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Retinal and peripapillary vascular deformations in prematurely born children aged 4-12 years with a history of retinopathy of prematurity. Sci Rep 2023; 13:3130. [PMID: 36813874 PMCID: PMC9946928 DOI: 10.1038/s41598-023-30166-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2022] [Accepted: 02/16/2023] [Indexed: 02/24/2023] Open
Abstract
In this study, foveal, parafoveal, peripapillary anatomical, and microvascular anomalies in prematurely born children aged 4-12 years with a history of retinopathy of prematurity (ROP) were evaluated. Seventy-eight eyes of 78 prematurely born children ([tROP]: ROP with laser treatment, [srROP]: spontaneously regressed ROP) and 43 eyes of 43 healthy children were included. Foveal and peripapillary morphological parameters (including ganglion cell and inner plexiform layer (GCIPL) thickness, peripapillary retinal nerve fiber layer (pRNFL) thickness) and vasculature parameters (including foveal avascular zone area, vessel density from superficial retinal capillary plexus (SRCP), deep retinal capillary plexus (DRCP), and radial peripapillary capillary (RPC) segments) were analyzed. Foveal vessel densities in SRCP and DRCP were increased and parafoveal vessel densities in SRCP and RPC segments vessel density were decreased in both ROP groups compared with those of control eyes. The best-corrected visual acuity was negatively correlated with pRNFL thickness in the tROP group. Refractive error was negatively correlated with vessel density of RPC segments in the srROP group. In children born preterm with a history of ROP, it was found that foveal, parafoveal, and peripapillary structural and vascular anomalies and redistribution were accompanied. These retinal vascular and anatomical structure anomalies showed close relationships with visual functions.
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Fieß A, Brandt M, Mildenberger E, Urschitz MS, Wagner FM, Grabitz SD, Hoffmann EM, Pfeiffer N, Schuster AK. Adults Born Small for Gestational Age at Term Have Thinner Peripapillary Retinal Nerve Fiber Layers Than Controls. Eye Brain 2022; 14:127-135. [DOI: 10.2147/eb.s383231] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2022] [Accepted: 10/18/2022] [Indexed: 11/27/2022] Open
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Guo BQ, Li HB, Zhai DS, Yang LQ. Prevalence of autism spectrum disorder diagnosis by birth weight, gestational age, and size for gestational age: a systematic review, meta-analysis, and meta-regression. Eur Child Adolesc Psychiatry 2022:10.1007/s00787-022-02078-4. [PMID: 36066648 DOI: 10.1007/s00787-022-02078-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2022] [Accepted: 08/31/2022] [Indexed: 11/03/2022]
Abstract
We aimed to comprehensively pool the prevalence of autism spectrum disorder (ASD) diagnosis by birth weight, gestational age, and size for gestational age. PubMed, EMBASE, Web of Science, Ovid PsycINFO, and Cochrane Library were searched up to December 22, 2021. We pooled data using the random-effects model and quantified heterogeneity using the I2 statistic. Of 66 643 records initially identified, 75 studies were included in the meta-analysis. The pooled prevalence estimates of ASD diagnosis are as follows: very-low-birth weight, 3.1% (912 ASD/66,445 individuals); low-birth weight, 2.3% (5672 ASD/593,927 individuals); normal-birth weight, 0.5% (17,361 ASD/2,378,933 individuals); high-birth weight, 0.6% (4505 ASD/430,699 individuals); very preterm, 2.8% (2113 ASD/128,513 individuals); preterm, 2.1% (19 672 ASD/1 725 244 individuals); term, 0.6% (113,261 ASD/15,297,259 individuals); postterm, 0.6% (9419 ASD/1,138,215 individuals); small-for-gestational-age, 1.9% (6314 ASD/796,550 individuals); appropriate-for-gestational-age, 0.7% (21,026 ASD/5,936,704 individuals); and large-for-gestational-age, 0.6% (2607 ASD/635,666 individuals). Compared with the reference prevalence (those in normal-birth weight, term, and appropriate-for-gestational-age individuals), the prevalence estimates of ASD diagnosis in very-low-birth weight, low-birth weight, very preterm, preterm, and small-for-gestational-age individuals increased significantly, while those in high-birth weight, postterm, and large-for-gestational-age individuals did not change significantly. There were geographical differences in the prevalence estimates. This meta-analysis provided reliable estimates of the prevalence of ASD diagnosis by birth weight, gestational age, and size for gestational age, and suggested that low-birth weight (especially very-low-birth weight), preterm (especially very preterm), and small-for-gestational-age births, rather than high-birth weight, postterm, and large-for-gestational-age births, were associated with increased risk of ASD diagnosis. However, in view of marked between-study heterogeneity in most conditions, unknown effects of certain important confounders associated with ASD due to limited information in original articles, and included studies from a relatively small number of countries, the findings of this study should be interpreted with caution.
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Affiliation(s)
- Bao-Qiang Guo
- School of Public Health, Xinxiang Medical University, 601 Jinsui Road, Xinxiang, Henan, 453003, China.
| | - Hong-Bin Li
- School of Public Health, Xinxiang Medical University, 601 Jinsui Road, Xinxiang, Henan, 453003, China
| | - De-Sheng Zhai
- School of Public Health, Xinxiang Medical University, 601 Jinsui Road, Xinxiang, Henan, 453003, China
| | - Li-Qiang Yang
- School of Public Health, Xinxiang Medical University, 601 Jinsui Road, Xinxiang, Henan, 453003, China
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Ortueta‐Olartecoechea A, Torres‐Peña JL, Muñoz‐Gallego A, Torres‐Valdivieso MJ, Vázquez‐Román S, De la Cruz J, Tejada‐Palacios P. Retinal ganglion cell complex thickness at school-age, prematurity and neonatal stressors. Acta Ophthalmol 2021; 100:e1253-e1263. [PMID: 34873863 DOI: 10.1111/aos.15073] [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: 11/27/2020] [Revised: 11/10/2021] [Accepted: 11/19/2021] [Indexed: 10/19/2022]
Abstract
PURPOSE To investigate the association between the ganglion cell complex (GCC) thickness at early school-age and prematurity and other neonatal factors. METHODS Cross-sectional study. The sample included very preterm children with gestational age (GA) below 32 weeks or birthweight below 1500 g enrolled in a follow-up program (n = 101) and a comparison group of term-born children (n = 49). Ganglion cell complex (GCC) thickness was measured at 4-8 years using high-quality optical coherence tomography (OCT) images. Data on neonatal and postnatal features were extracted from clinical records; analyses included mixed linear models. RESULTS Ganglion cell layer (GCL) and retinal nerve fiber layer (mRNFL) were thicker in term than in preterm born children (2.9 μm and 2.4 μm respectively, p < 0.001). Within the preterm group, lower GA was associated with a decrease in total GCL (0.7 μm per week, p < 0.001). Being small for GA was associated with further thinning in both layers (1.4 and 2.8 µm). Postnatal corticosteroids therapy and severe brain lesion were associated with thinning in the total GCL of 6 µm (p < 0.001) and 4.1 µm (p = 0.002), respectively, and shock was associated with thinning in total mRNFL of 6 µm (p < 0.001). CONCLUSIONS Lower GA or birthweight are associated with thinning of GCC layers. When performing an OCT examination at school-age and a decrease in GCC thickness is observed, it may be relevant to ask about a history of prematurity, and further enquire about neonatal shock, postnatal corticosteroids therapy or severe brain lesion that are related to additional decrease in GCC thickness.
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Affiliation(s)
| | - Jose L. Torres‐Peña
- Madrid University Hospital “12 de Octubre”, Department of Ophthalmology Madrid Spain
| | - Alicia Muñoz‐Gallego
- Madrid University Hospital “12 de Octubre”, Department of Ophthalmology Madrid Spain
| | | | - Sara Vázquez‐Román
- Madrid University Hospital “12 de Octubre”, Department of Neonatology Madrid Spain
| | - Javier De la Cruz
- Madrid University Hospital “12 de Octubre”, Research Institute (imas12) Madrid Spain
- Mother and Child Health, and Development Research Network SAMIDISCIII Madrid Spain
| | - Pilar Tejada‐Palacios
- Madrid University Hospital “12 de Octubre”, Department of Ophthalmology Madrid Spain
- Madrid University Hospital “12 de Octubre”, Research Institute (imas12) Madrid Spain
- Madrid University Complutense Madrid Spain
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Paules C, Miranda J, Policiano C, Crovetto F, Youssef L, Hahner N, Nakaki A, Crispi F, Gratacós E, Eixarch E. Fetal neurosonography detects differences in cortical development and corpus callosum in late-onset small fetuses. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2021; 58:42-47. [PMID: 33438307 DOI: 10.1002/uog.23592] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/04/2020] [Revised: 11/17/2020] [Accepted: 12/24/2020] [Indexed: 06/12/2023]
Abstract
OBJECTIVE To explore whether neurosonography can detect differences in cortical development and corpus callosal length in late-onset small fetuses subclassified into small-for-gestational age (SGA) or growth restricted (FGR). METHODS This was a prospective cohort study in singleton pregnancies, including normally grown fetuses (birth weight between the 10th and 90th centiles) and late-onset small fetuses (estimated fetal weight < 10th centile, diagnosed after 32 weeks of gestation and confirmed by birth weight < 10th centile). Small fetuses were subclassified into SGA (birth weight between the 3rd and 9th centiles and normal fetoplacental Doppler) and FGR (birth weight < 3rd centile and/or abnormal cerebroplacental ratio and/or abnormal uterine artery Doppler). Neurosonography was performed at 33 ± 1 weeks of gestation to assess the depth of the insula, Sylvian fissure and parieto-occipital sulcus in the axial views and corpus callosal length in the midsagittal plane. Measurements were performed offline using Alma Workstation software and were adjusted by biparietal diameter or cephalic index. Linear regression analysis was used to assess the association between the neurosonographic variables and study group, adjusting for confounding factors such as gender, gestational age at neurosonography, nulliparity and pre-eclampsia. RESULTS In total, 318 fetuses were included, of which 97 were normally grown and 221 were late-onset small fetuses that were further subdivided into late-onset SGA (n = 67) or late-onset FGR (n = 154). Compared to controls, both SGA and FGR cases showed significantly increased insular depth adjusted for biparietal diameter (median (interquartile range), controls 0.329 (0.312-0.342) vs SGA 0.339 (0.321-0.347) vs FGR 0.336 (0.325-0.349); P = 0.006). A linear tendency to reduced Sylvian fissure depth adjusted for biparietal diameter was also observed across the study groups (mean ± SD, controls 0.148 ± 0.021 vs SGA 0.142 ± 0.025 vs FGR 0.139 ± 0.022; P = 0.003). However, differences were significant only between the FGR and control groups. Corpus callosal length adjusted for cephalic index was significantly reduced in FGR cases compared with both controls and SGA cases, while there was no difference between SGA cases and controls (median (interquartile range), controls 0.500 (0.478-0.531) vs SGA 0.502 (0.487-0.526) vs FGR 0.475 (0.447-0.508); P = 0.005). No differences were found in parieto-occipital sulcus depth between the three study groups. CONCLUSION Neurosonography seems to be a sensitive tool to detect subtle structural differences in brain development in late-onset small fetuses. © 2021 International Society of Ultrasound in Obstetrics and Gynecology.
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Affiliation(s)
- C Paules
- BCNatal - Fetal Medicine Research Center (Hospital Clínic and Hospital Sant Joan de Déu), University of Barcelona, Barcelona, Spain
- Instituto de Investigación Sanitaria Aragón (IISAragon), Red de Salud Materno Infantil y del Desarrollo (SAMID), RETICS, Instituto de Salud Carlos III (ISCIII), Subdirección General de Evaluación y Fomento de la Investigación y Fondo Europeo de Desarrollo Regional (FEDER), Zaragoza, Spain
| | - J Miranda
- BCNatal - Fetal Medicine Research Center (Hospital Clínic and Hospital Sant Joan de Déu), University of Barcelona, Barcelona, Spain
| | - C Policiano
- BCNatal - Fetal Medicine Research Center (Hospital Clínic and Hospital Sant Joan de Déu), University of Barcelona, Barcelona, Spain
- Departamento de Obstetrícia, Ginecologia e Medicina da Reproduçao, Hospital Universitário de Santa Maria, Centro Hospitalar Lisboa Norte, Lisbon, Portugal
| | - F Crovetto
- BCNatal - Fetal Medicine Research Center (Hospital Clínic and Hospital Sant Joan de Déu), University of Barcelona, Barcelona, Spain
- Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | - L Youssef
- BCNatal - Fetal Medicine Research Center (Hospital Clínic and Hospital Sant Joan de Déu), University of Barcelona, Barcelona, Spain
- Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | - N Hahner
- BCNatal - Fetal Medicine Research Center (Hospital Clínic and Hospital Sant Joan de Déu), University of Barcelona, Barcelona, Spain
- Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | - A Nakaki
- BCNatal - Fetal Medicine Research Center (Hospital Clínic and Hospital Sant Joan de Déu), University of Barcelona, Barcelona, Spain
- Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | - F Crispi
- BCNatal - Fetal Medicine Research Center (Hospital Clínic and Hospital Sant Joan de Déu), University of Barcelona, Barcelona, Spain
- Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
- Centre for Biomedical Research on Rare Diseases (CIBER-ER), Madrid, Spain
| | - E Gratacós
- BCNatal - Fetal Medicine Research Center (Hospital Clínic and Hospital Sant Joan de Déu), University of Barcelona, Barcelona, Spain
- Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
- Centre for Biomedical Research on Rare Diseases (CIBER-ER), Madrid, Spain
| | - E Eixarch
- BCNatal - Fetal Medicine Research Center (Hospital Clínic and Hospital Sant Joan de Déu), University of Barcelona, Barcelona, Spain
- Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
- Centre for Biomedical Research on Rare Diseases (CIBER-ER), Madrid, Spain
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Zhao X, Li R, Huang D, Tong H, Zhu H, Wang Y, Zhang X, Hao Q, Sun Q, Liu H. Decreased retinal thickness in preschool offspring of maternal gestational hypertension: the Nanjing Eye Study. Acta Ophthalmol 2020; 98:e674-e679. [PMID: 32043838 DOI: 10.1111/aos.14351] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2019] [Accepted: 12/20/2019] [Indexed: 11/30/2022]
Abstract
PURPOSE To evaluate the influence of maternal gestational hypertension (GH) on retinal thickness of 5-6-year-old children, including macular thickness, ganglion cell-inner plexiform layer (GC-IPL) thickness and peripapillary retinal nerve fibre layer (RNFL) thickness. METHODS As part of Nanjing Eye Study, comprehensive ocular examinations were conducted in children aged 61-72 months, including noncycloplegic refraction, ocular biometric parameters and retinal parameters. Retinal thickness was measured by Spectral Domain-Optical Coherence Tomography. Data on pregnancy and birth history were obtained from a detailed questionnaire completed by parents. RESULTS Among 1062 children [mean age (standard deviation): 66.9 (3.4) months] with complete from eye examination and questionnaire, 30 (2.8%) children were born with maternal GH. In generalized linear models (adjusted for sex, age, spherical equivalent, axial length, body mass index, birth weight and premature history), children born with maternal GH had thinner average RNFL thickness (100.5 versus 104.4 μm, p = 0.035), superior RNFL thickness (123.7 versus 132.0 μm, p = 0.007), superior GC-IPL thickness (83.7 versus 86.4 μm, p = 0.005), superior-nasal GC-IPL thickness (86.3 versus 88.4 μm, p = 0.029) and superior outer macular thickness (278.0 versus 283.0 μm, p = 0.034) than children born with normal pregnancy. CONCLUSION Children exposed to maternal GH tended to have thinner macular, RNFL and GC-IPL thickness. These findings suggest that maternal GH may affect the development of retina in children thus hinders the development of the offspring's nervous system.
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Affiliation(s)
- Xiaoyan Zhao
- Department of Ophthalmology The First Affiliated Hospital with Nanjing Medical University Nanjing China
| | - Rui Li
- Department of Ophthalmology The First Affiliated Hospital with Nanjing Medical University Nanjing China
| | - Dan Huang
- Department of Child Healthcare The First Affiliated Hospital with Nanjing Medical University Nanjing China
| | - Haohai Tong
- Department of Ophthalmology The First Affiliated Hospital with Nanjing Medical University Nanjing China
| | - Hui Zhu
- Department of Ophthalmology The First Affiliated Hospital with Nanjing Medical University Nanjing China
| | - Yue Wang
- Department of Ophthalmology The First Affiliated Hospital with Nanjing Medical University Nanjing China
| | - Xiaohan Zhang
- Department of Ophthalmology Wuxi Children's Hospital Wuxi China
| | - Qingfeng Hao
- Department of Ophthalmology The First Affiliated Hospital with Nanjing Medical University Nanjing China
| | - Qigang Sun
- Department of Ophthalmology The First Affiliated Hospital with Nanjing Medical University Nanjing China
| | - Hu Liu
- Department of Ophthalmology The First Affiliated Hospital with Nanjing Medical University Nanjing China
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Morken TS, Dammann O, Skranes J, Austeng D. Retinopathy of prematurity, visual and neurodevelopmental outcome, and imaging of the central nervous system. Semin Perinatol 2019; 43:381-389. [PMID: 31174874 DOI: 10.1053/j.semperi.2019.05.012] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
Recent findings indicate that retinopathy of prematurity (ROP), presently classified by clinical examinations of retinal vascular tissue, is associated with structural alterations of the central nervous system. Such alterations may be the correlate of the association between ROP and impaired long-term neurocognitive and visual development. The advent of imaging techniques such as structural and diffusion tensor magnetic resonance imaging of the brain, and optical coherence tomography of the retina, will allow the complete visual system to be characterized in greater detail. It has been suggested that ROP may be not only a vascular, but a neurovascular disease, being part of a spectrum that includes pathological development in both the retinal and cerebral neurovascular interphase. We review the present knowledge in the field and point to future directions for research to tackle these questions.
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Affiliation(s)
- Tora Sund Morken
- Department of Neuromedicine and Movement Science, Norwegian University of Science and Technology (NTNU), Trondheim, Norway; Norway and Department of Ophthalmology, St. Olavs Hospital, Trondheim University Hospital, Trondheim, Norway.
| | - Olaf Dammann
- Department of Neuromedicine and Movement Science, Norwegian University of Science and Technology (NTNU), Trondheim, Norway; Department of Public Health and Community Medicine, Tufts University School of Medicine, Boston, MA, USA; Department of Gynecology and Obstetrics, Hannover Medical School, Hannover, Germany
| | - Jon Skranes
- Department of Clinical and Molecular Medicine, NTNU, Trondheim, Norway; Department of Child Neurology and Rehabilitation and Regional Competence Center for children with prenatal alcohol/drug exposure, Sørlandet Hospital, Arendal, Norway
| | - Dordi Austeng
- Department of Neuromedicine and Movement Science, Norwegian University of Science and Technology (NTNU), Trondheim, Norway; Norway and Department of Ophthalmology, St. Olavs Hospital, Trondheim University Hospital, Trondheim, Norway
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Castillo O, González I, Prieto E, Pérez T, Altemir I, Pablo LE, Pueyo V. Effects of prenatal exposure to alcohol, tobacco and other drugs of abuse on retinal development. ARCHIVOS DE LA SOCIEDAD ESPANOLA DE OFTALMOLOGIA 2019; 94:18-24. [PMID: 30270036 DOI: 10.1016/j.oftal.2018.08.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/07/2018] [Revised: 07/31/2018] [Accepted: 08/05/2018] [Indexed: 06/08/2023]
Abstract
PURPOSE To assess structural changes in the retina using optical coherence tomography (OCT) in children prenatally exposed to toxic substances. METHODS The study included a total of 49 infants, aged between 5 and 18years, exposed to toxic substances during pregnancy. Among the exposed children, 25 were exposed to tobacco, 20 were exposed to alcohol, and 4 children were exposed to other drugs of abuse. All children underwent a complete ophthalmology examination, including an OCT. The results were compared against a control group composed of 25 infants, age matched with controlled pregnancy, and not exposed to toxic substances. RESULTS Children prenatally exposed to toxic substances showed significantly thinner average retinal nerve fibre layer (RNFL) compared with control children (81.5 vs. 99.7μm; P<.005), as well as RNFL thinning in its four quadrants (superior RNFL: 97.5 vs. 127.5μm; P<.005; nasal RNFL: 61.5 vs. 72.3μm; P<.005; inferior RNFL: 99.8 vs. 128.6μm; P<.005, temporal RNFL: 58.3 vs. 68.2μm; P<.005). Exposed children also exhibited a thinner ganglion cell layer (72.9 vs. 85.9; P<.005). Greater RNFL thinning was observed in children exposed to drugs of abuse (RNFL thinner average=72), followed by children exposed to alcohol (RNFL thinner average=72.9), and finally the least affected were those children exposed to tobacco during pregnancy (RNFL=94.6). CONCLUSION Toxic substances during pregnancy interfere in retinal development. These results strengthen the evidence about the avoidance of any toxic substance during pregnancy.
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Affiliation(s)
- O Castillo
- Instituto Investigación Sanitaria Aragón (IIS Aragón), Servicio de Oftalmología, Hospital Universitario Miguel Servet, Zaragoza, España.
| | - I González
- Instituto Investigación Sanitaria Aragón (IIS Aragón), Servicio de Oftalmología, Hospital Universitario Miguel Servet, Zaragoza, España
| | - E Prieto
- Instituto Investigación Sanitaria Aragón (IIS Aragón), Servicio de Oftalmología, Hospital Universitario Miguel Servet, Zaragoza, España
| | - T Pérez
- Instituto Investigación Sanitaria Aragón (IIS Aragón), Servicio de Oftalmología, Hospital Universitario Miguel Servet, Zaragoza, España
| | - I Altemir
- Instituto Investigación Sanitaria Aragón (IIS Aragón), Servicio de Oftalmología, Hospital Universitario Miguel Servet, Zaragoza, España
| | - L E Pablo
- Instituto Investigación Sanitaria Aragón (IIS Aragón), Servicio de Oftalmología, Hospital Universitario Miguel Servet, Zaragoza, España
| | - V Pueyo
- Instituto Investigación Sanitaria Aragón (IIS Aragón), Servicio de Oftalmología, Hospital Universitario Miguel Servet, Zaragoza, España
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