Anterior and posterior capsulorhexis in children

Refractive surgery in children should be limited to those who have no alternative, Professor Michael O’Keefe, head of paediatric ophthalmology in University College, Dublin, told delegates yesterday.

“To improve or prevent amblyopia it must be performed early. It is not a substitute for patching,” he declared, concluding, ”We have learned a lot from adult refractive surgery. It is safe to apply some of this to paediatric refractive surgery.”

He explained that surgery is not commonly performed in paediatric patients. In the published literature between LASIK,LASEK and intraocular lenses there are less than 500 children treated.

“There are many reasons for this. The paediatric eye is different, with ocular growth to the mid teens, the sclera and cornea are less rigid and the visual system is developing. ”

He said there are are specific problems, too, such as anaesthesia, pre operative work up, exposure, the appropriate type of surgery and the post operative care. “There are not the same commercial drivers as there are only a handful of indications such as bilateral high myopia, anisometropia, accommodative strabismus and children who have undergone previous cataract surgery.”He said that most criticism of refractive surgery in children reflected the quality of published studies.

Published studies are retrospective or of dubious prospective nature, numbers studied are small and the follow up short. Some of the claims, such as restoration of stereopsis or improvement in amblyopia, lack scientific credibility. “It is not possible to restore any sort of improved vision or stereopsis when the child is beyond the age of cortical visual maturity,” Prof. O’Keefe, stated. He also noted that paediatric ophthalmologists tended to the other extreme, being more critical.

O'Keefe summarised refractive technique, namely LASIK versus LASEK.“I've experience of both procedures. In the LASIK group published in BJO (2004) we encountered no surgical complications. They all needed general anaesthesia. Those who had early refractive surgery got improved vision with patching and those who had late refractive surgery did not improve,” he said. Also, there are more numbers of children who have LASEK performed than LASIK because it is safer with less risk of flap displacement due to eye rubbing, common in children.

Pain is not as much a problem in children as in adults, he said. Regression remains the major issue because many have large refractive errors with high risk of keratocytes mediated re growth and epithelial hyperplasia .

“Papesse in a long term study 2004 reported a 33% regression over 3 years. So these children need Mitomycin and steroids post surgery. The mere thought of using these agents is likely to excite many paediatric ophthalmologists,“he told delegates.

He concluded that paediatric refractive surgery has a role but must be deployed with care.