Comparison of 2 anaesthesia techniques for pediatric refractive surgery
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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

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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


Comparison of 2 anaesthesia techniques for pediatric refractive surgery

  • Only 1 case of regression

  • Recurrence of ET


Essentials to success

Essentials to success

  • Good binocular function

  • Good acuity

  • Careful selection of patients

  • ? Timing of surgery


Comparison of 2 anaesthesia techniques for pediatric refractive surgery

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


Refractive surgery for children

Refractive surgery for Children

Review by L.Tychsen


Comparison of 2 anaesthesia techniques for pediatric refractive surgery

  • Corneal surface ablation

  • Phakic IOL

  • Clear Lens Exchange


Comparison of 2 anaesthesia techniques for pediatric refractive surgery

Who

  • Anisometropia – spectacle non-compliant

    2.0 D - hypermetropes

    3.0 to 4.0 D - myopes

  • Intolerance of specs or CL

  • Neuro-behavioural disorders


Comparison of 2 anaesthesia techniques for pediatric refractive surgery

Who

  • Iso-ametropia

  • Spectacle non-compliant

  • Amblyopia approaching 50%

  • Neuro-behavioural disorders

  • Visual autism


Comparison of 2 anaesthesia techniques for pediatric refractive surgery

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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