Injections or Laser for a Premature Baby's Eyes? What Two New Reviews Tell Families

Plain-language coverage of two 2026 research reviews comparing eye injections with laser treatment for retinopathy of prematurity

Two large research reviews published in 2026 compared the two main treatments for retinopathy of prematurity, an eye condition affecting babies born very early. Injections of anti-VEGF medicine left children with much less short-sightedness than laser treatment, but the disease was more likely to come back after injections in some parts of the eye — meaning babies treated with injections need eye check-ups for much longer.

Why This Question Exists

Babies born many weeks early have eyes that are not finished. The blood vessels that feed the retina — the light-sensing layer at the back of the eye — normally grow outward from the centre during the last weeks of pregnancy. When a baby is born before that growth is complete, the process is disrupted. Later, the eye tries to catch up, and it can do so chaotically, sprouting fragile abnormal vessels that can scar and, in the worst cases, pull the retina away from the back of the eye. That is retinopathy of prematurity, or ROP, and it remains one of the world's leading causes of childhood blindness.

For decades, the answer was to deliberately destroy the outer edge of the retina — the part that was still starved of blood supply and sending out the distress signal that drove the abnormal growth. Removing the signal stopped the disease. The first proof came from a large North American study called the Multicenter Trial of Cryotherapy for Retinopathy of Prematurity (CRYO-ROP), which froze the retinal edge and showed that this genuinely protected sight [1]. Freezing was later replaced by laser, which does the same job more precisely, and a further multi-centre American study, the Early Treatment for Retinopathy of Prematurity (ETROP) trial, showed that treating earlier gave better results [2]. Those studies saved a great deal of vision. But families who lived through that era will recognise what came with it: a child whose peripheral retina was permanently gone, and who very often needed strong glasses for the rest of their life.

Then, in 2011, an American study called the Bevacizumab Eliminates the Angiogenic Threat of Retinopathy of Prematurity (BEAT-ROP) trial tried something different — a tiny injection of a medicine into the eye that switches off the chemical signal driving the abnormal vessels, rather than destroying the tissue producing it [3]. Nothing is burned away. The retina is left intact and, in principle, can carry on growing normally. That idea has reshaped ROP treatment worldwide over the past fifteen years, and it has raised a question that families and doctors have been living with ever since: which is actually better?

The Two Reviews

Neither of the 2026 papers covered here is a new treatment study. Both are what researchers call a systematic review and meta-analysis: a careful, rules-based collection of every previous study on a question, combined statistically to give a clearer overall picture than any one study can. The two reviews came out five months apart and, usefully, they asked about different things.

The first, by Krungkraipetch and colleagues in Thailand, asked whether the disease comes back [4]. They searched four large research databases for studies published between 2010 and 2025 that directly compared injections with laser, and combined 15 studies covering 1,784 eyes. They counted how often ROP returned after treatment, how often a second treatment was needed, and how long after the first treatment the disease reappeared.

The second, by Huang and colleagues in Taiwan, asked what the child's vision is like years later [5]. They searched four databases from the beginning of each database up to July 2025 and combined 86 studies covering 10,269 treated eyes, following children anywhere from six months to eighteen years afterwards, with a typical follow-up of three years. Their main measure was how short-sighted (myopic) the eye became, measured in units called dioptres, and how many children ended up with severe short-sightedness.

The evidence in both reviews includes some randomised trials — the strongest kind of study, where treatment is assigned by chance — such as the RAINBOW trial, which compared the medicine ranibizumab with laser across many countries, and the FIREFLEYE trial, which did the same for a medicine called aflibercept [6][7]. But much of the evidence comes from hospitals looking back at their own records, which is weaker.

What They Found

On whether the disease comes back, the overall answer was genuinely unclear. When all the studies were combined, injections and laser looked broadly similar, but the results varied so wildly between studies that the researchers themselves concluded the combined figure could not be trusted as a real answer. In plain terms: the studies disagreed too much for the average to mean much [4].

But looking at where in the eye the disease sat changed everything. Eye doctors divide the retina into zones, with zone I being the innermost and most serious. In zone I, injections tended to do better than laser. In zone II — the middle band, and the more common situation — ROP came back after injections around three times as often as after laser. The medicine used also mattered: ranibizumab, which clears from the eye fastest, had the highest rate of the disease returning, while bevacizumab and aflibercept did better. One study of ranibizumab in zone II found a very large increase in the need for a second treatment [8], and a large multi-hospital comparison also found more repeat treatments after ranibizumab than after bevacizumab [9].

Timing was the other important finding. After laser, if ROP came back, it usually did so early — within the window when the baby is still being checked routinely. After injections, it could return as early as 7 to 10 weeks, but also much later, sometimes beyond 50 weeks of the baby's corrected age. That is well after most babies have gone home. This is exactly why national guidance requires longer eye follow-up after injections than after laser [10], and it is the single most important thing for a family to hold on to: a good eye examination at discharge does not mean the story is finished.

On long-term vision, the difference was large and clear. Averaged across thousands of eyes, children treated with injections were mildly short-sighted (−1.9 dioptres), children treated with laser considerably more so (−3.8), and children who had had freezing treatment or surgery for a detached retina more so still (−5.8 and −6.3) [5]. Severe short-sightedness — strong enough to need thick corrective lenses — affected about one in five children after injections, more than two in five after laser, and more than half after freezing or surgery. The gap was widest in the most serious zone I disease. One other detail is worth knowing: short-sightedness after injections increases gradually with age, going from about −0.9 dioptres at one year to −2.3 dioptres by three years. So an encouraging first glasses test is not a final verdict, and continuing check-ups matter.

What This Means for Your Baby

If your baby's ROP is in zone I — the most serious position — both reviews point the same way, and an injection is likely to be recommended. If the disease is in zone II, there is a real trade-off, and it is one your team should explain to you: injections are likely to leave your child with better vision, but the disease is more likely to come back, sometimes months later.

That makes eye appointments after discharge genuinely important rather than routine. If your baby has had an injection, ask three questions before you leave hospital: which medicine was used, how long the eye check-ups need to continue, and who to contact if an appointment is missed or you move. If travel, cost, or distance to a specialist eye service is going to be difficult for your family, say so before treatment is chosen — it is a legitimate part of the decision, and in some circumstances laser is the safer option precisely because it needs less watching afterwards.

It is also fair to expect glasses. Most children treated for serious ROP will need them, and needing glasses is a good outcome, not a failure of treatment. Vision that can be corrected with lenses is vision.

One question families often ask is whether the medicine, which does enter the bloodstream in small amounts, affects a child's brain development. This is the least settled part of the picture and deserves an honest answer rather than a reassuring one. Some studies that looked back at hospital records reported a possible link [11][12]; other studies, including stronger ones, have not found it [13]. Longer follow-up of the RAINBOW children at two years and at five years has also been reported [14][15], and an earlier international review concluded that the evidence overall was not yet strong enough to settle the question [16]. The researchers behind the 2026 recurrence review rated the certainty of the evidence on this point as very low. That means: not proven, not disproven, and worth discussing openly with your team.

What Researchers Are Working On Next

Three things would help most. Researchers need to agree on exactly what counts as the disease "coming back", because at the moment different hospitals count it differently, which is a large part of why the combined results were so unclear. They need trials comparing the different injection medicines head to head, so families can be told which one suits their baby's situation rather than being offered whichever the hospital stocks. And they need studies that follow the same children for vision, eye health and development together over many years, instead of measuring each separately.

Until then, the picture is reassuring in one respect and demanding in another. Both treatments work, and the medicine-based approach is gentler on the developing eye than anything that came before it. But it asks more of families afterwards — more appointments, over more years — and that is a reasonable price for better sight, provided everyone knows it is being asked.

References

  1. Cryotherapy for Retinopathy of Prematurity Cooperative Group. Multicenter trial of cryotherapy for retinopathy of prematurity: preliminary results. Arch Ophthalmol. 1988;106(4):471–479. doi:10.1001/archopht.1988.01060130517027 ↩
  2. Early Treatment for Retinopathy of Prematurity Cooperative Group. Revised indications for the treatment of retinopathy of prematurity: results of the Early Treatment for Retinopathy of Prematurity randomized trial. Arch Ophthalmol. 2003;121(12):1684–1694. doi:10.1001/archopht.121.12.1684 ↩
  3. 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(7):603–615. doi:10.1056/NEJMoa1007374 ↩
  4. Krungkraipetch L, Krungkraipetch D, Krungkraipetch K. Anti-VEGF versus laser therapy for retinopathy of prematurity: a systematic review and meta-analysis focusing on recurrence patterns and retreatment needs. Int J Retina Vitreous. 2026;12(1):30. doi:10.1186/s40942-026-00810-9 ↩
  5. Huang YT, Wang IM, Wang IJ, Shao YC, Hsia NY, Lin HJ. Refractive outcomes following anti-VEGF, vitrectomy, cryotherapy, and laser photocoagulation for retinopathy of prematurity: a systematic review and meta-analysis. Front Med. 2026;13:1813154. doi:10.3389/fmed.2026.1813154 ↩
  6. Stahl A, Lepore D, Fielder A, et al. Ranibizumab versus laser therapy for the treatment of very low birthweight infants with retinopathy of prematurity (RAINBOW): an open-label randomised controlled trial. Lancet. 2019;394(10208):1551–1559. doi:10.1016/S0140-6736(19)31344-331344-3) ↩
  7. Stahl A, Sukgen EA, Wu WC, et al. Effect of intravitreal aflibercept vs laser photocoagulation on treatment success of retinopathy of prematurity: the FIREFLEYE randomized clinical trial. JAMA. 2022;328(4):348–359. doi:10.1001/jama.2022.10564 ↩
  8. Zhang G, Yang M, Zeng J, et al. Comparison of intravitreal injection of ranibizumab versus laser therapy for zone II treatment-requiring retinopathy of prematurity. Retina. 2017;37(4):710–717. doi:10.1097/IAE.0000000000001241 ↩
  9. Patel NA, Acaba-Berrocal LA, Hoyek S, et al. Comparison in retreatments between bevacizumab and ranibizumab intravitreal injections for retinopathy of prematurity: a multicenter study. Ophthalmology. 2023;130(4):373–378. doi:10.1016/j.ophtha.2022.11.014 ↩
  10. Fierson WM; American Academy of Pediatrics Section on Ophthalmology, American Academy of Ophthalmology, American Association for Pediatric Ophthalmology and Strabismus, American Association of Certified Orthoptists. Screening examination of premature infants for retinopathy of prematurity. Pediatrics. 2018;142(6):e20183061. doi:10.1542/peds.2018-3061 ↩
  11. Morin J, Luu TM, Superstein R, et al. Neurodevelopmental outcomes following bevacizumab injections for retinopathy of prematurity. Pediatrics. 2016;137(4):e20153218. doi:10.1542/peds.2015-3218 ↩
  12. Natarajan G, Shankaran S, Nolen TL, et al. Neurodevelopmental outcomes of preterm infants with retinopathy of prematurity by treatment. Pediatrics. 2019;144(2):e20183537. doi:10.1542/peds.2018-3537 ↩
  13. Raghuram K, Isaac M, Yang J, Mireskandari K. Neurodevelopmental outcomes in infants treated with intravitreal bevacizumab versus laser. J Perinatol. 2019;39(10):1300–1308. doi:10.1038/s41372-019-0420-z ↩
  14. Marlow N, Stahl A, Lepore D, et al. 2-year outcomes of ranibizumab versus laser therapy for the treatment of very low birthweight infants with retinopathy of prematurity (RAINBOW extension study): prospective follow-up of an open-label, randomised controlled trial. Lancet Child Adolesc Health. 2021;5(10):698–707. doi:10.1016/S2352-4642(21)00195-400195-4) ↩
  15. Marlow N, Stahl A, Moreira A, et al. Ranibizumab versus laser therapy for the treatment of very low birthweight infants with retinopathy of prematurity (RAINBOW): 5-year outcomes of an open-label randomised controlled trial. Lancet Child Adolesc Health. 2024;8(6):407–416. doi:10.1016/S2352-4642(24)00071-700071-7) ↩
  16. Sankar MJ, Sankar J, Mehta M, Bhat V, Srinivasan R. Anti-vascular endothelial growth factor (VEGF) drugs for treatment of retinopathy of prematurity. Cochrane Database Syst Rev. 2016;2(2):CD009734. doi:10.1002/14651858.CD009734.pub2 ↩