LOS ANGELES (March 25, 1999) -- A laser technique approved by the Food and Drug Administration last November for correction of farsightedness in adults has been used for the first time to treat a child, allowing a 12-year-old boy to shed unattractive glasses and enjoy a more active life.
Kenneth Wright, M.D., a Cedars-Sinai Medical Center ophthalmologist specializing in the treatment of pediatric patients, performed the operation on Feb. 11. He was assisted by James Salz, M.D., an ophthalmologist who specializes in laser surgery.
The patient, Kiley Bedwell, has from birth battled an unusual condition in which the vision in one eye is normal but the other is extremely farsighted. Kiley had 20/20 vision in his right eye but he was legally blind in his left. According to Dr. Wright, when one eye is able to focus and the other remains extremely out of focus in childhood, the brain learns to "turn off" the blurred image. Glasses usually provide only minimal help because by the time they are fitted, the brain has been trained to ignore the message from the out-of-focus eye.
Kiley's parents, Marty and Linda Bedwell, first took Kiley to Dr. Wright when they became aware of their son's vision problems when he was 5. For more than six months, he often wore a patch over his "good" eye to force his brain to work with his out-of-focus eye. He also wore glasses to improve the vision in that eye to 20/60.
Those glasses, however, always had one clear lens and one extremely thick one, which not only created an unflattering appearance but also hindered Kiley's depth perception, curtailing his involvement and success in sports and other activities.
"It's very hard to wear glasses with a 6-diopter difference," said Dr. Salz, referring to the disparity between the clear lens and the thick one. "In fact, most adults can't do it. If you put glasses like that on an adult, they'd feel like they were on a boat."
Dr. Salz served as principal investigator at Cedars-Sinai for the multi-center study of laser surgery for the correction of farsightedness (hyperopia). Although the FDA's guidelines for the procedure limit its use to an adult population -- as do those of the manufacturer of the equipment, VISX Excimer Laser Systems (TM) -- both doctors thought Kiley was an excellent candidate to benefit from it.
"Dr. Wright and I discussed this case in detail to consider the risks and the benefits," said Dr. Salz. "We knew that the risks in a young person should certainly be no higher than they are in an older person. Risk of infection, for example, in a healthy young child with good tear flow is probably less than it is in a 60- or 70-year-old adult with decreased tear flow. Personal hygiene is generally going to be a little bit better, too. So we felt that in terms of serious complications -- and the only really serious one would be getting an infection -- he would not be at any higher risk than an adult. If anything, his risk would probably be lower because his resistance is probably better and his healing would probably be quicker."
Without hesitation, Kiley's parents consented to the laser's "off-label" use. "I trust Dr. Wright and whatever he says," said Linda. "And I thought, 'If the surgery works, it would be great.' Kiley's eye was so bad anyway, the risk wasn't that great to me."
Dr. Salz said that in the study of the procedure, hundreds of farsighted adults were treated and observed for about two years. No serious infections occurred. Results were similar in a Canadian study. Furthermore, nearsighted patients have benefited from laser surgery for about a decade and complications are rare.
Dr. Wright said photorefractive keratectomy is a two-step surgery that is accomplished in minutes. The eye is numbed with drops before the epithelium or outer skin of the cornea is rubbed off with a small brush. The laser is then used to reshape the curvature of the cornea. In treatment for farsightedness such as Kiley's, the laser is used to make the curvature more steep -- by less than the width of a human hair.
Although the procedure is not painful, it can be intimidating and it requires a level of cooperation from the patient. The equipment makes loud noises and the patient must look at a flashing light for up to two minutes. Before scheduling the surgery, Dr. Wright used a small flashing light to represent the laser and test Kiley's steadiness.
"I don't think all 12-year-old kids could have this done," said Dr. Salz. "Some adults have trouble but Kiley did an outstanding job." The doctors said Kiley's vision in the eye is now corrected to 20/60 without glasses, and his "stereoscopic vision" -- the ability of his eyes to work together -- has actually improved.
"This eye was not correctable to 20/20 vision," said Dr. Salz. "We knew we probably weren't going to make it possible for him to see better than he saw with his glasses. What we hoped to accomplish was to get him to see as well as he did with the glasses, but without them."
Linda Bedwell is glad she will not need to nag Kiley to wear his glasses. The family will not have to replace broken frames or lost contact lenses. More importantly, Kiley does not have to worry about looking "different," and he will be better prepared to play baseball. "When he played outfield, he couldn't judge the ball very well," she said. "And when he was batting, he would get hit more often than other kids would because he couldn't judge the distance. Now his depth perception is almost perfect. And he doesn't have to fight wearing the glasses."
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