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ABSTRACT.
Purpose: We aimed to evaluate visual elds (VFs) and optic disc morphology
in very low birthweight (VLBW) adolescents compared with age- and gendermatched controls, and to relate the ndings to magnetic resonance imaging
(MRI) results.
Methods: Fifty-nine VLBW adolescents and 55 age- and gender-matched controls with normal birthweight were examined. Visual elds were tested using
computerized rarebit perimetry (RB). Optic nerve and retinal vessel morphology were evaluated by digital image analysis of fundus photographs. Brain
MRI was conducted in the VLBW subjects.
Results: Ten of the 57 VLBW subjects (p = 0.022) had subnormal VF results
dened as a mean hit rate below the fth percentile of the controls (i.e.
< 89%). All of these also had signicantly lower mean hit rates (p = 0.039)
in the inferior hemield. Sixteen of 57 (28%) VLBW subjects had white matter damage of immaturity (WMDI) on MRI. Six of 15 subjects with WMDI
(who underwent VF testing) also had subnormal RB results, compared with
four of 39 with normal MRI ndings (p = 0.02). The mean neural retinal rim
area was 9% smaller (p = 0.018) in the VLBW group than in the control
group. The VLBW adolescents had a signicantly higher index for tortuosity
of arterioles than the controls (p < 0.001).
Conclusions: In the present study, 18% of all VLBW adolescents and 40% of
those with WMDI had subnormal RB VF ndings. The VLBW group had
increased arterial tortuosity and a somewhat smaller (9%) mean neural retinal
rim area than the control group. Thus sequels to VLBW appear to persist in
adolescence.
Key words: magnetic resonance tomography optic disc rarebit vascular morphology very
low birthweight visual elds
doi: 10.1111/j.1755-3768.2008.01365.x
Introduction
Children with very low birthweight
(VLBW) ( 1500 g [Platt et al. 2007])
have an increased morbidity of the central nervous and vascular systems, such
as white matter damage of immaturity
(WMDI) (Olsen et al. 1997; KragelohMann 2004). Magnetic resonance
imaging (MRI) of the brain is the
method of choice for diagnosing
WMDI (Flodmark et al. 1989). A relationship between WMDI and optic
nerve hypoplasia (ONH) has been documented (Brodsky & Glasier 1993).
Morphometric studies on fundus photographs from preterm children with
WMDI have demonstrated reduced
neuronal volume, expressed as reduced
optic disc rim area (ORA), and a variant of ONH, manifested as normalsized optic discs with large cups (Jacobson et al. 1997). A previous population-based study of children born
before 29 weeks gestational age demonstrated signicantly smaller ORA
and optic disc area (ODA) in the premature group than in controls born at
term (Hellstrom et al. 2002). In addition, a higher index for tortuosity of
arterioles (ITA), indicating increased
arterial tortuosity in the retina, has
been reported in infants and adolescents born prematurely compared with
controls born at full-term (Hellstrom
et al. 2002; Kistner et al. 2002).
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Visual eld (VF) disturbances, especially in the inferior part of the VF,
have been documented in subjects with
WMDI (Jacobson et al. 1996, 2006).
Increased resolution thresholds in the
central part of the VF have been
reported in prematurely born children
(Larsson et al. 2004), but this could
not be conrmed in a recent study by
Lindqvist et al. (2007), which examined VLBW teenagers using Humphrey
perimetry. A correlation between a
small rim : disc ratio (ORA : ODA)
and subnormal rarebit (RB) VF results
has been demonstrated in adolescents
born after intrauterine growth restriction (Martin et al. 2004).
In a previous study (Hellgren et al.
2007), we showed that 30% of VLBW
subjects had abnormal MRI ndings
and that these subjects performed less
well in visual acuity and stereo acuity
testing, and had lower intellectual
capacity and more cognitive visual
problems, compared with both VLBW
subjects without MRI pathology and
with the normal control group.
The aim of the present study was to
evaluate VFs and optic disc morphology in a group of VLBW adolescents
compared with age- and gendermatched controls, and to relate the
ndings to MRI results.
n
Gender, F M
Age at VF examination,
years
Birthweight, g
SDS of birthweight
GA, weeks
BCVA RE
Refraction RE
VLBW subjects
Control subjects
59
26 33
17.0 1.9 (14.720.1)
55
26 29
16.4 1.6 (14.820.1)
40 1 (3742)
1.37 0.26 (0.82.0)
0.5 1.37 () 3.87 to 4.38)
VLBW = very low birthweight; F = female; M = male; VF = visual eld; SDS = standard
deviation score; GA = gestational age; BCVA = best corrected visual acuity; RE = right eye;
Refraction = spherical equivalent in dioptres.
Methods
VF testing, using rarebit perimetry
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Results
Fifty VLBW subjects and 46 controls
performed all examinations. The distribution of participants in the different examinations is shown in Fig. 1.
Visual eld results
Statistics
RB hit rate %
Superior hemield
Inferior hemield
Diff SI
VLBW subjects
(n = 57)
Control subjects
(n = 52)
Signicance of
difference (p)
96 (44100)
95.5 (46100)
96.5 (42.5100)
0 ()47 to 47)
96.5 (88100)
96.5 (85100)
97 (86100)
) 1 ()22 to 10)
0.18
0.69
0.092
0.020
VLBW = very low birthweight; RB =- rarebit; Diff SI, superior hemieldinferior hemield.
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Discussion
Fig. 2. Rarebit mean hit rate (%) in the examined groups. Box = interquartile range; whiskers = 1.5 interquartile range; bold line inside box = median; small ring = outlier;
* = extreme values. RB = rarebit; VLBW = very low birthweight.
Fig. 3. Rarebit visual elds from a very low birthweight subject (to the left) and a control subject (to the right). Note the difference between the superior and the inferior hemield in the
very low birth weight subject.
Table 3. Optic disc parameters in the two examined groups, showing mean standard deviation (range).
ODA
OCA
ORA
RADA
ITA
Signicance of difference
(p) Unpaired t-test
2.04
0.28
1.77
0.87
1.1
2.13
0.18
1.95
0.92
1.08
0.32
0.013
0.018
0.012
<0.001
0.44
0.23
0.36
0.09
0.07
(1.053.15)
(00.88)
(1.052.87)
(0.631.0)
(0.711.21)
0.41
0.18
0.43
0.08
0.26
(1.323.19)
(00.71)
(1.223.19)
(0.691.0)
(1.041.15)
VLBW = very low birthweight; ODA = optic disc area, mm2; OCA = optic cup area, mm2;
ORA = optic rim area, mm2; RADA = ORA : ODA; ITA = index for tortuosity of arterioles.
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variables
or
arterial
tortuosity
between VLBW subjects with and
without abnormal MRI ndings. The
three subjects with moderate to severe
WMDI had less arterial tortuosity
and fewer retinal vessel branching
points, and two of them also had
smaller rim areas compared with those
with mild WMDI.
Fig. 4. Fundus photographs from a very low birthweight subject (to the left) and a control subject (to the right). Note the increased arterial tortuosity and larger optic cup in the very low
birthweight subject. The optic discs are of similar size.
1999). In the current study this variant of ONH was not correlated to
WMDI, but to VLBW per se. This
might be explained by the MRI technique used in the current study. A
recently developed technique using
diffusion image MRI and volume
measurements has documented the
presence of more subtle brain damage
than we were able to show. Consequently, our study group may include
VLBW subjects with ischaemic brain
damage that is not apparent with the
technique used here. An enlarged cup
size may represent the result of
destruction of nerve bres secondary
to increased intraocular pressure
(IOP). However, as no relationship
between increased IOP and prematurity had been found (Spierer et al.
1994) at the time we planned the current study, IOP measurements were
not included. Further observations
similar to those reported by Spierer
et al. (1994) were published recently
(Ng et al. 2008). Another group examined a sample of preterm children
with periventricular leukomalacia who
were found to have large cups and
WMDI, but in whom IOP was normal
(Jacobson et al. 1997). As no relationship between optic disc parameters
and VF results were found in the current study, the risk for glaucoma was
judged to be low. Yet, in retrospect,
our failure to include IOP measurements in the current study may reect
a study weakness.
The VLBW adolescents had a signicantly higher ITA compared with
the controls, but this was not correlated to WMDI. This nding may represent a response to a diminished need
Conclusions
In the present study, 18% of the
VLBW adolescents had subnormal
RB VFs and 28% had WMDI. Six of
the latter had subnormal RB VF
results. The VLBW group had somewhat smaller (9%) mean ORA than
the control group. Thus sequels of
VLBW appear to persist into adolescence.
Acknowledgements
This report is part of a multidisciplinary, prospective, follow-up study of
very low birthweight children and
controls in southeast Sweden. The
examination at 15 years of age was
planned and performed by a working
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