Ophthalmic manifestations in preterm children without retinopathy of prematurity: A review

We synthesized current evidence on the spectrum of ophthalmic alterations in prematurely born children without retinopathy of prematurity (ROP). A literature review was conducted in accordance with PRISMA guidelines. Scopus, PubMed, Web of Science, and Cochrane Library were searched for English-language studies published between 2000 and 2025. Eligible studies included observational designs reporting ophthalmic outcomes in infants born before 37 weeks of gestation without ROP. A total of 32 studies consisting of 4548 individuals were investigated. Data were qualitatively synthesized across visual, refractive, anterior segment, and posterior segment domains. Mean visual acuity in preterm children without ROP ranged from -0.06-0.16 LogMAR and was generally comparable to term peers. Stereoacuity was reduced but showed improvement with age. Strabismus was reported in 5-20% of cases, increasing with age, and most commonly presented as esotropia. Nystagmus incidence ranged from 0% to 14%. Anisometropia was reported in 1.4-16.7% of preterm children without ROP, with one study demonstrating a higher prevalence compared to term peers. Hyperopia was highly prevalent, ranging from 20.9% to 86.2%, while astigmatism was reported in 14.1-65.1% of cases. Astigmatism predominated at 1 year of age, whereas hyperopia became the most common refractive error by six years. Hyperopia tends to increase with age, astigmatism gradually declines, and myopia rates remain relatively stable. Anterior segment findings in infancy included greater central corneal thickness, smaller corneal diameter, reduced axial length, shallower anterior chamber depth, and increased lens thickness. Posterior segment alterations included thicker central macula and focal thinning of the retinal nerve fiber layer in some reports. Premature birth, even in the absence of ROP, is independently associated with persistent structural and functional ophthalmic alterations. These findings highlight the need for long-term surveillance and early ophthalmologic intervention in this population.