A Randomized Trial of Low-Dose Bevacizumab Versus Laser for Type 1 Retinopathy of Prematurity
Phase: PHASE3
Conditions: Retinopathy of Prematurity
Sponsor: Jaeb Center for Health Research

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A RANDOMIZED TRIAL OF LOW-DOSE 
BEVACIZUMAB VERSUS LASER FOR 
TYPE 1 RETINOPATHY OF 
PREMATURITY 
 
 
Protocol Identifying Number: ROP3 
IND Sponsor: Jaeb Center for Health Research 
Funded by: National Eye Institute, National Institutes of Health 
 
 
Version Number: 1.3 
28 April 2022 
 
 
NCT04634604

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PROTOCOL AMENDMENT #2 
11 February 2022 
This amendment provides for the following protocol changes:  
Protocol Change # 1:  
Current Protocol 
For unilateral cases with type 1 ROP in one eye at the time of enrollment, the current protocol 
does not specify treatment options for the fellow eye unless it meets criteria for type 1 ROP at a 
later time.  If the fellow eye becomes eligible for treatment by developing type 1 ROP after 
enrollment, the eye will receive the randomized treatment assigned to the first eligible eye (the 
study eye). If the study eye has failed, then then the investigator may choose to treat the fellow 
eye with either laser or bevacizumab 0.25 mg. 
Proposed Change 
Sections 2.5 and 3.1 have been updated to specify treatment options for fellow eyes.  The 
investigator is not limited to treatment options by eligibility of the fellow eye. At investigator 
discretion, the fellow eye may be treated at the same time as the eligible eye using the same 
randomized treatment assigned to the eligible eye.  The investigator may also choose to treat the 
fellow eye at a later time using the same randomized treatment assigned to the eligible eye.  
However, if the eligible eye has non-response to the initial treatment, then the fellow eye may be 
treated with either laser or bevacizumab. Also, if the infant is > 45 weeks PMA or it has been > 4 
weeks since treatment of the eligible eye with bevacizumab, then the fellow eye may be treated 
with either laser or bevacizumab. 
Rationale for Change  
It is in the participant’s best interest to have a fellow eye treated at investigator discretion. For 
example, if one eye is type 1 ROP and the other eye has impending type 1 ROP, and the infant is 
randomized to laser, some centers perform laser under general anesthesia. In such a case, the 
investigator may want to treat both eyes at the same time. Also, if the first eye has non-response 
to one treatment, it will be in the infant’s best interest if the investigator has the option to use a 
different treatment for the 2nd eye.  
Additional Protocol Changes  
In addition to the change above, the following clarifications have been made to the protocol:  
1. The schedule of study visits and procedures has been updated:  
a. To reflect that information related to medical and ocular history will be collected 
at every protocol visit; and  
b. To reflect systemic outcome collection as specified in protocol at the time of 
enrollment.  
2. Section 3.8 has been added to describe non-case report form data access. 

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3. The IQ and Neuropsychiatric tests referenced throughout the protocol has been updated 
to reflect the current versions (Wechsler Preschool and Primary Scale of Intelligence 
(WPPSI-IV) and Beery–Buktenic Developmental Test of Visual-Motor Integration, 6th 
edition (VMI-6)) 
4. Section 8.8 Safety Analyses has been updated to reflect a comparison of mean blood 
pressure measurements between treatment groups. Furthermore, adverse events in 
untreated fellow eyes will be tabulated separately.  Adverse events in treated fellow eyes 
without type 1 ROP will be tabulated separately.  
5. Gestational age stratification factor for randomization has been clarified as <=25 weeks 
and zero days versus >= 25 weeks and one day.  
6. The definition of plus disease has been updated to be consistent with the ICROP3 
classification. 
7. The timing of retinal imaging has been made consistent throughout the protocol. 

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PROTOCOL AMENDMENT #1 
26 August 2021 
This amendment provides for the following protocol change: 
Minor changes to the visit windows for the one, two, and four-week post-treatment exams. These 
changes will affect the definition of the primary outcome 
Protocol Version 1.1 
Visit 
Target Day 
Target Window 
(Around Target 
Day) 
Allowable 
Window 
(Around Target 
Day) 
 
1 week post-treatment* 
Treatment Date + 1 week 
6 to 8 days 
3 to 10 days 
2 weeks post-treatment* 
Treatment Date + 2 weeks 
11 to 17 days 
11 to 17 days 
4 weeks post-treatment* 
Treatment Date + 4 weeks 
25 to 31 days 
18 to 38 days 
 
Treatment success, determined at 6 months corrected age, and meeting all the following criteria: 
• Five to 13 days after treatment (or re-treatment if indicated), there is no increase in the 
extent or severity of stage 3, or development of new plus disease. 
• Two weeks after treatment (or re-treatment if indicated) to 6 months corrected age, there 
is no plus disease or severe neovascularization.  
• At 6 months corrected age, there is no unfavorable structural outcome, defined as (1) 
macular ectopia, (2) a posterior retinal fold involving the macula, (3) a retinal detachment 
involving the macula, or (4) retrolental tissue or mass obscuring the view of the posterior 
pole.  
• No scleral buckle or vitrectomy has been done by 6 months corrected age. 
 
Protocol Version 1.2 
Visit 
Target Day 
Target Window 
(Around Target 
Day) 
Allowable 
Window 
(Around Target 
Day) 
 
1 week post-treatment* 
Treatment Date + 1 week 
5 to 9 days 
5 to 11 days 
2 weeks post-treatment* 
Treatment Date + 2 weeks 
12 to 16 days 
12 to 16 days 
4 weeks post-treatment* 
Treatment Date + 4 weeks 
25 to 31 days 
17 to 38 days 
 
Treatment success, determined at 6 months corrected age, and meeting all the following criteria: 
• Five to 11 days after treatment (or re-treatment if indicated), there is no increase in the 
extent or severity of stage 3, or development of new plus disease. 

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• Twelve to 16 days after treatment (or re-treatment if indicated) to 6 months corrected age, 
there is no plus disease or severe neovascularization.  
• At 6 months corrected age, there is no unfavorable structural outcome, defined as (1) 
macular ectopia, (2) a posterior retinal fold involving the macula, (3) a retinal detachment 
involving the macula, or (4) retrolental tissue or mass obscuring the view of the posterior 
pole.  
• No scleral buckle or vitrectomy has been done by 6 months corrected age. 
 
 
Rationale for the change 
The rationale for changing the one-week exam window from 5-13 days to 5-11 days is because 
the routine 2-week follow-up exam will occur at 12, 13 or 14 days after treatment.  ROP rounds 
are typically done on the same day each week, and treatment may occur on the day that type 1 
ROP is diagnosed, or 1 to 2 days after that exam. E.g. Rounds on Tuesday, type 1 diagnosed, 
treatment Thursday, 1 week exam on Tuesday (5 days post-treatment) and 2-week exam on the 
following Tuesday (12 days post-treatment).  It has always been intended that there must be 
improvement by the 2-week exam, or non-response would be declared and additional treatment 
allowed. Since the target for the 2-week exam is being clarified as 12-16 days, it requires a 
corresponding change in the time period before the 2-week exam from 5-13 days to 5-11 days.  
 
 

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KEY ROLES 
Protocol Chair 
Name, degree 
David K. Wallace, M.D., M.P.H. 
Title 
Chair, Department of Ophthalmology 
Institution Name 
Indiana University School of Medicine 
1160 W. Michigan St,  
Indianapolis, IN, 46202 
Phone:  317-278-2651 
Email: dwallac@iu.edu 
Signature/ Date 
 
Protocol Vice-Chair  
Name, degree 
G. Baker Hubbard, M.D. 
Title 
Thomas M. Aaberg Sr. Professor of Ophthalmology 
Institution Name 
The Emory Eye Center 
Emory University School of Medicine 
1365B Clifton Rd. NE 
Atlanta, GA 30322 
Email:  ghubba2@emory.edu  
Signature/ Date 
 
Protocol Vice-Chair 
Name, degree 
Daniel F. Martin, M.D. 
Title 
Chairman 
Institution Name 
Cole Eye Institute, Cleveland Clinic 
9500 Euclid Avenue 
Cleveland, OH 44195 
Email:  martind5@ccf.org 
Signature/ Date 
 
Protocol Vice-Chair 
Name, degree 
William V. Good, M.D. 
Title 
Senior Scientist 
Institution Name 
Smith-Kettlewell Eye Research Institute 
2318 Fillmore Street 
San Francisco, CA 94115 
Email:  good@ski.org  
Signature/ Date 
 
 
 

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JCHR Protocol Director  
Name, degree 
Robert J. Henderson, M.S. 
Title 
Biostatistician, PEDIG Coordinating Center  
Institution Name 
Jaeb Center for Health Research 
15310 Amberly Drive, Suite 350 
Tampa, FL 33647 
Phone: 1-888-797-3344 
Email: rhenderson@jaeb.org  
Signature/ Date 
 
JCHR Coordinating Center Director 
Name, degree 
Raymond T. Kraker, M.S.P.H. 
Title 
Director, PEDIG Coordinating Center  
Institution Name 
Jaeb Center for Health Research 
15310 Amberly Drive, Suite 350 
Tampa, FL 33647 
Phone: 1-888-797-3344 
Email: rkraker@jaeb.org 
Signature/ Date 
 
Medical Monitors 
Name, degree 
O.J. Daniel, MBBS, PhD 
Title 
Medical Officer 
Institution Name 
The Emmes Company, LLC 
401 North Washington Street 
Rockville, MD 20850 
Email:  odaniel@emmes.com 
Signature/ Date 
 
 
Name, degree 
J.A. Sliman, MD, MPH 
Title 
Chief Medical Officer 
Institution Name 
The Emmes Company, LLC 
401 North Washington Street 
Rockville, MD 20850 
Email:  jsliman@emmes.com 
Signature/ Date 
 
Central Laboratory for Blood Testing 
Name, degree 
Mary E. Hartnett, M.D. 
Title 
Lab Director 
Institution Name 
John A. Moran Eye Center 
University of Utah Department of Ophthalmology and Visual Sciences 
65 Mario Capecchi Drive 
Salt Lake City, UT 84132 
Signature/ Date 
 
 

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TABLE OF CONTENTS 
 
CHAPTER 1: BACKGROUND INFORMATION ............................................................................................. 18 
1.1 Introduction ....................................................................................................................................... 18 
 Retinopathy of Prematurity ......................................................................................................... 18 
 Pathophysiology of ROP ............................................................................................................. 19 
 Clinical Studies of ROP Treatment ............................................................................................. 21 
 Phase 1 Dosing De-escalation Study ........................................................................................... 22 
1.2 Public Health Importance .................................................................................................................. 22 
1.3 Study objectives ................................................................................................................................. 23 
1.4 Rationale ............................................................................................................................................ 24 
1.5 Potential Risks and Benefits of Bevacizumab ................................................................................... 24 
 Known Potential Risks of Bevacizumab ..................................................................................... 24 
 Potential Adverse Effects of Intravitreous Injection ................................................................... 26 
 Known Potential Benefits of Bevacizumab ................................................................................. 27 
 Potential Adverse Effects of Laser Treatment ............................................................................. 28 
 Risks of Examination or Testing Procedures .............................................................................. 28 
1.6 Risk Assessment ................................................................................................................................ 29 
1.7 General Considerations...................................................................................................................... 29 
CHAPTER 2: STUDY ENROLLMENT AND SCREENING .............................................................................. 30 
2.1 Participant Recruitment and Enrollment ........................................................................................... 30 
 Informed Consent and Authorization Procedures ....................................................................... 30 
2.2 Participant Inclusion Criteria ............................................................................................................. 30 
2.3 Participant Exclusion Criteria ............................................................................................................ 31 
2.4 Data Collection and Examination at Enrollment ............................................................................... 31 
 Historical Information ................................................................................................................. 31 
 ROP Classification ...................................................................................................................... 31 
 Retinal Images ............................................................................................................................. 33 
 Optional Imaging ......................................................................................................................... 33 
 Optional Blood Collection ........................................................................................................... 33 
2.5 Randomization ................................................................................................................................... 33 
CHAPTER 3: RANDOMIZED TRIAL PROCEDURES .................................................................................... 35 
3.1 Treatment ........................................................................................................................................... 35 
 Bevacizumab Injection ................................................................................................................ 35 
 Treatment of Non-response / Severe Recurrence after Initial Bevacizumab ...................... 35 

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 Treatment of Non-response / Severe Recurrence after Re-treatment with Bevacizumab ... 36 
 Prophylactic Laser Treatment after Bevacizumab .............................................................. 36 
 Laser Treatment ........................................................................................................................... 36 
 Treatment of Non-response / Severe Recurrence after Initial Laser Treatment.................. 36 
 Treatment of Non-response / Severe Recurrence after Re-treatment with Laser ............... 36 
 Re-treatment of Fellow Eyes in Asymmetric Cases ........................................................... 37 
3.2 Definition of Non-responder / Severe Recurrence ............................................................................ 37 
3.3 Definition of Success ......................................................................................................................... 37 
3.4 Study Visits and Phone Contacts ....................................................................................................... 38 
 Procedures at Study Visits ........................................................................................................... 39 
3.5 Phone Contacts .................................................................................................................................. 41 
3.6 Unscheduled Visits ............................................................................................................................ 41 
3.7 Participant Access to Study Agent at Study Closure ......................................................................... 41 
3.8 Non-Case Report Form Data Access ................................................................................................. 42 
CHAPTER 4: STUDY DRUG ......................................................................................................................... 43 
4.1 Study Agent(s) and Control Description ........................................................................................... 43 
 Acquisition .................................................................................................................................. 43 
 Formulation, Appearance, Packaging, and Labeling ................................................................... 43 
 Product Storage and Stability ...................................................................................................... 43 
 Preparation ................................................................................................................................... 43 
 Dosing and Administration .......................................................................................................... 43 
 Route of Administration .............................................................................................................. 43 
 Starting Dose and Dose Escalation Schedule .............................................................................. 43 
 Dose Adjustments/Modifications/Delays .................................................................................... 43 
 Duration of Therapy .................................................................................................................... 44 
 Tracking of Dose ....................................................................................................................... 44 
4.2 Study Agent Accountability Procedures ............................................................................................ 44 
CHAPTER 5: TESTING PROCEDURES ........................................................................................................ 45 
CHAPTER 6: UNANTICIPATED PROBLEM AND ADVERSE EVENT REPORTING ....................................... 47 
6.1 Unanticipated Problems ..................................................................................................................... 47 
6.2 Adverse Events .................................................................................................................................. 47 
 Definitions ................................................................................................................................... 47 
 Reportable Adverse Events ......................................................................................................... 48 
 Relationship of Adverse Event to Study Treatment or Study Procedure .................................... 48 
 Severity (Intensity) of Adverse Event ......................................................................................... 48 

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 Expectedness ............................................................................................................................... 49 
 Coding of Adverse Events ........................................................................................................... 49 
 Outcome of Adverse Event ......................................................................................................... 49 
6.3 Timing of Event Reporting ................................................................................................................ 50 
6.4 Safety Oversight ................................................................................................................................ 50 
6.5 Stopping Criteria ............................................................................................................................... 51 
 Participant Discontinuation of Study Drug ................................................................................. 51 
 Criteria for Suspending or Stopping Overall Study ..................................................................... 51 
6.6 Unmasking due to Adverse Event ..................................................................................................... 51 
CHAPTER 7: MISCELLANEOUS CONSIDERATIONS ................................................................................... 52 
7.1 Collection of Medical Conditions and Medications .......................................................................... 52 
7.2 Prohibited Medications, Treatments, and Procedures ....................................................................... 52 
7.3 Precautionary Medications, Treatments, and Procedures .................................................................. 52 
7.4 Participant Compensation .................................................................................................................. 52 
7.5 Participant Withdrawal ...................................................................................................................... 52 
7.6 Confidentiality ................................................................................................................................... 52 
7.7 Contact Information Provided to the Coordinating Center ................................................................ 52 
CHAPTER 8: STATISTICAL CONSIDERATIONS .......................................................................................... 54 
8.1 Statistical and Analytical Plans ......................................................................................................... 54 
8.2 Study Objectives and Hypothesis ...................................................................................................... 54 
 Primary Efficacy Outcome – Treatment Success At 6 Months Corrected age ............................ 54 
 Margin Choice ............................................................................................................................. 54 
8.3 Sample Size ....................................................................................................................................... 55 
8.4 Analysis Dataset ................................................................................................................................ 55 
8.5 Analysis of the Primary Efficacy Outcome ....................................................................................... 55 
8.6 Sensitivity Analyses for Primary Outcome ....................................................................................... 56 
 Tipping Point Analysis for Imaging and Repeat ROP Exam ...................................................... 56 
 Deaths as Failures ........................................................................................................................ 56 
 Primary Outcome Contingency Plan ........................................................................................... 57 
8.7 Analysis of the Secondary Outcomes ................................................................................................ 57 
 Bayley Neurodevelopmental Outcomes ...................................................................................... 58 
 General Movements Assessment ................................................................................................. 59 
 Wechsler Preschool and Primary Scale of Intelligence (WPPSI-IV), 
categorical. ........................................................................................................................................... 60 
 PedEyeQ ...................................................................................................................................... 60 
8.8 Safety Analyses ................................................................................................................................. 60 

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8.9 Protocol Adherence and Retention .................................................................................................... 62 
8.10 Baseline Descriptive Statistics ......................................................................................................... 62 
8.11 Planned Interim Analyses ................................................................................................................ 62 
8.12 Sub-Group Analyses ........................................................................................................................ 62 
CHAPTER 9: DATA COLLECTION AND MONITORING .............................................................................. 63 
9.1 Case Report Forms and Data Collection ........................................................................................... 63 
9.2 Study Records Retention ................................................................................................................... 63 
9.3 Quality Assurance and Monitoring .................................................................................................... 63 
9.4 Protocol Deviations ........................................................................................................................... 64 
CHAPTER 10: ETHICS/PROTECTION OF HUMAN PARTICIPANTS ............................................................ 65 
10.1 Ethical Standard ............................................................................................................................... 65 
10.2 Institutional Review Boards ............................................................................................................ 65 
10.3 Informed Consent Process ............................................................................................................... 65 
 Consent Procedures and Documentation ................................................................................... 65 
 Participant and Data Confidentiality ......................................................................................... 65 
 Future Use of Stored Specimens and Data ................................................................................ 66 
CHAPTER 11: REFERENCES ....................................................................................................................... 67 
 
 
 

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LIST OF ABBREVIATIONS 
ABBREVIATION 
DEFINITION 
AE 
Adverse Event 
ATS-HOTV 
Amblyopia Treatment Study – HOTV Visual Acuity Testing Protocol  
BEAT-ROP 
Bevacizumab Eliminates the Angiogenic Threat of Retinopathy of Prematurity 
CFR 
Code of Federal Regulations 
CI 
Confidence interval 
D 
Diopter 
DD 
Disc Diopter 
DHHS 
Department of Health and Human Services 
DSMC 
Data safety and monitoring committee 
eCRF 
Electronic Case Report Form  
EDC 
Estimated Date of Confinement 
ETROP 
Early Treatment for ROP 
EVA 
Electronic Visual Acuity Tester 
FA 
Fluorescein Angiography 
FDA 
Food and Drug Administration 
FDR 
False Discovery Rate 
GCP  
Good clinical practice 
GEE 
Generalized Estimation Equations 
GMA 
General Movements Assessment 
ICH 
International Council for Harmonization 
ICROP 
International Classification of ROP 
IND 
Investigational New Drug Application  
IRB 
Institutional Review Board 
IQ 
Intelligence Quotient 
ITT 
Intention to Treat 
IUGR 
Intrauterine growth restriction 
JCHR 
Jaeb Center for Health Research  
NIH 
National Institutes of Health 
OCT 
Optical Coherence Tomography 
OSHA 
Occupational Safety and Health Administration 
PACT 
Prism and Alternate Cover Test 
PEDIG 
Pediatric Eye Disease Investigator Group  
PMA 
Post-menstrual age 
QA 
Quality assurance 
QC 
Quality control 
RBM 
Risk based monitoring 
RCT 
Randomized clinical trial 
ROP 
Retinopathy of Prematurity 
SAE 
Serious Adverse Event 
SAP 
Statistical Analysis Plan  
SD 
Standard Deviation 
SE 
Spherical equivalent refractive error (Sphere + ½ Cylinder) 
US 
United States 
USA 
United States of America 
VEGF  
Vascular endothelial growth factor 
 

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SITE PRINCIPAL INVESTIGATOR STATEMENT OF COMPLIANCE 
Protocol Title: A Randomized Trial of Low-Dose Bevacizumab versus Laser for Type 1 
Retinopathy of Prematurity (ROP3) 
I have read the protocol specified above. In my formal capacity as a Site Principal Investigator, 
my duties include ensuring the safety of the study participants enrolled under my supervision and 
providing the Jaeb Center for Health Research, which serves as the Coordinating Center for the 
protocol, with complete and timely information, as outlined in the protocol. It is understood that 
all information pertaining to the study will be held strictly confidential and that this 
confidentiality requirement applies to all study staff at this site. 
This trial will be carried out in accordance with ICH E6 Good Clinical Practice (GCP) and as 
required by the following United States (US) Code of Federal Regulations (CFR) applicable to 
clinical studies: 45 CFR Part 46 (protection of human subjects), 21 CFR Part 50 (informed 
consent and safeguards for children), 21 CFR Part 56 (institutional review boards), and 21 CFR 
Part 312 (FDA investigational new drug application). 
As the Principal Investigator, I will assure that no deviation from, or changes to the protocol 
will take place without prior agreement from the sponsor and documented approval from the 
Institutional Review Board (IRB), except where necessary to eliminate an immediate hazard(s) 
to the trial participants. 
All key personnel (all individuals responsible for the design and conduct of this trial) have 
completed Human Participants Protection Training and Good Clinical Practice Training. Further, 
I agree to ensure that all staff members involved in the conduct of this study are informed about 
their obligations in meeting the above commitments. 
Investigator’s Signature __________________________________ Date: _____ / _____ / _____ 
 
dd 
mmm 
yyyy 
Investigator’s Name: ____________________________________ 
Site Name / Number: ____________________________________ 
 
 
 

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PROTOCOL SUMMARY 
ITEM 
DESCRIPTION 
Title 
A Randomized Trial of Low-Dose Bevacizumab versus Laser for Type 1 
Retinopathy of Prematurity (ROP3) 
Précis 
This randomized clinical trial will compare retinal outcomes with low-
dose intravitreous bevacizumab (0.063 mg) versus laser photocoagulation 
as treatment for infants with type 1 retinopathy of prematurity (ROP).  
The study also will assess neurodevelopment, refractive error, visual 
acuity, and peripheral visual fields.  
Investigational Drug 
Bevacizumab. 
Objectives 
The primary objective is to determine if infants with type 1 ROP treated 
with intravitreous bevacizumab have retinal treatment success rates that 
are noninferior to that of infants treated with laser photocoagulation.  
Secondary objectives are to compare the number of re-treatments, extent 
of retinal vascularization, refractive error, visual acuity, visual fields, 
neurodevelopment, and systemic morbidities between treatment groups. 
Study Design 
Multicenter, randomized clinical trial.  
Number of Sites 
Up to forty (40) clinical sites in North America  
Outcomes 
Primary Efficacy Outcome 
Treatment success, determined at 6 months corrected age, and meeting all 
the following criteria: 
• 
Five to 11 days after treatment (or re-treatment if indicated), 
there is no increase in the extent or severity of stage 3, or 
development of new plus disease. 
• 
Two weeks (12-16 days) after treatment (or re-treatment if 
indicated) to 6 months corrected age, there is no plus disease or 
severe neovascularization.  
• 
At 6 months corrected age, there is no unfavorable structural 
outcome, defined as (1) macular ectopia, (2) a posterior retinal 
fold involving the macula, (3) a retinal detachment involving 
the macula, or (4) retrolental tissue or mass obscuring the view 
of the posterior pole.  
• 
No scleral buckle or vitrectomy has been done by 6 months 
corrected age. 
 
Secondary Efficacy Outcomes 
• 
Number of re-treatments 
• 
Extent of retinal vascularization  
• 
Refractive error 
• 
Visual acuity 
• 
Visual fields  
• 
Neurodevelopment, by General Movements Assessment 
• 
Neurodevelopment, by the Bayley-4 test 
• 
IQ and Neuropsychiatric Testing  
• 
Systemic morbidities 
 
Key Safety Outcomes 
Systemic 
• 
Neurodevelopment, by General Movements Assessment 
• 
Neurodevelopment, by the Bayley-4 test 
• 
IQ and Neuropsychiatric Testing 
• 
A battery of systemic markers, including general, neurological, 
pulmonary, renal, hepatic, gastrointestinal, and auditory  
Ocular 
• 
Endophthalmitis 
• 
Cataract 
• 
Retinal detachment 

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ITEM 
DESCRIPTION 
Population 
Key Inclusion Criteria: 
1. 
Birth weight < 1251 grams 
2. 
Type 1 ROP in one or both eyes; meeting the following criteria: 
• 
Zone I, any stage ROP with plus disease, with retinal 
vessels or ROP in Zone II in any quadrant, or 
• 
Zone I, stage 3 ROP without plus disease, with retinal 
vessels or ROP in Zone II in any quadrant, or 
• 
Zone II, stage 2 or 3 ROP with plus disease  
 
Key Exclusion Criteria: 
1. 
Previous treatment for ROP 
2. 
All ROP in zone I in either eye (no retinal vessels or ROP 
extend into zone II in any quadrant)  
3. 
Treatment could not be done within 2 days of diagnosis of type 
1 ROP 
4. 
Investigator unwilling to randomize or parent unwilling to 
accept random assignment to either treatment 
5. 
Transfer to another hospital not covered by study-certified 
examiners anticipated within the next 4 weeks 
6. 
Active ocular infection or purulent nasolacrimal duct 
obstruction 
7. 
Stage 4 or Stage 5 in either eye 
 
Eye excluded (but the other eye may be eligible) if: 
8. 
Visually significant ocular anomaly (e.g., cataract, coloboma) 
9. 
Opacity that precludes an adequate view of the retina 
 
Sample Size 
212 participants (106 in each treatment group)   
Phase 
Phase III Randomized Clinical Trial 
Treatment Groups 
Participants will be randomly assigned with equal probability to treatment 
of one or both eyes with type 1 ROP to either: 
1. 
Intravitreous bevacizumab 0.063 mg, re-treatment with 0.25 mg 
when indicated, and laser treatment later when indicated 
2. 
Retinal laser photocoagulation, and re-treatment with laser 
when indicated 
 
Participant Duration 
Study exams will occur at 1, 2, and 4 weeks, and at 2 and 4-months post-
treatment (and re-treatment when indicated). Additional study exams will 
occur at corrected ages (chronological age minus number of weeks born 
prematurely) 6 months, 1, 2, 3, 4, 5 and 6 years. It is anticipated that non-
study visits will occur more frequently, and the timing of these will be at 
investigator discretion. 
Protocol Overview/Synopsis 
Infants with type 1 ROP and no prior treatment for ROP will be randomly 
assigned (1:1) to treatment with either intravitreous bevacizumab 0.063 
mg or peripheral retinal laser ablation. Study exams will be at weeks 1, 2, 
and 4 weeks, and at 2 and 4-months post-treatment (and re-treatment 
when indicated). Additional study exams will occur at corrected age 6 
months, 1 year, and then annually for 5 more years. Non-study 
examinations will be at clinician discretion and are likely to occur more 
often. The primary outcome will be treatment success, defined as no 
worsening of ROP 5-11 days after treatment (or re-treatment if indicated), 
no plus disease or severe neovascularization 2 weeks to 6 months after 
treatment (or re-treatment if indicated), and no unfavorable structural 
outcome (or prior scleral buckle or vitrectomy) at 6 months corrected age. 
Important secondary outcomes include the number of re-treatments, 
extent of retinal vascularization, refractive error, neurodevelopment 
assessed by the Bayley-4 test, IQ and neuropsychiatric testing, visual 
acuity, visual fields, General Movement Assessment and systemic 
morbidities. 

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STUDY SUMMARY FLOWCHART 
 
 
 
Enrollment 
• 
Informed Consent  
• 
Eye Exam 
• 
One or both eyes with type 1 ROP  
• 
Newly diagnosed within 2 days 
• 
No previous treatment for ROP 
If Eligible,  
RANDOMIZE 
If NOT Eligible, Study Ends / 
Not Randomized 
BEVACIZUMAB 
• 
As soon as possible, within 2 days of diagnosis. 
• 
Initial treatment with intravitreous bevacizumab 0.063mg 
LASER 
• 
As soon as possible, within 2 days of diagnosis. 
• 
Initial laser treatment. 
RESPONDER? 
Continue without 
retreatment 
NON-RESPONDER / 
SEVERE 
RECURRENCE? 
Retreatment after Initial Bevacizumab 
• 
Retreatment with intravitreous bevacizumab 
0.25mg 
RESPONDER? 
Continue without 
retreatment 
NON-RESPONDER / 
SEVERE 
RECURRENCE? 
Retreatment after Initial Laser 
• 
Retreatment with laser when indicated 
YES - Prophylactic 
Laser 
 Treatment 
Responder/ Success 
Criteria Met So Far? 
Continue without 
retreatment 
Retreatment Failure? 
Responder / Success 
Criteria Met So Far? 
Continue without 
retreatment 
Retreatment Failure? 
Additional treatment with 
bevacizumab 0.25 mg 
and/or laser 
Additional treatment with 
bevacizumab 0.25 mg 
and/or laser 
Avascular Retina 
at 50-65-weeks PMA 
NO - No Additional 
Treatment 

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SCHEDULE OF STUDY VISITS AND PROCEDURES 
 
 
Enroll 
1w* 
2w* 
4w* 
2m* 
4m* 
6m† 
1y† 
2y† 
3y† 
4y† 
5y† 
6y† 
Informed Consent 
X 
 
 
 
 
 
 
 
 
 
 
 
 
Medical/Ocular Historya 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
Ocular Exam/Classify ROP 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
Retinal Imaging  
(or Second Ocular Exam) 
Xb 
 
 
 
 
 
 
 
 
 
 
 
 
Cycloplegic Refraction 
 
 
 
 
 
 
X 
X 
X 
X 
X 
X 
X 
Visual Acuity 
 
 
 
 
 
 
 
 
X 
X 
X 
X 
X 
Visual Fields 
 
 
 
 
 
 
 
 
 
 
 
 
X 
General Movements Assessment 
 
 
 
 
 
Xc 
 
 
 
 
 
 
 
Bayley-4 
 
 
 
 
 
 
 
 
X 
 
 
 
 
IQ test + Neuropsychiatric exam 
 
 
 
 
 
 
 
 
 
 
 
 
X 
Adverse Events 
 
Xd 
Xd 
Xd 
Xe 
Xe 
Xe 
Xe 
Xe 
Xe 
Xe 
Xe 
Xe 
Systemic Outcomes 
X 
X 
 
X 
 
 
X 
X 
X 
X 
X 
X 
X 
Quality of Life 
 
 
 
 
 
 
 
X 
 
 
 
X 
X 
Optional:  
 
 
 
 
 
 
 
 
 
 
 
 
 
Fluorescein Angiography  
Xb 
 
 
 
 
 
 
 
 
 
 
 
 
OCT 
Xb 
 
 
 
 
 
 
 
 
 
 
 
 
Wide-Fundus Photography 
 
 
 
 
 
 
 
 
 
 
 
 
X 
Plasma VEGF 
X 
 
X 
X 
 
X 
 
 
 
 
 
 
 
*Exams through 4 months are timed based on initial treatment (and re-treatment when indicated).  
†Exams 6 months and beyond are based on corrected age (defined as number of days since the date of birth minus number of days the 
baby was preterm). If a vitrectomy or scleral buckle is scheduled prior to the 6-month exam, then the 6-month exam will be completed 
early and prior to vitrectomy or scleral buckle surgery. 
 
a Medical and ocular history to include concomitant medications and pre-existing medical conditions at time of enrollment   
b Done at Enrollment, 40 weeks PMA and will also be collected when there is treatment failure before the 6 month xam.  If a site or 
location does not have a retinal camera, a second examiner will classify ROP at enrollment and if there is treatment failure. OCT and 
FA are optional. 
c General Movements Assessment will be recorded at home by parent(s) at 54 (52-56) weeks PMA 
d All adverse events recorded at each visit until 4 weeks post-treatment  
e Only serious adverse events and ocular adverse events recorded beyond 4 weeks post-treatment  

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Chapter 1: Background Information 
1 
1.1 Introduction 
2 
 
3 
 Retinopathy of Prematurity 
4 
Retinopathy of prematurity (ROP) is a significant cause of childhood vision loss in the United 
5 
States.1  It is characterized by retinal vascular abnormal alterations that may occur during the 
6 
first several months after premature delivery. The vascular changes may be mild and regress with 
7 
time, or they may continue to progress to preretinal neovascularization and fibrosis that may 
8 
ultimately lead to retinal traction and detachment. Other sequelae include tortuosity of the retinal 
9 
vessels, dragged retina, displacement of the macula, temporal folds of the retina, equatorial folds, 
10 
chorioretinal scarring, retinal pigment abnormalities, retinoschisis, Coats'-like changes, increased 
11 
incidence of lattice degeneration, vitreous hemorrhage, elevated retinal vessels, vitreous 
12 
membranes, exudative and tractional retinal detachments, retinal breaks, amblyopia, myopia, 
13 
strabismus, glaucoma, cataract, band keratopathy, microphthalmia, nystagmus, shallow anterior 
14 
chamber, and steep corneal curvature.2-13  
15 
 
16 
Important risk factors for ROP include low birth weight, young gestational age, twin status, 
17 
outborn status, and supplemental oxygen. Despite the judicious use of supplemental oxygen and 
18 
effective screening and management of ROP in most developed countries, it continues to be a 
19 
significant cause of visual impairment. Severe visual loss is particularly common in middle 
20 
income countries such as China and India.1,14 In severe cases of ROP, vascular endothelial 
21 
growth factor (VEGF) accumulates in the retina and vitreous, leading to retinal 
22 
neovascularization and cicatrization. Peripheral retinal photocoagulation destroys the avascular 
23 
area of retina without blood vessels (i.e. anterior to the vascular/avascular junction) that produces 
24 
VEGF. More recently, treatments have targeted blockade of pro-angiogenic growth factors, such 
25 
as vascular endothelial growth factor (VEGF). Anti-VEGF treatment of severe ROP may provide 
26 
a more direct and effective approach to reducing intraocular VEGF levels and preventing retinal 
27 
detachment. One such anti-VEGF antibody is bevacizumab, which binds several VEGF 
28 
isoforms. Bevacizumab (trade name Avastin®; Genentech, Inc., South San Francisco, CA) is a 
29 
humanized monoclonal antibody which binds to VEGF, prevents coupling of VEGF to its 
30 
receptor, and inhibits angiogenesis. Initially approved by the FDA for anti-angiogenic treatment 
31 
of metastatic colorectal cancer, bevacizumab is used increasingly in the US and abroad as an off-
32 
label treatment for severe (type 1) ROP, given by intravitreous injection at a small fraction of the 
33 
systemic dose for cancer. Intravitreous injection of bevacizumab is also used in the treatment of 
34 
other ocular diseases involving neovascularization, including age-related macular degeneration 
35 
and diabetic retinopathy. 
36 
Examination findings in ROP are classified according to the international classification of ROP 
37 
(ICROP)15 and the revised ICROP.16  Zone refers to location of disease, from zone I (most 
38 
posterior) to zone III (most anterior). Stage refers to activity at the vascular/avascular border. 
39 
Stage 1 is a demarcation line, stage 2 is a ridge, stage 3 is neovascular tissue, stage 4 is partial 
40 
retinal detachment, and stage 5 is total retinal detachment. Plus disease is dilation and tortuosity 
41 
of the posterior retinal vessels meeting or exceeding the amount seen in a standard photograph 
42 
that has been used in many clinical trials. The Early Treatment for ROP (ETROP) study 
43 
established “type 1 ROP” as the degree of disease severity for which treatment with laser is 
44 

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indicated. Type 1 ROP is defined as any stage ROP in zone I with plus disease, stage 2 or 3 ROP 
45 
in zone II with plus disease, or stage 3 ROP in zone I without plus disease.17  
46 
 
47 
 Pathophysiology of ROP 
48 
Studies in both humans and in animal models have shown that the pathophysiology of ROP is 
49 
complex, in that it may be affected by genetic differences18 as well as environmental risks.19 
50 
ROP also has different characteristics throughout the world that may depend on a number of 
51 
factors, including prenatal care and the ability to monitor and regulate oxygen levels.14  
52 
In the US, when ROP was first identified in the 1940’s, high oxygen at birth was the major risk 
53 
factor.20-23 Since then, technologic advancements in oxygen monitoring and regulation in the US 
54 
reduced the incidence of ROP, but with further improvements in neonatal care and greater ability 
55 
to save infants of small birth weights and young gestational ages, ROP has re-emerged and 
56 
additional risk factors are recognized.24 From these observations it has also been recognized that 
57 
some ROP is associated with high oxygen (as in ROP of the 1940’s in the US and elsewhere now 
58 
in developing countries) that constricts and attenuates newly developed blood vessels and 
59 
capillaries in the preterm infant. ROP is also associated with fluctuations in oxygen, oxidative 
60 
stress, supplemental oxygen, poor postnatal weight gain and intrauterine growth restriction 
61 
(IUGR),25,26 which appear to delay normal retinal vascular development.  
62 
 
63 
Because external factors that influence the course of ROP are different throughout the world 
64 
based on resources for neonatal care, and because neonatal care is constantly changing, 
65 
understanding the pathophysiology of ROP is challenging. A hypothesis to describe the 
66 
development of ROP and account for these worldwide differences is that the disease occurs in 
67 
different phases. Initially, a retinal avascular phase occurs associated with a delay in 
68 
developmental angiogenesis and/or constriction of newly formed blood vessels and capillaries. 
69 
Later, as the number of photoreceptors and retinal metabolism increase, the lack of vascular 
70 
support causes retinal hypoxia and upregulation of angiogenic factors.27,28 Finally, disordering of 
71 
physiologic retinal angiogenesis causes vessels to grow into the vitreous (intravitreous 
72 
neovascularization) rather than continue physiologic intraretinal angiogenesis.19 This hypothesis 
73 
has been refined to clarify the pathophysiology of current day ROP and to link the “phases”, 
74 
which described research from animal models in the 1950’s to the clinical stages that were 
75 
developed decades later to describe human ROP.29,30  
76 
 
77 
Many angiogenic factors have both physiologic and pathologic effects. Evidence is increasing 
78 
that there may be a threshold of signaling that, when exceeded, causes normal retinovascular 
79 
development to become pathologic. The timing of these signaling events may also be important. 
80 
That is, angiogenesis during a growth-restricted phase can be beneficial to physiologic retinal 
81 
angiogenesis.31-36 However, angiogenesis induced during a “vasoproliferative phase” can cause 
82 
pathologic intravitreous neovascularization.  
83 
 
84 
Vascular endothelial growth factor (VEGF) is a 45 kD protein that is important in vascular 
85 
permeability and angiogenesis.37 Since its discovery, VEGF has been found essential to 
86 
physiologic retinal vascular development, which is ongoing in the preterm infant.38-41 Other 
87 
pathways are also important, but VEGF is an important mediator of many of these pathways or 
88 
of their biologic outcomes.42-44 However, VEGF is also one of the most important angiogenic 
89 
factors that cause pathologic choroidal neovascular diseases, such as in age-related macular 
90 

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degeneration, or retinovascular diseases, such as in diabetic retinopathy and retinal vein 
91 
occlusion, in which blood vessels grow into the vitreous rather than the retina.44 Injections of 
92 
large doses of VEGF into the vitreous in mice cause endothelial cell filopodia to point into the 
93 
vitreous,38 promoting retinal vascular pathologic changes.45 Inhibition of VEGF bioactivity 
94 
reduces pathology in animal models and in human disease.46-48   
95 
 
96 
Long-term clinical evidence for the benefits of anti-VEGF treatment in retinal vascular diseases 
97 
exists for adults, but not for the preterm infant. In the developing infant, there is concern about 
98 
inhibiting a factor that is important in physiologic as well as pathologic angiogenesis. There is 
99 
ample evidence that inducing relative hypoxia in animal models reduces intravitreous endothelial 
100 
growth,49 including the Smith and D’Amore model, and the Penn model, of oxygen induced 
101 
retinopathy.50 However, there is also evidence suggesting that exceeding a threshold of VEGF 
102 
signaling, particularly through the angiogenic receptor, VEGF receptor 2 (VEGFR2), may be 
103 
detrimental to the retinal vasculature and affect the orderliness of developmental angiogenesis.51 
104 
Zeng et al. have used an embryonic stem cell model that allows study of genes that produce 
105 
nonviable knockouts. One such gene encodes VEGF receptor (R)1 (murine equivalent flt-1-/- ), 
106 
which traps VEGF during development, thereby regulating the amount of VEGF available to 
107 
bind and trigger signaling through VEGFR2. Zeng et al. showed that increased VEGF-VEGFR2 
108 
signaling caused disoriented cleavage planes in dividing endothelial cells during anaphase in the 
109 
flt-1-/- model. Ordered angiogenesis was restored with a PECAM-sflt-1 transgene, providing 
110 
evidence that excessive VEGF-VEGFR2 signaling caused disordered developmental 
111 
angiogenesis. This study also supports the notion that restoring physiologic levels of VEGF can 
112 
be beneficial to promote developmental angiogenesis.51  
113 
 
114 
In a rat model of fluctuating oxygen developed by John Penn, cleavage planes of dividing 
115 
vascular cells were analyzed in vivo in newly formed major retinal vessels at developmental time 
116 
points when retinal VEGF was increased compared to room air raised rat pups. Increased VEGF-
117 
VEGFR2 signaling caused a greater proportion of vascular cleavage planes in veins to be 
118 
parallel, favoring dilation, rather than perpendicular, which would favor elongation. Tortuosity 
119 
of the arterioles was also increased. The pattern of dilation and tortuosity was reduced by 
120 
neutralizing VEGF with intravitreous antibody.52 The study provides evidence that excessive 
121 
VEGF signaling may relate to “plus disease” seen in human severe ROP. Using the same model, 
122 
neutralizing VEGF with antibody or with a VEGFR2 tyrosine kinase inhibitor at certain doses 
123 
delivered into the vitreous reduced intravitreous neovascularization without interfering with 
124 
ongoing retinal vascular development.53 Additional studies showed the importance of specific 
125 
regulation of VEGFR2 in retinal endothelial cells. Using gene therapy to specifically knockdown 
126 
and regulate, but not knockout, VEGFR2 in retinal endothelial cells, Simmons et al. showed that 
127 
VEGFR2 regulation in retinal endothelial cells not only reduced intravitreous neovascularization, 
128 
but also permitted extension of physiologic retinal vascular development. However, when VEGF 
129 
was reduced using a different gene therapy approach that knocked down VEGF expressed in 
130 
Mueller cells, the neural retina appeared to be adversely affected. These findings together 
131 
suggest that reducing VEGF available to bind other receptors in cells besides retinal endothelial 
132 
cells had unwanted consequences. However, the authors also addressed the question of dose by 
133 
knocking down a splice variant of VEGF, VEGF164, which enabled other forms of VEGF to still 
134 
have access to the retina. Using this approach, the neural retinal appeared less adversely affected 
135 
than when the full length VEGF was knocked down in Mueller cells.54 These findings suggested 
136 

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that a dose of intravitreous anti-VEGF might be found that would regulate VEGFR2 signaling in 
137 
endothelial cells and be safe. Further evidence was found in a beagle model of ROP, in which a 
138 
high dose of VEGFtrap virtually stopped pathologic and physiologic angiogenesis, whereas low 
139 
dose VEGFtrap inhibited pathologic intravitreous neovascularization and permitted physiologic 
140 
angiogenesis.55 These studies support the importance of dose and the quandary of determining 
141 
the right dose for an individual infant. The finding that increased VEGFR2 activation caused 
142 
venous dilation and arteriolar tortuosity in the rat ROP model suggest that the optimal timing of 
143 
anti-VEGF treatment may be at the time of onset of human plus disease.27 Clinical observations 
144 
also suggest that treatment should be prior to the onset of fibrovascular changes.31 Thus, a 
145 
window of treatment for anti-VEGF therapy may be at the time of plus disease and prior to the 
146 
onset of fibrovascular activity. In addition, evidence from basic science suggests that inhibiting 
147 
VEGF in an ROP model can lead to compensatory signaling through other angiogenic 
148 
pathways.56 Therefore, follow up of preterm infants treated with anti-VEGF agents will need to 
149 
be longer than proposed in previous clinical studies. 
150 
 
151 
 Clinical Studies of ROP Treatment 
152 
The CRYO-ROP Study first demonstrated the effectiveness of peripheral retinal ablation in 
153 
curtailing progression of ROP to cicatricial stages.57 However, the impact of peripheral retinal 
154 
ablation on visual outcome was less dramatic than the structural benefit. The ETROP Study 
155 
showed that treatment of eyes at high-risk prethreshold resulted in better visual and structural 
156 
outcomes than treatment at threshold.17  Based on these results, laser was established as the 
157 
standard of care in the US for treatment of type 1 ROP. Although laser usually prevents retinal 
158 
detachment, it does not promote ongoing retinal vascular development, leaving areas of 
159 
avascular peripheral retina which seem to be nonfunctional. Also, visual impairment and high 
160 
myopia are common outcomes even among those infants successfully treated with laser.34,58 
161 
Finally, although peripheral retinal ablation significantly reduces the incidence of retinal 
162 
detachment and blindness, fewer than 20% of 5½ year old children whose eyes reached threshold 
163 
for treatment in the CRYO-ROP study achieved 20/40 vision.59 In the ETROP Study, only about 
164 
35% of children had visual acuity better than 20/40, even with earlier treatment.60 Many 
165 
premature infants treated for ROP also develop other significant ocular defects. These data, 
166 
coupled with improved survival rates of very low birth weight infants, support the need to 
167 
develop better treatment strategies for severe ROP.  
168 
 
169 
In the past decade, intravitreous injections of anti-VEGF drugs have been used increasingly to 
170 
treat severe ROP. The most commonly used agent is bevacizumab, and several case series and 
171 
results from one randomized trial have shown that bevacizumab is effective in treating severe 
172 
ROP.61-69 The BEAT-ROP study (Bevacizumab Eliminates the Angiogenic Threat of 
173 
Retinopathy of Prematurity) was a randomized trial of bevacizumab monotherapy versus 
174 
conventional laser therapy for zone I and posterior zone II, stage 3+ ROP.61 The primary 
175 
outcome was recurrence of ROP in one or both eyes requiring retreatment before 54 weeks’ 
176 
postmenstrual age. ROP recurred in 4 of 70 infants (6%) in the bevacizumab group and 19 of 73 
177 
infants (26%) in the laser group (P = 0.002). When stratified by zone, results suggested a benefit 
178 
of bevacizumab treatment over conventional laser therapy for zone I ROP but not for zone II 
179 
ROP. In addition, high myopia was much less common after bevacizumab compared with laser. 
180 
Among nonrandomized studies, Wu et al found that 37 of 41 eyes (90%) with stage 3 ROP 
181 
regressed after a single bevacizumab injection. Four eyes required additional laser treatment, and 
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4 eyes had a vitreous or pre-retinal hemorrhage.64  Quiroz-Mercado et al observed neovascular 
183 
regression in 17 of 18 eyes with high-risk prethreshold, threshold, or stage 4 ROP after 
184 
intravitreous bevacizumab.66 Travassos et al injected the worse eye of three patients with 
185 
aggressive, posterior retinopathy of prematurity with 0.75 mg of bevacizumab as monotherapy or 
186 
complementary to laser therapy. All injected eyes showed rapid regression of tunica vasculosa 
187 
lentis and iris vessel engorgement, disappearance of iris rigidity, and regression of plus disease 
188 
and retinal proliferation.68 
189 
 
190 
The RAINBOW study randomized 225 infants with ROP to treatment with the anti-VEGF agent 
191 
ranibizumab 0.2 mg, ranibizumab 0.1 mg, or laser therapy.70 The primary outcome, treatment 
192 
success, was defined as survival with no active retinopathy, no unfavorable structural outcomes, 
193 
and no need for a different treatment modality at or before 24 weeks. Treatment success occurred 
194 
in 56 (80%) of 70 infants receiving ranibizumab 0.2 mg compared with 57 (75%) of 76 infants 
195 
receiving ranibizumab 0.1 mg and 45 (66%) of 68 infants after laser therapy. The odds ratio 
196 
(OR) of treatment success following ranibizumab 0.2 mg compared with laser was 2.19 (95% Cl 
197 
0.99−4.82, p=0.051), for ranibizumab 0.1 mg compared with laser the OR was 1.57 (95% Cl 
198 
0.76−3.26); for ranibizumab 0.2 mg compared with 0.1 mg the OR was 1.35 (95% Cl 
199 
0.61−2.98). Death, serious and non-serious systemic adverse events, and ocular adverse events 
200 
were evenly distributed between the three groups. 
201 
 
202 
 Phase 1 Dosing De-escalation Study 
203 
BEAT-ROP used a dose of 0.625 mg, which was chosen empirically as half of the adult dose. 
204 
Other investigators have used doses of bevacizumab between 0.25 mg and 0.625 mg.61  
205 
However, these doses are likely much higher that necessary to effectively treat ROP. In addition, 
206 
intravitreous bevacizumab reaches the systemic circulation, with large persistent reductions in 
207 
serum VEGF levels,71 raising concerns about potential systemic toxicity. VEGF is necessary for 
208 
normal development of many tissues, including brain, lungs, bones, kidneys, and retina; thus, 
209 
blocking VEGF’s action could be detrimental to premature infants. In particular, there is concern 
210 
that anti-VEGF drugs increase the risk for neurodevelopmental disability.72,73  
211 
 
212 
To determine whether a much lower dose of bevacizumab than previously used may be effective 
213 
in treating severe ROP, PEDIG conducted a masked, multicenter, dose de-escalation phase 1 
214 
study.69 Success was defined as improvement in preinjection plus disease or zone I stage 3 ROP 
215 
by 5 days after injection or sooner, and no recurrence of type 1 ROP or severe neovascularization 
216 
requiring additional treatment within 4 weeks. One hundred twenty premature infants with type 1 
217 
ROP were enrolled and treated, and success was achieved in 11 of 11 eyes at 0.25 mg, 14 of 14 
218 
eyes at 0.125 mg, 21 of 24 eyes at 0.063 mg, 9 of 9 eyes at 0.031 mg, 13 of 13 eyes at 0.016 mg, 
219 
9 of 9 eyes at 0.008 mg, and 9 of 10 eyes at 0.004 mg; but success was achieved in only 17 of 23 
220 
eyes (74%) receiving 0.002 mg. These data were analyzed using a Bayesian statistical model, 
221 
and it was calculated that there is a 94% probability that 0.063 mg is at least 95% effective in 
222 
treating type 1 ROP. The probability that 0.125mg is at least 95% successful is 99%.  
223 
 
224 
1.2 Public Health Importance 
225 
Laser therapy is still considered by most clinicians to be the standard primary treatment for ROP, 
226 
except for posterior zone I case, although bevacizumab is increasingly used in the US for 
227 
primary treatment of ROP. Studies published to date report that bevacizumab’s effectiveness in 
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preventing retinal detachment is at least as good as laser. In addition, there are potential 
229 
advantages of bevacizumab when compared with laser, including ease of administration, less 
230 
myopia, and better peripheral retinal vascularization that could translate to better visual fields 
231 
later in life. One disadvantage is that there can be late recurrence of disease that is not observed 
232 
after laser; therefore, many ophthalmologists now give prophylactic laser treatment several 
233 
weeks following bevacizumab treatment, after there has been vascular growth toward the retinal 
234 
periphery. The primary concern with bevacizumab is that sustained VEGF blockage could cause 
235 
ocular or systemic side effects. There is particular concern about neurodevelopment, and 2 
236 
observational studies have reported worse neurological outcomes after bevacizumab compared 
237 
with laser.72,73 Other studies have found no difference in neurodevelopment between infants 
238 
treated with bevacizumab or laser.74-76 These observational studies are confounded by baseline 
239 
factors associated with neurodevelopment, such as low birth weight, young gestational age, and 
240 
systemic illness, because the smallest, sickest infants are more likely be treated with anti-VEGF 
241 
agents, since the treatment takes less time than laser and is less stressful to the infant. Therefore, 
242 
a randomized trial is necessary to compare ocular and neurological outcomes after bevacizumab 
243 
versus laser. Both the BEAT-ROP and RAINBOW studies are randomized trials, but neither will 
244 
be able to answer the question of whether neurological outcomes are worse after bevacizumab 
245 
compared with laser. The BEAT-ROP study included neurodevelopmental assessment for only 
246 
16 of the participants, so it was underpowered to detect a difference between groups. The 
247 
RAINBOW study plans neurodevelopmental assessments when the participants are older, but the 
248 
study evaluated ranibizumab instead of bevacizumab. Ranibizumab has a shorter half-life in the 
249 
serum than bevacizumab, and the dosage in their study was much higher relative to the adult 
250 
dose than is planned in the current study, so it will not answer the question of whether low-dose 
251 
bevacizumab causes neurological morbidity.  
252 
 
253 
If this study shows that bevacizumab is at least as effective as laser, and neurological outcomes 
254 
are not worse, then it would have an important impact on treatment of infants with ROP, even 
255 
beyond the US. Because of its advantages over laser, bevacizumab would likely be more widely 
256 
used for the primary treatment of ROP. Compared with peripheral retinal photocoagulation, 
257 
bevacizumab injection is less expensive, takes less time to perform, is less stressful for infants, 
258 
and, in some locations, is more readily available. Also, because there is growth of blood vessels 
259 
into the previously avascular retinal periphery after bevacizumab treatment, it may possibly 
260 
result in better peripheral visual fields (and perhaps less myopia) than peripheral laser 
261 
photocoagulation. Some ophthalmologists currently use ranibizumab instead of bevacizumab 
262 
because it has a shorter half-life in the bloodstream, so it may have better systemic safety, but it 
263 
is much more expensive that bevacizumab. If low-dose bevacizumab demonstrates a good safety 
264 
profile in this study, then these ophthalmologists who use ranibizumab for ROP could feel 
265 
reassured to switch to bevacizumab. However, if bevacizumab is less effective than peripheral 
266 
retinal photocoagulation or if it causes worse neurodevelopmental outcomes, then peripheral 
267 
retinal photocoagulation would remain the standard of care for most infants with severe 
268 
retinopathy of prematurity. 
269 
 
270 
1.3 Study objectives 
271 
The primary objective is to determine if infants with type 1 ROP treated with intravitreous 
272 
bevacizumab have retinal treatment success rates that are not worse compared with infants 
273 
treated with laser. Secondary objectives are to compare neurodevelopment, number of re-
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treatments, extent of retinal vascularization, refractive error, visual acuity, visual fields, and 
275 
systemic morbidities between treatment groups. 
276 
 
277 
1.4 Rationale 
278 
Peripheral retinal laser is the standard of care for most cases of severe ROP. An alternative for 
279 
primary treatment is intravitreous bevacizumab, which an increasing number of ophthalmologists 
280 
are using to treat severe ROP. Bevacizumab has several advantages, but it is unknown whether it 
281 
causes systemic side effects, such as adverse neurodevelopmental outcomes. No adequately 
282 
powered randomized trial has been done to compare ocular and neurodevelopmental outcomes in 
283 
infants treated with bevacizumab versus laser.  
284 
 
285 
Our hypothesis is that infants with type 1 ROP treated with intravitreous bevacizumab have 
286 
retinal treatment success rates that are not worse compared with infants treated with laser. The 
287 
study population will include premature infants with zone II or anterior zone I ROP (i.e. 
288 
“straddlers,” with at least some retinal vessels or ROP advanced into zone II). PEDIG recently 
289 
completed a phase 1 dose de-escalation study to find a low dose of bevacizumab that was 
290 
effective, and based on these data, a dosage of 0.063 mg was selected to use in the phase 3 trial. 
291 
Using a Bayesian statistical model, it was estimated that there is a 94% probability that 0.063 mg 
292 
is at least 95% effective. Even though 0.031 mg, 0.016 mg and 0.008 mg were both successful in 
293 
most or all eyes in the phase 1 study, their probabilities of 95% effectiveness were estimated to 
294 
be 84%, 64% and 33%, respectively.  
295 
 
296 
Laser treatment serves as the ideal comparison group, because (1) it is the standard of care, and 
297 
(2) infants treated with laser will not be exposed to anti-VEGF treatment, allowing for 
298 
assessment of any effect of anti-VEGF treatment on neurodevelopment or other systemic 
299 
outcomes. A potential problem when assessing systemic outcomes will be crossover of the laser 
300 
therapy group. If laser treatment and re-treatment are not successful, then investigators may use 
301 
bevacizumab as a treatment alternative.  
302 
 
303 
1.5 Potential Risks and Benefits of Bevacizumab 
304 
 
305 
 Known Potential Risks of Bevacizumab 
306 
Little is known about the safety of using bevacizumab for ROP,77  as the BEAT-ROP study 
307 
provided little short-term and no long-term safety data. In the BEAT-ROP study, 5 infants 
308 
undergoing bevacizumab injection and 2 infants undergoing laser treatment died before the age 
309 
of 54 weeks, but the study was not powered to evaluate whether the death rate was any higher 
310 
following bevacizumab injection.61  At 2 ½ years of age the death rate was similar between 
311 
groups, with a total of 6 infants treated with bevacizumab and 7 infants in the laser treated group 
312 
dying prior to age 2 ½ years.78  Angiogenesis is an important process in the normal development 
313 
of other organ systems such as the lungs, kidneys, brain, and bones. Intravitreous bevacizumab 
314 
reaches the systemic circulation, so there is potential for negative systemic side effects. The dose 
315 
of bevacizumab used in the BEAT-ROP study (0.625 mg in 25 µl) was chosen empirically as 
316 
one-half the adult dose used for macular degeneration.61 Reducing the dose of bevacizumab to 
317 
0.063 mg is expected to reduce the likelihood of negative systemic side effects.79  
318 
 
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In a meta-analysis performed by Genentech, Inc. on all clinical trial results using intravenously 
320 
administered bevacizumab (usually dosed as 5 mg/kg every 14 days) in adults, it was found that 
321 
adult study participants were at an increased risk for certain adverse events, some of which were 
322 
potentially fatal. These included wound healing complications, bowel perforation, hemorrhage, 
323 
stroke, myocardial infarction, hypertension, congestive heart failure, and proteinuria. Warnings 
324 
and precautions included in the package insert for intravenously administered bevacizumab 
325 
include gastrointestinal perforations, surgery and wound healing complications, hemorrhage, 
326 
non-gastrointestinal fistula formation, arterial thromboembolic events, hypertension, reversible 
327 
posterior leukoencephalopathy syndrome, proteinuria, infusion reactions, ovarian failure, and 
328 
infertility in females with reproductive potential.80  
329 
 
330 
The safety and pharmacokinetics of bevacizumab in pediatric patients have not been 
331 
established,80  although there is potential for similar adverse events in infants as in adults. Doses 
332 
administered to infants for treatment of ROP (typically 0.125 mg to 0.625 mg) are lower than 
333 
those administered to adults for treatment of ocular conditions, and much less than intravenous 
334 
doses used for cancer treatments. A study by Sato et al found serum concentrations of 
335 
bevacizumab following a 0.5 mg intravitreous injection for ROP were well above concentrations 
336 
required to completely block in vitro VEGF activities in human umbilical vein endothelial 
337 
cells.81  There was an inverse relationship between the serum bevacizumab and serum VEGF 
338 
concentrations. Sato et al concluded that bevacizumab has the ability to cross the blood retinal 
339 
barrier and enter the systemic circulation in relatively high concentrations.81  Others have 
340 
reported similar effects with a lower dose (0.375 mg) of bevacizumab.82  Because of the 
341 
vasculoproliferative role that VEGF plays in the normal development of organs, systemic 
342 
bevacizumab presents a potential risk to the developing organs of the premature neonate.   
343 
 
344 
Ocular side effects have been reported after intravitreous injections of bevacizumab. In some 
345 
cases, retinal traction may be worsened by injection of bevacizumab, leading to retinal 
346 
detachment,83 particularly if fibrovascular tissue has already begun to form.84 Regression of ROP 
347 
following bevacizumab treatment may in some cases be transient, with recurrence of ROP 
348 
occurring later than what is observed with laser treatment.85  Other complications observed 
349 
following bevacizumab treatment for ROP include cataract,86 retinal hemorrhage,63,64 transient 
350 
vascular sheathing,64 choroidal ischemia,87 and abnormalities of the retinal periphery (large 
351 
avascular areas, abnormal branching, shunts) and of the posterior pole (hyperfluorescent areas, 
352 
absence of the foveal avascular zone). It is unknown if these changes will have an effect on 
353 
vision.88    
354 
 
355 
It is unclear whether the mortality rate of premature infants receiving intravitreous bevacizumab 
356 
is any higher than those treated with laser. In the BEAT-ROP study, 7 of 150 infants died prior to 
357 
the 54-week post-menstrual age outcome examination (5 after intravitreous bevacizumab, 2 after 
358 
laser).61 While the mortality was higher in infants receiving bevacizumab, this result was 
359 
statistically non-significant, although it was acknowledged that the study was grossly 
360 
underpowered to detect a difference (a sample of 2800 infants would be required to assess a 
361 
death rate 1.5 times the 5.4% mortality rate observed in the ETROP study by 9 months at an 
362 
alpha of 0.05 and 80% power).17  Another study reported death of 2 of 7 infants with ROP 
363 
following a 0.75 mg bevacizumab injection, but attributed the mortality to complications of their 
364 
previous systemic conditions.89 However, it is unclear whether systemic bevacizumab may have 
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exacerbated the existing conditions, particularly in cases of multiple organ failure or lung failure. 
366 
In the dose de-escalation phase 1 study conducted by PEDIG69 in which 120 infants were treated 
367 
with low doses of bevacizumab ranging from 0.625 mg to 0.002 mg, 8 infants passed away 
368 
during the study due to reasons judged by the Data Safety and Monitoring Committee to be 
369 
unrelated to intravitreous bevacizumab. Additional dosing studies and long-term follow-up 
370 
studies with a large number of infants are required to determine the safety of intravitreous 
371 
bevacizumab injection for the treatment of ROP.61,77,90 
372 
 
373 
There are potential concerns about inhibiting VEGF in the developing infant, because drugs 
374 
introduced into the vitreous enter the blood stream and are minimally diluted in the infant’s small 
375 
blood volume. Testing of pharmacokinetics of bevacizumab in the blood stream is difficult even 
376 
in animal models, because bevacizumab is a mouse monoclonal antibody and is not effective in 
377 
mice and rats, the most commonly used models in ROP. VEGF is neuroprotective and its 
378 
inhibition may adversely affect the developing organs, such as lung, kidney and brain.72,73 
379 
Therefore, long-term safety data on neural structure and cognitive development are very 
380 
important. 
381 
 
382 
Bevacizumab package inserts warn of the potential risk of ovarian failure and infertility in 
383 
females with reproductive potential,80 and it is unclear if this same risk applies to female 
384 
neonates.  
385 
 
386 
 Potential Adverse Effects of Intravitreous Injection 
387 
Rarely, the topical drugs used to anesthetize the eye before the injections (proparacaine, 
388 
tetracaine, or xylocaine) can cause an allergic reaction, seizures, and an irregular heartbeat. 
389 
Generally, infants will have already been exposed to topical anesthetic during diagnostic 
390 
examinations. 
391 
 
392 
Temporary stinging, burning and conjunctival redness may occur with the use of proparacaine. A 
393 
rare, severe, immediate-type, apparently hyperallergic corneal reaction characterized by acute, 
394 
intense, and diffuse epithelial keratitis, a gray, ground glass appearance, sloughing of large areas 
395 
of necrotic epithelium, corneal filaments and iritis with descemetitis has also been reported. 
396 
Subconjunctival hemorrhage will commonly occur as a result of the intravitreous injection. Mild 
397 
discomfort, ocular hyperemia, increased lacrimation, discharge, or itching lasting for a few days 
398 
is also likely. 
399 
 
400 
Immediately following the injection, there may be elevation of intraocular pressure. It usually 
401 
returns to normal spontaneously but may need to be treated with topical drugs or a paracentesis 
402 
to lower the pressure. Indirect ophthalmoscopy is performed immediately post-injection to 
403 
ensure adequate posterior circulation.  
404 
 
405 
A rare complication of injection is endophthalmitis. It can be due to infection with pathogens 
406 
such as bacteria of fungi or can be noninfectious. Clinical features include eyelid edema, 
407 
conjunctival injection, corneal edema, anterior chamber and vitreous inflammation and 
408 
hypopyon. Endophthalmitis is treated by intravitreous injection of antibiotics, and there is a risk 
409 
of permanent severe loss of vision. A meta-analysis of 24 studies in adults reporting 
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endophthalmitis after intravitreous injection of an anti-VEGF agent estimated the risk of 
411 
endophthalmitis per injection to be 0.049% (95% CI, 0.038% to 0.065%). 91 
412 
 
413 
Retinal detachment is a rare complication of intravitreous injection. If this occurs, surgery may 
414 
be needed, which is usually successful at reattaching the retina. However, a retinal detachment 
415 
can produce permanent and sometimes severe loss of vision. The risk of retinal detachment has 
416 
been reported to be less than 0.1% in adults.92 
417 
 
418 
The risk of vitreous hemorrhage after intravitreous injection has been reported to be less than 1% 
419 
in adults.92  When it occurs, it usually resolves spontaneously, but vitrectomy is sometimes 
420 
needed, and vision loss may result in some cases. Retinal detachment and vitreous hemorrhage 
421 
can also occur from severe ROP. 
422 
 
423 
Some infants have oxygen desaturations or bradycardic episodes before, during, or after the 
424 
injection.  
425 
 
426 
 Known Potential Benefits of Bevacizumab 
427 
The BEAT-ROP trial (Bevacizumab Eliminates the Angiogenic Threat of Retinopathy of 
428 
Prematurity), was a randomized trial of bevacizumab monotherapy versus conventional laser 
429 
therapy for zone I and posterior zone II, stage 3+ ROP.61  Results of the BEAT-ROP trial 
430 
suggested a benefit of bevacizumab treatment over conventional laser therapy for zone I ROP. In 
431 
addition, the incidence of high myopia was much less common after bevacizumab compared 
432 
with laser. The authors reported that the recurrence of ROP was higher in the laser group than the 
433 
bevacizumab group, but the outcomes from the laser treated group were much poorer than those 
434 
reported in the Early Treatment For Retinopathy Of Prematurity Cooperative Group (ETROP) 
435 
study.17   
436 
 
437 
Prior to the BEAT-ROP study, Mintz-Hittner and Kuffel reported on a retrospective, 
438 
consecutive, noncomparative case series of moderate and severe stage 3 ROP in zone I or 
439 
posterior zone II treated by bilateral intravitreous injections of bevacizumab.67 Eleven infants 
440 
received intravitreous injections of bevacizumab (0.625 mg in 0.025 mL) and never had laser 
441 
therapy. All 22 eyes were treated successfully (no retinal detachment, macular ectopia, high 
442 
myopia, anisometropia, or other ocular abnormalities) with only 1 injection. No complications 
443 
(local or systemic) were encountered. They concluded that intravitreous injection of 
444 
bevacizumab was safe and effective in treating stage 3 ROP in zone I and posterior zone II in a 
445 
small series of patients.  
446 
 
447 
In a retrospective chart review of 23 consecutive eyes of 14 patients, Kusaka et al93 evaluated the 
448 
short-term efficacy of intravitreous injections of bevacizumab for severe retinopathy of 
449 
prematurity (ROP). Patients received an intravitreous injection of bevacizumab (0.5 mg), either 
450 
as the initial treatment (15 eyes) or at the end of vitrectomy (eight eyes). After injection of 
451 
bevacizumab as the initial treatment, reduced neovascular activity was seen on fluorescein 
452 
angiography in 14 of 15 eyes. In three eyes, a tractional retinal detachment developed or 
453 
progressed after bevacizumab injection. No other ocular or systemic adverse effects were 
454 
identified. These results suggest that intravitreous injection of bevacizumab seems to be 
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associated with reduced neovascularization without apparent ocular or systemic adverse effects, 
456 
and is beneficial for treating severe ROP. 
457 
 
458 
Dorta and Kychenthal reported on a noncomparative consecutive case series 12 consecutive eyes 
459 
of 7 premature infants with type 1 retinopathy of prematurity treated with only one intravitreous 
460 
injection of bevacizumab (0.625mg).63 All eyes showed regression of the disease with no 
461 
additional treatment needed. No complications attributable to the bevacizumab were seen in any 
462 
of their patients. An epiretinal hemorrhage was seen in one eye as a consequence of the injection 
463 
procedure. The hemorrhage spontaneously reabsorbed without consequence. The authors 
464 
concluded that intravitreous bevacizumab is a useful therapy for type 1 ROP.  
465 
 
466 
Wu et al64 investigated the effects and complications of bevacizumab as treatment of ROP in 
467 
Taiwanese patients. They reported results of a multicenter, retrospective case series study of 27 
468 
patients (49 eyes) receiving intravitreous injections of bevacizumab (0.625 mg). Patients were 
469 
followed for at least 6 months after bevacizumab injection. All of the eyes received only a single 
470 
injection. A total of 37 of 41 eyes (90%) with stage 3 ROP regressed after bevacizumab injection 
471 
only. Four eyes (10%) required additional laser treatment. Of 6 eyes (3 patients) with stage 4A 
472 
ROP, 2 eyes (1 patient; 33%) regressed after bevacizumab injection and 4 eyes (67%) regressed 
473 
after bevacizumab injection and subsequent vitrectomy. The 2 eyes with stage 5 ROP exhibited 
474 
decreased vascular tortuosity after bevacizumab injection, but the retina failed to reattach after 
475 
vitrectomy. Major complications included vitreous or pre-retinal hemorrhage in 4 eyes (8%) and 
476 
transient vascular sheathing in 2 eyes (4%). The authors concluded that bevacizumab injection 
477 
seems effective and well tolerated in some cases of ROP, especially in stage 3 ROP.  
478 
 
479 
Law et al89 reported the results of bevacizumab used in eyes with ROP at high risk for 
480 
progression. Records of all infants with ROP treated with bevacizumab were reviewed. 
481 
Bevacizumab was given when conventional laser therapy was not possible in patients with poor 
482 
pupillary dilation from iris rubeosis, dense vitreous hemorrhage, or increasing vascular activity 
483 
and vitreoretinal traction despite completed laser therapy. Thirteen eyes of 7 infants were treated 
484 
with an intravitreous injection of 0.75 mg bevacizumab. Injection was not used as monotherapy 
485 
in any case. Definitive treatment (laser or vitrectomy) was completed successfully within 72 
486 
hours of injection. No systemic complications attributable to bevacizumab treatment were 
487 
recorded within 2 to 17 months of follow-up. The authors concluded that treatment with 
488 
bevacizumab may be used to improve visualization for more definitive laser or surgical treatment 
489 
and may facilitate disease regression without obvious systemic toxicity.  
490 
 
491 
 Potential Adverse Effects of Laser Treatment 
492 
Laser treatment can be associated with bradycardia, arrhythmia, asystole, hypoventilation, apnea, 
493 
aspiration, seizures and feeding intolerance. Laser treatment can be complicated by corneal burns, 
494 
iris burns, cataract, rupture of Bruch's membrane, and accidental photocoagulation of the macula, 
495 
including the fovea. Post-treatment complications of laser include intraocular inflammation, retinal 
496 
and/or preretinal hemorrhage, posterior synechiae, and band keratopathy. Rare postoperative 
497 
complications include serous retinal detachment, choroidal effusion, hypotony and phthisis.  
498 
 Risks of Examination or Testing Procedures 
499 
There is a rare risk of an allergic response to the topical medications used to anesthetize the eye 
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or dilate the pupil. There may be some redness or bleeding on the surface of the eye after the 
501 
examination. Some infants have oxygen desaturations or bradycardic episodes during or after the 
502 
eye exams. 
503 
 
504 
There are no known risks associated with OCT or fundus photographs. The bright flashes used to 
505 
take the photographs may be annoying, but are not painful and do not cause damage to the ocular 
506 
structures. 
507 
 
508 
For fluorescein angiography, both the skin and urine are expected to turn yellow/orange for up to 
509 
24 hours after the injection of fluorescein dye. There is a small risk of discomfort or phlebitis at 
510 
the site of the injection. An allergic reaction to the dye used to do the fluorescein angiography 
511 
imaging is rare. A rash or pruritus (itching) can develop, but the incidence of true anaphylactic 
512 
reactions is less than 0.1%.94   
513 
 
514 
1.6 Risk Assessment 
515 
The Sponsor has determined that the protocol’s level of risk is consistent with 45 CFR 46.405 
516 
and 21 CFR 50.52, which indicates research involving greater than minimal risk but presenting 
517 
the prospect of direct benefit to the individual child involved in the research.  
518 
 
519 
1.7 General Considerations 
520 
The study is being conducted in compliance with the policies described in the study policies 
521 
document, with the ethical principles that have their origin in the Declaration of Helsinki, with 
522 
the protocol described herein, and with the standards of Good Clinical Practice (GCP). 
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Chapter 2: Study Enrollment and Screening 
524 
2.1 Participant Recruitment and Enrollment 
525 
A minimum of 212 participants are expected to be enrolled and have treatment randomly 
526 
assigned.  As the enrollment goal approaches, sites will be notified of the end date for 
527 
recruitment. Study participants whose parents have signed an informed consent form can be 
528 
randomized (or enrolled) up until the end date, which means the recruitment goals might be 
529 
exceeded.  
530 
 
531 
Study participants will be recruited from approximately 40 clinical centers in North America. All 
532 
eligible participants will be included without regard to gender, race, or ethnicity. There is no 
533 
restriction on the number of participants to be enrolled or randomized by each site toward the 
534 
overall recruitment goal. 
535 
 
536 
 Informed Consent and Authorization Procedures 
537 
A participant will be considered for the study after undergoing a routine examination (as part of 
538 
standard care) that identifies type 1 ROP in one or both eyes that meets the eligibility criteria. 
539 
The study will be discussed with the infant’s parent(s) or guardian(s) (referred to subsequently as 
540 
parent(s)).  
541 
Potential eligibility may be assessed as part of a routine-care examination.  Before completing any 
542 
procedures or collecting any data that are not part of usual care, written or electronic informed 
543 
consent will be obtained. 
544 
A parent/legal guardian will be provided with the Informed Consent Form to read and will be given 
545 
the opportunity to ask questions. If the parent is interested in the study, the investigator will meet 
546 
with the parent to discuss the study, and if the parent agrees to participate, the Informed Consent 
547 
Form will be signed.  A copy of the signed consent form will be provided to the parent and the 
548 
original signed informed consent will be added to the participant’s study record. 
549 
As part of the informed consent process, the parent will be asked to sign an authorization for release 
550 
of personal information. The authorization form may be combined with the consent or may be on 
551 
a separate form if the site requires their own process. The investigator, or his or her designee, will 
552 
review the study-specific information that will be collected and to whom that information will be 
553 
disclosed.  After speaking with the parent, questions will be answered about the details regarding 
554 
authorization. 
555 
A participant is considered enrolled when the informed consent form has been signed and HIPAA 
556 
authorization has been provided. 
557 
 
558 
2.2 Participant Inclusion Criteria 
559 
Participants must meet all the following inclusion criteria in order to be eligible to participate in 
560 
the study. 
561 
 
562 
• Birth weight < 1251 grams 
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• Newly diagnosed (within 2 days) type 1 ROP in one or both eyes; meeting the following 
564 
criteria: 
565 
o Zone I, any stage ROP with plus disease, with retinal vessels or ROP in Zone II in 
566 
any quadrant, or 
567 
o Zone I, stage 3 ROP without plus disease, with retinal vessels or ROP in zone II 
568 
in any quadrant or 
569 
o Zone II, stage 2 or 3 ROP with plus disease  
570 
 
571 
2.3 Participant Exclusion Criteria 
572 
Participants meeting any of the following exclusion criteria will be excluded from study 
573 
participation. 
574 
 
575 
• Previous treatment for ROP 
576 
• Stage 4 or 5 ROP in either eye 
577 
• All ROP in zone I in either eye (no retinal vessels or ROP extend into zone II in any 
578 
quadrant) 
579 
• Either treatment could not be done within 2 days of diagnosis of type 1 ROP 
580 
• Investigator unwilling to randomize or parent unwilling to accept random assignment to 
581 
either treatment 
582 
• Transfer to another hospital not covered by study-certified examiners anticipated within 
583 
the next 4 weeks 
584 
• Active ocular infection or purulent nasolacrimal duct obstruction in either eye 
585 
 
586 
One eye will be excluded, and other eye may be eligible, if either of the following are present: 
587 
• Visually significant ocular anomaly (e.g., cataract, coloboma)  
588 
• Opacity that precludes an adequate view of the retina 
589 
 
590 
2.4 Data Collection and Examination at Enrollment 
591 
 
592 
 Historical Information 
593 
Historical information recorded at enrollment will include gestational age at birth, birth weight, 
594 
current weight, head circumference, blood pressure, gender, race, ethnicity, concurrent medical 
595 
conditions (e.g. intraventricular hemorrhage (IVH), periventricular leukomalacia (PVL), 
596 
hydrocephalus bronchopulmonary dysplasia, sepsis), and current medications. 
597 
 
598 
 ROP Classification 
599 
ROP will be classified by the investigator using the revised International Classification of 
600 
Retinopathy of Prematurity (ICROP) criteria. Location, extent, and stage of disease, as well as 
601 
presence of pre-plus or plus disease, will be recorded as follows:  
602 
 
603 
Location: Location will be recorded as follows:  
604 
• Zone I: circle centered on the optic nerve with a radius of twice the distance from 
605 
the center of the optic nerve to the center of the macula  
606 
• Zone II: extends centrifugally from the edge of zone I to the nasal ora serrata and 
607 
is concentric to zone I 
608 
• Zone III:  residual crescent of retina anterior to zone II 
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610 
Stage: Stage will be recorded as follows:  
611 
• Stage 0:  Incomplete retinal vascularization without demarcation line or ridge 
612 
• Stage 1: Demarcation line 
613 
• Stage 2: Ridge  
614 
• Stage 3: Extraretinal fibrovascular proliferation  
615 
• Stage 4: Partial retinal detachment. Stage 4 will be further classified based on 
616 
location of the partial retinal detachment: 
617 
o Stage 4A: Extrafoveal  
618 
o Stage 4B: Involving the fovea  
619 
• Stage 5: Total retinal detachment 
620 
 
621 
Extent of Disease (clock hours): Extent of the highest stage will be recorded in 30 degree 
622 
increments, or clock hours. 
623 
 
624 
Extent of Retinal Vascularization: extent of retinal vascularization in each quadrant will be 
625 
classified as:  
626 
• Posterior Zone I - when optic nerve is centered using a 28D lens, no vessels extend 
627 
even to the edge of the lens view 
628 
• Anterior Zone I - when optic nerve is centered using a 28D lens, vessels extend to 
629 
the edge of the lens view or beyond, but not to zone II (when placing the optic nerve 
630 
at the edge of the view with a 28D lens, and the other lens edge approximates the 
631 
zone I – zone II border) 
632 
• Posterior Zone II – posterior one-third of zone II 
633 
• Mid Zone II – mid one-third of zone II 
634 
• Anterior Zone II – anterior one-third of zone II 
635 
• Zone III – vascularized to within one disc diameter of the ora serrata nasally, but not 
636 
temporally   
637 
• Full Vascularization – within one disc diameter of the ora serrata 
638 
 
639 
Plus Disease: A diagnosis of plus disease is made when there is abnormal dilation and tortuosity 
640 
of retinal blood vessels in zone I, and the degree of abnormality meets or exceeds that shown in 
641 
representative photographs of plus disease from ICROP3.95 
642 
 
643 
Pre-plus Disease: A diagnosis of pre-plus disease will be made when there is abnormal dilation 
644 
and tortuosity, but it is insufficient to diagnose plus disease. 
645 
 
646 
Type 1 ROP is the degree of disease severity for which treatment is indicated. It is defined as:  
647 
• Zone I, any stage ROP with plus disease, or  
648 
• Zone I, stage 3 ROP without plus disease, or  
649 
• Zone II, stage 2 or 3 ROP with plus disease 
650 
 
651 
 
652 
 
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 Retinal Images 
654 
Wide-angle retinal images will be obtained after enrollment, at 40 weeks PMA, and if there is 
655 
failure prior to the 6 month exam.  Six images will be obtained for each eye: anterior segment, 
656 
posterior pole, superior, temporal, inferior, and nasal as described in the ROP Procedures 
657 
Manual. To mitigate unmasked assessment bias, these images will later be reviewed by masked 
658 
expert readers for purposes of quality control. Investigators will be informed throughout the 
659 
study if their clinical diagnoses disagree with those of expert readers. 
660 
 
661 
If a participating site or location does not have a retinal camera, a second examination will be 
662 
done by a study-certified examiner after enrollment and if there is treatment failure to assess the 
663 
location, extent, and stage of disease, as well as presence of pre-plus or plus disease. Results of 
664 
this exam will only be used for quality control, similar to review of retinal images.  
665 
 
666 
 Optional Imaging 
667 
Optical Coherence Tomography (OCT) and Fluorescein Angiography (FA) will be offered as an 
668 
optional part of the study at sites with those imaging capabilities. OCT and/or FA imaging will 
669 
occur at enrollment as described in the ROP Procedures Manual.  OCT and/or FA will also be 
670 
done at 40 weeks PMA post-treatment and if there is failure prior to the 6-month exam.   
671 
 
672 
 Optional Blood Collection 
673 
The parents of each infant enrolled in the study will be given the option to participate in a study 
674 
to measure plasma levels of VEGF for both groups (laser group VEGF levels will serve as a 
675 
control). Participants in this optional study will have blood collected at enrollment, 2 weeks, 4 
676 
weeks, and 4 months post-treatment. Scavenged blood may be used when feasible. Parents will 
677 
be asked for permission to use these blood samples for future biomarker studies. A single, 
678 
centralized laboratory will be used for VEGF measurements, and details of sample 
679 
management will be included in the lab manual of procedures. 
680 
 
681 
2.5 Randomization 
682 
Eligible participants will be randomly assigned with equal probability to receive either:  
683 
• Intravitreous bevacizumab 0.063 mg, re-treatment with 0.25 mg when indicated, and 
684 
prophylactic laser treatment later when indicated  
685 
• Retinal laser photocoagulation, and re-treatment with laser when indicated 
686 
 
687 
If both eyes are eligible, then both eyes will receive the assigned treatment. If one eye is eligible 
688 
and the fellow eye is not, then the eligible eye will receive the randomized treatment. If the 
689 
fellow eye requires treatment  (i.e., has type 1 ROP, or, in the investigator’s judgment, requires 
690 
treatment for ROP), then the fellow eye will receive the same randomized treatment assigned to 
691 
the first eye. In the following scenarios, the fellow eye may receive a different treatment. (1)I If 
692 
the eligible eye has non-response to the initial treatment, then the fellow eye may be treated with 
693 
either laser or bevacizumab. (2) If treatment of the eligible eye was with bevacizumab, and the 
694 
infant is now > 45 weeks PMA or it has been > 4 weeks since treatment of the eligible eye, then 
695 
the fellow eye may be treated with either laser or bevacizumab. In these asymmetric cases, the 
696 
eye treated later will not be included in the primary analysis. 
697 
 
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Randomization will be stratified by zone (I vs II) for the most severe eye and by gestational age 
699 
(< 25 weeks and zero days vs > 25 weeks and one day). 
700 
 
701 
Once a study participant is randomized, that participant will be included regardless of whether 
702 
the assigned treatment is received. Thus, the investigator must not proceed to randomize an 
703 
individual until they confirm that the individual is eligible and the parent(s) will accept 
704 
whichever treatment group is assigned through randomization. 
705 
 
706 
Treatment of eligible eye/s by injection or with laser must be given within 2 calendar days of the 
707 
diagnosis of type 1 ROP.
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Chapter 3: Randomized Trial Procedures 
709 
 
710 
3.1 Treatment 
711 
Treatment of eligible eye/s should be given as soon as possible but no later than 2 calendar days 
712 
after the diagnosis of type 1 ROP. If both eyes are eligible then both eyes will receive the 
713 
assigned treatment. If one eye is eligible and the fellow eye is not, then the eligible eye will 
714 
receive the randomized treatment. If the fellow eye requires treatment at the same time or later 
715 
(based on investigator judgment), then the fellow eye will receive the same randomized 
716 
treatment assignment to the first eye. However, if the eligible eye has non-response to the initial 
717 
treatment, then the fellow eye may be treated with either laser or bevacizumab. Also, if the infant 
718 
is > 45 weeks PMA or it has been > 4 weeks since treatment of the eligible eye with 
719 
bevacizumab, then the fellow eye may be treated with either laser or bevacizumab. In these 
720 
asymmetric cases, the eye treated later will not be included in the primary analysis. 
721 
 
722 
 Bevacizumab Injection 
723 
For infants randomized to bevacizumab, the injection will be given no later than 2 days after the 
724 
diagnosis of type 1 ROP. The ophthalmologist may choose to give the intravitreous injection in 
725 
the operating room or at the bedside, with or without anesthesia, after consultation with the 
726 
attending neonatologist. A binocular indirect ophthalmoscope with an appropriate condensing 
727 
lens will be available, and the pupils will be dilated. 
728 
 
729 
Intravitreous bevacizumab 0.063 mg will be provided by the research pharmacy at the 
730 
investigator’s institution. The pharmacy will prepare the bevacizumab in a sterile manner, 
731 
adhering to USP standards 789, 797, and 800. Syringes containing bevacizumab at the 
732 
appropriate study concentration will be prepared. If one eye is to be injected, then two syringes 
733 
will be prepared. If two eyes are to be injected, then four syringes will be prepared. Two syringes 
734 
(one for each planned injection) will serve as backups and will only be used if the other syringes 
735 
are compromised for any reason; otherwise, the backup syringes will be discarded if unused. 
736 
 
737 
If only one eye is to be treated, the treating investigator and a second person will review the 
738 
Bevacizumab Study Syringe Label to confirm which eye will receive the intravitreous injection.  
739 
 
740 
Prior to injection, it should be confirmed that the label information on the study syringe to be 
741 
used for injection matches the information on the Bevacizumab Study Syringe Preparation Form.  
742 
 
743 
The investigator who gives the injection will be certified for the study and must have previous 
744 
experience giving intravitreous injections.  
745 
 
746 
The injection will be done as outlined in the ROP Procedures Manual. 
747 
 
748 
 Treatment of Non-response / Severe Recurrence after Initial Bevacizumab 
749 
If there is inadequate improvement after initial treatment (non-response) or severe recurrence 
750 
(see definition section 3.2), then the investigator will re-treat using bevacizumab at a dose of 
751 
0.25 mg.  If the infant is > 45 weeks PMA or it has been > 4 weeks since the initial bevacizumab 
752 
injection, then the investigator may choose to treat with laser instead of a 2nd bevacizumab 
753 
injection.  If there is fibrovascular or vitreous organization, or retinal dragging, then 
754 

JAEB CENTER FOR HEALTH RESEARCH 
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bevacizumab should be avoided at any age, and re-treatment should instead be with laser, unless 
755 
under the direct recommendation of a vitreoretinal specialist with ROP surgical experience. 
756 
 
757 
 Treatment of Non-response / Severe Recurrence after Re-treatment with 
758 
Bevacizumab 
759 
If there is inadequate improvement after re-treatment (non-response) or severe recurrence, then 
760 
failure is declared and the investigator may give laser treatment and/or bevacizumab 0.25 mg. If 
761 
there is fibrovascular or vitreous organization, or retinal dragging, then bevacizumab should be 
762 
avoided, unless under the direct recommendation of a vitreoretinal specialist with ROP surgical 
763 
experience.  Off-protocol treatment should first be discussed with the protocol chair. 
764 
 
765 
 Prophylactic Laser Treatment after Bevacizumab 
766 
Prophylactic laser to avascular retina will be done at 50-65 weeks PMA, or sooner if an infant is 
767 
being transferred to another hospital, or is being discharged to home and arranging for outpatient 
768 
laser would be difficult and/or not in the infant’s best interest.  If retina vessels/mild ROP are in 
769 
zone III, or if retina vascularization is full or within 2 DD of the ora serrata both nasally and 
770 
temporally by 65 weeks PMA, then laser is not required and is at investigator discretion.  
771 
Investigators may also choose to give prophylactic laser at 50-65 PMA weeks at their discretion 
772 
for reasons other than avascular retina, such as a worrisome appearance of ROP at the vascular-
773 
avascular junction, even if it does not meet criteria for severe recurrence.  Laser treatment should 
774 
not be given sooner than 4 weeks after bevacizumab unless failure has occurred.  
775 
 
776 
 Laser Treatment 
777 
For infants randomized to laser treatment, it will be given in conjunction with a binocular 
778 
indirect ophthalmoscope and an appropriate condensing lens, by a study-certified 
779 
ophthalmologist experienced in the use of this equipment. The treating investigator will be 
780 
certified as having sufficient experience with laser for ROP, and adequacy of laser treatment will 
781 
be confirmed by expert review of photographs.  Special laser precautions, as mandated by OSHA 
782 
and facility standards, will be followed.  The procedure will be done as outlined in the ROP 
783 
Procedures Manual. 
784 
 
785 
Note: Re-treatment with laser may also be done in the absence of criteria for non-response / 
786 
severe recurrence, at investigator discretion, to fill in lightly treated or skip areas. 
787 
 
788 
 Treatment of Non-response / Severe Recurrence after Initial Laser Treatment 
789 
If there is inadequate improvement after initial laser treatment (non-response) or severe 
790 
recurrence (see definition section 3.2), then the investigator will re-treat using laser when 
791 
indicated. Re-treatment will be indicated if, in the judgment of the investigator, there is 
792 
opportunity to enhance the initial treatment by filling in lightly treated or untreated (skip) areas. 
793 
If there is no such opportunity, then failure will be declared and treatment with bevacizumab 
794 
0.25 mg may be given instead.  
795 
 
796 
 Treatment of Non-response / Severe Recurrence after Re-treatment with Laser 
797 
If there is inadequate improvement after re-treatment (i.e. non-responder) or severe recurrence, 
798 
then failure is declared and the investigator may give laser treatment and/or bevacizumab 0.25 
799 
mg. If there is fibrovascular or vitreous organization, or retinal dragging, then bevacizumab 
800 

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37 
should be avoided, unless under the direct recommendation of a vitreoretinal specialist with ROP 
801 
surgical experience. Off-protocol treatment should first be discussed with the protocol chair. 
802 
 
803 
 Re-treatment of Fellow Eyes in Asymmetric Cases 
804 
If the fellow eye is treated for type 1 ROP, then additional treatment will be guided by the same 
805 
non-response and failure criteria as the study eye. If the fellow eye did not have type 1 ROP 
806 
when treated, then the investigator will decide if and when to re-treat, based on their clinical 
807 
judgment. If re-treatment is needed,  choice of treatment modality will follow the same 
808 
guidelines as described above for the study eye.  
809 
 
810 
3.2 Definition of Non-responder / Severe Recurrence 
811 
An eligible eye will be classified as non-response / severe recurrence when any of the following 
812 
are present: 
813 
• Worse ROP 5 to 11 days after treatment, defined as an increase in the extent or severity 
814 
of stage 3, or development of new plus disease 
815 
• No improvement* 12-16 days after treatment (two-week exam) 
816 
• Beyond the 2-week exam, recurrence of severe neovascularization** or recurrence of 
817 
plus disease*** 
818 
 
819 
* For infants with pre-treatment plus disease, improvement is defined as plus disease no longer being 
820 
present. For infants with pre-treatment zone I, stage 3, with pre-plus disease, improvement is defined as: (1) 
821 
pre-plus no longer present (neither plus nor pre-plus disease), or (2) a reduction in severity and/or extent of 
822 
extraretinal neovascularization. For infants with pre-treatment zone I, stage 3, with neither plus nor pre-plus 
823 
disease, improvement is defined as a reduction in severity and/or extent of extraretinal neovascularization. 
824 
 
825 
** Severe neovascularization is defined as at least one clock hour of extraretinal vascularization that, in the 
826 
judgment of the investigator, poses a significant risk for retinal detachment and/or dragging. 
827 
 
828 
*** Recurrent plus disease is defined as both dilation and tortuosity meeting or exceeding the degree of 
829 
abnormality represented by the standard photograph of plus disease.  Tortuosity without significant dilation 
830 
is common after bevacizumab and does not meet criteria for recurrent plus disease. 
831 
 
832 
3.3 Definition of Success 
833 
The primary efficacy outcome will be treatment success at the eligible eye level determined at 6 
834 
months corrected age, where success is defined as meeting all the following criteria as 
835 
determined by the investigator: 
836 
• Five to 11 days after treatment (or re-treatment if indicated), there is no increase in the 
837 
extent or severity of stage 3, or development of new plus disease 
838 
• Two weeks (12-16 days) after treatment (or re-treatment if indicated) to 6 months 
839 
corrected age, there is no plus disease or severe neovascularization  
840 
• No unfavorable structural outcome at 6 months corrected age defined as (1) macular 
841 
ectopia*, (2) a posterior retinal fold involving the macula, (3) a retinal detachment 
842 
involving the macula, or (4) retrolental tissue or mass obscuring the view of the posterior 
843 
pole.  
844 
• No scleral buckle or vitrectomy by 6 months corrected age.  
845 
 
846 
* Macular ectopia must be definite to meet criteria for an unfavorable outcome.  Questionable ectopia or vessel 
847 
straightening alone are not considered unfavorable. 
848 
 
849 

JAEB CENTER FOR HEALTH RESEARCH 
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3.4 Study Visits and Phone Contacts 
850 
Data will be collected on the day of treatment with injection or laser. Post-treatment study exams 
851 
will occur at 1, 2, and 4 weeks, and at 2 and 4 months after initial treatment (and re-treatment if 
852 
indicated).  
853 
 
854 
Additional study exams will occur at corrected ages 6 months, 1, 2, 3, 4, 5 and 6 years 
855 
(calculated as chronological age minus number of weeks born prematurely). It is anticipated that 
856 
non-study visits will occur more frequently, and the timing of these will be at clinician 
857 
discretion. 
858 
 
859 
Protocol-specified study visits (and target windows) are as follows: 
860 
 
861 
Table 1: Visit Schedule 
862 
Visit 
Target Day 
Target Window 
(Around Target 
Day) 
Allowable 
Window (Around 
Target Day) 
 
ROP diagnosis 
Enrollment / Randomization 
N/A 
N/A 
N/A 
Randomized Treatment 
(with Injection or Laser) 
Day of Randomization 
+ 1 day 
+ 2 days 
1 week post-treatment* 
Treatment Date + 1 week 
5 to 9 days 
5 to 11 days 
2 weeks post-treatment* 
Treatment Date + 2 weeks 
12 to 16 days 
12 to 16 days 
4 weeks post-treatment* 
Treatment Date + 4 weeks 
25 to 31 days 
17 to 38 days 
2 months post-treatment* 
Treatment Date + 2 months 
54 to 68 days 
39 to 83 days 
4 months post-treatment* 
Treatment Date + 4 months 
115 to 129 days 
84 to 168 days 
6 months corrected age 
EDC + 6 months 
169 to 197 days 
124 to 242 days 
1 year corrected age 
EDC + 1 year 
335 to 395 days 
243 to 547 days 
2 years corrected age 
EDC + 2 years 
700 to 760 days 
548 to 912 days 
3 years corrected age 
EDC + 3 years 
1065 to 1125 days 
913 to 1277 days 
4 years corrected age 
EDC + 4 years 
1431 to 1491 days 
1278 to 1643 days 
5 years corrected age 
EDC + 5 years 
1796 to 1856 days 
1644 to 2008 days 
6 years corrected age 
EDC + 6 years 
2162 to 2222 days 
2009 to 2375 days 
 
863 
* Post-initial treatment. If re-treatment is indicated and performed, exams will be repeated after 
864 
re-treatment.  
865 
 
866 
Due to retreatments, it is possible that retreatment windows will overlap with the corrected age 
867 
visits. In these cases, the corrected age visits will take priority. 
868 
 
869 
The goal is for all participants to complete all scheduled visits. However, participants who 
870 
(because of unforeseen circumstances) are unable or unwilling to return for all follow-up visits 
871 
will be permitted to return for as many study visits as possible as an alternative to withdrawal 
872 
from the study. When a participant is placed into this status, missed visits will not be recorded as 
873 
protocol deviations (since they would not be recorded as protocol deviations if the participant 
874 
was dropped from the study). 
875 
 
876 

JAEB CENTER FOR HEALTH RESEARCH 
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39 
If any study-mandated examination is deferred because of an infant’s unstable medical status, then 
877 
that examination will be done as soon as possible within the allowable window. 
878 
 
879 
 Procedures at Study Visits 
880 
The following procedures will be performed in both groups at each visit as defined in Chapter 5 
881 
and the ROP Procedures Manual: 
882 
 
883 
1) Classification of ROP: Will be determined at each follow-up exam as described in section 
884 
2.4.2. It is not expected that scleral depression will be done routinely after 50 weeks 
885 
postmenstrual age, or after the 4-month post-treatment exam. Extent of retinal 
886 
vascularization will be assessed for each quadrant as posterior or anterior zone I, 
887 
posterior/mid/anterior zone II, zone III, or complete vascularization (as defined in ROP 
888 
Procedures Manual). If a vitrectomy or scleral buckle is scheduled prior to the 6-month 
889 
exam, then the 6-month exam will be completed early prior to vitrectomy or scleral 
890 
buckle surgery. 
891 
2) Assessment of Amblyopia: Beginning at 6 months corrected age (when able). For infants 
892 
and young children with a manifest tropia, binocular fixation patterns in best spectacle 
893 
correction (if worn) will be used. For those without strabismus or with a microtropia, the 
894 
induced tropia test will be done. 
895 
3) Ocular Alignment: Will be assessed by the cover test beginning at 6 months corrected age 
896 
(when able). If a tropia or intermittent tropia is detected, then it will be quantified by the 
897 
prism and alternate cover test (PACT), if able, or by the Krimsky test if unable to do 
898 
PACT. 
899 
4) Cycloplegic Refraction: Will be done at 6 months corrected age and every study visit 
900 
thereafter. 
901 
5) Visual Acuity Assessment: Recognition visual acuity will be done (when able) beginning 
902 
at 2 years corrected age and every year thereafter using ATS-HOTV.    
903 
6) Assessment of Visual Fields: Will be measured using kinetic sphere perimetry at the 6-
904 
year corrected age exam. 
905 
7) General Movements Assessment:  Will be administered at 54 weeks PMA by the 
906 
parent(s) 
907 
8) Bayley-4 Test: Will be administered at 2 years corrected age.   
908 
9) IQ and Neuropsychiatric Testing:  Will occur at age 6 years corrected age. Testing will 
909 
include: 
910 
a. Wechsler Preschool and Primary Scale of Intelligence (WPPSI-IV) 
911 
b. Beery–Buktenic Developmental Test of Visual-Motor Integration, 6th edition 
912 
(VMI-6) 
913 
c. A pediatric neurologist and/or a clinical nurse specialist in child neurology will 
914 
conduct a standard neurologic examination and give their overall impression 
915 
using the following disability scale: 
916 
i. 1 point indicating a normal result,  
917 
ii. 2 points normal or questionable results,  
918 
iii. 3 points abnormal results with minimal functional disability,  
919 
iv. 4 points abnormal results with moderate functional disability, and  
920 
v. 5 points abnormal results with severe functional disability 
921 
10) PedEyeQ Quality of Life Questionnaires at 1, 5, and 6 years corrected age: 
922 

JAEB CENTER FOR HEALTH RESEARCH 
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40 
a. A child questionnaire will be administered by study personnel to children at 5 and 
923 
6 years corrected age.  
924 
b. Parent and proxy questionnaires will be completed by the parent at 1, 5, and 6 
925 
years corrected age.  
926 
11) Retinal imaging:  
927 
a. At sites with a retinal camera, wide-angle retinal images will be obtained after 
928 
enrollment and at 40 weeks PMA. Images will also be collected when treatment 
929 
failure is declared before the 6 month exam. Six images should be obtained for 
930 
each eye: anterior segment, posterior pole, superior, temporal, inferior, and nasal. 
931 
These images will later be reviewed by masked expert readers for purposes of 
932 
quality control. Investigators will be informed throughout the study if their 
933 
clinical diagnoses disagree with those of expert readers.  
934 
b. If a participating site or location does not have a retinal camera, a second 
935 
examination will be done by a study-certified examiner after enrollment and if 
936 
there is treatment failure to assess the location, extent, and stage of disease, as 
937 
well as presence of pre-plus or plus disease. Results of this exam will only be 
938 
used for quality control, similar to review of retinal images.   
939 
12) Plasma levels of VEGF: For infants participating in the optional study of plasma VEGF 
940 
level, their blood will be collected at baseline, 2 weeks, 4 weeks, and 4 months post-
941 
treatment. Scavenged blood may be used when feasible. 
942 
13) OCT (+/- OCT-A) and FA: Will be offered as an optional part of the study at sites with 
943 
those imaging capabilities. OCT (+/- OCT-A) and/or FA imaging will occur at 
944 
enrollment, at 40 weeks PMA, and if there is failure prior to the 6-month exam.  
945 
14) Wide-Fundus Photographs (e.g. Optos): Will be offered as an optional part of the study at 
946 
sites with imaging capability at 6 years corrected age. 
947 
 
948 
The following information will be collected by interviewing parent(s) and reviewing the medical 
949 
records: 
950 
 
951 
15) Assessment of Adverse Events: All adverse events between the time of study eye 
952 
treatment and the 4-week ocular exam will be recorded. After the 4-week ocular exam, 
953 
only serious adverse events (see section 6.2), ocular adverse events, and any events 
954 
judged by the investigator to be related to injection and/or treatment will be recorded.  
955 
16) Blood Pressure: Systolic and diastolic blood pressure measurements will be obtained 
956 
from chart review at 1, 2, 3, and 4-weeks after treatment from chart reviews at 1, 2, and 4 
957 
weeks 
958 
17) Assessment of Systemic Outcome Measures as follows: 
959 
 
960 
Table 2: Systemic Outcome Measures and Study Visits at Which They Are Assessed 
961 
System 
Outcome measure 
Study visit 
Enrollment 
1 week 
after 
treatment 
4 weeks 
after 
treatment 
6 months 
corrected 
age 
Annually 1-6 
years 
corrected age 
General 
Surgical wound infection 
x 
x 
x 
  
  
General 
Delayed healing of surgical wound 
x 
x 
x 
  
  
General 
Re-hospitalization (defined as inpatient status) 
  
  
  
x 
x 
General 
If yes, number of times re-hospitalized 
  
  
  
x 
x 
General 
If yes, primary reason(s) for re-hospitalization 
(from list) 
  
  
  
x 
x 

JAEB CENTER FOR HEALTH RESEARCH 
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41 
General 
Age at initial hospital discharge (post-birth) 
  
  
x 
x 
  
General 
Weight 
x 
x 
x 
x 
x 
General 
Recumbent length / height 
  
  
  
x 
x 
Neurological 
Intraventricular hemorrhage (grade) 
x 
  
  
  
  
Neurological 
Periventricular leukomalacia 
x 
  
  
x 
  
Neurological 
Hydrocephalus requiring shunt 
x 
  
  
x 
  
Neurological 
Cerebral palsy (mild, mod, severe) 
  
  
  
x 
x 
Neurological 
Seizures, excluding febrile 
x 
x 
x 
x 
x 
Neurological 
Autism spectrum disorder - physician diagnosed 
  
  
  
x 
x 
Neurological 
Cerebrovascular accident / thrombosis 
x 
x 
x 
  
  
Neurological 
Occipital-frontal circumference (cm) 
  
  
  
x 
  
Pulmonary 
Effective inspired oxygen concentration 
x 
x 
x 
  
  
Pulmonary 
Increased oxygen requirement after treatment 
  
x 
x 
  
  
Pulmonary 
If yes, days until O2 need returns to baseline 
  
x 
x 
  
  
Pulmonary 
Bronchopulmonary dysplasia 
x 
  
  
  
  
Pulmonary 
Asthma diagnosed by a physician 
  
  
  
  
x 
Pulmonary 
Age at which supplemental oxygen discontinued 
  
  
x 
x 
x 
Pulmonary 
Coughing or vomiting blood 
  
  
  
x 
x 
Pulmonary 
Need for re-intubation after treatment 
  
x 
x 
  
  
Renal 
Serum creatinine – most recent 
x 
x 
  
  
  
Renal 
Systemic edema 
x 
x 
x 
  
  
Renal 
Hypertension requiring daily medication 
x 
x 
x 
x 
x 
Hepatic 
Scleral icterus 
x 
x 
x 
  
  
Hepatic 
Serum alanine aminotransferase (ALT) – most 
recent 
x 
x 
  
  
  
Hepatic 
Serum aspartate aminotransferase (AST) – most 
recent 
x 
x 
  
  
  
Hepatic 
Serum bilirubin, total and direct – most recent 
x 
x 
  
  
  
Hepatic 
Serum albumin– most recent 
x 
x 
  
  
  
Gastrointestinal 
After tx, time (hours) until full enteral feeds 
  
x 
x 
  
  
Gastrointestinal 
Necrotizing enterocolitis (surgical / nonsurgical) 
x 
x 
x 
  
  
Gastrointestinal 
Blood in stool, noted grossly 
x 
x 
x 
x 
x 
Cardiovascular 
Cardiac arrest 
  
x 
x 
  
  
Cardiovascular 
Vascular thrombosis, not cerebral 
x 
x 
x 
  
  
Auditory 
Hearing screen at discharge: AABR or OAE; 
normal / abnormal 
  
  
  
x 
  
Auditory 
Hearing aid requirement (right, left, both) 
  
  
  
x 
x 
Auditory 
Cochlear implant (right, left, both) 
  
  
  
x 
x 
  
Currently using any of the following: 
  
  
  
  
  
Pulmonary 
Apnea monitor 
  
  
  
x 
x 
Pulmonary 
Oxygen 
  
  
  
x 
x 
Pulmonary 
Ventilator/CPAP 
  
  
  
x 
x 
Pulmonary 
Tracheostomy 
  
  
  
x 
x 
Pulmonary 
Pulse oximeter 
  
  
  
x 
x 
Gastrointestinal 
Gastrostomy tube and/or tube feeding 
  
  
  
x 
x 
 
962 
3.5 Phone Contacts 
963 
A phone contact from the site to the parent will be scheduled in between follow-up visits at 18, 
964 
30, 42, 54 and 66 months corrected age. The purpose of the phone contact is to remind parents 
965 
about upcoming study visits and to maximize study retention. 
966 
 
967 
Additional phone contacts may be performed as needed. 
968 
 
969 
3.6 Unscheduled Visits 
970 
Additional (non-study) examinations may be done at clinician discretion. 
971 
 
972 
3.7 Participant Access to Study Agent at Study Closure 
973 
Participants will be treated or retreated with bevacizumab as defined in the sections above 
974 
describing non-response / severe recurrence. Bevacizumab will not be offered to any participant 
975 
at the end of the study.  
976 

JAEB CENTER FOR HEALTH RESEARCH 
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42 
 
977 
3.8 Non-Case Report Form Data Access 
978 
Participants will be able to access GMA, Bayley, and other neurological testing results via 
979 
reports from the patient menu. Sites can request optional blood test results from the coordinating 
980 
center.
981 

JAEB CENTER FOR HEALTH RESEARCH 
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43 
Chapter 4: Study Drug 
982 
 
983 
4.1 Study Agent(s) and Control Description 
984 
 
985 
 Acquisition 
986 
Intravitreous bevacizumab will be provided by the pharmacy at the investigator’s institution. 
987 
 
988 
 Formulation, Appearance, Packaging, and Labeling 
989 
Syringes containing bevacizumab at the appropriate study concentration will be prepared by the 
990 
pharmacy at the investigator’s institution. If one eye is to be injected, then two syringes will be 
991 
prepared. If two eyes are to be injected, then four syringes will be prepared. Two syringes (one 
992 
for each planned injection) will serve as backups and will only be used if the other syringes are 
993 
compromised for any reason; otherwise, the backup syringes will be discarded if unused. All 
994 
syringes will be packaged and labeled as outlined in the ROP Procedures Manual. 
995 
 
996 
 Product Storage and Stability 
997 
Bevacizumab used in the study will be provided by the study pharmacy at the investigator’s 
998 
institution and diluted to the appropriate concentration by the institution per the procedures 
999 
outlined in the ROP Procedures Manual. The institution pharmacy will prepare the bevacizumab 
1000 
in a sterile manner, adhering to USP standards 789, 797, and 800.  Syringes must be refrigerated 
1001 
at 2 to 8⸰ Celsius and protected from light and must be used within 8 hours once prepared. 
1002 
 
1003 
 Preparation 
1004 
Bevacizumab used in the study will be diluted to the appropriate concentration by the study 
1005 
pharmacy at the investigator’s institution per the procedures outlined in the ROP Procedures 
1006 
Manual. The pharmacy will prepare the bevacizumab in a sterile manner, adhering to USP 
1007 
standards 789, 797, and 800.  
1008 
 
1009 
 Dosing and Administration 
1010 
Bevacizumab at the proper study concentration and dose will be administered by intravitreous 
1011 
injection as outlined in the ROP Procedures Manual. 
1012 
 
1013 
 Route of Administration 
1014 
Bevacizumab will be administered by intravitreous injection as outlined in the ROP Procedures 
1015 
Manual. 
1016 
 
1017 
  Starting Dose and Dose Escalation Schedule  
1018 
The initial dose of Bevacizumab injected into the study eye (or fellow eye if eligible) will be 
1019 
0.063 mg; eyes may be retreated with 0.25 mg Bevacizumab after non-response / severe 
1020 
recurrence to initial treatment as defined in Chapter 3.  
1021 
 
1022 
 Dose Adjustments/Modifications/Delays 
1023 
The dose should not be adjusted for any reason without first consulting with the protocol chair. 
1024 
For infants randomized to bevacizumab, the injection will be given preferably within 24 hours, 
1025 
but no later than 2 days, after the diagnosis of type 1 ROP. If injection is delayed beyond 2 days 
1026 
after diagnosis for any reason, the injection may still be done after consultation with the protocol 
1027 

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44 
chair. For analysis purposes, even if the dose is delayed, participants will be counted towards the 
1028 
randomly assigned treatment arm. 
1029 
    
1030 
 Duration of Therapy 
1031 
After initial injection, eyes may be retreated as described in Chapter 3.  
1032 
 
1033 
 Tracking of Dose 
1034 
All syringes will be packaged and labeled by the study pharmacy at the investigator’s institution 
1035 
and diluted to the appropriate concentration by the institution per the procedures outlined in the 
1036 
ROP Procedures Manual. The pharmacy will prepare the bevacizumab in a sterile manner, 
1037 
adhering to USP standards 789 and 800. A second trained and delegated pharmacist will check 
1038 
that the preparation was compounded correctly and release syringes for use.  
1039 
 
1040 
4.2 Study Agent Accountability Procedures 
1041 
Drug accountability procedures will be detailed in the ROP Procedures Manual. If only one eye 
1042 
is to be treated, the treating investigator and a second person will review the Bevacizumab Study 
1043 
Syringe Label to confirm which eye will receive the intravitreous injection. 
1044 
 
1045 
The investigator who gives the injection must have previous experience giving intravitreous 
1046 
injections. If the injection is the first given by the investigator for ROP, then it must be given 
1047 
with the assistance of an ophthalmologist who has previously given intravitreous injections for 
1048 
ROP. 
1049 

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Chapter 5: Testing Procedures  
1050 
The following procedures will be performed in both groups at each visit as defined in the ROP 
1051 
Procedures Manual:  
1052 
 
1053 
1) Classification of ROP: Classification of ROP will be determined at each follow-up exam 
1054 
as described in section 2.4.2. It is not expected that scleral depression will be done 
1055 
routinely after 50 weeks postmenstrual age, or the 4-month post-treatment exam. If a 
1056 
vitrectomy or scleral buckle is scheduled prior to the 6-month exam, then the 6-month 
1057 
exam will be completed early prior to vitrectomy or scleral buckle surgery. 
1058 
• The exam must be done by a certified examiner. Certification will require attendance 
1059 
on a conference call to review standardized examples with the protocol chair.  
1060 
2) Assessment of Amblyopia beginning at 6 months (when able). For infants and children 
1061 
unable to do recognition visual acuity, the presence or absence of amblyopia will be 
1062 
determined by tests of fixation preference. For those participants with no strabismus (or 
1063 
microtropia), fixation preference will be assessed using the induced tropia test. For those 
1064 
participants with strabismus, fixation preference will be assessed using binocular fixation 
1065 
patterns. Testing time is typically about one minute. See ROP Procedures Manual for 
1066 
details. 
1067 
3) Ocular Alignment: ocular alignment will be assessed by the cover test beginning at 6 
1068 
months corrected age (when able). If a tropia or intermittent tropia is detected, then it will 
1069 
be quantified by the prism and alternate cover test (PACT), if able, or by the Krimsky test 
1070 
if unable to do PACT. Testing time is typically in the range of 1 to 3 minutes. 
1071 
4) Cycloplegic Refraction: A cycloplegic refraction will be done for both eyes at 6 months 
1072 
corrected age and every study visit thereafter. After administration of eye drops, it 
1073 
typically takes 30 minutes to achieve cycloplegia, and testing time for refraction of both 
1074 
eyes is in the range of 2 to 10 minutes. 
1075 
5) Visual acuity will be tested in both eyes (when able) beginning at 2 years corrected age 
1076 
and every year thereafter through age 6, beginning with the ATS HOTV testing protocol 
1077 
on the Electronic Visual Acuity Tester (EVA). Testing time for both eyes typically is in 
1078 
the range of 5 to 15 minutes. 
1079 
6) Assessment of Visual Fields: Visual fields will be measured using kinetic sphere 
1080 
perimetry at the 6-year exam. Testing time is typically in the range of 25 to 35 minutes. 
1081 
7) General Movements Assessment:  The GMA test will be administered at 54 weeks (52-
1082 
56) PMA. See ROP Procedures Manual for details. 
1083 
8) Bayley-4 Test: The Bayley-4 test of infant and toddler development will be administered 
1084 
at 2 years corrected age. See ROP Procedures Manual for details.  
1085 
9) IQ and Neuropsychiatric Testing:  IQ and neuropsychiatric testing will occur at age 6 
1086 
years. See ROP Procedures Manual for details. 
1087 
10) PedEyeQ Questionnaires96-99: Surveys will be administered at given timepoints to the 
1088 
applicable participants and parents of participants. Testing time is typically in the range 
1089 
of 3 to 5 minutes for the children and the same for their parents. 
1090 
11) Retinal imaging 
1091 
a. Wide-angle retinal images will be obtained after enrollment and at 40 weeks 
1092 
PMA. Images will also be collected when treatment failure is declared before the 
1093 
6 month exam. Six images should be obtained for each eye: anterior segment, 
1094 

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46 
posterior pole, superior, temporal, inferior, and nasal. These images will later be 
1095 
reviewed by masked expert readers for purposes of quality control. If an 
1096 
investigator’s clinical diagnoses disagree with that of the expert readers, then the 
1097 
protocol chair or vice-chair will discuss the findings with the investigator. Testing 
1098 
time for both eyes is typically in the range of 5 to 15 minutes. Details are in the 
1099 
ROP Procedures Manual. 
1100 
b. If a participating site or location does not have a retinal camera, a second 
1101 
examination will be done by a study-certified examiner after enrollment and if 
1102 
there is treatment failure to assess the location, extent, and stage of disease, as 
1103 
well as presence of pre-plus or plus disease. Results of this exam will only be 
1104 
used for quality control, similar to review of retinal images. Repeat exam time for 
1105 
both eyes is typically in the range of 1-5 minutes. 
1106 
12) Plasma levels of VEGF: For infants participating in the optional study of plasma VEGF 
1107 
level, their blood will be collected at baseline, 2 weeks, 4 weeks, and 4 months post-
1108 
treatment. Scavenged blood may be used when feasible. If needed, time to collect blood 
1109 
is typically in the range of 2 to 10 minutes. 
1110 
13) OCT (+/- OCT-A) and FA: These tests will be offered as an optional part of the study at 
1111 
sites with those imaging capabilities. Testing time for both eyes is typically in the range 
1112 
of 10 to 20 minutes for each of these procedures. Details are in the ROP Procedures 
1113 
Manual. 
1114 
14) Wide-Fundus Photographs (e.g.Optos): Will be offered as an optional part of the study at 
1115 
sites with imaging capability at 6 years corrected age.  Testing time for both eyes is 
1116 
typically in the range of 10-20 minutes for the procedure. Details are in the ROP 
1117 
Procedures Manual. 
1118 
 
1119 
The following information will be collected by interviewing parent(s) and reviewing the medical 
1120 
records: 
1121 
 
1122 
15) Assessment of Adverse Events: All adverse events between the time of study eye 
1123 
treatment and the 4-week ocular exam will be recorded. After the 4-week ocular exam, 
1124 
only serious adverse events (see section 6), ocular adverse events, and any events judged 
1125 
by the investigator to be related to injection and/or treatment will be recorded.  
1126 
 
 
1127 

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Chapter 6: Unanticipated Problem and Adverse Event Reporting  
1128 
6.1 Unanticipated Problems 
1129 
Site investigators will promptly report to the Coordinating Center on an eCRF all unanticipated 
1130 
problems meeting the criteria below. Sites must report Unanticipated Problems to the IRB within 
1131 
seven (7) calendar days of recognition. For this protocol, an unanticipated problem is an incident, 
1132 
experience, or outcome that meets all of the following criteria: 
1133 
 
1134 
• Unexpected (in terms of nature, severity, or frequency) given (a) the research procedures 
1135 
that are described in the protocol related documents, such as the IRB-approved research 
1136 
protocol and informed consent document; and (b) the characteristics of the participant 
1137 
population being studied. 
1138 
• Related or possibly related to participation in the research (possibly related means there is 
1139 
a reasonable possibility that the incident, experience, or outcome may have been caused 
1140 
by the procedures involved in the research) 
1141 
• Suggests that the research places participants or others at a greater risk of harm than was 
1142 
previously known or recognized (including physical, psychological, economic, or social 
1143 
harm)   
1144 
 
1145 
The Coordinating Center also will report to the IRB all unanticipated problems not directly 
1146 
involving a specific site such as unanticipated problems that occur at the Coordinating Center or 
1147 
at another participating entity such as a pharmacy or laboratory. These instances must be 
1148 
reported to the JCHR IRB within seven calendar days of recognition. The Director of the Human 
1149 
Research Protection Program will report to the appropriate regulatory authorities if the IRB 
1150 
determines that the event indeed meets the criteria of an Unanticipated Problem that requires 
1151 
further reporting.  
1152 
 
1153 
6.2 Adverse Events 
1154 
 
1155 
 Definitions 
1156 
Adverse Event (AE): Any untoward medical occurrence in a study participant, irrespective of the 
1157 
relationship between the adverse event and the drug(s) under investigation.  
1158 
 
1159 
Serious Adverse Event (SAE): Any untoward medical occurrence that: 
1160 
• Results in death. 
1161 
• Is life-threatening; (a non-life-threatening event which, had it been more severe, might have 
1162 
become life-threatening, is not necessarily considered a serious adverse event). 
1163 
• Requires inpatient hospitalization or prolongation of existing hospitalization. 
1164 
• Results in persistent or significant disability/incapacity or substantial disruption of the ability 
1165 
to conduct normal life functions (sight threatening). 
1166 
• Is a congenital anomaly or birth defect. 
1167 
• Is considered a significant medical event by the investigator based on medical judgment (e.g., 
1168 
may jeopardize the participant or may require medical/surgical intervention to prevent one of 
1169 
the outcomes listed above). 
1170 
 
1171 

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 Reportable Adverse Events 
1172 
For this protocol, all adverse events between the time of study eye treatment until 4 weeks will be 
1173 
recorded.100  Any events between randomization and initial treatment will be entered as prior 
1174 
medical conditions.   
1175 
 
1176 
After 4 weeks, only serious adverse events (see section 6.2.1), ocular adverse events, and any 
1177 
events judged by the investigator to be related to study injection and/or study treatment will be 
1178 
recorded. There will be no imputation of data for participants who die or are lost to follow-up 
1179 
prior to the six-month adjusted-age outcome visit. Several systemic measures will be monitored 
1180 
throughout the study (see Table 2, section 3.3.1).  
1181 
 
1182 
All reportable Adverse Events whether volunteered by the participant’s parents, discovered by 
1183 
study personnel during questioning, or detected through physical examination, laboratory test, or 
1184 
other means will be reported on an adverse event form online. Each adverse event form is 
1185 
reviewed by the Medical Monitor to verify the coding and the reporting that is required. 
1186 
 
1187 
 Relationship of Adverse Event to Study Treatment or Study Procedure 
1188 
The study investigator will assess the relationship of each adverse event to be related or 
1189 
unrelated by deciding if there is a reasonable possibility that the adverse event may have been 
1190 
caused by the treatment or study procedure. The investigator brochure will list potential adverse 
1191 
events that may be expected.  
1192 
 
1193 
To ensure consistency of adverse event causality assessments, investigators should apply the 
1194 
following general guideline when determining whether an adverse event is related: 
1195 
 
1196 
Yes 
1197 
There is a plausible temporal relationship between the onset of the adverse event and 
1198 
administration of the study treatment and the adverse event cannot be readily explained 
1199 
by the participant’s clinical state, intercurrent illness, or concomitant therapies; and/or the 
1200 
adverse event follows a known pattern of response to the study treatment. 
1201 
 
1202 
No 
1203 
Evidence exists that the adverse event has an etiology other than the study treatment (e.g., 
1204 
preexisting medical condition, underlying disease, intercurrent illness, or concomitant 
1205 
medication); and/or the adverse event has no plausible temporal relationship to study 
1206 
treatment administration.   
1207 
 
1208 
 Severity (Intensity) of Adverse Event 
1209 
The severity (intensity) of an adverse event will be rated on a three-point scale: (1) mild, (2) 
1210 
moderate, or (3) severe. A severity assessment is a clinical determination of the intensity of an 
1211 
event. Thus, a severe adverse event is not necessarily serious. For example, itching for several 
1212 
days may be rated as severe, but may not be clinically serious. 
1213 
 
1214 
• MILD: Usually transient, requires no special treatment, and does not interfere with the 
1215 
participant’s daily activities. 
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• MODERATE: Usually causes a low level of inconvenience, discomfort or concern to the 
1217 
participant and may interfere with daily activities, but is usually ameliorated by simple 
1218 
therapeutic measures and participant is able to continue in study. 
1219 
• SEVERE: Interrupts a participant’s usual daily activities, causes severe discomfort, may 
1220 
cause discontinuation of study drug, and generally requires systemic drug therapy or 
1221 
other treatment. 
1222 
 
1223 
 Expectedness 
1224 
For a serious adverse event that is considered possibly related to study drug, the Medical Monitor 
1225 
will classify the event as unexpected if the nature, severity, or frequency of the event is not 
1226 
consistent with the risk information previously described below. 
1227 
 
1228 
 Coding of Adverse Events 
1229 
Adverse events will be coded using the MedDRA dictionary. To facilitate coding, the site will 
1230 
enter a preliminary MedDRA code which the Medical Monitor may accept or change (the 
1231 
Medical Monitor’s MedDRA coding will be used for all reporting). The Medical Monitor will 
1232 
review the investigator’s assessment of causality and may agree or disagree. Both the 
1233 
investigator’s and Medical Monitor’s assessments will be recorded. The Medical Monitor will 
1234 
have the final say in determining the causality as well as whether an event is classified as a 
1235 
serious adverse event and as a serious unanticipated event. 
1236 
 
1237 
 Outcome of Adverse Event 
1238 
The outcome of each reportable adverse event will be classified by the investigator as follows: 
1239 
 
1240 
• RECOVERED/RESOLVED: The participant recovered from the AE/SAE without sequelae. 
1241 
Record the AE/SAE stop date. 
1242 
 
1243 
• RECOVERED/RESOLVED WITH SEQUELAE: The event persisted and had stabilized 
1244 
without change in the event anticipated. Record the AE/SAE stop date. 
1245 
 
1246 
• FATAL: A fatal outcome is defined as the SAE that resulted in death. Only the event that 
1247 
was the cause of death should be reported as fatal. AEs/SAEs that were ongoing at the time 
1248 
of death; however, were not the cause of death, will be recorded as “resolved” at the time of 
1249 
death. Primary and secondary (if applicable) causes of death will be recorded. 
1250 
 
1251 
• NOT RECOVERED/NOT RESOLVED (ONGOING): An ongoing AE/SAE is defined as the 
1252 
event was ongoing with an undetermined outcome. 
1253 
 
An ongoing outcome will require follow-up by the site in order to determine the final 
1254 
outcome of the AE/SAE. 
1255 
 
The outcome of an ongoing event at the time of death that was not the cause of death, 
1256 
will be updated and recorded as “resolved” with the date of death recorded as the stop 
1257 
date.  
1258 
 
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50 
• UNKNOWN: An unknown outcome is defined as an inability to access the participant or 
1260 
the participant’s records to determine the outcome (for example, a participant that was 
1261 
lost to follow-up). 
1262 
 
1263 
If any reported adverse events are ongoing when a participant completes the study (or 
1264 
withdraws), adverse events classified as suspected, unexpected serious adverse reactions 
1265 
(SUSARs) will be followed until they are either resolved, or have no prospect of improvement or 
1266 
change, even after the participant has completed all applicable study visits/contacts. For all other 
1267 
adverse events, data collection will end at the time the participant completes the study. Note: 
1268 
participants should continue to receive appropriate medical care for an adverse event after their 
1269 
participation in the study ends. 
1270 
 
1271 
6.3 Timing of Event Reporting 
1272 
Serious or unexpected adverse events must be reported to the Coordinating Center within 24 
1273 
hours via completion of the online serious adverse event form. 
1274 
 
1275 
Other reportable adverse events will be reported within 3 days of the investigator becoming 
1276 
aware of the event by completion of an electronic case report form.  
1277 
 
1278 
The Coordinating Center will notify all participating investigators of any adverse event that is 
1279 
serious, related, and unexpected. Notification will be made no later than 15 calendar days after 
1280 
the Coordinating Center becomes aware of the event, and no later than seven calendar days 
1281 
where the event is fatal or life-threatening. 
1282 
 
1283 
Each principal investigator is responsible for reporting serious study-related adverse events and 
1284 
abiding by any other reporting requirements specific to his/her Institutional Review Board or 
1285 
Ethics Committee. Where the JCHR IRB is the overseeing IRB, sites must report all serious, 
1286 
related adverse events regardless of whether they are expected/anticipated and regardless of 
1287 
whether they are fatal or life-threatening to the JCHR IRB within seven (7) calendar days.  
1288 
 
1289 
The Coordinating Center will be responsible for notifying the FDA of any unexpected fatal or 
1290 
life-threatening suspected adverse reaction as soon as possible, but in no case later than seven (7) 
1291 
calendar days after initial receipt of the information. In addition, the Coordinating Center will 
1292 
notify FDA and all participating investigators in an Investigational New Drug (IND) safety 
1293 
report of potential serious risks, from clinical trials or any other source, as soon as possible, but 
1294 
in no case later than 15 calendar days after the sponsor determines that the information qualifies 
1295 
for reporting.  
1296 
 
1297 
6.4 Safety Oversight 
1298 
The study Medical Monitor will review all adverse events that are reported during the study. 
1299 
SAEs related to study treatment typically will be reviewed within 24 hours of reporting. Other 
1300 
AEs typically will be reviewed on a weekly basis. Additionally, the Medical Monitor will review 
1301 
compiled safety data at periodic intervals (generally timed to the review of compiled safety data 
1302 
by the DSMC). 
1303 
 
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51 
A Data and Safety Monitoring Committee (DSMC) will review compiled safety data at periodic 
1305 
intervals, with a frequency of no less than twice a year. The DSMC can request modifications to 
1306 
the study protocol or suspension or outright stoppage of the study if deemed necessary based on 
1307 
the totality of safety data available. Details regarding DSMC review will be documented in a 
1308 
separate DSMC charter. 
1309 
 
1310 
6.5 Stopping Criteria 
1311 
The study may be discontinued by the Steering Committee (with approval of the Data and Safety 
1312 
Monitoring Committee) prior to the preplanned completion of follow-up for all study 
1313 
participants. 
1314 
 
1315 
 Participant Discontinuation of Study Drug 
1316 
Rules for discontinuing study drug use are described below.  
1317 
 
1318 
• The investigator believes it is unsafe for the participant to continue to receive the drug. 
1319 
This could be due to the development of a potential side effect of the drug, a new medical 
1320 
condition or worsening of an existing condition; or participant behavior contrary to the 
1321 
indications for use of the drug that imposes on the participant’s safety 
1322 
• The participant requests that the treatment be stopped 
1323 
 
1324 
Even if the study drug is discontinued, the participant will be encouraged to remain in the study 
1325 
through the final study visit.  
1326 
 
1327 
 Criteria for Suspending or Stopping Overall Study 
1328 
The objective of the safety review is to decide whether the study (or study agent for an individual 
1329 
or study cohort) should continue per protocol, proceed with caution, be further investigated, be 
1330 
discontinued, or be modified and then proceed. Suspension of enrollment (for a particular group, 
1331 
a particular study site or for the entire study) is a potential outcome of a safety review. 
1332 
Subsequent review of serious, unexpected, and related AEs by the Medical Monitor, DSMB, 
1333 
IRB, the sponsor(s), or the FDA or relevant local regulatory authorities may also result in 
1334 
suspension of further study agent administration at a site. The FDA and study sponsor(s) retain 
1335 
the authority to suspend additional enrollment and study agent for the entire study, as applicable. 
1336 
 
1337 
6.6 Unmasking due to Adverse Event 
1338 
Parents, investigators, coordinators, and examiners will not be masked to randomized treatment 
1339 
group.    
1340 

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Chapter 7: Miscellaneous Considerations 
1341 
 
1342 
7.1 Collection of Medical Conditions and Medications 
1343 
A pre-existing condition is defined as any medical condition that is either present at screening, a 
1344 
chronic disease, or a prior condition that could impact the participant’s health during the course 
1345 
of the study (e.g., prior myocardial infarction or stroke). Pre-existing conditions will be recorded. 
1346 
 
1347 
All medications that the participant is currently taking at enrollment or during the course of the 
1348 
study will be recorded. Preventative treatment also will be recorded (nutraceuticals will not be 
1349 
recorded). 
1350 
 
1351 
7.2 Prohibited Medications, Treatments, and Procedures 
1352 
There are no prohibited medications, treatments, or procedures.  
1353 
 
1354 
7.3 Precautionary Medications, Treatments, and Procedures 
1355 
There are no rescue medications, treatments, or procedures.  
1356 
 
1357 
7.4 Participant Compensation 
1358 
Participant compensation will be specified in the informed consent form. 
1359 
 
1360 
7.5 Participant Withdrawal 
1361 
Participation in the study is voluntary, and a parent may withdraw at any time.  
1362 
If a parent is considering withdrawal from the study, the principal investigator should personally 
1363 
speak to the individual about the reasons, and every effort should be made to accommodate the 
1364 
parent to allow continued participation if possible.  
1365 
 
1366 
The goal for the study is to have as few losses to follow-up as possible. The Coordinating Center 
1367 
will assist in the tracking of study participants who cannot be contacted by the site. The 
1368 
Coordinating Center will be responsible for classifying a study participant as lost to follow-up. 
1369 
Study participants who have an adverse event attributable to a study treatment or procedure at 
1370 
the time of withdrawal will be asked to continue in follow-up until the adverse event has 
1371 
resolved or stabilized. 
1372 
 
1373 
For participants who withdraw, their data will be used up until the time of withdrawal. Those that 
1374 
receive off-protocol treatment will be encouraged to remain in the study. 
1375 
 
1376 
7.6 Confidentiality 
1377 
For security and confidentiality purposes, participants will be assigned an identifier that will be 
1378 
used instead of their name. Protected health information gathered for this study will be shared 
1379 
with the coordinating center, the Jaeb Center for Health Research in Tampa, FL. De-identified 
1380 
participant information may also be provided to research sites involved in the study. 
1381 
 
1382 
7.7 Contact Information Provided to the Coordinating Center 
1383 
The Coordinating Center will be provided with contact information for each study participant. 
1384 
Permission to obtain such information will be included in the Informed Consent Form. The contact 
1385 
information will be maintained in a secure database and will be maintained separately from the 
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53 
study data. 
1387 
 
1388 
Phone contact or mailings from the Coordinating Center may be made with each study 
1389 
participant to facilitate the scheduling of the study participant for follow-up visits. A study 
1390 
participant-oriented newsletter may be sent once a year. A study logo item may be sent once a 
1391 
year.   
1392 

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54 
Chapter 8: Statistical Considerations 
1393 
8.1 Statistical and Analytical Plans 
1394 
The approach to sample size and statistical analyses are summarized below.    
1395 
 
1396 
8.2 Study Objectives and Hypothesis 
1397 
 
1398 
 Primary Efficacy Outcome – Treatment Success At 6 Months Corrected age   
1399 
The primary objective for the randomized trial is to determine if infants with type 1 ROP treated 
1400 
with intravitreal bevacizumab (subsequently referred to as BV) have a treatment success rate 
1401 
determined at 6 months corrected age that is non-inferior compared with infants treated with 
1402 
laser photocoagulation (subsequently referred to as LASER).  
1403 
 
1404 
The primary efficacy outcome will be treatment success at the eye level (for eyes meeting 
1405 
eligibility criteria at time of enrollment) determined at 6 months corrected age, where success is 
1406 
defined as meeting all the following criteria as determined by the investigator: 
1407 
 
1408 
• Five to 11 days after treatment (or re-treatment if indicated), there is no increase in the 
1409 
extent or severity of stage 3, or development of new plus disease 
1410 
• Two weeks (12-16 days) after treatment (or re-treatment if indicated) to 6 months 
1411 
corrected age, there is no plus disease or severe neovascularization  
1412 
• No unfavorable structural outcome at 6 months corrected age defined as (1) macular 
1413 
ectopia*, (2) a posterior retinal fold involving the macula, (3) a retinal detachment 
1414 
involving the macula, or (4) retrolental tissue or mass obscuring the view of the posterior 
1415 
pole.  
1416 
• No scleral buckle or vitrectomy by 6 months corrected age.  
1417 
 
1418 
* Macular ectopia must be definite to meet criteria for an unfavorable outcome.  Questionable ectopia or vessel 
1419 
straightening alone are not considered unfavorable. 
1420 
 
1421 
The study is designed as a non-inferiority study to evaluate a 1-sided null hypothesis that the 
1422 
success probability after six months with BV is inferior to LASER by 5% or more in favor of the 
1423 
alternative hypothesis that the success probability with BV is not inferior to LASER (>-5%).  
1424 
 
1425 
Hnull  
 
= BVsuccess% at 6m minus LASER success% at 6m <= -5% (BV inferior to LASER) 
1426 
Halternative  
= BVsuccess% at 6m minus LASER success% at 6m > -5% (BV not inferior to LASER) 
1427 
 
1428 
Non-inferiority of BV compared to LASER will be declared if the LOWER limit of the upper 1-
1429 
sided 97.5% CI for the difference between treatment groups in success proportions (BV minus 
1430 
LASER) is greater than the non-inferiority limit of -5% favoring laser.  
1431 
 
1432 
If non-inferiority is declared, a test of no difference (superiority test) for BV compared with laser 
1433 
will be conducted. 
1434 
 
1435 
 Margin Choice 
1436 
The 5% non-inferiority margin was selected by the planning committee based on clinical 
1437 
judgment.  Planning committee members were willing to accept that bevacizumab may be 
1438 

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55 
slightly inferior to laser (up to 5%) because bevacizumab has several other advantages, including 
1439 
ease of administration, less stress to infants during treatment, less myopia, better peripheral 
1440 
vascularization, and possibly better visual fields. Planning committee members were unwilling to 
1441 
accept a margin greater than 5% as “non-inferior,” because severe ROP can lead to blindness, 
1442 
and laser is generally successful in preventing blindness.   
1443 
 
1444 
8.3 Sample Size 
1445 
The non-inferiority margin was selected based upon clinical judgement. For the primary efficacy 
1446 
outcome, treatment success at six months corrected age, members of the planning committee felt 
1447 
that a difference of 5% or more was a clinically meaningful difference.  
1448 
 
1449 
It is expected that there will be a high correlation with respect to success between eyes of the 
1450 
same participant in those with bilateral treatment. Therefore, sample size calculations have been 
1451 
calculated based upon the number of participants to be conservative. 
1452 
 
1453 
Based on previous data analyzed, the treatment success rate was estimated to be 95% for eyes 
1454 
initially treated with BV 0.063 mg (and retreated with BV 0.25 mg if necessary), and 85% for 
1455 
eyes initially treated with LASER (and retreated with LASER if necessary).17,61,70   
1456 
 
1457 
Assuming that the true difference in success rates is 10% favoring BV, a total sample size of 180 
1458 
participants (90 per group) will have 90% power to reject a 1-sided null hypothesis that the 
1459 
success rate after six months with BV is inferior to LASER by 5% or more in favor of the 
1460 
alternative hypothesis that the success rate with BV is not inferior to LASER (> -5%), with a 
1461 
type 1 error rate of 2.5%.  
1462 
 
1463 
The percentage of participants lost to follow-up or withdrawn prior to six months corrected age 
1464 
is expected to be no more than 15% and equal between the two treatment groups. After adjusting 
1465 
for 15% lost to follow-up, the total sample size is 212 participants (~106 per group).  
1466 
 
1467 
8.4 Analysis Dataset 
1468 
The primary efficacy analysis will follow an intent-to-treat (ITT) principle. Therefore, the 
1469 
primary analysis dataset will include all eligible eyes at time of enrollment for randomized 
1470 
participants. 
1471 
 
1472 
8.5 Analysis of the Primary Efficacy Outcome 
1473 
The proportion of eyes eligible at randomization that achieve success will be tabulated by 
1474 
treatment group.   
1475 
 
1476 
With a short time to primary outcome, it is expected that lost to follow-up to be minimal and 
1477 
non-informative. However, there may be a few participants who die or are lost to follow up 
1478 
before the 6-month visit. To use the information of these participants as much as possible, a time 
1479 
to event analysis will be performed. Censoring will occur at the time of death or lost to follow up 
1480 
before the 6-month outcome. If a participant reaches failure criteria at one of the visits before the 
1481 
censoring event, that participant will be counted as a failure. The protocol visit that reports the 
1482 
failure or censoring event will be used as the timepoint for the analysis: 1-week post-treatment, 2 
1483 
weeks post-treatment, 4 weeks post-treatment, 2 months post-treatment, 4 months post-treatment, 
1484 

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56 
6 months corrected age. The number of failures, censoring events, and 6-month visits by 
1485 
treatment group will also be reported on an eye level. 
1486 
 
1487 
The hazard ratio of failure for BV: Laser and a one-sided upper tailed confidence (CI) will be 
1488 
calculated with a Cox model with robust variance estimation to control for correlation arising 
1489 
from participants contributing two study eyes to the analysis. Analyses will be adjusted for the 
1490 
stratification factors of zone (I vs II) for the most severe eye and by gestational age (< 25 weeks 
1491 
vs > 25 weeks). An estimate of the success probability difference at 6 months with the upper 1-
1492 
sided 97.5% CI will be calculated with direct adjustment methods. The proportional hazards 
1493 
assumption will be checked.  
1494 
 
1495 
8.6 Sensitivity Analyses for Primary Outcome 
1496 
 
1497 
 Tipping Point Analysis for Imaging and Repeat ROP Exam 
1498 
Wide-angle retinal images will be obtained after enrollment, at 40 weeks PMA, and if there is 
1499 
treatment failure before the 6-month exam. Six images will be obtained for each eye: anterior 
1500 
segment, posterior pole, superior, temporal, inferior, and nasal as described in the ROP 
1501 
Procedures Manual. To mitigate unmasked assessment bias, these images will later be reviewed 
1502 
by masked expert readers for purposes of quality control. Investigators will be informed 
1503 
throughout the study if their clinical diagnoses disagree with those of expert readers. 
1504 
 
1505 
If a participating site or location does not have a retinal camera, a second examination will be 
1506 
done by a study-certified examiner after enrollment and if there is treatment failure to assess the 
1507 
location, extent, and stage of disease, as well as presence of pre-plus or plus disease. Results of 
1508 
this exam will only be used for quality control, similar to review of retinal images.  
1509 
 
1510 
 
1511 
The number of discrepancies between the site diagnosis and the masked retinal image reviewer 
1512 
diagnosis OR diagnosis by second study certified ROP examiner will be calculated at each visit.  
1513 
If there are cases where the investigator declared failure and masked review of the images OR 
1514 
second study certified examiner does not confirm failure, then a sensitivity tipping point analysis 
1515 
will be done to evaluate the number of discrepancies required to tip results from significant to 
1516 
not or vice versa. If there are discrepancies at enrollment, a sensitivity analysis excluding those 
1517 
participants will be performed. 
1518 
 
1519 
 Deaths as Failures  
1520 
To check for informative censoring, a sensitivity analysis will be performed where deaths before 
1521 
failure are counted as failures instead of censoring. If deaths are believed to be independent of 
1522 
treatment, this will overestimate the failure rate in each group.  
1523 
 
1524 
However, if one group’s failure rate meaningfully increases compared to the other, this may 
1525 
indicate informative censoring. In this case, the primary analysis may be adjusted to use Fine and 
1526 
Gray's extension of the Cox model to fit deaths as a competing risk to protocol treatment failure. 
1527 
 
1528 

JAEB CENTER FOR HEALTH RESEARCH 
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 Primary Outcome Contingency Plan 
1529 
If Cox model assumptions fail, exact logistic regression with the same adjustments of zone (I vs 
1530 
II) for the most severe eye and by gestational age (< 25 weeks vs > 25 weeks) will be attempted. 
1531 
This analysis of success or failure will be on a per-participant basis (if either eye fails, that 
1532 
participant is counted as a failure). Multiple imputation will be used based on baseline 
1533 
information for missing values. 
1534 
 
1535 
If the model fails to converge, a model will be fit without the adjustments for stratification. If 
1536 
exact logistic regression still fails to converge, Barnard’s exact test will be performed.   
1537 
 
1538 
8.7 Analysis of the Secondary Outcomes 
1539 
All secondary outcomes will be tabulated and/or summarized with descriptive statistics. There 
1540 
will be additional regression analyses for some outcomes (Table 3). 
1541 
Multiplicity: 
1542 
Type I error for the primary outcome analysis will be 5%, as only one analysis is pre-specified as 
1543 
primary. All other outcomes and their analyses will be pre-specified as either secondary or 
1544 
exploratory. Multiplicity in pre-specified secondary outcome analyses will be controlled using 
1545 
the False Discovery Rate (FDR) method. It is planned to report results for secondary outcomes 
1546 
annually; the FDR will be set to 5% for each of the annual reports and will apply to all pre-
1547 
specified secondary analyses.  
1548 
For FDR-controlled outcomes, an estimate and FDR-adjusted confidence interval for the 
1549 
difference between treatments will be provided. Estimates and 95% confidence intervals within 
1550 
each treatment also will be provided for all secondary outcomes.  
1551 
Table 3. Secondary Outcomes 
1552 
 
6- 
Month 
1  
year 
2 
year 
3 
year 
4 
year 
5 
year 
6 
year 
FDR or 
Exploratory 
Outcome type 
Additional 
Analyses 
Number of re-
treatments 
X 
 
 
 
 
 
 
Exploratory 
Count 
 
Refractive error 
X 
X 
X 
X 
X 
X 
X 
FDR 
Continuous 
Regression 
Proportion of study 
eyes with myopia 
(spherical 
equivalent 
refractive error <= -
5.0D) 
X 
X 
X 
X 
X 
X 
X 
FDR 
Binary 
Regression 
Bayley Neuro-
development 
continuous1 
 
 
X 
 
 
 
 
FDR 
Ordinal analyzed as 
continuous 
Regression 
Bayley Neuro-
development 
categories1 
 
 
X 
 
 
 
 
Exploratory 
Categorical 
See 
section 
8.7.1) 
Wechsler Preschool 
and Primary Scale 
of Intelligence 
(WPPSI-IV), 
continuous 
 
 
 
 
 
 
X 
FDR 
Ordinal analyzed as 
continuous 
Regression 

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58 
Wechsler Preschool 
and Primary Scale 
of Intelligence 
(WPPSI-IV), 
categorical 
 
 
 
 
 
 
 
Exploratory 
Categorical 
See 
section 
8.7.2 ) 
Beery–Buktenic 
Developmental Test 
of Visual-Motor 
Integration, 6th 
edition (VMI-6) 
 
 
 
 
 
 
X 
FDR 
Ordinal analyzed as 
continuous 
Regression 
Visual acuity 
 
 
X 
X 
X 
X 
X 
FDR 
Continuous 
Regression 
Visual fields  
 
 
 
 
 
 
X 
FDR 
Continuous 
Regression 
Systemic 
morbidities 
X 
X 
X 
X 
X 
X 
X 
Exploratory 
Counts 
 
Extent of retinal 
vascularization 
 
X 
 
 
 
 
 
Exploratory 
Categorical 
 
Proxy PedEyeQ2 
 
X 
 
 
 
X 
X 
FDR 
Ordinal analyzed as 
continuous 
Regression 
Parent PedEyeQ3 
 
X 
 
 
 
X 
X 
FDR 
Ordinal analyzed as 
continuous 
Regression 
Child PedEyeQ4 
 
 
 
 
 
X 
X 
FDR 
Ordinal analyzed as 
continuous 
Regression 
1. Contains  
1553 
a. 
Bayley Cognitive subscale 
1554 
b. Bayley Language subscale 
1555 
c. 
Bayley Motor subscale 
1556 
d. Bayley Social-Emotional subscale 
1557 
e. 
Bayley Adaptive Behavior subscale 
1558 
2. Contains domains: 
1559 
a. 
Functional Vision 
1560 
b. Bothered by Eyes and Vision 
1561 
c. 
Social  
1562 
d. Frustration / Worry 
1563 
e. 
Eyecare 
1564 
3. Contains domains 
1565 
a. 
Impact on Parent and Family 
1566 
b. Worry about Child’s Eye Condition 
1567 
c. 
Worry about Self-perception and Interactions 
1568 
d. Worry about Functional Vision 
1569 
4. Contains domains: 
1570 
a. 
Functional Vision 
1571 
b. Bothered by Eyes and Vision 
1572 
c. 
Social  
1573 
d. Frustration / Worry 
1574 
 
1575 
 
1576 
 
1577 
 Bayley Neurodevelopmental Outcomes   
1578 
Secondary neurodevelopmental outcomes will be determined at 2 years corrected age as 
1579 
measured by the Bayley Scales of Infant and Toddler Development Fourth Edition Test (Bayley-
1580 
IV, subsequently referred to as Bayley).  
1581 
 
1582 

JAEB CENTER FOR HEALTH RESEARCH 
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59 
The Bayley has five major component scales that are tested for each child: Cognitive, Language, 
1583 
Motor, Social-Emotional, and Adaptive Behavior.  
1584 
 
1585 
Scores for each scale range from 45 to 155, with a SD of 15. The neurodevelopment analysis will 
1586 
follow a modified intent-to-treat (ITT) principle. Data will be included only from participants 
1587 
who complete the outcome at the time point in question. There will be no imputation of data for 
1588 
participants who are lost to follow-up or who die prior to a secondary outcome. Multiple 
1589 
imputation for missing data (other than death) will be performed as a secondary approach, and 
1590 
results of the analysis with imputation of missing data (other than death) will be assessed for 
1591 
consistency with the primary analysis. If the ITT with no imputation and analyses with 
1592 
imputation give inconsistent results, exploratory analyses will be performed to evaluate possible 
1593 
factors contributing to the difference.   
1594 
 
1595 
Table 4 gives the expected half-width of a 95% confidence interval around an observed 
1596 
difference for different number of outcomes expected at 1, 2, and 5 years corrected age, and 
1597 
possible standard deviations.  
1598 
 
1599 
Table 4. Expected Half-width of 95% Confidence Intervals for Various Total Sample Size 
1600 
and Standard Deviations    
1601 
 
1602 
Total 
Number of 
Outcomes 
SD = 13 
SD = 14 
SD = 15 
SD = 16 
SD = 17 
180  
(15% lost) 
+ 3.80 
+ 4.10 
+ 4.40 
+ 4.70 
+ 5.00 
170  
(20% lost) 
+ 3.95 
+ 4.25 
+ 4.55 
+ 4.85 
+ 5.15 
160  
(25% lost) 
+ 4.05 
+ 4.35 
+ 4.70 
+ 5.00 
+ 5.30 
 
1603 
At 2 years corrected age, each of the five Bayley composite subscale scores also will be 
1604 
categorized as normal, slightly impaired, or significantly impaired. Participants with scores 85 or 
1605 
higher are considered normal.72,75  Participants with scores 70 to 84 are considered slightly 
1606 
impaired; and participants with scores <70 are considered significantly impaired. The proportion 
1607 
of participants within each score category at 2 years corrected age visits will be compared to 
1608 
evaluate whether there is a difference in this outcome between randomized treatment groups. 
1609 
Depending on cell counts in each treatment group and Bayley category, an ordinal logistic 
1610 
regression model will be considered. 
1611 
 
1612 
 General Movements Assessment 
1613 
A certified general movements assessment (GMA) expert will review the video taken at 52 to 56 
1614 
weeks PMA and grade the infant’s movements as normal, absent, and abnormal as follows:    
1615 
• Normal: fidgety general movements are intermittently or continuously present 
1616 
• Absent: fidgety general movements are not observed or are sporadically present 
1617 
• Abnormal: fidgety general movements are exaggerated in speed and amplitude 
1618 

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60 
 
1619 
The proportion of infants with normal, absent, and abnormal gradings will be tabulated by 
1620 
treatment group.   
1621 
To explore whether or not the GMA is predictive of neurodevelopment at 2 years corrected age, 
1622 
an ordinal logistic regression model will be considered.  
1623 
 
1624 
 Wechsler Preschool and Primary Scale of Intelligence (WPPSI-IV), categorical. 
1625 
The overall WPPSI-IV score has cut points that will be tabulated in each treatment group: 
1626 
o below 70 is Extremely Low 
1627 
o 70-79 is Borderline 
1628 
o 80-89 is Low Average 
1629 
o 90-109 is Average 
1630 
o 110-119 is High Average  
1631 
o 120-129 is Superior 
1632 
o 130+ is Very Superior 
1633 
 
1634 
 PedEyeQ 
1635 
Rasch scores for each questionnaire item will be obtained from published look-up tables 
1636 
available at www.pedig.net. For each domain below, a score will be calculated for each participant 
1637 
and summarized by treatment group. Scores will also be converted to a 0-100 scale to aid in 
1638 
interpretation.  
1639 
 
1640 
• Child PedEyeQ: 
1641 
o Functional Vision 
1642 
o Bothered by Eyes and Vision 
1643 
o Social  
1644 
o Frustration / Worry 
1645 
• Proxy PedEyeQ: 
1646 
o Functional Vision 
1647 
o Bothered by Eyes and Vision 
1648 
o Social  
1649 
o Frustration / Worry 
1650 
o Eyecare 
1651 
• Parent PedEyeQ: 
1652 
o Impact on Parent and Family 
1653 
o Worry about Child’s Eye Condition 
1654 
o Worry about Self-perception and Interactions 
1655 
o Worry about Functional Vision 
1656 
 
1657 
8.8 Safety Analyses 
1658 
Ocular 
1659 
Ocular adverse events will be tabulated separately for eligible eyes at the time of enrollment 
1660 
receiving randomized treatment.  The total number of adverse ocular events occurring in each 
1661 
randomized group will be counted. For outcomes that are possible in each treatment group, the 
1662 

JAEB CENTER FOR HEALTH RESEARCH 
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61 
percentage of eyes experiencing each outcome at least once will be compared between treatment 
1663 
groups, separately for each outcome. If possible, correlation will be accounted for. Adverse 
1664 
events in fellow eyes will be tabulated separately in groups defined by how they were treated (or 
1665 
not treated) for ROP at investigator discretion.   
1666 
 
1667 
The following ocular adverse events are of primary interest:  
1668 
o Endophthalmitis 
1669 
o Retinal detachment 
1670 
o Cataract 
1671 
o Vitreous hemorrhage  
1672 
o Inflammation 
1673 
o Neovascular glaucoma 
1674 
o Iris neovascularization 
1675 
 
1676 
Systemic 
1677 
Systemic adverse events will be reported with treatment grouped two ways: 
1678 
 
1679 
The first grouping will be according to laterality and randomized treatment assignment (ITT 
1680 
groups): 
1681 
1.Unilateral participants randomized to laser 
1682 
2.Bilateral participants randomized to laser 
1683 
3.Unilateral participants randomized to bevacizumab 
1684 
4.Bilateral participants randomized to bevacizumab 
1685 
 
1686 
The second grouping will be per protocol, i.e. participants will be classified based upon how they 
1687 
were actually treated (or retreated), with infants who ever received bevacizumab included in one 
1688 
group and infants who never received bevacizumab included in the other, regardless of 
1689 
randomized treatment assignment.  
1690 
 
1691 
Systemic 
1692 
The following systemic adverse events are of primary interest: 
1693 
o Death 
1694 
o Serious adverse event (at least one) 
1695 
o Hospitalization (at least one) 
1696 
o Cardiovascular/cerebrovascular events 
1697 
▪ The change in systolic and diastolic blood pressure measures at 1, 2, 3, and 4-
1698 
weeks post-treatment  between treatment groups will be evaluated.  
1699 
▪ Non-fatal myocardial infarction 
1700 
▪ Non-fatal stroke (counted only if symptoms lasted at least 24 hours) 
1701 
▪ Death of unknown cause 
1702 
▪ Death attributed to cardiac, cerebral, hemorrhagic, embolic, or other vascular 
1703 
cause (does not need to be ischemic in origin) 
1704 
Notes: Transient ischemic attacks, angina, and possible myocardial infarction 
1705 
or stroke are not counted. ‘Nonfatal’ myocardial infarction or stroke require 
1706 
that the participant is alive at the end of the study. If not, only the death is 
1707 
counted. 
1708 

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62 
 
1709 
o Secondary systemic adverse events of interest: 
1710 
▪ For each MedDRA system organ class, percentage of participants with at least 
1711 
one event  
1712 
 
1713 
A tabulation of all study eye ocular, non-study eye ocular, and systemic adverse events will be 
1714 
tabulated according to treatment groups as described above. 
1715 
 
1716 
8.9 Protocol Adherence and Retention 
1717 
Protocol deviations will be tabulated by randomized treatment group.  
1718 
Visit and call completion will be tabulated by randomized treatment group. A flow chart will 
1719 
account for all participant visits and phone calls.  
1720 
8.10 Baseline Descriptive Statistics 
1721 
Baseline characteristics will be tabulated according to randomized treatment group, overall, and 
1722 
by completion (vs non-completion) of each follow-up visit. Baseline characteristics will also be 
1723 
tabulated according to mortality.   
1724 
8.11 Planned Interim Analyses 
1725 
There will be no formal stopping rules or interim analyses for futility, efficacy, or re-estimation 
1726 
of sample size.  
1727 
 
1728 
8.12 Sub-Group Analyses 
1729 
Subgroup analyses/assessments of effect modification (interaction) will be considered 
1730 
exploratory and will be pre-defined in the SAP. 
1731 
 
1732 

JAEB CENTER FOR HEALTH RESEARCH 
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63 
Chapter 9: Data Collection and Monitoring 
1733 
 
1734 
9.1 Case Report Forms and Data Collection  
1735 
The main study data will be collected through electronic case report forms (CRFs). These 
1736 
electronic CRFs from the study website are considered the primary source documentation. 
1737 
When data are directly collected in electronic case report forms, this will be considered the 
1738 
source data. Each participating site will maintain appropriate medical and research records for 
1739 
this trial, in compliance with ICH E6 and regulatory and institutional requirements for the 
1740 
protection of confidentiality of participants. 
1741 
 
1742 
9.2 Study Records Retention 
1743 
Study documents will be retained for a minimum of 3 years following the submission of the final 
1744 
financial report for the last grant cycle for which the study is conducted or 2 years following the 
1745 
date a marketing application is approved for the drug for the indication for which it is being 
1746 
investigated; or if not approved, 2 years after the IND is withdrawn, whichever is later. No 
1747 
records will be destroyed without the written consent of the sponsor. It is the responsibility of the 
1748 
sponsor to inform the investigators when study documents no longer need to be retained. 
1749 
 
1750 
9.3 Quality Assurance and Monitoring 
1751 
Designated personnel from the Coordinating Center will be responsible for maintaining quality 
1752 
assurance (QA) and quality control (QC) systems to ensure that the clinical portion of the trial is 
1753 
conducted and data are generated, documented and reported in compliance with the protocol, 
1754 
Good Clinical Practice (GCP) and the applicable regulatory requirements. Adverse events will be 
1755 
prioritized for monitoring. 
1756 
 
1757 
A risk-based monitoring (RBM) plan will be developed and revised as needed during the course 
1758 
of the study, consistent with the FDA “Guidance for Industry Oversight of Clinical 
1759 
Investigations — A Risk-Based Approach to Monitoring” (August 2013). Study conduct and 
1760 
monitoring will conform with 21 Code of Federal Regulations (CFR) 312. 
1761 
 
1762 
The data of most importance for monitoring at the site are participant eligibility and adverse 
1763 
events. Therefore, the RBM plan will focus on these areas. As much as possible, remote 
1764 
monitoring will be performed in real-time with on-site monitoring performed to evaluate the 
1765 
verity and completeness of the key site data. Elements of the RBM may include: 
1766 
• Qualification assessment, training, and certification for sites and site personnel 
1767 
• Oversight of Institutional Review Board (IRB) coverage and informed consent procedures 
1768 
• Central (remote) data monitoring: validation of data entry, data edits/audit trail, protocol 
1769 
review of entered data and edits, statistical monitoring, study closeout 
1770 
• On-site monitoring (site visits): source data verification, site visit report 
1771 
• Communications with site staff 
1772 
• Patient retention and visit completion 
1773 
• Quality control reports 
1774 
• Management of noncompliance 
1775 
• Documenting monitoring activities 
1776 
• Adverse event reporting and monitoring 
1777 

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64 
Coordinating Center representatives or their designees may visit the study facilities at any time in 
1778 
order to maintain current and personal knowledge of the study through review of the records, 
1779 
comparison with source documents, observation and discussion of the conduct and progress of 
1780 
the study. 
1781 
 
1782 
9.4 Protocol Deviations 
1783 
A protocol deviation is any noncompliance with the clinical trial protocol, GCP, or procedure 
1784 
requirements. The noncompliance may be either on the part of the participant, the investigator, or 
1785 
the study site staff. As a result of deviations, corrective actions are to be developed by the site 
1786 
and implemented promptly. 
1787 
 
1788 
The site PI/study staff is responsible for knowing and adhering to the JCHR IRB requirements 
1789 
(i.e., reporting qualifying deviations to the JCHR IRB within seven (7) calendar days of 
1790 
identification). Further details about the handling of protocol deviations will be included in the 
1791 
monitoring plan.
1792 
 
 
1793 

JAEB CENTER FOR HEALTH RESEARCH 
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65 
Chapter 10: Ethics/Protection of Human Participants 
1794 
 
1795 
10.1 Ethical Standard 
1796 
The investigator will ensure that this study is conducted in full conformity with Regulations for 
1797 
the Protection of Human Participants of Research codified in 45 CFR Part 46, 21 CFR Part 50, 
1798 
21 CFR Part 56, and/or the ICH E6. 
1799 
 
1800 
10.2 Institutional Review Boards 
1801 
The protocol, informed consent form(s), recruitment materials, and all participant materials will 
1802 
be submitted to the IRB for review and approval. Approval of both the protocol and the consent 
1803 
form must be obtained before any participant is enrolled. Any amendment to the protocol will 
1804 
require review and approval by the IRB before the changes are implemented to the study. All 
1805 
changes to the consent form will be IRB approved; a determination will be made regarding 
1806 
whether previously consented participants need to be re-consented. 
1807 
 
1808 
10.3 Informed Consent Process 
1809 
 Consent Procedures and Documentation 
1810 
Informed consent is a process that is initiated prior to the parent agreeing to have their child 
1811 
participate in the study and continues throughout the individual’s study participation. Extensive 
1812 
discussion of risks and possible benefits of participation will be provided to the participants and 
1813 
their families. Consent forms will be IRB-approved and the parent will be asked to read and 
1814 
review the document. The investigator will explain the research study to the parent and answer 
1815 
any questions that may arise. All parent(s) will receive a verbal explanation in-person or via 
1816 
phone/videoconference in terms suited to their comprehension of the purposes, procedures, and 
1817 
potential risks of the study and of their child’s rights as research participants. Parent(s) will have 
1818 
the opportunity to carefully review the consent form and ask questions prior to signing. 
1819 
 
1820 
The parent(s) should have the opportunity to discuss the study with their surrogates or think 
1821 
about it prior to agreeing to participate. The parent will sign the informed consent document 
1822 
prior to any procedures being done specifically for the study. The participants may withdraw 
1823 
consent at any time throughout the course of the trial. The parent will be provided with a copy of 
1824 
the informed consent document for their records. The rights and welfare of the participants will 
1825 
be protected by emphasizing to them that the quality of their medical care will not be adversely 
1826 
affected if they decline to participate in this study. 
1827 
 
1828 
 Participant and Data Confidentiality 
1829 
Participant confidentiality is strictly held in trust by the participating investigators, their staff, 
1830 
and the sponsor(s) and their agents. This confidentiality is extended to cover testing of biological 
1831 
samples and imaging in addition to the clinical information relating to participants. Therefore, 
1832 
the study protocol, documentation, data, and all other information generated will be held in strict 
1833 
confidence. No information concerning the study or the data will be released to any unauthorized 
1834 
third party without prior written approval of the sponsor. 
1835 
 
1836 
The study monitor, other authorized representatives of the Jaeb Center for Health Research, or 
1837 
representatives of the IRB may inspect all documents and records required to be maintained by 
1838 
the investigator, including but not limited to, medical records (office, clinic, or hospital) and 
1839 

JAEB CENTER FOR HEALTH RESEARCH 
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66 
pharmacy records for the participants in this study. The clinical study site will permit access to 
1840 
such records. 
1841 
 
1842 
The study participant’s contact information will be securely stored at each clinical site for 
1843 
internal use during the study. At the end of the study, all records will continue to be kept in a 
1844 
secure location for as long a period as dictated by local IRB and Institutional regulations. 
1845 
Study participant research data, which is for purposes of statistical analysis and scientific 
1846 
reporting, will be transmitted to and stored at the Jaeb Center for Health Research. Individual 
1847 
participants and their research data will be identified by a unique study identification number.  
1848 
 
1849 
To further protect the privacy of study participants, a Certificate of Confidentiality will be 
1850 
obtained from the NIH. This certificate protects identifiable research information from forced 
1851 
disclosure. It allows the investigator and others who have access to research records to refuse to 
1852 
disclose identifying information on research participation in any civil, criminal, administrative, 
1853 
legislative, or other proceeding, whether at the federal, state, or local level. By protecting 
1854 
researchers and institutions from being compelled to disclose information that would identify 
1855 
research participants, Certificates of Confidentiality help achieve the research objectives and 
1856 
promote participation in studies by helping assure confidentiality and privacy to participants 
1857 
 
1858 
The study data entry and study management systems used by clinical sites and by the Jaeb Center 
1859 
for Health Research Coordinating Center research staff will be secured and password protected. 
1860 
At the end of the study, all study databases will be de-identified and archived at the Jaeb Center 
1861 
for Health Research and made available to the public. 
1862 
 
1863 
 Future Use of Stored Specimens and Data 
1864 
After testing for VEGF levels, any remaining blood or serum samples will be saved in a de-
1865 
identified manner and possibly used for other studies in the future, but will not be used for whole 
1866 
genome sequencing or other such genetic testing that could reidentify the participants.  All 
1867 
samples will be destroyed once all analyses are completed, results and published, and it is 
1868 
determined samples no longer need to be saved for future studies.  
1869 
 
1870 

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