Pediatric Ophthalmology

Pediatric Ophthalmology Publications

Sarangi S, Minaeva O, Ledoux DM, Parsons DS, Moncaster JA, Black CA, Hollander J, Tripodis Y, Clark JI, Hunter DG, Goldstein LE. In vivo quasi-elastic light scattering detects molecular changes in the lenses of adolescents with Down syndrome. Exp Eye Res 2024;241:109818.Abstract
Down syndrome (DS) is the most common chromosomal disorder in humans. DS is associated with increased prevalence of several ocular sequelae, including characteristic blue-dot cerulean cataract. DS is accompanied by age-dependent accumulation of Alzheimer's disease (AD) amyloid-β (Aβ) peptides and amyloid pathology in the brain and comorbid early-onset Aβ amyloidopathy and colocalizing cataracts in the lens. Quasi-elastic light scattering (QLS) is an established optical technique that noninvasively measures changes in protein size distributions in the human lens in vivo. In this cross-sectional study, lenticular QLS correlation time was decreased in adolescent subjects with DS compared to age-matched control subjects. Clinical QLS was consistent with alterations in relative particle hydrodynamic radius in lenses of adolescents with DS. These correlative results suggest that noninvasive QLS can be used to evaluate molecular changes in the lenses of individuals with DS.
Elwehidy AS, Toma J, Abd Elfattah D, Elhusseiny AM. The Use of Ologen Implant in Childhood Glaucoma Surgeries: A Review. Curr Eye Res 2024;:1-7.Abstract
PURPOSE: This study assesses the effectiveness and safety of using Ologen implants (Aeon Astron Europe BV, Leiden, The Netherlands) as an adjunctive therapy in childhood glaucoma surgeries. METHODS: We systematically reviewed the existing literature across various electronic databases to examine the effectiveness and safety of Ologen implants in childhood glaucoma surgeries. RESULTS: Our analysis encompassed 14 studies on the use of Ologen implants in childhood glaucoma. Among these, seven were prospective, five were retrospective, and two did not specify their study design. Success rates varied depending on the type of surgery and the included childhood glaucoma subtype. The success rates for Ologen implants-augmented surgeries were as follows: 33.3-70% for trabeculectomy, 50-81% for combined trabeculotomy-trabeculectomy procedure, 33%-87% for glaucoma drainage device, and 60% in deep sclerectomy. CONCLUSION: Ologen implant has a potential role in mitigating postoperative fibrosis and enhancing success rates in various childhood glaucoma surgeries. However, the existing literature is limited. Future comparative prospective studies with larger cohorts are needed.
Chiou CA, Lin LY, Stagner AM, Lee NG. Melanoma Arising Beneath the Lateral Rectus Muscle in a Teenager With Ocular Melanocytosis: Possible Origin From Intrascleral Melanocytes. Ophthalmic Plast Reconstr Surg 2024;Abstract
Ocular melanocytosis is a well-established risk factor for choroidal melanomas but, despite its reported associations in the literature, it is infrequently discussed in relation to orbital melanomas. The authors describe a teenage patient with ocular melanocytosis who presented with an asymptomatic ipsilateral right orbital mass associated with the lateral rectus muscle. An exploratory orbitotomy revealed a lesion lightly adherent to the underlying sclera. Histopathology demonstrated a markedly atypical epithelioid melanocytic proliferation, bound by a thin rim of superficial sclera, implying an origin from intrascleral melanocytes, likely within an emissary canal. Next-generation sequencing identified GNAQ and NF1 mutations. The histopathology and molecular genetics designated the lesion as having a uveal melanoma-like profile, suggesting that it may behave as a choroidal melanoma. This case underscores the importance of the association between ocular melanocytosis and orbital melanoma and provides additional evidence for primary orbital melanoma etiopathogenesis.
Sun JA, Estrela T, Gise R. Clinical Course and Visual Outcomes of Papilledema in Pediatric Cerebral Venous Sinus Thrombosis. Am J Ophthalmol 2024;Abstract
PURPOSE: Cerebral venous sinus thrombosis (CVST) is a rare but life-threatening event with significant neurologic and visual morbidity. In this study, we report on the natural history and visual outcomes of papilledema in children with CVST. DESIGN: Retrospective case series. METHODS: Patients with CVST evaluated by the Department of ophthalmology between 2000 and 2023 were included. Records were reviewed for presence and course of papilledema, treatment, and final visual outcomes following papilledema resolution. RESULTS: The study included 35 patients with a mean age of 9 ± 5 years and 40% were female. The most common risk factors for CVST were infection (69%), dehydration (26%), and hypercoagulability (23%). 31 patients (89%) had papilledema. Of these patients, 9 (29%) had progression of papilledema despite treatment, 17 patients (55%) did not have progression, and 5 patients (16%) lacked follow-up records. Initial Frisén grade among all cases was 2 ± 1, and cases with progression reached a grade of 4 ± 1 between 10 and 32 days following initial identification. Most patients (97%) were treated with anticoagulation and 100% required acetazolamide and/or lumbar puncture. Among 26 patients with follow-up, papilledema resolved in 107 ± 128 days. 54% of patients had permanent ophthalmic sequelae. An initial Frisén grade ≥3 (odds ratio [OR] 7.54, 95% confidence interval [CI] 6.53-8.70, p <0.001) was significantly associated with eventual optic atrophy. CONCLUSIONS: Children with CVST are at high risk for ophthalmologic sequelae. Papilledema can progress despite appropriate therapy. Our results highlight the importance of ophthalmologic follow-up during treatment course to prevent irreversible vision loss.
Martinez Sanchez M, Chan W-M, MacKinnon SE, Barry B, Hunter DG, Engle EC, Whitman MC. Presence of Copy Number Variants Associated With Esotropia in Patients With Exotropia. JAMA Ophthalmol 2024;Abstract
IMPORTANCE: Strabismus is a common ocular disorder of childhood. There is a clear genetic component to strabismus, but it is not known if esotropia and exotropia share genetic risk factors. OBJECTIVE: To determine whether genetic duplications associated with esotropia are also associated with exotropia. DESIGN, SETTING, AND PARTICIPANTS: This was a cross-sectional study conducted from November 2005 to December 2023. Individuals with constant or intermittent exotropia of any magnitude or a history of surgery for exotropia were recruited from pediatric ophthalmic practices. Data were analyzed from March to December 2023. EXPOSURE: Genetic duplication. MAIN OUTCOMES AND MEASURES: Presence of genetic duplications at 2p11.2, 4p15.2, and 10q11.22 assessed by digital droplet polymerase chain reaction. Orthoptic measurements and history of strabismus surgery were performed. RESULTS: A total of 234 individuals (mean [SD] age, 19.5 [19.0] years; 127 female [54.3%]) were included in this study. The chromosome 2 duplication was present in 1.7% of patients with exotropia (4 of 234; P = .40), a similar proportion to the 1.4% of patients with esotropia (23 of 1614) in whom it was previously reported and higher than the 0.1% of controls (4 of 3922) previously reported (difference, 1.6%; 95% CI, 0%-3.3%; P < .001). The chromosome 4 duplication was present in 3.0% of patients with exotropia (7 of 234; P = .10), a similar proportion to the 1.7% of patients with esotropia (27 of 1614) and higher than the 0.2% of controls (6 of 3922) in whom it was previously reported (difference, 2.8%; 95% CI, 0.6%-5.0%; P < .001). The chromosome 10 duplication was present in 6.0% of patients with exotropia (14 of 234; P = .08), a similar proportion to the 4% of patients with esotropia (64 of 1614) and higher than the 0.4% of controls (18 of 3922) in whom it was previously reported (difference, 5.6%; 95% CI, 2.5%-8.6%; P < .001). Individuals with a duplication had higher mean (SD) magnitude of deviation (31 [13] vs 22 [14] prism diopters [PD]; difference, 9 PD; 95% CI, 1-16 PD; P = .03), were more likely to have constant (vs intermittent) exotropia (70% vs 29%; difference, 41%; 95% CI, 20.8%-61.2%; P < .001), and had a higher rate of exotropia surgery than those without a duplication (58% vs 34%; difference, 24%; 95% CI, 3%-44%; P = .02). CONCLUSIONS AND RELEVANCE: In this cross-sectional study, results suggest that the genetic duplications on chromosomes 2, 4, and 10 were risk factors for exotropia as well as esotropia. These findings support the possibility that esotropia and exotropia have shared genetic risk factors. Whether esotropia or exotropia develops in the presence of these duplications may be influenced by other shared or independent genetic variants or by environmental factors.
Oke I, Elze T, Miller JW, Lorch AC, Hunter DG. Surgical Approach and Reoperation Risk in Intermittent Exotropia in the IRIS Registry. JAMA Ophthalmol 2024;142(1):48-52.Abstract
IMPORTANCE: There is no consensus on the optimal surgical treatment for children with intermittent exotropia (IXT). OBJECTIVE: To compare the 5-year reoperation rates for children with IXT treated with horizontal muscle strabismus surgery using bilateral lateral rectus recession (BLR) vs unilateral lateral rectus recession with medial rectus resection (RR). DESIGN, SETTING, AND PARTICIPANTS: This cohort study examined data obtained from the Intelligent Research in Sight (IRIS) Registry on 7482 children (age, <18 years) with IXT who underwent horizontal eye muscle strabismus surgery between January 1, 2013, and December 31, 2017. Children undergoing initial surgeries involving 3 or more horizontal muscles, vertical muscles, or reoperations were excluded. MAIN OUTCOMES AND MEASURES: The primary outcome was the adjusted cumulative incidence of repeat horizontal muscle surgery within 5 years after the initial surgery. Reoperation risk was analyzed using adjusted hazard ratios (AHRs) derived from multivariable Cox regression models, adjusting for individual demographic and surgical factors (age, sex, race and ethnicity, US Census region, and surgeon subspecialty). Data were analyzed between January 16 and September 20, 2023. RESULTS: The study included 7482 children (median [IQR] age at initial surgery, 6 [4-9] years; 3945 females [53%]) with IXT treated with horizontal muscle strabismus surgery. Bilateral lateral rectus recession was performed more frequently than RR (85.3% vs 14.7%, P < .001), especially in younger children (rates of BLR vs RR by age: age 0 to ≤4 years, 88.4% vs 11.6%; age 5 to ≤11 years, 84.7% vs 15.3%; age 12 to ≤17 years, 78.1% vs 21.9%; P < 0.001). After data adjustment, the 5-year cumulative incidence of reoperation was 21.3% (95% CI, 20.1%-22.5%). The adjusted 5-year cumulative incidence of reoperation was higher for BLR than for RR (22.2% vs 17.2%; difference, 4.9%; 95% CI, 1.9%-8.0%). Unilateral lateral rectus recession with medial rectus resection was associated with a lower 5-year reoperation risk compared with BLR (AHR, 0.77; 95% CI, 0.64-0.93). Younger age at time of initial surgery was associated with a higher reoperation risk (AHR per 1-year decrease, 1.09; 95% CI, 1.07-1.11) after adjusting for all other covariates. CONCLUSIONS AND RELEVANCE: In this nationwide registry, approximately 1 in 5 children with IXT underwent reoperation within 5 years after the initial surgery. Children treated with RR were less likely to require a reoperation within 5 years compared with those treated with BLR. Further efforts to identify modifiable risk factors for reoperation are needed to reduce the surgical burden and improve outcomes for children with IXT.
Hoyek S, Lemire C, Halawa O, Altamirano-Lamarque F, Gonzalez E, Patel NA. Longitudinal Assessment of Macular Thickness and Microvascular Changes in Children with Sickle Cell Disease. Ophthalmol Retina 2024;8(2):184-194.Abstract
PURPOSE: To longitudinally assess macular thickness and microvascular changes in children with sickle cell disease (SCD). DESIGN: A retrospective consecutive series. SUBJECTS: Children with SCD aged ≤ 18 years who had an ophthalmic examination at Boston Children's Hospital between January 1998 and August 2022. METHODS: Qualitative and quantitative analyses of both OCT and OCT angiography (OCTA) images were performed. MAIN OUTCOME MEASURES: Total retinal thickness measured on macular OCT, superficial capillary plexus and deep capillary plexus (DCP) vessel density (VD), and foveal avascular zone (FAZ) area measured on 6- × 6-mm OCTA scans. RESULTS: International Classification of Diseases, 10th Revision, code search identified 303 pediatric SCD patients who underwent ophthalmic examination during the study period. OCT and OCTA images were acquired on 104 (17.2%) and 60 (9.9%) eyes at presentation and on 159 (26.2%) and 100 (16.5%) eyes at final visit, respectively. Overall, temporal retinal thinning was noted qualitatively in 35.6% of SCD patients at presentation and 39.6% at final visit. Of those patients with macular thinning, 94.6% and 90.5% had peripheral sickle cell retinopathy (SCR) at presentation and final visit. On quantitative OCT analysis, HbSS eyes had a lower retinal thickness in the fovea and temporal parafovea compared with HbSC (P < 0.05). Eyes with peripheral SCR had a larger FAZ at presentation compared with eyes without peripheral SCR (P = 0.004), a lower DCP VD at final visit in the inferior temporal macula (P = 0.03), and a higher DCP VD at final visit in the superior nasal macula (P = 0.01). Eighty eyes of 40 patients had OCT, and 34 eyes of 20 patients had both OCT and OCTA images acquired at both initial and final visits. At final visit, retinal thickness decreased at the fovea, inferior perifovea, and temporal perifovea compared with presentation (P < 0.05). In parallel, VD DCP in the superonasal quadrant increased at final visit (P = 0.03). CONCLUSIONS: Macular retinal thinning was progressive and observed in eyes with and without peripheral SCR. Over time, there was a compensatory increase in DCP VD in the nasal macula on OCTA. FINANCIAL DISCLOSURE(S): Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.
Elhusseiny AM, Hennein L, VanderVeen DK. Bevacizumab as adjunctive therapy in anterior persistent fetal vasculature. Eur J Ophthalmol 2024;34(1):NP18-NP21.Abstract
PURPOSE: Surgical removal of a vascularized pupillary membrane may be challenging with the risk of intraoperative bleeding and postoperative recurrence. We present a case of a 4-week-old who presented with anterior persistent fetal vasculature (PFV) and dense vascularized pupillary membrane in which the use of intracameral and intravitreal bevacizumab may have contributed to successful treatment. OBSERVATION: A 4-week-old-month-old otherwise healthy girl was referred to Boston Children's Hospital for evaluation of cataract. Ocular examination revealed right microcornea and vascularized pupillary membrane. The left eye exam was unremarkable. Only three weeks after surgical excision of the pupillary membrane and cataract extraction, recurrence of a vascular pupillary membrane was noted. Repeat membranectomy with pupilloplasty and use of intracameral bevacizumab was performed. The pupillary opening was further opened 5 months later, after repeat (intravitreal) bevacizumab, and the pupil has remained open and stable with >6 months' follow-up. CONCLUSION AND IMPORTANCE: This case suggests a role for bevacizumab in the management of PFV, however, a cause-and-effect relationship cannot be proven. Further prospective comparative studies are needed to confirm our findings.
Alkharashi M, Aldokhayel F, Alekrish Y, Alotaibi M, Almazyad LM, Bajeaifer Y. The efficacy of part-time patching treatment for intermittent exotropia on different age groups. Eur J Ophthalmol 2023;:11206721231218654.Abstract
BACKGROUND: Intermittent exotropia (IXT) is one of the most common forms of strabismus usually seen in the pediatric age group, the prevalence of IXT is higher in Africa and the Middle East. IXT treatment strategies include both surgical and non-surgical methods, non-surgical management is preferred in general as it is less invasive and avoids the risks associated with surgery and anesthesia. AIMS: This study aims to determine the effectiveness of patching therapy for the treatment of IXT in different age groups and to compare the success of patching therapy in preventing surgery in IXT patients in different age groups. METHODOLOGY: A retrospective chart review was conducted from September 2022 until February 2023 at King Abdulaziz University Hospital in Riyadh. The data was collected retrospectively from electronic medical records from 2016 to 2021 of all patients diagnosed with IXT and were managed by patching therapy fitting the inclusion criteria. RESULTS: A total of 76 patients with IXT enrolled in the study with 56.5% of the participants were older than 7 years old. Overall, there was no improvement in the angle of deviation but 34% of patients had improved control over the follow-up period. 55.3% of the participants didn't require surgery. Younger age, longer duration of patching per month, and good compliance were significantly associated with treatment success. CONCLUSION: Younger age groups were more likely to benefit from patching therapy than older age groups, and good compliance to patching therapy is an important factor in preventing the need for surgery.
Zhang LJ, Traish AS, Dohlman TH. Temporal keratoconus in a pediatric patient. Am J Ophthalmol Case Rep 2023;32:101900.Abstract
PURPOSE: To report a pediatric patient with bilateral temporal keratoconus. OBSERVATIONS: A 14-year-old male presented with a two-year history of progressively worsening visual acuity in both eyes and suspicion for undiagnosed amblyopia in the right eye. Retinoscopy revealed a scissoring reflex in both eyes and corneal topography demonstrated high keratometry values (Kmax 57.9 D and 46.1 D in the right and left eyes, respectively), with relative temporal steepening approximately coinciding with the thinnest pachymetry in both eyes. Corneal cross-linking was recommended. CONCLUSIONS AND IMPORTANCE: Keratoconus can present as a temporal variant with relative temporal steepening and thinning. It is important to maintain a high index of suspicion for keratoconus in pediatric patients with sub-normal visual acuities. Prompt assessment and diagnosis may prevent progression of keratoconus and development of amblyopia.
Hotz A, Sprecher E, Bastianelli L, Rodean J, Stringfellow I, Barkoudah E, Cohen LE, Estrada C, Graham R, Greenwood J, Kyle J, Mann N, Pinkham M, Solari T, Rosen R, Saleeb S, Shah AS, Watters K, Wells S, Berry JG. Categorization of a Universal Coding System to Distinguish Use of Durable Medical Equipment and Supplies in Pediatric Patients. JAMA Netw Open 2023;6(10):e2339449.Abstract
IMPORTANCE: Although durable medical equipment and supplies (DMES) are commonly used to optimize the health and function in pediatric patients, little is known about the prevalence of use and spending on DMES. OBJECTIVE: To categorize the Healthcare Common Procedure Coding System (HCPCS) for distinguishing DMES types, and to measure the prevalence and related spending of DMES in pediatric patients using Medicaid. DESIGN, SETTING, AND PARTICIPANTS: This study is a cross-sectional analysis of the 2018 Merative Medicaid Database and included 4 569 473 pediatric patients aged 0 to 21 years enrolled in Medicaid in 12 US states from January 1 to December 31, 2018. Data were analyzed from February 2019 to April 2023. EXPOSURE: DMES exposure was identified with the Centers for Medicare & Medicaid Services HCPCS codes. Three pediatricians categorized HCPCS DMES codes submitted by vendors for reimbursement of dispensed DMES into DMES types and end-organ systems; 15 expert reviewers refined the categorization (2576 DMES codes, 164 DMES types, 14 organ systems). MAIN OUTCOMES AND MEASURES: The main outcome was DMES prevalence & Medicaid spending. The χ2 test was used to compare DMES prevalence and Wilcoxon rank sum tests were used to compare per-member-per-year (PMPY) spending by complex chronic conditions (CCC). RESULTS: Of the 4 569 473 patients in the study cohort, 49.3% were female and 56.1% were aged 5 to 15 years. Patients used 133 of 164 (81.1%) DMES types. The DMES prevalence was 17.1% (95% CI, 17.0%-17.2%) ranging from 10.1% (95% CI, 10.0%-10.2%) in patients with no chronic condition to 60.9% (95% CI, 60.8%-61.0%) for patients with 2 or more CCCs. The PMPY DMES spending was $593, ranging from $349 for no chronic condition to $4253 for 2 or more CCCs. Lens (7.9%), vision frames (6.2%), and orthotics for orthopedic injury (0.8%) were the most common DME in patients with no chronic condition. Enteral tube / feeding supplies (19.8%), diapers (19.2%), lower extremity orthotics (12.3%), wheelchair (9.6%), oxygen (9.0%), and urinary catheter equipment (4.2%) were among the most common DMES in children with 2 or more CCCs. CONCLUSIONS AND RELEVANCE: In this cross-sectional study, HCPCS distinguished a variety of DME types and use across pediatric populations. Further investigation should assess the utility of the HCPCS DMES categorization with efforts to optimize the quality and safety of DMES use.
Oke I, Slopen N, Hunter DG, Wu AC. Vision Testing for Adolescents in the US. JAMA Ophthalmol 2023;141(11):1068-1072.Abstract
IMPORTANCE: Untreated refractive error contributes to the racial, ethnic, and socioeconomic disparities in visual function of adolescent children in the US. OBJECTIVE: To describe patterns in vision testing as a function of age among US adolescents and identify sociodemographic factors associated with vision testing. DESIGN, SETTING, AND PARTICIPANTS: This cross-sectional study used data from the National Survey of Children's Health (2018-2019), a nationally representative survey of the noninstitutionalized US pediatric population. A total of 24 752 adolescent children (aged 12 to <18 years) were included. Data were analyzed from March 22 to August 11, 2023. MAIN OUTCOMES AND MEASURES: The primary outcome was the caregiver report of vision testing within the last 12 months. Linear regression was used to describe the patterns in reported vision testing as a function of participant age. Logistic regression was used to describe the association of sociodemographic factors with the report of vision testing in each setting. RESULTS: Among 24 752 adolescents, the median (IQR) age was 14 (13-16) years; 12 918 (weighted, 51%) were male. Vision testing in any setting within the previous year was reported by caregivers of 18 621 adolescents (weighted, 74%). Vision testing was reported to have occurred at an eye clinic in 13 323 participants (weighted, 51%), at a primary care clinic in 5230 participants (weighted, 22%), at a school in 2594 participants (weighted, 11%), and at a health center in 635 participants (weighted, 4%). The percentage of adolescents reported to have vision tested decreased with age (-1.3% per year; 95% CI, -2.5% to 0% per year) due to a decrease in testing in primary care and school settings. After adjusting for age and sex, there were lower odds of vision testing reported for adolescents who were uninsured vs insured (adjusted odds ratio [AOR], 0.81; 95% CI, 0.76-0.87), had caregivers with less than vs greater than high school education (AOR, 0.89; 95% CI, 0.84-0.95), and were from a family born outside vs inside the US (AOR, 0.90; 95% CI, 0.82-0.98). CONCLUSIONS AND RELEVANCE: In this cross-sectional study, vision testing in adolescents decreased as a function of age due to fewer reported tests performed in primary care and school-based settings. Relative to children in socioeconomically advantaged families, those from disadvantaged families were less likely to report receiving vision testing in clinical settings. Efforts to expand the role of school-based vision testing for older adolescents from disadvantaged backgrounds may enable opportunities to address disparities in untreated refractive error.
Huynh EM, Elhusseiny AM, Dagi LR. Ophthalmic Manifestations of Unilateral Coronal Synostosis. Curr Eye Res 2023;48(10):879-886.Abstract
PURPOSE: To summarize the ophthalmic manifestations of unilateral coronal synostosis patients. METHODS: We performed a literature search in the electronic database of PubMed, CENTRAL, Cochrane, and Ovid Medline guided by Preferred Reporting Items for Systematic Reviews and Meta-Analysis Statement for studies evaluating ophthalmic manifestations of unilateral coronal synostosis. RESULTS: Unilateral coronal synostosis, also called unicoronal synostosis, may be mistaken for deformational plagiocephaly, an asymmetric skull flattening common in newborns. Characteristic facial features, however, distinguish the two. Ophthalmic manifestations of unilateral coronal synostosis include a "harlequin deformity", anisometropic astigmatism, strabismus, amblyopia, and significant orbital asymmetry. The astigmatism is greater on the side opposite the fused coronal suture. Optic neuropathy is uncommon unless unilateral coronal synostosis accompanies more complex multi-suture craniosynostosis. In many cases, surgical intervention is recommended; without intervention, skull asymmetry and ophthalmic disorders tend to worsen with time. Unilateral coronal synostosis can be managed by early endoscopic stripping of the fused suture and helmeting through a year of age or by fronto-orbital-advancement at approximately 1 year of age. Several studies have demonstrated that anisometropic astigmatism, amblyopia, and severity of strabismus are significantly lower after earlier intervention with endoscopic strip craniectomy and helmeting compared to treatment by fronto-orbital-advancement. It remains unknown whether the earlier timing or the nature of the procedure is responsible for the improved outcomes. As endoscopic strip craniectomy can only be performed in the first few months of life, early recognition of the facial, orbital, eyelid, and ophthalmic characteristics by consultant ophthalmologists enables expeditious referral and optimized ophthalmic outcomes. CONCLUSION: Timely identification of craniofacial and ophthalmic manifestations of infants with unilateral coronal synostosis is important. Early recognition and prompt endoscopic treatment appears to optimize ocular outcomes.

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