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 Table of Contents  
Year : 2023  |  Volume : 3  |  Issue : 2  |  Page : 452-454

Myopia in retinopathy of prematurity: Boon or bane

Department of Ophthalmology, Dr. Rajendra Prasad Centre for Ophthalmic Sciences, AIIMS, New Delhi, India

Date of Submission17-Oct-2022
Date of Acceptance27-Dec-2022
Date of Web Publication28-Apr-2023

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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/IJO.IJO_2730_22

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Myopic changes in the fundus have been known to have a protective role in vasculopathy. The reduced metabolic demands prevent the progression of vascular disorders in myopic eyes. However, this theory might not be applicable for myopia in retinopathy of prematurity (ROP) babies. An increased retinal surface area in an eye with a longer axial length might aggravate the progression of ROP. We discuss two cases of unilateral progression of ROP in a longer axial length eye.

Keywords: Axial length, myopia, ROP

How to cite this article:
Banerjee M, Sharma A, Azad SV, Rao S. Myopia in retinopathy of prematurity: Boon or bane. Indian J Ophthalmol Case Rep 2023;3:452-4

How to cite this URL:
Banerjee M, Sharma A, Azad SV, Rao S. Myopia in retinopathy of prematurity: Boon or bane. Indian J Ophthalmol Case Rep [serial online] 2023 [cited 2023 Jun 2];3:452-4. Available from: https://www.ijoreports.in/text.asp?2023/3/2/452/374981

Myopia is a common refractive state in preterm infants when compared to full-term babies.[1] Retinopathy of prematurity (ROP) associated with myopia has a different refractive mechanism. Arrested anterior segment development with increased lenticular sphericity contributes to myopia in ROP, while axial myopia is more common in full-term babies.[2] A shorter axial length (AL) has been observed to be associated with a more severe form of ROP, with no significant difference in the rate of growth of eyes between the various stages of ROP.[2],[3]

We present two cases of unilateral progression of ROP in a longer AL eye.

  Case Reports Top

Case 1

A female premature infant with 35 weeks postmenstrual age (PMA) presented for ROP screening. She had a gestational age of 28 weeks born from normal vaginal delivery with an extremely low birth weight of 910 g. There was a history of neonatal intensive care unit (NICU) stay of 52 days with oxygen support Continuous Positive Airway Pressure (CPAP) provided for 7 days for respiratory distress.

On torchlight examination, a well-formed anterior chamber was noticed OU. Fundus screening revealed zone II posterior hybrid ROP with a demarcation line and flat neovascularization with vascular tortuosity (mild plus) OD [Figure 1]a and [Figure 1]b and vascularization reaching zone III with no ROP OS [Figure 1]c and [Figure 1]d. An AL of 18.2 mm OD and 16.3 mm OS was noticed with applanation A-scan biometry. Laser ablation of avascular areas OD was performed at 38 weeks PMA due to increase in the extent of flat neovascularization and difficulties faced by the parents for weekly follow-up. A reduction in vascular tortuosity was noted post-laser ablation [Figure 1]e and [Figure 1]f.
Figure 1: Retcam fundus image depicting zone II posterior hybrid ROP with vascular tortuosity (white arrow) OD (a). A combination of staged ROP (demarcation line, black arrow) with flat neovascularization (black arrowhead) can be appreciated (b). Retcam fundus photograph depicting vascularization reaching till zone III border OS with no evidence of ROP (c and d). Retcam fundus image at 38-week PMA post-laser ablation showing a reduction in vascular tortuosity and peripheral laser spots (e and f) PMA = postmenstrual age, ROP = retinopathy of prematurity

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Case 2

A 20-year-old male presented with diminution of vision in the right eye for 10 years. Best corrected visual acuity (BCVA) of 1/60 OD and 6/6 OS was noted with a refractive error of 11DS OD and -1.25DS OS. On fundus examination, tessellated fundus OU with unilateral high myopia with temporal avascular retina was observed OD, which was better appreciated on ultra-widefield fluorescein angiography [Figure 2]a and [Figure 2]b. On further enquiry of birth history, a preterm birth with gestation age of 30 weeks and low birth weight of 1200 g was revealed. History of NICU stay for 7 days was also reported. However, there was no history of ROP screening in our patient. Based on the history and clinical findings, a diagnosis of ROP sequalae with temporal avascular retina and unilateral high myopia OD was made.
Figure 2: Ultra-widefield fundus photograph revealing pathological myopia OD with temporal avascular retina, with Ultrawide field fundus fluorescein angiography (UWF FFA) revealing temporal hypofluorescence with no vasculature and supernumerary vessels at the junction of vascular–avascular retina (a). A tessellated fundus is observed OS (b)

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  Discussion Top

Linear growth in AL during the neonatal period in premature infants has been described in the literature.[3] Laws et al.[3] observed an increase in AL by 1.38 mm between 32 and 41 weeks post-conceptual age (from 15.27 to 16.65 mm) with an average of 0.18 mm/week growth of individual eyes in ROP babies. Haryama et al. (1981, Japan)[4] reported a mean AL of 15.23 mm in premature infants at 34 weeks and 16.08 mm at 36 weeks. Gordon and Donzis (1985, USA)[5] reported an average AL of 16.1 mm on applanation ultrasonography in preterm infants at 35–39 weeks PMA. Kardaras et al.[6] also reported similar observations with a mean AL of 16.37 mm at 35 weeks PMA. Our first patient had an AL of 16.3 mm OS, which was normal as per her age. However, a higher AL of 18.2 mm was noted in the right eye.

The asymmetry in ROP presentation in both eyes could also be explained by this interocular variation in AL. Nagra et al.[7] reported a significant correlation between quadrant retinal surface area with AL and equivalent increases in retinal area/mm increase in AL. An increase of 8.38%, 19.36%, and 31.50% in superotemporal retinal surface area was reported with an increase in AL of 1.35, 2.85, and 4.5 mm, respectively. An increased retinal surface area in the right eye compared to the fellow eye (equivalent to an approximate estimation of a 15% increase in the first case and 31.50% in the second case based on the aforementioned data) could have a role in overburdening the attenuated vasculature of the right eye to meet the excess metabolic demands. This may lead to an increased expression of hypoxia-inducible factors and subsequent vascular endothelial growth factor (VEGF) release, inciting the initiation of the proliferative phase in the right eye.

Phase 1 ROP is characterized by arrest in the retinal vessel growth (secondary to hyperoxia-driven reduction in insulin-like growth factor 1 [IGF-1] and VEGF levels). When the preterm baby reaches approximately 32–34 weeks, the growing avascular retina experiences an increase in metabolic demands, prompting the beginning of phase 2 of ROP characterized by the formation of neovascularization (secondary to increase in IGF-1 and VEGF levels due to increasing metabolic demands and hypoxia).[8] We know that an increase in retinal surface area is noted with every millimeter increase in AL. Thus, asymmetry in AL between the two eyes in preterm babies can lead to a rapid progression of ROP in phase 2 due to more metabolic demands of the growing retina in the eye with higher AL (having higher surface area).

Degenerative changes in the retina, choroid, and sclera induced by myopia have been considered to play a protective role in any vascular disorder. The degenerative changes result in reduced metabolic demands of the ocular tissues and prevent the progression of deleterious angiogenesis in any vasculopathy. Though a definitive cutoff age for myopic degenerative changes has not been described in children, 13.2% of young, highly myopic patients aged 3–19 years were found to have myopic pathological alterations.[9] Increasing age and AL elongation are considered to be the relevant risk factors for the appearance of degenerative changes in myopic eyes.[10],[11] An increased retinal surface area with increased metabolic demands (in the absence of the onset of degenerative changes) facilitated the unilateral progression of ROP in our patient.

  Conclusion Top

To conclude, we postulate a pivotal role of congenital axial myopia behind the unilateral progression of ROP to the proliferative phase in our patient.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient (s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initial s will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

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Conflicts of interest

There are no conflicts of interest.

  References Top

Fielder AR, Quinn GE. Myopia of prematurity: Nature, nurture, or disease? Br J Ophthalmol 1997;81:2-3.  Back to cited text no. 1
Garcia-Valenzuela E, Kaufman LM. High myopia associated with retinopathy of prematurity is primarily lenticular. J AAPOS 2005;9:121-8.  Back to cited text no. 2
Laws DE, Haslett R, Ashby D, O'Brien C, Clark D. Axial length biometry in infants with retinopathy of prematurity. Eye (Lond) 1994;8:427-30.  Back to cited text no. 3
Harayama K, Amemiya T, Nishimura H. Development of the eyeball during fetal life. J Pediatr Ophthalmol Strabismus. 1981;18:37-40.  Back to cited text no. 4
Gordon RA, Donzis PB. Refractive development of the human eye. Arch Ophthalmol 1985;103:785-9.  Back to cited text no. 5
Kardaras D, Papageorgiou E, Gaitana K, Grivea I, Dimitriou VA, Androudi S, et al. The association between retinopathy of prematurity and ocular growth. Invest Ophthalmol Vis Sci 2019;60:98-106.  Back to cited text no. 6
Nagra M, Gilmartin B, Thai NJ, Logan NS. Determination of retinal surface area. J Anat 2017;231:319-24.  Back to cited text no. 7
Hellström A, Smith LE, Dammann O. Retinopathy of prematurity. Lancet 2013;382:1445-57.  Back to cited text no. 8
Kobayashi K, Ohno-Matsui K, Kojima A, Shimada N, Yasuzumi K, Yoshida T, et al. Fundus characteristics of high myopia in children. Jap J Ophthalmol 2005;49:306-11.  Back to cited text no. 9
Chen SJ, Cheng CY, Li AF, Peng KL, Chou P, Chiou SH, et al. Prevalence and associated risk factors of myopic maculopathy in elderly Chinese: The Shihpai eye study. Invest Ophthalmol Vis Sci 2012;53:4868-73.  Back to cited text no. 10
Verkicharla PK, Ohno-Matsui K, Saw SM. Current and predicted demographics of high myopia and an update of its associated pathological changes. Ophthalmic Physiol Opt 2015;35:465-75.  Back to cited text no. 11


  [Figure 1], [Figure 2]


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