Patients with a variety of corneal diseases may develop stromal scars that interfere with vision. Vascularization of these scars may lead to inflammation, extravasation of lipid, and progressive opacification. Laser treatment of the neovascular vessels may induce regression of these vessels, with resultant increased corneal clarity and improved vision. We describe the treatment and outcome of 3 pediatric patients with vascularized corneal stromal scars treated with yellow dye laser. Using a PubMed search, we were unable to find any previous reports of this treatment in pediatric patients.
Informed consent was obtained from the patients and parents before performing the treatment. The affected eye was pretreated with pilocarpine hydrochloride, 2%. The laser was used with the patients awake using topical proparacaine hydrochloride. An iridotomy contact lens using high (×25) slitlamp magnification was used. A laser (Lumenis, Santa Clara, California) was used with a wavelength of 568 nm. The spot size was 50 μm. The power ranged from 200 to 300 mW, with a duration of 0.1 second. The laser was begun at the distal (corneal) end of the vessels and continued backward toward the limbus. The power was increased until occlusion of the vessels was visualized. The number of spots per session ranged from 30 to 501. Postoperatively, patients were treated with topical prednisolone acetate, 1%, drops 4 times a day and cyclopentolate hydrochloride, 1%, drops twice a day for 3 days.
A 6-year-old boy was referred 1 month after corneal laceration repair and lensectomy following a penetrating pencil injury. Visual acuity with aphakic correction was 20/125 OS. The patient had a vascularized inferior corneal scar with traumatic corectopia (Figure 1). The patient underwent secondary intraocular lens implantation. One month postoperatively, the visual acuity was 20/80, with − 0.25 + 2.25 × 140°, and the corneal vascularization and scarring had progressed. The patient underwent 3 treatments with a yellow dye laser. Fourteen months after treatment, his visual acuity was 20/40, with − 3.75 + 2.0 × 155° (Figure 2).
Patient 1 had vascularized inferior corneal scar.
Patient 1 had a decreased central vascularity and opacity 1 month following laser treatment.
A 16-year-old boy was struck in the left eye with a paintball, sustaining a corneoscleral laceration with iris prolapse that was surgically repaired. Postoperative ultrasonography revealed a retinal detachment, for which he underwent pars plana lensectomy and vitrectomy. His visual acuity 3 months following surgery was 20/200 with aphakic correction. He had a vascularized corneal scar. Three months following his third laser treatment, the central vascularization had resolved and his visual acuity was 20/20 with an aphakic contact lens.
A 15-year-old girl with hemifacial microsomia was observed since the age of 3 years. She had left-sided amblyopia, anisometropia, exotropia, ptosis with lagophthalmos, exposure keratopathy, and retinal and iris colobomas.Previous treatment included spectacles, patching, and penalization for amblyopia, strabismus surgery, and ocular lubrication. Her Snellen visual acuity maximized at 20/60 OS at the age of 6 years. She developed a dendritic corneal lesion at the age of 11 years, which was presumed to be herpetic. She was treated with acyclovir and topical corticosteroids. The active corneal lesion stabilized, but the patient continued to have a heavily vascularized corneal scar (Figure 3) and her visual acuity decreased to 20/200 because of the opacity and irregular astigmatism. She underwent 4 treatments with a yellow dye laser, with improvement in visual acuity to 20/70, with − 1.25 + 1.5 × 90°, and markedly decreased corneal vascularization (Figure 4).
Patient 3 had a heavily vascularized corneal scar.
Patient 3 had decreased vascularity and opacity 3 weeks following laser treatment.
Patients with corneal diseases may develop neovascularization of the cornea because of the growth of vessels across the limbus into the corneal stroma. This may result in opacification of the cornea, which may be exacerbated by leakage of lipid from the abnormal blood vessels.1Laser occlusion of the feeder vessels, initially with argon laser, has been used as a treatment for this condition.2,3The goals of treatment are to induce regression of neovascular vessels, resorb lipid, and improve visual function. Based on the absorption peak of hemoglobin in the yellow range, the yellow dye laser was demonstrated in animal studies to decrease neovascularization in animal models.4Baer and Foster5used the yellow dye laser to treat 23 patients with corneal neovascularization, with improvement in all patients except those with extensive neovascularization. Using a PubMed search, we were unable to find any previous reports of this treatment in pediatric patients.
The causes for the corneal neovascularization in our patients were traumatic corneal lacerations in patients 1 and 2 and a combination of chronic exposure keratopathy and presumed herpetic disease in patient 3. All patients demonstrated improvement in visual acuity. Possible complications of treatment include intrastromal hemorrhage, iris atrophy, and corneal thinning, none of which occurred in our patients. The laser is not adaptable for use under general anesthesia, so patients must be able to cooperate with applications at the slitlamp, including the use of a contact lens. The procedure is not painful but does require successive treatment sessions. Despite this, even our 6-year-old patient tolerated the treatment without difficulty.
The advantages of successful treatment of corneal neovascularization include improvement of visual acuity and appearance of the corneal scar. In addition, treatment may interrupt progressive opacification and lipid deposition and decrease the need for penetrating keratoplasty. In our 3 pediatric patients, the yellow dye laser safely and effectively decreased corneal neovascularization and improved visual function.
Correspondence:Dr Lueder, Departments of Ophthalmology and Visual Sciences and Pediatrics, St Louis Children's Hospital, Washington University School of Medicine, One Children's Place, Room 2s89, St Louis, MO 63110 (Lueder@vision.wustl.edu).
Financial Disclosure:None reported.
Previous Presentation:This study was presented at the American Association for Pediatric Ophthalmology and Strabismus Annual Meeting; April 12, 2007; Seattle, Washington.
Lueder GT, Culican S. Yellow Dye Laser Treatment of Vascularized Corneal Stromal Scars in Pediatric Patients. Arch Ophthalmol. 2008;126(4):564-566. doi:10.1001/archopht.126.4.564