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Refractive Surgery in ChildrenIs It Ready for Prime Time?

Correspondence: Requests for reprints should be addressed to: Evelyn A. Paysse, M.D., Baylor College of Medicine, Texas Children's Hospital, 6621 Fannin, MC 640.200, Houston, TX 77030; e-mail: epaysse{at}bcm.edu

Introduction: Potential indications for excimer laser procedures in children include accommodative esotropia, bilateral high ametropia, and severe anisometropia. Treatment of these conditions has traditionally included spectacle or contact lens use. This treatment, however, is often ineffective in children with severe anisometropia or bilateral ametropia, especially those with neuropsychological disorders. Refractive surgery may be a viable treatment option for these conditions.

Methods: The visual and refractive results from our studies on photorefractive keratectomy for pediatric anisometropic amblyopia are discussed. Also, I will present a review of the world literature on excimer laser procedures for accommodative esotropia, pediatric high anisometropia, and pediatric bilateral high ametropia.

Results: In our study, at 36 months follow-up, 7 of 9 patients who were able to perform psychophysical acuity testing preoperatively had improvement of two or more lines of uncorrected visual acuity and 6 of 9 had improvement of two or more lines of best corrected visual acuity. Fifty percent of the myopic patients and 100% of the hyperopic patients were within 2 D of refractive target at the 36-month follow-up visit. Refractive error stability has been good and corneal haze has been minimal.

Conclusions: Refractive surgery in children to reduce amblyopiogenic levels of refractive error is proving to be relatively stable. Best corrected and uncorrected visual acuity has also been shown to improve following the excimer laser procedures. Refractive surgery also appears to be effective for pure accommodative esotropia. Randomized clinical trials are needed to fully establish safety and efficacy. Other refractive procedures, such as clear lens extraction and phakic intraocular lenses, may also prove to be valid treatment options for these conditions in the future.

Key words: refractive surgery, excimer laser procedures, accommodative esotropia, anisometropia, ametropia