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Middle East African Journal of Ophthalmology Middle East African Journal of Ophthalmology
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REVIEW ARTICLE
Year : 2012  |  Volume : 19  |  Issue : 1  |  Page : 22-23  

Pediatric refractive surgery in evolution


Pediatric Ophthalmology Division, King Khaled Eye Specialist Hospital, Riyadh, Saudi Arabia

Date of Web Publication20-Jan-2012

Correspondence Address:
Jonathan Song
King Khaled Eye Specialist Hospital, P.O. Box 7191, Riyadh 11462
Saudi Arabia
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0974-9233.92112

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   Abstract 

With the advent of corneal refractive surgery using excimer laser technology, treatment for corneal and refractive disorders have advanced tremendously and become very precise and predictable. The use of these techniques in the treatment of corneal and refractive disorders in children, especially during the amblyogenic ages, would be invaluable. Numerous reports on refractive surgery in children have demonstrated that it can be performed safely and efficaciously in the pediatric population. However, controversy still exists whether it should be done in this population. We explore the available published data to address this controversy.

Keywords: Anisometropia Treatment, Pediatric Refractive Surgery, Refractive Error in Children


How to cite this article:
Song J, Al-Ghamdi I, Awad A. Pediatric refractive surgery in evolution. Middle East Afr J Ophthalmol 2012;19:22-3

How to cite this URL:
Song J, Al-Ghamdi I, Awad A. Pediatric refractive surgery in evolution. Middle East Afr J Ophthalmol [serial online] 2012 [cited 2021 Oct 18];19:22-3. Available from: http://www.meajo.org/text.asp?2012/19/1/22/92112


   Introduction Top


Refractive surgery was initially used to treat asymmetric or unilateral high myopia in children with ablyopia, who where refractory to conventional treatments such as spectacles, contact lenses, or traditional patching or penalization therapy. These studies showed that laser-assisted in situ keratomileusis (LASIK) and Photorefractive keratectomy (PRK) could be performed safely and effectively in children. [1],[2],[3],[4],[5] However, these studies only treated older children, mostly over the age of eight years. One of the limiting factors that did not allow younger children to be treated was the need for general anesthesia. Despite reporting successful treatment, these authors also reported the limited effects on the final visual outcomes, attributed to the fact that they were treating children outside the amblyogenic ages.


   Early Treatment Top


Successful visual recovery in children with refractive disorders requires early visual rehabilitation. It is generally accepted the earlier the intervention the better the outcome. This is especially true if children fail the current established treatment such as spectacle correction, contact lenses, and patching or penalization.

Anisekonia due to retinal disparity in children with significant anisometropia, greater than three diopters, is a major problem in a child that cannot wear contact lenses. [6] Corneal refractive surgery offers on the corneal plane treatment, aiding in the anisekonia. Initial studies aimed at treating the anisometropia by correcting the difference in the refractive disorders. Other studies have used refractive surgery in children to treat bilateral high myopia [7] and accommodative esotropia. [8],[9],[10]


   Techniques Top


Both LASIK and PRK have been used in children as young as two years of age. [7],[11],[12] LASEK (Laser subepithelial keratomileusis) has also been used with good success. [12],[13] Topical anesthesia with self-fixation can be employed in older, cooperative children. [3],[5],[14],[15] Premedication with anxiolytic agents such as midozolam or diazepam has also been used. [14],[16] In young children, general anesthesia with IV sedation or laryngeal mask can be used. [17]


   Outcomes Top


The first refractive study in children was published in 1995. [2] PRK, although effective initially, has been hampered by corneal haze. Corneal haze has been reported at a rate as high as 25% and has been associated with failure to comply with longer term steroid regimen postoperatively. [2],[7],[16] In one study, severe corneal haze was found in 2.5% of the patients in two month and in 7 % after seven months, especially in high myopic treatments. [16] In one study, a three-year follow-up on a cohort of patients treated with PRK, with myopia up to - 15D and hyperopia up to + 5D, found stable refraction and improvement in visual acuity and stereopsis, with minimal corneal haze. [11]

Myopic regression after PRK in children was noted at a level as high as 69% of the patients, with a shift toward myopia at a rate of 1D per year. [18] This was attributed to an axial myopic shift related to normal growth patterns of the eye and partly to the more rapid healing response observed in children.

Persistent corneal haze formation in LASIK is seldom seen in children and adults, and has been reported in one child. [4] LASIK flap complications have been reported, including epithelial ingrowth, wrinkles, diffuse lamellar keratitis, and free flaps, at a rate similar to adult LASIK surgery. [4],[14],[19] Despite early flap-related complications numerous studies have shown LASIK to be safe and effective even in children as young as two years of age. [4],[14],[20] Visual acuity outcome data is limited, given the younger age of children and ongoing treatment of amblyopia. Authors report the desired postoperative outcomes with patients remaining orthophoric, with residual refractive error of less than ± 0.375 with regression of 1.19D after one year. [1],[14],[21]


   Conclusion Top


Pediatric refractive surgery based on the current available data appears to be safe and effective. Current indications for refractive surgery include anisometropia, bilateral high myopia, and accommodative esotropia. Corneal haze is certainly a major concern in children receiving surface ablation, especially in high myopic treatments. Initial reports on the use of phakic intraocular lenses may be a good alternative in these cases. [22],[23] In LASIK, surgery flap complication rates, although appear similar to those in adults, is still a concern. Myopic regression is seen with both procedures, whether it is secondary to aggressive healing or natural growth of the eye is still to be determined. Prospective controlled clinical trials are still needed to better demonstrate long-term safety and efficacy.

 
   References Top

1.Rashad KM. Laser in situ keratomileusis for myopic anisometropia in children. J Refract Surg 1999;15:429-35.  Back to cited text no. 1
    
2.Singh D. Photorefractive keratectomy in pediatric patients. J Cataract Refract Surg 1995;21:630-2.  Back to cited text no. 2
    
3.Nano HD Jr, Muzzin s, Irigaray F. Excimer laser photorefractive keratectomy in pediatric patients. J Cataract Refract Surg 1997;23:736-9.  Back to cited text no. 3
    
4.Agarwal A, Agarwal A, Agarwal T, Siraj AA, Narang P, Narang S. Results of pediatric laser in situ Keratomileusis. J Cataract Refract Surg 2000;26:684-9.  Back to cited text no. 4
    
5.Nucci P, Drack AV. Refractive surgery for unilateral high myopia in children. J AAPOS 2001;5:348-51.  Back to cited text no. 5
    
6.Campos EC, Enoch JM. Amount of anisseikonia compatible with fine binocular vision: Some old and new concepts. J Pediatr Ophthalmolol Strabismus 1980;17:44-7.  Back to cited text no. 6
    
7.Astle WF, Huang PT, Ells AL, Cox RG, Deschenes MC, Vibert HM. Photorefractive keratectomy in children. J Cataract Refract Surg 2002;28:932-41.  Back to cited text no. 7
    
8.Nucci P, Serafino M, Hutchinson AK. Photorefractive keratectomy for treatment of purely refractive accommodative esotropia. J Cataract Refract Surg 2003;29:889-94.  Back to cited text no. 8
    
9.Hoyos JE, Cigales M, Hoyos-Chacon J, Ferrer J, Maldonado-Bas A. Hyperopic laser in situ keratomileusis for refractive accommodative esotripia. J Cataract Refract Surg 2002;28:1522-9.  Back to cited text no. 9
    
10.Stidham DB, Borissova O, Borrisov V, Prager TC. Effect of Hyperopic laser in situ keratomileusis on ocular alignment and stereopsis in patients with accommodative esotropia. Ophthalmology 2002;109:1148-53.  Back to cited text no. 10
    
11.Paysee EA, Coats DK, Hussein M, Hamill B, Koch DD. Long-term outcomes of photorefractive keratectomy for anisometropic amblyopia in children. Ophthalmology 2006;113:169-76.  Back to cited text no. 11
    
12.Tychsen L, Packwood E, Berdy G. Correction of large amblyopiogenic refractive errors in children using the excimer laser. J AAPOS 2005;9:224-33.  Back to cited text no. 12
    
13.Autrata R, Rehurek J. Laser-assisted subepithelial keratectomy and photorefractive keratectomy versus conventional treatment of myopic anisometropic amblyopia in children. J Cataract Refract Surg 2004;30:74-84.  Back to cited text no. 13
    
14.Nassaralla BR, Nassaralla JJ Jr. Laser in situ keratomileusis in children 8 to 15 years old. J Refract Surg 2001;17:519-24.  Back to cited text no. 14
    
15.Paysse EA, Hamill MB, Koch DD, Hussein MA, Brady McCreery KM, Coats DK. Epithelial healing and ocular discomfort after Photorefractive keratectomy in children. J Cataract Refract Surg 2003;29:478-81.  Back to cited text no. 15
    
16.Alió JL, Artola A, Claramonte P, Ayala MJ, Chipont E. Photorefractive keratectomy for pediatric myopic anisometropia. J Cataract Refract Surg 1998;24:327-30.  Back to cited text no. 16
    
17.Paysse EA, Hussein MA, Koch DD, Wang L, Brady McCreery KM, Glass NL, et al. Successful implementation of a protocol for photorefractive keratectomy in children requiring anesthesia. J Cataract Refract Surg 2003;29:1744-7.  Back to cited text no. 17
    
18.Tychsen L, Pachwood E, Berdy G. Correction of large amblyopiogenic refractive errors in children using the excimer laser. J AAPOS 2005;9:224-33.  Back to cited text no. 18
    
19.Rybintseva LV, Sheludchenko VM. Effectiveness of laser in situ keratomileusis with the NIDEK EC-5000 excimer laser for pediatric correction of spherical anisometropia. J Refract Surg 2001;17 Suppl 2:S224-8.  Back to cited text no. 19
    
20.O'Keefe M, Nolan L. Lasik in children. Br J Ophthalmol 2004;88:19-21.  Back to cited text no. 20
    
21.Drack AV, Nucci P. Refractive surgery in children. Ophthalmol Clin North Am 2001;14:457-66.  Back to cited text no. 21
    
22.Lesuer LC, Arne JL. Phakic intraocular lens to correct high myopic amblyopia in children. J Refract Surg 2002;18:519-23.  Back to cited text no. 22
    
23.Chipont EM, Garcia-Hermosa P, Alio JL. Reversal of myopic amblyopia with phakic intraocular lens implantation. J Refract Surg 2001;17:460-2.  Back to cited text no. 23
    



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    Abstract
   Introduction
   Early Treatment
   Techniques
   Outcomes
   Conclusion
    References

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