Refractive Surgery for High Bilateral Myopia in Children with Neurobehavioral Disorders: 2. Laser-Assisted Subepithelial Keratectomy (LASEK)

doi:10.1016/j.jaapos.2006.04.004

Journal of American Association for Pediatric Ophthalmology and Strabismus

Volume 10, Issue 4, August 2006, Pages 364-370

Presented at the American Association for Pediatric Ophthalmology and Strabismus Annual Meeting Orlando, Florida, March 2005.

https://doi.org/10.1016/j.jaapos.2006.04.004 Get rights and content

Introduction: A subpopulation of children with high myopia and neurobehavioral disorders is noncompliant with spectacle wear and ill-suited to correction using contact lenses. We report the results of refractive surgery in a series of these children treated bilaterally using excimer laser technology. Methods: Clinical course and outcome data were collated prospectively in a group of 9 children (mean age, 10.2 years; range, 3-16 years) with neurobehavioral disorders exacerbated by chronic noncompliance with spectacle wear, causing profoundly low functional vision. Myopia in the 18 eyes ranged from –3.75 to –11.5 D (mean –16.6 D) and the desired refraction was ∼+1D. Correction was achieved by bilateral laser-assisted subepithelial keratectomy (ie, LASEK) performed under brief general anesthesia. Mean follow-up was 17 months (range, 6-36 months). Results: Myopia correction averaged 7.9 D. Eighty-nine percent (16/18 eyes) were corrected to within ±1 D of goal refraction. Uncorrected acuity improved postoperatively in all 18 eyes, with commensurate gains in behavior and environmental visual interaction in 88% (15/17 children). Myopic regression averaged ∼0.8 D/year. The only complication encountered was mild (1+) corneal haze in 35% of treated eyes. Discussion/Conclusions: Bilateral excimer laser surgery is effective for improving functional vision substantially in highly myopic, neurobehaviorally impaired children who have difficulties wearing glasses. Myopic regression is common. Further study is indicated to determine the long-term safety of these and alternative refractive procedures in similar pediatric populations.

Section snippets

Patients and methods

Clinical outcome data displayed in TABLE 1, TABLE 2 were collated from a prospective study of 18 consecutive eyes treated bilaterally and simultaneously in 9 ametropic children and adolescents (5 boys, 4 girls; hereinafter referred to collectively as “children”). All surgery was performed at St. Louis Children’s Hospital between April 1997 and May 2004. Table 1 lists the preoperative and postoperative refractive data of each child. Table 2 itemizes acuity, ocular/visuomotor status, and

Refractive Error and Surgical Correction

Table 1 lists the preoperative refraction, goal refraction, and initial postoperative refraction for the 18 eyes in the 9 children. The preoperative refractive error ranged from –3.75 to –11.5 D (spherical equivalent [SE]; mean, –7.1 D). Ten of the 18 eyes treated (56%) also had astigmatism, ranging from 1.0 to 3.0 D (mean, 2.0 D). Treatment was tailored to achieve a goal refraction of plano to +2.00 in children ages 5 years and older. The goal refraction for children younger than age 5 was

Discussion

The purpose of this study was to review outcomes in a series of children treated by pediatric ophthalmologists using bilateral LASEK, with the goal of answering 2 major questions. Is the procedure an effective way to correct high myopia in children who, for one reason or another, are not suitable candidates for correction by other means? The answer to this question, based on the findings in the Results section, is yes, when effectiveness is measured as improvement in acuity or ability to

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Impact of Ocular Conditions and Improvements After Refractive Surgery in Quality of Life for Children With Neurodevelopmental Disorders
2023, American Journal of Ophthalmology
This study aims to characterize the eye-related quality of life of children with neurodevelopmental and ocular disorders at baseline and after refractive surgery.
Prospective interventional case series.
We enrolled children and adolescents 5 to 18 of age with neurodevelopmental disorders undergoing refractive surgery (6 for pre-/postsurgical assessment and 14 for baseline analysis). Eye-related quality of life was measured using the Pediatric Eye Questionnaire (PedEyeQ). Baseline levels of adaptive functioning and social behaviors were measured using the Adaptive Behavioral Assessment System (ABAS-3) and Social Responsiveness Scale (SRS-2). We assessed the correlation between baseline PedEyeQ scores, number of ocular comorbidities, magnitude of refractive error, and ABAS-3 and SRS-2 scores.
At baseline, 14 patients demonstrated decreased median eye-related quality of life (<60/100) in 5 of 9 PedEyeQ domains, moderate deficiencies in social behaviors (SRS-2 median 71, range 49-90), and low adaptive functioning (ABAS-3 median percentile for age of 0.100). Baseline PedEyeQ scores did not correlate with magnitude of refractive error or adaptive functioning scores but did correlate with number of ocular comorbidities and social behavior scores. Six patients have undergone refractive surgery without complication. Postoperatively, 11 of 11 eyes were within ±1.5 diopters spherical equivalent. Four of 6 patients exhibited clinically significant improvements in PedEyeQ scores after surgery.
Even in the presence of significant social and adaptive impairments, quality of life in children with neurodevelopmental disorders is decreased by ocular disorders. Refractive surgery is associated with clinically significant improvements in eye-related quality of life.
Developmental Improvement in Children With Intellectual Disability After Photorefractive Keratectomy for Severe Isoametropia
2022, American Journal of Ophthalmology
Citation Excerpt :
It has previously been shown that PRK and LASEK result in a decrease in the refractive error and improved visual acuity in children with isoametropic amblyopia and neurobehavioral problems.17,18 It has also been reported from parental questionnaires that children with isoametropic amblyopia and neurobehavioral problems improve socially after PRK or LASEK.17,18 There is, however, significant potential bias when using only a parental questionnaire to evaluate functional improvement, because parents have a large degree of investment both emotionally and financially after their children have undergone a surgical procedure.
To assess the impact of refractive error correction from photorefractive keratectomy on development in children with severe isoametropia, subnormal visual acuity, and intellectual disability unable to use refraction correction.
Prospective noncomparative interventional case series.
Before and after photorefractive keratometry (PRK), subjects who had plateaued developmentally for 18 or more months were assessed using a battery of developmental tests. The primary outcome measure was the change in the developmental quotient (DQ) 6 months after PRK. Secondary outcomes were the change in the DQ, uncorrected visual acuity, cycloplegic refraction, and corneal status 12, 24, and 36 months after PRK.
Sixteen subjects aged 2 to 8 years were included. Twelve were highly myopic (mean, –9.69 ± 3.82 diopters [D]), 3 highly hyperopic (mean, +5.75 ± 0.59 D) and 1 highly astigmatic (mean, +3.50 D). Six months after PRK, the DQ significantly improved for expressive communication (mean, 4.51 ± 2.27 months; P = .04), interpersonal relationships (mean, 9.45 ± 4.18 months; P = .02) and coping (mean, 6.44 ± 2.10 months; P = .05). Twelve months after PRK, the DQ significantly improved for receptive communication (8.04 ± 1.80 months; P < .001), expressive communication (6.99 ± 2.27 months; P < .05), written communication (9.28 ± 3.72 months; P < .04), domestic skills (6.50 ± 2.43 months; P < .03), interpersonal relationships (10.57 ± 4.17 months; P < .02), and coping (8.41 ± 3.25 months; P < .5).
PRK significantly improves developmental abilities of children with intellectual disability, severe isoametropia, and previously plateaued development, in addition to improving visual acuity and refractive error.
Visual acuity, refractive error, and regression outcomes in 169 children with high myopia who were implanted with Ophtec-Artisan or Visian phakic IOLs
2021, Journal of AAPOS
Citation Excerpt :
For the average 12 D of myopia we treated, the lack of regression is noteworthy. The mean regression reported by our group and other investigators after pediatric excimer laser surgery averages 0.5 to 1.0 D/year.3,11,35,36 Excimer laser ablation of an average 12 D of myopia would entail removal of 144 μm of corneal stroma.
To analyze outcomes in a large cohort of spectacle-aversive children with high myopia who were treated by implantation of the Ophtec-Artisan or Visian phakic intraocular lens (pIOL).
Outcome data were collated retrospectively in 78 children (115 eyes) implanted with the Ophtec-Artisan iris-enclaved anterior chamber pIOL and 91 children (154 eyes) implanted with the Visian ICL (intraocular collamer lens) sulcus pIOL. All children had difficulties with spectacle or contact lens wear. Mean age at surgery was 9.9 years; mean follow-up was 3.9 years (range, 0.6-14.1 years).
A total of 248 of 269 eyes (92%) were corrected to within ± 0.5 D of their target value. Spherical correction averaged 12.3 ± 1.0 D. Refractive spherical regression was −0.04 D/year at last follow-up. Uncorrected distance visual acuity improved from an average logMAR 1.8 to 0.4; corrected distance visual acuity improved an average 0.3 logMAR. Of the treated children, 68% had a gain in binocular fusion. Neurobehavioral and/or visuomotor comorbidities were present in 87% of children. Five eyes (2%) developed retinal detachment an average 6 years after implantation. Nine eyes (3%) implanted with the Ophtec-Artisan pIOL required repositioning after trauma.
Implantation of pIOLs in children is an effective method for correcting high myopia in spectacle noncompliant children. Rates of myopic regression after pIOL surgery are substantially lower than those reported for children treated by excimer laser photorefractive keratectomy (PRK). The prevalence of major complications was relatively low in this high-risk population.
Technique for pediatric corneal crosslinking under general anesthesia
2020, Journal of AAPOS
Corneal cross-linking (CXL) is typically performed under topical anesthesia, which may be unsuitable in children and individuals with severe anxiety, poor cooperation, or neurodevelopmental issues. We describe a technique of CXL under general anesthesia that uses sevoflurane and propofol with laryngeal airway or nasal oxygen cannulas, and forceps or microsponges to stabilize the eye position intraoperatively. We also developed a simple and time-saving technique of bilateral simultaneous CXL, whereby the second eye can undergo CXL concurrently with the first in a staggered fashion. Using this technique, we have been able to eliminate up to 25% of surgical time required in standard bilateral procedures. Postoperatively, multimodal analgesia was administered to ensure patient comfort and prevent excessive eye rubbing. In total, 21 eyes of 13 subjects ≤18 years of age were treated. During a median follow-up of 14.5 months (range, 4-43), the only complication observed was sterile corneal infiltrate in 1 eye that resolved with a short course of corticosteroids.
Phakic Intraocular Collamer Lens (Visian ICL) Implantation for Correction of Myopia in Spectacle-Aversive Special Needs Children
2017, American Journal of Ophthalmology
Citation Excerpt :
The main postoperative acuities reported are uncorrected because that is the relevant measure in children noncompliant with spectacle wear. The acuity gains are comparable with those we have reported in spectacle-noncompliant children with high ametropia treated by bilateral LASEK/photorefractive keratectomy (PRK),3,19–21 bilateral Artisan-Ophtec phakic IOL implantation,13 or bilateral refractive lensectomy.2 Despite the inherent variability of pediatric measures—and the extra work required to obtain them—the accuracy of correction was reasonable.
A subset of children with high anisometropia or isoametropia and neurobehavioral disorders have chronic difficulties with spectacle or contact lens wear. We report the results of refractive surgery in a series of these children treated using bilateral or unilateral intraocular collamer lens (Visian ICL) implantation for moderate to high myopia.
Prospective nonrandomized cohort study.
Clinical course and outcome data were collated prospectively for 40 implanted eyes in 23 children (mean age 10.2 ± 5.3 years, range, 1.8–17 years). Myopia ranged from −3.0 to −14.5 diopters (D), mean −9.2 ± 3.5 D. Goal refraction was plano to +1 D. Correction was achieved by sulcus implantation of a Visian ICL (STAAR Surgical, Monrovia, California, USA) under general anesthesia. Mean follow-up was 15.1 months (range, 6–22 months).
Thirty-five eyes (88%) were corrected to within ±1.0 D of goal refraction; the other 5 (12%) were corrected to within 1.5 D. Uncorrected distance visual acuity improved substantially in all eyes (from mean 20/1050 [logMAR 1.72] to mean 20/42 [logMAR 0.48]). Spherical regression at last follow-up was an average of +0.59 D. Visuomotor comorbidities (eg, amblyopia, nystagmus, foveopathy, optic neuropathy) accounted for residual postoperative subnormal visual acuity. Thirteen of the 23 children (57%) had a neurobehavioral disorder (eg, developmental delay/intellectual disability/mental retardation, Down syndrome, cerebral palsy, autism spectrum disorder). Eighty-five percent (11/13) of those children were reported to have enhanced visual awareness, attentiveness, or social interactions. Endothelial cell density was measureable in 6 cooperative children (10 eyes), showing an average 1% decline. Central corneal thickness, measured in all children, increased an average of 8 μm. Two children (8%) required unplanned return to the operating room on the first postoperative day to alleviate pupillary block caused by a nonpatent iridotomy. No other complications were encounterd.
Visian ICL implantation improves visual function in special needs children who have moderate to high myopia and difficulties wearing glasses or contact lenses.
Refractive surgery in children
2016, Taylor and Hoyt's Pediatric Ophthalmology and Strabismus, Fifth Edition

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Major articleRefractive Surgery for High Bilateral Myopia in Children with Neurobehavioral Disorders: 2. Laser-Assisted Subepithelial Keratectomy (LASEK)

Section snippets

Patients and methods

Refractive Error and Surgical Correction

Discussion

J Am Assoc Pediatr Ophthalmol Strabismus

J Cataract Refract Surg

J Cataract Refract Surg

J AAPOS

Vision Res

J AAPOS

Ophthalmology

Ophthalmology

J Cataract Refract Surg

Exp Eye Res

J Cataract Refract Surg

J Cataract Refract Surg

J Cataract Refract Surg

Ophthalmology

J Cataract Refract Surg

J Cataract Refract Surg

Major article
Refractive Surgery for High Bilateral Myopia in Children with Neurobehavioral Disorders: 2. Laser-Assisted Subepithelial Keratectomy (LASEK)