Paediatric SMILE?

SMILE effective for select cases of paediatric myopic anisometropia

Dermot McGrath

Posted: Friday, May 1, 2020

Soosan Jacob MS, FRCS

Small-incision lenticule extraction (SMILE®) is a safe and viable treatment option for select cases of children with ametropic and anisometropic amblyopia, according to Soosan Jacob MS, FRCS.

“These young patients can undergo refractive surgery if they are spectacle or contact lens intolerant for any reason. SMILE offers particular advantages in paediatric populations – it is safe, there are no flap complications to worry about and no haze or regression as in surface ablation treatments,” she told delegates attending the 37th Congress of the ESCRS in Paris.

Although considered controversial by some ophthalmologists, refractive surgery should not be ruled out completely in paediatric patients if strict selection criteria are adhered to and there are no other acceptable alternatives, noted Dr Jacob, Director and Chief at Dr Agarwal’s Refractive and Cornea Foundation, Chennai, India.

“Refractive surgery may be appropriate in bilateral high refractive error or unilateral severe anisometropia with amblyopia in children who cannot wear glasses or contact lenses. The majority of children with ametropia do well with glasses or contact lenses but a small minority do not. Refractive surgery can give them visual improvement, as well as social and psychological benefits that should not be underestimated,” she said.

Refractive surgery is particularly challenging in young patients, said Dr Jacob.

“We are dealing with an eye that is still growing and with changing refractive status. The preoperative assessment, the surgery itself, and postoperative assessment, are all more difficult in paediatric patients,” she said.

The advantages of refractive surgery in indicated children include a reduced chance for amblyopia, a better chance of binocularity, full-time correction of refractive error, and the outcome is not dependent on compliance, she said. It also avoids difficulties, challenges and risks associated with contact lens wear, she said.

“It is a safe procedure with the use of corneal suction and an immobile cap. There is less risk of flap rubbing, displacement, epithelial ingrowth or striae, and also less chance of general anaesthesia gases affecting the machine settings and outcomes. There is no need to shift between machines, there is less dry eye and better biomechanics,” she said.

Drawbacks of SMILE include the fact that it cannot currently be used to treat hyperopia or higher-order aberrations, said Dr Jacob.

To date, she said that she has successfully treated seven paediatric patients with a mean age of 10 years, all of whom were suffering from anisometropic amblyopia.

She advised, however, that rigorous follow-up for residual refractive error and occlusion therapy is required after surgery for these young patients.

Soosan Jacob: