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Pediatric intraocular lenses: Author’s reply
Ophthalmology
Volume 10.5, Number
JAMES B. RUBEN, MD
Sacramento, California References Crouch ER, PressmanSH, Crouch ER. Posteriorchamber intraocular lenses:long-term resultsin pediatric cataract patients.J PediatrOphthalmolStrabismus1995;32:210-8. Awner S, Buckley EG, DeVaro JM, SeaberJH. Unilateral pseudophakiain childrenunder4 years.J PediatrOphthalmol Strabismus1996;33:228-36. Taylor D. Editorial: monocularinfantile cataract,intraocular lenses,and amblyopia.Br J Ophthalmol1989;73:8578. Authors’ reply Dr. Ruben is correct that we did not mention the potential role of keratorefractive surgery to treat future myopic refractive errors in pseudophakic children. We think he is also correct that this evolving technology may hold promise for pseudophakic patients who have significant myopic refractive errors. We also agree that effective treatment of amblyopia in these young children is one of our prime goals when undertaking cataract surgery in young children with or without intraocular lenses(IOLs). We do not necessarily agree that the potential availability of modern keratorefractive procedures changesour postoperative refractive goals for pseudophakic children. The premise of Dr. Ruben’s argument is that amblyopia will be more easily or more successfully treated if these children are made emmetropic as opposedto hyperopic in the immediate postoperative period. This sounds plausible, but in reality may not be true. These children, even if made emmetropic for distance, will not be emmetropic for near and will need to wear a bifocal for optimal amblyopia treatment. Secondly, even if the child is emmetropic immediately postoperatively, the refractive error will invariably change in the myopic direction, and glassesfor anisometropia will be necessary. Further, a changing refraction can be anticipated over a period of months or years. Anisometropic amblyopia is probably the most easily and successfully treated type of amblyopia in a pediatric ophthalmology practice. Anisometropic hyperopia, whether phakic or pseudophakic, results in amblyopia only if untreated. In straight-eyed children, glassesalone are usually sufficient. Supplemental patching is sometimes indicated. If the child is strabismic, patching (or penalization) is invariably indicated. Since all pseudophakit children in the amblyopia age group need to wear glasses,putting a small hyperopic correction in the carrier that can be readily changed as the child’s refractive error changes is not an insurmountable or even difficult problem. Successful treatment of pseudophakic amblyopia requires at a minimum a competent physician, involved parents or guardians, some cooperation on the part of the child, and glasses.These requirements do not change whether the child’s immediate postoperative refraction is hyperopic, emmetropic, or myopic. We must also remember that the amblyopia treatment years make up only a
392
3, March
1998
very small percentage of the average person’s life. By giving these children an appropriate hyperopic cushion to outgrow in the first decade of life, they will hopefully have a long adult life, with only a minimal refractive error in the pseudophakic eye without the need for further surgery. As the age limit that ophthalmologists are generally comfortable implanting IOLs is gradually lowered toward the infant age group, the idea of making these very young children emmetropic postoperatively is even less desirable. Several anecdotal reports of IOL implantation in infancy have resulted in refractive errors in the -10 to -20 diopter range by the time the children were 10 years of age. By the time their refractive error has stabilized to a point where keratorefractive surgery may be contemplated, the anisometropic amblyopia years will have passed,the refractive error may be too great and the patient may not desire or be able to afford the keratorefractive surgery. Modern keratorefractive surgery is becoming more effective and, as Dr. Ruben points out, may be a good treatment option for significantly myopic pseudophakic patients. For us, these patients will become candidates for this surgery becausethey have an unanticipated large myopic refractive error, not because we engineered planned obsolescenceinto their initial postoperative refraction. DAVID A. PLAGER, MD FORREST D. ELLIS, MD DEREK T. SPRUNGER, MD NAVAL SONDHI, MD STEPHEN LIPSKY, MD STEVEN SNYDER, MD Indianapolis, Indiana
Minocycline
Dosage Error
Dear Editor: In a Letter to the Editor (Ophthalmology 1997; 104:12078), Wirostko cites a dosage of 200 mg q.i.d. of minocycline for adjunctive treatment of many signs and symptoms of rheumatoid arthritis. The article cited (Tilley, et al) used a dosage of 100 mg b.i.d. The amount written by Wirostko may be toxic. (As an aside, I placed a patient with intractable moderate dull pain from rheumatoid arthritis associatedscleritisepscleritis in both eyes on 200 mg q.i.d. while I waited obtaining the original article. Three days later I called him to go to the appropriate reduced dosage. He stated his eyes felt much better, though he had mild dizziness, while on the higher dosage. BARRY M. SCHER, MD Chula Vista, California Publisher’s Note: In the original Letter to the Editor, submitted by Dr. Wirostko, the correct dosage of 200 mg qd was supplied. The incorrect dosage was the result of a typographical error, The Publisher regrets the error and any inconvenience it has caused.
Volume 10.5, Number
JAMES B. RUBEN, MD
Sacramento, California References Crouch ER, PressmanSH, Crouch ER. Posteriorchamber intraocular lenses:long-term resultsin pediatric cataract patients.J PediatrOphthalmolStrabismus1995;32:210-8. Awner S, Buckley EG, DeVaro JM, SeaberJH. Unilateral pseudophakiain childrenunder4 years.J PediatrOphthalmol Strabismus1996;33:228-36. Taylor D. Editorial: monocularinfantile cataract,intraocular lenses,and amblyopia.Br J Ophthalmol1989;73:8578. Authors’ reply Dr. Ruben is correct that we did not mention the potential role of keratorefractive surgery to treat future myopic refractive errors in pseudophakic children. We think he is also correct that this evolving technology may hold promise for pseudophakic patients who have significant myopic refractive errors. We also agree that effective treatment of amblyopia in these young children is one of our prime goals when undertaking cataract surgery in young children with or without intraocular lenses(IOLs). We do not necessarily agree that the potential availability of modern keratorefractive procedures changesour postoperative refractive goals for pseudophakic children. The premise of Dr. Ruben’s argument is that amblyopia will be more easily or more successfully treated if these children are made emmetropic as opposedto hyperopic in the immediate postoperative period. This sounds plausible, but in reality may not be true. These children, even if made emmetropic for distance, will not be emmetropic for near and will need to wear a bifocal for optimal amblyopia treatment. Secondly, even if the child is emmetropic immediately postoperatively, the refractive error will invariably change in the myopic direction, and glassesfor anisometropia will be necessary. Further, a changing refraction can be anticipated over a period of months or years. Anisometropic amblyopia is probably the most easily and successfully treated type of amblyopia in a pediatric ophthalmology practice. Anisometropic hyperopia, whether phakic or pseudophakic, results in amblyopia only if untreated. In straight-eyed children, glassesalone are usually sufficient. Supplemental patching is sometimes indicated. If the child is strabismic, patching (or penalization) is invariably indicated. Since all pseudophakit children in the amblyopia age group need to wear glasses,putting a small hyperopic correction in the carrier that can be readily changed as the child’s refractive error changes is not an insurmountable or even difficult problem. Successful treatment of pseudophakic amblyopia requires at a minimum a competent physician, involved parents or guardians, some cooperation on the part of the child, and glasses.These requirements do not change whether the child’s immediate postoperative refraction is hyperopic, emmetropic, or myopic. We must also remember that the amblyopia treatment years make up only a
392
3, March
1998
very small percentage of the average person’s life. By giving these children an appropriate hyperopic cushion to outgrow in the first decade of life, they will hopefully have a long adult life, with only a minimal refractive error in the pseudophakic eye without the need for further surgery. As the age limit that ophthalmologists are generally comfortable implanting IOLs is gradually lowered toward the infant age group, the idea of making these very young children emmetropic postoperatively is even less desirable. Several anecdotal reports of IOL implantation in infancy have resulted in refractive errors in the -10 to -20 diopter range by the time the children were 10 years of age. By the time their refractive error has stabilized to a point where keratorefractive surgery may be contemplated, the anisometropic amblyopia years will have passed,the refractive error may be too great and the patient may not desire or be able to afford the keratorefractive surgery. Modern keratorefractive surgery is becoming more effective and, as Dr. Ruben points out, may be a good treatment option for significantly myopic pseudophakic patients. For us, these patients will become candidates for this surgery becausethey have an unanticipated large myopic refractive error, not because we engineered planned obsolescenceinto their initial postoperative refraction. DAVID A. PLAGER, MD FORREST D. ELLIS, MD DEREK T. SPRUNGER, MD NAVAL SONDHI, MD STEPHEN LIPSKY, MD STEVEN SNYDER, MD Indianapolis, Indiana
Minocycline
Dosage Error
Dear Editor: In a Letter to the Editor (Ophthalmology 1997; 104:12078), Wirostko cites a dosage of 200 mg q.i.d. of minocycline for adjunctive treatment of many signs and symptoms of rheumatoid arthritis. The article cited (Tilley, et al) used a dosage of 100 mg b.i.d. The amount written by Wirostko may be toxic. (As an aside, I placed a patient with intractable moderate dull pain from rheumatoid arthritis associatedscleritisepscleritis in both eyes on 200 mg q.i.d. while I waited obtaining the original article. Three days later I called him to go to the appropriate reduced dosage. He stated his eyes felt much better, though he had mild dizziness, while on the higher dosage. BARRY M. SCHER, MD Chula Vista, California Publisher’s Note: In the original Letter to the Editor, submitted by Dr. Wirostko, the correct dosage of 200 mg qd was supplied. The incorrect dosage was the result of a typographical error, The Publisher regrets the error and any inconvenience it has caused.