SAFER-ROP: Updated Protocol for Anti-VEGF Injections for Ret
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Retinopathy of prematurity (ROP) is one of the leading, yet treatable causes of childhood blindness. Its incidence is only increasing as medical advances have continued to push the age of viability to 21 weeks postmenstrual age. There have been many published standardized intravitreal injection techniques for adults to ensure safe and reproducible delivery. However, standardized techniques for anti-VEGF administration in ROP are lacking. upon this technique and propose the first published ROP treatment protocol entitled SAFER-ROP in order to deliver effective treatment while minimizing avoidable complications.

SAFER is an acronym used to describe the injection protocol, which consists of the following: (S)hort needle, (A)ntiseptic/antibiotic, (F) ollow-up, (E)xtra attention to detail, and (R)echeck every 1 to 2 weeks post-injection until complete retinal vascularization or additional laser has been administered to avascular retina. The “short needle” is a 32-gauge, thin-walled, stainless steel hypodermic needle 4 mm in length. The “antiseptic/antibiotic” utilized is topical 5% or 10% betadine. It is instilled before and after the injection. “Follow-up” should be performed 48 to 72 hours post-injection to rule out endophthalmitis. “Extra attention to detail” includes use of the ora nomogram to determine the safest injection distance from the limbus in each quadrant, Furthermore, unsheathed needles should not be held near the infant's CPAP, nose, or mouth while maneuvering into position for an injection. When teaching this technique, it may be best to ensure trainees hold the syringe in one hand and to use the other hand to depress the plunger. This way, the plunger is not accidentally depressed outside the eye as “pushing the needle in through sclera” and, hence, reducing drug dose in the vitreous. Additionally, there is less chance of inadvertent change in needle direction as they try to reach the plunger with fingers of the hand also holding the syringe.

Recheck the patient every 1 to 2 weeks following anti-VEGF treatment. Its also recommend considering performing a fluorescein angiogram for all treated patients by 60 and 65 weeks postmenstrual age, if not already vascularized into Zone III, with a view to treat with additional laser if necessary. This is important because although about 18% of eyes treated with anti-VEGF vascularized to zone III by three months post-injection, and at least 61% vascularized by 2.5 years,10–13 a significant number of infants do not fully vascularize their retina following intravitreal anti-VEGF injections.