Article Date: 7/1/2001

Practice Pulse
Tips, Trends, and News You Can Use

LASIK SURGERY FOR CHILDREN
Is Refractive Surgery a Legitimate Option for Minors?
By Karen Rodemich, Senior Associate Editor

Word has been going around about performing laser-assisted in situ keratomileusis (LASIK) on children less than 10 years of age. To some of you, this idea may seem a little premature or absurd. But Jonathan M. Davidorf, M.D., believes that in certain rare cases, LASIK may not just be the correct approach, but the only approach.

Specifically, Dr. Davidorf believes that LASIK is appropriate for children less than 10 years of age, as long as one of their eyes is much stronger than the other and if eyeglasses or contact lenses are troublesome for the child to manage. This anisometropia may facilitate the development of amblyopia.

Some, such as Paul Peng, O.D., J.D., who's the co-chairman of the Pacific Laser Center at the University of California, Berkeley believe that yes, some children may have difficulty with contact lenses, but that there are better, safer alternatives to LASIK. Dr. Peng believes that performing refractive surgery on a child is aggressive and that surgical intervention is inappropriate. He acknowledges the fact that some children have more trouble with contact lenses than others, but proper patient and parent education can make the task easier. Dr. Peng has been able to fit mentally retarded individuals with contact lenses.

Dr. Davidorf agrees that the child's eyes may continue to develop after the procedure, but insists that they'll at least develop at the same rate. He explains that even though actual eye size doesn't change much, refractive error does. By making them more equal, he says he's giving patients some fighting hope for better vision in the future.

If, a few years down the line, both eyes need correction, the patient can then elect to have the procedure performed again. In the initial surgical procedure, only the weaker eye is operated on -- and only in those patients who are amblyopic and refractory to conventional treatment methods (e.g., eyeglasses, contact lenses and patching).

Dr. Peng says, "If you're trying to treat an anisometropia, surgical intervention isn't the first way to do it, because there's a lack of long-term data on children. The alternative is contact lenses." He continues, saying, "The magic period is around 7.5 years old, so if you really want to intervene and prevent, you have to do it at age 6 because the cortical development is in place."

Dr. Davidorf agrees with the views of Dr. Peng and others. He says, "LASIK is totally inappropriate if conventional treatment is working. If not, you have two alternatives." Dr. Davidorf continues, "Do nothing, or think of something else. Doing nothing would be what we've been taught -- that there's really nothing else to do. If you look at doing something else, it might mean considering refractive surgery."

At this time, Dr. Davidorf has performed LASIK on two minors. One of the girls had high anisometropic amblyopia and her best corrected visual acuity was 20/70 pre-op. Her best corrected vision post-op was 20/50.

Dr. Davidorf's philosophy may seem a bit aggressive and perhaps unnecessary, so to put it into better perspective, consider this: He only performs LASIK on children under a study protocol and he says that evidence is surfacing that shows that there is some benefit to performing this procedure on minors. He's currently involved in a controlled study to see if this is indeed true.

Paul Karpecki, O.D., clinical director of refractive surgery, Hunkeler Eye Centers, Kansas City, Mo., believes that LASIK is warranted for children for the same circumstances cited by Dr. Davidorf. However, he says that he does recommend contact lenses or eyeglasses as a first option. "LASIK does help with anisometropia. Glasses don't work for it, and contact lenses aren't always an option, so I think it's valid in this scenario," he says.

Dr. Karpecki has performed LASIK on children as young as 9 years old. In total, he's successfully operated on 6 children less than age 16. All were anisometropic and contact lens intolerant.

Dr. Karpecki agrees that LASIK on children is aggressive, but that it may be the best treatment. He says that the individual has to be contact lens intolerant and anisometropic. "I don't recommend it as a mainstay. It's for extreme examples. You're not doing it for full correction, but for balancing," he says.

Robert T. Spector, M.D., F.A.C.S., is a practicing pediatric ophthalmologist, a clinical investigator for the Artisan lens and a neurologist. He says he's been strictly using reversible optical devices, such as implantable intraocular lenses (IOLs) and Intacs, as well as eyeglasses and contact lenses.

"We don't know the long-term effect of LASIK and the potential damage it could do in an infant," says Dr. Spector. "Also, LASIK isn't reversible. What appears to be anisometropia early on, with growth, can turn out to be ectasia."

He claims that the key to resolving anisometropia is eyeglasses, contact lenses or a product such as the Artisan lens. Another concern Dr. Spector voices regards the patient's stroma. He says, "That's the nub of this issue. Once you chisel away a stroma, you can't get it back."

Dr. Peng cites two reasons (functional and legal) why this surgery shouldn't be performed on children.

  1. Functional. If you're anisometropic, you'll have different image sizes at the brain level. Although both eyes can resolve 20/20, the different image sizes may cause strain and discomfort. At a young age, this effect may cause amblyopia. If the brain's not seeing things equally through both eyes, one eye will get the short end of the deal. If surgery is performed to mitigate amblyopia after age 8, it's too late. If the intent is to correct anisometropia and eliminate eye strain caused by different image sizes, it seems aggressive.
  2. Legal. LASIK is usually considered elective, so someone less than 18 years of age lacks the capacity to make the decision. And it's not a medically necessary treatment for anisometropia, so it's almost illegal and downright unethical. Until a doctor can prove that it's a medical treatment, he can't intervene until the patient is of legal age.
    That's why Dr. Karpecki says you have to get parental consent and explain the procedure to parents properly so they fully understand.

Dr. Peng says that contact lenses will solve the problem of image size. He also reiterates that the procedure is safer with adults. "Plus," he adds, "most surgical centers, including Pacific Laser Eye Center, have a prerequisite that unless your eyes have been stable for at least 6 months, the surgeons won't operate."

Whether you're for or against LASIK on children, M.D.s and O.D.s will still test to see if it's beneficial. If you're on the fence now, you may change your mind. 

O.D. NOTEBOOK
PEOPLE AND PROMOTIONS

Ghormley honored as Sportsman of the Year. Rex Ghormley, O.D., past president of the American Academy of Optometry, has been selected as the first recipient of the Blanton Collier Sportsman of the Year Award, which he received at the Annual Meeting of the International Academy of Sports Vision last month in Las Vegas. Dr. Ghormley is the team optometrist for the St. Louis Rams, the St. Louis Blues and the University of Missouri Tigers. He's in private practice in St. Louis.

UtlraVision's CEO resigns. Vincent Zuccaro, O.D., chief executive officer, co-founder, chairman of the board and director of UltraVision Corp. has resigned from his positions to devote his attention to helping staff develop new products, prepare them for launch and work more closely with customers.
William Garriock will serve as chairman, president and CEO until the company finds a replacement for Dr. Zuccaro.

IOL pioneer gone but not forgotten. British ophthalmologist Sir Harold Ridley, 94, died on Friday, May 25 of a cerebral hemorrhage. Ridley pioneered the intraocular lens (IOL) and implanted the first one in 1949 after noting that the eyes of World War II aviators were able to tolerate shards of plastic aircraft canopies.
In 1999, the American Society of Cataract and Refractive Surgery celebrated the 50th anniversary of the IOL implantation and honored Ridley as one of the "Ten Most Influential Ophthalmologists of the Twentieth Century." The following year, Queen Elizabeth II knighted Dr. Ridley.
He is survived by his wife and three children.

COMPANY NEWS

OSI gains recognition. Ocular Sciences has been included in Business Week's annual list of "Hot Growth Companies." The company was one of 100 best-performing small-cap companies selected from a pool of 10,000 publicly traded firms.

Advertising expansion. CIBA Vision recently announced that as a result of the ongoing integration of Wesley Jessen VisionCare, Inc., operations into CIBA Vision operations, it has consolidated its North American contact lens consumer advertising with Publicis, part of the U.S. division of the Publicis Groupe S.A.
The consolidation makes Publicis the lead agency for all consumer contact lens advertising for CIBA Vision in North America. The leading brands intended for advertising include the Focus and FreshLook families of contact lenses in all modalities.

BOARD CERTIFICATION
ABOP Killed; Specialties Now Grab the Spotlight
By Larisa Hubbs, Executive Editor

"Well, that was a lot easier than last year," Dr. Harvey Hanlen commented to the House of Delegates after the proposal to dismantle the board certification effort was unanimously passed -- without questions or comments -- during the AOA's annual meeting last month.

The proposal was put forth after a lengthy, involved effort by representatives from the AOA, the American Optometric Student Association, the Association of Schools and Colleges of Optometry, the Association of Regulatory Boards of Optometry, the American Academy of Optometry, the Veterans Administration and a handful of states.

These representatives met this past April 29 and 30 in St. Louis to hold a summit on the issue of board certification and continued competency.

"This was a very fair conference," said Dr. Alden Haffner to the House of Delegates. "There was no posturing, and it was a frank discussion."

During the summit, the participants answered four questions:

 

PROPOSAL ONE: The AOA House of Delegates should remove Resolution 1935 (board certification), as amended from the list of active policy pronouncements and place it in the historical archives.

OUTCOME: Unanimously passed.

  1.  Is there a need or demand for demonstrating continuing competency in optometry?
  2.  How can we best measure or demonstrate continued competency in optometry?
  3.  What measures of continued competency currently exist in the profession?
  4.  Can board certification be a useful tool to demonstrate continued competency in optometry?

After the 2-day meeting, the summit members developed a couple of proposals (see proposals one and two), which were presented to the House of Delegates at the AOA meeting.

After the first proposal was quickly passed by the House of Delegates, Dr. Haffner motioned to consider the second proposal, which stipulated that the AOA hold a summit for the purpose of discussing formally recognizing the optometric specialties.

Dr. Leland Carr from Oregon seconded the motion, and added "I think the atmosphere is right for this now."

Before voting for proposal two, Dr. Alan Roush from Indiana added a word of warning.

"I'm not opposed to studying this issue -- if it's done right.

PROPOSAL TWO: The American Optometric Association should convene a summit, ensuring profession-wide input, to study the issue of formally recognizing specialty areas within optometry.

OUTCOME: Passed by a majority vote.

"The summit just cleaned up a mess that was created 2 years ago. We need to use the ABOP issue as a role model for how not to study the specialty issue."

After this brief commentary, the proposal passed by an easy majority vote with a few "nays" among the delegates.

Also brought forth in the summit report was a consensus that from here on major policy decision-making by national optometric organizations should be preceded by substantive debate and discussion involving all stake holders.

In other House of Delegates news that day, one of the delegates announced that the governor of Oregon had just signed into law the authority for Oregon optometrists to prescribe orals and use injectables. The bill passed by a vote of 19 to 10 in the Senate, and 54 to 3 in the House. This passage was quite a feat because the governor is a former emergency room physician.


Optometric Management, Issue: July 2001