Correction of high ametropia in children with neurobehavioral disorders

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• Marc D. Myers, O.D.

Patients with neurobehavioral disorders frequently offer resistance to using spectacles and possess intolerance to contact lens wear. Unfortunately, this population has a greater incidence of high ametropia, anisometropia, amblyopia and strabismus, and concomitant developmental disorders, which compound their visual dysfunctions. Excimer laser photoablation and refractive lensectomy have been used in neurobehaviorly impaired children as well as adults to correct some ametropias. This study investigated the use of phakic intraocular lenses (IOL) in the correction of high ametropia in a population of children with neurobehavioral disorders.

In this prospective study of 20 consecutive surgeries of eyes in 12 children, the mean age at surgery was 10.1 years and ranged from 4 to 17 years. The indications for phakic IOL implementation included: (1) ametropia ≥10 diopters (D), (2) noncompliance with spectacles or intolerance/ill-suited for contact lenses, (3) no anterior or posterior segment disease, and (4) good rapport with the child's parents, who acknowledged the risks/alternatives and the importance of follow-up care. Correction was planned to achieve emmetropia or 1 D overcorrection of the spherical refractive error. To compare preoperative versus postoperative visual function, a 23-item Lickert scale visual function questionnaire was completed by the parent(s) before and an average of 3 months after the surgery. The Verisyse™/Artisan™ IOL (AMO, Santa Ana, California) was used in myopic patients, whereas the Ophtec IOL (Ophtec, Boca Raton, Florida) was used in hyperopes. Both lenses are identical in dimension, design, and material. The lenses were inserted into the anterior chamber and positioned over the pupil.

The initial myopic and hyperopic spherical correction averaged 14.5 ± 3.7 D and 9.4 ± 0.2 D, respectively. Seventeen eyes (86%) were corrected to within ±1 D of the spherical goal refraction, whereas the 3 remaining eyes were undercorrected by −1.1 ± 0.6 D. Even though surgical correction was not aimed at reducing astigmatism, mean cylinder before surgery was 2.6D ± 1.5 D but was reduced postoperatively to 1.6 ± 0.6 D. The reduction in preoperative versus postoperative refractive error was significant for both spherical (P = 0.0001) and cylindric (P = 0.03) correction.

The preoperative uncorrected visual acuity in the operated eyes averaged 20/3,400 with a range of 20/100 to 20/12,000. Postoperative uncorrected visual acuity averaged 20/57, representing a 60-fold improvement that was significant (P = 0.00). Eleven of the 12 children were noted to have enhanced visual awareness, attentiveness, or social interactions. Visual function scores improved by an average of 73% and 58% in bilateral ametropes and anisometropes, respectively. No eyes developed anterior or posterior segment complications, and only 1 patient required a second surgical procedure to correct a dislocated haptic.

Attempting to correct visual dysfunction in patients with neurobehavioral conditions can be challenging for eye care providers. The implantation of phakic IOLs represents a novel approach, with limited risk, for patients who would otherwise resist spectacle or contact lens correction. Additional studies must be completed to determine the long-term effects on vision, ocular function, and the social/emotional aspects of this approach.