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Kulmala MK, Jørgensen A, Austeng D, Evensen KAI, Kajantie E, Morken TS, Majander A. Imprint of preterm birth with very low birth weight on optic disc OCT in adulthood-A two-country birth cohort study. Acta Ophthalmol 2024. [PMID: 39417333 DOI: 10.1111/aos.16771] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2024] [Accepted: 09/29/2024] [Indexed: 10/19/2024]
Abstract
PURPOSE To determine the pattern, degree and prevalence of optic disc optical coherence tomography (OCT) alterations in adults born preterm with very low birth weight (VLBW; birth weight < 1500 g). METHODS Optic disc OCT was assessed in 98 VLBW participants and 139 term-born controls from birth cohorts in Finland and Norway at the mean age of 36 years. The participants had not been treated for retinopathy of prematurity and had no diagnosed brain abnormality. OCT assessment included parameters for optic disc size, neural rim and peripapillary retinal nerve fibre layer thickness (pRNFLT), and for the foveal developmental stage. Background data, visual acuity, refractive error and intraocular pressure were recorded. RESULTS In the VLBW group, optic disc neural rim and pRNFLT were significantly decreased, most frequently in the nasal and inferior sectors. In 40% (95% CI: 33-47) of the VLBW eyes, nerve fibre thickness of at least one optic disc sector was below the fifth percentile of the control group, including 9% (95% CI: 6-14) subgroup falling below the first percentile, that is, clinically below normal limits. VLBW participants with nerve fibre thickness below the fifth percentile did not differ by perinatal data or foveal developmental stage from the other VLBW participants. All participants had normal visual acuity. CONCLUSION A moderate decrease of the optic disc neural rim and pRNFLT is frequently seen in clinically healthy adults born preterm with VLBW. Awareness of the VLBW-related optic disc nerve fibre shallowness especially in the inferior and nasal sectors is important while evaluating acquired optic disc pathology in adulthood.
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Affiliation(s)
- Maarit K Kulmala
- Population Health Unit, Finnish Institute for Health and Welfare, Helsinki, Finland
- Department of Ophthalmology, Helsinki University Hospital, University of Helsinki, Helsinki, Finland
| | - Anna Jørgensen
- Department of Neuromedicine and Movement Science, Norwegian University of Science and Technology (NTNU), Trondheim, Norway
| | - Dordi Austeng
- Department of Neuromedicine and Movement Science, Norwegian University of Science and Technology (NTNU), Trondheim, Norway
- Department of Ophthalmology, St. Olavs Hospital, Trondheim University Hospital, Trondheim, Norway
| | - Kari Anne I Evensen
- Department of Clinical and Molecular Medicine, NTNU, Trondheim, Norway
- Children's Clinic, St. Olavs Hospital, Trondheim University Hospital, Trondheim, Norway
- Department of Rehabilitation Science and Health Technology, Oslo Metropolitan University, Oslo, Norway
| | - Eero Kajantie
- Population Health Unit, Finnish Institute for Health and Welfare, Helsinki, Finland
- Department of Clinical and Molecular Medicine, NTNU, Trondheim, Norway
- Clinical Medicine Research Unit, MRC Oulu, Oulu University Hospital and University of Oulu, Oulu, Finland
- Helsinki Children's Hospital, University of Helsinki and Helsinki University Central Hospital, Helsinki, Finland
| | - Tora Sund Morken
- Department of Neuromedicine and Movement Science, Norwegian University of Science and Technology (NTNU), Trondheim, Norway
- Department of Ophthalmology, St. Olavs Hospital, Trondheim University Hospital, Trondheim, Norway
| | - Anna Majander
- Department of Ophthalmology, Helsinki University Hospital, University of Helsinki, Helsinki, Finland
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Tesarz J, Schuster AK, Hermes M, Mildenberger E, Urschitz MS, Treede RD, Tost H, Ernst M, Beutel M, Stoffelns B, Zepp F, Pfeiffer N, Fieß A. Associations of preterm birth and neonatal stress exposure with chronic pain in adulthood - Results from the Gutenberg prematurity study. J Psychosom Res 2024; 187:111943. [PMID: 39341156 DOI: 10.1016/j.jpsychores.2024.111943] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2023] [Revised: 09/21/2024] [Accepted: 09/22/2024] [Indexed: 09/30/2024]
Abstract
Although the effect of early childhood stress on central nervous pain processing is well known, studies on the association of prematurity and chronic pain are scarce. This study used data from a single-centre retrospective cohort study followed by a prospective clinical examination and pain assessment. The study was based on data from the local birth registry. Newborns born between 1969 and 2002 who had reached adulthood were eligible .. Using a selection algorithm, a study cohort stratified by gestational age (GA) was recruited. Chronic pain conditions were assessed using questionnaire and standardized pain drawings. Data on the pre-, peri- and postnatal clinical course was assessed from medical records. Multivariable logistic regression analyses were conducted to investigate associations between prematurity and chronic pain with adjustment for age, gender, socioeconomic status, and perinatal stress factors. 427 participants born preterm and full-term were included (age 28.5 ± 8.7 years). Chronic pain conditions were similarly common between groups with different levels of prematurity (GA ≥ 37 weeks: 34.5 %, GA33-36 weeks: 37.6 %, GA32-29 weeks: 25.2 %, GA < 29 weeks: 30.4 %, p = 0.20). In multivariable analyses, no association between low GA and the presence of chronic pain was found (OR = 0.99 (CI95 %: 0.94-1.04, p = 0.63); this was also true for a subanalysis of widespread pain. While neither fetal nutritional status nor perinatal stressors were associated with pain, exposure to maternal but not paternal smoking during pregnancy was associated with increased risk to develop pain (OR = 2.77 (CI95 %: 1.31-5.88, p = 0.008) in adults born preterm and full-term. This study suggests that prematurity by itself does not increase the risk of chronic pain later in life, but provides preliminary evidence for maternal smoking during pregnancy as risk factor.
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Affiliation(s)
- J Tesarz
- Department of General Internal Medicine and Psychosomatics, University Hospital Heidelberg, Heidelberg University, Heidelberg, Germany; DZPG (German Centre for Mental Health - Partner Site Heidelberg, Mannheim, Germany; Department of Psychosomatic Medicine and Psychotherapy, University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany.
| | - A K Schuster
- Department of Ophthalmology, University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany
| | - M Hermes
- Department of General Internal Medicine and Psychosomatics, University Hospital Heidelberg, Heidelberg University, Heidelberg, Germany
| | - E Mildenberger
- Division of Neonatology, Department of Pediatrics, University Medical Center of the Johannes Gutenberg-University Mainz, Germany
| | - M S Urschitz
- Division of Pediatric Epidemiology, Institute for Medical Biostatistics, Epidemiology and Informatics, University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany
| | - R D Treede
- Department of Neurophysiology, MCTN, Medical Faculty Mannheim, Heidelberg University, Germany
| | - H Tost
- Department of Psychiatry and Psychotherapy, Central Institute of Mental Health Medical Faculty Mannheim, Heidelberg University, Germany
| | - M Ernst
- Department of Psychosomatic Medicine and Psychotherapy, University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany
| | - M Beutel
- Department of Psychosomatic Medicine and Psychotherapy, University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany
| | - B Stoffelns
- Department of Ophthalmology, University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany
| | - F Zepp
- Department of Ophthalmology, University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany
| | - N Pfeiffer
- Department of Ophthalmology, University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany
| | - A Fieß
- Department of Ophthalmology, University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany
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3
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Fieß A, Hartmann A, Mildenberger E, Urschitz MS, Laspas P, Schultheis A, Stoffelns B, Pfeiffer N, Gißler S, Schuster AK. Sex-Specific Differences in the Relationship Between Prematurity and Ocular Geometry. Invest Ophthalmol Vis Sci 2024; 65:23. [PMID: 38874964 PMCID: PMC11182371 DOI: 10.1167/iovs.65.6.23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2023] [Accepted: 03/19/2024] [Indexed: 06/15/2024] Open
Abstract
Purpose To explore differences in the relationship between gestational age (GA) and birth weight (BW) percentile and ocular geometry between males and females. Methods The Gutenberg Prematurity Eye Study involved a prospective ophthalmic examination of adults, aged 18 to 52 years, who were born preterm or at term, in Germany. The associations between GA and BW percentile on the main outcome measures were evaluated by uni- and multivariable linear regression analyses. The main outcome measures were central corneal thickness, corneal radius, anterior chamber depth, lens thickness, posterior segment length, and central foveal thickness. Potential sex-specific differences and an effect modification by sex were analyzed. Results This study involved 438 participants (245 females, 193 males) with an average age of 28.6 ± 8.7 years. In female participants, central foveal thickness was negatively associated with a higher GA (B = -2.99; P < 0.001). Similarly, male participants also demonstrated a negative association between central foveal thickness and GA (B = -4.27; P < 0.001). The multivariable model with effect modification revealed that the central foveal thickness was thicker with lower GA. There was an association between the effect modification of GA with sex and central foveal thickness, demonstrating a more pronounced effect of GA on central foveal thickness in male participants (B = 1.29; P = 0.04). Conclusions This study identified a sex-specific correlation between lower GA and thicker central foveal thickness, suggesting differences in the developmental trajectory of this biometric parameter concerning GA. A thicker central foveal thickness might affect the visual acuity of individuals born preterm in adulthood, with a more pronounced impact in males and a potential predisposition to age-related diseases later in life. Sex did not influence the association of GA or BW percentile to other ocular geometric parameters.
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Affiliation(s)
- Achim Fieß
- Department of Ophthalmology, University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany
| | - Alica Hartmann
- Department of Ophthalmology, University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany
| | - Eva Mildenberger
- Division of Neonatology, Department of Pediatrics, University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany
| | - Michael S. Urschitz
- Division of Pediatric Epidemiology, Institute for Medical Biostatistics, Epidemiology and Informatics, University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany
| | - Panagiotis Laspas
- Department of Ophthalmology, University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany
| | - Anna Schultheis
- Department of Ophthalmology, University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany
| | - Bernhard Stoffelns
- Department of Ophthalmology, University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany
| | - Norbert Pfeiffer
- Department of Ophthalmology, University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany
| | - Sandra Gißler
- Department of Ophthalmology, University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany
| | - Alexander K. Schuster
- Department of Ophthalmology, University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany
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Downes RA, Rachitskaya AV. Ophthalmic sequelae of prematurity in late childhood and adulthood: A review. Clin Exp Ophthalmol 2024; 52:355-364. [PMID: 38334000 DOI: 10.1111/ceo.14358] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2023] [Revised: 12/07/2023] [Accepted: 01/03/2024] [Indexed: 02/10/2024]
Abstract
Advances in the care of premature infants have resulted in unprecedented rates of survival of these infants into adulthood, including those born at very low gestational ages. Ophthalmologists have historically followed premature infants to assess for the presence of and potential need for treatment of retinopathy of prematurity. However, a growing body of literature suggests that the ophthalmic consequences of prematurity extended beyond retinopathy of prematurity and that ophthalmic sequelae of prematurity can endure through adulthood even among formerly preterm adults who were never diagnosed with retinopathy of prematurity. These abnormalities can include a range of both anterior segment and posterior segment sequelae, including higher rates of corneal aberrations, ocular hypertension, strabismus, foveal anomalies, and retinal tears and detachments. This review aims to summarise this literature, underscoring the importance of lifelong examinations and regular monitoring for these complications among adults who were born prematurely.
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Affiliation(s)
- Rachel A Downes
- Vitreoretinal Service, Cole Eye Institute, Cleveland Clinic Foundation, Cleveland, Ohio, USA
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5
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Scott DA, Wang MT, Danesh-Meyer HV, Hull S. Optic atrophy in prematurity: pathophysiology and clinical features. Clin Exp Optom 2024; 107:245-254. [PMID: 37867148 DOI: 10.1080/08164622.2023.2256734] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2022] [Accepted: 09/05/2023] [Indexed: 10/24/2023] Open
Abstract
Optic atrophy is an important cause of visual impairment in children, and the aetiological profile has changed over time. Technological advancements led by neuroimaging of the visual pathway and imaging of the optic nerve with optical coherence tomography have accelerated the understanding of this condition. In the new millennium, an increasing prevalence of prematurity as a cause of optic atrophy in children has been highlighted. This new shift has been linked with increasing rates of premature births and improved neonatal survival of preterm infants. The available literature is limited to hospital and registry-based cohorts with modest sample sizes, methodological heterogeneity and selection bias limitations. Larger studies that are better designed are required to better understand the contribution of prematurity to the disease burden. In addition to considering other life-threatening aetiologies, screening for premature birth should be covered as part of a comprehensive history when evaluating a child with paediatric optic atrophy.
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Affiliation(s)
- Daniel Ar Scott
- Department of Ophthalmology, University of Auckland, Auckland, New Zealand
| | - Michael Tm Wang
- Department of Ophthalmology, University of Auckland, Auckland, New Zealand
| | | | - Sarah Hull
- Department of Ophthalmology, University of Auckland, Auckland, New Zealand
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6
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Fieß A, Volmering C, Gißler S, Mildenberger E, Urschitz MS, Laspas P, Stoffelns B, Pfeiffer N, Schuster AK. Macular Curvature in Adults Born Preterm With and Without ROP: Results from the Gutenberg Prematurity Eye Study. Invest Ophthalmol Vis Sci 2024; 65:39. [PMID: 38551582 PMCID: PMC10981436 DOI: 10.1167/iovs.65.3.39] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2023] [Accepted: 02/19/2024] [Indexed: 04/01/2024] Open
Abstract
Purpose This study investigated the effects of prematurity and retinopathy of prematurity (ROP) as well as the associations of the ocular geometry with macular curvature in adults. Methods The Gutenberg Prematurity Eye Study is a retrospective cohort study of preterm and full-term participants aged 18 to 52 years with a prospective ophthalmologic examination. The main outcome measure was the macular curvature in the central foveal optical coherence tomography (OCT) scan and its associations with gestational age (GA), birth weight and birth weight percentile, ROP occurrence, ROP treatment, and other perinatal factors were evaluated in univariable and multivariable linear regression analyses. Furthermore, a second model assessed the association of ocular geometry with macular curvature. Results In the present study, 550 eyes of 284 adults born preterm and 277 eyes of 139 adults born full-term were examined (aged = 28.7 ± 8.7 years, 240 female subjects). In multivariable analyses for perinatal parameters, ROP treatment (B = -52.44, P = 0.023) and maternal smoking during pregnancy (B = 26.41, P = 0.019) showed an association with macular curvature. Regarding ocular geometric parameters, posterior segment length (B = 9.07, P < 0.001) and subfoveal choroidal thickness (B = -0.26, P < 0.001) were associated with macular curvature, central corneal thickness, anterior chamber depth, lens thickness, and foveal retinal thickness were not associated. Conclusions Adults treated for ROP had relatively more negative curvature values compared to the full-term group, indicating a macular protrusion toward the vitreous cave. A thicker subfoveal choroidal thickness was associated with a flatter macular curvature, whereas a longer posterior segment length was associated with a steeper macular curvature indicating the characteristics of the myopic elongation of the eye.
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Affiliation(s)
- Achim Fieß
- Department of Ophthalmology, University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany
| | - Christin Volmering
- Department of Ophthalmology, University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany
| | - Sandra Gißler
- Department of Ophthalmology, University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany
| | - Eva Mildenberger
- Division of Neonatology, Department of Pediatrics, University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany
| | - Michael S. Urschitz
- Division of Pediatric Epidemiology, Institute for Medical Biostatistics, Epidemiology and Informatics, University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany
| | - Panagiotis Laspas
- Department of Ophthalmology, University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany
| | - Bernhard Stoffelns
- Department of Ophthalmology, University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany
| | - Norbert Pfeiffer
- Department of Ophthalmology, University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany
| | - Alexander K. Schuster
- Department of Ophthalmology, University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany
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Zhang L, Buonfiglio F, Fieß A, Pfeiffer N, Gericke A. Retinopathy of Prematurity-Targeting Hypoxic and Redox Signaling Pathways. Antioxidants (Basel) 2024; 13:148. [PMID: 38397746 PMCID: PMC10885953 DOI: 10.3390/antiox13020148] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2023] [Revised: 01/19/2024] [Accepted: 01/21/2024] [Indexed: 02/25/2024] Open
Abstract
Retinopathy of prematurity (ROP) is a proliferative vascular ailment affecting the retina. It is the main risk factor for visual impairment and blindness in infants and young children worldwide. If left undiagnosed and untreated, it can progress to retinal detachment and severe visual impairment. Geographical variations in ROP epidemiology have emerged over recent decades, attributable to differing levels of care provided to preterm infants across countries and regions. Our understanding of the causes of ROP, screening, diagnosis, treatment, and associated risk factors continues to advance. This review article aims to present the pathophysiological mechanisms of ROP, including its treatment. Specifically, it delves into the latest cutting-edge treatment approaches targeting hypoxia and redox signaling pathways for this condition.
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Affiliation(s)
| | | | | | | | - Adrian Gericke
- Department of Ophthalmology, University Medical Center, Johannes Gutenberg University Mainz, Langenbeckstrasse 1, 55131 Mainz, Germany; (L.Z.); (F.B.); (A.F.); (N.P.)
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Fieß A, Wacker A, Gißler S, Fauer A, Mildenberger E, Urschitz MS, Elflein H, Stoffelns B, Pfeiffer N, Schuster AK. [Ophthalmic care of adults born preterm and full-term-results from the Gutenberg Prematurity Eye Study (GPES) : Premature birth and ophthalmological care]. DIE OPHTHALMOLOGIE 2023; 120:608-619. [PMID: 36416921 DOI: 10.1007/s00347-022-01746-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/01/2022] [Revised: 09/28/2022] [Accepted: 10/04/2022] [Indexed: 06/13/2023]
Abstract
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.
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Affiliation(s)
- Achim Fieß
- Klinik und Poliklinik für Augenheilkunde, Universitätsklinikum der Johannes Gutenberg-Universität Mainz, Langenbeckstr. 1, 55131, Mainz, Deutschland.
| | - Annika Wacker
- Klinik und Poliklinik für Augenheilkunde, Universitätsklinikum der Johannes Gutenberg-Universität Mainz, Langenbeckstr. 1, 55131, Mainz, Deutschland
| | - Sandra Gißler
- Klinik und Poliklinik für Augenheilkunde, Universitätsklinikum der Johannes Gutenberg-Universität Mainz, Langenbeckstr. 1, 55131, Mainz, Deutschland
| | - Agnes Fauer
- Klinik und Poliklinik für Augenheilkunde, Universitätsklinikum der Johannes Gutenberg-Universität Mainz, Langenbeckstr. 1, 55131, Mainz, Deutschland
| | - Eva Mildenberger
- Abteilung für Neonatologie, Klinik für Kinderheilkunde, Universitätsmedizin der Johannes Gutenberg-Universität Mainz, Mainz, Deutschland
| | - Michael S Urschitz
- Abteilung für Pädiatrische Epidemiologie, Institut für Medizinische Biostatistik, Epidemiologie und Informatik, Universitätsmedizin der Johannes Gutenberg-Universität Mainz, Mainz, Deutschland
| | - Heike Elflein
- Klinik und Poliklinik für Augenheilkunde, Universitätsklinikum der Johannes Gutenberg-Universität Mainz, Langenbeckstr. 1, 55131, Mainz, Deutschland
| | - Bernhard Stoffelns
- Klinik und Poliklinik für Augenheilkunde, Universitätsklinikum der Johannes Gutenberg-Universität Mainz, Langenbeckstr. 1, 55131, Mainz, Deutschland
| | - Norbert Pfeiffer
- Klinik und Poliklinik für Augenheilkunde, Universitätsklinikum der Johannes Gutenberg-Universität Mainz, Langenbeckstr. 1, 55131, Mainz, Deutschland
| | - Alexander K Schuster
- Klinik und Poliklinik für Augenheilkunde, Universitätsklinikum der Johannes Gutenberg-Universität Mainz, Langenbeckstr. 1, 55131, Mainz, Deutschland
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Fieß A, Grabitz SD, Mildenberger E, Urschitz MS, Fauer A, Hampel U, Wasielica-Poslednik J, Zepp F, Pfeiffer N, Schuster AK. A lower birth weight percentile is associated with central corneal thickness thinning: Results from the Gutenberg Prematurity Eye Study (GPES). JOURNAL OF OPTOMETRY 2023; 16:143-150. [PMID: 36182657 PMCID: PMC10104790 DOI: 10.1016/j.optom.2022.07.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/27/2022] [Revised: 06/17/2022] [Accepted: 07/03/2022] [Indexed: 06/16/2023]
Abstract
PURPOSE Prematurity, prenatal growth restriction, and retinopathy of prematurity (ROP) are associated with altered ocular geometry, such as a steeper corneal shape in childhood, but it is unclear whether perinatal history affects corneal thickness development, so this study investigated whether corneal thickness in adulthood is affected by perinatal history. MARTERIALS AND METHODS The Gutenberg Prematurity Eye Study (GPES) is a retrospective cohort study with a prospective ophthalmologic examination in Germany. The corneal thickness was measured by Scheimpflug imaging (Pentacam HR, Oculus Optikgeräte GmbH, Wetzlar, Germany), and the relationship between perinatal parameters respective birth weight percentile and corneal thickness at different locations was assessed using uni- and multivariable linear regression models. Covariates included age, sex, mean corneal radius, white-to-white distance, gestational age, birth weight percentile, ROP occurrence, and treatment. The main outcome measures were corneal thickness at the apex, the pupil center, and the corneal periphery. RESULTS The corneal thickness was measured in 390 participants (754 eyes, mean age 29.7+/-8.7 years, 224 females). In multivariable analyses, a lower birth weight percentile was associated with a lower corneal thickness at the apex (B = 0.20, p = 0.003) and the pupil (B = 0.19, p = 0.007). These effects diminished towards the corneal periphery and were not observed beyond the 4-mm diameter circle around the thinnest corneal position. Neither gestational age, ROP occurrence, or ROP treatment affected the corneal thickness. CONCLUSION A lower birth weight percentile in subjects born preterm as a proxy for restricted fetal growth is associated with corneal thickness thinning in adults aged 18 to 52 years, indicating that corneal thickness development, particularly in the corneal center, may originate in the fetal stage.
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Affiliation(s)
- Achim Fieß
- Department of Ophthalmology, University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany.
| | - Stephanie D Grabitz
- Department of Ophthalmology, University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany
| | - Eva Mildenberger
- Division of Neonatology, Department of Pediatrics, University Medical Center of the Johannes Gutenberg University Mainz, Germany
| | - Michael S Urschitz
- Division of Pediatric Epidemiology, Institute for Medical Biostatistics, Epidemiology and Informatics, University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany
| | - Agnes Fauer
- Department of Ophthalmology, University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany
| | - Ulrike Hampel
- Department of Ophthalmology, University Hospital Leipzig, Leipzig, Germany
| | - Joanna Wasielica-Poslednik
- Department of Ophthalmology, University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany
| | - Fred Zepp
- Division of Neonatology, Department of Pediatrics, University Medical Center of the Johannes Gutenberg University Mainz, Germany
| | - Norbert Pfeiffer
- Department of Ophthalmology, University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany
| | - Alexander K Schuster
- Department of Ophthalmology, University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany
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10
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Fieß A, Schäffler A, Mildenberger E, Urschitz MS, Wagner FM, Hoffmann EM, Zepp F, Pfeiffer N, Schuster AK. Peripapillary Retinal Nerve Fiber Layer Thickness in Adults Born Extremely, Very, and Moderately Preterm With and Without Retinopathy of Prematurity: Results From the Gutenberg Prematurity Eye Study (GPES). Am J Ophthalmol 2022; 244:88-97. [PMID: 35932823 DOI: 10.1016/j.ajo.2022.07.019] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2022] [Revised: 07/19/2022] [Accepted: 07/19/2022] [Indexed: 01/30/2023]
Abstract
PURPOSE This study investigated whether prematurity and associated factors or prenatal growth restriction have long-term effects on the peripapillary retinal nerve fiber layer (pRNFL) in adulthood. DESIGN Retrospective cohort study. METHODS The Gutenberg Prematurity Eye Study (GPES) is a retrospective cohort study with a prospective ophthalmologic examination in Germany. Selected individuals born term and preterm (age 18-52 years) were examined with spectral-domain optical coherence tomography (SD-OCT) in adulthood, and perinatal medical charts were reviewed. The pRNFL thickness was measured using SD-OCT. Univariate and multivariable linear regression analyses were conducted to investigate associations between pRNFL and gestational age (GA; categorical), birth weight percentile (categorical), retinopathy of prematurity (ROP) occurrence, and treatment and other perinatal parameters with adjustment for age, sex, and spherical equivalent. RESULTS In total, 766 eyes of 406 preterm and full-term individuals were included (mean age 28.4 ± 8.6 years, 228 females). After adjustment for age, sex, and spherical equivalent, global pRNFL thinning was associated with moderate (GA = 33-36 wk, β = -4.68, P < .001), very (GA = 29-32 wk, β = -5.72, P < .001), and extreme (GA ≤ 28 wk, β = -8.69, P < .001) prematurity but not with low birth weight percentile (<25th percentile, P = .9) and ROP occurrence (P = .9) in multivariable analysis. ROP treatment was associated with increased pRNFL in the temporal sector (P = .002). Maternal smoking during pregnancy showed an association with pRNFL thinning (P = .07). CONCLUSION Our data indicate that the more preterm individuals are born the more pRNFL thinning occurs, whereas prenatal growth restriction and postnatal occurrence of ROP show less effects on pRNFL thickness. Furthermore, individuals with severe ROP with treatment but not lower ROP stages without treatment showed an increased temporal pRNFL thickness.
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Affiliation(s)
- Achim Fieß
- From the Department of Ophthalmology (A.F., A.S., F.M.W., E.M.H., N.P., A.K.S.), University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany.
| | - Alina Schäffler
- From the Department of Ophthalmology (A.F., A.S., F.M.W., E.M.H., N.P., A.K.S.), University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany
| | - Eva Mildenberger
- Division of Neonatology, Department of Pediatrics (E.M., F.Z.), University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany
| | - Michael S Urschitz
- Division of Pediatric Epidemiology, Institute for Medical Biostatistics, Epidemiology and Informatics (M.S.U.), University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany
| | - Felix M Wagner
- From the Department of Ophthalmology (A.F., A.S., F.M.W., E.M.H., N.P., A.K.S.), University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany
| | - Esther M Hoffmann
- From the Department of Ophthalmology (A.F., A.S., F.M.W., E.M.H., N.P., A.K.S.), University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany
| | - Fred Zepp
- Division of Neonatology, Department of Pediatrics (E.M., F.Z.), University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany
| | - Norbert Pfeiffer
- From the Department of Ophthalmology (A.F., A.S., F.M.W., E.M.H., N.P., A.K.S.), University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany
| | - Alexander K Schuster
- From the Department of Ophthalmology (A.F., A.S., F.M.W., E.M.H., N.P., A.K.S.), University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany
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11
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Fieß A, Wacker A, Gißler S, Fauer A, Mildenberger E, Urschitz MS, Elflein HM, Stoffelns BM, Pfeiffer N, Schuster AK. Augenärztliche Versorgung früh- und reifgeborener Personen in deren Kindheit und Jugend – eine retrospektive Sicht der Eltern. Klin Monbl Augenheilkd 2022; 240:295-304. [PMID: 36257334 DOI: 10.1055/a-1890-5148] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
Zusammenfassung
Hintergrund Das Ziel der vorliegenden Studie war die Beschreibung der augenärztlichen Versorgung in der Kindheit und Jugend früh- und reifgeborener Personen aus der retrospektiven
Sicht der Eltern.
Patienten, Material und Methoden Die Gutenberg Prematurity Eye Study (GPES) ist eine retrospektive Kohortenstudie mit einer prospektiven augenärztlichen Untersuchung von früh- und
reifgeborenen Personen, die zwischen 1969 und 2002 geboren wurden (aktuelles Alter 18 bis 52 Jahre). Sie schließt eine Befragung von deren Eltern zur augenärztlichen Versorgung ihrer Kinder
in der Kindheit und Jugend aus der Retrospektive ein. Die Teilnehmenden und deren Eltern wurden in Personen mit normalem Gestationsalter (GA) ≥ 37 (Kontrollgruppe), Frühgeborene ohne ROP
(Retinopathy of Prematurity) mit GA 33 – 36 (Gruppe 2), GA 29 – 32 (Gruppe 3), GA ≤ 28 Wochen (Gruppe 4) und solche mit ROP ohne Behandlung (Gruppe 5) und mit ROP mit Behandlung (Gruppe 6)
gruppiert. Die Eltern der Teilnehmenden wurden zur augenärztlichen Versorgung und zur Zufriedenheit damit befragt.
Ergebnisse Insgesamt wurden die Daten von 57 reifgeborenen und 131 frühgeborenen Kindern und deren Eltern in die vorliegende Studie eingeschlossen. Die Eltern der Teilnehmenden gaben
an, dass eine augenärztliche Untersuchung bis zum 6. Lebensjahr in den jeweiligen Gruppen 1 bis 6 bei 22/57 (38,6%), 33/58 (56,9%), 22/38 (57,9%), 3/6 (50%), 19/21 (90,5%) und 7/8 (87,5%)
stattgefunden habe. Insgesamt gaben 83 – 100% der Eltern in den verschiedenen Gruppen an, dass die augenärztliche Betreuung gut gewesen sei. Einen Augenarztwechsel aufgrund von
Behandlungsunzufriedenheit berichteten insgesamt 4/57 (7%), 9/58 (15,5%), 8/38 (21,1%), 1/6 (16,7%), 1/21 (4,8%) und 2/8 (25%) in den jeweiligen Gruppen.
Schlussfolgerung Die vorliegende Studie zeigt eine gute Behandlungszufriedenheit hinsichtlich der augenärztlichen Betreuung von ehemaligen frühgeborenen Personen, insbesondere Eltern
von Kindern mit einer ROP bewerteten diese positiv.
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Affiliation(s)
- Achim Fieß
- Klinik und Poliklinik für Augenheilkunde, Universitätsklinikum der Johannes Gutenberg-Universität Mainz, Deutschland
| | - Annika Wacker
- Klinik und Poliklinik für Augenheilkunde, Universitätsklinikum der Johannes Gutenberg-Universität Mainz, Deutschland
| | - Sandra Gißler
- Klinik und Poliklinik für Augenheilkunde, Universitätsklinikum der Johannes Gutenberg-Universität Mainz, Deutschland
| | - Agnes Fauer
- Klinik und Poliklinik für Augenheilkunde, Universitätsklinikum der Johannes Gutenberg-Universität Mainz, Deutschland
| | - Eva Mildenberger
- Abteilung für Neonatologie, Klinik für Kinderheilkunde, Universitätsmedizin der Johannes Gutenberg-Universität Mainz, Deutschland
| | - Michael S. Urschitz
- Abteilung für Pädiatrische Epidemiologie, Institut für Medizinische Biostatistik, Epidemiologie und Informatik, Universitätsmedizin der Johannes Gutenberg-Universität Mainz,
Deutschland
| | - Heike Maria Elflein
- Klinik und Poliklinik für Augenheilkunde, Universitätsklinikum der Johannes Gutenberg-Universität Mainz, Deutschland
| | - Bernhard M. Stoffelns
- Klinik und Poliklinik für Augenheilkunde, Universitätsklinikum der Johannes Gutenberg-Universität Mainz, Deutschland
| | - Norbert Pfeiffer
- Klinik und Poliklinik für Augenheilkunde, Universitätsklinikum der Johannes Gutenberg-Universität Mainz, Deutschland
| | - Alexander K. Schuster
- Klinik und Poliklinik für Augenheilkunde, Universitätsklinikum der Johannes Gutenberg-Universität Mainz, Deutschland
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Visual acuity, amblyopia, and vision-related quality of life in preterm adults with and without ROP: results from the Gutenberg prematurity eye study. Eye (Lond) 2022:10.1038/s41433-022-02207-y. [DOI: 10.1038/s41433-022-02207-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2022] [Revised: 06/30/2022] [Accepted: 08/10/2022] [Indexed: 11/08/2022] Open
Abstract
Abstract
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.
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Fieß A, Berger LA, Riedl JC, Mildenberger E, Urschitz MS, Hampel U, Wasielica-Poslednik J, Zepp F, Stoffelns B, Pfeiffer N, Schuster AK. The role of preterm birth, retinopathy of prematurity and perinatal factors on corneal aberrations in adulthood: Results from the Gutenberg prematurity eye study. Ophthalmic Physiol Opt 2022; 42:1379-1389. [PMID: 36006775 DOI: 10.1111/opo.13038] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2022] [Revised: 06/18/2022] [Accepted: 07/19/2022] [Indexed: 12/11/2022]
Abstract
INTRODUCTION Prematurity and retinopathy of prematurity (ROP) are associated with altered corneal shape and reduced visual acuity in childhood, but their long-term effects on corneal shape in later life are still unclear. This study evaluated whether prematurity and related perinatal factors are associated with corneal aberrations in adulthood. METHODS The Gutenberg Prematurity Eye Study (GPES) is a cohort study using Scheimpflug imaging of the cornea. Associations were assessed between corneal Zernike aberrations and gestational age (GA), birth weight (BW), BW percentile, ROP occurrence, ROP treatment and other perinatal factors using univariate and multivariable linear regression analyses. RESULTS This study involved 444 eyes of 256 individuals born preterm (aged 28.1 ± 8.4 years, 146 females) and 231 eyes of 132 individuals born full-term (aged 29.8 ± 8.9 years, 77 females). Multivariable analyses revealed an association between corneal higher-order aberrations and lower birth weight percentile (B = -0.001, p < 0.001) as well as ROP treatment (B = 0.120, p = 0.03). Corneal lower-order aberrations were also associated with lower birth weight percentile (B = -0.004; p = 0.001) and ROP treatment (B = 0.838, p = 0.01) but not with ROP occurrence. Increased corneal aberrations were correlated with lower visual acuity and the spherical equivalent refractive error. CONCLUSIONS Perinatal factors, particularly low birth weight percentile and ROP treatment lead to a more irregular corneal shape in adulthood, thereby reducing optical image quality and potentially contributing to reduced visual acuity and altered refractive error.
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Affiliation(s)
- Achim Fieß
- Department of Ophthalmology, University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany
| | - Lina Amalia Berger
- Department of Ophthalmology, University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany
| | - Jana C Riedl
- Department of Ophthalmology, University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany
| | - Eva Mildenberger
- Division of Neonatology, Department of Pediatrics, University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany
| | - Michael S Urschitz
- Division of Pediatric Epidemiology, Institute for Medical Biostatistics, Epidemiology and Informatics, University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany
| | - Ulrike Hampel
- Department of Ophthalmology, University Hospital Leipzig, Leipzig, Germany
| | - Joanna Wasielica-Poslednik
- Department of Ophthalmology, University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany
| | - Fred Zepp
- Division of Neonatology, Department of Pediatrics, University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany
| | - Bernhard Stoffelns
- Department of Ophthalmology, University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany
| | - Norbert Pfeiffer
- Department of Ophthalmology, University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany
| | - Alexander K Schuster
- Department of Ophthalmology, University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany
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Fieß A, Hufschmidt-Merizian C, Gißler S, Hampel U, Mildenberger E, Urschitz MS, Zepp F, Stoffelns B, Pfeiffer N, Schuster AK. Dry Eye Parameters and Lid Geometry in Adults Born Extremely, Very, and Moderately Preterm with and without ROP: Results from the Gutenberg Prematurity Eye Study. J Clin Med 2022; 11:2702. [PMID: 35628829 PMCID: PMC9147172 DOI: 10.3390/jcm11102702] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2022] [Revised: 05/01/2022] [Accepted: 05/03/2022] [Indexed: 12/11/2022] Open
Abstract
Background/Aims: This study aimed to analyze the effects of perinatal history on tear film properties and lid geometry in adults born preterm. Methods: The Gutenberg Prematurity Eye Study (GPES) is a German prospective examination of adults born preterm and term aged 18 to 52 years with Keratograph® 5M and Schirmer test I. Main outcome measures were first non-invasive tear film break-up time (F-NITBUT), bulbar redness (BR), Schirmer test, and nasal palpebral angle measurement. The associations with gestational age (GA), birth weight (BW), and BW percentile, retinopathy of prematurity (ROP), ROP treatment, and other perinatal factors were evaluated using regression analyses. Results: 489 eyes of 255 preterm and 277 eyes of 139 full-term individuals (aged 28.6 +/− 8.8 years, 220 females) were included. Of these, 33 participants (56 eyes) had a history of spontaneously regressed ROP and 9 participants (16 eyes) had a history of ROP treatment. After adjustment for age and sex, lower F-NITBUT (<20 s) was associated with ROP treatment (OR = 4.42; p = 0.025). Lower GA correlated with increased bulbar redness (B = −0.02; p = 0.011) and increased length of wetting in the Schirmer test (B = −0.69; p = 0.003). Furthermore, low GA was associated with narrowing of the nasal palpebral angle (B = 0.22; p = 0.011) adjusted for age and sex, but not when considering ROP in the multivariable model. Conclusion: Our analyses indicate that perinatal history affects ocular surface properties, tear production and lid geometry in adults born term and preterm. This might indicate that affected persons have a predisposition to diseases of the corneal surface such as the dry eye disease.
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Affiliation(s)
- Achim Fieß
- Department of Ophthalmology, University Medical Center of the Johannes Gutenberg University Mainz, 55131 Mainz, Germany; (C.H.-M.); (S.G.); (B.S.); (N.P.); (A.K.S.)
| | - Clara Hufschmidt-Merizian
- Department of Ophthalmology, University Medical Center of the Johannes Gutenberg University Mainz, 55131 Mainz, Germany; (C.H.-M.); (S.G.); (B.S.); (N.P.); (A.K.S.)
| | - Sandra Gißler
- Department of Ophthalmology, University Medical Center of the Johannes Gutenberg University Mainz, 55131 Mainz, Germany; (C.H.-M.); (S.G.); (B.S.); (N.P.); (A.K.S.)
| | - Ulrike Hampel
- Department of Ophthalmology, University Hospital Leipzig, 04103 Leipzig, Germany;
| | - Eva Mildenberger
- Division of Neonatology, Department of Pediatrics, University Medical Center of the Johannes Gutenberg University Mainz, 55131 Mainz, Germany; (E.M.); (F.Z.)
| | - Michael S. Urschitz
- Division of Pediatric Epidemiology, Institute for Medical Biostatistics, Epidemiology and Informatics, University Medical Center of the Johannes Gutenberg University Mainz, 55131 Mainz, Germany;
| | - Fred Zepp
- Division of Neonatology, Department of Pediatrics, University Medical Center of the Johannes Gutenberg University Mainz, 55131 Mainz, Germany; (E.M.); (F.Z.)
| | - Bernhard Stoffelns
- Department of Ophthalmology, University Medical Center of the Johannes Gutenberg University Mainz, 55131 Mainz, Germany; (C.H.-M.); (S.G.); (B.S.); (N.P.); (A.K.S.)
| | - Norbert Pfeiffer
- Department of Ophthalmology, University Medical Center of the Johannes Gutenberg University Mainz, 55131 Mainz, Germany; (C.H.-M.); (S.G.); (B.S.); (N.P.); (A.K.S.)
| | - Alexander K. Schuster
- Department of Ophthalmology, University Medical Center of the Johannes Gutenberg University Mainz, 55131 Mainz, Germany; (C.H.-M.); (S.G.); (B.S.); (N.P.); (A.K.S.)
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