Cataract and Cornea

Purpose: To provide a summary of the most recent evidence-based data on the paediatric refractive surgery. Methods: A review of the published studies from 1990 to 2015 was undertaken with emphasis on recent articles from 2010 to 2015. Results: Searching Scopus and PubMed, using the keywords of refractive surgery, phakic, paediatric, IOL, children and amblyopia alone or in various combinations yielded a total of about 48 articles on this topic from 1990 to 2015. Excluding review articles, fewer than 35 articles were included. Original research articles were only in the form of case reports/series on corneal laser surgery and phakic intraocular lens implantation or clear lens extraction. A total of fewer than 800 patients and 700 eyes had undergone a form of refractive surgery listed above. No randomised clinical trial (RCT) study was available on the topic. Age varied from 7 months to 17 years for non-corneal cross-linking studies. Most commonly performed operations were corneal laser ablative procedures (photorefractive keratectomy [PRK], laser-assisted sub-epithelial keratectomy [LASEK], laser-assisted in situ keratomileusis [LASIK]), phakic intraocular lens implantations (p-IOL, anterior or posterior chamber) and clear lens extraction. The indications for surgical intervention were for refractive – high amplitude iso-ametropic or anisometropic – amblyopia in the setting of the previously failed medical interventions and spectacle intolerance or non-compliance (physical or neurobehavioral in nature) and high accommodative esotropia with/without amblyopia. The main objective of the studies was to assess for visual acuity gained or lost following surgery and for correction of strabismus, i.e. achieving orthophoria. Further search on the keywords ‘cross-linking, cornea, rings and children’ from the same databases resulted in 130 articles. No RCT study was available on the topic. Age varied from 7 months to 17 years for non-corneal cross-linking studies. The focus of the most recent refractive surgery articles has been on the treatment and stabilisation of irregular myopic astigmatism from kerato-ectatic conditions by means of corneal cross-linking and intrastromal ring/in-lay implantation. Discussion: Refractive surgery remains a controversial topic in paediatric age population. However, the evidence clearly supports refractive surgery for treatment of children with refractive amblyopia and for treatment of accommodative esotropia in children unable or unwilling to wear spectacles or contact lenses. Conclusion: Consensus exists among published authors that refractive surgery may be considered in children with refractive amblyopia after exhausting various therapeutic medical options for amblyopia. Published authors have universally endorsed undertaking prospective multi-centred RCTs to conclusively establish the long-term safety and efficacy of various types of refractive surgery in the paediatric patients of different age groups.