[Examination methods in the diagnosis of uni- and bilateral cataracts in childhood]

[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.

[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.

[Treatment of cataracts in childhood I: clinical picture und surgical approach]

Despite progress in microsurgical treatment, pediatric cataracts still imply potential risks for pathological unilateral or bilateral visual and binocular development. Surgical approaches have changed fundamentally over the last 30 years which are directly associated with modifications in the postoperative care. Due to these parallel developments a continuous dynamic process arises between anterior segment surgeons and pediatric ophthalmologists so that only small case series exist which try to combine both subspecialties because until now it was not possible to gather enough experience with a single linear approach. The first article of this two part series will explain the variability of the disease and surgical approaches and the second part will try to convey a linear approach for the postoperative care.

Chirurgische Therapie der kongenitalen Katarakt

Due to the anatomical dimensions being smaller and the tissue structures being softer and more elastic in the young patient, surgery of paediatric cataracts represents a special challenge for the ophthalmic surgeon. Surgery is performed via a limbal or pars plana approach. The extreme high rate of secondary cataract formation in the paediatric or adolescent eye with closed posterior capsules is countered by means of complicated capsular surgery, special intraocular lens (IOL) implantation techniques, and vitreoretinal surgical procedures. It is customary not to implant IOLs before the children are 1-2 years old as increased axial length growth must be expected during the first 18 months after birth. IOL power is selected so that postoperative refraction is within the hyperopic range and with time, undercorrection will be balanced by bulbus growth. Preoperative and postoperative therapy is highly dependant on the extent of trauma sustained during surgery and should contain anti-inflammatory medication with and without steroids as well as antibiotics. Orthoptic follow-up examinations are also decisive for the long-term result.