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Original Investigation |

Ophthalmologic Outcome of Extremely Preterm Infants at 6.5 Years of Age Extremely Preterm Infants in Sweden Study (EXPRESS)

Kerstin M. Hellgren, MD, PhD1; Kristina Tornqvist, MD, PhD2; Peter G. Jakobsson, MD, PhD3; Pia Lundgren, MD, PhD4; Birgitta Carlsson, MD5; Karin Källén, PhD6; Fredrik Serenius, MD, PhD7; Ann Hellström, MD, PhD8; Gerd Holmström, MD, PhD9
[+] Author Affiliations
1Department of Clinical Neuroscience, Karolinska Institutet, Astrid Lindgren Children’s Hospital, Stockholm, Sweden.
2Department of Ophthalmology, Lund University Hospital, Lund, Sweden
3Department of Clinical and Experimental Medicine, Linköping University, Linköping, Sweden
4Department of Ophthalmology, Umeå University, Umeå, Sweden
5Department of Ophthalmology, Örebro University, Örebro, Sweden
6Centre of Reproduction Epidemiology, Department of Obstetrics and Gynecology, Institute of Clinical Sciences, University of Lund, Lund, Sweden
7Section of Pediatrics, Department of Women’s and Children’s Health, Uppsala University, Uppsala, Sweden
8Section of Pediatric Ophthalmology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
9Department of Neuroscience (Ophthalmology), Uppsala University Hospital, Uppsala, Sweden
JAMA Ophthalmol. 2016;134(5):555-562. doi:10.1001/jamaophthalmol.2016.0391.
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Importance  This follow-up study of extremely preterm (EPT) children (<27 weeks’ gestational age [GA] at birth) revealed major eye and visual problems in 37.9% (147 of 388) of all EPT infants and in 55.4% (67 of 121) of the most immature subgroups at 6.5 years of age. These major eye and visual problems were strongly associated with treatment-requiring retinopathy of prematurity (ROP).

Objectives  To investigate the ophthalmologic outcome of a national cohort of EPT children at 6.5 years of age and to evaluate the impact of prematurity and ROP.

Design, Setting, and Participants  All surviving EPT children born in Sweden between April 1, 2004, and March 31, 2007, were included and compared with a matched term control group, as part of a prospective national follow-up study.

Main Outcomes and Measures  Visual acuity, refraction in cycloplegia, and manifest strabismus were evaluated and compared with GA at birth and with treatment-requiring ROP.

Results  The study cohort comprised 486 participants. The mean (SD) GA of the children who were included was 25 (1) weeks, and 45.7% (222 of 486) were female. At a median age of 6.6 years, 89.3% (434 of 486) of eligible EPT children were assessed and compared with 300 control group children. In the EPT group, 2.1% (9 of 434) were blind, 4.8% (21 of 434) were visually impaired according to the World Health Organization criteria, and 8.8% (38 of 434) were visually impaired according to the study criteria. Strabismus was found in 17.4% (68 of 390) and refractive errors in 29.7% (115 of 387) of the EPT children compared with 0% (0 of 299) and 5.9% (17 of 289), respectively, of the control children (P < .001). Altogether at 6.5 years of age, 37.9% (147 of 388) of the EPT children had some ophthalmologic abnormality compared with 6.2% (18 of 290) of the matched control group (95% CI of the difference, 26.1%-37.2%). When treatment-requiring ROP was adjusted for, no significant association between GA and visual impairment could be detected. For refractive errors, the association with GA remained after adjustment for treatment-requiring ROP (odds ratio, 0.72; 95% CI, 0.58-0.91 for each 1-week increment).

Conclusions and Relevance  In a Swedish national cohort of EPT children at 6.5 years of age, major eye and visual problems were frequently found. Treatment-requiring ROP was a stronger impact factor than GA on visual impairment and strabismus, but not on refractive errors, as a whole. In modern neonatal intensive care settings, ophthalmologic problems continue to account for a high proportion of long-term sequelae of prematurity.

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Figure 1.
Percentage of Visual Acuities in Better Eyes (n = 397) and Worse Eyes (n = 394) With Habitual Correction in the 6-Year EPT Group (n = 406) and the Control Group (n = 299)

EPT indicates extremely preterm.

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Figure 2.
Distribution of Refraction, Expressed as Spherical Equivalent (Left) and Visual Acuity (Right), in Better Eyes in the 6-Year Extremely Preterm (EPT) Group and the Control Group Relative to Stage and Treatment of Retinopathy of Prematurity (ROP)

Lines in boxes represent median values, and boxes represent interquartile ranges. Open circles represent outliers, and filled circles represent extreme values.

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