Refractive surgery in children: the rare cases where it is done, and why glasses usually win
A child who hates glasses, a parent who has read about LASIK: here is why surgery is not the ordinary answer, the rare cases where specialists consider it, the risks, and what helps instead.
- The FDA states that no lasers are approved for LASIK on persons under the age of 18. Laser is not offered to children on request.
- A child's eye is still growing, so the glasses number keeps moving, and surgery cannot follow a number that is still on the move.
- The main indications in the paediatric literature are anisometropic amblyopia and bilateral high ametropia, when glasses and contact lenses have failed, for example in a child who cannot wear them.
- Studies in selected children report better vision and depth perception for some, and also corneal haze, regression and other risks. The reviews say trials are still needed, so there is no promise for any child.
- A child who dislikes glasses is not a surgical candidate. Fit, frame choice, a current prescription, contact lenses when suitable and early review of the lazy eye are what help.
A child who hates glasses, a parent who has read about LASIK online: the question "can my child just have the laser?" is a reasonable one to type at midnight. For almost every child the answer is no, and I would like to explain why, kindly, and what helps instead.
Can a child have LASIK or laser eye surgery?
Not in the ordinary way. The US Food and Drug Administration (FDA) states: "Currently, no lasers are approved for LASIK on persons under the age of 18." Laser vision correction is a choice that adults make for convenience, and in children it is not offered on request. The rare exceptions are medical, decided by specialists, and described below. If you want the age rule for a teenager and why the glasses number must stop changing, when can a teenager have laser eye surgery covers it.
Why is laser not done on children like it is on adults?
Because the child's eye is still growing and the glasses number is still moving. The American Association for Pediatric Ophthalmology and Strabismus (AAPOS) says that in short-sightedness laser surgery "might be an option once the eyes stop growing". Surgery reshapes the front of the eye to suit the number measured on the day. If the eye then keeps growing, the number drifts and the new shape no longer matches it.
There is a second reason, which is practical. Laser needs a person who can keep still and look at a light while measurements are taken, and who can follow careful after-care. A young child often cannot, and the same difficulty makes the checks before surgery hard. Adult surgeons ask for months or years of stable records. A child rarely has them.
The action: if your child is under 18, put the question aside and ask the eye doctor what the number is doing now, and how to look after it. How often a child needs new glasses explains why it keeps changing.
When is refractive surgery ever done in a child?
Rarely, and for a medical reason, not for looks or convenience. A review in Review of Ophthalmology says: "The main indications for refractive surgery in the pediatric population are anisometropic amblyopia and bilateral high ametropia." In plain words, that is a lazy eye caused by a big difference in power between the two eyes, or a very high power in both eyes.
Even then, it is considered where conventional treatment has failed, for example in a child who cannot wear glasses or contact lenses. The same review says: "When conservative methods such as glasses and contact lenses fail, surgical correction of refractive error is the most reasonable solution." A paper by Dr Paysse, a paediatric ophthalmologist, notes that glasses and contact lenses are often ineffective in children with severe anisometropia or bilateral ametropia, "especially those with neuropsychological disorders". These are children for whom glasses are pulled off every time, however patiently a family tries.
That is a small group. A child who simply dislikes glasses is not in it, and no one should be made to feel they have failed for asking. Squint and lazy eye in children: a parent's guide explains how lazy eye is normally treated first.
What operations have been used in these children, and what do the studies report?
The 2012 workshop in the Journal of AAPOS (Paysse, Tychsen and Stahl) says refractive surgery "has now been used successfully to treat severe anisometropia and isoametropia associated with amblyopia in children who cannot wear standard spectacles or contact lenses". It lists surface and flap laser treatments (PRK, LASEK and LASIK), and, inside the eye, refractive lens exchange and phakic lenses (lenses placed in front of the natural lens). It describes the intraocular techniques as "still being investigated in children".
The best-known long-term report is a study of PRK in eleven children aged 2 to 11 with amblyopia who would not comply with glasses, contact lenses or patching. At last follow-up, about 31 months on average, five of seven children who could be tested had uncorrected vision better by at least two lines, and four of seven had better corrected vision by at least two lines. Five of nine had better depth perception (stereoacuity). Haze in the cornea remained negligible. The same paper reports that not every eye reached its target, and that some power returned.
The Review of Ophthalmology article gathers further figures: in one group of children treated for anisometropic amblyopia, 49 percent had measurable stereopsis after surgery compared with 18 percent before, and uncorrected and best-corrected vision improved by at least two lines in two-thirds. It also reports myopic regression of -0.15 D per year in one study and -0.43 D per year in another. These are small studies of selected children. A 2007 review concludes that "randomized clinical trials are needed to fully establish safety and efficacy". Nothing here is a promise for any individual child.
What are the risks?
They are real, and they are why this stays a last resort. The Review of Ophthalmology article says: "The primary risk after surface ablation in children is the development of corneal haze and ectasia." Parents should understand the risk of keratoconus, it adds, and for lens operations the risks include endothelial cell loss, lens dislocation, pigment dispersion and cataract. It also notes a difficulty in young patients: under general anaesthesia the eye can rotate slightly, which makes it harder to line up the treatment for astigmatism.
Power can also drift back, called regression, as the eye keeps growing. A child may need glasses again, and some may need a repeat procedure. That is why the decision weighs the lazy eye that glasses could not treat against these risks, rather than the other way round.
Who decides, and what happens if it is considered?
A paediatric ophthalmologist and a refractive surgeon who treats children decide together, after glasses, contact lenses and amblyopia treatment have been tried properly. Surgery in young children is done under general anaesthesia, and the child is followed for a long time afterwards, because the eye is still changing. Parents give consent only after a full talk about benefits, risks and the chance that glasses will still be needed.
In Malaysia, this is a specialist decision in a centre that does this work, not a package offered at a laser centre. Ask whether the doctor is a registered specialist: you can check the National Specialist Register. Finding a children's eye specialist in KL and Selangor explains how. For a child with autism or ADHD who struggles with glasses, eye checks for children with autism or ADHD is worth reading first.
Other laser and lens choices for adults are covered in LASIK, SMILE or PRK: what each laser does and ICL implantable lenses for a high prescription.
Why do glasses usually win?
They work, they are reversible, and they can change as the eye grows. AAPOS says that for short-sightedness "glasses with minus power are the most common treatment", with contact lenses "if the child is old enough to care for them". A pair of glasses can be taken off and changed, which an operation cannot, and the prescription can be updated at every visit. For short-sightedness there is also myopia control, which tries to slow the eye's growth: see slowing myopia down: drops, lenses and honest numbers.
Amblyopia has its own treatments too. Glasses alone often improve a lazy eye, with patching or drops added when needed, and the sooner a child is checked the better the chance.
My 10-year-old hates glasses. What helps instead?
First, a 10-year-old who hates glasses is not a surgical candidate. The answer is to find out what is getting in the way. It is often the frame fit, a lens that is scratched or out of date, or a child who is teased at school. Ask the eye doctor to check the fit and the number, let your child choose the frame, and ask the optical shop to adjust the nose pads and arms. My child needs glasses gives a first plan.
If your child is old enough, contact lenses for children and teens may be an option, with strict hygiene and the doctor's agreement. If glasses are still refused after real effort, tell the eye doctor, because the lazy eye must not be left untreated while you wait. Bring it up early, not when the number has doubled.
- Your child keeps taking the glasses off, or squeezes the eyes, tilts the head or sits very close to the screen even with glasses on.
- Your child says the picture is blurry with the glasses, or complains of headaches after reading.
- One eye is turning in or out, or your child covers or avoids using one eye.
- Patching or drops for a lazy eye are being refused or skipped, or the last check was more than a year ago.
- The glasses are scratched, bent or no longer fit, or the number has not been checked since the last growth spurt.
Common questions
Can a child have LASIK?
Is there laser surgery for a 10-year-old who hates glasses?
When is refractive surgery done in children?
What surgery has been used in children?
What are the risks of laser or lens surgery in a child?
Does surgery cure a lazy eye in a child?
Why do glasses usually win over surgery for children?
Who decides if a child can have refractive surgery in Malaysia?
- US Food and Drug Administration · When is LASIK not for me? · www.fda.gov
- American Association for Pediatric Ophthalmology and Strabismus · Refractive errors in children · aapos.org
- American Academy of Ophthalmology · LASIK: laser eye surgery · www.aao.org
- Review of Ophthalmology · Refractive surgery in pediatric patients (2018) · www.reviewofophthalmology.com
- Paysse EA, Tychsen L, Stahl E · Pediatric refractive surgery: corneal and intraocular techniques and beyond. J AAPOS 2012 (PubMed) · pubmed.ncbi.nlm.nih.gov
- Paysse EA et al. · Long-term outcomes of photorefractive keratectomy for anisometropic amblyopia in children. Ophthalmology 2006 (PubMed) · pubmed.ncbi.nlm.nih.gov
- Paysse EA · Refractive surgery in children: is it ready for prime time? Am Orthopt J 2007 (PubMed) · pubmed.ncbi.nlm.nih.gov