The Refractive Legacy of Prematurity: A Systematic Review and Meta-Analysis of Refractive Errors and Ocular Biometry in Infants With and Without Retinopathy of Prematurity

Objective: To compare the prevalence of refractive errors in children born prematurely with and without retinopathy of prematurity (ROP) and to identify potential factors contributing to heterogeneity. Materials and Methods: Relevant literature was systematically searched in PubMed, EMBASE, and CINAHL for studies available through January 2025. Studies were eligible if they used cross-sectional, cohort, or case-control designs and reported refractive outcomes among preterm children stratified by ROP status. Effect estimates were synthesized using random-effects models and expressed as pooled odds ratios and mean differences. Between-study variability was evaluated using Cochran's Q statistic and the I² metric. Additional analyses included subgroup comparisons, meta-regression, and assessment of potential publication bias. Results: Twelve studies were included. ROP was significantly associated with myopia (OR, 1.76; 95% CI, 1.17–2.64; p = 0.01) and astigmatism (OR, 1.90; 95% CI, 1.49–2.43; p < 0.001), but not hyperopia (OR, 0.97; 95% CI, 0.64–1.47; p = 0.89). Strong associations were observed in upper-middle–income countries. Age significantly modified the ROP–myopia association (p = 0.002). Biometric analysis showed greater vitreous thickness in ROP children (mean difference, 0.16 mm; p = 0.04), while axial length, lens thickness, and anterior chamber depth were not significantly different (all p > 0.4). No publication bias was detected. Conclusions: ROP is associated with increased risks of myopia and astigmatism, with effects influenced by age and socioeconomic context. Vitreous thickness was the only biometric parameter significantly affected, suggesting a potential mechanism underlying refractive sequelae, although this requires further validation.