We thank our colleagues for their suggestions. Although many of the points made are already addressed in our article, we largely agree with their comments and would like to add to this discussion. The topic of pediatric refractive surgery is an emerging field with sensitive issues. Depending on their interests, different colleagues have different focus points that they want to be addressed more than others. Addressing every detail would have been beyond the scope of The Journal’s Perspective section. We decided to focus on what we believe to be the most important points while staying within The Journal’s Perspective guidelines.
We agree that epikeratophakia and radial keratotomy are forms of refractive surgery. However, we restricted their discussion to a minimum, because they are outdated and largely have been replaced by procedures with better visual acuity outcomes.
Most reports on pediatric refractive surgery do indeed lack important information. This supports our recommendation for a multicenter, randomized, controlled trial with a defined protocol for preoperative evaluation, procedure details, and postoperative management. We certainly support the suggestion that professional organizations and societies in the pediatric and refractive surgery specialties assist in the endeavor to develop and implement these guidelines.
Some studies have shown that refractive surgery results in improved quality of life, improved behavior in some patients with neurodevelopmental disorders, or both. We believe this is an issue that deserves special attention as discussed and shown in the section Refractive Surgery for High Bilateral Myopia in Children and in Table 1. We discuss why this patient population especially may benefit from refractive surgery in the section Potential Indications for Pediatric Refractive Surgery.
Refractive surgery may be used in the treatment of some cases of refractive accommodative esotropia. Indeed, earlier versions of our manuscript had a section dedicated to this topic, but it was removed for the sake of brevity.
As we addressed in the second paragraph of the Discussion section, certain hurdles had to be overcome before laser refractive surgery could be used safely in the uncooperative children with the help of general anesthesia, as reported by Paysse and associates.
We focused our discussion on the pros and cons of laser in situ keratomileusis versus photorefractive keratectomy. We elected not to discuss details of laser-assisted subepithelial keratomileusis because photorefractive keratectomy and laser-assisted subepithelial keratomileusis are considered analogous procedures and usually are grouped together as surface ablation procedures.
As stated in our article, we maintain our stance that the option of a phakic intraocular lens remains a controversial topic and is not recommended for children at this time.
We agree with our colleagues that a team approach of experts will provide optimal outcomes for any of these pediatric refractive procedures. Furthermore, we remind all of our colleagues that pediatric refractive surgery should be performed with caution and should be reserved as a last resort for specific types of patients as discussed in the section Potential Indications for Pediatric Refractive Surgery.