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Is Laser Eye Surgery OK for Children?

From the WebMD Archives

Dec. 7, 2000 -- Nicole Sferra is a bright, enthusiastic business major at Chico State University in California. But three years ago she was a 16-year-old who feared sudden blindness would be the result of the bad vision that had plagued her since childhood.

Now she sees without the glasses that she had worn since she was 3 years old. The transformation is due to laser surgery performed to correct farsightedness, also known as hyperopia, in both eyes. Her case may be a step toward using laser in situ keratomileusis, or LASIK, as a standard treatment for certain vision problems in youngsters.

But before that happens, there are many doctors who will need to be convinced that the LASIK surgery should ever be practiced on children. The topic is a highly controversial one.

During the LASIK procedure, surgeons cut a flap of corneal tissue, move it out of the way, then use a laser to remove a piece of the tissue thinner than a human hair. The flap then is returned to its original position.

Jonathan Davidorf, MD, medical director of the Davidorf Eye Group and an ophthalmology clinical instructor at UCLA Jules Stein Eye Institute, believes LASIK surgery could correct sight for children who can't wear glasses or contacts. Initially, this would be for those whose vision is so poor that it hinders their learning abilities and social development, he tells WebMD.

An example of these would be youngsters with anisometropic amblyopia, what's known as lazy eye, who are unable to tolerate glasses or contact lenses. People with this condition have one eye that does not develop normal vision. Usually vision develops until about age 9, but for about 3% of people one eye is much weaker. This creates a vision imbalance between the two eyes and the brain tends to "shut down" the connection to the weaker eye.

Because the connections between the eye and the brain are established by the time you are 7 or 8 years old, it's important to maximize the vision in the weaker eye as soon as possible or the lost vision is unlikely to be regained. Treatments for this condition include wearing a patch over the "good" eye to force the child to use (and strengthen) the weaker eye, contact lenses or glasses, or sometimes surgery.

John Simon, MD, Albany Medical Center's ophthalmology chairman and a professor of pediatric ophthalmology, is just now warming to the idea of LASIK for adults (enough so, he says, that his wife is considering the procedure for her nearsightedness). But for a problem like lazy eye in children, Simon doesn't mince words.

"Glasses work perfectly well to protect what may be the one good eye. People with lazy eye won't have any better correction after LASIK, and you'll still have the compliance problem of not wearing a patch or contact," he tells WebMD.

"Fundamentally I have a problem [with the fact that] some of the aggressive LASIK surgeons will give false assumptions to parents that 'Johnny won't have crossed eyes any more.' That's just not true. I'm afraid that people will just say 'let's laser the child,'" he says.

As for Sferra, she fell into the category of having difficulty functioning because of her poor vision, making her the type of youngster Davidorf believes LASIK can most help.

"I had worn glasses since I was 3, and I had two eye muscle surgeries," Sferra explains. "When I was younger, glasses were no problem, but as I got older, I really hated them so much. Then I had hard contacts for two years but I broke one and couldn't replace it."

In addition, she wore a patch three times in an attempt to strengthen her weak eye when she was very young. "It was very embarrassing; kids were always asking what it was," Sferra tells WebMD.

Davidorf says her reactions are typical. "She had really heavy thick glasses. There is a stigma if a child is walking around with 'Coke bottles' on."

He says he knew they could use LASIK to correct her farsightedness by about 75% and because this type of vision problem often improves with age, this would be enough to give Sferra good functional vision that could get better. Currently, she doesn't wear glasses.

So far, Sferra is the only juvenile on whom Davidorf has performed the surgery but a group at the University of Pittsburgh Medical Center Eye and Ear Institute has used LASIK for children aged 5 to 8. Those youngsters also had anisometropic amblyopia but they were myopic, or nearsighted, rather than farsighted.

In a previous WebMD article on the University of Pittsburgh research, Simon claimed to be "uncomfortable" about using LASIK surgery on children under these circumstances, saying "it sends chills down my spine."

But Davidorf feels there is a place for LASIK surgery for children." We're studying the cases most in need of treatment," he says. "Once we find the protocol that is safe and effective, we can use LASIK on younger children."

Davidorf says he wants to try LASIK on youngsters under 10 years because it's "best to intervene early, the earlier the better." However, he cautions that it's important to first try other therapies for those with amblyopia, including patching the good eye to make the lazy eye work and wearing special contacts to correct the vision imbalance.

"As we age, the eye needs to be stimulated in order for it to develop properly," he says in explaining the therapies. But for those who don't respond to such treatment, LASIK may be an option. He cautions though that "it's not a surgery for kids who [just] want to throw away their glasses."

A number of roadblocks lie in the way of performing the laser procedure on those under 10. Davidorf says one of these is a technical problem in accurately evaluating children's vision. Another is that LASIK currently is FDA approved only for those over the age of 18. The surgeries done thus far on those younger have been under what is called Institutional Review Board approval, a committee at each institution that investigates the feasibility and safety of clinically testing a procedure on patients.

H. Dwight Cavanagh, MD, PhD, the vice chairman of ophthalmology at University of Texas Southwestern Medical Center at Dallas, says LASIK could be successfully performed on children and would provide long-term benefits. In addition, he tells WebMD, these benefits would most likely outweigh any risks to the patients. One positive would be eliminating wearing a patch or contacts.

"It's difficult trying to keep contact lenses on a 3-year-old," Cavanagh says. However he cautions that technical difficulties would have to be overcome. One is that because children must be asleep for the procedure, it increases the surgery's difficulty. Adults who undergo LASIK are awake, enabling the surgeon an optimal view while he or she is performing the procedure.

Special equipment needs to be developed to aid with LASIK in youngsters, who because of their age would not be able to stay awake and hold still long enough for the surgery, Cavanagh explains. In addition, the laser equipment currently used is not configured for people completely lying down and unconscious. "It's really an engineering problem rather than a medical one," he says of using the technique for children.

Simon agrees there is a problem with the technology. Namely, that LASIK is still a relatively new procedure. "The technology itself is a problem in children when we don't know the long-term effects. Children have a longer life expectancy than most adults who have LASIK done. We need to perfect it in adults before we use it on children," he tells WebMD.

What's needed to allow the use of LASIK on children, Cavanagh says, is a national study. Davidorf agrees and says that he is talking with the Institutional Review Board at his medical facility, West Hills Hospital in California's San Fernando Valley, about beginning an in-house clinical investigation of LASIK on children that he hopes will commence in January.

He has high hopes that though he can't guarantee LASIK will result in normal vision, he knows that it will improve vision dramatically, as it did for Sferra. "If my kid had this exact same problem, I would be signing them up," he says, adding that eventually it might be offered to youngsters just so they can feel more socially self-assured and to enable them to participate in things such as volleyball and tennis.

Already Sferra has reaped that benefit. "I'm more confident; I don't feel like I'm hiding behind glasses," she says.

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