Refractive outcomes following anti-VEGF, vitrectomy, cryotherapy, and laser photocoagulation for retinopathy of prematurity: a systematic review and meta-analysis

Background Retinopathy of prematurity (ROP) survivors commonly develop myopia, yet refractive sequelae may differ substantially by treatment. We compared long term refractive outcomes after anti-VEGF, laser photocoagulation, cryotherapy, and vitrectomy. Methods A systematic review was performed using PubMed, Embase, Web of Science, and the Cochrane Library from inception to July 2025. We also screened records from a curated EndNote library. The primary outcomes were mean spherical equivalent (SE) and the prevalence of high myopia (SE ≤ −5.0 D). Pooled estimates were calculated using a DerSimonian and Laird random effects model. Prespecified subgroup analyses compared treatment zone (Zone I vs. Zone II or III) and monotherapy vs. combination therapy. Results Eighty-six studies, including 10,269 eyes were analyzed. Anti-VEGF had the least myopic pooled mean SE (−1.9 D) compared with laser (−3.8 D), cryotherapy (−5.8 D), and vitrectomy (−6.3 D). High myopia prevalence was 21.3% after anti-VEGF versus 42.6% after laser, and 55.4% to 58.6% after vitrectomy or cryotherapy. Compared with laser, anti-VEGF reduced the risk of high myopia (RR = 0.39; 95% CI: 0.25–0.61). Heterogeneity was moderate to high (I 2 = 52%–78%), and Egger’s tests were not significant ( p = 0.21 for SE; p = 0.37 for high myopia). Conclusion Among major ROP treatments, anti-VEGF was associated with the most favorable refractive outcomes, while cryotherapy and vitrectomy showed the highest myopic burden. These findings support incorporating long term refractive consequences and zone-specific risk into treatment selection and follow up planning.