As hundreds of thousands of U.S. adults enthusiastically embrace Lasik eye surgery, it's no surprise that children are beginning to ask, "What about me?"
Eye surgeons report that a small but growing number of teen-agers who for various reasons cannot -- or don't want to -- wear glasses and contact lenses are seeking Lasik eye surgery. Some doctors question the ethics of performing Lasik on young eyes that are still developing while also noting that the procedure, despite a strong safety record, is not without risks.
Meanwhile, some researchers have begun performing Lasik on young children with serious eye disorders that have not responded well to other treatments. One such clinical trial is under way in Pittsburgh, and studies are set to begin soon in Los Angeles.
Lasik, which uses an excimer laser to reshape the cornea to correct nearsightedness and farsightedness, already has been studied in parts of Europe and India for children with certain vision problems. Those studies have produced favorable results, prompting some U.S. doctors to reconsider the long-standing belief that children's eyes are continuously changing and therefore should not be surgically corrected. And doctors are also encouraged by the safety record of some 2.5 million Lasik surgeries in the United States.
Although the long-term effects of Lasik -- especially repeated Lasik surgeries -- are unknown, short-term studies show a very low risk of serious complications, such as blindness, and a 5 percent to 15 percent rate of less serious complications, such as dry eyes, glare or light sensitivity, according to the American Academy of Ophthalmology.
"What's pushing this interest in children is the safety record in adults," said Dr. Jonathan Song, a pediatric ophthalmologist at Childrens Hospital in Los Angeles and the Doheny Eye Institute.
The notion that Lasik can't be performed in the still-developing eye of a child is "too simplistic," according to Song. Researchers know very little about how and why children's eyes change as they get older -- or about why some kids' eyes don't change at all. "There is a whole field of research (that needs) to be opened up," he said.
But other doctors are uneasy with the idea of performing Lasik on children. Even a remote possibility of causing blindness in a child for an elective surgical procedure is reason enough to err on the side of caution, they say.
"As a general rule, it's not appropriate to do Lasik in children whose eyes are still growing and are not stable," said Dr. Peter J. McDonnell, chief of ophthalmology at University of California, Irvine. "Even if treatment seems justified, doctors aren't sure how well Lasik and other refractive surgeries will work."
The U.S. Food and Drug Administration has approved the lasers used in Lasik for nearsighted adults ages 18 and older and for farsighted adults ages 21 and older. In actual practice, however, doctors can use the lasers however -- and on whomever -- they wish.
While Lasik in youths who simply don't want to wear glasses or contact lenses remains controversial, support is growing for studying Lasik in young children with a vision defect in which one eye is much worse than the other.
The condition, called anisometropia, affects about 1 percent of children at birth. Most children begin treatment as babies by wearing special glasses or contact lenses to improve vision. They may also wear a patch over the stronger eye to force the weaker eye to work.
If the treatment doesn't work, the child can develop amblyopia -- or lazy eye -- in which the brain sends messages to see through the stronger eye and ignore the weaker one. The weaker eye can eventually become useless.
But glasses often don't work because kids won't wear them or the treatment is ineffective, said Dr. Jonathan Davidorf, a Los Angeles ophthalmologist. And getting a toddler to wear contact lenses could be all but impossible. "With Lasik," he said, "we may be able to make a correction to the bad eye and allow the eyes to balance out. It can give these kids a fighting chance."
A few studies in India and Egypt have been promising, as has one small study under way at the University of Pittsburgh. Five young children with severe anisometropia who had failed conventional therapy have had Lasik to improve vision in the weaker eye, said Dr. Deepinder K. Dhaliwal, chief of refractive surgery at the University of Pittsburgh Medical Center.
None of the children had their vision worsen, while four of the five children had improved vision, said Dhaliwal, who said providing anesthesia to the children is one of the trickiest parts of the procedure.
"After the surgery they continue to do the patching (therapy). But they are much more accepting of the patch after the surgery," she said, adding that making the weaker eye even a little better can allow patching therapy to work.
The Pittsburgh team is overjoyed at the response, Dhaliwal said, "because if you don't intervene in these children early, they will never recover their vision. There is a sensitive period in visual development until about age 9. That is why we were motivated to try this in young children."
Song is also interested in trying Lasik in children whose corneas have been scarred by infection or an accident.
Children with corneal scarring often need a corneal transplant to preserve vision, Song said. But in children, there is a substantial risk that the body will reject the transplanted cornea.
Lasik might be the answer, he said. "If the scar is on the top layer of the cornea, we think we can laser it down (using Lasik)."
Tracking the progress of children who have had Lasik for anisometropia and corneal scarring will enable researchers to collect data on how the eye responds to such surgery, Song said.
"We need to learn how the cornea heals and changes over time," he said. "We need to know whether Lasik works in children because children might be able to benefit greatly."
Doctors who treat teens can take two approaches to correcting their vision. They can correct the current vision, knowing another surgery probably will be required in several years as the eyes change. Or they can over-correct the vision in anticipation that their eyesight will worsen for a few more years.
Still, most doctors would agree it's controversial to perform Lasik on teens who just don't like to wear contacts or glasses.
But some doctors predict attitudes will change if research demonstrates the effectiveness of laser eye surgeries for children and if, as expected, the procedures become safer and reversible as the technology improves.
"When contact lenses first came out, people said we shouldn't give them to children," Song said. "I think the same thing will hold true for Lasik. ... In the long run, I think laser surgery in children will become common."
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