The prenatal growth of the human eye

Dynamic changes in ocular shape during human development and its implications for retina fovea formation

The human fovea is known for its distinctive pit-like appearance, which results from the displacement of retinal layers superficial to the photoreceptors cells. The photoreceptors are found at high density within the foveal region but not the surrounding retina. Efforts to elucidate the mechanisms responsible for these unique features have ruled out cell death as an explanation for pit formation and changes in cell proliferation as the cause of increased photoreceptor density. These findings have led to speculation that mechanical forces acting within and on the retina during development underly the formation of foveal architecture. Here we review eye morphogenesis and retinal remodeling in human embryonic development. Our meta-analysis of the literature suggests that fovea formation is a protracted process involving dynamic changes in ocular shape that start early and continue throughout most of human embryonic development. From these observations, we propose a new model for fovea development.

Refractive development I: Biometric changes during emmetropisation

PURPOSE

Although there are many reports on ocular growth, these data are often fragmented into separate parameters or for limited age ranges. This work intends to create an overview of normal eye growth (i.e., in absence of myopisation) for the period before birth until 18 years of age.

METHODS

The data for this analysis were taken from a search of six literature databases using keywords such as "[Parameter] & [age group]", with [Parameter] the ocular parameter under study and [age group] an indication of age. This yielded 34,409 references that, after screening of title, abstract and text, left 294 references with usable data. Where possible, additional parameters were calculated, such as the Bennett crystalline lens power, whole eye power and axial power.

RESULTS

There were 3422 average values for 17 parameters, calculated over a combined total of 679,398 individually measured or calculated values. The age-related change in refractive error was best fitted by a sum of four exponentials (r²  = 0.58), while all other biometric parameters could be fitted well by a sum of two exponentials and a linear term ('bi-exponential function'; r² range: 0.64-0.99). The first exponential of the bi-exponential fits typically reached 95% of its end value before 18 months, suggesting that these reached genetically pre-programmed passive growth. The second exponentials reached this point between 4 years of age for the anterior curvature and well past adulthood for most lenticular dimensions, suggesting that this part represents the active control underlying emmetropisation. The ocular components each have different growth rates, but growth rate changes occur simultaneously at first and then act independently after birth.

CONCLUSIONS

Most biometric parameters grow according to a bi-exponential pattern associated with passive and actively modulated eye growth. This may form an interesting reference to understand myopisation.

The growth and shape of the eyeball and crystalline lens in utero documented by fetal MR imaging

Purpose

To study the growth model, shape, and developmental relationship of lens and eyeball, we used two-dimensional Magnetic Resonance (MR) imaging to investigate gestationally age-related changes in the selected ocular parameters in vivo.

Materials and methods

We retrospectively reviewed the MR images from 126 fetuses ranging from 21 to 39 weeks' gestation. Ocular parameters on MR imaging of transverse plane were measured including lens diameter (LD), anteroposterior lens diameter (APLD), lens surface area (LS), globe diameter (GD), anteroposterior globe diameter (APGD), globe surface area (GS). The growth model of each biometric against gestational age (GA), aspect ratio of lens and globe (LD/APLD and GD/APGD), and growing relationship between the ratio of lens and globe surface area (LS/GS) were studied by statistical analysis.

Results

The growth model of most biometry for gestational age is logarithmic, except for the diameter of the ocular globe (GD and APGD) showing a quadratic growth pattern. Our study showed that the lens was consistently larger in the transverse than the anteroposterior diameters during 21-39 weeks(P < 0.001). Besides, the ratio of surface area (LS/GS) was not significantly changing with GA(P = 0.4908), while the increase of LS was significantly accorded with that of GS(P < 0.001).

Conclusion

The lens shape throughout fetal life may take part in the process, shape changing from vertical ellipsoid, spherical to transversal ellipsoid, based on the logarithmically increased ratio of lens transverse and anteroposterior diameters. In the meanwhile, the aspect ratio of eyeball in late fetal life may imply a gradually spherical shape during gestation. Nomogram data from this study may provide appropriate information about morphological changes in the fetal lens and the synchronous relationship between lens and eyeball.

Ocular elongation and retraction in foveated reptiles

BACKGROUND

Pronounced asymmetric changes in ocular globe size during eye development have been observed in a number of species ranging from humans to lizards. In contrast, largely symmetric changes in globe size have been described for other species like rodents. We propose that asymmetric changes in the three-dimensional structure of the developing eye correlate with the types of retinal remodeling needed to produce areas of high photoreceptor density. To test this idea, we systematically examined three-dimensional aspects of globe size as a function of eye development in the bifoveated brown anole, Anolis sagrei.

RESULTS

During embryonic development, the anole eye undergoes dynamic changes in ocular shape. Initially spherical, the eye elongates in the presumptive foveal regions of the retina and then proceeds through a period of retraction that returns the eye to its spherical shape. During this period of retraction, pit formation and photoreceptor cell packing are observed. We found a similar pattern of elongation and retraction associated with the single fovea of the veiled chameleon, Chamaeleo calyptratus.

CONCLUSIONS

These results, together with those reported for other foveated species, support the idea that areas of high photoreceptor packing occur in regions where the ocular globe asymmetrically elongates and retracts during development.

Meta-analysis of ocular axial length in newborns and infants up to 3 years of age

In pediatric ophthalmology it is often necessary to obtain axial length in young children. For children older than 3 years, noncontact biometry can be used. For younger children this is usually not an option, and the clinician needs to rely on other imaging modalities. Depicted data curves in textbooks elaborate on few studies and limited number of subjects. The existing literature regarding normal axial length for preterm infants and term newborns is summarized and critically appraised for number of subjects, relevance, measurement method and error, gender and retinopathy of prematurity. We obtained axial length measurements for a total number of 6,575 eyes in 27 papers published from 1964 to 2018 (9 papers with 2,272 eyes for preterm children, 24 papers with 4,303 eyes for term children). Initially, axial length increases rapidly: from a mean 5.1-16.2 mm in week 12 to week 37 gestational age. From 38 weeks, growth rate decreases from 16.2 mm to a mean of 21.8 mm at 3 years old. Male infants have a larger average axial length than females at birth; the difference is 0.24 mm (95%CI: 0.15-0.33, P < 0.001). We present a useful growth curve and formula that may serve as a reference for diagnosing abnormal growth.

Development of Retinal Layers in Prenatal Human Retina

PURPOSE

To determine the developmental sequence of retinal layers to provide information on where in utero pathologic events might affect retinal development.

DESIGN

Qualitative and quantitative descriptive research.

METHODS

A histology collection of human eyes from fetal week (Fwk) 8 to postnatal (P) 10 weeks was analyzed. The length of the nasal and temporal retina was measured along the horizontal meridian in 20 eyes. The location of the inner plexiform layer (IPL) and outer plexiform layer (OPL) was identified at each age, and its length measured.

RESULTS

The human eye retinal length increased from 5.19 mm at Fwk 8 to 20.92 mm at midgestation to 32.88 mm just after birth. The IPL appeared in the presumptive fovea at Fwk 8, reached the eccentricity of the optic nerve by Fwk 12, and was present to both nasal and temporal peripheral edges by Fwk 18-21. By contrast, the OPL developed slowly. A short OPL was first present in the Fwk 11 fovea and did not reach the eccentricity of the optic nerve until midgestation. The OPL reached the retinal edges by Fwk 30. Laminar development of both IPL and OPL occurred before vascular formation.

CONCLUSIONS

In human fetal retina, the IPL reached the far peripheral edge of the retina by midgestation and the OPL by late gestation. Only very early in utero events could affect IPL lamination in the central retina, but events occurring after Fwk 20 in the peripheral retina would overlap OPL laminar development in outer retina.

Time to consider a new treatment protocol for aggressive posterior retinopathy of prematurity?

PURPOSE

To discuss treatment modalities for aggressive posterior retinopathy of prematurity (AP-ROP).

METHODS

The medical charts of all infants with AP-ROP at Uppsala University Hospital, Sweden, during a 2-year period (2009 and 2010) were reviewed. Eight infants (16 eyes) with a mean gestational age of 23.8 weeks and a mean birth weight of 592 g were treated with laser and/or intravitreal injections of bevacizumab (0.4 and 0.625 mg). RetCam photography was used to document the retinal appearance before and after treatment.

RESULTS

All infants (16 eyes) had AP-ROP in zone I. Mean time at initial treatment was 34 weeks postmenstrual age. Two eyes (one infant) were only treated with laser, and six eyes (three infants) were treated with laser therapy or cryopexy and, because of lack of regression, with bevacizumab as salvage therapy. Eight eyes (four infants) were treated with a first-line bevacizumab injection and four of these eyes (two infants) with additional laser ablation for continued disease progression in zone II. Macular dragging occurred in one eye of one infant primarily treated with laser.

CONCLUSIONS

Given the high complication rate of the extensive laser treatment for zone I ROP, it is worth considering anti-vascular endothelial growth factor treatment as an alternative therapy. Further knowledge concerning side effects and long-term ocular and systemic outcome is warranted before this drug becomes general clinical practice.

Human ocular biometry

The aim of this study was to examine growth of the human eye globe and cornea from early in gestation to late in adult life. Globe antero-posterior length, horizontal and vertical diameters, corneal horizontal and vertical (white to white) diameters and posterior pole to limbus distances were measured using digital calipers (±0.01 mm) in 541 postmortem eyes. Additional pre- and postnatal data for some of the dimensions were obtained from the literature. All dimensions examined increase rapidly during prenatal development but postnatal growth differs. Growth of globe antero-posterior length, vertical and horizontal diameters as well as corneal vertical and horizontal diameters stops within 1 year after birth. Logistic analysis is consistent with an asymptotic prenatal growth mode and no further growth after its completion around 1 year after birth. Horizontal and vertical globe diameters are the same at all ages but the corneal horizontal diameter is always larger than the vertical diameter. No differences could be detected between males and females in any of the ocular dimensions. Globe and corneal growth take place primarily during the prenatal growth mode and dimensions reach their maxima, shortly after birth. It is suggested that cessation of a growth stimulating signal at birth marks the end of the prenatal growth mode and that the small increases over the next year are due to cells already stimulated. Male and female eyes of the same age have the same globe and cornea dimensions.

Refractive status and ocular axial length in preterm infants without retinopathy of prematurity with regard to birth weight and gestational age

PURPOSE

To obtain ultrasonographic measurements of ocular axial length (AL) in preterm infants without retinopathy of prematurity (ROP) but with different refractive power in regard to birth weight (BW) and gestational age (GA).

METHODS

Refraction was measured after cycloplegia (at 6 months of life) in 350 eyes of 180 preterm (non-astigmatic) infants without ROP. Subjects were grouped according to the refractive error: A [above -6.0 dioptres (D)]; B (-3.1 to -6.0 D); C (0 to -3.0 D); D (0.1 to +3.0 D); E (+3.1 to +6.0 D); F (above +6.0 D). The AL measurement was performed by ocular A-scan ultrasound biometry (10 MHz probe).

RESULTS

The longest AL was found in group B (20.62 mm) compared to group D and E (19.35, 19.28 mm; P< or =0.01) and group F and A (19.63, 19.39 mm; P< or =0.05). Only regressive correction for BW was statistically significant. Correlations between AL and BW (Rs=0.23) or GA (Rs=0.17) were found only in group E.

CONCLUSIONS

AL of myopic eyes was significantly longer. In general, hyperopia was positively correlated with BW, whereas correlation between myopia and BW or GA was not found.

On the growth and internal structure of the human lens

Growth of the human lens and the development of its internal features are examined using in vivo and in vitro observations on dimensions, weights, cell sizes, protein gradients and other properties. In vitro studies have shown that human lens growth is biphasic, asymptotic until just after birth and linear for most of postnatal life. This generates two distinct compartments, the prenatal and the postnatal. The prenatal growth mode leads to the formation of an adult nuclear core of fixed dimensions and the postnatal, to an ever-expanding cortex. The nuclear core and the cortex have different properties and can readily be physically separated. Communication and adhesion between the compartments is poor in older lenses. In vivo slit lamp examination reveals several zones of optical discontinuity in the lens. Different nomenclatures have been used to describe these, with the most common recognizing the embryonic, foetal, juvenile and adult nuclei as well as the cortex and outer cortex. Implicit in this nomenclature is the idea that the nuclear zones were generated at defined periods of development and growth. This review examines the relationship between the two compartments observed in vitro and the internal structures revealed by slit lamp photography. Defining the relationship is not as simple as it might seem because of remodeling and cell compaction which take place, mostly in the first 20 years of postnatal life. In addition, different investigators use different nomenclatures when describing the same regions of the lens. From a consideration of the dimensions, the dry mass contents and the protein distributions in the lens and in the various zones, it can be concluded that the juvenile nucleus and the layers contained within it, as well as most of the adult nucleus, were actually produced during prenatal life and the adult nucleus was completed within 3 months after birth, in the final stages of the prenatal growth mode. Further postnatal growth takes place entirely within the cortex. It can also be demonstrated that the in vitro nuclear core corresponds to the combined slit lamp nuclear zones. In view of the information presented in this review, the use of the terms foetal, juvenile and adult nucleus seems inappropriate and should be abandoned.

Pre-term delivery and the growth of the eye. An oculometric study of eye size around term-time

Refraction and axial eye dimensions, evaluated by ultrasound measurements, were investigated in 101 pre-term infants and 25 full-term controls. Gestational ages in the pre-term group ranged from 25 to 34 weeks, birth weights from 728 to 2480 g. All were seen in the eye clinic due to risk of developing retinopathy of prematurity. Age at examination was 36-54 weeks (gestational/conceptional) in the pre-terms and 37.3-50 weeks in the term infants. Adjusted to a 40 weeks axial length value (based on an assumed average eye elongation of 0.14 mm per week) the term-values were similar, 17.02 and 17.03 mm in the two groups. Within the premature group, however, the 40-week adjusted axial lengths were shorter, the shorter the gestational age. The study demonstrated more foetal anterior segment proportions, with flatter anterior chambers and thicker, more spheroid lenses in the preterm infants. Probably this explains the early preponderance of myopia in that group, at feature eventually to disappear, and not to be confused with myopia of prematurity. As compared to the full-terms a correlational disturbance by pre-term delivery was further indicated by the absence of the usual correlation between axial length and refractive value.

Microphthalmia and brain atrophy: A novel neurodegenerative disease

OBJECTIVE

To delineate the features of a novel neurodegenerative disease.

METHODS

We report three children of three related families with congenital microphthalmia and blindness, and progressive spasticity, microcephaly, seizures, and profound mental retardation.

RESULTS

A magnetic resonance imaging scan was normal at birth. However, follow-up studies showed progressive atrophy involving the cerebral white matter and cortex, cerebellum, brainstem, and corpus callosum. The white matter changes extended into the subcortical region leaving only small islands of remaining cortical tissue. Known metabolic conditions involving white matter degeneration were excluded.

INTERPRETATION

We propose this to be a novel autosomal recessive neurodegenerative disorder to be coined MOBA (microphthalmia brain atrophy) disease.

Growth of the cornea from infancy to adolescence

The intraocular distance and iris diameter of children and young adolescents were measured, with the aid of a measuring microscope, from photographs of their faces. True intraocular distance was measured with an intraocular caliper at the same time that the photographs were taken. These data were then compiled and horizontal visible iris diameters (HVIDs) were calculated. An equation was derived from the optics of the Gullstrand model eye to calculate horizontal corneal diameter (HCD) from HVID. Comparisons of HVIDs revealed no significant correlation with age in either a regression plot of cross-sectional data for subjects aged 1 month to 1 year, or all subjects whose ages ranged from 1 month to adolescence. Additional longitudinal data for 13 individuals, who had been photographed as both an infant (mean = 3.4 months) and as an older child or adolescent (mean = 8.6 years), were then compiled and HVIDs for these subjects at two different ages were compared. A Wilcoxon signed rank test revealed a small but significant amount of growth, 0.318 mm (p-value = 0.013), in the HVIDs over a mean age difference of 8.3 years for individuals measured twice during their lifetimes. The regression equation for this growth was: HVID = 10.52 (+/-0.095 S.E.) + 0.0305 (+/-0.014) x Age (years). From a comparison of data from earlier literature and our own measurements, we conclude that, after birth, the fastest growth of the cornea must occur during the first few months of life.

Reappraisal of the human ocular growth curve in fetal life, infancy, and early childhood

AIMS

The aim of this study was to find an algorithm of better fit for early eye growth than the linear regression usually advanced.

METHODS

The analysis is based on previously published around term data, the main material being axial ultrasound measurements in preterm (n = 101) and full term infants (n = 25). The postconceptional age of the infants ranged between 36 and 54 weeks. Previously published Danish data from eyes of aborted fetuses were also used, as were averaged values from the literature regarding eye size at age 1 year (20 mm), 3 years (22 mm), and a presumed 13 year endpoint of 23 mm.

RESULTS

A second order exponential function fitted with the basic data within a standard deviation of 2%.

CONCLUSIONS

A simple symbolic expression and tabulated values for eye growth in infancy and childhood were derived. This is clearly of practical value, for example, when following the development of eyes treated for congenital glaucoma or assessing other developmental anomalies and early eye diseases.

Growth of the internal and external eye in term and preterm infants

BACKGROUND

Better knowledge of the growth patterns of the external and internal eyes of neonates would permit more accurate diagnosis of disorders that affect ocular size such as infantile glaucoma and microphthalmos. Such disorders preferentially may affect certain parts of the internal eye but not other parts. No previous study statistically has evaluated internal ocular growth in preterm newborns.

METHODS

A-scan ultrasonography was applied directly to the corneas of 101 healthy preterm and term newborns to determine axial length, anterior chamber depth, lens thickness, and vitreous chamber depth. The growth of these structures was evaluated by correlation and regression analyses.

RESULTS

At term, the mean measurements were axial length, 16.2 mm; anterior chamber depth, 2.0 mm; lens thickness, 3.8 mm; and vitreous chamber depth, 10.5 mm. Postconceptional age correlated to axial length (P < 0.001), anterior chamber depth (P = 0.032), and vitreous chamber depth (P < 0.001), but not to lens thickness (P = 0.48). By regression analysis, the eyes of males grew faster than those of females (P < 0.001) mainly due to the vitreous chamber.

CONCLUSION

In the last trimester and first 2 postnatal months, lens thickness remains constant, while the anterior chamber and, especially, the vitreous chamber deepen.