Use of A-scan Ultrasound and Optical Coherence Tomography to Differentiate Papilledema From Pseudopapilledema.

SIGNIFICANCE: Differentiating papilledema from pseudopapilledema reflecting tilted/crowded optic discs or disc drusen is critical but can be challenging. Our study suggests that spectral-domain optical coherence tomography (OCT) peripapillary retinal nerve fiber layer thickness and retrobulbar optic nerve sheath diameter (ONSD) measured by A-scan ultrasound provide useful information when differentiating the two conditions. PURPOSE: To evaluate the use of A-scan ultrasound and spectral-domain OCT retinal nerve fiber layer thickness (RNFLT) in differentiating papilledema associated with idiopathic intracranial hypertension from pseudopapilledema. METHODS: Retrospective cross-sectional analysis included 23 papilledema and 28 pseudopapilledema patients. Ultrasound-measured ONSD at primary gaze, percent change in ONSD at lateral gaze (30° test), and peripapillary RNFLT were analyzed. Receiver operating characteristic curves were constructed using one eye from each subject. RESULTS: Compared with pseudopapilledema, papilledema eyes showed larger mean ONSD (5.4 ± 0.6 vs. 4.0 ± 0.3 mm, P < .0001), greater change of ONSD at lateral gaze (22.4 ± 8.4% vs. 2.8 ± 4.8%, P < .0001), and thicker retinal nerve fiber layer (219.1 ± 104.6 vs. 102.4 ± 20.1 µm, P < .0001). Optic nerve sheath diameter and 30° test had the greatest area under the receiver operating characteristic curve, 0.98 and 0.97, respectively; followed by inferior quadrant (0.90) and average RNFLT (0.87). All papilledema eyes with Frisén scale greater than grade II were accurately diagnosed by ONSD, 30° test, or OCT. In mild papilledema (Frisén scale grades I and II, n = 15), area under the receiver operating characteristic curve remained high for ONSD (0.95) and 30° test (0.93) but decreased to 0.61 to 0.71 for RNFLT. At 95% specificity, sensitivities for ONSD, 30° test, and RNFLT were 91.3%, 91.3%, and 56.5%, respectively, for the entire papilledema group and 80.0%, 86.7%, and 13.3% for the mild papilledema subgroup. CONCLUSIONS: Retinal nerve fiber layer thickness can potentially be used to detect moderate to severe papilledema. A-scan may further assist differentiation of mild papilledema from pseudopapilledema.

Diagnostic Ophthalmic Ultrasound for Radiologists.

Ophthalmic ultrasound is an invaluable tool that provides quick and noninvasive evaluation of the eye and the orbit. It not only allows the clinicians to view structures that may not be visible with routine ophthalmic equipment or neuroimaging techniques but also provides unique diagnostic information in various ophthalmic conditions. In this article, the basic principles of ophthalmic ultrasound and examination techniques are discussed. Its clinical application is illustrated through a variety of ocular pathologic abnormalities (eg, narrow angles, ciliary body tumor, detached retina, choroidal melanoma, and papilledema).

Age and positional effect on the anterior chamber angle: assessment by ultrasound biomicroscopy.

Purpose. To investigate age- and position-related changes of anterior chamber angle anatomy in normal, healthy eyes. Patients and Methods. Thirty subjects were separated into a younger and older cohort. The superior and inferior anterior chamber angles of the eyes were measured in supine and sitting positions by ultrasound biomicroscopy (UBM) with bag/balloon technology. Statistical analysis was used to evaluate positional and age-related changes in angle morphology. Results. In the younger cohort, no location or positional differences in angle anatomy were observed. In the older cohort, the inferior quadrant was significantly narrower than the superior quadrant (P = 0.0186) in the supine position. This cohort also demonstrated an interaction effect between position and location. In the older cohort, the angle was deeper inferiorly while the subject was sitting but was deeper superiorly while the subject was supine. Conclusion. Comparison of positional variations in anterior chamber angle anatomy as measured by UBM has recently become possible. This study found that age-related positional changes in the anterior chamber angle anatomy exist in normal healthy eyes.

A comparison of two-way text versus conventional paging systems in an academic ophthalmology department.

Alphanumeric paging systems are unidirectional without prioritization capabilities. Newer electronic communication devices such as two-way text paging systems are capable of bidirectional paging and prioritization. While previous studies have evaluated alphanumeric paging systems in academic hospital settings, bidirectional two-way text paging systems have not been investigated. The goal of this study was to evaluate efficiency and impact on patient care delivery of a two-way text paging system compared to conventional one-way alphanumeric pagers. This unmasked, crossover prospective study was divided into three phases. In phase one, surveys were distributed to all ophthalmology attending physicians, residents, clinical technicians, and secretaries to assess the conventional alphanumeric paging system. In phase two, these participants used two-way text pagers without instruction (unstructured format) that they subsequently compared to the alphanumeric system with devised surveys assessing (on a scale of 0 to 100) time saved, increased daily efficiency, facilitation in patient care, and overall impression (helpfulness).In phase three, participants used a specific communication prioritization protocol (structured format) with the two-way text pagers with subsequent comparison and assessment with the same surveys. Compared to traditional alphanumeric pagers, new digital two-way text pagers were found to be statistically (p < 0.0001) more helpful by participants in all categories: as a time saver (80.33 vs. 56.95) p < 0.0001, increased daily efficiency (78.15 vs. 57.13) p < 0.0001, facilitation in patient care (78.79 vs. 56.95) p < 0.0001, and overall impression (helpfulness) (61.82 vs. 84.33) p < 0.0001. When compared to the alphanumeric pager, the two-way text pager was found to decrease subjectively call backs (73.6% to 45.6%, p < 0.0001), reduce interruptions of learning activities (43.63% to 26.6%, p < 0.0001) and enabled better patient care (59.8% to 42.2%, p < 0.0001). No significant statistical difference was found between the structured and unstructured system. Two-way text paging (structured versus unstructured guidance) was preferred over the conventional one-way alphanumeric paging system in every participant category. Two-way text paging is an effective alternative to alphanumeric paging, demonstrating saved time, increased daily efficiency, reduced call backs and interruptions of educational activities, and facilitation in patient care.

Effects of early maternal docosahexaenoic acid intake on neuropsychological status and visual acuity at five years of age of breast-fed term infants.

OBJECTIVE: We previously reported better psychomotor development at 30 months of age in infants whose mothers received a docosahexaenoic acid (DHA) (22:6n-3) supplement for the first 4 months of lactation. We now assess neuropsychological and visual function of the same children at 5 years of age. STUDY DESIGN: Breastfeeding women were assigned to receive identical capsules containing either a high-DHA algal oil (∼200 mg/d of DHA) or a vegetable oil (containing no DHA) from delivery until 4 months postpartum. Primary outcome variables at 5 years of age were measures of gross and fine motor function, perceptual/visual-motor function, attention, executive function, verbal skills, and visual function of the recipient children at 5 years of age. RESULTS: There were no differences in visual function as assessed by the Bailey-Lovie acuity chart, transient visual evoked potential or sweep visual evoked potential testing between children whose mothers received DHA versus placebo. Children whose mothers received DHA versus placebo performed significantly better on the Sustained Attention Subscale of the Leiter International Performance Scale (46.5 ± 8.9 vs 41.9 ± 9.3, P < .008) but there were no statistically significant differences between groups on other neuropsychological domains. CONCLUSIONS: Five-year-old children whose mothers received modest DHA supplementation versus placebo for the first 4 months of breastfeeding performed better on a test of sustained attention. This, along with the previously reported better performance of the children of DHA-supplemented mothers on a test of psychomotor development at 30 months of age, suggests that DHA intake during early infancy confers long-term benefits on specific aspects of neurodevelopment.

New technology for examining the anterior segment by ultrasonic biomicroscopy.

PURPOSE: To compare the comfort levels and measurement accuracy of the open-shell technique and a bag/balloon technology (ClearScan, ESI) in anterior segment ultrasound biomicroscopy. SETTING: Department of Ophthalmology and Visual Science, Robert Cizik Eye Clinic, University of Texas Medical School at Houston, Houston, Texas, USA. METHODS: In this prospective investigation, 20 subjects stated their preference and rated comfort (0 best to 5 worst) for the open-shell technique versus the bag/balloon technology. Three anterior chamber depth and sulcus-to-sulcus measurements were obtained, and the mean for each structure was taken as datum for each subject. Order presentation between the 2 methods was randomized. Pairwise t tests and linear regression analysis were used to determine statistical differences. RESULTS: One hundred percent of the cohort preferred the bag/balloon technology to the traditional open-shell technique. The mean comfort score was 0.40 +/- 0.53 (SD) and 2.95 +/- 0.90, respectively (P<.0001). Anterior chamber depth measurements did not differ clinically (0.056 mm) nor did sulcus-to-sulcus determinations (0.039 mm). CONCLUSION: Biometry, patient comfort, and ease of use were better with the ClearScan bag/balloon technology than with the traditional open-shell technique.

Empirical advanced orthokeratology through corneal topography: the University of Houston clinical study.

PURPOSE: Traditionally, orthokeratology has used diagnostic lenses to determine the best fit. The purpose of this study was to determine the efficacy of fitting empirically from corneal topography, without the use of diagnostic lenses. METHODS: Twenty-nine subjects, 18 to 37 years old, with myopia of 1.00 to 4.00 diopters (D) and astigmatism of no more than 1.50 D, were entered into this 6-month study. Corneal topography, scanning slit topography and corneal thickness (Orbscan), confocal microscopy, ultrasound corneal thickness, aberrometry, and biomicroscopy were used to assess corneal changes. Unaided logMAR high-contrast visual acuity, subjective refraction, and questionnaires were used to monitor vision and symptoms. Follow-up visits were scheduled after 1 day, 1 week, 2 weeks, 1 month, 3 months, and 6 months. RESULTS: For 6-month data, unaided logMAR acuity improved from 0.78 +/- 0.26 in the right eye and 0.75 +/- 0.22 in the left eye to 0.06 +/- 0.18 in the right eye and 0.04 +/- 0.16 in the left eye. Myopia decreased from -2.55 +/- 0.87 D in the right eye and -2.47 +/- 0.89 D in the left eye to +0.45 +/- 0.74 D in the right eye and -0.17 +/- 0.69 D in the left eye. Shape factor, using corneal topography, increased from 0.85 +/- 0.13 in the right eye and 0.85 +/- 0.15 in the left eye to 1.28 +/- 0.32 in the right eye and 1.30 +/- 0.29 in the left eye. Both eyes showed a decrease in lower-order aberrations (i.e., defocus) and an increase in higher-order aberrations (i.e., spherical aberrations and coma). CONCLUSIONS: Myopia reduction after 1 week was clinically insignificant from the 1-month results, indicating that the full effect is achieved by 1 week. Neither total nor epithelial corneal thickness varied significantly from baseline measurements.

Comparison of the ocular hypotensive efficacy of adjunctive brimonidine 0.15% or brinzolamide 1% in combination with travoprost 0.004%.

PURPOSE: To compare efficacies of adjunctive therapy with brimonidine 0.15% and adjunctive therapy with brinzolamide 1% in combination with travoprost 0.004%. DESIGN: Three-month randomized, parallel-group, double-masked, multicenter clinical trial. PARTICIPANTS: Patients with primary open-angle glaucoma, exfoliation glaucoma, or ocular hypertension with intraocular pressure (IOP) > 18 mmHg on monotherapy with travoprost (N = 163). METHODS: Patients were randomized to receive adjunctive therapy with twice-daily brimonidine (N = 79) or twice-daily brinzolamide (N = 84). Treatment efficacy was assessed after 1 and 3 months of combination therapy. Intraocular pressure was measured at 8 am, noon, and 4 pm at baseline (on travoprost monotherapy) and after 3 months of combination therapy. Mean diurnal IOP was defined as the average of the IOP measurements at these 3 time points. Adverse events were recorded at each visit. MAIN OUTCOME MEASURE: Difference between treatment groups in mean diurnal IOP at month 3, adjusted for difference in baseline IOP, using analysis of covariance. RESULTS: Mean diurnal IOPs (+/- standard error of the mean) at baseline were 21.7+/-0.33 mmHg in the brimonidine group and 21.1+/-0.29 mmHg in the brinzolamide group (P = 0.16). Mean diurnal IOPs at month 3 were 19.6+/-0.41 mmHg in the brimonidine group and 18.4+/-0.33 mm Hg in the brinzolamide group (P = 0.019). At month 3, mean diurnal IOPs, adjusted for difference in baseline IOP, were 19.3+/-0.27 in the brimonidine group and 18.6+/-0.25 in the brinzolamide group (P = 0.035). CONCLUSIONS: The combination of travoprost and brinzolamide was statistically significantly more efficacious than the combination of travoprost and brimonidine in lowering IOP. The clinical significance of this difference is uncertain.

Lodged intracanalicular plugs as a cause of lacrimal obstruction.

PURPOSE: To evaluate the complications and success of treatment of migrated or lodged intracanalicular and punctal plugs. METHODS: A retrospective chart review of all cases having either a dacryocystorhinostomy or surgical removal of an intracanalicular or punctal plug from 1992 to 2006, in a single physician referral oculoplastics practice, was performed to identify cases in which a retained lacrimal plug required surgical intervention. Patients presented with symptoms of tearing, infection, or granuloma formation. The charts of 998 surgical cases were reviewed, from which 66 eyes (6.6%) were determined to have had lodged lacrimal plugs that required surgical removal, thus qualifying them for inclusion in this study. Patients were followed after surgery until reconstructive silicone tubing was removed (range, 6 weeks to 6 months), and each patient was questioned regarding symptoms. A comparison group of 336 eyes that had collared punctal plugs placed served as the control group. RESULTS: All cases were noted to have complications from intracanalicular plugs. No complications were noted from other forms of lacrimal plugs. All eyes in this series required a canaliculotomy or a dacryocystorhinostomy after office irrigation failed to dislodge the plug. Five eyes presented with canaliculitis, 28 eyes presented with epiphora, and 29 eyes presented with dacryocystitis. Four of 66 eyes (6%) in this cohort presented with a pyogenic granuloma. Five eyes (8%) presented with canaliculitis. Forty-nine of 66 eyes (74%) were asymptomatic following treatment, with no observable infection or epiphora. Seven of 66 eyes (11%) had some improvement in symptoms and another 10 of 66 eyes (15%) had no change in symptoms after treatment. No complications requiring surgical intervention were encountered in the control group of collared punctal plugs. CONCLUSIONS: Intracanalicular-type plugs may lodge in the lacrimal outflow system. This may result in epiphora, canaliculitis, or dacryocystitis that may require major reconstructive surgery. Despite surgical intervention, these symptoms do not always resolve (26% of eyes in this study had persistent epiphora). Intracanalicular plugs were observed to be associated with a higher rate of granulation tissue formation in the lacrimal outflow tract when compared with other forms of punctal plugs. As a result of the increased number of complications seen with intracanalicular plugs, caution is advised with respect to use of these devices. The relative infrequency of complications seen with collared punctal plugs suggests a safer alternative. Data from this study lead the authors to advocate the consideration of other forms of lacrimal occlusion due to the high number of complications noted with intracanalicular plugs, and the availability of other reversible forms of punctal occlusion.

Ultrasound biomicroscopy for estimation of tumor thickness for conjunctival melanoma.

We assessed the feasibility of using high-frequency ultrasound biomicroscopy (UBM) in estimating thickness of conjunctival melanomas preoperatively. Three patients underwent UBM prior to excision of conjunctival melanoma between February 2003 and March 2006. Conjunctival tumor thickness was estimated via UBM in each case and compared with the estimated histopathologic tumor thickness (Breslow thickness). Patient 1 had an estimated thickness of 1.99 mm via UBM versus a Breslow thickness measurement of 1.5 mm based on the surgical specimen. Patient 2 had a UBM thickness measurement of 2.4 mm and a Breslow thickness of 2.23 mm based on the surgical specimen. In patient 3, both UBM thickness and Breslow thickness were 2.3 mm. The use of high-frequency UBM is feasible for the estimation of tumor thickness for conjunctival melanomas. UBM may serve as an additional diagnostic tool for estimating tumor thickness before surgical resection of conjunctival melanoma.

Classifying the severity of corneal ulcers by using the "1, 2, 3" rule.

PURPOSE: To propose and define the "1, 2, 3" rule as a system of categorizing the severity of bacterial keratitis and to determine its value in predicting the likelihood of visual loss after healing of bacterial corneal infection. METHODS: Seventy patients were evaluated for infectious corneal ulcers by 2 cornea subspecialists (J.D.L., M.C.V.) at a tertiary facility between October 30, 2001, and November 1, 2004. Forty-one patients met the inclusion criteria. Visual acuities, ulcer characteristics, culture results, and treatment data were collected. RESULTS: The sensitivity of the "1, 2, 3" rule for detecting potentially sight-threatening (PST) ulcers that would result in 0.20 logMAR (2 Snellen lines) or greater loss in best spectacle-corrected visual acuity (BSCVA) was 100%. The specificity of the "1, 2, 3" rule in correctly labeling an ulcer that did not cause vision loss as rarely sight threatening (RST) was 57.14%. The positive predictive value of the "1, 2, 3" rule was 28.57%. The negative predictive value of the "1, 2, 3" rule was 100%. CONCLUSIONS: Corneal ulcers classified as PST are at significantly higher risk for sustaining loss of BCSVA compared with RST corneal ulcers. The "1, 2, 3" rule is sensitive and specific enough to be clinically useful in predicting which ulcers are more likely to have vision loss and which ulcers are not.

Enhancing intraocular lens outcome precision: an evaluation of axial length determinations, keratometry, and IOL formulas.

Accurate biometry and intraocular lens (IOL) calculations have consequence in patient satisfaction and depend on correct determination of eye length, IOL position, refractive power of the cornea, and selection of the proper IOL formula. Familiarity with these variables will make it easier to achieve precise results in both the intact eyes and eyes that have had previous surgeries, including keratorefractive procedures. This articles provide practical tips and methods to avoid refractive surprises.

Effects of maternal docosahexaenoic acid intake on visual function and neurodevelopment in breastfed term infants.

BACKGROUND: Normal brain and visual development is thought to require exogenous docosahexaenoic acid (DHA; 22:6n-3) intake, but the amount needed is debatable. Because the supplementation of breastfeeding mothers with DHA increases the DHA content of their infants' plasma lipids, we hypothesized that it might also improve brain or visual function in the infants. OBJECTIVE: The objective was to determine the effect of DHA supplementation of breastfeeding mothers on neurodevelopmental status and visual function in the recipient infant. DESIGN: Breastfeeding women received capsules containing either a high-DHA algal oil ( approximately 200 mg DHA/d) or a vegetable oil (no DHA) for 4 mo after delivery. Outcome variables included the fatty acid pattern of maternal plasma phospholipid and milk lipids 4 mo postpartum, the fatty acid pattern of plasma phospholipids and visual function in infants at 4 and 8 mo of age, and neurodevelopmental indexes of the infants at 12 and 30 mo of age. RESULTS: Milk lipid and infant plasma phospholipid DHA contents of the supplemented and control groups were approximately 75% and approximately 35% higher, respectively, at 4 mo postpartum. However, neither the neurodevelopmental indexes of the infants at 12 mo of age nor the visual function at 4 or 8 mo of age differed significantly between groups. In contrast, the Bayley Psychomotor Development Index, but not the Mental Development Index, of the supplemented group was higher (P < 0.01) at 30 mo of age. CONCLUSION: DHA supplementation of breastfeeding mothers results in higher infant plasma phospholipid DHA contents during supplementation and a higher Bayley Psychomotor Development Index at 30 mo of age but results in no other advantages either at or before this age.

The diagnosis and characteristics of moderate dry eye in non-contact lens wearers.

PURPOSE: To identify and characterize moderate dry eye in non-contact lens wearers with a new scoring system-based dry eye questionnaire and to determine which objective tests better differentiate patients with moderate dry eye from healthy patients. METHODS: Fifty-two healthy subjects (21 women and 31 men with a mean age of 27.8 +/- 9.2 years) and 37 subjects with moderate dry eye (33 women and 4 men with a mean age of 36.4 +/- 12.9 years) completed a 42-item dry eye questionnaire. Seventeen healthy subjects (11 women and 6 men with a mean age of 30.5 +/- 9.7 years) and 28 subjects with moderate dry eye (24 women and 4 men with a mean age of 38.50 +/- 3.8 years) underwent additional objective assessment of ocular surface health, tear osmolality, tear stability, and tear volume. RESULTS: Subjects with moderate dry eye scored significantly higher (49.8 +/- 20.3, P<0.0001) on the dry eye questionnaire than did normal subjects (11.7 +/- 10.3). Ocular irritation symptoms worsened with progression of time of day in both groups of subjects. Internal reliability (0.95 Cronbach alpha) was excellent, and concurrent validity (Spearman rho 0.507) was acceptable when compared to the McMonnies and Ho dry eye questionnaire. Significant differences in tear osmolality (P<0.00001), invasive tear breakup time (P<0.034), and corneal vital dye staining (P<0.0001) were detected between the two groups of subjects. A stepwise linear regression on objective clinical tests, however, did not account for 77% of the total variance in the questionnaire scores. CONCLUSIONS: A unique scoring system-based dry eye questionnaire was validated to separate non-contact lens wearers with moderate dry eye from healthy subjects. Objective tests of tear osmolality and stability and ocular surface integrity were better than other clinical measures at identifying differences between the two subject groups. The results strongly support the evidence that the diagnosis and treatment of moderate dry eye requires a detailed assessment of self-perceived symptoms and that objective clinical testing alone may be insufficient.

Microbial contamination of immersion biometry ultrasound equipment.

PURPOSE: To investigate the prevalence of microorganisms on ultrasound biometry equipment and cleaning habits. DESIGN: Observational case series. PARTICIPANTS: Thirty-four university-based and private ophthalmology clinics. METHODS: In a prospective multicenter study, clinics representative of every region of the country sampled their fixed immersion biometry equipment (i.e., ultrasound probe, immersion shell, and infusion tubing) for bacteria and fungi. Assessment of the cleaning habits for this equipment was conducted by way of a standard questionnaire that included type of fluid and delivery method, frequency of fluid change, method of cleaning the probe and shell, and frequency of tubing change and/or cleaning. MAIN OUTCOME MEASURES: Frequency (prevalence), descriptive statistics, and type of microorganisms. RESULTS: Eighteen samples (53% [18/34]) grew organisms from either the probe/shell or tubing. Positive cultures were found in 32% (11/34) of the immersion shell/probes and in 31% (10/32) of the infusion tubing samples. The bacteria most commonly cultured from both probe/shell and tubing was coagulase-negative Staphylococcus, whereas Penicillium species was the most commonly cultured fungus (exclusively from the probe/shell). Overall, fungi (Penicillium and Alternaria species) were cultured in 12% of the probe/shell samples. Only 14% of the study sites adequately disinfected the probe/shell according to Centers for Disease Control and Prevention (CDC) guidelines, which recommend a 5-minute soak in antiseptic. CONCLUSIONS: The bacteria and fungi that colonize biometry equipment are not being adequately eliminated by the cleaning/disinfecting techniques employed in most ophthalmology clinics. These results also may apply to contact biometry, pachymetry, and tonometry equipment as well. Clinicians should follow the CDC recommendations for disinfecting instruments that come in contact with the eye, and the infusion tubing should be changed after each patient.

Laser in situ keratomileusis for treated anisometropic amblyopia in awake, autofixating pediatric and adolescent patients.

PURPOSE: To establish the safety and efficacy of laser in situ keratomileusis (LASIK) in pediatric and adolescent patients with anisometropic amblyopia who completed amblyopia therapy and had a visual acuity of 20/30 or better bilaterally. SETTING: Department of Ophthalmology and Visual Science, University of Texas-Houston Medical School, Houston, Texas, USA. METHODS: From August 2000 to March 2002, LASIK was performed in 21 eyes of 19 consecutive patients meeting eligibility requirements. The procedure was performed with the Summit Autonomous LADARVision 4000 excimer laser (Alcon Laboratories, Inc.) in the amblyopic eye for the correction of anisometropia or in both eyes. All patients were awake and autofixating during the procedure. RESULTS: The mean patient age was 13.14 years (range 8 to 19 years). Seventeen patients were treated in the amblyopic eye only to correct anisometropia; treatment was performed in both eyes of 2 patients who were older than 18 years. Patients were followed for a mean of 18.0 months (range 8.6 to 26.5 months). Anisometropia was greater than 2.00 diopters (D) in all cases (mean 4.43 D, range 13.25 to 2.25 D). The percentage deviation from the attempted correction in the myopic group was 4.0% +/- 4.0% (SD) (range 2.0% to 10.0%) and 38.0% +/- 13.0% (range 5.0% to 58.0%) in the hyperopic group. Anisometropia decreased uniformly to less than 2.00 D in all patients (mean 1.52 D). The percentage of patients with stereo acuity increased from 63.0% preoperatively to 84.0% postoperatively. CONCLUSIONS: Laser in situ keratomileusis safely and effectively reduced anisometropia in these patients. If stereo acuity is not possible preoperatively, it may be obtained postoperatively.

Laser in situ keratomileusis for high hyperopia in awake, autofixating pediatric and adolescent patients with fully or partially accommodative esotropia.

PURPOSE: To establish the safety and efficacy of laser in situ keratomileusis (LASIK) in pediatric and adolescent patients with bilateral visual acuity of 20/30 or better and accommodative or partially accommodative esotropia. SETTING: Department of Ophthalmology and Visual Science, University of Texas-Houston Medical School, Houston, Texas, USA. METHODS: The study comprised 30 eyes of 15 consecutive patients with accommodative or partially accommodative esotropia who met eligibility requirements and had bilateral LASIK using the Alcon Summit Autonomous LADARVision excimer laser to correct a refractive error after January 2001. All patients were awake and autofixating during the procedure. RESULTS: The mean age of the patients was 13.9 years (range 9.1 to 18.8 years) and the mean refractive error, +5.35 diopters (D) (range +3.75 to +8.50 D) with anisometropia of 2.0 D or less. The mean follow-up was 15.7 months (range 9.5 to 22.5 months). No intraoperative complications were encountered. The percentage of undercorrection [100% -[(treatment achieved/treatment attempted) x 100%]] [mean 34% +/- 17% (SD), coefficient of variation (SD/mean) 0.50, range 5% to 58%] was higher than expected. Seven patients (47%) required enhancement due to undercorrection of hyperopia with diplopia (6 patients) or astigmatism with decreased visual acuity (1 patient). In this small series, no patient lost best corrected visual acuity or stereo acuity. CONCLUSION: Laser in situ keratomileusis can safely and effectively reduce refractive error in this group of patients; however, patient selection is extremely critical and enhancement was required in almost half the patients.