Jalali and associates must be congratulated for their prospective series in which they report improved outcomes of laser photoablation for aggressive posterior retinopathy of prematurity (APROP).

The authors emphasized the importance of correcting systemic comorbidities in babies with APROP in their series, stating that among babies with a hemoglobin of <10 gm%, “packed cell/blood transfusions were encouraged in consultation with the neonatologist.” We would argue that this intervention may also have contributed to the good outcomes of laser treatment as we recently reported thrombocytopenia as a potentially treatable risk factor for APROP in our population of babies. We reported a near-complete resolution of the plus disease, vascular loops, and hemorrhages following platelet transfusions. The authors are urged to revisit their data for this factor. This may help to clarify how 26% of 19 eyes that required but did not undergo laser photoablation showed spontaneous resolution. These infants with “poor” systemic health may have been serendipitously corrected for known and unknown systemic parameters, causing disease resolution, especially in the subset of heavier babies.

Furthermore, the authors included “all cases of dilatation and tortuosity in zone 1 with or without flat neovascularization (FNV)” in their cohort. However, they do not elucidate how the FNV was managed. The PHOTO-ROP group suggested 2 options to manage FNV and the ischemic retina underlying it. The authors’ preferred method in managing this neovascular complex must be elaborated, which is essential in preventing progression.

The extent of disease in Zone 1 also needs clarification. An eye may be categorized as Zone 1 even if there is only a small posterior “dip” extending temporally into Zone 1 for 1 to 2 clock hours when the vast majority of the disease is in Zone 2. This will bias the outcome when comparing cases of true Zone 1 (360 degrees), which may have a poorer prognosis.

Lastly, the authors reported an incidence of Zone 1 ROP in 115 of 3654 preterm infants (3.14%). Their data are derived from an urban setting serving the sickest, most vulnerable infants that can afford better health care. This is unfortunately not a universal phenomenon. Over the past 3 years, our group has been involved in ROP screening using a tele-ophthalmology model in 23 centers from rural, semi-urban, and urban regions in southern India, with Bangalore as the epicenter. During this period, we have encountered an incidence of APROP that varied from 0% to 13% in the rural and semi-urban centers. Sixty-four of the 706 eyes (9.1%), from various centers received laser photocoagulation for Zone 1. This highlights the variable levels of neonatal care provided to infants born in developing middle-income countries where the sickest infants from rural areas either do not survive or are referred to higher centers in the cities, thus skewing the statistics. With improving neonatal care and survival in semi-urban and rural India, it will be interesting to study the trend of APROP in India and other countries experiencing the “third epidemic” in the years to come.