Children with ROP Face Higher Risk of Developing Strabismus

Strabismus often develops  among children with ROP, with higher cumulative incidence among those requiring treatment and with associated visual complications, this study found. Photo: Sgfin/Wikimedia Commons. Click image to enlarge. Retinopathy of prematurity (ROP), one of the leading causes of preventable visual impairment in children worldwide, can lead to strabismus, but little is known about the time course of strabismus development in such patients. Given these gaps, researchers of a recent study aimed to evaluate the cumulative incidence of strabismus among patients with ROP and to identify factors associated with its development, including the impact of treatment exposure. They found that ROP confers an increased hazard of developing subsequent strabismus, with higher cumulative incidence among children who undergo treatment for ROP. The findings were reported in American Journal of Ophthalmology.The study used the TriNetX database, analyzing 27,720 patients (973 treated, 26,747 untreated). Treated patients received either laser photocoagulation, intravitreal anti-VEGF or both. Cumulative incidence was calculated using Kaplan-Meier analysis at one, three and five years following diagnosis, while Cox proportional hazards models were used to determine associations. A sensitivity analysis restricted to children aged four years or younger confirmed the primary findings.At five years after diagnosis, the cumulative incidence of strabismus was 22.1% among children who did not require treatment for ROP and 34.8% among those who underwent treatment.Esodeviations were the most common subtype in both groups, and concurrent amblyopia and nystagmus were strong independent predictors for strabismus development.Treatment exposure for ROP was independently associated with an increased hazard of developing strabismus. “Children who receive treatment via photocoagulation or intravitreal injection can be understood to exhibit a more severe level of baseline retinal disease on presentation, warranting these interventions,” the authors wrote. “Therefore, treatment exposure may function as a recognizable risk marker for strabismus development in ROP, and in our study, children who required treatment for their ROP represented a subgroup with greater vulnerability to strabismus over time.” Importantly, the authors noted that this association remained consistent in a sensitivity analysis restricted to children aged four or younger at the index date, suggesting that delayed documentation of ROP diagnosis in administrative records is unlikely to explain the observed findings. One possible explanation is that ROP-related visual comorbidities contribute to strabismus development. “Early-life disruption of binocular visual development may predispose to decompensation of horizontal alignment during the critical period for stereopsis,” the researchers wrote. “In support of this hypothesis, amblyopia and nystagmus—both conditions reflecting impaired sensory input and fixation stability—were among the strongest correlates of subsequent strabismus in our multivariable model.” This is consistent with prior ROP studies, including the Early Treatment for Retinopathy of Prematurity cohort, in which amblyopia and other visual comorbidities were frequently associated with horizontal deviations.This study highlights the need for structured longitudinal ophthalmic surveillance of ocular alignment in children with ROP, the researchers concluded in their paper.Click here for the journal source. Almobayed A, Dihan Q. Cohen AK, et al. Incidence of strabismus in children with retinopathy of prematurity. Amer J Ophthalmol. April 23, 2026. [Epub ahead of print.] This article was developed by the editorial staff in conjunction with experts in the field. In the process, AI may have been among the editorial tools used to meet the goals of human editors, who approved all content.