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Refractive surgery in children

Understanding the needs

Refractive pediatric surgery is considered appropriate in children with severe myopic, hyperopic or astigmatic anisometropia (high dioptric difference between both eyes) or bilateral high ametropia (high refractive error) resistant to or with poor compliance with conventional therapy using spectacles or contact lens and conventional treatment of amblyopia.

The aim of refractive procedures in children is not to get rid of dependence on glasses or contact lenses, like in older patients in whom the process of visual development has ended.

It is a chance given today to these children to reduce anisometropia or to achieve isometropic status, to fully correct high refractive errors, much better than with standard / conventional treatment, and thus develop visual function as good as possible, better quality of visual acuity and binocular vision - tereopsis, facilitating patching treatment for amblyopia.

WHY IS IT IMPORTANT?

At the age critical for visual development (up to the age of 4 and 8, respectively), full correction of the refractive error is mandatory, but of course, in some cases, despite all the effort, this is impossible to achieve. Intolerance can be caused by physiological non-adaptation to spectacle aniseikonia and anisovergence (different size and shape of fixated object). A contact lens is not convenient at the early age.

Children with special needs and their parents are faced with one more stigma leading to a psychosocial problem. Most of these children have extreme refractive errors, in one or both eyes, together with some other ophthalmic problem (albinism, various forms of nystagmus, retinopathy of premature children...) or other medical disorder (autism, Sy Down, cerebral palsy and other neuromuscular impairments).

Without refractive surgery, these children are functionally blind, meaning very poor, limited visual function since the standard optical treatment is not working for them.

High refractive error in both or in one eye with a significant difference between the eyes (anisometropia) has a high potential for amblyopia development. The “better” eye (less error) conveys a better and sharper picture, accepted in the brain occipital vision center, than the other eye, (higher diopter), which needs higher correction, but still not the same quality of picture in comparison with the dominant. That is due to a different size and shape, looking through the spectacles. Amblyopia treatment demands an occlusion of the “weaker” eye, which is not accepted well by the child. Wearing glasses is compromised by making some “balance“ between both eyes and under correction of the higher diopter, but that may not reduce amblyopia effectively.

For some of them refractive surgery is the only way out of functional blindness, and for others it is an effective way to augment the treatment of amblyopia.

By now, Excimer laser pediatric surgery has a long follow up period, a lot of publications and studies issued concerning this topic that have shown it as an effective, predictable, safe and stable technique for the correction of the above mentioned refractive errors with a great amblyogenic potential.

That is the way to achieve isometropia and a better quality of vision, as well as a better quality of life for years to come.

Other solutions to achieve this aim, when laser is not indicated and conventional treatment is useless, are other refractive procedures, lens implant surgery, meaning Phakic intraocular lens implantation, and clear lens extraction with PC IOL implantation, as alternative. The aim of the phakic IOL implantation is to correct the high refractive error, preserving the biological, crystalline lens, with the preservation of accommodation. The procedure is indicated in high refractive errors beyond the range of 6 D and -13 D, even in a lower D value when thin corneas are not suitable for laser correction, and with an appropriate depth of the anterior chamber of 3.2 mm. The general anesthesia is required in these procedures involving children.