Glaucoma-Related Adverse Events in the First 5 Years After Unilateral Cataract Removal in the Infant Aphakia Treatment Study

Angle Surgery in Pediatric Glaucoma Following Cataract Surgery

Glaucoma is a common and sight-threatening complication of pediatric cataract surgery Reported incidence varies due to variability in study designs and length of follow-up. Consistent and replicable risk factors for developing glaucoma following cataract surgery (GFCS) are early age at the time of surgery, microcornea, and additional surgical interventions. The exact mechanism for GFCS has yet to be completely elucidated. While medical therapy is the first line for treatment of GFCS, many eyes require surgical intervention, with various surgical modalities each posing a unique host of risks and benefits. Angle surgical techniques include goniotomy and trabeculotomy, with trabeculotomy demonstrating increased success over goniotomy as an initial procedure in pediatric eyes with GFCS given the success demonstrated throughout the literature in reducing IOP and number of IOP-lowering medications required post-operatively. The advent of microcatheter facilitated circumferential trabeculotomies lead to increased success compared to traditional <180° rigid probe trabeculotomy in GFCS. The advent of two-site rigid-probe trabeculotomy indicated that similar results could be attained without the use of the more expensive microcatheter system. Further studies of larger scale, with increased follow-up, and utilizing randomization would be beneficial in determining optimum surgical management of pediatric GFCS.

The impact of late-treated pediatric cataract on intraocular pressure

PURPOSE

To assess the intraocular pressure and visual acuity before and after pediatric congenital cataract surgery performed at a relatively older age.

METHODS

A retrospective analysis of all consecutive pediatric patients diagnosed and operated for bilateral congenital cataracts during a seven-year period (2012-2018) in rural southern Ethiopia. Non-ambulatory vision was defined as hand motion or worse. The main outcome measures were intraocular pressure (IOP) and visual acuity.

RESULTS

Thirty-two children were included, 17 females (53.1%), with a mean age of 11 years (± 2.83) [range, 7-18]. A total of 59 eyes were operated on. The mean follow-up was 4.8 ± 1.8 years (range, 2-8). VA improved from 20/1400 preoperatively to 20/440 postoperatively OD and 20/540 OS (p < 0.001). More eyes had ambulatory vision after cataract surgery than pre-surgery (56 eyes [95%] vs. 29 eyes [49%], p < 0.001). The IOP decreased from a mean preoperative value of 18.4 ± 7.1 mmHg to 14.5 ± 2.9 postoperatively OD (p < 0.001) and 16.3 ± 5.9 mmHg to 13.9 ± 3.5 OS (p < 0.001). Fifteen eyes (24%) had increased IOP (> 21 mmHg) preoperatively, of which three remained high after surgery. Positive correlations were found between IOP, axial length and cup-to-disc ratio. None of the patients required pressure-lowering procedures.

CONCLUSION

Bilateral congenital cataracts may be associated with ocular hypertension, with possible progression to glaucoma if left untreated. Surgery at a relatively older age often was associated with a significant improvement in intraocular pressure and ambulatory vision.

Overhead Mounted Optical Coherence Tomography in Childhood Glaucoma Evaluation

PRéCIS:: Overhead mounted spectral-domain optical coherence tomography (OCT) enables high-quality imaging of the optic nerve and macula in childhood glaucoma, and is particularly useful when standard tabletop OCT has failed or is not possible.

PURPOSE

Tabletop OCT, integral to adult glaucoma management, can be limited in childhood glaucoma patients because of young age, poor cooperation, and/or technical challenges. To address these imaging difficulties, we determined the feasibility and quality of an overhead mounted unit in childhood glaucoma. Secondary aims included evaluation of peripapillary retinal nerve fiber layer (pRNFL), parafoveal total retinal thickness, and parafoveal ganglion cell complex (GCC) thickness.

MATERIALS AND METHODS

Children and adults with a diagnosis of childhood glaucoma were imaged with an overhead mounted spectral-domain OCT as part of a prospective cross-sectional study. Participants had poor quality or unobtainable tabletop OCT and were scheduled for an examination under anesthesia and/or surgery as part of standard care.

RESULTS

A total of 88 affected eyes in 60 of 65 (92.3%) enrolled patients (mean age, 5.9±5.9 y; range, 0.2 to 24.5) were successfully imaged. The mean image quality for analyzed scans was 22.9±6.0 dB (n=236 images). Mean values for pRNFL (80.5±31.0 µm; n=86), parafoveal total retinal thickness (301.10±39.9 µm; n=79), and parafoveal GCC thickness (96.0±21.6 µm; n=74) were calculated.

CONCLUSIONS

Overhead mounted OCT allowed high-quality image acquisition and analysis in childhood glaucoma patients unable to be imaged with the tabletop counterpart, presenting an opportunity for improved clinical management and study of childhood glaucoma-related pathophysiology. pRNFL, parafoveal total retinal thickness, and parafoveal GCC thickness were decreased for affected eyes of children under 6 years of age compared with age-matched controls from a companion normative study.

Incidence and Management of Glaucoma or Glaucoma Suspect in the First Year After Pediatric Lensectomy

Importance

Glaucoma can occur following cataract removal in children, and determining the risk for and factors associated with glaucoma and glaucoma suspect in a large cohort of children after lensectomy can guide clinical practice.

Objective

To estimate the incidence of glaucoma and glaucoma suspect and describe its management in the first year following lensectomy in children before 13 years of age.

Design, Setting, and Participants

A multicenter clinical research registry containing data for 1361 eyes of 994 children who underwent unilateral or bilateral lensectomy between June 2012 and July 2015 at 1 of 61 sites in the United States (n = 57), Canada (n = 3), and the United Kingdom (n = 1). Patients were eligible for inclusion in the study if they were enrolled in the registry within 45 days after lensectomy and had at least 1 office visit between 6 and 18 months after lensectomy. Patient data were reviewed, and glaucoma and glaucoma suspect were diagnosed by investigators using standardized criteria. Statistical analysis was performed between June 2017 and August 2019.

Exposures

Clinical care 6 to 18 months after lensectomy.

Main Outcomes and Measures

Incidence risk using standardized definitions of glaucoma and glaucoma suspect after lensectomy.

Results

Among 702 patients included in this cohort study, 353 (50.3%) were male and 427 (60.8%) were white; mean age at lensectomy was 3.4 years (range, 0.04-12.9 years). After lensectomy, glaucoma or glaucoma suspect was diagnosed in 66 of 970 eyes (adjusted overall incidence risk, 6.3%; 95% CI, 4.8%-8.3%). Glaucoma was diagnosed in 52 of the 66 eyes, and glaucoma suspect was diagnosed in the other 14 eyes. Mean age at lensectomy in these 66 eyes was 1.9 years (range, 0.07-11.2 years), and 40 of the 66 (60.6%) were eyes of female patients. Glaucoma surgery was performed in 23 of the 66 eyes (34.8%) at a median of 3.3 months (range, 0.9-14.8 months) after lensectomy. The incidence risk of glaucoma or glaucoma suspect was 15.7% (99% CI, 10.1%-24.5%) for 256 eyes of infants 3 months or younger at lensectomy vs 3.4% (99% CI, 1.9%-6.2%) for 714 eyes of infants older than 3 months (relative risk, 4.57; 99% CI, 2.19-9.57; P < .001) and 11.2% (99% CI, 7.6%-16.7%) for 438 aphakic eyes vs 2.6% (99% CI, 1.2%-5.6%) for 532 pseudophakic eyes (relative risk, 4.29; 99% CI, 1.84-10.01; P < .001). No association was observed between risk of developing glaucoma or glaucoma suspect and any of the following variables: sex, race/ethnicity, laterality of lensectomy, performance of anterior vitrectomy, prelensectomy presence of anterior segment abnormality, or intraoperative complications.

Conclusions and Relevance

This study found that glaucoma or glaucoma suspect developed in a small number of eyes in the first year after lensectomy and may be associated with aphakia and younger age at lensectomy. Frequent monitoring for signs of glaucoma following lensectomy is warranted, especially in infants 3 months or younger at lensectomy and in children with aphakia after lensectomy.

The Swedish National Pediatric Cataract Register (PECARE): incidence and onset of postoperative glaucoma

PURPOSE

The aim was to report cumulative incidence and time of onset of postoperative glaucoma in a paediatric early cataract surgery cohort.

METHODS

Data were retrieved from the Pediatric Cataract Register (PECARE), a prospective register of Swedish cataract operations before 8 years of age. All eyes with surgery between January 2007 and December 2014 and a registered follow-up were included. Cataracts caused by uveitis, trauma or coexisting congenital glaucoma were excluded. Glaucoma was defined as early onset if diagnosed within a year after surgery and late onset if diagnosed later.

RESULTS

The study included 288 eyes in 207 children (106 girls), 81 with bilateral and 126 with unilateral cataracts, with a mean follow-up of 3.31 ± 1.77 years. Of the 288, 168 (58.3%) had surgery before 3 months of age; most of these 92.3% (155/168) were defined as dense, 208 (72.2%) were below 1 year of age. Cumulative incidence of surgically treated glaucoma among individuals was 23.7% (49/207). Median time to glaucoma onset was 0.91 years (range: 0.05-4.97 years) for eyes. Early-onset glaucoma was found in 98 % (63/64), and late onset in 2% (1/64).

CONCLUSION

In this paediatric cataract cohort, a majority of eyes had surgery before 3 months of age (58.3%). Secondary glaucoma-onset peaked within the first postoperative year, with a cumulative incidence of 23.7%. Surgery performed after the first month of life, resulted in a lower glaucoma rate. Long-term follow-up will reveal whether the low rate of late-onset glaucoma with early surgery will last, and if so, the consequences.

Changes in intraocular pressure control in the first year after secondary intraocular lens implantation in children

PURPOSE

To compare intraocular pressure (IOP) control before and during the first year after secondary intraocular lens (IOL) implantation in children.

METHODS

This was a retrospective chart review of children who received secondary IOL implantation. We analyzed IOP and antiglaucoma medications before and after implantation. The latest exam with IOP measurement found within the 2-15 month period after IOL implantation was used for the postoperative data. Failure to maintain IOP control was defined as either the addition of antiglaucoma medication(s) or a rise in IOP > 4 mm Hg. Statistical analyses were performed to assess risk factors for failure to control IOP after surgery, namely age at IOL implantation, preoperative glaucoma status, and IOL fixation location.

RESULTS

A total of 100 eyes were included. The mean duration of follow-up was 7.74 months (SD = 3.11). Twenty-three of one hundred eyes failed to maintain IOP control according to our definition. Eyes with a history of having had a traumatic cataract (n = 3) had a more than threefold increased risk of failure (P = 0.015). Although not statistically significant, very young age at initial cataract surgery (<2 months old) had a twofold increased risk of failure compared to an older age (>12 months old) (P = 0.213). No other risk factors were found to have statistical significance.

CONCLUSION

Secondary IOL implantation carries a modest risk of worsening IOP control in the first year after implantation, for which, a history of ocular trauma or young age at initial cataract surgery seems to present the highest risk.

[Treatment of congenital and early childhood cataract]

The successful outcome of treatment for infant and childhood cataract depends on many factors. It is crucial that the treatment falls into a phase in which neither the eye nor the visual pathway and visual cortex are fully developed. This review summarizes the current state of knowledge and provides an overview of the epidemiology, causes and clinical forms, early detection and, above all, treatment options. Special attention is paid to time-critical stages of development, according to which the therapeutic concepts are based. Complications, such as amblyopia and glaucoma are discussed in detail. In addition to surgical aspects, much emphasis is placed on orthoptic-refractive aftercare, the quality and execution of which is the essential predictor of a good functional outcome.

Clinical Characteristics and Treatment of Secondary Glaucoma After Pediatric Congenital Cataract Surgery in a Tertiary Referral Hospital in Spain

PURPOSE

To analyze clinical characteristics, treatment, and long-term outcomes of pediatric patients with glaucoma after congenital cataract surgery at a single tertiary care hospital.

METHODS

Medical records of pediatric patients diagnosed as having glaucoma secondary to congenital cataract surgery between 1996 and 2016 were reviewed retrospectively.

RESULTS

A total of 58 eyes of 42 patients were included with a median follow-up time of 55 months (interquartile range [IQR]: 27 to 128) after glaucoma diagnosis. Mean time of glaucoma onset after cataract surgery was 35 months (IQR: 5 to 96). At diagnosis, 81% of the eyes were aphakic and the majority presented with an open angle (86%). Multivariate analysis demonstrated that glaucoma diagnosis was made earlier in eyes with persistent fetal vasculature (β = -0.334, P = .006) and aphakic eyes (β = 0.404, P = .001). Two-thirds of eyes required surgical treatment for glaucoma. Seventy percent had an Ahmed glaucoma valve (New World Medical, Inc) implantation as their primary procedure, followed by trabeculectomy (24%) and synechiolysis with peripheral iridotomy (6%). All medically treated eyes and 78% of the surgically treated eyes achieved intraocular pressure (IOP) control at the final visit.

CONCLUSIONS

Diagnosis of glaucoma after congenital cataract surgery seems to follow a bimodal distribution (years 1 and 5 after cataract surgery). Two-thirds of the eyes required surgical hypotensive treatment to achieve IOP control. Ahmed glaucoma valve implantation is a safe and effective surgical option to be considered as both first- and second-line treatment. Functional outcome was more favorable in those eyes with medically controlled glaucoma. [J Pediatr Ophthalmol Strabismus. 2020;57(5):292-300.].

Cataract management in children: a review of the literature and current practice across five large UK centres

Congenital and childhood cataracts are uncommon but regularly seen in the clinics of most paediatric ophthalmology teams in the UK. They are often associated with profound visual loss and a large proportion have a genetic aetiology, some with significant extra-ocular comorbidities. Optimal diagnosis and treatment typically require close collaboration within multidisciplinary teams. Surgery remains the mainstay of treatment. A variety of surgical techniques, timings of intervention and options for optical correction have been advocated making management seem complex for those seeing affected children infrequently. This paper summarises the proceedings of two recent RCOphth paediatric cataract study days, provides a literature review and describes the current UK 'state of play' in the management of paediatric cataracts.

Safety of piggyback intraocular lenses (polypseudophakia) in children: long-term outcomes of a 15-year, single-surgeon study

PURPOSE

To report the outcomes of piggyback (PB) intraocular lens (IOL) implantation, or temporary polypseudophakia, in children who have undergone cataract surgery and to assess their safety in pediatric patients.

METHODS

The medical records of consecutive patients who underwent PB IOL implantation at a single institution over a period of 15 years were reviewed retrospectively. Outcome measures were reoperation rate, complications, and outcome of planned explantation.

RESULTS

A total of 48 eyes of 38 children received PB IOL implantation: 40 eyes at the time of cataract surgery and 8 eyes as a later secondary procedure. Of these, 38 eyes of 31 patients with primary PB IOL implantation had follow-up of >3 years and were included in the present analysis. Median age at cataract surgery with PB IOL implantation was 6.5 months (0.5 months to 2.4 years). Median follow-up was 12.5 years (range, 3.0-20.7). Four eyes required reoperation for adverse events related to PB IOL implantation (1 each for IOL tilt, pupillary capture, pupillary block glaucoma, and pupillary membrane). All 4 of these eyes were operated for cataract before 3 months of age. The sulcus-fixated PB IOL underwent a planned explantation in 33/38 eyes. Eight eyes needed intraocular pressure-lowering topical medications. Planned PB IOL explantation was uncomplicated in our series.

CONCLUSIONS

Early complications occurred in 4 eyes, but late complications were not noted, and glaucoma developed at predictable rates for this population. Piggyback IOL placement in our cohort of young children appears to have an acceptable safety profile.

Outcomes of Bilateral Cataract Surgery in Infants 7 to 24 Months of Age Using the Toddler Aphakia and Pseudophakia Treatment Study Registry

PURPOSE

To evaluate outcomes of bilateral cataract surgery in children aged 7 to 24 months and compare rates of adverse events (AEs) with other Toddler Aphakia and Pseudophakia Study (TAPS) registry outcomes.

DESIGN

Retrospective clinical study at 10 Infant Aphakia Treatment Study (IATS) sites. Statistical analyses comparing this cohort with previously reported TAPS registry cohorts.

PARTICIPANTS

Children enrolled in the TAPS registry between 2004 and 2010.

METHODS

Children underwent bilateral cataract surgery with or without intraocular lens (IOL) placement at age 7 to 24 months with 5 years of postsurgical follow-up.

MAIN OUTCOME MEASURES

Visual acuity (VA), occurrence of strabismus, AEs, and reoperations.

RESULTS

A total of 40 children (76 eyes) who underwent bilateral cataract surgery with primary posterior capsulectomy were identified with a median age at cataract surgery of 11 months (7-23); 68% received a primary IOL. Recurrent visual axis opacification (VAO) occurred in 7.5% and was associated only with the use of an IOL (odds ratio, 6.10; P = 0.005). Glaucoma suspect (GS) was diagnosed in 2.5%, but no child developed glaucoma. In this bilateral cohort, AEs (8/40, 20%), including glaucoma or GS and VAO, and reoperations occurred in a similar proportion to that of the published unilateral TAPS cohort. When analyzed with children aged 1 to 7 months at bilateral surgery, the incidence of AEs and glaucoma or GS correlated strongly with age at surgery (P = 0.011/0.004) and glaucoma correlated with microcornea (P = 0.040) but not with IOL insertion (P = 0.15).

CONCLUSIONS

Follow-up to age 5 years after bilateral cataract surgery in children aged 7 to 24 months reveals a low rate of VAO and very rare glaucoma or GS diagnosis compared with infants with cataracts operated at < 7 months of age despite primary IOL implantation in most children in the group aged 7 to 24 months. The use of an IOL increases the risk of VAO irrespective of age at surgery.

Back to the Future: Vitreous Pupillary Block and Glaucoma in a Child After Lensectomy

The authors present a case of poorly controlled glaucoma following lensectomy. An examination under anesthesia revealed iris bombe of the anterior vitreous face. This case helps emphasize the importance of a generous anterior vitrectomy at the time of lensectomy in the pediatric population to avoid secondary glaucoma. [J Pediatr Ophthalmol Strabismus. 2020;57:e48-e50.].

Secondary glaucoma and visual outcome after paediatric cataract surgery with primary bag-in-the-lens intraocular lens

PURPOSE

To determine predictors of secondary glaucoma and poor visual outcome in children undergoing cataract surgery with bag-in-the-lens (BIL)-IOL implantation.

METHODS

Medical records were retrospectively analysed for children with primary implantation with BIL-IOL during 2009-2013.

RESULTS

The study included 109 eyes. Median age at surgery was 2.5 years (range 2 weeks-14.1 years), 26.6% being ≤12 weeks of age (= early group). Median follow-up time was 2.8 years (7 months-5.8 years). 15 eyes (13.8%) developed glaucoma, 14 (48.3%) in the early group and 1 (1.3%) in the late group (p < 0.001). Within the early group, mean time for surgery differed significantly. Patients developing glaucoma had cataract surgery at 3.5 ± 1.1 weeks (mean ± SD) and the non-glaucoma patients at 5.7 ± 3.3 weeks (p = 0.024). In the entire cohort, 21 eyes (19.3%) had conditions associated with glaucoma; 57.1% of these developed glaucoma compared to 3.4% without these conditions (p < 0.001). Corrected distance visual acuity (CDVA) (decimal) of ≥0.5 was seen in 50 eyes (48.5%), median 0.63 in the late group and 0.15 in the early group. Glaucoma eyes in the early group (surgery at 3.5 weeks) achieved 0.56 median (range, 0.4-1.0) logMAR, (0.28 decimal) CDVA, whereas non-glaucoma eyes (surgery at 5.7 weeks) achieved 0.89 median (range 0.7-1.6) logMAR (0.13 decimal) CDVA; p = 0.016. Glaucoma development in infants between 5 weeks and 2 years of age was 6.7% (n = 2/30).

CONCLUSIONS

Comorbidity strongly increases the risk of secondary glaucoma. Surgery during the first month is correlated with better CDVA outcome and glaucoma. After 5 weeks of age, glaucoma rate is low with the BIL-IOL.

Loteprednol etabonate gel 0.5% vs prednisolone acetate suspension 1% for the treatment of inflammation after cataract surgery in children

PURPOSE

To compare loteprednol etabonate (LE) gel 0.5% with prednisolone acetate suspension (PA) 1% for the treatment of inflammation after cataract surgery in children.

SETTING

Eleven sites in the United States.

DESIGN

Randomized, double-masked, parallel-group, noninferiority study.

METHODS

Eligible patients were aged 11 years or younger and candidates for routine, uncomplicated cataract surgery. Patients were randomized to a 4-week postsurgical regimen with LE gel 0.5% or PA 1%, twice on the day of surgery, 4 times daily for 2 weeks, twice daily for 1 week, and once daily for 1 week. Assessments included anterior chamber (AC) cells/flare, anterior chamber inflammation (ACI), synechiae, precipitates on the intraocular lens/cornea, visual acuity, and intraocular pressure.

RESULTS

The intent-to-treat population comprised 105 patients (LE gel, n = 53; PA 1%, n = 52) including 52 patients aged 3 years or younger. Patients achieved a similar mean ACI grade on postoperative day 14 (primary efficacy endpoint) whether treated with LE gel 0.5% or PA 1% (difference = 0.006, 2-sided 95% CI, -0.281 to 0.292). Similar ACI outcomes additionally were observed in patients aged 3 years or younger. LE gel 0.5% and PA 1% also appeared equally effective in resolving inflammation at all visits (days 7, 14, and 28 postsurgery), based on categorical distributions of ACI, AC cells, and AC flare scores/grades (P ≥ .06). Synechiae and corneal/IOL precipitates occurred infrequently with no significant differences between groups. No safety or tolerability concerns were identified, including no treatment-related IOP increases.

CONCLUSIONS

LE gel 0.5% was safe and effective in treating pediatric postcataract surgical inflammation, with similar outcomes as PA 1%.

[Timing of congenital cataract surgery : Amblyopia versus aphakic glaucoma]

A congenital cataract is a rare disorder, which is associated with a high risk of amblyopia. Ophthalmologists are faced with many diagnostic and surgical challenges in the management of this disease. Older children can undergo primary treatment with an intraocular lens, whereas children younger than 12 months of age usually initially remain aphakic. The most frequent long-term complication of aphakic eyes following congenital cataract surgery in connection with posterior capsulorrhexis and anterior vitrectomy is aphakic glaucoma, which in individual cases can lead to substantial impairment of vision. Many factors have been reported to increase the risk of postoperative glaucoma, including microphthalmos, fetal nuclear cataract, conspicuous family history and associated ocular malformations, such as persistent fetal vasculature (PFV). Cataract surgery during early infancy is well-established to be the most important factor for the formation of postoperative aphakic glaucoma. In individual treatment planning it has to be considered that although younger age at the time of cataract removal can provide better prerequisites for prophylaxis of amblyopia, it also confers a higher risk of development of aphakic glaucoma. Children undergoing congenital cataract surgery have to be regularly monitored given the lifelong risk for postoperative complications, such as aphakic glaucoma.

Analysis and management of intraoperative and early postoperative complications of bag-in-the-lens intraocular lens implantation in different age groups of paediatric cataract patients: report of the Giessen Paediatric Cataract Study Group

PURPOSE

To report the rate and management of intra- and early postoperative complications of bag-in-the-lens intraocular lens (IOL) implantation technique for cataract treatment in paediatric patients of different age groups.

SETTINGS

Department of Ophthalmology, Justus-Liebig-University Giessen, University Hospital Giessen and Marburg GmbH, Campus Giessen, Giessen, Germany.

DESIGN

Retrospective non-randomized consecutive case series.

METHODS

Ninety eyes of 60 paediatric cataract patients were enrolled to this retrospective non-randomized observational consecutive case series single-centre study. All patients underwent cataract surgery with bag-in-the-lens IOL implantation between January 2008 and December 2018, performed by two experienced surgeons. The entire cohort was divided into four age groups: first - 0-<3 months, second - 3-<12 months, third - 12-<36 and fourth - >36 months-17 years of age. The intra- and postoperative complications were based on the clinical records. The description of management of complications related specifically to bag-in-the-lens IOL technique was based on the 39 consecutive cases operated since 1 Jan 2016 by one single surgeon that were all video documented. The early postoperative period was defined as 12 months after surgery.

RESULTS

Overall, there were 27 unilateral and 33 bilateral surgical cases of 24 female and 36 male children. The mean age at surgery was 45.25 months (range 1-200 months). The most common intraoperative events were vitreous prolapse and anterior capsule rupture with 28.9% and 13.3%, respectively. Within 12 months of follow-up, five eyes (5.6%) were re-operated because of visual axis reo-pacification (VAR). Intraocular hypertension was diagnosed in seven eyes (7.8%), including two cases that required surgical treatment. In all cases with intra- and early postoperative complications related specifically to bag-in-the-lens technique, it was possible to manage them and successfully implant bag-in-the-lens IOL.

CONCLUSIONS

Implementation of bag-in-the-lens technique in the treatment of paediatric cataract was associated with a relatively low rate of intra- and postoperative complications, including rare cases of VAR. The correct management of complications related specifically to bag-in-the-lens IOL implantation technique shall to be considered during the learning curve.

The impact of an interactive, multifaceted education approach for congenital cataract on parental anxiety, knowledge and satisfaction: A randomized, controlled trial

OBJECTIVE

The aim of our research was to examine the impact of a patient education program for parents of children with congenital cataract on parental stress, comprehension of disease information and parental satisfaction.

METHODS

This prospective study included 177 parents of children with congenital cataract. The children were randomized into the following groups: the health education program with a multifaceted, interactive approach and conventional follow-up. Self-administered questionnaires were used for parental evaluation before and after the education program. The anxiety level, parental satisfaction and comprehension of the information were evaluated at each time point.

RESULTS

A multifaceted, interactive approach to education significantly reduced parental levels of anxiety compared with the conventional group (effect sizes: Parenting Stress Index, ƞ2 = 0.285; Ocular Treatment Index, ƞ2 = 0.346). This approach also improved comprehension-memorization scores (effect sizes: ƞ2 = 0.303) and parental satisfaction (p < 0.001). The impact of this new intervention was maintained for 6 and 12 months after the course.

CONCLUSION

The interactive, multifaceted education approach could efficiently improve the comprehension of disease-related information and parental satisfaction, resulting in significantly decreased parental anxiety.

PRACTICE IMPLICATIONS

This new patient education approach had a significant impact on congenital cataracts and may be generalized to other pediatric diseases.

Long-term visual and anatomic outcomes following early surgery for persistent fetal vasculature: a single-center, 20-year review

BACKGROUND

Persistent fetal vasculature (PFV) is a spectrum of congenital anomalies caused by complete or partial failure of the ocular fetal vasculature to regress. We report the visual and anatomic outcomes in a large cohort of patients who underwent early surgery for PFV.

METHODS

We retrospectively reviewed the medical records of patients who underwent lensectomy and anterior or core vitrectomy for unilateral PFV without primary intraocular lens implantation through limbal or pars plana/plicata approach. Inclusion criteria were surgery prior to 7 months of age, with at least 12 months of follow-up. Eyes with severe posterior segment involvement and retinal detachment deemed beyond repair were excluded.

RESULTS

A total of 58 patients met inclusion criteria. Mean age at surgery was 2.1 ± 1.5 months. Mean follow-up was 6.7 ± 4.2 years. At final follow-up, 19 eyes (33%) had visual acuity better than 1.0 logMAR. Thirty-three eyes (57%) developed 1 or more postoperative adverse events: glaucoma in 21 (36%) and retinal detachment in 11 (19%), 8 of which occurred in eyes that had pars plana or pars plicata incisions (P = 0.002). In patients with limbal incisions, 17 of 40 (43%) achieved a visual acuity better than 1.0 logMAR, compared with 2 of 18 patients (11%) with a pars plana/pars plicata incision (P = 0.03).

CONCLUSIONS

In our study cohort, early surgery for PFV achieved functional visual acuity in about one-third of patients. Limbal approach to surgery may result in better visual acuity and anatomic results.

Incidence and Risk Factors for Glaucoma Development After Bilateral Congenital Cataract Surgery in Microphthalmic Eyes

PURPOSE

To evaluate the long-term incidence and risk of glaucoma after bilateral congenital cataract surgery in microphthalmic eyes.

DESIGN

Retrospective, observational case series.

METHODS

Subjects: Children with microphthalmic eyes who had undergone surgery for bilateral congenital cataract within 6 months of birth and been followed up for at least 5 years.

PROCEDURES

Review of medical records at our institution.

MAIN OUTCOME MEASURES

Probability of an eye's developing glaucoma after bilateral congenital cataract surgery and associated risk factors.

RESULTS

Thirty-eight eyes of 19 children with bilateral congenital cataract were included. The mean age at surgery was 3.2 ± 1.7 months, and the mean follow-up duration was 7.79 ± 2.61 years. After cataract surgery, 11 eyes (29.0%) developed glaucoma at the age of 4.0 ± 1.4 years. Three of these eyes underwent Ahmed glaucoma valve implantation surgery. The probability of an eye's developing glaucoma was estimated to be 32.0% by 10 years after surgery. In a multivariate analysis, axial length was significantly associated with glaucoma development (odds ratio = 0.364, P = .025). Age at the time of cataract surgery, corneal diameter, and aphakia did not affect the risk of glaucoma (P > .10). Eyes without glaucoma had a better final visual outcome than those with glaucoma (0.75 ± 0.60 and 1.47 ± 1.10 logMAR, respectively, P = .049).

CONCLUSIONS

The long-term cumulative risk of postoperative glaucoma development was 32.0% by 10 years after bilateral congenital cataract surgery. Because the risk of developing glaucoma persists for several years after surgery, careful monitoring and control of intraocular pressure is needed to preserve vision in such patients.

Iridocorneal Angle and Anterior Segment Structure of Eyes in Children with Cataract

OBJECTIVE

To evaluate the morphology of iridocorneal angle and anterior segment in eyes of children with cataract.

METHODS

In this prospective cross-sectional study, we included eyes of children with bilateral cataract as well as unilateral cataract and fellow eyes. The iridocorneal angle was evaluated using gonioscopy. We compared the preoperative structures of iridocorneal angle and anterior segment between cataractous eyes and fellow eyes. The grading of iridocorneal angle and anatomical changes were analyzed.

RESULTS

We finally recruited 55 eyes of 55 children with bilateral cataract and 41 cataractous eyes and 33 fellow eyes of 41 children with unilateral cataract. The fellow eyes were used as a control group. The iridocorneal angle was open in eyes with pediatric cataract when compared to control eyes. The eyes with cataract exhibited more pigments on the trabecular meshwork than control eyes did (unilateral cataract vs. control, p = 0.013; bilateral cataract vs. control, p = 0.002). The eyes with cataract exhibited a smaller cornea than control eyes (unilateral cataract vs. control, p = 0.031; bilateral cataract vs. control, p < 0.001).

CONCLUSIONS

The iridocorneal angle is open in the eyes of children with cataract. Eyes with increased pigments on the trabecular meshwork need to be carefully monitored and surgeons should to be on the alert for postoperative glaucoma.

Outcomes of Bilateral Cataracts Removed in Infants 1 to 7 Months of Age Using the Toddler Aphakia and Pseudophakia Treatment Study Registry

PURPOSE

To evaluate outcomes of bilateral cataract surgery in infants 1 to 7 months of age performed by Infant Aphakia Treatment Study (IATS) investigators during IATS recruitment and to compare them with IATS unilateral outcomes.

DESIGN

Retrospective case series review at 10 IATS sites.

PARTICIPANTS

The Toddler Aphakia and Pseudophakia Study (TAPS) is a registry of children treated by surgeons who participated in the IATS.

METHODS

Children underwent bilateral cataract surgery with or without intraocular lens (IOL) placement during IATS enrollment years 2004 through 2010.

MAIN OUTCOME MEASURES

Visual acuity (VA), strabismus, adverse events (AEs), and reoperations.

RESULTS

One hundred seventy-eight eyes (96 children) were identified with a median age of 2.5 months (range, 1-7 months) at the time of cataract surgery. Forty-two eyes (24%) received primary IOL implantation. Median VA of the better-seeing eye at final study visit closest to 5 years of age with optotype VA testing was 0.35 logarithm of the minimum angle of resolution (logMAR; optotype equivalent, 20/45; range, 0.00-1.18 logMAR) in both aphakic and pseudophakic children. Corrected VA was excellent (<20/40) in 29% of better-seeing eyes, 15% of worse-seeing eyes. One percent showed poor acuity (≥20/200) in the better-seeing eye, 12% in the worse-seeing eye. Younger age at surgery and smaller (<9.5 mm) corneal diameter at surgery conferred an increased risk for glaucoma or glaucoma suspect designation (younger age: odds ratio [OR], 1.44; P = 0.037; and smaller cornea: OR, 3.95; P = 0.045). Adverse events also were associated with these 2 variables on multivariate analysis (younger age: OR, 1.36; P = 0.023; and smaller cornea: OR, 4.78; P = 0.057). Visual axis opacification was more common in pseudophakic (32%) than aphakic (8%) eyes (P = 0.009). Unplanned intraocular reoperation occurred in 28% of first enrolled eyes (including glaucoma surgery in 10%).

CONCLUSIONS

Visual acuity after bilateral cataract surgery in infants younger than 7 months is good, despite frequent systemic and ocular comorbidities. Although aphakia management did not affect VA outcome or AE incidence, IOL placement increased the risk of visual axis opacification. Adverse events and glaucoma correlated with a younger age at surgery and glaucoma correlated with the presence of microcornea.

Early Predictors of Long-term Outcomes in Childhood Glaucoma

PURPOSE

A data-based staging system for childhood glaucoma is likely to improve the prediction of visual acuity and intraocular pressure (IOP) control outcomes. We investigated early clinical factors associated with poor long-term visual, and IOP control outcomes in early-onset glaucoma as the initial steps to constructing a severity staging system.

DESIGN

Statistical modeling of retrospective case series data.

PARTICIPANTS

Glaucoma patients younger than 3 years of age who presented to Bascom Palmer Eye Institute between 1990 and 2010 with at least 5 years of follow up.

METHODS

Statistical modeling of retrospective case series data from first, second, third, 3-year, 5-year, and final visits.

MAIN OUTCOME MEASURES

Association of early clinical characteristics to final IOP-control outcomes and visual acuities.

RESULTS

A total of 26 eyes of 15 children were included. Nine of 15 (60%) of patients were male. Mean age at initial presentation: 9.98±10.55 months. Mean duration between initial and final visits: 11.13±3.55 years. By the third visit (mean 6.69 mo after presentation), presence of nystagmus, anterior segment dysgenesis (ASD) or having failed angle surgery increased the final LogMAR visual acuity by 0.76 (P=0.0516), 0.64 (P=0.0618), and 0.58 (P=0.0159), respectively. At year 3, failed amblyopia therapy, failed angle surgery, nystagmus, media opacity (MO), or ASD increased the final LogMAR by 1.30, 1.34, 1.21, 0.85, 0.64, respectively (all P<0.02). Failed angle surgery or MO increased the chance of uncontrolled IOP at the final visit (proportional odds ratio of 6.77 and 12.88, respectively).

CONCLUSIONS

In this pilot study of a modest size cohort, the presence of nystagmus, ASD or failed angle surgery early in the course of infantile-onset glaucoma management predicted poor final visual outcome, whereas failed angle surgery and presence of MO predicted poor final IOP control. These predictors of poor outcomes will serve as the initial steps in constructing a severity staging system.

Incidence of and Risk Factors for Suspected Glaucoma and Glaucoma After Congenital and Infantile Cataract Surgery: A Longitudinal Study in China

PRéCIS:: The overall incidence of postoperative suspected glaucoma and glaucoma after congenital cataract surgery is low; however, the identification of the associated risk factors helps to monitor susceptible individuals and to provide real-time surveillance and timely intervention.

PURPOSE

Pediatric patients who have undergone surgery for congenital or infantile cataracts have a risk of developing suspected glaucoma and glaucoma, but the current evidence does not address our understanding of the incidence and associated risk factors of suspected glaucoma/glaucoma for application in clinical standard care. Therefore, this study investigated the incidence of and risk factors for suspected glaucoma/glaucoma in patients who have undergone surgery for congenital/infantile cataracts.

METHODS

This study used a prospective cohort of 241 eyes from 241 patients who were 10 years of age or younger and who had undergone congenital/infantile cataract surgeries and were recruited from January 2011 to December 2016 at the Zhongshan Ophthalmic Center. Pediatric patients who underwent cataract surgery were classified into 2 groups according to intraocular lens (IOL) implantation. The patients' baseline characteristics and the incidence and risk factors for suspected glaucoma/glaucoma were assessed.

RESULTS

The incidence of suspected glaucoma after cataract surgery was 10.70% [26 of 241 eyes; 95% confidence interval (CI), 6.88%-14.70%]. The rate of suspected glaucoma developing into glaucoma was 26.92% (7 of 26 eyes; 95% CI, 9.87%-43.97%), and the incidence of glaucoma was 2.90% (7 of 241 eyes; 95% CI, 0.79%-5.03%). Our study revealed that the incidence of suspected glaucoma/glaucoma in patients who did not receive IOL implantation was 13.91% (21 of 151 eyes; 95% CI, 8.39%-19.42%), and the incidence in patients who received IOL implantation was 5.56% (5 of 90 eyes; 95% CI, 8.23%-10.28%). The preoperative central corneal thickness (hazard ratio, 1.003; 95% CI, 1.001 to 1.004; P=0.004) and a family history of congenital cataracts (hazard ratio, 2.314; 95% CI, 1.004-5.331; P=0.049) were significant risk factors in patients without IOL implantation. Patient age at the time of cataract surgery was not a statistically significant risk factor for the development of suspected glaucoma/glaucoma in patients without IOL implantation.

CONCLUSIONS

Identification of the incidence of and risk factors for suspected glaucoma/glaucoma may help clinicians monitor susceptible individuals and provide timely surveillance and interventions in a clinical setting. Age at the time of cataract surgery was not a risk factor for suspected glaucoma/glaucoma in patients without IOL implantation, and this may allow the timing window for pediatric cataract surgery to be expanded and support new insights into the optimal timing of surgery for standard care.

Glaucoma following cataract surgery in the first 2 years of life: frequency, risk factors and outcomes from IoLunder2

Background

We investigated glaucoma related adverse events, predictors and impact at 5 years following surgery in the IoLunder2 cohort

Methods

Population based observational cohort study of children undergoing cataract surgery aged 2 years or under between January 2009 and December 2010. Glaucoma was defined using internationally accepted taxonomies based on the consequences of elevated intraocular pressure (IOP). Glaucoma related adverse events were any involving elevated IOP. Multivariable analysis was undertaken to investigate potential predictors of secondary glaucoma with adjustment for within-child correlation in bilateral cataract. Unilateral and bilateral cataract were analysed separately.

Results

Complete follow-up data were available for 235 of 254, 93% of the inception cohort. By 5 years after primary cataract surgery, 20% of children with bilateral cataract and 12% with unilateral had developed secondary glaucoma. Glaucoma related complications had been diagnosed in 24% and 36% of children, respectively. Independent predictors of glaucoma were younger age at surgery (adjusted OR for reduction of week in age: 1.1, 95%C I 1.1 to 1.2, p<0.001); the presence of significant ocular comorbidity (adj OR 3.2, 95% CI 1.1 to 9.6, p=0.01); and shorter axial length (adj OR for each mm 1.7, 95% CI 10.0 to 1, p=0.05) for bilateral cataract. Shorter axial length was the single independent factor in unilateral disease (adj OR 9.6, 95% CI 1.7 to 52, p=0.009)

Conclusions

Both younger age at surgery (the strongest marker of ocular ‘immaturity’) and smaller ocular size (a marker of both immaturity and developmental vulnerability) can be used to identify those at greatest risk of glaucoma due to early life cataract surgery.

Congenital glycosylation disorder: a novel presentation of coexisting anterior and posterior segment pathology and its implications in pediatric cataract management

We report a case exhibiting the coexistence of anterior and posterior segment pathology in the same eye secondary to a congenital disorder of glycosylation resulting from a DPAGT1 gene mutation. This case details a novel gene mutation in a male infant found to have bilateral congenital cataracts, removed at 6 and 7 weeks of life, only to uncover bilateral retinal and optic atrophy. Our report highlights issues of surgical timing for syndrome-related pediatric cataracts, given the risks related to secondary glaucoma versus deprivation amblyopia, in an infant born with both cataracts and vision-limiting posterior segment pathology.

Association of Contact Lens Adherence With Visual Outcome in the Infant Aphakia Treatment Study: A Secondary Analysis of a Randomized Clinical Trial

Importance

Although contact lenses have been used for decades to optically correct eyes in children after cataract surgery, there has never been a prospective study looking at contact lens adherence in children with aphakia, to our knowledge.

Objective

To evaluate contact lens adherence and its association with visual outcome in a cohort of children treated for unilateral cataract surgery.

Design, Setting, and Participants

Secondary analysis of a multicenter randomized clinical trial of 57 infants born from August 22, 2004, to April 25, 2008, who were randomized to 1 of 2 treatments and followed up to age 5 years. Data analysis was performed from August 9, 2016, to December 7, 2017.

Interventions

Unilateral cataract extraction and randomization to implantation of an intraocular lens vs contact lens to correct aphakia.

Main Outcomes and Measures

Contact lens adherence was assessed by a 48-hour recall telephone interview that was administered every 3 months starting 3 months after surgery to age 5 years. A traveling examiner assessed visual acuity in patients at aged 4.5 years. Adherence to prescribed contact lens use was estimated as the mean percentage of waking hours as reported in 2 or more interviews for each year of life.

Results

Of 57 infants who were randomized to contact lens treatment, 32 (56%) were girls, and 49 (86%) were white. A total of 872 telephone interviews were completed. In year 1, a median of 95% participants wore their contacts lenses nearly all waking hours (interquartile range [IQR], 84%-100%); year 2, 93% (IQR, 85%-99%); year 3, 93% (IQR, 85%-99%); year 4, 93% (IQR, 75%-99%); and year 5, 89% (IQR, 71%-97%). There was a tendency for poorer reported adherence at older ages (F = 3.86, P < .001). No differences were identified when the results were analyzed by sex, insurance coverage, or age at cataract surgery. Using linear regression, children who wore the contact lens for a greater proportion of waking hours during the entire study period tended to have better visual acuity at age 4.5 years, even after accounting for adherence to patching (partial correlation = -0.026; P = .08).

Conclusions and Relevance

These results confirm that it is possible to achieve a high level of aphakic contact lens adherence over a 5-year period in children.

Trial Registration

clinicaltrials.gov Identifier: NCT00212134.

Secondary glaucoma and visual axis opacification in aphakic and pseudophakic patients following congenital cataract surgery: A 28-year longitudinal case series

Purpose:

To determine the incidence, timing and risk factors for glaucoma and visual axis opacification development following surgery for congenital cataract in the first year of life.

Methods:

A prospective case series of all cataract surgery performed in Temple Street Children’s University Hospital over a 28-year period was conducted. A total of 93 subjects (135 eyes) were analysed. Sixty-two eyes had a primary intraocular lens inserted at the time of surgery; 73 eyes were aphakic. We recorded patient demographics, age at surgery, length of follow-up, rates and time to diagnosis of glaucoma and rates of visual axis opacification. Relative risk analysis was performed to identify potential risk factors for secondary glaucoma and visual axis opacification.

Results:

Mean length of follow-up was 160.02 ± 64.42 months (13.3 years), range 40–336 months. Final mean LogMAR across all groups was 0.85 ± 0.51 (0.90). Overall 45 (33.33%) eyes developed secondary glaucoma, 12 (19.4%) in pseudophakic eyes and 33 (45.21%) in aphakic eyes. The incidence of glaucoma was highest in bilateral aphakia (relative risk 1.96, p = 0.0240) and in eyes with corneal diameter <9.5 mm (relative risk 1.93, p = 0.0364). There was no significant difference in glaucoma rates between pseudophakia and aphakia in those operated on less than 2.5 months of age. Secondary glaucoma occurred between 3 months to 16.5 years post surgery. Rates of visual axis opacification were lower in aphakia compared to pseudophakia (relative risk 0.59, p = 0.0098).

Conclusion:

Overall glaucoma rates of one-third are similar to those recorded in the infantile aphakic treatment study. It can occur up to 17 years post cataract surgery, evidence that long-term follow-up is imperative.

Risk of aphakic glaucoma after pars plana-lensectomy with and without removal of the peripheral lens capsule

BACKGROUND

The etiology of aphakic glaucoma is unclear. It has been suggested that remaining lens epithelium releases cytokines transducing trabecular meshwork cells. Therefore, we compared two cohorts of children undergoing lensectomy. In cohort 1, the entire lens including its capsule was removed, in cohort 2 the peripheral lens capsule was left intact, also to facilitate secondary intraocular lens implantation later on.

METHODS

We included children with uni- or bilateral congenital cataract who underwent lensectomy during the first year of life with subsequent contact lenses fitting. Group 1 comprised 41 eyes, group 2 comprised 33 eyes. In group 1, the median age at surgery was 4.0 months in unilateral and 3.0 months in bilateral cases 1, in group 2, 8.1 months and 2.4 months, respectively. The mean follow-up was 12.8 years in group 1 and 9.3 years in group 2. All cases were analyzed for the prevalence of aphakic glaucoma, for visual acuity and for compliance in visual rehabilitation (contact lens/occlusion therapy).

RESULTS

We found no significant difference in glaucoma prevalence between group 1 and group 2 (p = 0.68). The overall glaucoma rate was 26% after the mean follow-up of 11 years in both groups. In unilateral cases, the median visual acuity was logMAR 0.7 in both groups. In bilateral cases it was logMAR 0.4 in group 1 and logMAR 0.2 in group 2 (p = 0.05).

CONCLUSIONS

Leaving the peripheral lens capsule intact had no negative effect on the incidence of glaucoma and on resulting visual acuity.

The role of primary intraocular lens implantation in the risk of secondary glaucoma following congenital cataract surgery: A systematic review and meta-analysis

Objective

This meta-analysis aims to evaluate the incidence of secondary glaucoma in patients under the age of 2 years who underwent congenital cataract surgery with or without primary intraocular lens (IOL) implantation.

Methods

An electronic literature search was performed in Medline, EMBASE, and Web of Science databases to retrieve studies between January 2011 and November 2018. Patients with congenital cataract who did primary IOL implantation, aphakia, or secondary IOL implantation followed by receiving extraction surgery were included in this study. Relevant studies meeting defined eligibility criteria were selected and reviewed systematically by meta-analysis. Long-term incidences of secondary glaucoma, which developed at least one year after cataract surgery, were considered and discussed as clinical outcomes in each cohort. The pooled data were analyzed according to a random effects model.

Results

Eight publications involving 892 eyes were included in the current meta-analysis. In the general population of eyes with congenital cataract, the long-term incidence of secondary glaucoma was lower (P = 0.06) in eyes with primary IOL (9.5%) than in eyes without primary IOL (15.1%), including aphakia and secondary IOL. The pooled risk ratio (RR) favors primary IOL implantation in all patients (RR = 0.63). For bilateral congenital cataract, the incidence was 6.7% in eyes with primary IOL implantation, which is significantly lower than the 16.7% in eyes with aphakia and secondary IOL implantation (P<0.05, RR = 0.44). However, for unilateral congenital cataract surgery, the incidence was very similar in eyes with and without primary IOL (12.4% vs 12.0%, P = 0.61, RR = 0.87).

Conclusions

In patients under 2 years of age, primary IOL implantation for bilateral congenital cataract surgery is associated with a lower risk of secondary glaucoma.

Intraocular lens implantation as an isolated risk factor for secondary glaucoma in pediatric patients

OBJECTIVE

To evaluate the effect of intraocular lens (IOL) implantation on the development of secondary glaucoma after cataract surgery in pediatric patients.

DESIGN

Retrospective case series study.

METHODS

This study reviewed the medical records of children under 16 years of age who had undergone cataract surgery from 1996 to 2016 for congenital or developmental cataract. In every child an IOL was implanted in the primary surgery. Data collected included demographic information, age at cataract diagnosis and at surgery, surgical procedure, and postoperative follow-up of refraction, cup-to-disc ratio (C/D), intraocular pressure (IOP), and associated systemic and ocular anomalies. Patients with risk factors for glaucoma were excluded from the study.

RESULTS

Of the 255 children below age 16 years who underwent cataract extraction surgery with primary IOL implantation, 73 (124 eyes) met the inclusion criteria. Follow-up ranged from 4 to 18 years. Only 1 patient (0.8% of the 124 eyes) developed glaucoma in 1 of his 2 operated eyes; the surgeries were performed at 10 months, 1 week apart, and glaucoma was diagnosed 4 months later. One patient had suspected glaucoma in both eyes (incidence of 1.6%). Both these children were of Bedouin origin.

CONCLUSION

IOL implantation, by itself, is not a risk factor for development of secondary glaucoma after cataract surgery in a population below 16 years of age.

Medical Management of Children With Congenital/Infantile Cataract Associated With Microphthalmia, Microcornea, or Persistent Fetal Vasculature

PURPOSE

To report the surgical outcomes of children with cataract associated with microphthalmia, microcornea, or persistent fetal vasculature (MMP) and children with isolated cataract.

METHODS

The study included 111 children (cataract associated with MMP: n = 25) who underwent cataract surgery at younger than 16 years. Exclusion criteria were duration of follow-up less than 5 years, intraindividual differences in age at surgery, eye disorders other than MMP, secondary cataract, and syndromal diseases. Main outcome measures were proportion of eyes with glaucoma and best corrected visual acuity (BCVA). Both groups were dichotomized by age at surgery (early intervention group: ≤ 48 days). Descriptive analysis was performed throughout.

RESULTS

Median age at surgery was 3.9 months for cataract associated with MMP and 23.3 months for isolated cataract. The median (interquartile range [IQR]) duration of follow-up was 95.9 months (range: 76.0 to 154.5 months). In children with bilateral cataract associated with MMP, the proportion of eyes with final BCVA worse than 0.3 logMAR was similar regardless of age at surgery (early intervention: 80%, later intervention: 78%). In bilateral isolated cataract, the proportions were 56% and 33%, respectively. Children with cataract associated with MMP had a high prevalence of glaucoma (28%). Glaucoma prevalence was lower in the later intervention group.

CONCLUSIONS

In the presence of MMP, early cataract surgery is associated with a high risk of post-lensectomy glaucoma, but does not offer the benefit of better visual outcomes. [J Pediatr Ophthalmol Strabismus. 2019;56(1):43-49.].

Prospective analysis of the predictors of glaucoma following surgery for congenital and infantile cataract

PURPOSE

A prospective longitudinal cohort study was performed to assess the incidence of and risk factors for the development of glaucoma following surgery for congenital/infantile cataract.

METHODS

One hundred and one eyes of one hundred and one children, ≤12 years of age who had follow-up of ≥24 months were included. Group I included those who underwent surgery using an anterior approach, group II included those who underwent surgery using a posterior approach, and group III included those who underwent surgery using an anterior approach along with foldable intraocular lens implantation. Standard definitions for glaucoma and glaucoma suspect were used. The Cox proportional hazard model was used to analyze risk factors for glaucoma.

RESULTS

Group I: 30 eyes (29.7%); group II: 11 eyes (10.9%); group III 60 eyes (59.4%). The incidence of glaucoma + glaucoma suspect was 7.9% (95% CL: 2.6, 13.2%) in the entire group. The incidence in group I was 16.7% (95% CL 3%, 30%), in group II was 18.2% (95% CL: 0, 41%) and in group III was 1.7% (95% CL: 0, 4.9%). Gonioscopy revealed high iris insertion with grade I (modified Shaffer grading) in one eye each in the glaucoma and glaucoma suspect group and open angles in the rest. Age at surgery of ≤3 months (HR: 6.6, 95% CL: 1.4, 30.6, p = 0.01) was found to be a significant risk factor within the aphakic group.

CONCLUSIONS

Younger age at the time of surgery was the only identifiable risk factor for glaucoma.

Migration to aphakia and contact lens treatment is the trend in the management of unilateral congenital cataract in Britain and Ireland

BACKGROUND

The Infant Aphakia Treatment Study (IATS) compared the treatment of unilateral cataract in infants aged 1-6 months with primary intraocular lens (IOL) implantation vs aphakia with contact lens (CL) correction.

AIMS

This study aims to assess the current trends in the treatment of unilateral congenital cataract in infants less than 6 months at surgery in the UK and Ireland.

METHODS

An anonymous survey was emailed to the 200 members of the BIPOSA mailing list with 14 questions to assess treatment choice (primary intraocular lens (IOL) vs aphakia with contact lens (CL)), reasons for this choice, and assessment of local CL services.

RESULTS

There were 56 respondents, 39 of whom completed the entire survey. Aphakia with CL was the treatment choice for 74.4% of respondents. A quarter (25.6%) of respondents said they were performing primary IOL implantation prior to the publication of the Infant Aphakia Treatment Study (IATS), but now choose aphakia with CL. Amongst the 20.5% (n = 8) of respondents who chose primary IOL implantation, 5 attributed their choice to "inadequate CL service". The majority (84.6%) of respondents rated their infant CL service as either "good" or "very good".

CONCLUSION

Aphakia with CL rehabilitation was the most common approach to the treatment of unilateral congenital cataract in infants less than 6 months in this study. The results of the IATS appear to have influenced a change in practice from primary IOL implantation to aphakia and CL visual rehabilitation in approximately one quarter of those surveyed.

Long-term outcomes following primary intraocular lens implantation in infants younger than 6 months

Purpose:

To study the long-term safety profile and visual outcomes of primary intraocular lens (IOL) implantation in infants <6 months of age.

Methods:

This was a retrospective observational study conducted at a tertiary eye care center in South India. Infants under 6 months meeting the selection criteria who underwent cataract surgery (lens aspiration, primary posterior capsulorhexis, and anterior vitrectomy) with primary IOL implantation between January 2008 and December 2011 and minimum 3-year follow-up were included. Patient demographics, serial refractions, visual acuity, complications, and associated amblyopia/strabismus were reviewed. Visual acuity, myopic shift, and complications were the outcome measures.

Results:

Sixty-nine eyes of 38 infants (31 bilateral; mean age: 4.6 months) were reviewed. Mean follow-up was 51 months (range: 36–84). Median logMAR best-corrected visual acuity at the final visit was 0.74 (interquartile range [IQR]: 0.50–0.98) in eyes with bilateral cataracts and 0.87 (IQR: 0.60–1.14) in eyes with unilateral cataracts with an average myopic shift of 6.7 diopters over 4.2 years. Most common postoperative complication was visual axis opacification (VAO) (13 eyes, 18%), necessitating membranectomy followed by pigmentary IOL deposits (11 eyes, 15%), and IOL decentration and glaucoma in four eyes each (5.6%). Mixed linear effect model found no significant association of age, gender, laterality, and postoperative complications with final visual acuity (P ≥ 0.05). Eyes with unilateral cataracts had a greater myopic shift than bilateral cases (P = 0.03).

Conclusion:

Primary IOL implantation in infants <6 months is reasonably safe in appropriately selected infants. VAO was the most common postoperative complication, and a large myopic shift was observed.

Long-term efficacy of endoscopic cyclophotocoagulation in the management of glaucoma following cataract surgery in children

PURPOSE

To report the long-term efficacy of endoscopic cyclophotocoagulation (ECP) in pediatric glaucoma following cataract surgery (GFCS).

METHODS

ECP was performed on 35 eyes of 25 patients <16 years of age with GFCS. Patients were followed for a minimum of 2 years. Treatment failure was defined as consecutive postoperative intraocular pressure (IOP) of >24 mm Hg, alternative glaucoma procedure following ECP, or occurrence of visually significant complications. Analysis was performed to estimate risk factors for failure.

RESULTS

A total of 27 aphakic and 8 pseudophakic eyes were included. Pretreatment IOP averaged 33.9 ± 7.9 mm Hg. Final IOP after a mean follow-up period of 7.2 years was 18.9 ± 8.8 mm Hg (P < 0.001). The success rate was 54% (19/35 eyes). The failure rate was not increased in pseudophakic patients relative to aphakic patients. Patients with single ECP demonstrated preserved visual acuity from baseline to final follow-up.

CONCLUSIONS

In this patient cohort, with average follow-up period of 7.2 years, ECP was useful in the treatment of pediatric GFCS.

Outcome of Pediatric Cataract Surgeries in a Tertiary Center in Switzerland

Purpose

To determine and to analyze the outcome of pediatric cataract surgery.

Methods

A retrospective chart review of individuals aged up to 10 years who underwent cataract surgery between January 1, 2004, and December 31, 2014, at the UniversityHospital Zurich, Switzerland.

Results

63 children (94 affected eyes) with bilateral (68/94) or unilateral (26/94) cataract were identified. Surgery was performed at a median age of 1.5 months (IQR: 1.3–2.6 months) for the aphakic group (45/94) and of 50.7 months (IQR: 38.0–78.4 months) for the IOL group (49/94). At the last follow-up visit (median 31.1 months, IQR: 18.4–50.2 months), visual acuity was better in bilateral than in unilateral cataract cases. Posterior capsular opacification (PCO) was diagnosed in 30.9% of eyes without a significant difference in the IOL and aphakic groups (p = 0.12). Aphakic glaucoma was diagnosed in 12/45 eyes at a median of 6.8 months (IQR 2.1–13.3 months) after surgery. Microcornea (5/12) and anterior segment anomalies (8/12) were associated with glaucoma development (p < 0.05).

Conclusion

Laterality and timing of surgery influence the outcome of pediatric cataract surgery. PCO was the most frequent postoperative complication. Aphakic glaucoma is often associated with ocular developmental abnormalities and a poor visual outcome.

[Impact of timing of surgery on outcome in children with bilateral congenital cataract]

BACKGROUND

The optimal time for surgical intervention in bilateral congenital cataract is still a matter of controversy.

OBJECTIVES

Herein, we evaluated clinical and functional results after bilateral congenital cataract surgery and performed subgroup analysis based on the age at the time of surgery.

MATERIALS AND METHODS

We retrospectively reviewed the records of 52 eyes of 26 children who underwent surgery for bilateral congenital cataract without intraocular lens implantation within the first 12 months of life; 16 eyes underwent phacoaspiration within the first 10 weeks of life (group A) and 26 eyes had cataract extraction at an age of >10 weeks (group B). We defined the primary outcome measure to be the prevalence of mild, moderate, and severe amblyopia in relationship to age-dependent visual acuity norms after a mean follow-up of 59.7 ± 43.2 months. Secondary outcome measures were interocular difference of visual acuity and the presence of strabismus, nystagmus, posterior capsule opacification, and aphakic glaucoma.

RESULTS

The prevalence of amblyopia was not statistically different between the two age groups. Of all children, 62.5 % (A) and 61.1 % (B) developed age-dependent normal visual acuity or mild amblyopia. However, the younger cohort developed significantly less strabismus than the older cohort (P = 0.03). There was a strong relationship between cataract surgery within the first 14 weeks of life and the development of aphakic glaucoma. All children developing secondary cataract formation underwent cataract surgery in the first 20 weeks of life.

CONCLUSIONS

Our results suggest that long-term prevalence of mild, moderate, and severe amblyopia is similar between the two cohorts of bilateral congenital cataract eyes based on the age ≤ or >10 weeks at the time of surgery. Because there is a strong relationship between postoperative complications and a young age at the time of cataract surgery, close postoperative follow-up is essential. Strabismus is less likely to develop in infants after bilateral cataract surgery within the first 10 weeks of life.

Glaucoma following childhood cataract surgery: the South India experience

PURPOSE

To determine the characteristics and risk factors for the development of glaucoma after cataract surgery in children seen at a major referral tertiary eye centre in South India.

METHODS

This is a retrospective review of the medical records of consecutive patients seen at the glaucoma/paediatric eye clinic of the centre, with a diagnosis of glaucoma secondary to aphakia/pseudophakia over a 5-year period.

RESULTS

There were 21 eyes of 14 children that developed glaucoma and 23 eyes of 12 children were selected as control. The mean age (standard deviation SD) at the time of cataract surgery for the glaucoma group was 7.4 (± 10.1) months and 39.13 (± 41.2) months for the control. The mean follow-up (SD) period was 114.29 (± 61.9) months and 97.61 (± 43.5) months for the glaucoma and control, respectively. The mean duration from cataract surgery to onset of glaucoma was 81.19 (± 52.4) months (median 66 months, range 21-172 months). Multivariate analysis detected age at surgery younger than 12 months (OR 10.45, 95%CI 1.76-62.03, p = 0.010) and ocular anomalies mainly microcornea (OR 7.11, 95%CI 1.14-44.46, p = 0.036) as risk factors for development of glaucoma after paediatric cataract surgery.

CONCLUSION

Glaucoma can develop several years after childhood cataract surgery. Surgery in the first year of life and microcornea are risk factors for the development of glaucoma post-surgery. Signs of glaucoma should specifically be looked for during follow-up visits.