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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. 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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  1. Comparison of 2 Anaesthesia techniques for pediatric refractive surgery Magraby Eye and Ear Centre - OMAN

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

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

  4. Method • NBM overnight • Clear fluids till 4 hours before • LASIK or LASEK

  5. Monitoring • Heart rate • MABP • SaO2 O2 by nasal cannula if SaO2 ≤ 90%

  6. Results • Matched for: age weight duration of anesthesia duration of surgery

  7. 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

  8. Ophthalmologist satisfaction • Bells phenomenon • Nystagmus • Overall intra and post-op state • No significant difference • (used suction ring for fixation)

  9. Conclusions • Propofolpreferred • Shorter acting • Lower incidence of dysphoric effects • Greater potential for airway compromise.

  10. PRK and LASIK in accommodative esotropia University of L’Aquila, Italy

  11. 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)

  12. 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

  13. 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

  14. Post –op results 1 Year • ET’ 1.2 ∆esophoria • ET – orthophoric 2 Years • ET’ 2 ∆esophoria • ET 0.4 ∆

  15. 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

  16. 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

  17. Post –op results 1 Year • ET’ 1.7 ∆esophoria • ET 0.2 ∆esophoria 2 Years • No change

  18. Only 1 case of regression • Recurrence of ET

  19. Essentials to success • Good binocular function • Good acuity • Careful selection of patients • ? Timing of surgery

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

  21. Refractive surgery for Children Review by L.Tychsen

  22. Corneal surface ablation • Phakic IOL • Clear Lens Exchange

  23. Who • Anisometropia – spectacle non-compliant 2.0 D - hypermetropes 3.0 to 4.0 D - myopes • Intolerance of specs or CL • Neuro-behavioural disorders

  24. Who • Iso-ametropia • Spectacle non-compliant • Amblyopia approaching 50% • Neuro-behavioural disorders • Visual autism

  25. Who • Other special needs Craniofacial deformities • High hyperopia and esotropia Poor spectacle compliance

  26. Strategy • Baseline Repeated examinations EUA • Surface ablation +6.0 to -10.0 D • ACD ≥ 3.2 mm Phakic IOL • Remainder - Clear lens extraction

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

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

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

  30. Efficacy • Improvement in UCVA • Best with bilateral ametropia • Modest with anisometropia

  31. Results - Surface ablation • Ametropia avg 7.1 D • UCVA 20/180 to 20/60 (mean) • If glasses worn - BCVA 2-fold improvement

  32. Results – Phakic IOL • Ametropia – mean 15.0 D • UCVA 20/3400 to 20/57 (mean) • Similar results with CLE

  33. 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

  34. Complications • Low • Several years follow up • Small numbers

  35. 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

  36. Phakic IOL • No regression • Corneal endothelium? Low rate of loss • ? Posterior chamber IOLs • ? Glaucoma/ Cataract

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

  38. Conclusions • Substantial benefits for selected patients • Need more information/scrutiny/disclosure

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