A comparison of the rate of refractive growth in pediatric aphakic and pseudophakic eyes.

OBJECTIVE: To compare the rate of refractive growth in pseudophakic children's eyes to that of aphakic eyes. DESIGN: Multicenter, retrospective observational case series. PARTICIPANTS: 83 patients with pseudophakic eyes (100 eyes) and 74 patients with aphakic eyes (106 eyes), with an age of surgery between 3 months and 10 years and a minimum follow-up time of 3 years or more, depending on the age at surgery. METHODS: A logarithmic model was used to analyze the rate of refractive growth for each eye. MAIN OUTCOME MEASURES: Age at surgery, intraocular lens power, intraocular lens A-constant, initial postoperative refraction, final refraction, and final age. RESULTS: Overall, pseudophakic eyes showed a lesser rate of refractive growth than aphakic eyes (-4.6 diopter vs. -5.7 diopter, P = 0.03). This trend was also present but less significant when the eyes were grouped into those less than 6 months of age at surgery (-3.3 diopter vs. -4.6 diopter, P = 0.09) and older patients (-5.0 diopter vs. -6.1 diopter, P = 0.07). However, the mean quantity of myopic shift was greater in pseudophakic eyes than in aphakic eyes (-5.26 diopter vs. -4.54 diopter), despite shorter follow-up times in the pseudophakic eyes. This is due to the optical effects of a constant intraocular lens power in a growing eye. CONCLUSIONS: Pediatric pseudophakic eyes have a slightly lesser rate of refractive growth than aphakic eyes. The new rate values should be used for predicting future refractions in these eyes.

Intraocular lens calculator for childhood cataract.

PURPOSE: To evaluate a computer program to predict the pseudophakic refraction of a child at any age. SETTING: A pediatric ophthalmology practice. METHODS: A computer program was written for Windows 95 that calculates the initial postoperative pseudophakic refraction of a child using Holladay's formula, given the axial length and keratometry readings. The logarithmic model was used to predict the ultimate refraction at age 20 years and chart the predicted curve of refractive error with standard deviations. RESULTS: The program provided a graph of a child's predicted pseudophakic refraction versus age that would allow the surgeon to dynamically view the effects of changing the intraocular lens (IOL) power. CONCLUSIONS: If pseudophakia and aphakia have the same effect on the growth of the eye, this program should accurately predict the myopic shift of a pseudophakic child. This could help guide the surgeon's choice of IOL power.

Theoretic refractive changes after lens implantation in childhood.

OBJECTIVE: Children with aphakia tend to have decreasing hyperopia as they grow older. No large study of the long-term refractive changes in children with pseudophakia has been published, although myopic shifts of greater than 10 diopters (D) have been reported. The authors used the refractions of children with aphakia and long follow-up to calculate the theoretic long-term refractive effects of pseudophakia. DESIGN: The study design was a chart review of eyes that underwent cataract surgery before age 10 with documented refractions for more than 7 years. PARTICIPANTS: Ninety-three eyes were studied. INTERVENTION: The initial aphakic refractions of the study eyes were used to calculate the intraocular lens (IOL) powers that would have been required to give emmetropia at cataract removal. The aphakic refractions at last follow-up were used to calculate the final pseudophakic refractions, and these were compared with the predictions of a logarithmic model of myopic shift. RESULTS: The mean follow-up time was 11 years. The median calculated pseudophakic refraction at last follow-up was -6.6 D with a range of -36.3 to +2.9 D. Children who underwent surgery in the first 2 years of life had a substantially greater myopic shift than older children (P < 0.001) and a larger variance in this myopic shift (P < 0.001). The logarithmic model accurately predicted the final refraction within 3 D in 24% of eyes undergoing surgery before 2 years of age and in 77% of eyes undergoing surgery after this age. CONCLUSIONS: Pseudophakia in children is predicted to result in a large quantity of myopic shift, particularly in very young children. An IOL power chosen to leave a child initially hyperopic should lessen both the quantity of myopic shift and the extreme myopia that can result with growth. The surgeon who implants IOLs in young children must be prepared for a wide variation in long-term myopic shift.

Myopic shift after cataract removal in childhood.

BACKGROUND: Children who have had cataract removal tend to have decreasing hyperopia (myopic shift) as they grow older. We wondered if the rate of myopic shift could be determined by age at surgery, cataract type, glaucoma, or other factors. METHODS: We studied 156 aphakic eyes of children who had cataract surgery before age 10 and documented refractions for more than 3 years. Refraction was corrected with contact lenses and spectacles; glaucoma was managed with medicine and surgery. Stepwise multiple regression was used to analyze differences in the rate of myopic shift between subgroups. RESULTS: The average refraction tended to follow a logarithmic decline with age (P < 0.01, R2 = 0.97). The average rate of myopic shift (the slope of spectacle plane refraction vs log of age, where age is in years and log is base 10) was -5.5, with a standard deviation of 3.8. Age at surgery had a small but statistically significant effect on the rate (P < 0.01, R2 = 0.04). No other studied factor reached statistical significance. However, among the 86 eyes with cataract removal after age 6 months, age at surgery was not as significant (P = 0.21), and unilateral cataract eyes tended to have a greater rate than bilateral cataract eyes (-7.7 vs -5.7; P = 0.05, R2 = 0.05). CONCLUSIONS: Aphakic refraction tends to follow a logarithmic decline with age. The rate of myopic shift is determined partly by age at surgery and whether the cataract was unilateral or bilateral, although the effects are small. A wide variation in the rate of myopic shift exists. The following factors made little difference in the rate: cataract type, glaucoma, sex, side, and best corrected visual acuity.

Intranasal visualization for nasolacrimal duct intubation.

PURPOSE/METHODS: To improve intranasal visualization of nasolacrimal procedures we use a self-retaining nasal speculum with or without a sinuscope. RESULTS/CONCLUSIONS: Placement and retrieval of silicone stents can be accomplished with less trauma than with a blind sweep technique. Additionally, the valve of Hasner can be seen and the creation of false passages avoided.

Dissociated horizontal deviation.

Despite the emphasis placed on the vertical aspect of the deviation by its currently accepted clinical label, dissociated vertical deviation is well known to include movements in both the torsional and horizontal planes. When the horizontal component is very prominent, dissociated horizontal deviation is suggested as an appropriate label. We report the clinical characteristics and surgical treatment of six patients with a dissociated horizontal deviation that was marked enough to be the reason for seeking medical attention. All patients underwent lateral rectus recession unilaterally or bilaterally, alone or in combination with superior rectus recession. In addition, we report the use of the darkening wedge test to demonstrate the Bielschowsky phenomenon in the horizontal plane. This phenomenon, a dissociated exotropia spontaneously moving toward and crossing the midline to become an esotropia under cover when a progressively darkening filter is placed over the fixing eye, has not to our knowledge been previously reported.

Rhabdomyosarcoma of the ciliary body.

Rhabdomyosarcoma is the most common malignant orbital tumor of childhood. It has twice been reported to arise within the globe from the iris. In addition, teratoid medulloepithelioma, a tumor arising from the ciliary epithelium, can contain a rhabdomyoblastic component, often in combination with other heteroplastic elements. The authors report what may be the first recorded case of an embryonal rhabdomyosarcoma of the ciliary body, possibly representing a one-sided differentiation of a malignant teratoid medulloepithelioma.