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Research

JAMA Ophthalmology | Original Investigation

Reduction of Rod and Cone Function in 6.5-Year-Old Children


Born Extremely Preterm
Anna E. C. Molnar, MD, PhD; Sten O. Andrasson, MD, PhD; Eva K. B. Larsson, MD, PhD;
Hanna M. kerblom, MD, PhD; Gerd E. Holmstrm, MD, PhD

Invited Commentary
IMPORTANCE The function of rods and cones in children born extremely preterm has not yet
been fully investigated.

OBJECTIVE To compare retinal function via full-field electroretinographic (ffERG) recordings


in 6.5-year-old children born extremely preterm with children born at term.

DESIGN, SETTING, AND PARTICIPANTS A subcohort study was conducted from July 1, 2010, to
January 15, 2014, of the national Extremely Preterm Infants in Sweden Study, including
preterm children (<27 weeks gestational age) and children born at term, at 6.5 years of age
and living in the Uppsala health care region in Sweden. Full-field electroretinography was
performed binocularly, using DTL electrodes and electroretinographic (ERG) protocols with
flash strengths of 0.009, 0.17, 3.0, and 12.0 candelas (cd)/s/m2, together with 30-Hz flicker
and 3.0 cd/s/m2 single-cone flash.

MAIN OUTCOMES AND MEASURES The ffERG recordings were analyzed, and their associations
with gestational age and retinopathy of prematurity were examined.

RESULTS Adequate ffERG recordings were obtained from 52 preterm children (19 girls and
33 boys; mean [SD] age at examination, 6.6 [0.1] years) and 45 children born at term (22 girls
and 23 boys; mean [SD] age at examination, 6.6 [0.1] years). Lower amplitudes of the
combined rod and cone responses (the a-wave of the dark-adapted ERG protocol of
3.0 cd/s/m2: mean difference, 48.9 V [95% CI, 80.0 to 17.9 V]; P=.003; the a-wave of
the dark-adapted ERG protocol of 12.0 cd/s/m2: mean difference, 55.7 V [95% CI,
92.5 to 18.8 V]; P = .004), as well as of the isolated cone response (30-Hz flicker ERG:
mean difference, 12.1 V [95% CI, 22.5 to 1.6 V]; P = .03), were found in the preterm
group in comparison with the group born at term. The implicit time of the combined rod
and cone responses (the a-wave of the dark-adapted ERG protocol of 12.0 cd/s/m2) was
longer (mean difference, 1.2 milliseconds [95% CI, 0.3-2.0 milliseconds]; P = .01) in the
preterm group, as were the isolated cone responses (30-Hz flicker ERG: mean difference,
1.2 milliseconds [95% CI, 0.5-1.8 milliseconds]; P < .001), than in the group born at term. No
association was found between the ffERG recordings and gestational age or retinopathy of
prematurity in the preterm group.

CONCLUSIONS AND RELEVANCE Both rod function and cone function were reduced in children
born extremely preterm when compared with children born at term. There was no
association with retinopathy of prematurity in the preterm group, which suggests that being
born extremely preterm may be one of the main reasons for a general retinal dysfunction.

Author Affiliations: Department of


Neuroscience/Ophthalmology,
Uppsala University, Uppsala, Sweden
(Molnar, Larsson, kerblom,
Holmstrm); Department of
Ophthalmology, Lund University,
Lund, Sweden (Andrasson).
Corresponding Author: Gerd E.
Holmstrm, MD, PhD, Department of
Neuroscience/Ophthalmology,
Uppsala University,
JAMA Ophthalmol. doi:10.1001/jamaophthalmol.2017.2069 Uppsala 751 85, Sweden
Published online June 29, 2017. (gerd.holmstrom@neuro.uu.se).

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Research Original Investigation Rod and Cone Function in 6.5-Year-Old Children Born Extremely Preterm

A
dvanced neonatal care enables the survival of very
preterm children with low gestational age (GA) and has Key Points
resulted in a new group of children growing up today.
Question How does extreme preterm birth affect retinal function
The national population-based Extremely Preterm Infants in in children who are 6.5 years of age?
Sweden Study (EXPRESS) investigates the mortality and long-
Findings In this subcohort study of the Extremely Preterm Infants
term morbidity of children born extremely preterm (born
in Sweden Study, children 6.5 years of age who were born extremely
before GA of 27 weeks during 2004-2007).1-3 In the neonatal
preterm (<27 weeks gestational age) had reduced function of both
period, severe retinopathy of prematurity (ROP) was found in rods and cones when compared with children born at term,
35% of the infants, 20% of whom were treated for ROP.4 Among according to full-field electroretinography recordings.
the infants surviving to 1 year of age, 55% had major neonatal
Meaning A reduced function of both rods and cones is reported in
morbidities such as ROP, periventricular leukomalacia, se-
children born extremely preterm, compared with children born at
vere intraventricular hemorrhage, and bronchopulmonary term, which may contribute to the various visual problems of this
dysplasia.1 At a recent 6.5-year follow-up, ophthalmologic prob- new population as they age.
lems such as low visual acuity (VA), high refractive errors, and
strabismus were found in 38% of the children who were born
extremely preterm.5 Screening and Grading of ROP
The retina is still histologically immature at birth,6 and the The preterm children were screened for ROP in the neonatal pe-
development process continues for several years. At around 4 riod; ROP was graded according to the International Commit-
years of age, the fovea shows histologic signs of maturation but tee for the Classification of Retinopathy of Prematurity.15 Mild
has not reached adult cone density.7 The function of the devel- ROP was defined as stages 1 and 2, and severe ROP as stages 3
oping retinal maturation is reflected by the full-field electro- to 5. Indication for treatment followed the recommendations
retinographic (ffERG) recordings showing larger amplitudes and of the Early Treatment for Retinopathy of Prematurity study.16
shorter implicit times with increasing age.8,9 In very preterm
Intraventricular Hemorrhage
infants (born <32 weeks GA), during the neonatal period, the
and Periventricular Leukomalacia
macular photoreceptors show signs of underdevelopment com-
All preterm children underwent cranial ultrasonography dur-
pared with those of children born at term, when examined with
ing the neonatal period. Intraventricular hemorrhage was
spectral-domain optical coherence tomography.10 Central macu-
graded according to Papile et al,17 and periventricular leuko-
lar thickness has recently been reported as thicker in a subco-
malacia was diagnosed according to de Vries et al.18
hort of 6.5-year-old children born extremely preterm, partici-
pating in the EXPRESS, in comparison with children born at Eye Examination
term.11 Furthermore, retinal function is reduced in preterm At the 6.5-year follow-up, the children underwent monocu-
infants, with smaller electroretinographic (ERG) amplitudes lar VA testing with habitual correction using logMAR Lea
compared with infants born at term.12,13 Hyvrinen symbol charts.19 An automated refractor measure-
Several ERG studies have investigated the retinal func- ment in cycloplegia (using eye drops of cyclopentolate hydro-
tion in preterm infants and children, but, to our knowledge, chloride, 0.85%, and phenylephrine hydrochloride, 1.5%) was
no study has examined a group consisting only of children born performed, and the spherical equivalent (SE) was calculated.
extremely preterm. The aim of our study was to evaluate the All examinations took place between July 1, 2010, and Janu-
combined rod and cone function and isolated cone function ary 15, 2014, in Uppsala University Hospital.
assessed with ffERG in children born extremely preterm and
to compare the recordings with children born at term. The sec- ffERG Recordings
ond aim was to investigate the association between ffERG Full-field ERG was performed with the Espion Ganzfeld system
recordings in the preterm group and GA and ROP. (Diagnosys LCC). The recordings were performed in accordance
with the recommendations of the International Society for Clini-
cal Electrophysiology of Vision,20 except the light-adaption time,
which was excluded to adapt the examination to children.
Methods Full-field ERG was performed binocularly using DTL
Study Participants electrodes21 with previous installation of anesthetic eye drops
The original cohort consisted of 87 preterm children and 66 (tetracaine hydrochloride, 1%). Reference electrodes were placed
children born at term, all of whom were 6.5 years of age, liv- on the skin of the right and left zygomatic bones. A ground elec-
ing in the Uppsala health care region in Sweden, and partici- trode was positioned on the back of 1 hand. Electrical impedance
pating in the EXPRESS.1,2 The children born at term were age of less than 10 k of all electrodes was required. Pupils were di-
matched with and born in the same region as the preterm chil- lated with eye drops (cyclopentolate hydrochloride, 0.85%, and
dren, and met the inclusion criteria of GA of 37 weeks or more phenylephrine hydrochloride, 1.5%), and at least 8 mm of dila-
and birth weight of 2500 g or more. The study was performed tion was required before the recordings were made.
according to the Declaration of Helsinki,14 with approval from During the ffERG recordings, 6 protocols with different
the Regional Ethics Boards of Lund University. The parents of flash strengths from light-emitting diode light sources were
the participating children provided prior written consent, and used (Table 1). The light intensity of the flashes was mea-
the children provided verbal consent. sured in candela-seconds per square meter (cd/s/m2).

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Rod and Cone Function in 6.5-Year-Old Children Born Extremely Preterm Original Investigation Research

Dark adaptation during 20 minutes was performed. The


Table 1. Six Full-Field Electroretinographic Protocols
dark-adapted protocols were assessed with at least 6 record-
Flash Type of
ings and the 30-Hz flicker and 3.0 single-cone flash ERG with Strength, Photoreceptor
at least 2 recordings, ensuring the responses were reproduc- cd/s/m2 Nomenclature Response
ible. Mean calculations of the 6 ffERG recordings of the dark- 0.009 Dark-adapted 0.009 ERG Rods
adapted protocols and the 2 recordings of the 30-Hz flicker and 0.17 Dark-adapted 0.17 ERG Rods and cones
3.0 single-cone flash ERG were performed, from which the fi- 3.0 Dark-adapted 3 ERG Rods and cones

nal ffERG curve was established and from which amplitudes 12.0 Dark-adapted 12 ERG Rods and cones
3.0 30-Hz flicker ERG Cones
and the implicit times of the a-wave and the b-wave were mea-
3.0 3 Single-cone flash ERG Cones
sured. Cone stimulation with 30-Hz flicker and 3.0 single-
cone flash ERG were performed with a background dome light Abbreviation: ERG, electroretinography.
of 34 cd/m2 and room light without previous light adapta-
tion. The a-wave was measured and analyzed in the com- P values should be descriptive. The number of children included
bined rod and cone protocols: 0.17, 3.0, and 12.0 ERG. An was not based on any formal sample size calculation, and thus
amplitude greater than 1 V was required for inclusion. The the study was not powered to show statistical differences.
b-wave was recorded and analyzed in all ERG protocols. The
b-wave in 30-Hz flicker is referred to as the peak of the wave.
The ffERG signals were filtered through a band-pass filter
of 0.3 to 300 Hz, and artifact rejection was used, excluding re-
Results
sponses greater than 1000 V. The child had to be seated in a Of the original EXPRESS cohort of children in the Uppsala
relaxed position before the recordings were started. The ex- health care region, 73 of 87 preterm children (84%) and 64 of
aminer also encouraged the child and monitored the ERG re- 66 children born at term (97%) participated in the present study
sponses throughout the assessment. Fixation and coopera- at the 6.5-year follow-up. Full-field ERG recordings (accord-
tion (detection of larger eye movements and/or blinks) were ing to the inclusion criteria) were obtained in at least 1 eye in
both monitored with an infrared camera in the Ganzfeld dome 52 preterm children (50 right eyes and 48 left eyes) and 45 chil-
and were evaluated by the examiner during the recordings. dren born at term (45 right eyes and 45 left eyes), who com-
The inclusion criteria for the ffERG recordings were adequate prised the study population. Background data on this popu-
cooperation without a lot of large eye and body movements. lation and the mean VA and the mean SE are described in
Furthermore, ffERG recordings with present alternating- Table 2. Owing to missing data on the SE of 1 child in the con-
current disturbances were excluded. trol group, the results of 44 right and left eyes are presented
in Table 2.
Statistical Analysis Only 4 children had severe intraventricular hemorrhage
Statistical calculations were performed with SPSS, version 22 (grades 3-4), and none had a diagnosis of neonatal periven-
(IBM Corp), and R, version 3.2.3 (The R Foundation). Mean (SD) tricular leukomalacia, so further statistical analyses of the as-
values and ranges were calculated for the continuous data. Lin- sociation between these conditions and the ffERG responses
ear mixed models were performed to analyze the ffERG record- could not be performed. The preterm children had lower VA
ings (all 6 protocols included) between the preterm and control (logMAR VA mean difference, 0.082 [95% CI, 0.017-0.147];
groups, as well as within the preterm and control groups. The P = .02) and higher SE values (mean difference, 0.944 [95% CI,
data were validated and considered acceptable before entering 0.297-1.592]; P = .005) than the children in the control group,
in the parametric regression model. In the linear mixed mod- according to the mixed model analyses. Three children in the
els, the eye (right and left eye) and group (preterm and control preterm group had myopia less than 3 diopters (D), and 8 chil-
group) were the fixed factors, and the participants were the ran- dren had hypermetropia greater than 3.0 D. In the control
dom factors. Initially, the preterm group was compared with the group, no children had myopia and 3 children had hyperme-
control group regarding the ffERG recordings, with adjustment tropia greater than 3.0 D.
for sex and refraction (SE). The results from the regression analy- The mean (SD) values and ranges of the ffERG recordings
sis were initially presented as the mean difference between the (right and left eyes) in the preterm and control groups are pre-
groups with 95% CIs. Thereafter, linear mixed models were per- sented in Table 3. The preterm children had lower ampli-
formed within the preterm and control groups separately for tudes of the a-wave of the dark-adapted 3.0-cd/s/m2 protocol
the explanatory variables VA, SE, eye (right and left), and sex (mean difference, 48.9 V [95% CI, 80.0 to 17.9 V];
for each of the ffERG values. In the preterm group, the explana- P = .003) and of the a-wave of the dark-adapted 12.0-cd/s/m2
tory variables GA, birth weight, and ROP (present or not present) protocol (mean difference, 55.7 V [95% CI, 92.5 to 18.8 V];
vs ffERG recordings were compared according to the linear P = .004), as well as of the peak of 30-Hz flicker (mean differ-
mixed models. Further analyses within the preterm group were ence, 12.1 V [95% CI, 22.5 to 1.6 V]; P = .03), when com-
performed, dividing ROP into the following groups: no ROP, mild pared with the control group (Figure 1).
ROP, severe ROP, severe untreated ROP, and severe treated ROP. Implicit times of the a-wave of the dark-adapted
The results from the linear mixed models were presented with 12.0-cd/s/m2 ERG protocol (mean difference, 1.2 millisec-
95% CIs. P < .05 was considered statistically significant. There onds [95% CI, 0.3-2.0 milliseconds]; P = .01) and of the peak
was no adjustment for multiplicity, so the interpretation of of 30-Hz flicker ERG (mean difference, 1.2 milliseconds [95%

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Research Original Investigation Rod and Cone Function in 6.5-Year-Old Children Born Extremely Preterm

Table 2. Demographic Data During the Neonatal Period and at the 6.5-Year Follow-up
Preterm Group Control Group
Characteristic (n = 52) (n = 45)
Age at examination, 6.6 (0.1) [6.3 to 6.7] 6.6 (0.1) [6.3 to 6.7]
mean (SD) [range], y
Sex, No.
Boys 33 23
Girls 19 22
GA, mean (SD) [range], wk 25 (1.1) [22 to 26] 40 (1.1) [37 to 41]
Week, No.
22 1 NA
23 5 NA
24 10 NA
25 17 NA
26 19 NA
BW, mean (SD) [range], g 766 (175) [492 to 1218] 3636 (427) [2740 to 4360]
ROP stages, No.
Abbreviations: BW, birth weight;
None RE: 21; LE: 20 NA GA, gestational age; LE, left eye;
Mild RE: 20; LE: 23 NA NA, not applicable; RE, right eye;
Severe RE: 11; LE: 9 NA ROP, retinopathy of prematurity;
Treatment for ROP RE: 6; LE: 5 NA VA, visual acuity.
a
logMAR VA, RE: 0.13 (0.20) [0.00 to 0.70]; RE: 0.03 (0.06) [0.10 to 0.20]; Preterm group: 50 right eyes and
mean (SD) [range]a LE: 0.12 (0.31) [0.10 to 2.00] LE: 0.03 (0.07) [0.10 to 0.20] 48 left eyes; control group: 45 right
Snellen fraction VA, RE: 20/25 (20/100 to 20/20); RE: 20/21 (20/32 to 20/16); eyes and 45 left eyes.
mean (range) LE: 20/26 (20/2000 to 20/16) LE: 20/21 (20/32 to 20/16) b
Preterm group: 50 right eyes and
Refraction, spherical equivalent, RE: 1.59 (2.34) [7.63 to 7.50]; RE: 1.39 (0.70) [0.25 to 4.00]; 48 left eyes; control group: 44 right
mean (SD) [range]b LE: 1.18 (3.44) [13.25 to 7.38] LE: 1.35 (0.64) [0.25 to 3.63] eyes and 44 left eyes.

CI, 0.5-1.8]; P < .001) were longer in the preterm children than isolated cone response (30-Hz flicker ERG) compared with the
the control group (Figure 1). The ffERG recordings for the control group. Furthermore, implicit times were longer in the
6 protocols from a child born extremely preterm and a child a-wave of combined rod and cone response (the dark-adapted
born at term are shown in Figure 2. The mean value of all ffERG 12.0-cd/s/m 2 ERG protocol) and in the peak of the cone
recordings is shown as the middle trace, whereas the 2 other response (30-Hz flicker ERG). The a-wave measures the re-
traces show the reproducibility of the recordings. sponse from the photoreceptors,22,23 and the b-wave reflects pri-
Within the preterm group, there was no association be- marily the bipolar cells response.24,25 Consequently, our find-
tween GA, birth weight, previous ROP, stage of ROP, or treated ings revealed a general dysfunction of the rod and cone
ROP for any of the ffERG values. When investigating the as- photoreceptors, as well as that of the cone bipolar cells in chil-
sociation between the 6 ffERG protocols and sex, VA, and SE dren 6.5 years of age who were born extremely preterm.
in the preterm and the control groups, there was only a small The results of our study are in line with those of several
number of P values below .05 (preterm group: SE and ampli- ffERG studies, revealing a retinal dysfunction in infants and chil-
tude of the a-wave of dark-adapted 0.17 ERG [P = .02], SE and dren who were born preterm.13,26-33 However, most of these
implicit time of the a-wave of the dark-adapted 0.17 ERG studies reported a predominantly negative association with rod
[P = .011], VA and amplitude of the b-wave of 3 single-cone flash function,27-29,31,32 and Fulton et al32 have described that cone
ERG [P = .02]; control group: sex and implicit time of the peak function was less affected by preterm birth than was rod re-
30-Hz ficker (P = .004), SE and implicit time of the a-wave of sponse. In contrast, our study found that cone function was also
the dark-adapted 12 ERG [P = .02], VA and implicit time of the reduced, which might be explained by the extreme prematu-
a-wave of the dark-adapted 3 ERG [P = .003]), indicating no rity of the study group, resulting in an early arrest of the devel-
systemic associations. Furthermore, there was no difference opment of cone photoreceptors and bipolar cells. The creation
in the ERG recordings between the right and left eyes in either of cone photoreceptors starts before the formation of the rod
the preterm group or the control group. photoreceptors.34,35 Cones have been identified as early as
fetal week 8, the same time that the inner plexiform layer is
created.36 When an extremely preterm infant is born, as early
as fetal week 22, all retinal layers and cell types can be identi-
Discussion fied histologically in the parafovea.36 However, retinal vascu-
This population-based study revealed both reduced rod and larization is not complete at this stage,37,38 and important steps
cone functions in 6.5-year-old children born extremely pre- of further retinal development take place between fetal weeks
term when compared with age- and region-matched children 25 and 38. During this period, photoreceptors develop more
born at term. The preterm children had lower amplitudes of the distinct inner and outer segments, the avascular zone in the
a-wave of combined rod-cone response (the dark-adapted fovea is created, and the outer plexiform layer, as well as the reti-
3.0 and 12.0-cd/s/m2 ERG protocols) as well as of the peak of the nal vasculature, extend to the retinal periphery.7,36-39 It can be

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Rod and Cone Function in 6.5-Year-Old Children Born Extremely Preterm Original Investigation Research

Table 3. Full-Field Electroretinographic Recordings in the Right and Left Eyes of the Preterm and Control Groups

Mean (SD) [range]


Preterm Group Control Group
(n = 52) (n = 45)
ERG Protocol Right Eye Left Eye Right Eye Left Eye
Dark-adapted 0.009 ERG
b-Wave, V 291.0 (108.2) 271.6 (121.5) 333.0 (124.7) 317.3 (111.5)
[38.5 to 561.9] [65.8 to 666.2] [129.3 to 693.6] [134.8 to 579.7]
b-Wave, ms 93.1 (12.8) 94.5 (14.1) 93.0 (12.6) 94.3 (16.1)
[71.0 to 130.0] [74.5 to 160.0] [63.5 to 127.5] [71.0 to 139.0]
Dark-adapted 0.17 ERG
a-Wave, V 94.4 (50.6) 78.5 (43.9) 96.2 (47.8) 98.3 (44.6)
[226.7 to 15.8] [197.1 to 1.6] [207.4 to 3.4] [187.4 to 25.7]
a-Wave, ms 25.3 (2.6) 25.2 (2.9) 25.3 (2.2) 25.3 (1.3)
[13.0 to 30.5] [17.0 to 30.5] [17.5 to 30.5] [19.0 to 27.5]
b-Wave, V 365.0 (116.7) 351.1 (108) 410.5 (111.5) 382.5 (111.7)
[133.4 to 656.6] [131.9 to 577.3] [162.1 to 663.3] [163.3 to 625.1]
b-Wave, ms 71.5 (12.6) 73.1 (11.9) 69.9 (13.2) 69.9 (12.7)
[43.5 to 85.0] [44.0 to 85.0] [43.5 to 85.0] [43.0 to 85.0]
Dark-adapted 3 ERG
a-Wave, V 220.2 (78.0) 201.8 (81.4) 256.9 (86.6) 263.7 (81.5)
[395.9 to 81.9] [443.0 to 32.9] [453.5 to 114.5] [423.3 to 113.7]
a-Wave, ms 15.3 (2.1) 15.2 (0.8) 15.0 (0.4) 15.0 (0.5)
[12.5 to 28.0] [11.0 to 16.5] [14.0 to 16.0] [13.5 to 16.0]
b-Wave, V 450.5 (130.1) 431.4 (118.1) 484.2 (128.2) 457.5 (120.5)
[180.8 to 796.4] [234.6 to 669.9] [174.8 to 772.6] [217.6 to 736.5]
b-Wave, ms 52.6 (4.7) 53.1 (4.6) 53.1 (5.3) 53.3 (5.3)
[44.5 to 60.0] [44.0 to 60.0] [43.5 to 60.0] [43.5 to 60.0]
Dark-adapted 12 ERG
a-Wave, V 252.5 (93.0) 232.2 (70.9) 300.8 (106.2) 295.4 (106.3)
[482.9 to 51.6] [380.3 to 90.3] [527.3 to 103.9] [522.5 to 90.9]
a-Wave, ms 13.6 (2.4) 13.8 (2.9) 12.6 (1.8) 12.5 (1.4)
[10.5 to 27.0] [10.0 to 25.5] [10.0 to 19.0] [10.0 to 19.5]
b-Wave, V 441.1 (135.2) 421.2 (110.5) 495.7 (156.0) 458.6 (143.0)
[208.8 to 691.0] [234.2 to 657.5] [236.1 to 905.6] [185.4 to 784.3]
b-Wave, ms 49.8 (3.9) 50.3 (4.2) 49.7 (5.0) 50.2 (4.9)
[40.0 to 55.0] [40.5 to 55.0] [39.5 to 55.0] [38.5 to 55.0]
30-Hz flicker ERG
b-Wave, V 78.6 (30.4) 67.3 (22.5) 85.8 (23.2) 80.6 (22.1)
[26.9 to 164.4] [17.4 to 122.5] [32.1 to 164.3] [33.9 to 119.1]
b-Wave, ms 28.3 (1.6) 28.6 (2.0) 27.5 (1.4) 27.3 (1.2)
[25.5 to 32.0] [24.0 to 32.0] [25.0 to 31.0] [25.0 to 30.5]
3 Single-cone flash ERG
b-Wave, V 111.2 (42.4) 106.2 (38.4) 126.7 (36.8) 122.1 (37.8)
[34.9 to 228.1] [36.9 to 193.2] [43.3 to 221.0] [48.8 to 212.0]
b-Wave, ms 30.5 (1.3) 29.9 (1.5) 30.0 (1.1) 29.9 (1.0) Abbreviation:
[28.0 to 35.0] [25.0 to 33.0] [27.0 to 32.5] [27.0 to 32.0] ERG, electroretinography.

Figure 1. Mean Difference of the Full-Field Electroretinographic (ffERG) Recordings Between the Preterm and Control Groups

A Amplitude B Implicit time

0.009-cd/s/m2 b-wave 0.009-cd/s/m2 b-wave


0.17-cd/s/m2 a-wave 0.17-cd/s/m2 a-wave
0.17-cd/s/m2 b-wave 0.17-cd/s/m2 b-wave
3.0-cd/s/m2 a-wave 3.0-cd/s/m2 a-wave
3.0-cd/s/m2 b-wave 3.0-cd/s/m2 b-wave
12.0-cd/s/m2 a-wave 12.0-cd/s/m2 a-wave
12.0-cd/s/m2 b-wave 12.0-cd/s/m2 b-wave
30-Hz peak 30-Hz peak
3.0-cd/s/m2 single-cone b-wave 3.0-cd/s/m2 single-cone b-wave
120 100 80 60 40 20 0 20 10 5 0 5 10
Difference in Amplitude Between Difference in Implicit Time Between
Preterm and Control Groups, V Preterm and Control Groups, ms

Mean differences of each ffERG protocol. Dots indicate the mean difference and bars indicate the 95% CIs.

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Research Original Investigation Rod and Cone Function in 6.5-Year-Old Children Born Extremely Preterm

Figure 2. The 6 Full-Field Electroretinographic (ffERG) Protocols of 2 Study Participants

A Preterm child B Child in the control group


Dark-adapted 0.009 ERG Dark-adapted 0.009 ERG
RE LE RE LE
800 800 800 b-Wave 800
b-Wave
Amplitude, V

Amplitude, V

Amplitude, V

Amplitude, V
400 b-Wave 400 b-Wave 400 400
0 0 0 0
a-Wave a-Wave a-Wave a-Wave
400 400 400 400
800 800 800 800
0 50 100 150 200 0 50 100 150 200 0 50 100 150 200 0 50 100 150 200
Implicit Time, ms Implicit Time, ms Implicit Time, ms Implicit Time, ms

Dark-adapted 0.17 ERG Dark-adapted 0.17 ERG


800 800 800 b-Wave 800
b-Wave
Amplitude, V

Amplitude, V

Amplitude, V

Amplitude, V
400 b-Wave 400 b-Wave 400 400
0 0 0 0
a-Wave a-Wave a-Wave a-Wave
400 400 400 400
800 800 800 800
0 50 100 150 200 0 50 100 150 200 0 50 100 150 200 0 50 100 150 200
Implicit Time, ms Implicit Time, ms Implicit Time, ms Implicit Time, ms

Dark-adapted 3 ERG Dark-adapted 3 ERG


800 800 800 800
Amplitude, V

Amplitude, V

Amplitude, V

Amplitude, V
b-Wave
400 b-Wave 400 b-Wave 400 400 b-Wave

0 0 0 0
400 a-Wave 400 a-Wave 400 a-Wave 400 a-Wave
800 800 800 800
0 50 100 150 200 0 50 100 150 200 0 50 100 150 200 0 50 100 150 200
Implicit Time, ms Implicit Time, ms Implicit Time, ms Implicit Time, ms

Dark-adapted 12 ERG Dark-adapted 12 ERG


800 800 800 800
Amplitude, V

Amplitude, V

Amplitude, V

Amplitude, V
b-Wave b-Wave 400 b-Wave
400 400 b-Wave 400
0
0 0 0
400
400 a-Wave 400 400 a-Wave
a-Wave a-Wave 800
800 800 800 1000
0 50 100 150 200 0 50 100 150 200 0 50 100 150 200 0 50 100 150 200
Implicit Time, ms Implicit Time, ms Implicit Time, ms Implicit Time, ms

30-Hz flicker ERG 30-Hz flicker ERG


140 140 140 140
Peak Peak
Amplitude, V

Amplitude, V

Amplitude, V

Amplitude, V

70 Peak 70 Peak 70 70
0 0 0 0
Trough
70 Trough 70 70 Trough 70 Trough
140 140 140 140
0 20 40 60 80 100 0 20 40 60 80 100 0 20 40 60 80 100 0 20 40 60 80 100
Implicit Time, ms Implicit Time, ms Implicit Time, ms Implicit Time, ms

3 Single-cone flash ERG 3 Single-cone flash ERG


140 140 b-Wave 140 b-Wave 210
b-Wave b-Wave
Amplitude, V

Amplitude, V

Amplitude, V

Amplitude, V

70 70 70 140
70
0 0 0
0
70 a-Wave 70 a-Wave 70 70 a-Wave
a-Wave
140 140 140 140
20 0 20 40 60 80 100 20 0 20 40 60 80 100 20 0 20 40 60 80 100 20 0 20 40 60 80 100
Implicit Time, ms Implicit Time, ms Implicit Time, ms Implicit Time, ms

Amplitudes and implicit times of the a-waves and b-waves of the 6 ffERG protocols of a child born extremely preterm (A) and a child born at term (B). The mean
value of the ffERG recordings is the middle trace. ERG indicates electroretinography; LE, left eye; and RE, right eye.

assumed that the remaining abnormal retinal development in retinas. Hence, exposure to oxygen would also be a potential
this cohort of children born extremely preterm explains both reason for an arrest of normal retinal development.
their reduced rod and cone functions at 6.5 years of age. Fur- Recently published studies, in which multifocal ERG was
thermore, oxygen exposure has been identified to affect the rod performed and visual evoked potentials recorded, also de-
photoreceptor morphology40 and to reduce rod function41 in rat scribe a reduced electrophysiological response in children born

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Rod and Cone Function in 6.5-Year-Old Children Born Extremely Preterm Original Investigation Research

preterm in comparison with children born at term.33,42,43 Those results were not affected by high values of SEs. An adjustment
findings suggest that there is reduced macular function and for sex was also performed because there was an unequal dis-
affected visual pathways in preterm children. tribution of girls and boys in the cohort, and a sex-associated
Within the preterm group of our study, there was no as- difference in ffERG measurements has been reported.8 In our
sociation between the ffERG recordings and GA, stage of ROP, study, however, there was no significant association between
or laser-treated ROP. Several ERG studies of prematurely born the ffERG values and sex in the preterm and control groups.
infants and children reveal different conclusions regarding the
association with GA, ROP, and treated ROP.26-32 However, the Limitations
studies are not comparable because the GA range, the num- A limitation of the study was the small number of children who
ber of preterm children, the age at examination, and the ERG had been treated for ROP. The conclusion regarding the effect
methods were all different. kerblom et al26 reported a posi- of treated ROP is therefore limited.
tive correlation between the rod and cone response and in-
creasing GA in preterm children with a GA of between 22 and
32 weeks at birth. Several articles have reported that previ-
ous ROP reduces the rod function26-29,31 and that there is an
Conclusions
association between the severity of ROP and the dysfunction This cohort of children 6.5 years of age who were born
of rod photoreceptors.27 Furthermore, both rod dysfunction extremely preterm in a very narrow range of GA had a
and cone dysfunction are seen in infants with treated ROP.29,30 reduced function of both rods and cones. Although ampli-
Our study encompassed a homogenous group of children, born tudes and implicit times of the ffERG in premature infants
within a very narrow range of GA. Furthermore, a large num- increase and develop over time,50,51 there seems to be an
ber (35 of 52 [67%]) of the preterm children had ROP diag- arrest in the normal retinal development that appears to per-
nosed during the neonatal period, and only 6 children had re- sist later into childhood, with reduced rod and cone func-
ceived laser therapy for ROP (1 eye also received cryotherapy). tions. This finding accords with previously reported retinal
These facts might explain the lack of association between reti- structural and morphologic disturbances present after birth
nal dysfunction and GA or ROP in this cohort. and during adolescence in the prematurely born child.10,52-55
The preterm children in our study had lower VA and higher Rod and cone disorders are known to result in night vision
values of refraction (SE) than did those in the control group, problems, loss of the visual field, reduced color vision, and
which is in line with results of previous studies.44,45 High photophobia.56-58 It can be speculated how reduced retinal
refractive errors and axial length affect the results of ERG in chil- function may be expressed in this new, vulnerable popula-
dren and adults.46-49 When the preterm and control groups tion of children as they age. To be able to provide correct
were compared regarding the ffERG recordings, an adjust- habilitation, long-term ophthalmologic follow-up of these
ment for refractive errors was performed, thus ensuring that the children is therefore necessary.

ARTICLE INFORMATION Role of the Funder/Sponsor: The funding sources 2. EXPRESS Group. Incidence of and risk factors for
Accepted for Publication: May 8, 2017. had no role in the design and conduct of the study; neonatal morbidity after active perinatal care:
collection, management, analysis, and extremely preterm infants study in Sweden
Published Online: June 29, 2017. interpretation of the data; preparation, review, or (EXPRESS). Acta Paediatr. 2010;99(7):978-992.
doi:10.1001/jamaophthalmol.2017.2069 approval of the manuscript; and the decision to 3. Holmstrm GE, Kllen K, Hellstrm A, et al.
Author Contributions: Drs Molnar and Holmstrm submit the manuscript for publication. Ophthalmologic outcome at 30 months corrected
had full access to all the data in the study and take Additional Contributions: Eva Nuija, Uppsala age of a prospective Swedish cohort of children
responsibility for the integrity of the data and the University Hospital, assisted with the dataset. born before 27 weeks of gestation: the Extremely
accuracy of the data analysis. Jonina Hreinsdottir, Uppsala University Hospital, Preterm Infants in Sweden Study. JAMA Ophthalmol.
Study concept and design: Andrasson, Larsson, assisted with the ophthalmologic examinations. 2014;132(2):182-189.
kerblom, Holmstrm. Margareta Grindlund and Berit Lindgren, Uppsala
Acquisition, analysis, or interpretation of data: All 4. Austeng D, Kllen KB, Ewald UW, Jakobsson PG,
University Hospital, assisted with the full-field Holmstrm GE. Incidence of retinopathy of
authors. electroretinographic recordings. Olav Mepea, PhD,
Drafting of the manuscript: All authors. prematurity in infants born before 27 weeks
Uppsala University Hospital, assisted with the gestation in Sweden. Arch Ophthalmol. 2009;127
Critical revision of the manuscript for important creation of Figure 2. Marcus Thuresson, PhD,
intellectual content: All authors. (10):1315-1319.
Statisticon AB, assisted with the statistical analyses,
Statistical analysis: Molnar, Larsson, Holmstrm. performed the mixed model analyses, and created 5. Hellgren KM, Tornqvist K, Jakobsson PG, et al.
Obtained funding: Molnar, Holmstrm. Figure 1. Mss Nuija, Hreinsdottir, Grindlund, and Ophthalmologic outcome of extremely preterm
Administrative, technical, or material support: All Lindgren and Drs Mepea and Thuresson were infants at 6.5 years of age: Extremely Preterm
authors. compensated for their contributions. We also thank Infants in Sweden Study (EXPRESS) [published
Study supervision: All authors. the EXPRESS (Extremely Preterm Infants in Sweden online March 24, 2016]. JAMA Ophthalmol.
Conflict of Interest Disclosures: All authors have Study) group for allowing us to follow up with the doi:10.1001/jamaophthalmol.2016.0391
completed and submitted the ICMJE Form for subcohort of children participating in the EXPRESS 6. Hendrickson A, Drucker D. The development of
Disclosure of Potential Conflicts of Interest and and thank all study participants and their parents. parafoveal and mid-peripheral human retina. Behav
none were reported. Brain Res. 1992;49(1):21-31.
Funding/Support: This study was funded by the REFERENCES 7. Hendrickson A, Possin D, Vajzovic L, Toth CA.
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