We read with great interest the article by Daoud and associates. We congratulate the authors for an excellent discussion of this controversial issue. We have a few suggestions as well.

According to the authors, intraocular lens implantation after cataract extraction was the earliest form of refractive surgery in children. However, we believe that epikeratophakia also may be considered a form of refractive surgery. There are also early reports of radial keratotomy being performed in children.

Most reports on pediatric refractive surgery lack crucial data such as residual stromal thickness, size of optical zone, intended correction, uncorrected visual acuity before and after surgery, details of preoperative evaluation, and so forth. We would have liked to know how the investigators performed topography in children under anesthesia, a detail most such reports lack. If we are to synthesize data across different studies, reporting formats should be uniform. Refractive surgery societies and other professional organizations may take the initiative to develop reporting guidelines on pediatric refractive surgery.

The issue of improved quality of life after refractive surgery in children with neurodevelopmental disorders deserves special attention; this was not well highlighted in the article. We believe that it is important for these studies to have a child behavior expert who is masked to the intervention and who can, in an unbiased and reliable manner, observe the impact on a child’s functions.

The usefulness of refractive surgery in refractive accommodative esotropia is not discussed in the article. Results from previous studies indicate that a child with refractive accommodative esotropia who resists all attempts at spectacle wear may be a candidate for refractive surgery.

The article mentions controversial issues like problems arising from the use of general anesthesia, decentration, the lack of a nomogram for children, and so forth. We expected the authors to comment on how these issues were dealt with in published studies and to give recommendations about managing them.

While discussing the procedure of choice, the authors do not discuss laser-assisted subepithelial keratomileusis, which combines the advantages of photorefractive keratectomy and laser in situ keratomileusis while eliminating disadvantages of both, probably making it a procedure of choice in children. Laser-assisted subepithelial keratomileusis was used in many of the studies reviewed in this article. Also, while selecting a patient for phakic intraocular lens implantation, the important criterion of the anterior chamber depth being more than 3.2 mm is not emphasized.

While performing these procedures, it would be desirable to have a team that includes an experienced refractive surgeon, a pediatric ophthalmologist, an experienced pediatric anesthesia team, and a child behavior expert.

It is very important to convey the message to the refractive surgery community that pediatric refractive surgery is meant for a selected group who otherwise would have permanently reduced vision. At the same time it must be emphasized that refractive surgery is not indicated in children who are functioning well with glasses or contact lenses.