Round table: Refractive surgery in pediatric patients

In part 2 of a three-part round table, pediatric ophthalmologists discuss the indications for and limitations of refractive surgery in children.

Issue: June 15, 2006

Round Table Participants
Moderator
Robert S. Gold	David K. Coats
Evelyn A. Paysse	Naval Sondhi

Robert S. Gold, MD: In my practice, questions about refractive surgery in the pediatric population are raised every single day. With more adults having these procedures, more parents are coming in asking question like, “When can my 8-year-old who’s myopic and getting progressively more myopic have refractive surgery?”

What should we be telling the families of our patients about this type of surgery?

Evelyn A. Paysse, MD: For children who just have myopia of a normal amount, I tell the parents that if the child is able to wear glasses, and they’re compliant and having no problem, they need to wait until they’re adults. When their eyes have finished growing and the refractive error is stable, that is when refractive surgery is appropriate.

David K. Coats, MD: I don’t think refractive surgery is ready for prime time for routine use in children, so I say follow the Food and Drug Administration labeling regarding the application of lasers for refractive errors. I agree, right now I wouldn’t offer it to kids, but would rather wait until they become adults.

Naval Sondhi, MD: I agree, it’s not appropriate before the 20 to 21 year age range for that population.

Anisometropic amblyopia

Dr. Gold: We all agree on that situation; those questions are going to come up in our practices and we’ll continue to answer them the same way.

Let’s talk about the research that’s been done in children who are anisometropic amblyopes. Evelyn, you’ve been involved in that.

Dr. Paysse: We’re still in the experimental days of using refractive surgery in this population. Quite a few small studies have been published over the past 5 years regarding refractive surgery in children who have anisometropic amblyopia. Most of the patients in those studies have been noncompliant with traditional therapies and have extremely high refractive errors in their amblyopic eye. So at this point, depending on which study you look at, it’s been successful with regard to refractive outcome. There is some regression of treatment effect in the myopic group. Corneal haze has been minimal, and mild to moderate improvement in visual acuity has been achieved.

The group that I have followed now for almost 5 years has had mild improvements in vision, but many of them were older at the time of treatment. There was a 2-year-old child, but then there were a lot of children in the study who were 6 to 12 years old. The older children had minimal improvements in vision, but the younger ones did better. The 2-year-old has great vision. He has 20/30 vision in his previously –14 D eye.

Most studies to date have not had a control group, so we aren’t comparing standard therapy to refractive surgery. We also need larger numbers because none of these studies have had numbers large enough to give statistically significant results.

Dr. Sondhi: Dr. Paysse is right. The studies done to date have shown that it is a possible treatment modality in the pediatric age group. There are a lot of unanswered questions. As she mentioned, most studies show little or a not very significant improvement in visual acuity. There may be other factors in these children, especially the hyperopic children, that must be kept in mind — for example, associated strabismus and so forth. But the important thing is that the procedure is possible, it is relatively safe in children, and the next step is to perform more detailed and better controlled studies.

Dr. Coats: The studies that have been done so far have answered at least one important question: Refractive surgery to treat severe anisometropia in older children probably is not warranted because the visual results are not particularly good. But it has also shown us that the technique can be safely applied to these children. So we really need what Evelyn described, a true double-blind study, to test younger children who have severe anisometropia. It’s probably also reasonable to consider the noncompliant older kids who have mild to moderate anisometropia as laser surgery candidates, and to test them in the same format.

The ideal patient

Dr. Gold: Let’s talk about the ideal patient. Obviously, most of our patients are not ideal patients because they have already had other difficulties with anisometropia, with patching and so on. But for what patient would you recommend to the family that refractive surgery be done? What age, what timing, how much refractive error, how much anisometropia? When would you do this in your practice? You do this on an occasional basis, probably more than many people around the country, so these are questions you must have addressed.

Dr. Paysse: We don’t have large numbers. From my experience with about 20 patients now, the younger children do better, as you would expect in patients that are being treated for amblyopia. They have more visual plasticity.

The ideal patient would not be someone who has been undergoing treatment for a long time with standard therapy, coming in 3, 4, 5, or 6 years later and having it done. An ideal patient would instead be someone who is not responding to standard therapy in a shorter period of time, probably 4 to 6 months. The age of the ideal patient would probably be 2 to 4 years.

With regards to refractive error, anisometropia in the range of 5 D to 10 D is ideal, although we had good responses in higher levels of myopia.

Dr. Gold: We have been hearing that this is another therapy that at some point may be part of our armamentarium. So we need to know these guidelines.

Dr. Coats: I feel similarly, although I’d break it down slightly differently. I would say the child of 3 years of age or less who has severe anisometropia on the order of 5 D to 10 D, probably worse than that, I would feel less favorable about.

If they don’t show a willingness to comply with treatment within a fairly rapid period of time, I don’t have any problem offering refractive surgery. What I’d like to be able to do is to offer that child of 2 years, 3 years of age, seeing them the first time, offer the ability to enter a study, be subjected to laser vs. standard treatment.

Dr. Sondhi: Essentially, in my mind it is the anisometropic child who is the candidate. Putting a parameter of a dioptric range is difficult because in my mind any child who has enough anisometropia to cause significant amblyopia, not responding to traditional therapy, would be a candidate here. That’s the type of patient we need to put into a study.

Dr. Paysse: I would add one limit. I think the earliest age to do an excimer laser procedure would be 2 years, and that’s because there’s so much change in refractive power over that first 2 years of life, where the child loses a lot of power in the eye. About 90% of the growth in the eyes is completed by 2 years.

Dr. Gold: Thank you all. In part 3 of this round table, to be printed in an upcoming issue of Ocular Surgery News, we will discuss risk management and screening guidelines for retinopathy of prematurity.

For more information:

Robert S. Gold, MD, is in private group practice in Longwood and Winter Park, Fla. He can be reached at 225 W. State Road 434, Suite 111, Longwood, FL 32750; 407-767-6411; fax: 407- 767-8160; e-mail: rsgeye@aol.com.

Naval Sondhi, MD, is in private group practice and is a clinical professor at Indiana University. He can be reached at Midwest Eye Institute, 201 Pennsylvania Parkway, Indianapolis, IN 46239; 317-817-1333; fax; 317-817-1331.

David K. Coats, MD, is an assistant professor of ophthalmology at Baylor College of Medicine. He can be reached at 6701 Fannin St., CC 640.00, Houston, TX 77030; 713-824-3230; fax: 713-796-8110; e-mail: dcoats@bcm.tmc.edu.

Evelyn A. Paysse, MD, is an assistant professor of ophthalmology at Baylor College of Medicine. She can be reached at 1102 Bates St., Suite 300, CC 640.00, Houston, TX 77030; 832-822-3234; fax: 713-796-8110; e-mail: epaysse@bcm.tmc.edu.