Techniques in pediatric refractive surgery

Abstract

Pediatric refractive surgery treats refractive errors and their associated comorbidities such as amblyopia and strabismus in special needs children intolerant of spectacles or contact lenses. Children with neurobehavioral disorders undergoing refractive surgery have improvements in visual acuity, communication, socialization, motor skills, adaptive behaviors, visual perception, and cognitive function. Contrary to adults, amblyopia is frequently an indication for refractive surgery in special needs children. Pediatric refractive surgery techniques modify ametropia at the corneal, anterior chamber, posterior chamber, and lens planes. This article will discuss the most common modalities used today in pediatric refractive surgery, including laser keratorefractive surgery, phakic intraocular lenses, and refractive lens exchange. Practical pearls are discussed for the implementation of pediatric refractive surgery, reviewing preoperative diagnostics, surgical techniques, and postoperative care.

Keywords: Amblyopia; ametropia; pediatric refractive surgery; special needs.

Figure 1

This shows the necessary equipment for an exam under anesthesia for pediatric refractive surgery. Beginning from left to right, the image shows an ultrasound unit with A-scan, B-scan, and ultrasound biomicroscopy, topical anesthetic drop, tape to close the eyelids to prevent corneal dehydration, mydriatic drops including a cycloplegic agent, hand-held slit lamp, hand-held autorefractor keratometer, contact tonometry and pachymetry devices, digital calipers, gonioscopy lens, normal saline for hydrating the corneal surface, cotton tips for performing limbal rub to accelerate mydriasis, immersion lens for A-scan, scleral depressor, eyelid speculum, retinoscope with lens racks, and binocular indirect ophthalmoscope with indirect viewing lens

Figure 2

This shows the author positioning the patient underneath the excimer laser. The flexible extension tube of the laryngeal mask airway allows for the laser beam and pupil tracking system to be unobstructed. The patient’s iris plane is parallel to the floor, and the patient’s head is in line with his body

Figure 3

The axis of the toric implantable collamer lens is aligned using microscope alignment software

Figure 4

Intraoperative optical coherence tomography allows for the assessment of appropriate vaulting of the implantable collamer lens (ICL) over the crystalline lens, as well as iridocorneal angle viewing to check for angle closure. The green asterisks mark the anterior and posterior surfaces of the ICL. The red asterisks mark the anterior surface of the crystalline lens

Figure 5

In bicapsular capture, the optic of the three-piece intraocular lens has been captured through the anterior (green asterisks) and posterior (red asterisks) capsular openings, while the haptics reside in the iridociliary sulcus