Utility of refractive surgery in pediatric patients

Dr. David Granet discusses age limits, reasons for surgery and complications.

John A. Hovanesian

David B. Granet

John A. Hovanesian, MD, FACS: Today we are interviewing David B. Granet, MD, FACS, FAAP, FAAO, who is the Anne Ratner Professor of Ophthalmology at the University of California San Diego Shiley Eye Center. Dr. Granet, welcome.

David B. Granet, MD, FACS, FAAP, FAAO: Thank you.

Dr. Hovanesian: We are talking today about refractive surgery in pediatric patients, and obviously this is a new and somewhat controversial subject. David, is there an age limit under which we have not or should not perform refractive surgery?

Dr. Granet: There are age limits that have been set from a political standpoint by the U.S. Food and Drug Administration, but that is very different from the way physicians look at age limits. We are looking at whether or not the physiology sets a point at which we should not go beyond. Currently there have been children certainly into the single digits who have had refractive surgery worldwide with various levels of success, depending upon what we are looking for.

Dr. Hovanesian: When a parent might approach you with the idea of refractive surgery for his or her child, what concerns might you have as a physician?

Dr. Granet: The reason why parents come to us is because they do not want to have their child wear glasses or they think they are going to get away without having to patch their child. Those are the issues that they see. “How can I make my life easier?” The parents have often had refractive surgery. We have an era in which there have been millions of refractive surgical adults who are parents now, and they see no reason why their kids cannot have it. My concern is that if they think their children can have that refractive surgery if they fail the use of glasses, then they will fail the use of glasses.

Dr. Hovanesian: In other words, if we make it available to them, they may not try so hard at amblyopia therapy.

Dr. Granet: Absolutely.

Dr. Hovanesian: Are we talking about a particular subset of pediatric amblyopic patients? What sort of pediatric conditions are most amenable to refractive surgery?

Dr. Granet: Strabismic amblyopia you would not think of using refractive surgery for, so this is anisometropic amblyopia. Axial myopia most specifically would be the more common thing. Say a child is +1 D in one eye and –4 D in the other eye, and those are the kids who do not want to wear their glasses because they see just fine out of their good eye, and you battle with them. And we are so good at myopic refractive surgery, that is very tempting to want to just cure it.

Dr. Hovanesian: As we can in adults. And what sort of results have there been in children who you have seen in your practice?

Dr. Granet: We have a handful of kids who we have used this with with great success. We have limited our kids to true failures with standard therapy, and it turns out that the kids who we failed with are kids with other issues, either autism or behavioral problems.

Dr. Hovanesian: Are there any complications that seem to be occurring with any frequency among these young patients?

Dr. Granet: We all worried about the fact that these kids would be easier to self-traumatize. They are going to rub their eyes more frequently; allergic conjunctivitis is common in kids. Would that become a problem? It does not seem to be. In a great review by Amy Hutchinson, who is now at Emory, she was not able to find an increase in those kinds of changes in the flaps.

The other thing that we worried about was, would they take their drops postoperatively.

In some small studies, there was evidence of increased haze early on that has been dealt with by increasing the amount of steroids you give the kids, and that seems to have taken care of it.

Dr. Hovanesian: Any other long-term complications that we should be concerned with as the eye grows and the refractive era changes or as the visual motor system matures?

Dr. Granet: We don’t know if the reason why the eye was amblyopic, or let’s say myopic or hyperopic, in the first place was that there is something different about how it grows. So we don’t know if we are going to impede emmetropization. We don’t know if this eye, if we make the two eyes the same refractive error, if as the child grows they will grow evenly. So no one, long-term, really understands what the issue is.

Will we have a problem with identifying glaucoma in these patients as they get older because there’s a change in the corneal thickness? If we use a flap, will it be a problem 30 years later? With kids, we think in longer time periods than adults.

I think currently refractive surgery in children should remain in specialized centers. However, in the future, with proper guidelines, pediatric refractive surgery may end up in the hands of the comprehensive ophthalmologist.

• David B. Granet, MD, FACS, FAAP, FAAO, can be reached at Shiley Eye Center, 9415 Campus Point Drive, La Jolla, CA 92039; 858-534-2020; fax: 858-534-5695; e-mail: dgranet@ucsd.edu.
• John A. Hovanesian, MD, FACS, can be reached at Harvard Eye Associates, 24401 Calle De La Louisa, Suite 300, Laguna Hills, CA 92653; 949-951-2020; fax: 949-380-7856; e-mail: drhovanesian@harvardeye.com.