Complications Occurring Through 5 Years Following Primary Intraocular Lens Implantation for Pediatric Cataract

Importance

Lensectomy with primary intraocular lens (IOL) implantation is often used in the management of nontraumatic pediatric cataract, but long-term data evaluating the association of age and IOL location with the incidence of complications are limited.

Objective

To describe the incidence of complications and additional eye surgeries through 5 years following pediatric lensectomy with primary IOL implantation and association with age at surgery and IOL location.

Design, Setting, and Participants

This prospective cohort study used Pediatric Eye Disease Investigator Group cataract registry data from 61 institution- and community-based practices over 3 years (June 2012 to July 2015). Participants were children younger than 13 years without baseline glaucoma who had primary IOL implantation (345 bilateral and 264 unilateral) for nontraumatic cataract. Data analysis was performed between September 2021 and January 2023.

Exposures

Lensectomy with primary IOL implantation.

Main Outcome and Measures

Five-year cumulative incidence of complications by age at surgery (<2 years, 2 to <4 years, 4 to <7 years, and 7 to <13 years) and by IOL location (sulcus vs capsular bag) were estimated using Cox proportional hazards models.

Results

The cohort included 609 eyes from 491 children (mean [SD] age, 5.6 [3.3] years; 261 [53%] male and 230 [47%] female). Following cataract extraction with primary IOL implantation, a frequent complication was surgery for visual axis opacification (VAO) (cumulative incidence, 32%; 95% CI, 27%-36%). Cumulative incidence was lower with anterior vitrectomy at the time of IOL placement (12%; 95% CI, 8%-16%) vs without (58%; 95% CI, 50%-65%), and the risk of undergoing surgery for VAO was associated with not performing anterior vitrectomy (hazard ratio [HR], 6.19; 95% CI, 3.70-10.34; P < .001). After adjusting for anterior vitrectomy at lens surgery, there were no differences in incidence of surgery for VAO by age at surgery (<2 years, HR, 1.35 [95% CI, 0.63-2.87], 2 to <4 years, HR, 0.86 [95% CI, 0.44-1.68], 4 to <7 years, HR, 1.06 [95% CI, 0.72-1.56]; P = .74) or by capsular bag vs sulcus IOL fixation (HR, 1.22; 95% CI, 0.36-4.17; P = .75). Cumulative incidence of glaucoma plus glaucoma suspect by 5 years was 7% (95% CI, 4%-9%), which did not differ by age after controlling for IOL location and laterality.

Conclusions and Relevance

In this cohort study, a frequent complication following pediatric lensectomy with primary IOL was surgery for VAO, which was associated with primary anterior vitrectomy not being performed but was not associated with age at surgery or IOL location. The risk of glaucoma development across all ages at surgery suggests a need for long-term monitoring.

Prevalence of cerebrotendinous xanthomatosis among patients diagnosed with early-onset idiopathic bilateral cataracts: final analysis

Cerebrotendinous xanthomatosis (CTX) is a rare, autosomal recessive bile acid synthesis disorder caused by pathologic variants in CYP27A1, a gene involved in bile acid synthesis. Impaired function in this gene leads to accumulation of plasma cholestanol (PC) in various tissues, often in early childhood, resulting in such clinical signs as infantile diarrhea, early-onset bilateral cataracts, and neurological deterioration. The current study aimed to identify cases of CTX in a population of patients with a greater CTX prevalence than the general population, to facilitate early diagnosis. Patients diagnosed with early-onset, apparently idiopathic, bilateral cataracts between the ages of 2 and 21 years were enrolled. Genetic testing of patients with elevated PC and urinary bile alcohol (UBA) levels was used to confirm CTX diagnosis and determine CTX prevalence. Of 426 patients who completed the study, 26 met genetic testing criteria (PC ≥ 0.4 mg/dL and positive UBA test), and 4 were confirmed to have CTX. Prevalence was found to be 0.9% in enrolled patients, and 15.4% in patients who met the criteria for genetic testing.

Green nail syndrome complicated by pseudomonal keratitis in a teenager with artificial nails

Green nail syndrome (GNS) is a pseudomonal nail infection that presents with characteristic green nail discoloration. It typically affects patients with preexisting nail conditions or chronic exposure to wet environments but can also be seen with local trauma. Our patient presented with a pseudomonal corneal ulcer of the left eye and was incidentally found to have GNS, which developed after home artificial nail application. This unusual case of extensive pediatric GNS illustrates a rare and serious infectious complication of prolonged artificial nails.

Visual Acuity and Ophthalmic Outcomes 5 Years After Cataract Surgery Among Children Younger Than 13 Years

IMPORTANCE

Cataract is an important cause of visual impairment in children. Data from a large pediatric cataract surgery registry can provide real-world estimates of visual outcomes and the 5-year cumulative incidence of adverse events.

OBJECTIVE

To assess visual acuity (VA), incidence of complications and additional eye operations, and refractive error outcomes 5 years after pediatric lensectomy among children younger than 13 years.

DESIGN, SETTING, AND PARTICIPANTS

This prospective cohort study used data from the Pediatric Eye Disease Investigator Group clinical research registry. From June 2012 to July 2015, 61 eye care practices in the US, Canada, and the UK enrolled children from birth to less than 13 years of age who had undergone lensectomy for any reason during the preceding 45 days. Data were collected from medical record reviews annually thereafter for 5 years until September 28, 2020.

EXPOSURES

Lensectomy with or without implantation of an intraocular lens (IOL).

MAIN OUTCOMES AND MEASURES

Best-corrected VA and refractive error were measured from 4 to 6 years after the initial lensectomy. Cox proportional hazards regression was used to assess the 5-year incidence of glaucoma or glaucoma suspect and additional eye operations. Factors were evaluated separately for unilateral and bilateral aphakia and pseudophakia.

RESULTS

A total of 994 children (1268 eyes) undergoing bilateral or unilateral lensectomy were included (504 [51%] male; median age, 3.6 years; range, 2 weeks to 12.9 years). Five years after the initial lensectomy, the median VA among 701 eyes with available VA data (55%) was 20/63 (range, 20/40 to 20/100) in 182 of 316 bilateral aphakic eyes (58%), 20/32 (range, 20/25 to 20/50) in 209 of 386 bilateral pseudophakic eyes (54%), 20/200 (range, 20/50 to 20/618) in 124 of 202 unilateral aphakic eyes (61%), and 20/65 (range, 20/32 to 20/230) in 186 of 364 unilateral pseudophakic eyes (51%). The 5-year cumulative incidence of glaucoma or glaucoma suspect was 46% (95% CI, 28%-59%) in participants with bilateral aphakia, 7% (95% CI, 1%-12%) in those with bilateral pseudophakia, 25% (95% CI, 15%-34%) in those with unilateral aphakia, and 17% (95% CI, 5%-28%) in those with unilateral pseudophakia. The most common additional eye surgery was clearing the visual axis, with a 5-year cumulative incidence of 13% (95% CI, 8%-17%) in participants with bilateral aphakia, 33% (95% CI, 26%-39%) in those with bilateral pseudophakia, 11% (95% CI, 6%-15%) in those with unilateral aphakia, and 34% (95% CI, 28%-39%) in those with unilateral pseudophakia. The median 5-year change in spherical equivalent refractive error was -8.38 D (IQR, -11.38 D to -2.75 D) among 89 bilateral aphakic eyes, -1.63 D (IQR, -3.13 D to -0.25 D) among 130 bilateral pseudophakic eyes, -10.75 D (IQR, -20.50 D to -4.50 D) among 43 unilateral aphakic eyes, and -1.94 D (IQR, -3.25 D to -0.69 D) among 112 unilateral pseudophakic eyes.

CONCLUSIONS AND RELEVANCE

In this cohort study, development of glaucoma or glaucoma suspect was common in children 5 years after lensectomy. Myopic shift was modest during the 5 years after placement of an intraocular lens, which should be factored into implant power selection. These results support frequent monitoring after pediatric cataract surgery to detect glaucoma, visual axis obscuration causing reduced vision, and refractive error.

Anisocoria secondary to antiperspirant wipes in a pediatric population: a case series

Acute-onset anisocoria or mydriasis in children carries a broad differential diagnosis and includes both benign and life-threatening causes, ranging from systemic or topical drug use to peripheral or central nervous system disease. The topical anticholinergic agent glycopyrronium (approved by the Food and Drug Administration in June 2018) is used to treat hyperhidrosis. We present the first case series of pediatric patients presenting with acute mydriasis due to exposure to glycopyrronium wipes. Six cases (ages 12-16) were identified: 3 presented emergently and 3 to a primary care physician. Additional symptoms included blurry vision (4/6) and unilateral headache (1/6). In 3 cases, use of glycopyrronium wipes was not elicited initially, neuroimaging was obtained, and ophthalmology (2/3) or neurology (1/3) was consulted. One patient remained undiagnosed and presented emergently again 2 months later. In all patients, symptoms resolved without further treatment.

Outcomes of Bilateral Cataract Surgery in Infants 7 to 24 Months of Age Using the Toddler Aphakia and Pseudophakia Treatment Study Registry

PURPOSE

To evaluate outcomes of bilateral cataract surgery in children aged 7 to 24 months and compare rates of adverse events (AEs) with other Toddler Aphakia and Pseudophakia Study (TAPS) registry outcomes.

DESIGN

Retrospective clinical study at 10 Infant Aphakia Treatment Study (IATS) sites. Statistical analyses comparing this cohort with previously reported TAPS registry cohorts.

PARTICIPANTS

Children enrolled in the TAPS registry between 2004 and 2010.

METHODS

Children underwent bilateral cataract surgery with or without intraocular lens (IOL) placement at age 7 to 24 months with 5 years of postsurgical follow-up.

MAIN OUTCOME MEASURES

Visual acuity (VA), occurrence of strabismus, AEs, and reoperations.

RESULTS

A total of 40 children (76 eyes) who underwent bilateral cataract surgery with primary posterior capsulectomy were identified with a median age at cataract surgery of 11 months (7-23); 68% received a primary IOL. Recurrent visual axis opacification (VAO) occurred in 7.5% and was associated only with the use of an IOL (odds ratio, 6.10; P = 0.005). Glaucoma suspect (GS) was diagnosed in 2.5%, but no child developed glaucoma. In this bilateral cohort, AEs (8/40, 20%), including glaucoma or GS and VAO, and reoperations occurred in a similar proportion to that of the published unilateral TAPS cohort. When analyzed with children aged 1 to 7 months at bilateral surgery, the incidence of AEs and glaucoma or GS correlated strongly with age at surgery (P = 0.011/0.004) and glaucoma correlated with microcornea (P = 0.040) but not with IOL insertion (P = 0.15).

CONCLUSIONS

Follow-up to age 5 years after bilateral cataract surgery in children aged 7 to 24 months reveals a low rate of VAO and very rare glaucoma or GS diagnosis compared with infants with cataracts operated at < 7 months of age despite primary IOL implantation in most children in the group aged 7 to 24 months. The use of an IOL increases the risk of VAO irrespective of age at surgery.

Abnormal Red Reflex: Etiologies in a Pediatric Ophthalmology Population

Children who present with an abnormal red reflex (ARR) are often referred to ophthalmology due to concern for retinoblastoma. However, an ARR can indicate a wide variety of pathologies, all of which have the potential to develop amblyopia and irreversible vision loss. In this retrospective cohort study, we demonstrate that children who presented with an ARR had a mean age of 22.0 ± 32.5 months and were more frequently referred by their pediatricians (74.5%). The majority of these patients (61.8%) had a normal examination on further evaluation, followed by refractive error (20.4%). Amblyopia was diagnosed in 83.9% of patients with refractive error, with a mean age of 50.3 ± 49.2 months. Because many ARR-associated pathologies require time-sensitive treatment to prevent vision loss, proper screening is critical for diagnosis. Pediatricians play a key role in screening, so education on more common ARR pathologies can better facilitate referrals and improve outcomes.

Recessive ACO2 variants as a cause of isolated ophthalmologic phenotypes

The mitochondrial aconitase gene (ACO2) encodes an enzyme that catalyzes the conversion of citrate to isocitrate in the tricarboxylic acid cycle. Biallelic variants in ACO2 are purported to cause two distinct disorders: infantile cerebellar-retinal degeneration (ICRD) which is characterized by CNS abnormalities, neurodevelopmental phenotypes, optic atrophy and retinal degeneration; and optic atrophy 9 (OPA9), characterized by isolated ophthalmologic phenotypes including optic atrophy and low vision. However, some doubt remains as to whether biallelic ACO2 variants can cause isolated ophthalmologic phenotypes. A review of the literature revealed five individuals from three families who carry biallelic ACO2 variants whose phenotypes are consistent with OPA9. Here, we describe a brother and sister with OPA9 who are compound heterozygous for novel missense variants in ACO2; c.[487G>T];[1894G>A], p.[(Val163Leu)];[(Val632Met)]. A review of pathogenic ACO2 variants revealed that those associated with OPA9 are distinct from those associated with ICRD. Missense variants associated with either OPA9 or ICRD do not cluster in distinct ACO2 domains, making it difficult to predict the severity of a variant based on position alone. We conclude that biallelic variants in ACO2 can cause the milder OPA9 phenotype, and that the OPA9-related ACO2 variants identified to date are distinct from those that cause ICRD.

Outcomes of Bilateral Cataracts Removed in Infants 1 to 7 Months of Age Using the Toddler Aphakia and Pseudophakia Treatment Study Registry

PURPOSE

To evaluate outcomes of bilateral cataract surgery in infants 1 to 7 months of age performed by Infant Aphakia Treatment Study (IATS) investigators during IATS recruitment and to compare them with IATS unilateral outcomes.

DESIGN

Retrospective case series review at 10 IATS sites.

PARTICIPANTS

The Toddler Aphakia and Pseudophakia Study (TAPS) is a registry of children treated by surgeons who participated in the IATS.

METHODS

Children underwent bilateral cataract surgery with or without intraocular lens (IOL) placement during IATS enrollment years 2004 through 2010.

MAIN OUTCOME MEASURES

Visual acuity (VA), strabismus, adverse events (AEs), and reoperations.

RESULTS

One hundred seventy-eight eyes (96 children) were identified with a median age of 2.5 months (range, 1-7 months) at the time of cataract surgery. Forty-two eyes (24%) received primary IOL implantation. Median VA of the better-seeing eye at final study visit closest to 5 years of age with optotype VA testing was 0.35 logarithm of the minimum angle of resolution (logMAR; optotype equivalent, 20/45; range, 0.00-1.18 logMAR) in both aphakic and pseudophakic children. Corrected VA was excellent (<20/40) in 29% of better-seeing eyes, 15% of worse-seeing eyes. One percent showed poor acuity (≥20/200) in the better-seeing eye, 12% in the worse-seeing eye. Younger age at surgery and smaller (<9.5 mm) corneal diameter at surgery conferred an increased risk for glaucoma or glaucoma suspect designation (younger age: odds ratio [OR], 1.44; P = 0.037; and smaller cornea: OR, 3.95; P = 0.045). Adverse events also were associated with these 2 variables on multivariate analysis (younger age: OR, 1.36; P = 0.023; and smaller cornea: OR, 4.78; P = 0.057). Visual axis opacification was more common in pseudophakic (32%) than aphakic (8%) eyes (P = 0.009). Unplanned intraocular reoperation occurred in 28% of first enrolled eyes (including glaucoma surgery in 10%).

CONCLUSIONS

Visual acuity after bilateral cataract surgery in infants younger than 7 months is good, despite frequent systemic and ocular comorbidities. Although aphakia management did not affect VA outcome or AE incidence, IOL placement increased the risk of visual axis opacification. Adverse events and glaucoma correlated with a younger age at surgery and glaucoma correlated with the presence of microcornea.

Band keratopathy in children previously treated with diode laser for type 1 retinopathy of prematurity

Band keratopathy is a corneal degeneration caused by chronic inflammation, systemic abnormalities, or, rarely, a primary biallelic SLC4A4 mutation leading to calcium hydroxyapatite deposition in Bowman's layer. We report a series of 16 eyes of 10 children with a remote history of diode laser treated retinopathy of prematurity who developed late-onset band keratopathy without evidence of other prior risk factors. The majority of patients developed band keratopathy bilaterally. Five eyes had visually significant central band keratopathy that required treatment with disodium ethylenediaminetetracetic acid (EDTA) chelation or phototherapeutic keratectomy. Band keratopathy may be an underreported late ophthalmic complication of diode-laser treated retinopathy of prematurity.

Cortical Visual Impairment in Congenital Cytomegalovirus Infection

PURPOSE

To describe the presentation, evolution, and long-term outcome of cortical visual impairment (CVI) in patients with symptomatic congenital cytomegalovirus (CMV) infection, and to identify risk factors for the development of CVI in patients with symptomatic congenital CMV.

METHODS

Retrospective subanalysis of a long-term prospective cohort study with data gathered from 1982 to 2013.

RESULTS

Eleven of 77 (14.3%) patients with symptomatic CMV, 0 of 109 with asymptomatic CMV, and 51 control patients had CVI. Overall, patients with symptomatic CMV had worse vision than patients with asymptomatic CMV, who in turn had worse vision than control patients. Microcephaly, intracranial calcification, dilatation of ventricles, encephalomalacia, seizure at birth, optic atrophy, chorioretinitis/retinal scars, strabismus, and neonatal onset of sensorineural hearing loss were risk factors associated with CVI.

CONCLUSIONS

CVI may result from symptomatic congenital CMV infection. The relationship of CVI and its risk factors in patients with CMV suggests the potential to predict the development of CVI through predictive modeling in future research. Early screening of CVI in children born with symptomatic congenital CMV can facilitate educational, social, and developmental interventions. [J Pediatr Ophthalmol Strabismus. 2019;56(3):194-202.].

Characteristics of Anterior Lens Opacities in Children

BACKGROUND

Anterior lens opacities (ALO) are found in 3-14% of pediatric patients with cataracts. No clear guidelines exist in the management and treatment of these cataracts.

OBJECTIVE

To evaluate pediatric patients with anterior lens opacities and assess rate of amblyopia and need for surgery over time.

METHODS

A retrospective chart review was performed on patients with unilateral and bilateral anterior lens opacities (ALOs) seen between January 2008 and December 2014. Size, location, and type of ALO were noted. Refractive error, necessity for treatment of amblyopia, and interventions were recorded.

RESULTS

A total of 31 patients were included in the study. 17 patients had unilateral ALOs and 14 had bilateral ALOs. The majority of the cataracts (90.3%) were centrally located. The most common type of cataract was the polar type of cataract and the vast majority (48.4%) was < 1mm in size. 38.7% of patients had concurrent ocular conditions and 9.7% had systemic associations. 28.6% of patients with bilateral cataracts and 35.3% of the patients with unilateral cataracts were treated for amblyopia. Three patients required cataract surgery.

CONCLUSION

About half of anterior lens opacities are less than 1mm in size and the majority are of the polar type. Risk of amblyopia in these patients is higher than in the general population. Anisometropia is the most common cause of amblyopia. Ocular associations are seen at a relatively high frequency and systemic associations can occur but are uncommon. The need for surgical intervention is infrequent; however, growth of ALOs and associated cortical changes may be risk factors for surgery.

Visual outcomes of patients presenting with bilateral infantile cataracts and nystagmus

OBJECTIVE

To evaluate the outcomes of cataract surgery in pediatric patients presenting with bilateral infantile cataracts and nystagmus.

DESIGN

Retrospective case study.

PARTICIPANTS

Thirteen pediatric patients who presented between September 2002 and February 2014 at a single tertiary care institution.

METHODS

Patients were included if they presented with bilateral visually significant cataracts and preoperative manifest nystagmus and had no other systemic or ocular condition that could explain the presence of the nystagmus. Data collected included best-corrected visual acuity (BCVA), etiology of cataracts, associated systemic/ocular conditions, status of strabismus, surgical complications, and presence of nystagmus.

RESULTS

Mean age at diagnosis of the cataracts was 8.1 ± 10.6 months. Mean age at surgery was 8.4 ± 10.5 months. Average length of follow-up was 54.3 ± 32.6 months. Twelve patients were left aphakic bilaterally; 1 patient received primary intraocular lenses bilaterally. Ten patients were able to perform visual acuity at the most recent visit, with 5 out of 10 having BCVA ≥20/40 in the better-seeing eye. Two patients had no visible nystagmus and 3 patients had latent nystagmus only at the most recent visit.

CONCLUSIONS

The presence of preoperative nystagmus does not preclude good visual outcomes in pediatric patients with cataracts.

Long-term Outcomes of Primary Intraocular Lens Implantation in Patients Aged 7 to 24 Months

PURPOSE

To report long-term outcomes of primary intraocular lens (IOL) placement in patients aged 7 to 24 months.

METHODS

This was a retrospective study of 27 consecutive patients (28 eyes) aged 7 to 24 months who underwent cataract surgery with primary IOL placement.

RESULTS

Average follow-up was 62.7 ± 41.7 months and the mean age of surgery was 14.4 ± 5.6 months. Mean final visual acuity was 1.02 ± 0.72 logMAR (20/209). Adverse events occurred in 7 eyes (25%) and included visual axis opacification in 6 eyes and pupillary block glaucoma in 1 eye. Seven patients (25.9%) required additional intraocular surgery. Strabismus was present in 19 patients (70.4%). Better stereopsis was correlated with better final acuity.

CONCLUSIONS

Cataract surgery with IOL placement in patients aged 7 to 24 months is associated with few complications. Visual axis opacification is the most frequent adverse event. [J Pediatr Ophthalmol Strabismus. 2017;54(3):149-155.].

Cataract Surgery in Children from Birth to Less than 13 Years of Age: Baseline Characteristics of the Cohort

OBJECTIVE

To describe baseline characteristics, initial postoperative refractive errors, operative complications, and magnitude of the intraocular lens (IOL) prediction error for refractive outcome in children undergoing lensectomy largely in North America.

DESIGN

Prospective registry study of children from birth to <13 years of age who underwent lensectomy for any reason within 45 days preceding enrollment.

PARTICIPANTS

Total of 1266 eyes of 994 children; 49% female and 59% white.

METHODS

Measurement of refractive error, axial length, and complete ophthalmic examination.

MAIN OUTCOME MEASURES

Eye and systemic associated conditions, IOL style, refractive error, pseudophakic refraction prediction error, operative and perioperative complications.

RESULTS

Mean age at first eligible lens surgery was 4.2 years; 337 (34%) were <1 year of age. Unilateral surgery was performed in 584 children (59%). Additional ocular abnormalities were noted in 301 eyes (24%). An IOL was placed in 35 of 460 eyes (8%) when surgery was performed before 1 year of age, in 70 of 90 eyes (78%) from 1 to <2 years of age, and in 645 of 716 eyes (90%) from 2 to <13 years of age. The odds of IOL implantation were greater in children ≥2 years of age than in those <2 years of age (odds ratio = 29.1; P < 0.001; 95% confidence interval: 19.6-43.3). Intraoperative complications were reported for 69 eyes (5%), with the most common being unplanned posterior capsule rupture in 14 eyes, 10 of which had an IOL placed. Prediction error of the implanted IOL was <1.00 diopter in 54% of eyes, but >2.00 diopters in 15% of eyes.

CONCLUSIONS

Lensectomy surgery was performed throughout childhood, with about two-thirds of cases performed after 1 year of age. Initial surgery seemed safe, with a low complication rate. IOL placement was nearly universal in children 2 years of age and older. The immediate postoperative refraction was within 1 diopter of the target for about one-half of eyes.

Long-Term Outcomes of Iris-sutured Posterior Chamber Intraocular Lenses in Children

PURPOSE

To report the long-term outcomes and complications of iris-sutured posterior chamber intraocular lenses (PCIOLs) in the pediatric population.

DESIGN

Retrospective interventional case study.

METHODS

This study involved 12 consecutive pediatric patients (17 eyes) who underwent placement of foldable iris-sutured PCIOLs between September 2004 and September 2007. Outcome measures included change in visual acuity and complications.

RESULTS

Of the 17 eyes were reviewed, 6 (35%) had hereditary or idiopathic ectopia lentis, 5 (29%) had Marfan syndrome, 2 (12%) were aphakic after pars plana vitrectomy and 4 (24%) were aphakic after surgical intervention for trauma. Average follow-up was 4.69 ± 3.21 years and mean age of surgery was 7.21 ± 3.78 years. Seven eyes suffered dislocation of the PCIOL an average of 12.11 ± 11.97 months after surgery, with 2 patients undergoing dislocation a second time. There was a higher rate of dislocation in patients with a history of ectopia lentis due to Marfan syndrome, idiopathic causes, or hereditary causes than in patients being treated for aphakia resulting from other causes (71% vs 29%). Mean visual acuity improved in 12 of 17 patients (71%), from 0.80 ± 0.6 logMAR preoperatively to 0.35 ± 0.5 logMAR at most recent visit, P = .009. One eye of a Marfan patient sustained a retinal detachment 8 months after dislocation of the PCIOL, and 1 patient experienced iris capture of the PCIOL after surgery.

CONCLUSIONS

Iris-sutured intraocular lenses have been used as an alternative to transsclerally sutured intraocular lenses to correct aphakia in pediatric patients. Dislocation of the intraocular lenses can occur frequently, however. The procedure should be considered with caution in pediatric patients.

Stereopsis results at 4.5 years of age in the infant aphakia treatment study

PURPOSE

To determine whether stereopsis of infants treated for monocular cataracts varies with the type of optical correction used.

DESIGN

Randomized prospective clinical trial.

METHODS

The Infant Aphakia Treatment Study randomized 114 patients with unilateral cataracts at age 1-7 months to either primary intraocular lens (IOL) or contact lens correction. At 4.5 years of age a masked examiner assessed stereopsis on these patients using 3 different tests: (1) Frisby; (2) Randot Preschool; and (3) Titmus Fly.

RESULTS

Twenty-eight patients (25%) had a positive response to at least 1 of the stereopsis tests. There was no statistically significant difference in stereopsis between the 2 treatment groups: Frisby (contact lens, 6 [11%]; IOL, 7 [13%]; P = .99), Randot (contact lens, 3 [6%]; IOL, 1 [2%]; P = .62), or Titmus (contact lens, 8 [15%]; IOL, 13 [23%]; P = .34). The median age at surgery for patients with stereopsis was younger than for those without stereopsis (1.2 vs 2.4 months; P = .002). The median visual acuity for patients with stereopsis was better than for those without stereopsis (20/40 vs 20/252; P = .0003).

CONCLUSION

The type of optical correction did not influence stereopsis outcomes. However, 2 other factors did: age at surgery and visual acuity in the treated eye at age 4.5 years. Early surgery for unilateral congenital cataract and the presence of visual acuity better than or equal to 20/40 appear to be more important than the type of initial optical correction used for the development of stereopsis.

Scleral-fixated capsular tension rings and segments for ectopia lentis in children

PURPOSE

To report the short-term outcomes and complications of implantation of scleral-fixated capsular tension rings and/or capsular tension segments with intraocular lenses (IOL) in pediatric patients with ectopia lentis.

DESIGN

Retrospective, observational case series.

METHODS

Thirteen consecutive pediatric patients (19 eyes) underwent placement of in-the-bag IOL with either a Cionni modified capsular tension ring or a capsular tension segment in conjunction with a conventional capsular tension ring between January 1, 2009 and March 30, 2013 by 3 anterior segment surgeons at a single academic center. The scleral fixation suture was 9-0 polypropylene in 16 eyes and CV-8 Gore-Tex (expanded polytetrafluoroethylene) in 3 eyes. Outcome measures included change in corrected distance visual acuity (CDVA) and complications.

RESULTS

The mean age was 10.2 years ± 4.8 (SD) and the median follow-up, 23.4 months. A Cionni modified capsular tension ring was implanted in 5 eyes and a capsular tension segment with an unsutured capsular tension ring was implanted in 12 eyes. In 2 eyes, capsular tension segment alone was placed. The mean CDVA at the final follow-up (0.10 ± 0.11 logMAR, 18 eyes) was significantly better than preoperatively (0.58 ± 0.26 logMAR, 15 eyes) (P < .001). The CDVA at the final follow-up was 20/40 or better in 18 eyes (94.7%). All IOLs were well centered. Posterior capsule opacification developed in 11 eyes (57.9%), 9 eyes (47.4%) required neodymium-yttrium-aluminum-garnet capsulotomy, and 3 eyes (15.8%) required pars plana vitrectomy and posterior capsulotomy. Other complications included broken suture (5.3%) (9-0 polypropylene at CTR eyelet, repaired with CV-8 Gore-Tex), conjunctival dehiscence (5.3%), suture exposure (5.3%) (trans-scleral 9-0 polypropylene), and vitreous strand at inferior paracentesis (5.3%).

CONCLUSIONS

Implantation of in-the-bag IOL with either a Cionni modified capsular tension ring or a capsular tension segment in conjunction with a conventional capsular tension ring appears to be a safe and effective technique for visual rehabilitation in pediatric ectopia lentis.

Complications in the first 5 years following cataract surgery in infants with and without intraocular lens implantation in the Infant Aphakia Treatment Study

PURPOSE

To compare rates and severity of complications between infants undergoing cataract surgery with and without intraocular lens (IOL) implantation.

DESIGN

Prospective randomized clinical trial.

METHODS

A total of 114 infants were enrolled in the Infant Aphakia Treatment Study, a randomized, multi-center (12) clinical trial comparing the treatment of unilateral aphakia in patients under 7 months of age with a primary IOL implant or contact lens. The rate, character, and severity of intraoperative complications, adverse events, and additional intraocular surgeries during the first 5 postoperative years in the 2 groups were examined.

RESULTS

There were more patients with intraoperative complications (28% vs 11%, P = .031), adverse events (81% vs 56%, P = .008), and more additional intraocular surgeries (72% vs 16%, P < .0001) in the IOL group than in the contact lens group. However, the number of patients with adverse events in the contact lens group increased (15 to 24) in postoperative years 2-5 compared to the first postoperative year, while it decreased (44 to 14) in years 2-5 compared to the first postoperative year in the IOL group. If only one half of the patients in the contact lens (aphakic) group eventually undergo secondary IOL implantation, the number of additional intraocular surgeries in the 2 groups will be approximately equal.

CONCLUSION

The increased rate of complications, adverse events, and additional intraocular surgeries associated with IOL implantation in infants <7 months of age militates toward leaving babies aphakic if it is considered likely that the family will be successful with contact lens correction.

An evidence-based approach to physician etiquette in pediatric ophthalmology

PURPOSE

Little objective evidence exists to guide physician etiquette in pediatric ophthalmology. This article describes the preferences of families visiting a pediatric ophthalmology clinic for the first time.

METHODS

Review of 149 questionnaires completed by the families of patients visiting a pediatric ophthalmology clinic in a tertiary care center. The Fisher exact and chi-square tests were used to compare subpopulations.

RESULTS

Most respondents preferred that their physician wear a white coat. Men preferred a handshake to a verbal greeting (P = .0264) and professional to business casual attire for both male and female physicians (P = .01, both). African-American parents were more likely to prefer being addressed by surname than other races (P = .008). No statistically significant differences were found comparing the preferences of parents with an advanced education (bachelor and graduate degrees) to those without.

CONCLUSION

Pediatric ophthalmologists may wish to consider wearing white coats and business casual attire in clinic and addressing parents informally as "mom" or "dad" or by their first name, although etiquette should ultimately be determined on an individual patient basis.

Inflammatory disorders of the orbit in childhood: a case series

PURPOSE

To describe a series of cases of orbital inflammatory disorders in children.

DESIGN

Retrospective case series.

METHODS

The medical records of pediatric patients diagnosed with orbital inflammation between September 1, 2002, and December 31, 2008, at Texas Children's Hospital were reviewed. Data collected included age at presentation, final diagnosis, treatment, workup and evaluation, need for biopsy and biopsy results, and involvement of lacrimal gland and muscles.

RESULTS

Twelve cases were identified. Six cases were males and 6 were females with age at presentation ranging from 1.3 to 16.2 years (mean, 11.9 years). The most common presentation was lacrimal gland enlargement, which was bilateral in 3 cases. Other common presenting signs were proptosis, extraocular motility limitation, and pain on eye movement. Half of our patients had systemic complaints at presentation, the most common of which was fever. Four patients were diagnosed as having a systemic cause and 2 of these patients had systemic symptoms.

CONCLUSIONS

Idiopathic orbital inflammatory conditions in children are uncommon, but can be associated with systemic conditions. Patients typically have lacrimal gland involvement, pain with eye movement, proptosis, and motility deficits at presentation. Bilateral cases may have a higher incidence of systemic disease.

Outcome and prognosis of pediatric patients with delayed diagnosis of open-globe injuries

PURPOSE

Open-globe injuries in children can present in a delayed fashion, potentially increasing the risk of endophthalmitis and delaying surgical intervention. This article presents the outcome of pediatric patients with delayed diagnosis of open-globe injuries for 24 hours or more.

METHODS

The study was a retrospective observational case series of patients who presented with open-globe injuries diagnosed 24 hours or more after the injury between July 2002 and March 2007.

RESULTS

Thirteen patients were included in the study. The average age at presentation was 5.8 +/- 2.8 years; average follow-up was 11.5 +/- 14.5 months. Mean time of presentation after injury was 9.2 +/- 16.0 days. The most common chief complaints were chronic red eye (7 of 13 patients), eye pain (5 of 13 patients), and decreased vision (4 of 13 patients). All patients had self-sealing corneal wounds; 8 of 13 patients had a visually significant traumatic cataract. One patient had sympathetic ophthalmia. Initial visual acuity was 20/200 or worse in 10 patients, and final visual acuity was 20/40 or better in 6 patients. No patient had endophthalmitis.

CONCLUSION

Open-globe injuries, especially self-sealing corneal wounds, can present in a delayed fashion in children or may be missed if obvious findings, such as subconjunctival hemorrhage or prolapsed iris tissue, are not present. Pediatricians should be educated that they should maintain a high level of suspicion in the setting of chronic unilateral red eye, decreased visual acuity, or abnormal red reflex.

Orbital approach for retrieval of transected extraocular muscles

Transection of an extraocular muscle can occur from orbital and facial trauma, or as a complication of surgery. The injury can occur either near the muscle insertion or in the muscle belly. Identification of the proximal end of the muscle in the orbit may be difficult, especially if the transection occurs a farther distance from the insertion, and, in these cases, the muscle is often considered lost. We present two patients who suffered from traumatic transections of an extraocular muscle more than 10 mm from the insertion. Both patients underwent transconjunctival orbitotomy to retrieve and secure the severed extraocular muscle. Both patients achieved good primary gaze alignment postoperatively. Preoperative imaging should be considered in cases of traumatic extraocular muscle transection.

Surgical intervention for traumatic cataracts in children: Epidemiology, complications, and outcomes

PURPOSE

To describe the presentation, treatment, and outcomes of a series of patients with unilateral traumatic cataracts.

METHODS

Retrospective, noncomparative review of 25 consecutive children with unilateral traumatic cataracts managed at a single institution during a 5-year period with regard to demographic data, mode of injury, clinical course, and outcome.

RESULTS

Paintball and BB gun injuries were the most common mode of injury, accounting for 28% of all cases, followed by injury from pens and pencils (16%). Preoperative visual acuity was poor in 19 patients (76%), and final postoperative visual acuity was poor (20/200 or worse) in 4 patients (16%); this difference was statistically significant (p < 0.001). Twenty-one percent of children with poor vision on initial examination had poor vision at their final examination, and no patients with vision better than 20/200 on initial examination developed poor vision postoperatively (p = 0.29). Patients who developed poor final vision were younger on average than those who achieved satisfactory vision (5.25 years vs 7.5 years). Poor visual outcome did not appear to depend on the time from injury to presentation and time interval between injury and cataract extraction.

CONCLUSIONS

Children with visually significant traumatic cataracts can have good outcomes if they are managed aggressively and appropriately. In our patient population, paintballs and BB guns accounted for more than 25% of traumatic cataract injuries, and a large number of traumatic cataracts were sustained by pens and pencils.

Change in astigmatism after temporal clear corneal cataract extraction in the pediatric population

Purpose:

To evaluate the early postoperative change in astigmatism in pediatric patients having cataract extraction with intraocular lens implantation using sutured temporal clear corneal incision. Methods: A retrospective chart review was performed on all pediatric patients who underwent clear corneal cataract surgery with intraocular lens implantation between 12/01/2005 and 11/30/2006. Results: A total of 31 eyes of 22 patients who underwent temporal clear corneal cataract surgery and intraocular lens implantation were included. The mean patient age at surgery was 6.05 years (range 1.5 months to 17 years). Mean postoperative refractive astigmatism the first day after surgery was 2.35±1.37 diopters (D). There was a statistically significant decrease in mean postoperative astigmatism by postoperative week 1 to 1.45 ± 0.79 D. Mean astigmatism was 1.48 ± 0.98 D by postoperative months 2-4, which was not a statistically significant change from postoperative day 1. Conclusions: Postoperative astigmatism can be expected after sutured temporal clear corneal surgery in pediatric patients and decreases over time without removal of sutures. The amount of postoperative astigmatism in children requires close follow-up after pediatric cataract surgery.

The frequency of ocular abnormalities in inpatient pediatric ophthalmology consultations

OBJECTIVE

To determine the frequency, type, and results of pediatric ophthalmology service consultations at a tertiary care children's hospital and to offer advice as to the timing of the initial consultation based on the patient's diagnosis and likelihood of ocular disease,

METHOD

A retrospective evaluation of inpatient ophthalmology consultations from September 1, 2003, to August 31, 2004, at Texas Children's Hospital was conducted. Patients were identified using the Current Procedural Terminology listing of billing codes for various levels of service for new initial inpatient consultations.

RESULTS

During the 1-year period, 445 new inpatient consultations were requested from the pediatric ophthalmology service, primarily to rule out ophthalmic problems or manifestations (55.9%) and to evaluate ocular complaints or ocular abnormalities as noted by the primary team (44.1%). Of the 445 patients, 215 (48.3%) were found to have ocular abnormalities and 230 (51.7%) had no ocular abnormalities at the time of initial consultation.

CONCLUSION

Patients with ocular signs or symptoms of disease should receive urgent ophthalmic consultation. Consideration should be given to the usefulness of urgent consultations in patients suspected of having fungemia, sepsis, and headache.

Microbiology of pediatric orbital cellulitis

PURPOSE

To evaluate the microbiology of pediatric orbital cellulitis associated with sinusitis.

DESIGN

Retrospective review of medical records of pediatric patients treated for orbital cellulitis.

METHODS

All pediatric patients treated for orbital cellulitis associated with sinusitis at Texas Children's Hospital between December 1, 2001 and September 30, 2005 were reviewed. Data collected included patient age, history, microbiology results, and surgical intervention.

RESULTS

Thirty-eight cases were identified. Fifteen cases required medical management, whereas 23 patients received a combination of medical and surgical intervention. Three patients had multiple surgical procedures performed. Of the procedures performed, four were sinus irrigation, 12 were sinusotomy and drainage, nine were orbitotomy with drainage of abscess, and one was craniotomy with drainage of abscess. Surgical aspirate specimens yielded a higher positive culture result rate with 9/9 of orbital abscesses and 13/16 of sinus aspirates demonstrating a positive yield. Two of the 27 blood cultures had a positive yield. Staphylococcus species was the most common organism isolated. Methicillin-resistant S. aureus (MRSA) represented 73% of S. aureus isolates. Streptococcus species was the next most common pathogen. Three cultures yielded Haemophilus species with one being positive for H. influenzae.

CONCLUSIONS

Organisms responsible for causing pediatric orbital cellulitis are evolving, with Staphylococcus followed by Streptococcus species being the most common pathogens. The occurrence of MRSA in pediatric orbital cellulitis is increasing, and empiric antimicrobial therapy should be directed against these organisms if they are prevalent in the community. Sinus and orbital abscess aspirates yielded the greatest number of positive cultures, though these invasive surgical procedures should be performed only when clinically indicated.

Current trends in the surgical management of orbital dermoid cysts among pediatric ophthalmologists

PURPOSE

To survey the membership of the American Association for Pediatric Ophthalmology and Strabismus on their preferences in the management of dermoid cysts.

METHODS

The 689 active members of the American Association for Pediatric Ophthalmology and Strabismus were surveyed by mail on their preferences in the management of dermoid cysts. The survey addressed use of imaging, timing of surgery, surgical approach, use of corticosteroids, and satisfaction with results.

RESULTS

Of the 689 members surveyed, 62.4% responded. Of these, 75.8% performed orbital dermoid excisions in their pediatric ophthalmology practices. Imaging was always obtained by 9.5%, never obtained by 9.5%, and obtained for specific reasons by 81.0%. Computed tomography scan was the preferred imaging modality of 66.2% of respondents. Surgery was deferred until older than 6 months by 68.9%, and 71.9% cited anesthetic risk as the reason for waiting. Surgical approaches used were sub-brow incision only (53.9%), eyelid crease incision only (15.8%), or either (22.6%). Ninety-six percent of respondents never used adjunct corticosteroids, and 99.2% of respondents were satisfied with their surgical results.

CONCLUSIONS

The majority of American Association for Pediatric Ophthalmology and Strabismus members defer orbital dermoid surgery until 6 months of age due to anesthesia risk, use the sub-brow incision, and obtain imaging only for specific reasons. Most respondents never use systemic corticosteroids at the time of surgery, and are satisfied with their results.

Effect of corticosteroids in the acute management of pediatric orbital cellulitis with subperiosteal abscess

PURPOSE

To determine the effect of intravenous corticosteroids in the acute management of pediatric orbital cellulitis with subperiosteal abscess.

METHODS

The inpatient records of all patients treated for orbital cellulitis with subperiosteal orbital abscess between January 2001 and August 2003 were reviewed. The use of corticosteroids, length of hospital stay, need for surgical drainage, treatment course, and clinical outcomes were reviewed. A t test and Fisher exact test analysis were calculated to evaluate statistical significance.

RESULTS

Twelve patients received intravenous corticosteroids and 11 patients did not receive corticosteroids. All patients had complete resolution of their abscess without complications. Length of hospitalization between the patients treated with and without intravenous corticosteroids was not significantly different (p = 0.26). Four of 12 patients treated with intravenous corticosteroids underwent orbitotomy for drainage of the abscess, and 6 of 11 patients treated without intravenous corticosteroids underwent surgical drainage (p = 0.20). Two of 12 patients treated with corticosteroids received intravenous antibiotics after discharge, whereas 7 of 11 in the group not treated with corticosteroids received intravenous antibiotics after discharge (p = 0.03).

CONCLUSIONS

The use of intravenous corticosteroids does not appear to adversely affect clinical outcomes and may be beneficial in the treatment of pediatric orbital cellulitis with subperiosteal abscess. Review of our data suggests that a prospective, randomized trial is warranted to further clarify the role of corticosteroids in the acute management of pediatric orbital cellulitis with subperiosteal abscess.

Recurrent Acute Lymphoblastic Leukemia Presenting in the Lacrimal Gland

A 14-year-old girl with a history of acute lymphoblastic leukemia presented with periorbital swelling of the right eyelid associated with enlargement of the lacrimal gland and cervical lymphadenopathy. Radiographic imaging showed diffuse enlargement and enhancement of the right lacrimal gland. The patient underwent an incisional biopsy of the lacrimal gland that showed atypical lymphocytes consistent with recurrent acute lymphoblastic leukemia. The lacrimal gland is a rare extramedullary site for recurrence of this disease.

Chiari I malformation and acute acquired comitant esotropia

The authors describe a rare case of a Chiari I malformation presenting with acute acquired comitant esotropia (AACE) in a 5-year-old boy. A posterior fossa decompression with duraplasty and a C1-2 laminectomy were performed. There was an immediate postoperative improvement in the esotropia, which completely resolved by 7 months following surgery. The pertinent literature is discussed and reasons are presented for recommending posterior fossa decompression in certain patients, rather than strabismus surgery, as the initial treatment for esotropia. The authors suggest that in patients with AACE, even subtle symptoms and signs of Chiari I malformation should prompt imaging of the posterior fossa. Strong consideration should be given to performing posterior fossa decompression in patients with Chiari I malformation and AACE before strabismus surgery because the esotropia may completely resolve with decompression.

Bilateral endogenous endophthalmitis secondary to endocarditis with negative transesophageal echocardiogram

PURPOSE

To present a case of bilateral endogenous endophthalmitis as the primary manifestation of an aortic root abscess and endocarditis, both of which were undetected by transesophageal echocardiogram.

DESIGN

Observational case report.

METHODS

A 13-year-old male presented with bilateral endogenous endophthalmitis and previously undiagnosed ventricular septal defect, subaortic stenosis, and a mitral valve cleft.

RESULTS

Cardiac evaluation, systemic evaluation, and transesophageal echocardiogram were negative for endocarditis, but endocarditis and aortic root abscess were discovered at time of cardiac surgery. The patient responded to systemic treatment for endocarditis and surgical management of his cardiac defect.

CONCLUSION

A cardiac source for endogenous endophthalmitis should be considered in the presence of clinical diagnosis of bacteremia, despite a negative transesophageal echocardiogram and systemic evaluation.

Alternating ptosis associated with intermittent exotropia

A unique case of alternating, poorly controlled, intermittent strabismus that improved after repair of bilateral, alternating congenital ptosis is described. A 7-year-old boy with bilateral, alternating congenital ptosis and poorly controlled, intermittent exotropia underwent bilateral frontalis suspensions. After surgery, the patient demonstrated improved control of his exotropia. We conclude that an alternating ptosis may lead to sensory deprivation of the occluded eye and decreased fusion, causing an intermittent strabismus to be poorly controlled. Repair of the ptosis to a sufficient eyelid height bilaterally may improve control of the strabismus, obviating strabismus surgery.

Telephotoscreening to detect retinopathy of prematurity: preliminary study of the optimum time to employ digital fundus camera imaging to detect ROP

PURPOSE

Labor-intensive screening of infants in the neonatal intensive care units is the only way presently to detect retinopathy of prematurity (ROP). Our purpose is to determine if RetCam 120 images (Massie Research Laboratories, Inc, Dublin, Calif), acquired by a neonatal nurse, can be used to screen for ROP by performing 2 screening sessions, at 32 to 34 weeks' (examination 1) and 38 to 40 weeks' (examination 2) postconceptional age.

METHODS

RetCam examinations were performed by a nurse on infants at examination 1 and examination 2 intervals. At the same time, an examination was performed by an experienced ophthalmologist. Masked readers evaluated the digital images for the presence of ROP and, if ROP was present, estimated the risk of that eye progressing to prethreshold or threshold disease. The data were compared to the eye's clinical course.

RESULTS

A total of 46 eyes were assessed at examination 1 and 50 eyes at examination 2 from July 1, 1999, to December 15, 1999. For detecting ROP, the sensitivity and specificity were 46% and 100% for examination 1 and 76% and 100% for examination 2. Sensitivity and specificity of predicting prethreshold was 64% and 97%, respectively, for examination 1 and 2. Sensitivity for predicting ROP threshold at examination 1 was 0% (only 1 photo was available for grading of sensitivity) and specificity for predicting ROP threshold at examination 1 was 95%. At examination 2, sensitivity and specificity were 100%.

CONCLUSION

The RetCam examination had insufficient sensitivity to be recommended as a substitute for indirect ophthalmoscopy in screening for ROP. Reasons for low sensitivity are the technical limitation of the camera design itself, which creates difficulty in photographing the peripheral retina in small eyes, and the need for a lid speculum better adapted to the contact camera optical system design. Both of these issues are being addressed as part of an ongoing project to study the feasibility of employing telemetry of digital fundus images from remote, underserved neonatal intensive care units to ophthalmologists capable of diagnosing ROP.

The optimum time to employ telephotoscreening to detect retinopathy of prematurity

PURPOSE

Labor-intensive screening of infants in the neonatal intensive care units is the only way to detect retinopathy of prematurity (ROP). Our purpose is to determine if RetCam 120 photos, acquired by a neonatal nurse, can be used to screen for ROP by performing 2 screening examinations, at 32 to 34 weeks (exam 1) and at 38 to 40 weeks (exam 2) post-conceptional age.

METHODS

RetCam examinations are performed by a nurse on infants at exam 1 and exam 2 intervals. At the same time, an examination is performed by an experienced ophthalmologist. Masked readers evaluate the photos for ROP and determine if each eye will progress to prethreshold or threshold disease. The data are compared to the clinical course of the eyes.

RESULTS

Forty-six eyes were photographed at exam 1 and 50 eyes at exam 2 from July 1, 1999, to December 15, 1999. Sensitivity and specificity of detecting ROP were 76% and 100% for exam 2 and 46% and 100% for exam 1. Sensitivity and specificity of predicting prethreshold disease were 64% and 97% for exam 2 and 33% and 100% for exam 1. Sensitivity and specificity of predicting threshold were both 100% at exam 2 and 0% (one photo in category) and 95% at exam 1.

CONCLUSION

A potential reason for low sensitivity is technical limitations of the Retcam, such as the difficulty in capturing peripheral retina in small eyes and the need for a better lid speculum.

An in vivo model of femtosecond laser intrastromal refractive surgery

BACKGROUND AND OBJECTIVE

To develop an animal model for evaluation of femtosecond laser intrastromal refractive surgery.

METHODS

Intrastromal photodisruption was performed in New Zealand Albino rabbits using a femtosecond laser system. This surgical pattern consisted of a 100 microm-tick pyramid of laser pulses starting 180 microm below the corneal surface. Animals underwent serial slit lamp examinations and corneal thickness measurements at 1,3,7,14, and 28 days, then monthly up to 1 year.

RESULTS

Approximately 70 microm of central corneal thinning were seen at 1 week, remaining stable up to 7 months.

CONCLUSIONS

Intrastromal photodisruption with femtosecond lasers produced consistent changes in corneal thickness without loss of corneal transparency. These changes were more stable than those produced with excimer laser procedures in a similar animal model.