Rebound myopia and prem-patient findings

March 2, 2025 Dr Sarah Hull

Clear lens extraction and intraocular lens implantation to correct extreme myopia after retinopathy of prematurity 

Correa-Venegas et al

Journal of AAPOS 2024. Epub ahead of print. PMID: 39413986

 

Review: Three patients, all born extremely premature (23–25 weeks) are reported with severe retinopathy of prematurity (ROP) in zone 1 (very posterior) and treated with bilateral indirect retinal laser. Myopia ranged from -23D to -35D spherical equivalent with axial lengths ranging from 25.7mm to 28.1mm. All patients were intolerant of contact lenses. Clear lens extraction and insertion of intraocular lenses (range +3D to +11.5D) was performed at age 7–21 years without complication with improvement of visual acuity for all three patients (post-op range: 20/50 to 20/125) and no complications except for posterior capsular opacification after follow-up of 1–10 years.

 

Comment: Zone 1 disease is now typically treated with intravitreal anti-VEGF injections. The landmark Bevacizumab Eliminates the Angiogenic Threat of Retinopathy of Prematurity (BEAT-ROP) study, which compared anti-VEGF vs laser in posterior threshold ROP, was published in 2011. Widespread adoption of this as the primary treatment has only occurred in the last several years and likely after this group of patients initially presented.

 

Refractive clear lens exchange in adults is an established approach to glasses independence. In children, lens surgery is typically performed for congenital cataract, with refractive indications rare. The extreme myopia in these children was not just axial, as the axial lengths were less than expected for the degree of myopia. Lenticular and corneal abnormalities also contribute to myopia of prematurity. Glasses for this degree of myopia have problematic minification and aberrations and, if contact lenses are not tolerated, options are limited. Clear lens surgery for this fortunately rare indication appears to be a safe and effective approach.

 

 

Myopia progression following 0.01% atropine cessation in Australian children: findings from the WA-ATOM study

Lee SS et al.

Clinical and Experimental Ophthalmology 2024;52:507–515. PMID: 38400607

 

Review: This is a follow-up report from the initial Western Australia – Atropine for the Treatment of Myopia (WA-ATOM) study (a single centre, randomised double-masked placebo-controlled trial) looking specifically at whether cycloplegic spherical equivalent (SE) and axial length rebound after low-dose (0.01%) atropine treatment is stopped. Included were 153 children, randomised 2:1 for treatment (0.01% atropine drops at night in both eyes) vs placebo for two years. All patients then underwent a one-year washout period. Twelve patients dropped out from the treatment arm and 12 from the placebo arm.

 

After one year of washout, the treatment group showed significantly faster progression than the placebo group, with SE change of -0.41D vs -0.28D and axial length increase of +0.20mm vs +0.13mm. After three years, SE and axial length changes were similar between the groups.

 

Comment: Rebound myopia and axial length change have been noted in other myopia control studies but this study provides useful information as there was a placebo group for the whole study. Other reports, such as the LAMP study, had a placebo arm for the first year only, with those participants then switched to treatment.

 

Outcomes in this study were the same for treatment and placebo groups. The demonstrated rebound in this study and in others raises the concern that treatment only delays eventual myopia rather than controls it. It is unknown just how long low-dose atropine drops need to be used for, how patients should be weaned off them and whether 0.01% should be used at all. With other treatment modalities now widely available that incorporate myopia control into patients’ refractive correction with glasses or contact lenses, low-dose atropine should probably be considered as an adjunctive treatment only.

 

 

Prevalence of strabismus and risk factors in adults born preterm with and without ROP: results from the Gutenberg Prematurity Eye Study

Fieß A et al 

British Journal of Ophthalmology. 2024 Oct 22;108(11):1590-1597. PMID: 38503479

 

Review: This retrospective cohort study compared patients born prematurely with a group born at term (³37 weeks), with patients divided into groups based on gestational age, non-treated retinopathy of prematurity (ROP) and treated ROP (15 eyes, eight treated with cryotherapy, seven with laser). Patients were prospectively examined at age 18–51 years, with 892 eyes of 450 patients included in analysis. With 938 patients invited to the study, this represented a 48% response rate. Strabismus was strongly associated with gestational age, found in 11.1–17.4% of patients born <32 weeks. Rates in patients who had ROP were even higher at 27.1% for non-treated ROP patients and 60% for those treated, all of whom had esotropia. Onset of strabismus was in the first 10 years of life for the majority of patients. Refractive error was also strongly associated with risk of strabismus developing.

 

Comment: There are limited published data on strabismus outcomes in prematurity. The study provides a useful contribution to this knowledge gap, with long-term outcome data presented. Patients were identified based on retrospective records with detailed prospective examinations performed, providing comprehensive and detailed data expected to be more accurate than a retrospective records review. Of those invited, 48% completed the examination, which gives a potential selection bias. It is possible that patients more impacted by their ophthalmic history were more likely to participate.

 

The high rate of esotropia in treated ROP should be interpreted cautiously for counselling patients, since the numbers are small (n=15) and treatment approaches have changed over time, with cryotherapy no longer preferred. The rate in untreated ROP of 27.1% (all esotropia) is useful information for counselling families and ensuring surveillance in childhood.

 

 

Dr Sarah Hull is a specialist in paediatrics, genetics and strabismus, working at Te Whatu Ora Health New Zealand, Auckland and Auckland Eye. She is also a senior lecturer at the University of Auckland.