What is the minimum age for refractive surgery, such as LASIK (Laser-Assisted In Situ Keratomileusis) or PRK (Photorefractive Keratectomy), for a patient with a significant refractive error?

Minimum Age for Refractive Surgery

The minimum age for refractive surgery is 18 years, though the procedure can be performed in carefully selected adolescents as young as the mid-teens when refractive stability has been documented and the benefits clearly outweigh the risks. 1

Age-Based Recommendations

Standard Minimum Age

• Refractive surgery should generally be deferred until at least 18 years of age when refractive error has stabilized 1
• The American Academy of Ophthalmology guidelines reference refractive surgery as an option for correcting symptomatic refractive errors in adults, with comprehensive eye examinations recommended every 5-10 years for patients under 40 years old 1
• Over 8.5 million Americans have undergone keratorefractive surgery since 1995, with the vast majority being adults 1

Adolescent Considerations

• Adolescents can achieve comparable or even slightly better safety and efficacy outcomes compared to young adults aged 20-40 years 2
• In a large cohort study, adolescents under 18 years demonstrated better safety and efficacy indices with lower retreatment rates (1% versus 2.7%) compared to the 20-40 age group 2
• However, adolescent refractive surgery should only be considered when:
  • Refractive stability has been documented over at least 12 months 2
  • There is a compelling indication (such as anisometropia, contact lens intolerance, or occupational requirements) 2
  • The patient and family understand that further refractive changes may occur with continued eye growth 2

Critical Stability Requirements

Refractive Stability Assessment

• Myopia progression is common in children and adolescents, with prevalence of 9% in children aged 5-17 years in the United States 1
• Younger patients with keratoconus demonstrate faster disease progression, making early detection crucial but also necessitating caution with any corneal surgery 1
• Natural progression of corneal steepening decelerates after age 30, but progression can still occur in older patients with high baseline keratometry values 1

Documentation Requirements

• At least 12 months of stable refraction should be documented before proceeding with surgery in younger patients 2
• Serial refractions should demonstrate changes of less than 0.50 D over the observation period 2
• Corneal topography following contact lens abstinence is essential to rule out irregular astigmatism or ectasia risk 1

Special Populations and Exceptions

Accommodative Esotropia

• Refractive surgery for accommodative esotropia may be considered in adults with corrected esodeviation ≤10 prism diopters 3
• There is insufficient evidence to recommend refractive surgery for patients under 18 years with accommodative esotropia, despite case reports describing procedures in children as young as 7 years 3
• The safety and predictability remain unclear for pediatric patients, and long-term follow-up data are lacking 3

Older Adults

• Patients over 60 years can safely undergo refractive surgery, though they demonstrate lower efficacy indices and higher retreatment rates compared to younger adults 2
• For hyperopic treatments in patients >60 years: safety index 0.95 versus 0.99 in young adults, with retreatment rates of 6.2% versus 2.5% 2
• For myopic treatments in patients >60 years: efficacy index 0.88 versus 0.97 in young adults, with retreatment rates of 11% versus 1.1% 2

Preoperative Screening Essentials

Mandatory Evaluations

• Comprehensive corneal topography and tomography to exclude keratoconus, forme fruste keratoconus, or other ectatic disorders 1
• Evaluation of posterior corneal surface abnormalities, as these may predict unpredictable outcomes and post-surgical ectasia progression 1
• Assessment of higher-order aberrations, particularly vertical coma, which is elevated in keratoconus 1
• Cycloplegic refraction to ensure accurate measurement of refractive error, especially in younger patients with active accommodation 1

Risk Factor Assessment

• Patients should refrain from eye rubbing, which is associated with keratoconus progression 1
• Consider mast cell stabilizers for patients with ocular allergies to reduce eye rubbing behavior 1
• Closer follow-up is recommended for patients younger than 17 years and those with corneal steepening >55 D 1

Common Pitfalls to Avoid

• Do not perform refractive surgery on patients with unstable refraction, regardless of age, as this leads to suboptimal outcomes and higher retreatment rates 2
• Do not skip corneal tomography in the preoperative evaluation, as topography alone may miss posterior corneal abnormalities suggestive of ectasia risk 1
• Do not assume that excellent visual acuity excludes serious eye disease—comprehensive evaluation is mandatory 1
• Avoid surgery in patients with evidence of progressive keratoconus until corneal cross-linking has been performed and stability documented 1
• Be cautious with IOL prediction accuracy in younger patients, as prediction error exceeds 2.00 diopters in 15% of pediatric cases 4