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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.

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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
Background
  • Difficulties with children and LA
  • Reports of NO2 interference with Laser function
  • Aim – compare propfol/fentanyl and

ketamine/midazolam

method
Method
  • Prospective
  • 30 patients
  • Randomized to 2 groups
  • Age 3 to 12 years
  • Aniso/Amblyopia
method1
Method
  • NBM overnight
  • Clear fluids till 4 hours before
  • LASIK or LASEK
monitoring
Monitoring
  • Heart rate
  • MABP
  • SaO2

O2 by nasal cannula if SaO2 ≤ 90%

results
Results
  • Matched for: age

weight

duration of anesthesia

duration of surgery

results1
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
Ophthalmologist satisfaction
  • Bells phenomenon
  • Nystagmus
  • Overall intra and post-op state
  • No significant difference
  • (used suction ring for fixation)
conclusions
Conclusions
  • Propofolpreferred
  • Shorter acting
  • Lower incidence of dysphoric effects
  • Greater potential for airway compromise.
prk and lasik in accommodative esotropia

PRK and LASIK in accommodative esotropia

University of L’Aquila, Italy

methods
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
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
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
Post –op results

1 Year

  • ET’ 1.2 ∆esophoria
  • ET – orthophoric

2 Years

  • ET’ 2 ∆esophoria
  • ET 0.4 ∆
pre op group b
Pre-op Group B

Without 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 cl1
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 results1
Post –op results

1 Year

  • ET’ 1.7 ∆esophoria
  • ET 0.2 ∆esophoria

2 Years

  • No change
essentials to success
Essentials to success
  • Good binocular function
  • Good acuity
  • Careful selection of patients
  • ? Timing of surgery
slide22

Corneal surface ablation

  • Phakic IOL
  • Clear Lens Exchange
slide23
Who
  • Anisometropia – spectacle non-compliant

2.0 D - hypermetropes

3.0 to 4.0 D - myopes

  • Intolerance of specs or CL
  • Neuro-behavioural disorders
slide24
Who
  • Iso-ametropia
  • Spectacle non-compliant
  • Amblyopia approaching 50%
  • Neuro-behavioural disorders
  • Visual autism
slide25
Who
  • Other special needs

Craniofacial deformities

  • High hyperopia and esotropia

Poor spectacle compliance

strategy
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
Surface ablation
  • Volatile induction
  • Intravenous anaesthetic
  • EUA
  • LASEK or PTK/PRK
  • BCL and goggles
  • Epithelial healing as in adults
  • Better tolerated
phakic iol
Phakic IOL
  • Artisan iris enclaved
  • Bilateral sequential – 1 month interval
  • Absorbable sutures
  • Limbal relaxing incisions
  • Arm band restraints
refractive lens exchange
Refractive lens exchange
  • Above 20.0 D
  • ACD ≤ 3.2 mm
  • Lensectomy
  • Posterior capsulectomy
  • Anterior vitrectomy
  • Acrylic IOL
  • AL ≥ 29 mm - Prophylactic laser
efficacy
Efficacy
  • Improvement in UCVA
  • Best with bilateral ametropia
  • Modest with anisometropia
results surface ablation
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
Results – Phakic IOL
  • Ametropia – mean 15.0 D
  • UCVA 20/3400 to 20/57 (mean)
  • Similar results with CLE
surface ablation and anisometropia
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
Complications
  • Low
  • Several years follow up
  • Small numbers
surface ablation1
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 iol1
Phakic IOL
  • No regression
  • Corneal endothelium? Low rate of loss
  • ? Posterior chamber IOLs
  • ? Glaucoma/ Cataract
clear lens extraction
Clear lens extraction
  • Accomodation
  • Multifocal IOLS?
  • RD risk – 3% long term
conclusions1
Conclusions
  • Substantial benefits for selected patients
  • Need more information/scrutiny/disclosure
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