Sir,

We read with interest the study by Ells et al.1 The authors have succinctly highlighted the role of laser posterior to the neovascular ridge in severe retinopathy of prematurity (ROP) in a select group of patients.

Ells et al1 have themselves highlighted some of the limitations in their study. In addition, we feel, they could have nuanced the study findings.

Confluent laser treatment to larger avascular retina in Zone II ROP is likely to be more beneficial than secondary treatment to a small strip of vascular posterior retina while allowing skip areas in the avascular retina.2 We reckon that posterior laser to vascular retina should be considered as a last resort after treatment to avascular retina has been completed. This, especially, should be the case with the temporal retina in Zone II, where the macula shows temporal traction and accurate laser posterior to ridge is fraught with the risk of macular laser/foveal laser in an awake infant. In this regard, the ‘safer zones’ for such laser would be nasal, superior, and inferior. This could be a practical point of consideration for clinicians treating ROP.

Also it would be an overstatement to infer that laser treatment posterior to ridge results in rapid regression of ROP as the authors conclude. We have not seen this in the present study findings, and the progression of two eyes to retinal detachment belies the claim.

We agree with the authors that posterior retinal laser is a safe option of ROP treatment and it may have a role in reducing the chances of retinal detachment, but that remains to be proven with controlled trials.