Multifactorial determinants of visual outcome in very and extremely preterm infants: A systematic literature review of risk factors for visual and oculomotor dysfunctions.

Preterm birth is often associated with neurological, neurodevelopmental and visual impairment arising from the complex interplay of ocular, visual pathway, and cerebral vulnerability in the immature infant. Visual dysfunction in premature infants may reflect ocular, anterior visual pathways, retrogeniculate pathways and visual associative areas abnormalities, as seen in Cerebral Visual Impairment. This systematic review synthesized evidence on the association between pre-, peri-, i and postnatal factors on basic visual (visual acuity, contrast sensitivity, visual field) and oculomotor (fixation, smooth pursuit and saccades) functions in very and extremely preterm infants. MEDLINE/PubMed, Scopus, Web of Science, and the Cochrane Library were searched for studies published between January 2010 and 6 June 2025. Twenty-five studies were included. Across the included studies, VA was the most frequently assessed outcome, whereas contrast sensitivity, visual field, visual fixation, and smooth pursuit were less extensively examined. Retinopathy of prematurity, neuroimaging abnormalities, lower gestational age, and lower birth weight were the most frequently investigated risk factors; associations with visual outcomes were reported for each factor, although the associations varied across studies. Evidence concerning systemic, metabolic, and prenatal factors was more limited and heterogeneous. This review highlights the multifactorial nature of visual dysfunction in very and extremely preterm infants, further emphasizing the complex relationship between preterm birth, visual outcomes, and neurological vulnerability.