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What should be the preferred technique in pediatric refractive surgery, PRK or LASIK?
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Moving away from LASIK
 Rudolph S. Wagner |
I think we need to first establish that this is not a common procedure being done in children. Most commonly, refractive correction is being done in patients with severe anisometropia and in patients with high bilateral refractive errors with other factors that prevent them from wearing glasses or contacts. And it is being done in conjunction with amblyopia therapy, so it will not replace patching or occlusion therapy.
This is also a relatively new indication for refractive surgery. At the onset, LASIK may have been more widely accepted, but a lot of the studies now are going away from LASIK and toward what is termed advanced surface ablation, which is either PRK or LASEK. There are a number of reasons for this shift.
In general, most refractive procedures being done in adult patients with myopia are done with LASIK. However, this is not an ideal option for children for several reasons. First, as with all laser procedures, you are limited by the range of refractive error. You can correct to –10 D on the myopic side, maybe +4 D or +5 D on the hyperopic side. You have the same problem with both PRK or LASEK.
The main disadvantage with LASIK is the flap. You are concerned about eye rubbing in this population, which might dislodge the flap. There is also concern about healing because the cornea may not clear as quickly in these kids because of stromal involvement. The healing phase is important in this age group because if you are already in this amblyogenic age group, and you have any kind of delayed healing, it can actually work against you in the treatment of the amblyopia. These children usually require months of topical steroid therapy. Lastly, you are cutting into the stroma, which causes more thinning of the cornea. You would like to avoid this, especially if you are going to have to reoperate on them, because there is always concern about regression or change in their refraction, especially in the very high myopes.
The disadvantage with PRK or LASEK is that you have a couple of days where the cornea is going to heal. There is some discomfort as a result of the abraded cornea, and that is why a lot of people prefer LASIK in young adults. However, pediatric patients do not seem to be as sensitive to the discomfort from removing the epithelium.
Rudolph S. Wagner, MD, is an OSN Pediatrics/Strabismus Board Member.
It depends on the case
The choice of refractive technique will depend on the patient and what study you look at. There have been a number of studies with PRK and LASIK. Advocates of PRK will say that the results are very good, and the procedure may be safer in children.
 Michael O'Keeffe |
The degree of myopia and the corneal thickness may also influence the choice. I have done a number of children with surface laser PRK with good outcomes. I have not seen a lot of haze or regression in them, but I have to say I have not performed PRK in children above –8 D of myopia. With LASIK, I have gone up to –12 D. However, there is a concern here because you may not have enough tissue for the procedure you require.
One of the emerging techniques in anisometropia is not LASIK or PRK, but phakic IOLs. That is a big option in young children because in many cases you can put a foldable implant into the eye. We are not seeing the endothelial cell loss that was predicted, at least in adults. Adults with phakic IOLs are remaining stable, and these implants are reversible in many cases. You can take them out and replace them or change them. In my view, they will probably replace laser surgery in young children with myopic anisometropia.
Michael O’Keeffe, FRCS, is a surgeon at Children’s University Hospital in Dublin, Ireland.