific Vitreo-Retina Society (APVRS 2025) from 12-14 December in Manila, Philippines.