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For adult eyes only?

Young eyes have been off-limits to Lasik. Some predict the popular surgery will be as common for children as braces. Others, mindful of the risks, say that time is not now - if ever.

By Susan FitzGerald
INQUIRER STAFF WRITER

Now that more than a million adults have undergone laser surgery to improve their eyesight, doctors are starting to look at whether it could be appropriate for some children.

Lasik eye surgery is currently recommended only for adults because young eyes are still developing. But several studies are evaluating Lasik for a childhood vision problem commonly known as "lazy eye," which if not effectively treated can lead to a lifetime of poor eyesight.

At the same time, ophthalmologists who do Lasik surgery say they are getting more requests for it from teens who want to shed glasses or contact lenses or can't tolerate wearing them.

While all but a handful have been turned away until they're older, some doctors foresee the day when teens might get Lasik surgery - or more likely some outgrowth of the procedure - to improve their vision.

"I'm sure we're going to be doing that, just like we now give kids braces to fix their teeth," said Jonathan Davidorf, a Los Angeles-area ophthalmologist who recently reported on the results of doing Lasik surgery on a 16-year-old girl who was extremely farsighted.

For now, though, performing Lasik on children and teens is controversial - and highly experimental.

"Hopefully, anyone who understands kids' eyes would not do it when glasses and contact lenses can fix someone's vision," said ophthalmologist Jack Dugan Jr., director of refractive surgery at Wills Eye Hospital in Philadelphia.

Still, some doctors worry that the fierce competition for patients - ads touting discount prices for Lasik are common - coupled with all the adults who are pleased with their results, could lead to a gradual relaxing of the age standard.

"We've gotten so good at doing the surgery that doctors are now advertising it as if it's a trivial procedure, like being fitted for contacts," said Dr. Michael E. Sulewski, director of refractive surgery at the University of Pennsylvania's Scheie Eye Institute. "It's not. Things can go wrong."

Lasik stands for laser in situ keratomileusis. It involves using a laser to reshape the cornea, the clear covering of the eye that, along with the lens, focuses incoming light on the retina.

In people with normal vision, the cornea helps direct light precisely on the retina. But in people with farsightedness or nearsightedness, the shape of the cornea is slightly off; light does not hit the retina properly, blurring vision.

In Lasik, a surgeon uses a special knife to peel back a flap of the surface of the cornea. Then the laser is used to reshape it so that incoming light will be directed correctly. The flap is then put back in place; no stitches are required.

The Food and Drug Administration approved the use of lasers on people at least age 18 or 21, depending on the brand. As with all medical devices, doctors have discretion to use them on whomever they feel is suitable.

The cost of the procedure varies widely but typically is $3,000 to $6,000 for both eyes. It usually is not covered by medical insurance.

More than 1.5 million people have had Lasik surgery since 1995, according to the American Society of Cataract and Refractive Surgery. The American Academy of Ophthalmology says about 70 percent have their vision improved to 20/20 by the surgery, and studies so far have turned up no long-term concerns.

Potential risks include infection, corneal scarring, problems with night vision that necessitate wearing glasses, and "loss of best visual acuity," meaning vision after surgery, even with glasses or contacts, may not be as good as with glasses or contacts before surgery. Some people require a second "enhancement" surgery to improve the results. And even good results do not mean that the person won't need reading glasses in middle age.

While enthusiasm for Lasik continues to grow, Dugan, the Wills Eye ophthalmologist, said "there are many reasons why it shouldn't be done on children."

Among them:

Eyesight continues to change, often until the early or mid-20s. Lasik may correct a child's vision for a time, but a second surgery would likely be needed once vision stabilized in early adulthood.

Unlike adults, children need general anesthesia because they don't keep still during surgery.

Children may be more prone to complications such as infections because they are more likely to touch and rub their eyes.

It is improper to subject a child to the risks of Lasik surgery when good vision can be achieved through glasses and contacts.

But one area where researchers are studying whether Lasik surgery may be a good idea is for treating a type of amblyopia, or lazy eye.

The condition can develop when a child is born with vision that is much worse in one eye than the other. Basically, the good eye begins doing all the work, so neural connections in the visual pathway between the weaker eye and the brain don't develop properly, rendering the eye almost useless. Standard treatment is to patch the strong eye to force the bad eye, usually aided by glasses, to begin doing its job.

But not all children get good results from the treatment, and keeping the patch on and wearing thick glasses can be difficult for both kids and parents. And if amblyopia isn't diagnosed until after about age 9, it may be too late to stimulate good vision.

At the University of Pittsburgh Medical Center, researchers are testing Lasik on children who have failed conventional treatment for amblyopia. So far five children between the ages of 5 and 8 have had the surgery to improve vision in their weak eye, said Dr. Deepinder K. Dhaliwal, chief of refractive surgery.

"They essentially have no hope," Dhaliwal said. "If we leave these kids alone, we're never going to see improvement."

So far, she said, Lasik has proved safe and useful for such patients. Four out of five have improved vision in their weaker eye and, while patching was still required afterward, the children tolerated the treatment well.

Still, Dhaliwal sees no reason to think that the surgery would have wider use in children and teens.

"We are using Lasik as a therapeutic treatment for lazy eye," she said. "We aren't just doing it so the kids can get out of glasses."

Frederic Kremer, a Philadelphia ophthalmologist and pioneer in laser eye surgery, said there may be a place for the technique in very select cases of older children who have very bad vision and cannot tolerate glasses or contacts for either physical or psychological reasons.

In one such case, he said he performed surgery that was a precursor to Lasik on a 13-year-old girl who was constantly made fun of because of her thick, ugly glasses and was feeling traumatized.

Rebecca Tongsinoon - now 24 and a computer consultant in Austin, Texas - said her eyes were so bad she couldn't see the bedside clock, and the lenses of her glasses looked like Coca-Cola bottles.

"I couldn't wear wire rims because my lenses were so thick," she said, and she got infections from contacts. She went into the vision-correcting surgery knowing that she would have to repeat the procedure in early adulthood.

Tongsinoon needed no glasses after the surgery and then had an adjustment done on one eye at age 17 and the other at 21.

Kremer said he's done a couple of Lasik surgeries on older teens, but when teens ask for it, his advice is to be patient and wait.

Greg Chandler, 16, of Malvern, said he is eager to get Lasik because he's seen the good results his older brother got with the surgery.

"I'm told I'm still a little young," he said, but at his last eyecheck the doctor said his vision was stabilizing, so he may be ready by the time he is 18.

Because Greg wants to learn to fly, having the best vision he possibly can is important to him.

Davidorf, the Los Angeles ophthalmologist, said the 16-year-old girl he used Lasik on was badly farsighted and walking around barely able to see. When she first inquired about Lasik, his "knee-jerk response was 'Of course not, her eyes are still changing, she's in high school.' " But when she and her mother asked a second time, "then a lightbulb went off, maybe it wouldn't be so unreasonable."

Davidorf, who also is beginning a study of Lasik for children with lazy eye, said research will eventually sort out its most appropriate use for children and teens.

Meanwhile, teens are already viewing their glasses "as a totally temporary state," Davidorf said. "When we were growing up you were sentenced to glasses or contacts for life."


 

Susan FitzGerald's e-mail address is sfitzgerald@phillynews.com.


This article appeared in the Philadelphia Inquirer  2/12/01

Reprinted by permission Philadelphia Inquirer

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