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Letters to the Editors
Is Ophthalmic Follow-up of
Premature Infants Necessary?
To the Editors:
There is currently no definitive guidance on the
long-term ophthalmic follow-up of neonates who
fulfill the criteria for retinopathy of prematurity
(ROP) screening (less than 32 weeks of gestational
age and/or 1,500 grams birth weight) but are not
found to have ROP. Previous studies have reported
rates of ophthalmic disorders as high as 17.6% to
51.5%1-5 in this cohort, which has led to the recommendation of routine follow-up of these children.2,4,5 To investigate national practices, we designed an online survey consisting of four questions:
1. Do you routinely observe infants born preterm
who were screened for but NOT found to have
ROP in your clinic?
2. When do you first see them, following discharge
from the neonatal intensive care unit?
3. Which clinic are the majority of their followups scheduled within?
4. What is the age at which you discharge them
from your care, if no ophthalmic findings are
discovered?
The survey was sent to all members of the United Kingdom pediatric listserv, which consists of pediatric ophthalmologists and senior orthoptists (169
members); 58 responses were received (34.3%).
Of the 58 respondents, 21 (36.2%) routinely
observed this cohort in clinic and the remaining 37
(63.8%) did not. Of the 21 who followed up this
cohort, most (11, 52.4%) first see them at or before
6 months, 6 (28.6%) at 1 year, and 4 (19.0%) after
1 year. These patients are seen by a variety of eye
professionals: 8 respondents stated they are seen by
an ophthalmologist, 7 by orthoptists and optometrists, 4 by orthoptists only, and 2 by a combination
of ophthalmologists and orthoptists/optometrists.
The age at discharge is also highly variable: 3 respondents discharge patients at or before 1 year, 5
at 2 years, 6 at 3 years, 4 at 4 years or older, and 3
discharge on the basis of satisfactory visual acuity or
uniocular activity when it is finally obtained.
There is a high degree of variability in the oph-
thalmic follow-up of premature children in the
United Kingdom. Further research is needed to establish the true incidence of ocular pathology in this
cohort for the development of national guidelines.
REFERENCES
1. Hard AL, Hellstrom A. Ophthalmological follow-up at 2 years of
age of all children previously screened for retinopathy of prematurity: is it worthwhile? Acta Ophthalmol Scand. 2006;84:631-635.
2. Holmstrom G, Larsson E. Long-term follow-up of visual functions in prematurely born children: a prospective populationbased study up to 10 years of age. J AAPOS. 2008;12:157-162.
3. O’Connor AR, Stephenson T, Johnson A, et al. Long-term ophthalmic outcome of low birth weight children with and without
retinopathy of prematurity. Pediatrics. 2002;109:12-18.
4. Page JM, Schneeweiss S, Whyte HEA, Harvey P. Ocular sequelae
in premature infants. Pediatrics. 1993;92:787-790.
5. Tuppurainen K, Herrgard E, Martikainen A, Mantyjarvi M. Ocular findings in prematurely born children at 5 years of age. Graefes
Arch Clin Exp Ophthalmol. 1993;231:261-266.
Melissa Chiu, BSc
Charles Hennings, MEng
Saurabh Jain, MBBS, MS, FRCOphth
London, United Kingdom
The authors have no financial or proprietary interest in
the materials presented herein.
doi: 10.3928/01913913-20130708-99
Amblyopia in Children Referred
With Congenital Dacryostenosis
From the Arabian Peninsula
To the Editors:
Recent studies have suggested an association between congenital dacryostenosis and anisometropic
amblyopia in Western populations,1-4 often quoting
a range of 5% to 10% (with an estimated prevalence of amblyopia in the general population of 3%
to 5%).5 To investigate this in the Arab population,
we reviewed the records of children with congenital dacryostenosis referred to a regional eye hospital (King Khaled Eye Specialist Hospital) between
January 2001 and January 2010 after institutional
board approval.
We only analyzed records of children evaluated
by pediatric ophthalmologists because otherwise vi-
Journal of Pediatric Ophthalmology & Strabismus • Vol. 50, No. 6, 2013
327
Letters to the Editors
sual acuities were often not documented for young
children. Of 467 identified children (mean age: 25
months; range: 1 to 108 months), 106 were seen
by a pediatric ophthalmologist (and had a documented cycloplegic refraction). Forty-seven of these
106 children had amblyopia (44.3%), which was
refractive in 24 (22.6%) and non-refractive in 23
(21.7%). In the 24 children with refractive amblyopia, 20 (83.3%) had unilateral and 4 (16.6%) had
bilateral congenital dacryostenosis. Most children
with unilateral congenital dacryostenosis had ipsilateral anisometropic amblyopia related to a difference in hyperopia greater than +1.50 diopters (16 of
20); the remainder had contralateral anisometropic
amblyopia related to a difference in hyperopia greater than +1.50 diopters (2 of 20) or bilateral amblyopia related to uncorrected high myopia (2 of 20).
The 23 children with non-refractive amblyopia had
cataract, glaucoma, retinal dystrophy, chorioretinal
coloboma, albinism, incomitant strabismus, or severe ptosis. Our sample is biased toward children
who were also evaluated by pediatric ophthalmologists; however, were we to conservatively assume
that none of the children without pediatric ophthalmologist evaluation had amblyopia, the risk in this
cohort remains high (47 of 467 = 10.1%).
In contrast to studies from Western populations, which document anisometropia as the major
amblyogenic factor in congenital dacryostenosis,
approximately half (23 of 47, 48.9%) of our cohort had amblyopia related to non-refractive ocular disease. Pediatric ocular genetic disease is more
common on the Arabian Peninsula.6 Because its actual prevalence is not known, we cannot comment
whether ocular genetic disease is more common in
children with congenital dacryostenosis in this region. Similarly, the prevalence of amblyopia in the
general population in this region is not available for
comparison.
328
Our study is limited by the exclusion of children
not seen by pediatric ophthalmologists, which was
the majority of patients. However, we conservatively
assumed all such children not to have amblyopia
and thus our estimated prevalence statistic of 10% is
likely an underestimation. Another limitation is that
the diagnosis of amblyopia was made by different
pediatric ophthalmologists without a standardized
protocol. However, our findings do suggest that at
least 10% of children from the region referred with
congenital dacryostenosis have amblyopia and that
non-refractive causes are common. All children with
congenital dacryostenosis need to have cycloplegic
refraction and amblyopia assessment/management,
and this is particularly true for affected children
from the Arabian Peninsula.
REFERENCES
1. Chalmers R, Griffiths PG. Is congenital nasolacrimal duct obstruction a risk factor for the development of amblyopia? Br Orthopt J. 1996;53:29-30.
2. Simon JW, Ngo Y, Ahn E, Khachikian S. Anisometropic amblyopia and nasolacrimal duct obstruction. J Pediatr Ophthalmol Strabismus. 2009;46:182-183.
3.Piotrowski JT, Diehl NN, Mohney BG. Neonatal dacryostenosis as a risk factor for anisometropia. Arch Ophthalmol.
2010;128:1166-1169.
4. Mataftsi A, Vlavianos A, Tsaousis KT, Tzamalis A, Dimitrakos SA.
High prevalence of amblyopia risk factors in preverbal children
with nasolacrimal duct obstruction. J AAPOS. 2012;16:213.
5. Kanonidou E. Amblyopia: a mini review of the literature. Int
Ophthalmol. 2011;31:249-256.
6. Khan AO, Al-Mesfer S. Pediatric ophthalmology and strabismus
in the Kingdom of Saudi Arabia. J AAPOS. 2004;8:513-514.
Ahmed Al-Salem, MD
Arif O. Khan, MD
Riyadh, Saudi Arabia
The authors have no financial or proprietary interest in
the materials presented herein.
doi: 10.3928/01913913-20131009-01
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