Purpose To evaluate the long-term clinical outcomes after initial management with retinal laser photocoagulation (RLP) versus intravitreal bevacizumab (IVB) injection in identical twins with zone Ⅰ aggressive posterior retinopathy of prematurity (AP-ROP). Observations Identical female twins were born at a gestational age of 28 2/7 weeks, weighing 970 g and 1020 g. The twins were diagnosed with bilateral AP-ROP, referred to a different hospital due to unavilability of a neonatal intensive care unitand received different initial treatments. At a postmenstrual age of 32 6/7 weeks, the first-born infant underwent bilateral IVB (0.313 mg) injection, whereas the second-born infant received bilateral laser photocoagulation on the same day. To treat recurrence, the first-born infant underwent additional bilateral IVB reinjection at 10 weeks post-treatment, while the second-born infant underwent combined bilateral laser photocoagulation and IVB injection at 2 weeks post-treatment. After 10 years, the first-born infant's best corrected visual acuities (BCVAs) of the right and left eyes were 20/20 and 20/50, respectively. Both eyes showed complete retinal vascularization of the peripheral retina and an anatomically normal foveal contour on swept-source optical coherence tomography (SS-OCT). However, the second-born infant's BCVAs of the right and left eyes were 20/50 and 1-m finger-counting, respectively. Both eyes of the second-born infant showed panretinal chorioretinal atrophy due to laser scars, a flattened foveal contour with thin epiretinal membrane in the right eye, and loss of foveal curvature in the left eye on SS-OCT images, 10 years after the initial treatment. Moreover, severe myopia and astigmatism were observed in both eyes of the second-born infant, compared with those of the first-born infant during follow-up. Conclusion and importance These cases involving identical twins indicated that the effect of initial IVB injection for AP-ROP was superior to that of initial RLP in terms of functional and anatomical outcomes during a 10-year follow-up.