A common theme of the symposia here in Kuala Lumpur at the 5th World Congress of Paediatric Ophthalmology & Strabismus (WCPOS V 2024) is a focus on the practical. Translational medicine is an essential component of any ophthalmology meeting, but at WCPOS V, clinical pearls and takeaway tips have taken center stage.
A Day 2 symposium on the pediatric cornea was no different. From advice on identifying and treating rare corneal diseases to the ins and outs of pediatric keratoplasty and corneal infections, pragmatic tips for saving pediatric sight—and lives—were on the menu at the Banquet Hall of the Kuala Lumpur Convention Centre.
Cornea plana and AS-OCT
Dr. Meena Lakshmipathy (India) led off with a bevy of expertise on cornea plana, a rare genetic disease leading to the flattening of the cornea and a lifetime of visual complications.

Dr. Lakshmipathy started off by describing the disease and presenting four cases involving various subtypes and presentations of the disease, after which she noted key differences between autosomal dominant and recessive variants.

One key pearl from her talk was the importance of emerging technology anterior segment optical coherence tomography (AS-OCT).
“I’d like to stress the role of AS-OCT. It’s a non-invasive tool and it helps us to bring on keratometry and show us the anterior chamber depth and posterior thickening of the stroma in these patients,” Dr. Lakshmipathy said. “And when you suspect autosomal recessive you can also see iris adhesions to the cornea.”
Dr. Lakshmipathy’s takeaways were many. A close work-up is key, she said, as is doing all of the non-invasive imaging, including AS-OCT. Working closely with specialized pediatric ophthalmologists was also high on her list, with general ophthalmologists urged to be on the look-out for glaucoma over the long term.
A picture is worth…
This talk was the beginning of a run of talks on imaging, underscoring its critical importance in the field of pediatric cornea. Dr. Asim Ali (Canada) took up the mantle first, discussing the intersection of imaging, assessment during the critical period and surgical intervention.

Dr. Ali spoke on three specific types of imaging for surgical considerations in pediatric cornea— B-scan ultrasound, ultrasound biomicroscopy (UBM) and OCT. There are many reasons for using imaging, but for pediatric cornea, one in particular stood out.
“Imaging is very important in helping diagnose the phenotype in particular, as it aids surgical planning. It also establishes prognosis in all of these conditions, which is very helpful for the family to predict and plan for what will happen in the future,” Dr. Ali said.
Dr. Ali then highlighted the usefulness of each type of imaging in his process: ultrasound B-scans for persistent fetal vasculature, the presence of the lens, and the presence of mass, vitreous hemorrhage and retinal detachment; UBM for assessment of corneal structure, the iris, lens and anterior chamber; and OCT for looking further into glaucoma prognoses and deciding between different types of keratoplasty in certain corneal diseases.
He then commented on the critical period for surgical intervention, indicating that imaging results and considerations of potential complications, such as increased risk of glaucoma should outweigh conventional wisdom and alacrity.
“Timing of surgery is not absolute,” he said. “In some cases, especially when there are a lot of associated eye abnormalities, I’ll wait a little longer, as I really don’t think this affects the visual prognosis.”
Dr. Gerald Zaidman (USA) picked up from there with emphasis on the growing necessity for pediatric ophthalmologists to have access to intraoperative OCT. “Intraoperative OCT/ReScan can help guide all of us here in managing children and infants with congenital cataracts and anterior segment disorders,” he advised.

Checking in on pediatric keratoplasty
Pediatric keratoplasty was up next, with Dr. Nikolas Ziakas (Greece) providing an update on the state of the art in this tricky topic.

According to Dr. Ziakas, challenges abound throughout the perioperative period in keratoplasty in children. It is difficult to get children to cooperate with examinations, and measurements like visual acuity can make for an uncertain foundation.
Intraoperatively, surgeons must battle with everything from low scleral rigidity to donor sizing issues, higher vitreous pressure and more. And postoperatively, issues like cooperation, eye rubbing, neovascularization and the need for constant vigilance can lead to poor graft survival, ranging from 37-97% in pediatric patients.
But Dr. Ziakas had some pearls. For timing, Dr. Ziakas echoed Dr. Ali’s sentiments about bucking conventional wisdom. For unilateral cases, he recommended immediate intervention. But delaying for several weeks is advisable in bilateral cases, and issues with intraocular pressure should always be considered first.
Top tips for graft selection included a donor between 5 and 30 years of age, a donor cornea size of ≤8 mm (5.5-7.0 mm for infants), and oversizing by 0.5 -1.0 mm. For surgical tips, Dr. Ziakas recommended a 10/0 nylon suture, using the Price graft-over-host technique for PVP, and using preoperative pilocarpine or mannitol, among others.
But despite these tips and the obvious benefits keratoplasty brings, surgeons must always keep one thing in mind. “Despite successful operations, tear grafts, etc.—the final visual outcomes are often disappointing,” Dr. Ziakas cautioned.
Pediatric corneal infection insights
After a comprehensive walkthrough through surgical case videos involving pediatric corneal keloids from Dr. Muralidhar Ramappa (India), Dr. Merle Fernandes (India) brought the session to a close with tips on therapeutic strategies and decision-making in pediatric corneal infections.

Management of corneal infections comes with a lot of questions, according to Dr. Fernandes. How to assess the eye when you aren’t able to see the eye well? Apply anesthesia for an examination? How severe is the ulcer? Does every patient need a microbiological workup? What’s the management protocol? How to manage amblyopia when it sets in?
Over the next 10 minutes, Dr. Fernandes tried to provide answers to this tangle of interrelated questions via seven case studies. Examine under anesthesia when the patient is not cooperative. Microbiological workups become more necessary as the ulcer becomes more severe. Empirical therapy can commence in non-severe cases, but timely referral is necessary when no response is seen. Watch for risk factors including prior trauma and surgeries or a compromised ocular surface.
In the end, however, Dr. Fernandes denoted that each case is unique, and physician judgment has no substitute. “In kids, the management of microbial keratitis is especially challenging,” she said—but like all of the diseases discussed over the day, perhaps a little less so with the many tips on display from Dr. Fernandes and her co-presenters.
Editor’s Note: Reporting for this article occurred at the 5th World Congress of Paediatric Ophthalmology & Strabismus (WCPOS V 2024) from 11-13 July in Kuala Lumpur, Malaysia.