comparison of 2 anaesthesia techniques for pediatric refractive surgery

COMPARISON OF 2 ANAESTHESIA TECHNIQUES FOR PEDIATRIC

REFRACTIVE SURGERY

Magraby Eye and Ear Centre - OMAN

Background Difficulties with children and LA

Reports of NO2 interference with Laser function

Aim – compare propfol/fentanyl and ketamine/midazolam

Method

Prospective 30 patients Randomized to 2 groups Age 3 to 12 years Aniso/Amblyopia

Method

NBM overnight

Clear fluids till 4 hours before

LASIK or LASEK

Monitoring

Heart rate

MABP

SaO2 O2 by nasal cannula if SaO2 ≤ 90%

Results

Matched for: age weight duration of anesthesia duration of surgery

Results Time to recovery shorter in P/F group Opposite effects on BP and HR P/F group 3 patients needed O2

Post-op agitation and vomiting higher in K/M group

Airway obstruction (needing jaw thrust) higher in P/F group

Ophthalmologist satisfaction

Bells phenomenon Nystagmus Overall intra and post-op state

No significant difference (used suction ring for fixation)

Conclusions

Propofol preferred Shorter acting Lower incidence of dysphoric effects Greater potential for airway compromise.

PRK AND LASIK IN ACCOMMODATIVE ESOTROPIA

University of L’Aquila, Italy

Methods Prospective 18 consecutive patients Mean age 32.4 (range 21 to 52) Accommodative eso (normal AC/A) No suppression 8 – PRK (Group A) 10 – LASIK (Group B)

Pre-op – Group A Without correction ET’ 14.4 ∆ (10 to 19) ET 11.6 ∆ (8 to 14)

With correction ET’ 5 ∆ (4 to 6) ET 2.4 ∆ (2 to 4)

Mean 71.2 sec/arc

30 days in CL 2∆ esophoria – near 1.2 ∆ esophoria – distance

Refraction +4.6 D (mean) (range +3.50 to +6.00)

Mean BSCVA – 20/20

Post –op results 1 Year ET’ 1.2 ∆ esophoria ET – orthophoric

2 Years ET’ 2 ∆ esophoria ET 0.4 ∆

Pre-op Group BWithout correction ET’ 13.4 ∆ (8 to 21) ET 11.5 ∆ (6 to 19) With correction ET’ 5.4 ∆ (2 to 8) ET 2.8 ∆ (orthophoria to 6)

Mean 81 sec/arc

30 days in CL 2.5 ∆ esophoria – near 1.1 ∆ esophoria – distance

Refraction +6.46 D (mean) (range +5.00 to +8.50)

Mean BSCVA – 20/20

Post –op results 1 Year ET’ 1.7 ∆ esophoria ET 0.2 ∆ esophoria

2 Years No change

Only 1 case of regression Recurrence of ET

Essentials to success Good binocular function

Good acuity

Careful selection of patients

? Timing of surgery

Possible application to older children and young adults?????

REFRACTIVE SURGERY FOR CHILDREN

Review by L.Tychsen

Corneal surface ablation

Phakic IOL

Clear Lens Exchange

Who Anisometropia – spectacle non-compliant 2.0 D - hypermetropes 3.0 to 4.0 D - myopes

Intolerance of specs or CL

Neuro-behavioural disorders

Who Iso-ametropia Spectacle non-compliant Amblyopia approaching 50%

Neuro-behavioural disorders Visual autism

Who

Other special needs Craniofacial deformities

High hyperopia and esotropia Poor spectacle compliance

Strategy Baseline Repeated examinations EUA

Surface ablation +6.0 to -10.0 D ACD ≥ 3.2 mm Phakic IOL Remainder - Clear lens extraction

Surface ablation Volatile induction Intravenous anaesthetic EUA LASEK or PTK/PRK BCL and goggles Epithelial healing as in adults Better tolerated

Phakic IOL Artisan iris enclaved Bilateral sequential – 1 month interval Absorbable sutures Limbal relaxing incisions Arm band restraints

Refractive lens exchange Above 20.0 D ACD ≤ 3.2 mm Lensectomy Posterior capsulectomy Anterior vitrectomy Acrylic IOL AL ≥ 29 mm - Prophylactic laser

Efficacy

Improvement in UCVA

Best with bilateral ametropia

Modest with anisometropia

Results - Surface ablation

Ametropia avg 7.1 D

UCVA 20/180 to 20/60 (mean)

If glasses worn - BCVA 2-fold improvement

Results – Phakic IOL Ametropia – mean 15.0 D

UCVA 20/3400 to 20/57 (mean)

Similar results with CLE

Surface ablation and Anisometropia

90% within 1.5 D of emmetropia

Variable improvement in UCVA and BCVA

No reported loss of acuity

50% improvement in fusion and stereopsis

Complications Low

Several years follow up

Small numbers

Surface ablation 260 eyes - 1998 to 2008 Negligible rate of sight-threatening

complications LASIK – flap complications LASEK – thicker residual stroma Regression - 1.0 D/year ? Over-correction for myopes

Phakic IOL No regression

Corneal endothelium? Low rate of loss

? Posterior chamber IOLs

? Glaucoma/ Cataract

Clear lens extraction Accomodation Multifocal IOLS? RD risk – 3% long term

Conclusions

Substantial benefits for selected patients

Need more information/scrutiny/disclosure