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Anesthesia in young children
Letters to the Editor ANESTHESIA IN YOUNG CHILDREN To the Editor: I read with great interest William V. Good’s important editorial, “Is anesthesia safe for young children.”1 In addition to his comments, we should note the “Smart Tots” initiative (www.smarttots.org). This project was begun in cooperation with the International Anesthesia Research Society and the US Food and Drug Administration (FDA). They created a valuable consensus statement endorsed by the International Anesthesia Research Society, the FDA, the American Academy of Pediatrics, the Society for Pediatric Anesthesia, the Society for Neuroscience in Anesthesiology and Critical Care, the American Society of Anesthesiologists, and the European Society of Anesthesiology regarding anesthesia safety in children.2 The Smart Tots group is reviewing the available information and funding research regarding anesthetic affects on children on an ongoing basis. All specialists dealing with children should follow their work. David B. Granet, MD Department of Ophthalmology, University of California, San Diego References 1. Good WV. Is anesthesia safe for young children? J AAPOS 2014;18: 519-20. 2. Consensus statement on the use of anesthetics and sedatives in children. http://www.smarttots.org/resources/consensus2012.html. Accessed January 28, 2014. http://dx.doi.org/10.1016/j.jaapos.2015.02.005 J AAPOS 2015;19:293. Copyright Ó 2015 by the American Association for Pediatric Ophthalmology and Strabismus. 1091-8531/$36.00
REPLY To the Editor: Let me extend my thank you to David Granet for his letter, providing the Journal’s readers the link to updated information about anesthesia effects on the developing brain (Smarttots). David’s reminder, that all pediatric surgeons should monitor this issue, should be taken seriously. Until we know when anesthetics can be harmful (ie, the dose, type of anesthetic, duration of administration, and age at administration), we cannot make evidence-based informed decisions about elective or semielective surgery. William V. Good, MD Smith-Kettlewell Eye Research Institute San Francisco, California http://dx.doi.org/10.1016/j.jaapos.2015.05.002 J AAPOS 2015;19:293. Copyright Ó 2015 by the American Association for Pediatric Ophthalmology and Strabismus. 1091-8531/$36.00
Journal of AAPOS
UNILATERAL STRABISMUS SURGERY IN PATIENTS WITH EXOTROPIA RESULTS IN POSTOPERATIVE LATERAL INCOMITANCE To the Editor: We read with great enthusiasm the article by Deacon and colleagues1 studying the incidence and amount of lateral incomitance after unilateral surgery in exotropia both immediately after surgery and with longterm follow-up. We would like to highlight a few points in the methodology and results that require further discussion. In the above study, a wide range of exotropia (12D-85D) was treated using unilateral surgery in subjects with visual acuity of $20/40. A short description of the surgical technique as well as a table of the surgical doses would have been useful in understanding the surgical results. The authors combined the results of unilateral lateral rectus recession with that of unilateral lateral rectus recession and medial rectus resection. Addition of a resection of medial rectus muscle is believed to have a tethering effect and increases the chances of overcorrection in the ipsilateral gaze.2,3 Therefore it is advised to limit the amount of medial rectus resection, especially in adults patients with good vision.2 Three subjects in Deacon and colleagues’ study (e-Supplement 1: A5 [20 XT], A26 [13 XT], and A2 [46 XT]) had large lateral incomitance ($20D) at final follow-up. The maximum amount of lateral rectus recession and medial rectus resection performed in them was 10 mm and 7 mm, respectively. Such large recession-resection procedures are expected to exaggerate lateral incomitance and are therefore preferred for operations on the visually poor eye in cases with sensory exotropia.4 A recessionresection procedure when performed in moderation, does not increase the risk of lateral incomitance. In our own experience, in 35 patients older than 7 years of age who underwent unilateral surgery (maximum 9 mm lateral rectus recession and 6.5 mm medial rectus resection) in 2012 for a mean exotropia of 40D (18D-55D), we have not found lateral incomitance of .5D at the last follow-up (average, 8 months). Also none of the subjects complained of double vision. There were 6 subjects in Deacon and colleagues’ study (e-Supplement 1: A11, A12, A27, A5, A26, A14) who had preoperative ipsilateral incomitance of $5D (ie, exotropia was lesser in the gaze toward the operated eye). We believe that unilateral surgery should have been performed on the contralateral eye of these patients (ie, the eye toward which exotropia is greater) to reduce the chances of iatrogenic incomitance. This study highlights the fact the large unilateral recession-resection procedure should be used with caution in eyes with good vision and reserved for eyes with poor vision because it can cause significant and persistent lateral incomitance in some patients.
293
REPLY To the Editor: Let me extend my thank you to David Granet for his letter, providing the Journal’s readers the link to updated information about anesthesia effects on the developing brain (Smarttots). David’s reminder, that all pediatric surgeons should monitor this issue, should be taken seriously. Until we know when anesthetics can be harmful (ie, the dose, type of anesthetic, duration of administration, and age at administration), we cannot make evidence-based informed decisions about elective or semielective surgery. William V. Good, MD Smith-Kettlewell Eye Research Institute San Francisco, California http://dx.doi.org/10.1016/j.jaapos.2015.05.002 J AAPOS 2015;19:293. Copyright Ó 2015 by the American Association for Pediatric Ophthalmology and Strabismus. 1091-8531/$36.00
Journal of AAPOS
UNILATERAL STRABISMUS SURGERY IN PATIENTS WITH EXOTROPIA RESULTS IN POSTOPERATIVE LATERAL INCOMITANCE To the Editor: We read with great enthusiasm the article by Deacon and colleagues1 studying the incidence and amount of lateral incomitance after unilateral surgery in exotropia both immediately after surgery and with longterm follow-up. We would like to highlight a few points in the methodology and results that require further discussion. In the above study, a wide range of exotropia (12D-85D) was treated using unilateral surgery in subjects with visual acuity of $20/40. A short description of the surgical technique as well as a table of the surgical doses would have been useful in understanding the surgical results. The authors combined the results of unilateral lateral rectus recession with that of unilateral lateral rectus recession and medial rectus resection. Addition of a resection of medial rectus muscle is believed to have a tethering effect and increases the chances of overcorrection in the ipsilateral gaze.2,3 Therefore it is advised to limit the amount of medial rectus resection, especially in adults patients with good vision.2 Three subjects in Deacon and colleagues’ study (e-Supplement 1: A5 [20 XT], A26 [13 XT], and A2 [46 XT]) had large lateral incomitance ($20D) at final follow-up. The maximum amount of lateral rectus recession and medial rectus resection performed in them was 10 mm and 7 mm, respectively. Such large recession-resection procedures are expected to exaggerate lateral incomitance and are therefore preferred for operations on the visually poor eye in cases with sensory exotropia.4 A recessionresection procedure when performed in moderation, does not increase the risk of lateral incomitance. In our own experience, in 35 patients older than 7 years of age who underwent unilateral surgery (maximum 9 mm lateral rectus recession and 6.5 mm medial rectus resection) in 2012 for a mean exotropia of 40D (18D-55D), we have not found lateral incomitance of .5D at the last follow-up (average, 8 months). Also none of the subjects complained of double vision. There were 6 subjects in Deacon and colleagues’ study (e-Supplement 1: A11, A12, A27, A5, A26, A14) who had preoperative ipsilateral incomitance of $5D (ie, exotropia was lesser in the gaze toward the operated eye). We believe that unilateral surgery should have been performed on the contralateral eye of these patients (ie, the eye toward which exotropia is greater) to reduce the chances of iatrogenic incomitance. This study highlights the fact the large unilateral recession-resection procedure should be used with caution in eyes with good vision and reserved for eyes with poor vision because it can cause significant and persistent lateral incomitance in some patients.
293