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Refractive surgery for special needs children.

These are the hard cases and the children with greatest need. Their spherical-equivalent myopia or hyperopia exceeds approximately 4 to 5 diopters (D). The uncorrected myopia translates to a distant acuity of 20/200 or worse (legal blindness). The uncorrected acuity for the child with hyperopia can be better during epochs when the child accommodates partially, but accommodation is often impaired in children with neurobehavioral disorders. The prevalence of isoametropic amblyopia in children with uncorrected high hyperopia approaches 50%. Add to this the substantial risk (about 80%) of refractive esophoria or esotropia. A variety of neurobehavioral disorders impede spectacle wear. The most common are moderate to severe cerebral palsy (ie, Gross Motor Function Classification Scale levels 3-5), autism, Angelman syndrome, more severe Down syndrome, and suboptimally controlled seizure disorders. Other causes are idiopathic developmental delay/ mental retardation and progressive childhood encephalopathies. The uncorrected ametropia exacerbates the neurobehavioral disorder. The child lives in a cocoon of blur, promoting fearfulness, reduced interest in the outside world, and blunted social interactions (a constellation labeled “visual autism”). The extreme refractive error is seldom the only visual deficit. Common comorbidities include strabismus, amblyopia, optic neuropathies, foveopathies, and nystagmus. Comorbidities do not mean that the refractive error is unimportant or that correcting the error would not improve visual function. Too many ophthalmologists, after examining a child with an intimidating array of neurobehavioral and visuomotor deficits, succumb to the bigotry of low expectations. The uncorrected vision is dismissed as “good enough for a child with multiple disabilities.” Why is prescribing glasses ineffective in a substantial fraction of these children? Many are aversive to wearing any head or facial appliance. They dislodge glasses repeatedly, despite heroic efforts to enforce compliance on the part of parents, teachers, therapists, and caregivers. If the battle is won to keep the glasses in place, the benefit may be negated by poor motor control of the head, neck, and trunk or gaze palsies and apraxias. The motorcontrol disorders cause chronic viewing over, around, or at the edges of spectacle lenses. Contact lenses are seldom a suitable option. Insertion and removal may require bodily restraint by multiple family members and vigorous eyelid manipulation to overcome intense blepharospasm. Repeated rounds of this exhaust— physically and emotionally—even the most committed parents.