What Happens If ROP Laser or Anti-VEGF Treatment Fails?

Learning that your baby’s initial ROP treatment (laser therapy or anti-VEGF injections) was not fully successful can be terrifying. It is important to know that “treatment failure” does not automatically mean your baby will lose their vision. Sometimes, the disease simply persists or reactivates, requiring repeat laser therapy, another injection, or close monitoring ^[1]. However, if the abnormal blood vessels and scar tissue continue to grow, they can begin to pull the retina (the light-sensitive tissue at the back of the eye) away from the inner wall of the eye ^[1]. When a partial or total tractional retinal detachment occurs, the disease has progressed to Stage 4 or Stage 5 ^[2].

If your baby’s care team suspects the retina is detaching, this is a medical urgency. Your baby needs a prompt evaluation by an experienced pediatric vitreoretinal surgeon to discuss advanced eye surgery ^[1]. The goals of advanced surgery are to reattach the retina, preserve the physical structure of the eye, and save as much useful vision as possible ^[3].

Confirming the Stage of Progression

A pediatric retina specialist will perform a detailed examination, often under anesthesia, to determine exactly what is happening in the eye ^[1]. They may use wide-field imaging, ocular ultrasound, or a specialized scan called Optical Coherence Tomography (OCT) to help confirm the diagnosis and plan the surgical approach ^[4].

If the retina is detaching, it is categorized by stage:

• Stage 4A: A partial retinal detachment that does not involve the fovea (the very center of the macula, responsible for sharp, detailed straight-ahead vision) ^[1]. Surgery at this stage generally has the best chance of success.
• Stage 4B: A partial detachment that does involve the fovea/macula ^[5].
• Stage 5: A complete, total detachment of the retina ^[2].

Advanced Surgical Options

The surgical plan is highly individualized based on the baby’s specific eye anatomy, the stage of detachment, and the surgeon’s findings. The primary options include:

1. Vitrectomy
This is the most common procedure for advanced ROP. The surgeon makes microscopic incisions to carefully remove the vitreous (the gel inside the eye) and cut away the scar tissue that is pulling on the retina ^[1].

• Lens-Sparing Vitrectomy: Whenever technically feasible (often in Stage 4A or early 4B), surgeons try to leave the baby’s natural lens in place ^[5][1].
• Lensectomy: In advanced Stage 4B or Stage 5, severe scar tissue often sits directly behind the lens. The surgeon may need to remove the natural lens to safely reach and release the scar tissue ^[6][7]. Removing the lens results in a condition called aphakia. Because the eye can no longer focus on its own, the baby will require prompt and ongoing optical correction (like special contact lenses or glasses) and treatments to support visual development ^[7].

2. Scleral Buckle
For certain specific types of Stage 4 detachments where the pulling is mainly on the outer edges of the retina, a surgeon might use a scleral buckle ^[8]. This is a flexible silicone band placed around the outside of the eye to gently push the eye wall inward against the detached retina ^[9]. It is generally not a standard equivalent for treating total Stage 5 detachments.

Realistic Goals and Outcomes

It is critical to understand the difference between anatomical success (successfully reattaching the retina) and functional success (how well the baby will actually be able to see).

• Stage 4 Outcomes: Surgery is most successful when performed at Stage 4A, before the fovea detaches. Selected studies show that vitrectomy can achieve anatomical reattachment in 82% to 97% of Stage 4 cases ^[10][11]. While many of these children retain useful or “navigational” vision (enough sight to move around safely and interact with their environment), it does not guarantee normal, sharp eyesight ^[10].
• Stage 5 Outcomes: Stage 5 is significantly more difficult to treat. Studies indicate that specialized vitrectomy achieves anatomical success in only about one-third of Stage 5 cases ^[2]. Visual recovery is often very limited. At this stage, the primary goal of surgery may be to preserve the eye’s physical structure, ensure the baby’s physical comfort, and save any remaining light perception or limited vision ^[3][2].

Surgery Recovery and Long-Term Care

Advanced eye surgery in premature infants involves general anesthesia and a recovery period requiring careful administration of prescribed eye drops for healing and comfort. Because prematurity, retinal damage, and surgery all impact how the eye develops, care does not end in the operating room.

Your child will need long-term, possibly lifelong, monitoring by an eye care team. Common developmental issues include the need for strong glasses to correct refractive errors, crossed eyes (strabismus), and “lazy eye” (amblyopia), which may require patching therapy ^[7]. While less common, serious complications from the advanced disease or surgery can include cataracts, high eye pressure (glaucoma), macular holes, or recurrent retinal detachments that require further operations ^[12][13][14]. Early intervention programs and low-vision support services are essential tools to help support your child’s overall growth and development.