Author’s Disclosure Block: Kristina Nazzicone, none; Rachel Kim, none; Alexa Fine, none; Aidan Pucchio, none; Laura Wheaton, LW served as an advisor for Alexion Pharma Canada on Koselugo (Selumetinib) in February 2024; Christine Law, none 

Abstract Body
Purpose: Ocular involvement in pediatric leukemia is often under-recognized, especially in asymptomatic cases. Prevalence estimates of childhood leukemic ophthalmopathy range from 0.32% to 71%, depending on the Study Design and population. This study aimed to describe the breadth and determine the prevalence of ocular involvement in newly diagnosed pediatric leukemia through systematic review and meta-analysis. Study Design: Systematic review and meta-analysis. Methods: The protocol for this review was registered on PROSPERO (CRD42024548493). A comprehensive search of MEDLINE, Embase, Cochrane, and Web of Science were searched from inception to July 2024. Primary studies reporting on ocular involvement in children with newly diagnosed leukemia aged 18 years or younger were included. Cases of relapsed disease were excluded as were those receiving concurrent treatment. Cases where it was unclear if ocular involvement was due totreatment were also excluded. Two reviewers independently screened all potentially eligible articles at the title/abstract and full-text levels using Covidence. Data extraction and risk of bias (RoB) was performed independently by one reviewer with 10% of articles verified by a second reviewer to ensure agreement. RoB was assessed using the Joanna Briggs Institute Critical Appraisal Checklist for Prevalence Studies. Descriptive study and patient information, sample size, and the frequency and description of ocular involvement was extracted. A random effects meta-analysis using an inverse-variance restricted maximum likelihood approach was used for prevalence estimates. All analyses were performed using R Statistics (version 4.4.0). Results: Fourteen studies involving 2989 pediatric leukemia patients were included. Intraretinal hemorrhage and exophthalmos were the most commonly reported manifestations, affecting 62 and 42 patients, respectively. Other manifestations included increased intraocular pressure, papilledema, decreased visual acuity, and various retinal, anterior segment and neuro-ophthalmic findings. The overall pooled prevalence of ocular involvement at diagnosis was 20.32% (95%CI=9.88-33.08%). The prevalence of asymptomatic ocular involvement was higher at 23.90% (95%CI=10.27-40.63%) compared to 14.75% (95%CI=0.00-45.31%) for symptomatic involvement alone. High heterogeneity (I²=97.7%) was observed across studies, likely driven by differences in Study Design and study populations. Conclusions: Ocular involvement in newly diagnosed pediatric leukemia is more common than previously understood, particularly for asymptomatic cases. Current practices of selective ophthalmic assessment may miss a number of early-stage ocular manifestations, emphasizing the need for all newly diagnosed patients to be screened for ophthalmic involvement at the time of diagnosis.