Risk of Pediatric Eye Disease in Children with Neurodevelopmental and Behavioral Disorders in the United States.

Abstract

Objective: To evaluate the association of neurodevelopmental disorders (NDDs) and behavioral disorders with amblyopia, myopia, strabismus, and strabismus surgery rates.

Design: Retrospective cohort study.

Participants: Children aged ≤18 years with and without NDDs or behavioral disorders identified in a nationwide multicenter federated electronic health record network.

Methods: Children diagnosed with attention-deficit/hyperactivity disorder, autism spectrum disorder, learning disorders, conduct disorder, or oppositional defiant disorder between 2013 and 2025 were compared with children without NDDs or behavioral disorders. Propensity score matching (1:1) was performed using demographics, medical comorbidities, laboratory values, and healthcare utilization metrics. After matching, time-to-event analyses were conducted using Kaplan-Meier estimation and Cox proportional hazards models, with prespecified sensitivity and negative control analyses. Disorder-specific analyses and exploratory analyses of strabismus surgery rates among children with strabismus or strabismic amblyopia were also performed.

Main outcome measures: Hazard ratios (HRs) with 95% confidence intervals (CIs) for amblyopia, myopia, and strabismus derived from propensity score-matched cohorts.

Results: The primary analysis included 1,429,440 children with NDDs or behavioral disorders and 3,522,241 controls, yielding 1,156,503 matched pairs. Baseline characteristics were well-balanced after matching. Children with NDDs or behavioral disorders had an increased risk of amblyopia (HR: 1.60; 95% CI: 1.45-1.79), strabismus (HR: 1.66; 95% CI: 1.57-1.71), and myopia (HR: 1.55; 95% CI: 1.45-1.70) compared with controls following the initial diagnosis of an NDD or behavioral disorder (all P < 0.001). Increased risk was also observed across clinically relevant disease subtypes, individual disorders, and multiple follow-up intervals (all P < 0.001). Children with NDDs or behavioral disorders underwent strabismus surgery less frequently than controls (19.2% vs. 28.4%; P < 0.001).

Conclusions: NDDs and behavioral disorders were associated with increased risk of amblyopia, myopia, and strabismus across multiple follow-up intervals, disease subtypes, and individual disorders. Pediatric eye disease may represent an important component of the overall health burden in this population. These findings support heightened clinical awareness and developmentally appropriate vision screening strategies in children with NDDs or behavioral disorders. Lower rates of strabismus surgery in this population warrant further investigation.