Prospective study of New Zealand infants with birth weight less than 1500 g and screened for retinopathy of prematurity: visual outcome at age 7-8 years

Visuospatial outcomes of a prospective national cohort of young adults with very low birthweight

BACKGROUND

Visuospatial processing is reportedly impaired in children born very preterm (VP) compared with full term (FT) controls but there are few data for VP adults.

METHODS

At 26-30 years, 225 very low birthweight (VLBW) adults (70% national cohort survivors) and 100 FT controls were assessed on motor-dependent visuospatial skills using the Block Design subtest of the Wechsler Adult Intelligence Scale, and nonmotor-dependent skills by the Benton Judgment of Line Orientation and Brixton Spatial Anticipation tests. A composite score was created by summing standardized scores for the three tests. MRI measures of cortical volume, thickness and surface area were obtained for 150 VLBW participants.

RESULTS

VLBW born adults performed less well than controls across all visuospatial measures and their composite score (P < 0.001), with moderate to large effect sizes (Cohen's ds = 0.41-0.82). Between group differences were not explained by current vision impairment, cerebral palsy, sex, ethnicity or socio-demographic factors. The unadjusted visuospatial composite score was significantly correlated with reduced cortical surface area and cortical volume, but few correlations remained significant after adjustment for age, sex and intracranial volume.

CONCLUSION

The visuospatial functioning of adults born VLBW is significantly poorer than their FT peers with only modest associations with cortical brain structure.

IMPACT

Previous reports have shown very preterm children have impaired visuospatial processing compared with term-born peers but only limited data address whether these impairments persist into adulthood. Visuospatial functioning, assessed by both motor and non-motor dependent tests, of adults born very low birthweight is significantly poorer than that of term-born peers. Poorer visuospatial functioning in this very low birthweight cohort is not explained by vision impairment and had only modest associations with cranial MRI brain structure. Persisting visuospatial impairment in very preterm adults may significantly impact quality of life. Early recognition of these difficulties could facilitate support strategies to improve outcomes.

Long-term ocular sequelae in preterm Thai infants: A comprehensive retrospective study

Prematurity can lead to various ocular conditions, including strabismus, refractive errors, amblyopia, and cataracts. However, comprehensive data on these outcomes in preterm Thai infants is limited. This study aimed to investigate the incidence of retinopathy of prematurity (ROP) and assess long-term ocular sequelae, such as cataracts, refractive errors, strabismus, and amblyopia, among preterm infants at Phramongkutklao Hospital. A retrospective review of medical records was conducted for premature infants screened for ROP between January 2011 and April 2022. Data were collected at birth, and follow-up visits were analyzed at 6 months, 1 year, and 2 years of age. The primary outcomes included the incidence of ROP and the prevalence of long-term ocular sequelae. A total of 308 preterm infants were included in the study. The incidence of ROP was found to be 31.5%. At the 2-year follow-up, the prevalence of cataracts was 0.65%, strabismus 14.4%, and amblyopia 6%. Refractive errors were observed in 51.8% of the infants, with 18.1% showing myopia and 33.7% hyperopia. Logistic regression analysis indicated that delayed growth and development (adjusted odds ratio = 13.28, 95% confidence interval: 1.83-96.68) and amblyopia (adjusted odds ratio = 19.65, 95% confidence interval: 2.85-135.54) were significantly associated with an increased risk of developing strabismus, after adjusting for confounding factors. The study identified an ROP incidence of 31.5% in the preterm cohort. At 2 years, long-term ocular sequelae included a prevalence of cataracts (0.65%), strabismus (14.4%), amblyopia (6%), and refractive errors (51.8%). Delayed growth and development, along with amblyopia, were found to elevate the risk of strabismus development significantly.

A comparative study of stereopsis in term and preterm children with and without retinopathy of prematurity

PURPOSE

To evaluate stereopsis in term-born, preterm, and preterm children with and without retinopathy of prematurity (ROP) and its treatment.

METHODS

The cross-sectional study included 322 children between 3 and 11 years of age born term or preterm, with or without ROP, and with or without treatment for ROP. The ROP treatments were laser therapy, intravitreal injection (IVI) of anti-vascular endothelial growth factor, or their combination. Stereoacuity was measured using the Titmus Stereo Test, and the results among various age groups were analyzed.

RESULTS

Stereopsis was found to improve with increasing age at testing (P < 0.001) across the entire study population. The term group exhibited significantly better stereoacuity than the preterm group (P < 0.001). At 3-5 years and 6-8 years, the preterm children without ROP exhibited significantly better stereoacuity than did those with ROP (P < 0.001 and P = 0.02, respectively); however, at 9-11 years, both groups exhibited similar stereoacuity (P = 0.34). The stereoacuity in the children with untreated ROP was similar to that of the children with treated ROP in all age groups (P > 0.05). No significant differences in stereopsis were identified between children with ROP treated with laser versus with IVI (P > 0.05). From multivariate analysis, younger age at testing (P = 0.001) and younger gestational age (P < 0.001) were associated with poorer stereopsis.

CONCLUSIONS

Stereopsis development gradually improved with age in all groups. The children born preterm exhibited poorer stereoacuity than those born term. Children with ROP treated with laser photocoagulation versus IVI may exhibit similar levels of stereoacuity. Younger age at testing and gestational age were independent risk factors for poorer stereoacuity.

The incidence, clinical features, and management of essential infantile esotropia in the United Kingdom. A British Ophthalmology Surveillance Unit (BOSU) study

BACKGROUND/OBJECTIVES

A national study was undertaken through the British ophthalmology surveillance unit (BOSU) to determine the incidence, presenting features and management of essential infantile esotropia (EIE) in the UK.

METHODS

Data from a prospective national observational study of newly diagnosed EIE presenting to clinicians in the United Kingdom over a 12-month period were collected. Cases with a confirmed diagnosis by a clinician of a constant, non-accommodative esotropia ≥20 prism dioptres (PD), presenting at ≤12 months, with no neurological or ocular abnormalities were identified through BOSU. Follow-up data were collected at 12 months.

RESULTS

A total of 57 cases were reported giving an incidence of EIE of 1 in 12,828 live births. The mean age of diagnosis and intervention were 7.05 ± 2.6 months (range 2-12) and 14.7 ± 4.9 months (range 6.5-28.1), respectively. Management was surgical in 59.6%, botulinum toxin alone in 22.8%, and 17.5% were observed. The preoperative angle of esotropia was smaller in the observation group (P = 0.04). The postoperative angle of esotropia was not statistically significant between botulinum toxin or surgery (P = 0.3), although the age of intervention was earlier in the botulinum group (P = 0.007). Early intervention (before 12 months of age) did not influence the post-intervention motor outcomes between 0 and 10 prism dioptres of esotropia (P = 0.78).

CONCLUSIONS

The incidence of EIE in the UK is considerably lower than reported in other population-based studies. The preferred method of treatment was surgical with earlier intervention in those treated with botulinum toxin. An early age of intervention (<12 months) did not influence motor outcomes.

Prevalence and causes of ocular disorders and visual impairment among preterm children in Ethiopia

OBJECTIVE

The aim of this study was to determine the prevalence, causes of ocular disorders and visual impairment among preterm children previously admitted to neonatal intensive care units in Addis Ababa, Ethiopia.

METHODS AND ANALYSIS

A prospective screening survey was conducted from February to June 2019 at the paediatric eye clinic of Menelik II Hospital. Children who were preterm at birth and who attended the eye clinic were included in the study. Data on demographic and neonatal characteristics, neonatal and maternal comorbidities and ocular disorders were collected. OR and univariate analysis were used to identify predictors of ocular diseases and visual impairment.

RESULTS

There were 222 children included in the study with a mean age at presentation of 2.62 years (range 2.08-6.38 years), mean gestational age 34.11 weeks (range 30-36) weeks and mean birth weight 1941.72 g (range 953-3500 g). Nearly two-thirds had ocular disorders with refractive error (51.8%), strabismus (11.3%) and a history of retinopathy of prematurity (ROP) (7.2%) being more common. One-fourth of the children had visual impairment, and the prevalence of amblyopia was 40.1%. Uncorrected refractive errors, strabismus and ROP were causes for visual impairment.

CONCLUSION

Visual impairment and amblyopia are common in Ethiopia. There is a need to develop a screening protocol for ocular disorders for preterm children to enhance early detection and prevention of childhood visual impairment.

[Ophthalmological long-term sequelae of premature birth-Persisting into adulthood : Eye development and premature birth anamnesis]

BACKGROUND

Premature birth and the postnatal occurrence of retinopathy of prematurity (ROP) are the main risk factors for reduced visual acuity and blindness in childhood and adolescence accompanied by numerous morphological ocular changes.

OBJECTIVE

It can be assumed that these alterations persist throughout life and could represent a potential risk factor for ocular diseases, although little is known to date about the long-term effects of prematurity on ocular function and morphology in adulthood.

METHODS

The aim of the present study is to review the literature on the long-term effects of prematurity and associated factors.

RESULTS

Individuals born preterm exhibit reduced visual acuity, lower visual quality of life, and steeper corneal configuration in adulthood. Furthermore, individuals with advanced ROP and need for ROP treatment are at particularly high risk for myopic refractive error, the occurrence of strabismus, and increased lens opacities with thicker lenses. Low gestational age is associated with thinner peripapillary retinal nerve fiber layer thickness as well as thicker foveal retinal thickness and more frequent occurrence of foveal hypoplasia. In addition, data from the Gutenberg Health Study showed that low birth weight as a surrogate marker for prematurity and fetal growth restriction are associated with an increased prevalence of age-related macular degeneration as well as more frequently with diabetes and consequently diabetic retinopathy.

DISCUSSION

Premature birth and associated factors lead to life-long functional and morphological ocular changes. There is evidence that this can lead to retinal diseases later in life and thus, there appear to be fetal origins for adult eye disease. This may have implications for ophthalmic controls and its intervals in adulthood.

[Ophthalmic care of adults born preterm and full-term-results from the Gutenberg Prematurity Eye Study (GPES) : Premature birth and ophthalmological care]

BACKGROUND

Prematurity and the presence of retinopathy of prematurity (ROP) increase the risk for the occurrence of amblyogenic risk factors in childhood and adolescence.

AIM

The aim of the present study was to evaluate ocular morbidities and the ophthalmological care of former preterm and full-term persons in adulthood.

MATERIAL AND METHODS

The Gutenberg prematurity eye study (GPES) is a retrospective cohort study with a prospective ophthalmological examination of individuals formerly born preterm and full term between 1969 and 2002 (now aged 18-52 years). All participants underwent a detailed ophthalmological examination and were asked about the frequency of ophthalmological care. Participants were grouped into those with normal gestational age (GA) ≥ 37 weeks (control group), preterm individuals without ROP and GA 33-36 weeks (group 2), GA 29-32 weeks (group 3), GA ≤ 28 weeks (group 4), and those with ROP without treatment (group 5) and with ROP with treatment (group 6). All participants were asked if they had an ophthalmological examination within the last 12 months.

RESULTS

In total, data from 140 term and 310 preterm adults were included in the present study. Strabismus was present in 2.1 % (3/140), 6.6 % (9/137), 17.4 % (16/92), 11.1 % (2/18), 27.1 % (13/48) and 60 % (9/15) in groups 1-6, respectively. The proportion of subjects with an ophthalmological examination within the last 12 months was highest in the groups of extremely preterm persons with and without ROP compared with the control group. Overall, 33.3 % (1/3) of the term and 57.1 % (28/49) of the preterm subjects with strabismus and 0 % (0/3) of the term and 46.9 % (15/32) of the preterm individuals with amblyopia had an ophthalmological examination within the past 12 months.

DISCUSSION

Extremely preterm adults with and without postnatal ROP showed the highest rate of eye diseases as well as the highest rate of ophthalmological check-ups within the last 12 months. This suggests that extremely preterm adults particularly with the occurrence of postnatal ROP perceive more frequent ophthalmological check-ups throughout their lives.

Visual Acuity and Contrast Sensitivity in Preterm and Full-Term Children Using a Novel Digital Test

Visual assessment in preverbal children mostly relies on the preferential looking paradigm. It requires an experienced observer to interpret the child's responses to a stimulus. DIVE (Device for an Integral Visual Examination) is a digital tool with an integrated eye tracker (ET) that lifts this requirement and automatizes this process. The aim of our study was to assess the development of two visual functions, visual acuity (VA) and contrast sensitivity (CS), with DIVE, in a large sample of children from 6 months to 14 years (y) of age, and to compare the results of preterm and full-term children. Participants were recruited in clinical settings from five countries. There were 2208 children tested, 609 of them were born preterm. Both VA and CS improved throughout childhood, with the maximum increase during the first 5 years of age. Gestational age, refractive error and age had an impact on VA results, while CS values were only influenced by age. With this study we report normative reference outcomes for VA and CS throughout childhood and validate the DIVE tests as a useful tool to measure basic visual functions in children.

Retinopathy of prematurity screening: A narrative review of current programs, teleophthalmology, and diagnostic support systems

PURPOSE

Neonatal care in middle-income countries has improved over the last decade, leading to a "third epidemic" of retinopathy of prematurity (ROP). Without concomitant improvements in ROP screening infrastructure, reduction of ROP-associated visual loss remains a challenge worldwide. The emergence of teleophthalmology screening programs and artificial intelligence (AI) technologies represents promising methods to address this growing unmet demand in ROP screening. An improved understanding of current ROP screening programs may inform the adoption of these novel technologies in ROP care.

METHODS

A critical narrative review of the literature was carried out. Publications that were representative of established or emerging ROP screening programs in high-, middle-, and low-income countries were selected for review. Screening programs were reviewed for inclusion criteria, screening frequency and duration, modality, and published sensitivity and specificity.

RESULTS

Screening inclusion criteria, including age and birth weight cutoffs, showed significant heterogeneity globally. Countries of similar income tend to have similar criteria. Three primary screening modalities including binocular indirect ophthalmoscopy (BIO), wide-field digital retinal imaging (WFDRI), and teleophthalmology were identified and reviewed. BIO has documented limitations in reduced interoperator agreement, scalability, and geographical access barriers, which are mitigated in part by WFDRI. Teleophthalmology screening may address limitations in ROP screening workforce distribution and training. Opportunities for AI technologies were identified in the context of these limitations, including interoperator reliability and possibilities for point-of-care diagnosis.

CONCLUSION

Limitations in the current ROP screening include scalability, geographical access, and high screening burden with low treatment yield. These may be addressable through increased adoption of teleophthalmology and AI technologies. As the global incidence of ROP continues to increase, implementation of these novel modalities requires greater consideration.

Visual acuity, amblyopia, and vision-related quality of life in preterm adults with and without ROP: results from the Gutenberg prematurity eye study

Objectives

This study investigated the effects of prematurity and ROP on visual acuity and VRQoL in adults (18–52 years).

Methods

The Gutenberg Prematurity Eye Study is a retrospective cohort study with a prospective ophthalmologic examination. Preterm and full-term participants at an age from 18 to 52 years were included. Distant corrected visual acuity (DCVA) and VRQoL were assessed in participants (892 eyes of 450 individuals aged 28.6 ± 8.6 years, 251 females) grouped into full-term controls (gestational age [GA] at birth ≥37 weeks), preterm participants without ROP and GA 33–36 weeks (group 2), GA 29–32 weeks (group 3), GA ≤ 28 weeks (group 4), non-treated ROP (group 5) and treated ROP (group 6). Main outcome measures were distant corrected visual acuity (DCVA), VRQoL and prevalence of amblyopia.

Results

The DCVA of the better eye correlated (p < 0.001) with GA, birth weight, ROP, ROP treatment, and perinatal adverse events and was poorer in both ROP groups. Visual acuity of <20/200 in the better eye was observed in two participants (4.2%) in the ROP group and one person (6.7%) in the treated ROP group. The prevalence of amblyopia increased in the ROP groups. Compared to full-term controls, visual functioning VRQoL scores were lower in preterm individuals independent of ROP while socioemotional VRQoL scores were only lower in the treated ROP group.

Conclusion

Participants with postnatal ROP and its treatment showed decreased visual acuity and VRQol in adulthood, with amblyopia occurring more frequently in more preterm participants with ROP.

Real-World Visual Outcomes of Laser and Anti-VEGF Treatments for Retinopathy of Prematurity

PURPOSE

To characterize visual outcomes in children screened for retinopathy of prematurity (ROP).

DESIGN

Retrospective, interventional case series.

METHODS

Patients who received ROP screening examinations at UCLA Medical Centers and were followed with outpatient eye examinations at Stein Eye Institute and/or Doheny Eye Institute (Los Angeles, California) were included. Data were collected on birth characteristics, worst type of ROP, and ROP treatment. Adverse visual outcomes included myopia, strabismus, amblyopia, macular dragging, and optic atrophy. Snellen visual acuity was reported for children 4 years and older.

RESULTS

A total of 175 infants (350 eyes) were included for analysis (mean gestational age = 28.2 weeks and birth weight = 1059 g) from a screening population of 539 infants (1078 eyes, 32.4% follow-up) over a 9-year period. Fifteen eyes received primary anti-vascular endothelial growth factor (anti-VEGF) therapy, whereas 59 eyes received primary laser therapy. Primary anti-VEGF therapy, as compared with primary laser treatment, was associated with a decreased incidence of amblyopia (adjusted odds ratio [aOR] = 0.6-0.86, P < .0001) after controlling for gestational age and birth weight. The rates of optic atrophy (P = .79), strabismus (P = .98), and myopia (P = .93) were not different between anti-VEGF and laser treatment groups. Infants receiving anti-VEGF therapy had more posterior disease than laser-treated infants (P = .041). Infants receiving laser therapy were more likely to have severe myopia (aOR = 1.02-1.3, P = .023), amblyopia (aOR = 1.12-1.61, P = .002), and optic atrophy (aOR = 1.01-1.32, P = .045) than infants not treated.

CONCLUSION

These findings add to the advantages of anti-VEGF treatment compared with primary laser treatment, particularly in posterior ROP.

[Ocular abnormalities of children born prematurely at the Yaoundé Gynaeco-Obstetrics And Pediatric Hospital]

PURPOSE

To identify ocular abnormalities in premature children in order to treat reversible visual disorders and help prevent low vision and blindness in this population at risk.

METHODOLOGY

This was a cross-sectional, analytical study carried out from November 1, 2018 to July 31, 2019 at the Yaoundé Gyneco-Obstetric And Pediatric Hospital, including premature children, aged 3 to 15 years. The variables studied were age, sex, prenatal, birth and past ophthalmological history, visual acuity, oculomotor examination and fundus examination. For statistical analysis, we used the epi-info software 3.5.4, the Chi² test, odds ratio and a 95% confidence interval with a significance P<0.05.

RESULTS

Of the 50 patients examined, the mean age was 6.02 years±2.58. Of the 22 optically corrected patients, hyperopia and hyperopic astigmatism were predominant (70.5%) (n=31). Distance visual acuity, measured in 31 cooperative patients (62 eyes), was between 3/10 and 8/10 in 14 eyes (22.6%), and<3/10 in two eyes (3.2%). Strabismus was present in 21 patients (42%), of which 13 cases were esotropia (61.9%). Tropical endemic limbo-conjunctivitis was found in eight eyes (8%). There were no cases of retinopathy of prematurity. Very low birth weight (<1500g) and neonatal resuscitation were associated with strabismus.

CONCLUSION

Ocular abnormalities in preterm infants are dominated by strabismus, which is associated with very low birth weight and neonatal resuscitation.

Strabismus, stereoacuity, accommodation and convergence in young adults born premature and screened for retinopathy of prematurity

PURPOSE

The aim of the study was to evaluate strabismus, stereoacuity, accommodation and convergence in prematurely born young adults; screened for retinopathy of prematurity in the neonatal period and compare with term-born individuals of the same age.

MATERIALS AND METHODS

The study participants included 59 prematurely born individuals with a birthweight of ≤1,500 grams and 44 term-born controls, all born during 1988-1990 in Stockholm County, Sweden. Ocular alignment was assessed with a cover test, stereoacuity with the TNO stereo test and the amplitude of accommodation and the near point of convergence with the Royal Air Force Rule.

RESULTS

Seven of 59 (12%) preterms had manifest strabismus, 4/59 (7%) had esotropia and 3/59 (5%) exotropia. One of 44 (2%) controls had esotropia; no other controls had manifest strabismus. Stereoacuity was within normal limits in 38/59 (64%) preterms and 43/44 (98%) controls, p < 0.01; the difference remained after excluding those with strabismus. A neurological complication at 2.5 years of age was the strongest risk factor for subnormal stereoacuity within the preterm group after excluding those with strabismus. The mean amplitude of accommodation was poorer in the preterms than the controls in better (p < 0.05) and worse eyes (p < 0.05). The preterms were more likely to have an amplitude of accommodation below the minimum, according to Hofstetter's equation. There were no differences between the groups regarding the near point of convergence.

CONCLUSION

Prematurely born young adults had a higher prevalence of strabismus, reduced stereoacuity and worse amplitude of accommodation than term-born controls.

Long-term visual outcomes of children screened for retinopathy of prematurity with telemedicine in New Zealand

CLINICAL RELEVANCE

Children with a history of regressed retinopathy of prematurity (ROP) are at increased risk of peripheral avascular retina. Wide-field digital retinal imaging and telemedicine is an effective tool for ROP screening. Ophthalmologists and Optometrists should have a high level of clinical suspicion for peripheral retinal changes in children screened for ROP.

BACKGROUND

Retinopathy of prematurity, a vaso-proliferative disorder of the pre-term retina, is a preventable cause of childhood visual impairment. The Auckland Regional Telemedicine ROP (ART-ROP) network, established in 2006, utilises wide-field digital imaging and telemedicine to screen at-risk infants for ROP. This prospective observational study reports the long-term ocular outcomes of ART-ROP network infants.

METHODS

A comprehensive paediatric eye examination including cycloplegic autorefraction and wide-field retinal imaging was completed on all participants. Participants had been screened for ROP by the ART-ROP network between May 2008 and October 2011.

RESULTS

A total of 69 children, with a mean age of 5 to 8 years old were assessed and divided into two groups: those with or without a history of ROP, 44 and 25 children, respectively. Infants with a history of ROP had significantly lower gestational age (26.6 ± 1.9 vs. 29.1 ± 1.6 weeks, p < 0.001) and birth weight (937 ± 237 vs. 1177 ± 311 grams, p = 0.001). No significant differences were detected between the two groups for visual acuity (p = 0.596), stereopsis (p = 0.219), refractive error (p = 0.472), or strabismus. Clinically significant refractive error was noted in 10 participants; none with moderate or high myopia. Retinal imaging exposed asymptomatic, persistent, peripheral avascular retina in four children, all of whom had a history of regressed ROP.

CONCLUSION

Visual and ocular outcomes did not vary based on history of ROP, with no participant having reduced vision as a result of undetected or untreated ROP. Further research is required into the long-term implication of persistent avascular retina in regressed ROP.

Refraction and its development in young adults born prematurely and screened for retinopathy of prematurity

PURPOSE

To evaluate refraction and its development in young adults born prematurely, screened for retinopathy of prematurity, and to compare with individuals of the same age born at term.

MATERIALS AND METHODS

The participants were 59 preterms, with a birthweight of ≤ 1500 g, and 43 term-born controls, all born during 1988-1990. The refraction was measured in cycloplegia, and the spherical equivalent (SE) was calculated. The axial length (AL), anterior chamber depth and corneal radius (CR) were measured, and the AL/CR ratio was calculated.

RESULTS

The mean SE was -0.5 dioptres (D) (SD 2.5) in right eyes (REs) and -0.4 D (SD 2.3) in left eyes (LEs) of preterms, and -0.2 D (SD 1.5) in REs and -0.2 D (SD 1.5) in LEs of controls. The distribution of refraction was wider in the preterm group compared to the control group. In the preterm group, 12% had a SE ≥ 1.5 D, but none of the controls. Ten preterms, but none of the controls, had anisometropia ≥ 1.0 D. The prevalence of astigmatism ≥ 1.0 D was higher in preterms than controls. The SE decreased around 1 D in both preterms and controls from 10 to 25 years of age. The AL and CR were shorter in the preterms; however, the AL/CR ratio was similar in both groups. Within the preterm group, cryotherapy was correlated with astigmatism, but not with SE and anisometropia at this age.

CONCLUSION

Prematurely born individuals had higher prevalence of refractive errors in young adulthood compared to term-born controls.

Assessment and management of retinopathy of prematurity in the era of anti-vascular endothelial growth factor (VEGF)

The incidence of retinopathy of prematurity (ROP) continues to rise due to the improved survival of very low birth weight infants in developed countries. This epidemic is also fueled by increased survival of preterm babies with variable use of oxygen and a lack of ROP awareness and screening services in resource-limited regions. Improvements in technology and a basic understanding of the disease pathophysiology have changed the way we screen and manage ROP, educate providers and patients, and improve ROP awareness. Advancements in imaging techniques, expansion of telemedicine services, and the potential for artificial intelligence-assisted ROP screening programs have created opportunities to improve ROP care in areas with a shortage of ophthalmologists trained in ROP. To address the gap in provider knowledge regarding ROP, the Global Education Network for Retinopathy of Prematurity (GEN-ROP) created a web-based tele-education training module that can be used to educate all providers involved in ROP, including non-physician ROP screeners. Over the past 50 years, the treatment of severe ROP has evolved from limited treatment modalities to cryotherapy and laser photocoagulation. More recently, there has been growing evidence to support the use of anti-vascular endothelial growth factor (VEGF) agents for the treatment of severe ROP. However, VEGF is known to be important in organogenesis and microvascular maintenance, and given that intravitreal anti-VEGF treatment can result in systemic VEGF suppression over a period of at least 1-12 weeks, there are concerns regarding adverse effects and long-term ocular and systemic developmental consequences of anti-VEGF therapy. Future research in ophthalmology to address the growing burden of ROP should focus on cost-effective fundus imaging devices, implementation of artificial intelligence platforms, updated treatment algorithms with optimal use of anti-VEGF and careful investigation of its long-term effects, and surgical options in advanced ROP. Addressing these unmet needs will aid the global effort against the ROP epidemic and optimize our understanding and treatment of this blinding disease.

Association of Birth Weight With Foveolar Thickness in Adulthood: Results From a Population-Based Study

Purpose

Low birth weight (BW) is associated with alterations of foveal shape development in childhood-leading to an increased retinal thickness of the fovea. The aim of the present study was to assess whether BW has a long-term effect on foveal retinal thickness (RT) and is still present in adulthood.

Methods

In the German population-based Gutenberg Health Study (GHS), participants were examined with spectral-domain optical coherence tomography. The association between self-reported BW and RT in the foveolar and perifoveal locations was assessed. Multivariable linear regression analyses with adjustment for potential confounders and grading of foveal hypoplasia were performed.

Results

Overall, RT measurements and self-reported BW were available for 2,539 participants (1300 female, mean age 54.5 ± 9.7 years). The absolute foveolar RT was 239.6 ± 25.8 µm, 232.2 ± 20.1 µm and 234.8 ± 21.0 µm, respectively, in the low (<2500 g), normal (2500-4000 g) and high (>4000 g) BW groups (P < 0.001). After adjustment for confounders, an association was observed between lower BW and increased foveolar thickness (B = -0.35 [95% confidence interval {CI}: -0.49; -0.20] µm/100 g; P < 0.001), whereas only a weak association with RT was observed with the nasal (P = 0.010), temporal (P = 0.011), and inferior (P = 0.021) quadrants in the 1 mm distance, with no association in the 2 mm distance to the fovea. Foveal hypoplasia grade 1 was more frequent in the low BW group (6.8%) compared to the normal (0.9%) and high BW group (1.2%).

Conclusions

This study provides evidence of an association between lower BW and increased foveolar thickness and foveal hypoplasia, indicating that prenatal growth may affect macular morphology, which in turn may persist until adulthood and predispose to retinal disease later in life.

Early visual and neuro-development in preterm infants with and without retinopathy

BACKGROUND

Retinopathy of prematurity (ROP) is often associated with visual impairment and multiple developmental disabilities.

AIMS

As most of the previous studies include infants with brain lesions, that can determine visual impairment per se, a cohort of low neurological risk preterm infants without ROP and with various degree of severity of ROP was assessed in order to establish visual and neurodevelopmental outcome.

STUDY DESIGN

Preterm infants born at <31 weeks gestation, without major brain lesions, underwent visual function assessment at 1 year corrected age and neurodevelopmental assessment at 2 years corrected age.

SUBJECTS

One hundred and five infants were included in the study: 42 infants did not develop ROP, 7 reached stage 1 in zone 2 ROP, 37 reached prethreshold (untreated) type 2 ROP. The remaining 19 infants were classified as type 1 ROP.

OUTCOME MEASURES

Visual function (including fixing, tracking, visual acuity, visual field, attention at distance and nystagmus) were assessed at 12 months corrected age and Griffiths Scales at 2 years corrected age.

RESULTS

The severity of ROP was strongly correlated (p < 0.001) with both visual function at 1 year and neurodevelopment at 2 years. Similarly, the presence of nystagmus was also strongly correlated with visual and neurodevelopmental sequelae.

CONCLUSIONS

Infants with no or milder retinopathy showed normal visual function at 1 year and neurodevelopment at 2 years. Infants who underwent treatment more frequently showed abnormal results on several aspects of visual function. Presence of nystagmus appeared to increase the risk for abnormal visual function and neurodevelopmental outcome.

Amblyopia Risk Factors in Premature Children in the First 3 Years of Life

PURPOSE

To determine the incidence of amblyopia risk factors during the first 3 years of life in premature children.

METHODS

This prospective cohort included 145 premature children (gestational age of less than 37 weeks) who were evaluated for amblyopia risk factors every 6 months until age 3 years. The incidence rate, cumulative incidence, and prevalence of any amblyopia risk factor were assessed in retinopathy of prematurity (ROP) and non-ROP screened groups. Multivariate logistic regression was performed to evaluate variables associated with the development of an amblyopia risk factor.

RESULTS

The 3-year incidence rates of amblyopia risk factors were similar between the non-ROP and ROP screened groups (18 versus 19 cases per 1,000 person-years, respectively). The 3-year cumulative incidence was also similar: 32% (95% confidence interval [CI]: 18 to 47) in the non-ROP and 14% (95% CI: 5 to 28) in the ROP screened group (P > .05). In the ROP screened group, the prevalence rates were 20% or greater at most time points. In the non-ROP screened group, the prevalence rates were 11% to 14% during the first 18 months and increased to more than 20% at 24 months and thereafter. Astigmatism was the most prevalent amblyopia risk factor in both groups (7% to 18%).

CONCLUSIONS

The incidence of amblyopia risk factors was not significantly different between non-ROP and ROP screened children in our cohort. The prevalence of refractive errors among premature non-ROP screened children was higher than that reported in childhood in the literature. It may be appropriate to screen all children with a history of prematurity for refractive errors around 24 months of age. [J Pediatr Ophthalmol Strabismus. 2019;56(2):88-94.].

Comparative study of visual dysfunctions in 6-10-year-old very preterm- and full-term-born children

PURPOSE

To compare visual dysfunction between very preterm-born (VPB) children with no retinopathy of prematurity (no-ROP) at 6-10 years of age and age- and sex-matched full-term-born controls.

METHODS

This is an observational, prospective study that included 30 children, 6-10 years of age, born ≤ 32 weeks of gestation, with no-ROP, and 30 age- and sex-matched full-term-born controls, conducted from January 2015 until August 2015. All children underwent complete ophthalmic evaluation. Main outcome measures include visual functions (best corrected visual acuity (BCVA), color vision, and stereoacuity), ocular alignment, refractive errors, and the presence of amblyopia and nystagmus.

RESULTS

Mean BCVA of the right eyes was 0.04 ± 0.08 logMAR for VPB children and 0.02 ± 0.05 logMAR for the full-term children (P = 0.075). Mean BCVA for the left eyes was 0.07 ± 0.09 logMAR for VPB children and 0.02 ± 0.05 logMAR for the full-term children (P = 0.014). Refractive errors were slightly higher though not statistically significant in VPB children compared to full-term children (P = 0.125). The incidence of myopia and hypermetropia was 16.7 and 40%, respectively, in VPB children and 10 and 23.3%, respectively, in full-term children. Anisometropia found only in VPB children with an incidence of 16.7%. Amblyopia found in 10% of VPB children compared to 3.3% in full-term children. Strabismus was found equally in 10% of each group.

CONCLUSION

VPB children with no-ROP are at an increased risk of developing decreased BCVA at least in one eye and anisometropia compared to age-matched full-term controls.

Association of low birth weight with myopic refractive error and lower visual acuity in adulthood: results from the population-based Gutenberg Health Study (GHS)

Purpose

Low birth weight (BW) is linked to impaired organ development in childhood, including altered ocular morphological and functional development. The aim of this study was to evaluate whether low BW has long-term effects on visual acuity and refraction in adulthood.

Methods

The Gutenberg Health Study is a population-based, observational cohort study in Germany, including 15 010 participants aged between 35 and 74 years. These participants were divided into three different BW groups (low: <2500 g; normal: between 2500 and 4000 g; and high: >4000 g). Best-corrected visual acuity and objective refraction were examined. We used multivariable linear regression models with adjustment for age, sex, socioeconomic status and self-reported glaucoma, age-related macular degeneration, corneal disease and cataract to assess associations between BW and the main outcome measures, best-corrected visual acuity, spherical equivalent and astigmatism.

Results

Overall, 8369 participants reported their BW. In a multivariable analysis, an association for low BW with spherical equivalent (B=−0.28 per dioptre, P=0.005) and best-corrected visual acuity (B=0.02 logarithm of the minimum angle of resolution, P=0.006) compared with normal BW was observed. For participants with high BW, an association was observed with spherical equivalent (B=0.29 per dioptre, P<0.001), while none with visual acuity.

Conclusions

Our data demonstrated that low BW is linked to visual acuity and refractive long-term outcomes long after childhood. Individuals with low BW are more likely to have lower visual acuity and a higher myopic refractive error in adulthood. Adults with high BW are more likely to have a more hyperopic refractive error.

Vision in former very low birthweight young adults with and without retinopathy of prematurity compared with term born controls: the NZ 1986 VLBW follow-up study

Objective

There are few data on visual outcomes in adulthood of former very low birthweight (VLBW; <1500 g) infants. We aimed to assess vision at 27–29 years in a national cohort of VLBW infants born in 1986 and assessed for retinopathy of prematurity (ROP) when no treatment was available, compared with term born controls.

Methods

The cohort and controls attended a 2-day assessment in Christchurch as part of a larger study. Visual assessment included glasses prescription measured by focimeter, logarithm of the minimum angle of resolution (logMAR) distance visual acuity (VA), contrast sensitivity, autorefraction, retinal photographs and a questionnaire on vision-related everyday activities. Rates of reduced VA and myopia in the VLBW cohort at 27–29 were compared with the results of vision testing at 7–8 years.

Results

250 VLBW adults (77% those alive) gave study consent and 229 (45 with a history of ROP) were assessed in Christchurch, plus 100 term born controls. VLBW adults with ROP had reduced VA compared with no ROP and controls (mean logMAR score (SD); 0.003 (0.19), –0.021 (0.16), –0.078 (0.09), P=0.001). There were no differences in myopia (>2 D) between the groups but high myopia (>5 D) was confined to those with ROP. VLBW adults with ROP drove a car less often and had higher difficulties with everyday activities scores due to eyesight. Between 7–8 and 27–29 years rates of reduced VA were stable but myopia increased.

Conclusion

Former VLBW young adults with ROP have ongoing problems with vision affecting daily living and should continue in regular ophthalmological review.

Trial registration number

ACTRN12612000995875, Pre-results .

Pathophysiology, screening and treatment of ROP: A multi-disciplinary perspective

The population of infants at risk for retinopathy of prematurity (ROP) varies by world region; in countries with well developed neonatal intensive care services, the highest risk infants are those born at less than 28 weeks gestational age (GA) and less than 1 kg at birth, while, in regions where many aspects of neonatal intensive and ophthalmological care are not routinely available, more mature infants up to 2000 g at birth and 37 weeks GA are also at risk for severe ROP. Treatment options for both groups of patients include standard retinal laser photocoagulation or, more recently, intravitreal anti-VEGF drugs. In addition to detection and treatment of ROP, this review highlights new opportunities created by telemedicine, where screening and diagnosis of ROP in remote locations can be undertaken by non-ophthalmologists using digital fundus cameras. The ophthalmological care of the ROP infant is undertaken in the wider context of neonatal care and general wellbeing of the infant. Because of this context, this review takes a multi-disciplinary perspective with contributions from retinal vascular biologists, pediatric ophthalmologists, an epidemiologist and a neonatologist. This review highlights the latest insights regarding cellular and molecular mechanisms in the formation of the retinal vasculature in the human infant, pathogenesis of ROP, detection and treatment of severe ROP, the risks and benefits of anti-VEGF therapy, the identification of new therapies over the horizon, and the optimal neonatal care regimen for best ROP outcomes, and the benefits and pitfalls of telemedicine in the remote screening and diagnosis of ROP, all of which have the potential to improve ROP outcomes.

Refractive errors characteristic of the patients at the Children's Ophthalmology Outpatient Department of Kauno klinikos Hospital (Lithuanian University of Health Sciences) from 1 January 2012 to 31 December 2012

BACKGROUND

The purpose of our study was to assess the distribution and patterns of refractive errors in children for the proper planning of paediatric eye care at the centre.

MATERIAL AND METHODS

The study was conducted in the hospital of the Lithuanian University of Health Sciences in Kaunas, from 1 January 2012 to 31 December 2012. During this period, a total of 11,406 children, aged 0-18 years, were evaluated at the outpatient department of paediatric ophthalmology, Kauno klinikos, the Lithuanian University of Health Sciences. All the children underwent a complete ophthalmic examination with cycloplegic refraction.

RESULTS

Myopia increased from 1.5% (95% CI:1.2, 1.8) in the age group of 0-1 to 44.7% (95% CI:43.46, 45.94) in the age group of 14-18 (p < 0.001). Myopia was associated with older age, female gender (20.3%; 95% CI:19.3, 21.3; p < 0.001). Hypermetropia decreased from 84.6% (95% CI:83.7, 85.5) in the cohort of 0-1 to 11.4% (95% CI: 10.61, 12.19) in the 14-18 age group (p < 0.001). Hypermetropia was associated with younger age, male gender (43.4%; 95% CI:42.16, 44.64; p < 0.001), preterm birth (56.1%; 95% CI:54.86, 57.34; 43.4%; p < 0.001), low birth weight (61.8%; 95% CI:60.59, 63.01; p < 0.001), and birth by Caesarean section (57.1%; 95% CI: 55.87; 58.33) (p < 0.001). The prevalence of astigmatism was 25.5% (95% CI: 24.41; 26.59) (p < 0.001). Astigmatism was associated with female gender (20.1%; 95%. CI: 19.1; 21.1) and too big pregnancy weight (22.1%.; 95%. CI: 21.06; 23.14) (p < 0.001).

CONCLUSIONS

Of the 14-18 age group, 44.7% of the patients were myopic. Of the 0-1 age group, 84.6% were hypermetropic. Astigmatism was detected in about 25.5% of children. The prevalence of refractive errors was associated with age, gender, gestation age, gestation weight, and parental refractive error.

Ophthalmologic Outcomes of Children Born Premature Without ROP: Correlations With Gestational Age and Psychomotor Development

PURPOSE

To study ophthalmological outcomes of premature children with no retinopathy of prematurity (ROP) and correlate with neurodevelopmental outcomes.

METHODS

A total of 69 former preterm infants were evaluated at 2 to 7 years of age. Detailed ophthalmologic examinations were performed. Neurodevelopment was assessed using the Peabody Developmental Motor Scale and Wechsler Preschool and Primary Scale of Intelligence. Another 69 healthy children served as controls.

RESULTS

The 69 preterm children (38 of 69 boys) and 69 controls (38 of 69 boys) had a mean age of 4.9 ± 1.5 and 4.9 ± 1.4 years, respectively. Compared to controls, preterm infants had vision impairment of 19% versus 1.4% (P = .001), hyperopia of 87% versus 98.5% (P = .21), myopia of 11% versus 1.4% (P = .017), and astigmatism of 39% versus 30.4% (P = .37). Children with any motor disability tended to have worse vision.

CONCLUSIONS

In the absence of ROP, hyperopia was more common in infants 32 weeks or older who weighed more than 1,500 g at birth; other vision problems were similar in subgroups. This may represent impending myopia in those younger than 32 weeks weighing less than 1,500 g. [J Pediatr Ophthalmol Strabismus. 2017;54(1):32-38.].

Strabismus at Age 2 Years in Children Born Before 28 Weeks' Gestation: Antecedents and Correlates

Children born very preterm are at greater risk of ophthalmic morbidities, including strabismus, than children born at term. We evaluated perinatal factors associated with strabismus at age 2 years in a large population of infants delivered before 28 weeks' gestation. A total of 996 infants in the multicenter ELGAN (Extremely Low Gestational Age Newborn) study who had a retinal exam in infancy and a developmental assessment at 2 years corrected age are included. Their mothers were interviewed about the pregnancy, and both mother and newborn charts were reviewed. Certified examiners administered the Bayley Scales of Infant Development-II and performed an examination of ocular alignment. Time-oriented logistic regression risk models were created to evaluate the associations of characteristics and exposures with the development of strabismus. Overall, 14% (n = 141) of the children had strabismus at 2 years, and 80% of strabismic children had esotropia. Characteristics associated with strabismus were birth before 26 weeks' gestation, severe fetal growth restriction, and maternal history of aspirin ingestion. Associated postnatal factors included a SNAP-II (Score for Neonatal Acute Physiology) illness severity value ≥ 30, brain ventriculomegaly, type I retinopathy of prematurity, and ventilator-dependent severe bronchopulmonary dysplasia. Strabismus in very preterm populations is associated with a number of antenatal and postnatal antecedents as well as clinical and imaging correlates indicative of brain damage in these children. Routine ophthalmologic assessments in the early years can allow appropriate and timely interventions.

The contribution of visual processing to academic achievement in adolescents born extremely preterm or extremely low birth weight

Children born extremely preterm (EP, <28 weeks) and/or extremely low birth weight (ELBW, <1000 g) have more academic deficiencies than their term-born peers, which may be due to problems with visual processing. The aim of this study is to determine (1) if visual processing is related to poor academic outcomes in EP/ELBW adolescents, and (2) how much of the variance in academic achievement in EP/ELBW adolescents is explained by visual processing ability after controlling for perinatal risk factors and other known contributors to academic performance, particularly attention and working memory. A geographically determined cohort of 228 surviving EP/ELBW adolescents (mean age 17 years) was studied. The relationships between measures of visual processing (visual acuity, binocular stereopsis, eye convergence, and visual perception) and academic achievement were explored within the EP/ELBW group. Analyses were repeated controlling for perinatal and social risk, and measures of attention and working memory. It was found that visual acuity, convergence and visual perception are related to scores for academic achievement on univariable regression analyses. After controlling for potential confounds (perinatal and social risk, working memory and attention), visual acuity, convergence and visual perception remained associated with reading and math computation, but only convergence and visual perception are related to spelling. The additional variance explained by visual processing is up to 6.6% for reading, 2.7% for spelling, and 2.2% for math computation. None of the visual processing variables or visual motor integration are associated with handwriting on multivariable analysis. Working memory is generally a stronger predictor of reading, spelling, and math computation than visual processing. It was concluded that visual processing difficulties are significantly related to academic outcomes in EP/ELBW adolescents; therefore, specific attention should be paid to academic remediation strategies incorporating the management of working memory and visual processing in EP/ELBW children.

Correlation of central visual function and ROP risk factors in prematures with and without acute ROP at the age of 6-13 years: the Giessen long-term ROP study

AIM

To correlate light increment sensitivity (LIS) and visual acuity (VA) with birth weight (BW), gestational age (GA) and stage of acute retinopathy of prematurity (ROP) (STG) in premature children at school age.

METHODS

180 children (150 former prematures and 30 age-matched term-born children) were enrolled at age 6-13 years. Former prematures were categorised by the results of the initial ROP screening based on digital wide-field fundus imaging: absence of ROP (n=100) and spontaneously resolved ROP (n=50). The latter group was further subdivided according to their STG (Stg 1; Stg 2; Stg 3). Both groups were categorised into sectors by BW (<1000 g; 1000-1500 g; >1500 g), and GA (≤28 weeks; >28<32 weeks; ≥32 weeks). VA was assessed with Early Treatment of Diabetic Retinopathy Study letters, LIS was measured at 0°, 2.8° and 8° in the visual field (Microperimeter MP1, Nidek Technologies), and spherical equivalent refraction assessed with a Nidek autorefractor (Nidek, Italy).

RESULTS

Central and pericentral LIS (0° and 2.8°) and VA were significantly lower in all groups and sectors compared with term-born controls except for BW >1500 g for LIS and GA >28 to <32 W for VA. No significant differences were found for LIS at 8° in all groups. No correlation was found between LIS and VA on an individual basis.

CONCLUSIONS

Low BW, GA and increasing severity of spontaneously resolving ROP were associated with significantly decreased central visual function. In addition to VA, LIS measurement further describes foveal function and is a unique parameter to assess parafoveal function.

The Effect of Achieving Immediate Target Angle on Success of Strabismus Surgery in Children

PURPOSE

To determine if achieving the ideal postoperative target range increases the long-term success of pediatric strabismus surgery.

DESIGN

Interventional case series.

METHODS

Children below 12 years old with horizontal strabismus who underwent surgical correction by recession, resection, advancement, or a combination of both between 1996 and 2011 were included. Alignment was measured within 1 week and at a minimum of 6 months after surgery. The ideal postoperative target range was defined as 0-8 prism diopters (PD) of esotropia in exotropic patients and within 4 PD of orthotropia in esotropic patients measured within 1 week after the surgery. Success was defined as a measurement within 10 PD of orthotropia at the latest postoperative visit. The main outcome measures were surgical success rate and the factors affecting it.

RESULTS

We included 352 patients with mean follow-up of 18 months. Overall, patients within the target range had a higher success rate than those outside it (75.6% vs 57% P = .0004). This was highly significant for exotropia (P = .0002) but not for esotropia (P = .4). Multiple regression analysis revealed that being within target range was the strongest predictor of long-term success (odds ratio [OR] = 2.3, range 1.4-3.7). Overall, surgeries on patients with esotropia were more likely to be successful than on those with exotropia (OR = 1.9, range 1.2-3), and premature patients had poorer outcomes (OR = 0.2, range 0.1-0.8).

CONCLUSION

Achieving the ideal target range within 1 week after surgery is associated with a high rate of long-term success in exotropia surgery in children.

Visual Development and Neuropsychological Profile in Preterm Children from 6 Months to School Age

The aim of this semilongitudinal study was to investigate the development of central visual pathways in children born preterm but without major neurologic impairments and to establish their cognitive and behavioral profile at school age. Ten children born preterm were assessed at 6 months and at school age, using visual evoked potentials at both time points and cognitive and behavioral tests at school age. We also tested 10 age-matched children born full-term. At 6 months' corrected age, we found no significant differences between preterm and full-term groups for either amplitude or latency of N1 and P1 components. At school age, the preterm group manifested significantly higher N1 amplitudes and tended to show higher P1 amplitudes than the full-term group. We found no significant differences in cognitive and behavioral measures at school age. These results suggest that preterm birth affects visual pathways development, yet the children born preterm did not manifest cognitive problems.

Association of birth parameters with refractive status in a sample of caucasian children aged 4-17 years

Purpose. To investigate the association of birth parameters with refractive status in different age groups of Caucasian children. Materials and Methods. This cross-sectional study included 564 eyes of 282 children aged 4 to 17 years. All children underwent complete ophthalmologic examination. The children were divided into three groups according to their refractive status (emmetropia,myopia, and hyperopia), ages (4-7, 8-9, 10-12, and 13-17), and appropriateness for gestational age, respectively. Results. The mean age of the children was 9.2 ± 2.8 (age range 4-17 years). The mean spheric equivalent was +0.3 ± 1.7 (range: (-10.0)-(+10.0) diopters). The mean birth weight and gestational age were 2681.1 ± 930.8 grams (750-5000 grams) and 37.2 ± 3.7 weeks (25-42 weeks). According to multinominal logistic regression analysis, children with myopia were more likely to have higher birth weights than emmetropic children (OR: 1.0, 95% CI: 1.000-1.001, and P = 0.028). The hypermetropes were found to be significantly small for gestational age between 13 and 17 years of age. Conclusion. Birth weight and appropriateness for gestational age as birth parameters may have an impact on development of all types of refractive errors. The hypermetropic children tended to be small for gestational age.

Ocular alignment and refraction in preterm children at 1 and 6 years old

Purpose

To investigate cycloplegic refraction and ocular alignment in a population of preterm children at 1 and 6 years old.

Patients and methods

We included 261 preterm infants with a birth weight ≤1,500 g and a gestational age ≤32 weeks; there were 217 preterm infants (group 1), 28 preterm infants with mild retinopathy of prematurity (ROP) (group 2), and 16 preterm infants affected by severe ROP (group 3). Each patient underwent retinoscopy, ocular alignment assessment, and fundus examination at 1 and 6 years old.

Results

The prevalence of refractive errors and ocular alignment abnormalities at 1 year old in groups 2 and 3 compared to group 1 were, respectively (P<0.05): myopia 18% and 40.6% versus 6.9%; hyperopia 28.6% and 22% versus 39.2%; astigmatism 53.4% and 37.4% versus 53.9%; and strabismus 12.5% and 38% versus 5.3%. At 6 years old, they were, respectively (P<0.05): myopia 10.8% and 28.4% versus 7.4%; hyperopia 48.3% and 40.5% versus 62%; astigmatism 40.9% and 31.1% versus 30.6%; and strabismus 25% and 56.25% versus 11.5%.

Conclusion

At 6 years old, we observed increased rates of both hyperopia and strabismus in all groups compared to 1-year-old children. In preterm children with mild and severe ROP, we recorded increased rates of myopia and strabismus versus preterm children without ROP, and the risk of developing these disorders increased significantly with ROP severity. Astigmatism at 1 year old is not predictive of further development during growth. Patients born prematurely should be informed of the possible risks of ocular alterations due to refractive and ocular component changes.

Long-term growth and general health for the tiniest or most immature infants

Given the improving survival rates of extremely preterm (EP, gestational age <28 weeks) infants, there is a need to understand their general growth and health outcomes not only in childhood, but also into adulthood. EP children are shorter and lighter compared with term children at term-equivalent age; with time, the weight disadvantage diminishes but the height disadvantage remains relatively unchanged. EP children and young adults also have higher rates of reported health concerns, medical conditions and visual impairment. Hospital readmissions are higher in early childhood, mostly attributed to respiratory illness. Individuals born EP have reduced bone health and are at increased risk for metabolic disorders. Increased rates of conditions such as diabetes or pathological fractures are not reported in the literature, although follow-up studies so far have only tracked EP individuals into young adulthood. Consequently, health care utilization and costs are increased in EP children and young adults. A thorough knowledge of the health risks related to EP birth is essential in planning surveillance and intervention strategies to optimize their health and wellbeing. Despite the increased risk of health problems, EP young adults generally report their quality of life to be similar to that reported in their term counterparts.

Ophthalmological outcome and visuospatial ability in very preterm children measured at 2.5 years corrected age

AIM

To investigate the ophthalmological outcome of very preterm children at 2.5 years corrected age (CA) and perform a test of visuospatial and cognitive abilities.

METHODS

A population-based, prospective study (LOVIS study) in Uppsala County, Sweden, comprised 111 very preterm children (<32 w gestational age [GA]) born between 1 January 2004 and 31 December 2007. Ophthalmic evaluations were undertaken in 98/109 children (89.9%) alive at 2.5 years. Spatial cognition was investigated with a test of five alternative blocks in 48 preterm and 25 term-born children.

RESULTS

Visual impairment, strabismus or refractive errors, were found in 12% of the children. None of the children were blind in both eyes. Logistic regression analyses revealed significant associations between strabismus and periventricular leucomalacia/intraventricular haemorrhage (OR 9.6, p = 0.025) and between refractive errors and severe retinopathy of prematurity (OR 9.8, p = 0.011) and GA (OR 0.763, p = 0.034). Oval and rectangular blocks were significantly more difficult to insert into a box for preterm than full-term children (p = 0.048 and 0.013, respectively). There was a significant correlation between total scores for the five blocks and GA at birth (p = 0.035).

CONCLUSION

Eye and visual problems were found in 12% of the preterm children at 30 months CA. Preterm children had difficulties with blocks of complex shapes.

Outcome of retinopathy of prematurity

In prematurely born children, various visual and ophthalmologic sequelae occur because of both retinopathy of prematurity (ROP) and preterm birth per se. Several long-term follow-up studies have described the outcome of ROP. Visual impairment and blindness are well-known consequences, but the prevalence varies globally because of differing neonatal and ophthalmologic care. Improving treatment options and criteria for the treatment of ROP are continuously changing the ophthalmologic outcome. The anatomic outcome has improved with treatment, but good anatomic outcome in treated severe ROP does not always reflect the functional outcome. There is no consensus regarding long-term follow-up of prematurely born children.

Visual function in 6 to 7 year-old children born extremely preterm: a population-based study

PURPOSE

Progress in neonatal care has caused an increased survival of children born extremely preterm. The aims of this study were to examine the long-term visual function and ocular development in an unselected cohort of extremely preterm infants and relate the results to neonatal morbidity and long-term neurodevelopmental outcome.

METHODS

All children with gestational age of 22-27 completed weeks or birth weight of 500-999 g born in the years 1999-2000 in two counties of Western Norway (n = 52) were invited to an eye examination that included visual acuity, refractive error, binocular function, accommodative amplitude and fundus examination. Cognitive function was assessed with the WPSSI-R test and motor abilities with the ABC movement test.

RESULTS

Neonatal morbidities and neurodevelopmental outcome were known for all, while 37 of the 52 children underwent the eye examination. None were blind or visually impaired, but 46% had subnormal visual acuity (logMAR ≥0.1). Ninety per cent were emmetropic or slightly hypermetropic (0 to +3D), while 10% had manifest and 51% latent strabismus. Performance IQ on the WPSSI-R test and ABC total score were associated with best visual acuity (p = 0.03 and p < 0.01, respectively). In a multiple linear regression model, visual acuity in the best eye was significantly associated with performance IQ (p = 0.03) and ABC total score (p = 0.02).

CONCLUSION

This study suggests a more favourable long-term prognosis on important ocular and visual parameters in survivors of extreme prematurity than expected from similar reports on children born less prematurely and that performance IQ and motor function are related to visual acuity.

An assessment of ocular morbidities of children born prematurely in early childhood

PURPOSE

To assess the ocular morbidities of premature children in early childhood.

METHODS

One hundred seventeen children with a history of gestational age of less than 37 weeks at birth underwent ophthalmic examination including visual acuity testing with Lea symbols, anterior and posterior segment examination, refraction, orthoptic examination for strabismus, and ocular biometry. They were subdivided into three groups according to gestational age (28 or less, 29 to 32, and 33 to 36 weeks). The prevalence of ocular morbidities and mean value of refractive errors were studied.

RESULTS

The mean age of the subjects at examination was 37.6 ± 1.1 months (range: 20 to 65 months). Only 62.4% of the eyes had visual acuity better than 20/32. The prevalence of high myopia (above -5.0 diopters [D]), myopia (below -5.0 D), and strabismus was 12.5%, 22.5% and 33.3% in the 28 weeks or less group and 3.6%, 18.9%, and 24.1% in the 29 to 32 weeks group, respectively, whereas 7.9% of the 33 to 36 weeks group had myopia and 13.2% had strabismus. Spherical equivalent in eyes that received cryotherapy and with macular heterotopia was -2.7 ± 3.9 and - 4.4 ± 3.4 D, respectively. Biometric measurements showed that high myopic eyes had statistically significantly thicker lenses compared to myopic and hyperopic eyes (P = .01).

CONCLUSION

This study confirms that children born prematurely are at increased risk of ocular morbidities such as defective visual acuity, myopia, and strabismus. High myopic eyes have thicker lenses compared to myopic and hyperopic eyes, and eyes with macular heterotropia and treated with cryotherapy are more prone to development of high myopia.

Follow-up studies of very low birthweight children in Sweden

Follow-up studies are essential to our knowledge of outcome in very low birthweight (VLBW) or extremely preterm (EPT) infants because those children have a greater risk for developing neurosensory disabilities and behavioural and educational problems and have decreased probability for an optimal transition into adulthood compared to term controls. Outcome data are of interest not only to healthcare professionals but also to parents, schoolteachers and society. The aim of this review is to describe the follow-up studies of seven populations of VLBW or EPT infants performed in Sweden and published between 1995 and 2009.

CONCLUSION

 The time has come to implement evident data from these Swedish follow-up studies into clinical practice and to perform regular and specific follow-up examinations during childhood for all VLBW and EPT children. These assessments, specially designed for high-risk infants, should consider the potential outcomes for neurological, visual, auditory function and cognitive function as well as behaviour and growth, from birth to school-start.

Prediction of neurodevelopmental and sensory outcome at 5 years in Norwegian children born extremely preterm

OBJECTIVE

To examine the prevalence of neurodevelopmental disability and the predictive value of pre-, peri-, and postnatal data on neurologic, sensory, cognitive, and motor function in children born extremely preterm.

METHODS

This was a prospective observational study of all infants born in Norway between 1999 and 2000 with gestational ages between 22 and 27 weeks or birth weights between 500 and 999 g. Cognitive function was assessed with the Wechsler Preschool and Primary Scale of Intelligence-Revised, motor function with the Movement Assessment Battery for Children, and severity of cerebral palsy with the Gross Motor Function Classification for Cerebral Palsy. Disabilities were described as mild, moderate, or severe.

RESULTS

Of 371 eligible children, 306 (82%) were examined at a mean (SD) age of 5 years and 10 (4) months. For gestational age less than 28 weeks (n = 239), 26 (11%) children had cerebral palsy alone (n = 21) or in combination with blindness (n = 3) or deafness (n = 2); 1 was blind and 1 was deaf. Of the remaining children, the mean full-scale IQ was 94 ± 15, and significant predictors were (values given as the difference in IQ points [95% confidence intervals]) high maternal education (9.6 [5.7-13.4]), preeclampsia (-7.7 [-12.7 to -2.7]), and retinopathy of prematurity higher than grade 2 (-17.5 [-27.1 to -8.0]). Movement Assessment Battery for Children scores were positively associated with gestational age and prenatal steroids and negatively associated with being small for gestational age, male gender, and having retinopathy of prematurity. Moderate to severe neurodevelopmental disability was more common for gestational ages 25 weeks or less (28 of 87 children) than for 26 to 27 weeks (12 of 152 children; P < .001) and 28 weeks or more (7 of 67 children; P = .001).

CONCLUSIONS

The outcome was poorer for children with gestational ages of 25 weeks or less compared with those with gestational ages between 26 and 27 weeks. For those without cerebral palsy, blindness, or deafness, however, gestational age had a limited association with cognitive and motor function.

Risk of refractive pathology after spontaneously regressed ROP in emmetropic patients

PURPOSE

To evaluate the development of refractive error abnormalities after a normal first examination in children with spontaneously regressed retinopathy of prematurity (ROP).

METHODS

Two hundred twenty-six children with a history of spontaneously regressed ROP who had a cycloplegic refraction prior to 18 months of age were examined by a pediatric ophthalmologist. Children with a history of threshold ROP, strabismus, or a structural abnormality of the eye were excluded. A normal cycloplegic retinoscopy was defined as plano to less than +3.5 diopters of hypermetropia, less than +1.50 of symmetric astigmatism, and no anisometropia greater than 1.5 diopters in any meridian.

RESULTS

Of the 226 children, 87 had a second examination and cycloplegic refraction at a mean of 2 years after the initial visit. In 63 of the children, the second examination and refraction remained normal. Three (3.4%) children had significant refractive error and were treated with spectacles: two had anisometropia and one had myopic astigmatism. Twenty-one had symmetric low magnitude myopia that did not warrant treatment.

CONCLUSION

Children with spontaneously regressed ROP and no significant refractive error on cycloplegic retinoscopy at first follow-up examination have a risk of developing ametropia that is similar to that of the general population. Such children can likely be observed with a verbal vision screening in the pediatrician's office at 3 to 4 years of age.

Visuospatial skills, ocular alignment, and magnetic resonance imaging findings in very low birth weight adolescents

PURPOSE

To describe ocular alignment and stereoacuity in adolescents with very low birth weight (VLBW) in comparison with a matched control group and to investigate associations with white matter damage of immaturity (WMDI) and visuospatial skills in the VLBW group.

METHODS

Fifty-nine 15-year-old VLBW subjects and 55 age- and sex-matched controls with normal birth weight underwent examination, including measurement of ocular alignment using cover test and Maddox rod and cycloplegic refraction. Stereoacuity was assessed with the TNO test, best-corrected visual acuity with a Konstantin Moutakis letter chart, and visuospatial skills with the performance tests, defined as performance intelligence quotient (IQ), in the Wechsler Intelligence Scale for Children (WISC-III). All VLBW subjects underwent magnetic resonance imaging of the brain.

RESULTS

Ocular misalignment was significantly more common in the VLBW group than in the control group (22% compared with 4%; p = 0.004). Exophoria, subnormal stereoacuity, and subnormal performance IQ were significantly more common in the VLBW group than in the control group (p = 0.006, p = 0.011, and p = 0.015, respectively). Ocular misalignment was associated with WMDI (p = 0.035) and subnormal performance IQ (p = 0.020). Of the VLBW subjects with ocular misalignment, 69% had WMDI and/or subnormal performance IQ.

CONCLUSIONS

The VLBW adolescents had more visuospatial problems, lower stereoacuity, and more ocular misalignment than the control subjects. Ocular misalignment was associated with visuospatial deficiencies and/or WMDI in the VLBW group and was a better predictor for visuospatial deficits than WMDI.

Admissions of all gestations to a regional neonatal unit versus controls: 2-year outcome

AIMS

To assess neurodevelopmental outcome at 2 years for neonatal intensive care unit (NICU) admissions compared with controls, and to trial a parent-reporting scheme.

METHODS

All infants admitted to the NICU at Christchurch Women's Hospital over a 12-month period and whose parents were domiciled in a defined geographical region were eligible for study, together with every eighth term infant not admitted (to a total of 300). Parents completed a two-page questionnaire on their child's 2nd birthday. All infants <28 weeks gestation and a random 300 NICU admissions and 108 controls underwent a paediatric examination and Bayley II assessment at 2 years of age.

RESULTS

A total of 387 NICU infants (86% eligible) and 306 controls were enrolled. At 2 years of age, 276 NICU infants (89% survivors) and 94 controls (87%) had some follow up. For infants of <33 weeks, 33-36 weeks, > or =37 weeks gestation and controls, the percentage >1 SD below the mean on the Bayley Mental Development Index scales were 33.3, 36.5, 44.6 and 24.1, respectively (P= 0.03); on the Psychomotor Developmental Index scales were 30.0, 29.1, 41.1 and 19.5 (P= 0.02) and the percentage with any cerebral palsy were 11.1, 2.8, 5.2 and 1.2.

CONCLUSIONS

At 2 years of age, NICU graduates have more developmental problems than controls across a range of measures. In many cases, term NICU graduates have the least favourable outcome. There was only moderate agreement between parents' reporting of moderate or severe developmental disability by means of a questionnaire, compared with professionals (kappa statistic 0.38), with parents tending to underestimate problems.

Astigmatism in the Early Treatment for Retinopathy Of Prematurity Study: findings to 3 years of age

PURPOSE

To examine the prevalence of astigmatism (> or =1.00 diopter [D]) and high astigmatism (> or =2.00 D) at 6 and 9 months corrected age and 2 and 3 years postnatal age, in preterm children with birth weight of less than 1251 g in whom high-risk prethreshold retinopathy of prematurity (ROP) developed and who participated in the Early Treatment for Retinopathy of Prematurity (ETROP) Study.

DESIGN

Randomized, controlled clinical trial.

PARTICIPANTS

Four hundred one infants in whom prethreshold ROP developed in one or both eyes and who were randomized after they were determined to have a high risk (> or =15%) of poor structural outcome without treatment using the Risk Management of Retinopathy of Prematurity (RM-ROP2) program. Refractive error was measured by cycloplegic retinoscopy. Eyes with additional retinal, glaucoma, or cataract surgery were excluded.

INTERVENTION

Eyes were randomized to receive laser photocoagulation at high-risk prethreshold ROP (early treated [ET]) or to be conventionally managed (CM), receiving treatment only if threshold ROP developed.

MAIN OUTCOME MEASURES

Astigmatism and high astigmatism at each visit. Astigmatism was classified as with-the-rule (WTR; 75 degrees -105 degrees ), against-the-rule (ATR; 0 degrees -15 degrees and 165 degrees -180 degrees ), or oblique (OBL; 16 degrees -74 degrees and 106 degrees -164 degrees ).

RESULTS

The prevalence of astigmatism in ET and CM eyes was similar at each test age. For both groups, there was an increase in prevalence of astigmatism from approximately 32% at 6 months to approximately 42% by 3 years, mostly occurring between 6 and 9 months. Among eyes that could be refracted, astigmatism was not influenced by zone of acute-phase ROP, presence of plus disease, or retinal residua of ROP. Eyes with astigmatism and high astigmatism most often had WTR astigmatism.

CONCLUSIONS

By age 3 years, nearly 43% of eyes treated at high-risk prethreshold ROP developed astigmatism of > or =1.00 D and nearly 20% had astigmatism of > or =2.00 D. Presence of astigmatism was not influenced by timing of treatment of acute-phase ROP or by characteristics of acute-phase or cicatricial ROP. These findings reinforce the need for follow-up eye examinations in infants with high-risk prethreshold ROP.

FINANCIAL DISCLOSURE(S)

The author(s) have no proprietary or commercial interest in any materials discussed in this article.

Eye movements and binocular function in low birthweight teenagers

PURPOSE

To assess eye movements and binocular function in 14-year-olds with very low birthweight (VLBW: birthweight </= 1500 g) and 14-year-olds born at term but small for gestational age (SGA: birthweight < 10th percentile) in a population-based study.

METHODS

Ophthalmological examinations including measurements of heterophoria/tropia, near point of convergence, accommodative amplitude, stereopsis, nystagmus, saccades and smooth pursuit were performed in 51 adolescents with VLBW, 58 adolescents born SGA and in a control group consisting of 75 subjects of the same age.

RESULTS

Latent or manifest strabismus, poor stereopsis, poor convergence and nystagmus were all more frequent in the VLBW group than in the control group. The VLBW group did not differ from the control group regarding accommodative amplitude or saccades and smooth pursuit. The SGA population did not differ from the control group in the measured variables.

CONCLUSIONS

Premature birth with VLBW affects binocular visual functions negatively in adolescence, whereas birth small for date at term does not appear to be a risk factor for impaired eye movements and binocular function.