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Pediatric Ophthalmology

Congenital catatact

Congenital cataracts cause visual deprivation that may result in severe amblyopia.

Early detection of a cataract involving the central visual axis in the child’s eye may save the vision. This disturbance has a great potential for amblyopia development, especially if present in one eye, and in the critical age for visual development, unless operated in time. Changing refraction with amblyopia treatment is a great challenge to visual rehabilitation, after pediatric cataract surgery. Nowadays, with better understanding of the pediatric eye growth and very suitable intraocular lens implants available for the child’s eye, special custom calculation for IOL and refined pediatric surgical treatments have become an established model for cataract treatment in children.

Visual rehabilitation is much better in pseudophakic IOL implantation, than aphacic convencional correction (glasses or contact lenses).

If the cataract is not dense and the visual axis is free, the risk of severe amblyopia is lower, and the operation could be planned for later.

Multifocal implants are considered from the age of 6 onwards, if satisfactory visual acuity is preserved, with the aim to “restore” the loss of accommodation, meaning compensation for near, distance and intermediate vision.

This will only give a chance to visual development, but strong amblyopia treatment is suggested after surgery for full visual rehabilitation.

Congenital glaukoma

Congenital glaucoma is a severe disease of the eye, sometimes discovered at birth and in some cases after a few years. Congenital glaucoma is expected to exist together with other eye disturbances (iris anomaly, congenital cataract, etc…).

Immediate treatment is necessary, with medications and/or surgical treatment, without delay.

Strabismus

Strabismus is defined as a misalignment of the visual axes and has prevalence ranging from 3 to 8 percent of the pediatric population. This condition is often recognized by parents themselves. The parallel position of the eyes is an important factor for normal visual function. In the age group up to three years of age, the interval between the onset of strabismus and treatment is the key factor in determining the prognosis. The earlier the operation, the better prognosis for the quality of binocular vision…

Some of the deviations are treated with an adequate correction of the refractive error (accommodative strabismus). Laser refractive surgery in these cases is indicated in contact lens or spectacles intolerance.

Concerning this topic, strabismus could be sub classified in several ways with the most basic one reflecting the direction of deviation: horizontal (eso-convergent and exo-divergent), vertical or torsional; then, concomitant (the same deviation angle in all the fields of gaze) and inconcomitant (deviation angle varies in the fields of gaze), usually associated with paralytic, restrictive or special syndromes (Duane’s and Mobius sy).

Ptosis

CONGENITAL ANOMALIES OF LIDS, ANTERIOR SEGMENT ANOMALY, PTOSIS, NASOLACRIMAL DUCT OBSTRUCTIONS, ETC

Ptosis, when covering the visual axes at the age up to 4, threatens the development of the normal visual function of that eye, and therefore should be corrected. This is not the question of aesthetics but function.

Nasolacrimal duct obstruction in children is manifested by sustained tearing, photophobia, and frequent ocular infections. The surgery must be performed with the aim of releasing the abnormal pathway of the tears and prevent further infection, by implanting special drainage micro tubing, only temporarily, for a few months. After achieving communication again, the artificial tubing is removed.

Corneal disorders

CONGENITAL AND ACQUIRED CORNEAL DISORDERS

Some of these corneal superficial changes are treatable today with excimer laser modalities.

PTK approach is aimed to remove the superficial, “bad” epithelial tissue and facilitate the corneal epithelization.

PTK – phototherapeutic keratectomy is used to ease the epithelial healing in recidivans epithelial erosions, to remove some of superficial scars, with polishing the superficial cornea and making it smooth. In combination with PRK (photorefractive keratectomy), a pre-existing refractive problem could be solved at the same time.

Progressive high myopia / Scleroplasty

The development of high myopia is mostly due to “uncontrolled“ enlargement of the globe axial length. Normally, in young patients, the shape and curvature of the crystalline lens compensate for this enlargement of the globe. This process is called emmetropization.

Sometimes, this is not enough, and the globe enlargement overtakes the emmetropization range and results in certain values of myopia. The globe wall tissue becomes thin, and the view of the posterior segment, the retina image has a special “myopic” presentation, tiny and vulnerable, with the risk of retinal detachment.

To stop the progression of the axial length growing, and decrease further myopia development, preserve the globe wall tissue from further thinning, and make the risk of retinal detachment lower, scleroplasty is recommended as a surgical procedure.

This procedure has been performed for years.

It is done in general anesthesia, now with the special biocompatible implants, very much used in many other fields of medicine (cardiovascular implants, etc.). There is no need for rest in hospital and the child goes home the very same day, a few hours after surgery.

A control visit is made about three weeks after surgery with further follow ups, thereafter.

High myopia development could be expected in various or unknown etiologies, genetics, in pseudophakic eye after cataract surgery, due to loosing the compensatory emmetropization process of the crystalline lens, which is very well known and encountered in a lens implant calculation, having in mind the age of the child, in Down syndrome, in the regressed stage of retinopathy of prematurity.

Refractive surgery in children

Refractive pediatric surgery is considered appropriate in children with severe myopic, hyperopic or astigmatic anisometropia (high dioptric difference between both eyes) or bilateral high ametropia (high refractive error) resistant to or with poor compliance with conventional therapy using spectacles or contact lens and conventional treatment of amblyopia.
The aim of refractive procedures in children is not to get rid of dependence on glasses or contact lenses, like in older patients in whom the process of visual development has ended.
It is a chance given today to these children to reduce anisometropia or to achieve isometropic status, to fully correct high refractive errors, much better than with standard / conventional treatment, and thus develop visual function as good as possible, better quality of visual acuity and binocular vision – tereopsis, facilitating patching treatment for amblyopia.

WHY IS IT IMPORTANT?

At the age critical for visual development (up to the age of 4 and 8, respectively), full correction of the refractive error is mandatory, but of course, in some cases, despite all the effort, this is impossible to achieve. Intolerance can be caused by physiological non-adaptation to spectacle aniseikonia and anisovergence (different size and shape of fixated object). A contact lens is not convenient at the early age.

Children with special needs and their parents are faced with one more stigma leading to a psychosocial problem. Most of these children have extreme refractive errors, in one or both eyes, together with some other ophthalmic problem (albinism, various forms of nystagmus, retinopathy of premature children…) or other medical disorder (autism, Sy Down, cerebral palsy and other neuromuscular impairments).

Without refractive surgery, these children are functionally blind, meaning very poor, limited visual function since the standard optical treatment is not working for them.

High refractive error in both or in one eye with a significant difference between the eyes (anisometropia) has a high potential for amblyopia development. The “better” eye (less error) conveys a better and sharper picture, accepted in the brain occipital vision center, than the other eye, (higher diopter), which needs higher correction, but still not the same quality of picture in comparison with the dominant. That is due to a different size and shape, looking through the spectacles. Amblyopia treatment demands an occlusion of the “weaker” eye, which is not accepted well by the child. Wearing glasses is compromised by making some “balance“ between both eyes and under correction of the higher diopter, but that may not reduce amblyopia effectively.

For some of them refractive surgery is the only way out of functional blindness, and for others it is an effective way to augment the treatment of amblyopia.

By now, Excimer laser pediatric surgery has a long follow up period, a lot of publications and studies issued concerning this topic that have shown it as an effective, predictable, safe and stable technique for the correction of the above mentioned refractive errors with a great amblyogenic potential.

That is the way to achieve isometropia and a better quality of vision, as well as a better quality of life for years to come.

Other solutions to achieve this aim, when laser is not indicated and conventional treatment is useless, are other refractive procedures, lens implant surgery, meaning Phakic intraocular lens implantation, and clear lens extraction with PC IOL implantation, as alternative. The aim of the phakic IOL implantation is to correct the high refractive error, preserving the biological, crystalline lens, with the preservation of accommodation. The procedure is indicated in high refractive errors beyond the range of 6 D and -13 D, even in a lower D value when thin corneas are not suitable for laser correction, and with an appropriate depth of the anterior chamber of 3.2 mm. The general anesthesia is required in these procedures involving children.

Excimer laser and refractive surgery in Sveti Vid

Refractive laser pediatric surgery in SVETI VID is advocated strictly to medical indications: severe anisometropia or bilateral high ametropia (myopia, hyperopia or astigmatism), with great amblyogenic potential in children incompliant and resistant to conventional therapy with spectacles or contact lenses, including children with special needs.

Advanced surface ablation (PRK and LASEK), ranging up to -13 D and up to 6 D is performed, with the sufficient corneal thickness, respectively. LASIK is prohibited in children population.

The procedures are performed on Schwind Amaris Excimer Laser, with an appropriate routine preoperative examination, cycloplegic refraction, ultrasound corneal thickness measurement, corneal topography, corneal and ocular wavefront.

Most of the procedures are performed in general anesthesia, in appropriate surgical surroundings, with a team with decades of experience in children population, in every kind of ophthalmic surgery.

Prof Dr Rudolf Autrata is performing pediatric refractive surgery in SVETI VID. He is a renowned ophthalmologist, among the leaders in this field of ophthalmology in the world, with a lot of well recognized publications and studies in high indexed ophthalmic journals. Devoted to the pediatric ophthalmology through his whole life, he has received many awards for his outstanding work and contribution to the development of pediatric ophthalmology, especially refractive surgery in children.

He started performing refractive pediatric surgery in the early 1990s, at the Children’s Hospital on Masaryk University in Brno, and established crown highlights in this pediatric field. He is a very much cited author.

Nowadays, refractive pediatric surgery is very well accepted in strict medical indications, and performed in a few qualified world university pediatric clinics, implying superb surgery, a high level of experience and a long period of performing.

From these places, as well as from the work of Prof. Autrata, came the very positive acceptance of these procedures, as regular, with stable, predictable and safe results published in their studies, as well (USA, Houston, Washington, New York, Calgary-Canada, Alicante-Spain, UK, Italy, etc.).

Special Hospital SVETI VID, in Belgrade, Serbia, is now among them, with the high quality of pediatric ophthalmology, and pediatric refractive surgery, with Professor Autrata, now a member of the team, who has established here in SVETI VID another great center of pediatric ophthalmic surgery.

Laser for children

The period of the most intensive development of vision starts at the age of two and lasts until the age of eight. This is when most can be done, regardless of whether cataract, refractive error, glaucoma or any other problem is concerned. Interventions performed later have less effect and therefore the first ophthalmologic examinations carried out around the time when the child is to start going to school are deemed too late.

LASER DIOPTRE CORRECTION IN CHILDREN

Laser dioptre correction in ophthalmology has been applied for more than 15 years. It is performed in certain, indicated cases in which conventional corrections with glasses or contact lenses cannot provide proper visual acuity. The primary aim of laser dioptre correction in children is not getting rid of glasses or contact lenses, but the treatment of amblyopia through an adequate dioptre correction, i.e. through creating conditions for the development of better visual acuity. This is the difference between the application of this method and the application of laser procedures in adults, in particular in persons older than 18 when the development of vision is finished.

This is very important as it is known that reaction must come in early childhood when almost 80 percent of problems in children may be successfully solved. The period of the most intensive development of vision starts at the age of two and lasts until the age of eight. This is when most can be done regardless of whether cataract, refractive error, glaucoma or any other problem is concerned. Interventions performed later have less effect and therefore professionals deem that the first ophthalmologic examinations carried out around the time when the child is to start going to school are too late. Waiting for laser correction until the age of 18 is meaningful only if visual acuity is preserved and laser is to remove the “dependence” on glasses or contact lenses. Even unstable dioptre cannot be an obstacle for laser. Correction offers the patient a clear and sharp image, while possible changes in dioptre will be “additionally corrected” by laser. However, if the development of vision in early youth is disturbed due to the impossibility of wearing glasses and contact lenses, waiting for a lacer procedure until the age of 18 is absurd as at that time there is no chance to recover visual function.

Indications for the application of laser in children in early childhood are as follows:

1. High difference in dioptre in both eyes, or high dioptre in both eyes

2. Accommodative strabismus, turning eye, as a consequence of uncorrected high farsightedness

3. Refractive surgery has shown good results in children with special needs (muscular dystrophy, autism, cerebral palsy, Down syndrome), when due to difficulties in communication it is difficult to achieve correction with glasses or contact lenses.

4. Superficial damages and irregularities of the cornea, superficial blur, scars, dystrophies. For more that 15 years I have been dealing with paediatric ophthalmology and refractive surgery in children, as well as with strabismus surgery. My papers have been published in renowned high-indexed ophthalmologic journals: Journal of Cataract and Refractive Surgery, Ophthalmologica, European Journal of Ophthalmology. I have been awarded several times at professional gatherings dedicated to this topic.

I have published the results of a thirteen-year study on the application of laser refractive and therapeutic procedures in certain indications in children.

The same results have also been published by many of my dear and appreciated colleagues from all over the world:

Dr Lawrence Tychsen, Professor of Ophthalmology in Washington (St Louis Children’s Hospital), Jorge L. Alio, Alicante, Spain, (Catedratico de Oftalmologia, Universidad Miguel Hernandes), Prof. Evelyn A. Paysse, M.D. Professor of Ophthalmology and Paediatrics, (Baylor College of Medicine, Texas Children’s Hospital, Houston), Marguarite McDonald, Professor of Ophthalmology at the universities in New York and New Orleans, Specialist for Refractive Surgery and Cornea, (until recently, President of the International Society of Refractive Surgery, ISRS , at the American Academy of Ophthalmology) MD, William F. Astle, University of Calgary, Canada, Regional Director of Alberta Children’s Hospital and many other eminent experts: Dr. Paulo Nucci, Dr. Michael O.Kneefe.

All interested persons may access these publications on the Internet, on www.PubMed.gov (key words: Pediatric Refractive Surgery), where they can find the mentioned authors and their publications.

A doctor’s obligation is to be informed about contemporary treatments and to inform the patient about treatment possibilities.

Prof. Dr. Rudolf Autrata, PhD, MBA
Professor of Ophthalmology and Director of Paediatric Ophthalmology Clinic of Masaryk University of Brno, Czech Republic
President of the Czech Association for Paediatric Ophthalmology and Strabismus
Professor-Consultant – Head of the Paediatric Ophthalmology Department of Special Hospital Sveti Vid, Belgrade, Serbia.

Pediatric Ophthalmology
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