Foveal Identification and Development in Prematurity-Implications on Zone Localization and Nutritional Supplementation.

Abstract

Purpose: Accurate identification of retinal Zone I in retinopathy of prematurity (ROP) is critical for treatment decisions and prognosis. Current definitions rely on identifying the macular center, limited by absence of the foveal light reflex (FLR) early in screening. Understanding factors influencing FLR development could improve zone localization and guide nutritional interventions. We sought to determine whether absolute infant weight gain independently predicts FLR development in premature infants, beyond postmenstrual age (PMA).

Methods: Prospective observational cohort study conducted from November 2024 to March 2025 within a multicenter telemedicine-based ROP screening program (GHANAROP). Premature infants meeting ROP screening criteria, screened before 37 weeks PMA, who subsequently developed FLR identifiable on wide-field digital retinal imaging were included. Logistic regression assessed associations between FLR presence, PMA, and infant weight. Multivariate logistic regression with elastic net regularization evaluated combined predictive value of PMA and weight.

Results: Among 318 eyes, FLR was first identified at mean PMA of 35 0/7 weeks (low risk ROP) and 35 2/7 weeks (more than low risk ROP), and mean weight of 1723g (low risk) and 1565g (more than low risk). Univariate modeling found that each additional week of PMA increased odds of FLR presence by 44.6% (OR = 1.446; 95% CI, 1.371-1.524) and that each 200g increase in weight increased odds by 23.1% (OR = 1.231; 95% CI, 1.113-1.360). Multivariate modeling demonstrated PMA and weight as predictors of FLR development, achieving 84.8% predictive accuracy (Nagelkerke R² = 0.2783).

Conclusions: Absolute infant weight independently predicts FLR development beyond PMA alone, highlighting opportunities for nutritional interventions to accelerate foveal maturation and potentially enhance visual outcomes.