Ординатура / Офтальмология / Английские материалы / Handbook of Pediatric Retinal Disease_Wright, Spiegel, Thompson_2006

Patients of all ages with high myopia often read better without their myopic correction, and some may prefer undercorrection even for distance; this is often related to minification with high minus lenses, and contact lenses may improve the situation. Myopes reading without glasses may be bothered by phorias or tropias causing asthenopia. Low-vision aids should be recommended when appropriate. Highly myopic eyes may develop strabismus later in life, often esotropia, and surgery of the extraocular muscles may be required.7 In addition, highly myopic eyes may require scleral buckling procedures for retinal detachment, and the buckles themselves may induce strabismus which requires surgical correction. Various vitamin and dietary regimens have been recommended, but scientific evidence of their efficacy is lacking.

TREATMENT

In preverbal children, correction should generally be given for myopia greater than 6.00 diopters, or if they demonstrate symptoms. Older children should be prescribed their full cycloplegic refraction for constant wear once the uncorrected visual acuity drops below the 20/40 range. In children, adolescents, or patients in their late teens or early twenties who develop an increase in myopia during periods of intense study or close work, a case can be made for doing close work without the myopic correction, or with a near plus add.36,54 Although several studies have failed to find significant benefit from this,18,23,44 there is a tendency for “high-risk” children (see above) to have less progression of myopia when bifocals are worn.23 Contact lenses offer improved quality of vision for patients with higher levels of myopia (especially those with anisometropia); they also afford benefits for those who participate in contact sports or other activities in which glasses cannot be worn, and for patients who do not want to wear glasses. The age at which contact lenses should be considered depends on the magnitude of the refractive error, the maturity of the child, and the wishes of the parents. Despite reports that contact lenses halt the progression of myopia, there is evidence that axial length continues to increase.3 The CLAMP study (Contact Lens and Myopia Progression) will revisit whether rigid contact lenses slow myopic progression, using a different study design that attempts to circumvent limitations of previous trials. At the start of the study,

78.4% of eligible children were able to tolerate rigid contact lens wear.64 Use of night-time wear contact lenses to temporarily reshape the cornea is also being studied.

Keratorefractive surgery of various types can be performed in an attempt to improve visual acuity without prosthetic devices. The long-term effects of these procedures in children with myopia is not known. Because childhood myopia is a progressive condition, one refractive surgery procedure is unlikely to be sufficient, and reoperation carries a higher risk of complications. Several small studies have examined the role of pediatric refractive surgery for unilateral high myopia with amblyopia. This condition often results in very poor vision in the amblyopic eye because of noncompliance with unilateral contact lens wear or refusal to wear very asymmetrical spectacles. Also, this type of myopia tends to be nonprogressive. Adult nomograms appear to provide good myopic correction in these eyes for children 9 years and older; however, the correction may regress over time.2,10 Corneal haze following photorefractive keratectomy (PRK) may exacerbate amblyopia, and the possibility of the corneal flap dehiscing with eye rubbing in uncooperative children who have laser in situ keratomileusis (LASIK) could cause serious complications. Also, in children old enough to cooperate with topical anesthesia for the procedure, amblyopia is already well established and best corrected visual acuity is only modestly improved or unchanged in most patients.40 Clear lens extraction or anterior chamber minus intraocular lenses are also used by some practitioners to correct high myopia. Because these eyes are already at increased risk of retinal detachment and glaucoma and the long-term results are not known, these procedures are not usually recommended for children.

Myopic patients should have yearly examinations to screen for the associated complications of cataracts, glaucoma, and retinal detachment. In young children with physiological myopia, intraocular pressure determinations are not usually necessary unless there are signs of glaucoma. In any infant or young child presenting with myopia, particularly under the age of 3 or 4 years when the sclera is still very distensible, congenital or developmental glaucoma must be excluded as an etiology. Corneal diameters and clarity should be evaluated, and intraocular pressure measurement and/or axial eye length determinations should be made and followed. Sedation may be necessary for some of these tests. Other causes of myopia such as diabetes mellitis and various medications should be considered.

The retinal complications of myopia are the most common and are potentially sight threatening. Approximately 40% of retinal detachments occur in myopic eyes. The risk of retinal detachment following intracapsular cataract surgery is elevated, especially if there is vitreous loss.22,24 According to a study by Perkins,45 the risk of retinal detachment increases gradually from eyes with high hyperopia, to low hyperopia, to low myopia, and finally high myopia. Another study showed that retinal detachment is correlated with increased equatorial diameter rather than just with refraction or axial length.35

Children and young adults with high myopia may present with complaints of new floaters and flashes of light. Posterior vitreous detachment (PVD) must be looked for in these patients with indirect ophthalmoscopy and (when possible) slit lamp biomicroscopy. Approximately 10% to 15% of eyes with a new PVD develop a retinal tear.24 Because tears may develop weeks after the PVD, another retinal examination should be performed 4 to 6 weeks after a new PVD is diagnosed. Some children with high myopia complain of bothersome floaters even in the absence of a PVD. If the retinal and vitreous examination are stable, reassurance is all that is required.

Symptomatic retinal tears, large horseshoe tears, and tears in the fellow eye of an eye that has had a detachment should be treated in children just as in adults. If the child is old enough and is cooperative, laser treatment can be done. In younger children general anesthesia and cryotherapy, or laser therapy with an indirect ophthalmoscope delivery system, may be required. In young children with vitreoretinal syndromes such as Stickler’s, prophylactic peripheral retinal laser treatment performed under general anesthesia may be indicated. Prophylactic peripheral laser treatment of the fellow eye should be considered, especially if one eye suffers a retinal detachment. All highly myopic children and their parents should know the symptoms of retinal tears and detachments and who to call if they occur. The risk of retinal detachment in children with physiological and low grades of intermediate myopia is very low.

Myopic children or young adults with retinal detachments should be treated with scleral buckling or vitrectomy. If encircling bands are used in the repair of detachments in infants and children, they may need to be divided or removed as the child grows. Encircling bands may induce additional myopia. In premature infants with retinopathy of prematurity in whom large retinal detachments occur within the first year of life, the prog-

FIGURE 12-7. A choroidal neovascular membrane in a myopic eye. Note the adjacent lacquer crack.

nosis for useful vision is poor, even in many of those with a good anatomic result48; this may occur because the retina quickly degenerates after detachment in very young infants.28 In uncomplicated myopic detachments occurring later in childhood, however, results may be good, unless coexisting myopic macular degeneration, sequelae from ROP, or an associated condition such as Stickler syndrome is present.

Subretinal neovascular membranes may form in the macula (Fig. 12-7). The results of laser treatment have not been as good as for membranes with other etiologies but should be considered if fluorescein angiography demonstrates a discrete membrane in a juxtafoveal or extrafoveal location.

Acknowledgments. Revision of this chapter was supported in part by the Georgia Lions Children’s Eyecare Center. This chapter is dedicated to Bill and Elise Emerson.

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