23-Gauge-Lentektomie zur operativen Behandlung einer angeborenen Katarakt

Surgical Outcomes of Lensectomy-Vitrectomy with Primary Intraocular Lens Implantation in Children with Bilateral Congenital Cataracts

In this study, we evaluated the long-term surgical outcomes of lensectomy-vitrectomy with primary intraocular lens (IOL) implantation in children with bilateral congenital cataracts (CCs) and investigated the potential risk factors for low vision. A total of 148 eyes in 74 children who underwent lensectomy-vitrectomy with primary IOL implantation were enrolled in this study. The surgery age was 44.04 ± 14.60 months, with a follow-up period of 46.66 ± 14.34 months. The final BCVA was 0.24 ± 0.32 logMAR, and low vision was found in 22 eyes (14.9%). Postoperative complications requiring additional surgeries included VAO (4 eyes, 5.4%), IOL pupillary captures (2 eyes, 2.0%), iris incarceration (1 eye, 0.7%), and glaucoma (1 eye, 0.7%). A higher incidence of VAO and larger postoperative refractive error was observed in younger children (≤2 years old) than in elder children (>2 years old) (p = 0.003, p = 0.047, respectively). Final BCVA was affected by preexisting comorbidity (p < 0.001), cataract density (p < 0.001), cataract size (p = 0.020), occurrence of postoperative complications (p = 0.011), and ASE (p = 0.008). Multivariate analysis showed that denser cataracts (OR = 9.303, p = 0.035) and preexisting comorbidity (OR = 4.712, p = 0.004) were the significant predictors of low vision. In conclusion, lensectomy-vitrectomy with primary IOL implantation is an effective and safe treatment for CC. The long-term visual outcome is encouraging in children with bilateral CC undergoing this procedure with a low rate of postoperative complications requiring surgeries. Moreover, eyes with denser cataracts and preexisting comorbidity may have a high risk of low vision.

23G Minimally Invasive Vitrectomy Combined with Glaucoma Drainage Valve Implantation and Phacoemulsification Cataract Extraction for Neovascular Glaucoma Secondary to Proliferative Diabetic Retinopathy with Vitreous Hemorrhage

Objective

To evaluate the clinical efficacy of the combined application of 23G minimally invasive vitrectomy, glaucoma drainage valve implantation, and phacoemulsification cataract extraction in the treatment of neovascular glaucoma (NVG) secondary to proliferative diabetic retinopathy (PDR) combined with vitreous hemorrhage (VH).

Methods

Eighty-three patients (91 eyes) with PDR diagnosed as NVG phase III complicated with VH from June 2018 to May 2020 were selected as the study subjects. The subjects were randomly divided into 3 groups: group A was treated with 23G minimally invasive vitrectomy combined with glaucoma drainage valve implantation; group B was given 23G minimally invasive vitrectomy combined with phacoemulsification cataract extraction; and group C was treated with 23G minimally invasive vitrectomy combined with glaucoma drainage valve implantation and phacoemulsification cataract extraction. The uncorrected visual acuity (UCVA), intraocular pressure (IOP), and iris neovascularization (INV) scores were recorded and compared among the 3 groups before and after operation, and then the postoperative pain relief and complications were observed.

Results

Through observation, there was no significant difference in the UCVA, IOP, and INV scores in the 3 groups before operation. After the operation, the UCVA, IOP, and INV scores of the 3 groups were significantly lower than those before operation. After operation, the UCVA of the 3 groups increased first and then decreased, and it improved most significantly in the 3rd month after operation and decreased in the 4th month after operation. There were significant differences in UCVA among the 3 groups at each time point after operation. From the 1st day to the 6th month after operation, the IOP of the 3 groups showed an upward trend, and there was no significant difference among the 3 groups in IOP at each time point after operation. At the 1st, 3rd, and 6th months after operation, the INV score of group A and group B was higher than that of group C. There was no significant difference in the INV score between group A and group B. The incidence of complications was not significantly different among the 3 groups.

Conclusion

23G minimally invasive vitrectomy, glaucoma drainage valve implantation, and phacoemulsification cataract extraction can effectively improve the UCVA, IOP, and INV scores of NVG secondary to PDR with VH, and the combined application of the 3 methods has better security.

Single-port transconjunctival vitrectomy for malignant glaucoma

The management of malignant glaucoma involves either anterior vitrectomy with zonulectomy and iridectomy or 3-port core pars plana vitrectomy (PPV) by retinal surgeons. The proposed modification can be performed with reasonable success rates. In this technique, synechiolysis and anterior chamber irrigation were performed through a limbal incision, and a single-port 23- or 25-gauge vitrector was introduced through PPV superotemporally to perform anterior vitrectomy and central posterior capsulotomy in pseudophakic eyes. The same procedure can be performed after cataract surgery in phakic eyes. Vitrectomy is continued until anterior chamber deepens, ensuring a conduit between anterior and posterior chambers through the posterior capsulotomy alone, bypassing the need for a posterior iridectomy/zonulectomy. In a series on 9 eyes, all achieved optimization of anterior chamber depth with intraocular pressure normalization in 8 of 9 eyes, without showing any signs of recurrence at a mean follow-up of 8.6 months.

[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.

Corneal approach 20 Guage vitrectomy system for the management of congenital cataract

Objective:

To evaluate the efficacy and complications of 20 gauge vitrectomy via corneal approach for the management of congenital cataract.

Method:

We performed anterior capsular vitreorhexis, lens matter aspiration (LMA), primary posterior vitrectorhexis and anterior vitrectomy via corneal approach using 20 gauge vitrectomy system in children younger than two years of age with congenital cataract between January 2014 to December 2014. The intra and postoperative complications were observed.

Results:

Twenty nine eyes of 21 children were included in this study. Congenital cataract surgery using 20 gauge vitrectomy system via corneal approach did not reveal any intra operative complication. Post operatively all children were able to freely open their operated eyes. Conjunctival congestion at the incision site in four eyes and mild anterior chamber reaction in 8 eyes were seen on 1^st daywhich resolved at one week follow up. Other major post operative complications such as inflammatory membrane, irregular pupil, posterior/anterior syneache and opacification of visual axis were not seen during follow up period.

Conclusion:

The 20-gauge vitrectomy system via corneal approach is easy to perform, is less time consuming, safe and effective for the management of congenital cataract in younger children.

Advances in the management of the surgical complications for congenital cataract

The greatest concern in children with cataracts is irreversible visual loss. The timing of congenital cataract surgery is critical for the visual rehabilitation. Cataract surgery in children remains complex and challenging. The incidence of complications during or after operation is higher in children than adults. Some complications could be avoided by meticulous attention to surgical technique and postoperative care, and others were caused by more exuberant inflammatory response associated with surgery on an immature eye or the intrinsic eyes abnormalities. Utilizing of advanced techniques and timely applying topical corticosteroids and cycloplegic agents can reduce the occurrence of visual axis opacification. Operation on children with strabismus or nystagmus, and applying occlusion therapy on amblyopic eyes can balance the visual inputs to the two eyes. Diagnosis of glaucoma following congenital cataract surgery requires lifelong surveillance and continuous assessment of the problem. So cataract surgeries in children are not the end of journey, but one step on the long road to visual rehabilitation. This paper describes recent evidence from the literature regarding the advance of management after congenital cataract surgery.

Advantages and limitations of small gauge vitrectomy

Small gauge vitrectomy utilizing 23- and 25-gauge instrumentation has definite advantages, but also limitations, due to the physics of smaller instruments and sutureless surgery. Higher infusion and aspiration pressures are needed to remove the vitreous using 23- and 25-gauge probes. The advantages include decreased surgical times, less tissue manipulation, reduced inflammation and pain postoperatively with more rapid visual recovery. A disadvantage is greater instrument flexion than 20-gauge probes, making small gauge vitrectomy more appropriate for indications such as vitreous opacities, epiretinal membranes, macular holes, and simple retinal detachments. There are also some increased complications related to small gauge vitrectomy, including dislocation of cannulas intraoperatively, early postoperative hypotony, choroidal detachment, and possibly an increased risk of infectious endophthalmitis.