ICRS implantation in the corneal periphery flattens the central c

ICRS implantation in the corneal periphery flattens the central corneal apex,3 while cross-linking induces additional covalent bonds between collagen molecules to increase corneal strength.11 A patient receiving than both treatments consecutively may receive the beneficial effects of improved corneal topography and stabilization of corneal ectasia. We believe that a stepwise progression from IOP-lowering medication to ICRS implantation to collagen cross-linking may be an appropriate treatment strategy for cases of post-LASIK corneal ectasia. We did not combine our treatment measures with photorefractive keratectomy (PRK), as described by Kanellopoulos in the Athens Protocol,13 because we have had little experience with this modality and also because the long-term results of further corneal thinning and destabilization remain uncertain.

The combination of these two minimally invasive therapies, Intacs and cross-linking, for the treatment of post-LASIK ectasia appears to be a promising alternative to lamellar or penetrating lamellar keratoplasty. Longer follow-up and larger studies are needed to evaluate the refractive and topographic stability of these alternative and desirable treatment options.
It is generally assumed that orbitocranial penetrating injuries are rare in civilian practice in general and in children in particular. Some case reports highlight the danger posed to children from lead pencils.A retrospective study performed at a large urban pediatric hospital on non-missile, non-bite injuries in their trauma registry revealed that of the 14 injuries from pens and pencils, 9 involved the head and neck.

As a result, 11 children were admitted in the hospital and 8 required surgical intervention.1 Another retrospective case review of orbital injuries managed at the Wills Eye Institute and Massachusetts Eye and Ear Infirmary found 23 patients with intraorbital foreign bodies, the most common being wood pencils (39% of subjects).2 Most patients had normal or near normal best-corrected visual acuity (20/20�C20/40) on examination. Pencil injuries in children have also been reported by Elgin et al,3 Ozer et al,4 and Shriwas and Kinzha.5 In civilian life, intraorbital foreign bodies are usually occupational in nature. Orbital roof fractures are also reportedly common. This is assumed to be due to the reflex extension of the patient��s head backward, exposing the orbital roof.

The thin bony plate of the roof offers little resistance to the foreign body. However, the Wills Eye Institute study2 Cilengitide found the medial wall to be the most common site for foreign bodies to become lodged. It is important to assess the actual extent of injury so that appropriate management can be planned. Globe perforations and orbitocranial fractures are other injuries that must also be ruled out.

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