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Multifaceted chemotherapy for trilateral retinoblastoma.

that developed haze either had stage III keratoconus or more advanced changes including thinner corneas, higher keratometry values, and prominent Vogt striae. Mazzotta et al reported that hyporeflective bands in a reticular pattern representing stromal microstriae prior to CXL could be a confocal sign of advanced keratoconus, predicting haze formation. This pattern was not seen in our cases, consistent with the milder clinical picture. Despite the lower risk profile of our patients, both developed dense, deep stromal scars that were morphologically different and more severe than the faint haze described by Mazzotta et al and Raiskup et al. The deep stromal scar also occurred at the junction between the treated and untreated cornea along the demarcation line, which has not been previously described. Mazzotta et al also described increased keratocyte density in the region of the scar, in contrast to the reduced keratocyte population in our cases. Riboflavin– UV-A exposure typically causes keratocyte apoptosis in the early postoperative period, and we speculate that a sublethal effect in the deep stroma where the UV-A irradiation dose is lower may lead instead to fibroblastic transformation and an aberrant scarring response. This would explain the delayed reaction seen and, if proven in subsequent study, may suggest that longer or higherintensity UV-A irradiation is indicated. Performing a modification of the technique in which the epithelium is not removed may also help prevent this complication. In conclusion, deep corneal stromal scarring may complicate CXL for mild keratoconus and, if severe, may lead to a significant increase in astigmatism.