Retinopathy of prematurity in the anti-VEGF era: Screening systems and practical treatment decision-making across anti-VEGF, laser, and surgery

Retinopathy of prematurity (ROP) is a vasoproliferative disease of the incompletely vascularized retina and remains a major preventable cause of childhood blindness. Its clinical profile varies by region: in high-income countries, severe ROP mainly affects extremely preterm infants, whereas in many low- and middle-income countries (LMICs), it may also occur in larger, more mature infants because neonatal survival has improved faster than screening capacity. The introduction of intravitreal anti-vascular endothelial growth factor (anti-VEGF) therapy has changed ROP management. Anti-VEGF agents can rapidly regress posterior and aggressive ROP (A-ROP) and may allow continued peripheral vascularization, but they also introduce challenges including persistent avascular retina (PAR), delayed reactivation, retreatment uncertainty, and systemic safety concerns. This review summarizes evidence across the ROP care pathway, including classification, screening, treatment decision-making, surgery, and long-term outcomes. In the anti-VEGF era, treatment success should extend beyond short-term regression to continued retinal vascularization, prevention of tractional complications, and sustained developmental follow-up. Anti-VEGF therapy is best supported for Zone I, posterior Zone II, and A-ROP, whereas laser remains important for anterior disease, unreliable follow-up settings, and residual avascular retina. Surgery remains necessary for advanced tractional disease. Ranibizumab and aflibercept appear to have more reassuring systemic profiles than bevacizumab, although long-term comparative data remain limited. Faricimab and topical dexamethasone remain investigational. Future priorities include integrated screening networks, standardized retreatment algorithms, and longitudinal registries tracking ocular and developmental outcomes.