Complications in the first 5 years following cataract surgery in infants with and without intraocular lens implantation in the Infant Aphakia Treatment Study

Secondary IOL implantation for an aphakic patient with congenital cataract living in Bonin Islands; follow-up study

Introduction: We previously reported a case of a patient with bilateral congenital cataract identified in the Ogasawara village, Bonin Islands, Japan, on a visit by an ophthalmologist and describe its course over 17 years from initial surgery. Here, we report on a secondary intraocular lens (IOL) implantation that was subsequently performed at 22 years and 5 months of age. Methods: After cataract surgery at 7 months, the aphakic patient began amblyopia treatment using extended-wear soft contact lenses (SCLs). After 10 years of age, SCLs were chosen to achieve crossed monovision considering the cosmetic appearance when facing other people. At 22 years of age, a secondary IOL implantation was performed. Secondary implant in the patient considered appearance and postoperative vision without glasses, we selected the crossed monovision method using a monofocal IOL. The postoperative targeted refraction for the right (non-dominant eye) and left eyes (dominant eye) planed - 0.33D and - 2.25D, respectively. Results: At 3 months after surgery, the corrected distance visual acuity (CDVA) with IOLs for the right and left eyes was 20/16 and 20/60, respectively, and the binocular visual acuity was 20/16 for distant vision and 20/25 for near vision. The CDVA for the right eye was: 20/13 × IOL = sph-0.25D and that for the left eye was: 20/13 × IOL = sph -1.75D D/cyl -0.50D/Ax170°. Although the exotropia was complicated by dissociated horizontal deviation and dissociated vertical deviation, there were no significant changes in ocular position before and after surgery. The patient was satisfied with achieving independence from spectacles and SCLs. Conclusion: The use of the crossed monovision method with monofocal IOLs in this patient and defective binocular function created a visual environment with no inconvenience in everyday life after secondary IOL implantation. In terms of secondary implant after amblyopia treatment, the IOL type or postoperative targeted refraction must be chosen to maintain or improve the visual environment obtained with the amblyopia treatment.

The outcomes of paediatric cataract surgery with intraocular lens insertion in sub-Saharan Africa: a systematic review

IMPORTANCE

Cataract is one of the leading causes of childhood blindness in Africa. The management of this condition requires timely surgical extraction of the cataractous lens with immediate optical correction and long-term follow-up to monitor visual improvement and manage complications that may arise. This review provides an opportunity to benchmark outcomes and to shed light on the reasons for those outcomes.

OBJECTIVES

To review the published literature and report on the outcomes of paediatric cataract surgery with intraocular lens insertion in sub-Saharan Africa.

DATA SOURCE

The EMBASE, PubMed, Scopus, and Web of Science were searched for relevant articles.

STUDY SELECTION

We included all published primary studies from sub-Saharan Africa on cataract surgery outcomes in children aged 0-16 years with primary intraocular lens implantation conducted between 1990 and 2020. Eligible studies were those published in English or for which an English translation was available. In addition, reviewers screened the reference lists of all studies included in the full-text review for eligible studies. During the review, studies fitting the inclusion criteria above except for having been conducted in middle and high-income countries were tagged and placed in a comparison arm.

DATA EXTRACTION AND SYNTHESIS

Study eligibility was determined by two independent reviewers, and data extraction was conducted by one reviewer with entries checked for accuracy by another reviewer. Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines for data synthesis were followed. The Joanna Briggs Institute (JBI) critical appraisal checklist was used for quality appraisal of the studies. The statistical software R was used in the analysis, and data were pooled using a random-effects model. Forest plots were generated using the R package 'metafor'.

MAIN OUTCOMES AND MEASURES

The primary outcome was visual acuity (VA) after cataract surgery and the proportions of eyes that achieved good, borderline, or poor visual outcome according to the World Health Organisation (WHO) categorisation of post-operative visual acuity. The secondary outcome measures reported included lag time to surgery, rates of follow-up, and rate of complications.

RESULTS

Eight out of 4763 studies were eligible for inclusion in this review, and seven were included in the quantitative analysis. There was a male preponderance in the study population, and the mean age at the time of cataract surgery ranged from 3.4 to 8.4 years. Visual outcomes were available for short-term visual outcomes (1 to 6 months) as the studies had a significant loss to follow-up. The pooled proportion of eyes that achieved a good visual acuity (i.e. equal to or greater than 6/18) in the short-term period was 31% (CI, 20-42). The comparative studies from middle and high-income countries reported proportions ranging from 41 to 91%, with higher thresholds for good visual acuity of 6/12 and 6/15.

CONCLUSION AND RELEVANCE

This review reports that there is a lower proportion of eyes with good outcomes after undergoing paediatric cataract surgery in sub-Saharan Africa than in middle- and high-income countries. Furthermore, this review states that there is a high proportion of patients lost to follow-up and suboptimal refractive correction and amblyopia treatment after paediatric cataract surgery.

Ten-year outcomes of congenital cataract surgery performed within the first six months of life

PURPOSE

To investigate the long-term outcomes of congenital cataract surgery performed within the first 6 months of life.

SETTING

11 ophthalmic surgical sites in Japan.

DESIGN

Retrospective chart review.

METHODS

Medical charts were retrospectively reviewed for 216 eyes of 121 patients. The age at surgery was 2.9 ± 1.7 months, with follow-up duration 13.0 ± 2.3 years. The cohort consisted of 83 cases with bilateral aphakia, 12 with bilateral pseudophakia, 20 with unilateral aphakia, and 6 with unilateral pseudophakia.

RESULTS

Surgical intervention within the critical period of visual system development (10 weeks for bilateral and 6 weeks for unilateral cases) led to significantly better final visual acuity than surgery conducted after this time frame. The incidence of secondary glaucoma was similar between groups while the occurrence of visual axis opacification was more frequent with earlier surgery. A forward stepwise multiple regression analysis revealed that the final visual acuity was significantly associated with laterality of cataract (better outcomes in bilateral cases), phakic status (with pseudophakia outperforming aphakia), presence of systemic and ocular comorbidities, and development of secondary glaucoma. Secondary glaucoma was significantly more prevalent in aphakic eyes than pseudophakic eyes.

CONCLUSIONS

In patients with genuine congenital cataract, surgery within the critical period of visual development results in better final visual acuity, albeit with an increased risk of visual axis opacification. The use of IOL with sophisticated surgical techniques shows promise even in congenital cataract surgery.

Nationwide incidence of congenital and infantile cataract requiring surgery in Korea

Congenital and infantile (CI) cataract is one of the most important and preventable cause of blindness in children, but the incidence has not been studied in Korea. We collected data from the national claims database of the National Health Insurance Service of Korea from 2002 through 2019. We identified children who underwent cataract surgery within the age of 5 years, and cumulative incidence rates were calculated for each of the three age criteria. 989 patients out of 4,221,459 births underwent surgery with CI cataract during the period. The cumulative incidence rates per 10,000 births were 1.60 (0-1 years), 2.38 (0-3 years), and 2.95 (0-5 years), respectively. The incidence peaked in the 2007 birth cohort, which coincides with the start of the national screening program for infants/children. Primary intraocular lens implantation was performed in 439 patients (44%). Strabismus and glaucoma requiring surgery occurred in 291 patients (29.4%) and 32 patients (3.2%), respectively, within 8 years after cataract surgery. The incidence rates of CI cataract in Korea appear to be comparable to previous studies in other regions. The early screening program for infants may reduce delayed diagnosis and increase the proportion of patients undergoing surgery at a critical time for visual development.

Surgical challenges of posterior optic capture in pediatric cataract surgery

PURPOSE

The efficacy of posterior optic capture (POC) in reducing posterior capsule opacification (PCO) in pediatric cataract is well recognized. The purpose of this paper was to identify the surgical challenges when attempting this technique and highlight the etiquettes to follow when performing this maneuver.

METHODS

Prospective observational noncomparative case series. Children diagnosed with congenital or developmental cataracts undergoing cataract surgery and primary IOL implantation with posterior optic capture (and no anterior vitrectomy) from June 2017 to April 2022 at a tertiary care referral institute were included. Records of all intraoperative findings and postoperative complications until the last follow-up were noted.

RESULTS

Posterior optic capture was attempted in 53 eyes of 49 children aged 2.4 ± 1.98 years. The mean follow-up of the patients was 16.5 ± 14.2 months (range 6 months-5 years). Successful POC could be performed in 46 eyes (86.8%). Two eyes developed posterior capsular opacification at the last follow-up. In eyes where POC could not be performed, five of these (83%) were children below 12 months of age with half of them having a preexisting posterior capsular defect.

CONCLUSION

Posterior optic capture is technically challenging with a steep learning curve that can be mastered over time. Adequate relative sizing of the anterior and posterior capsulorhexis is important. Caution is advised when using this technique in infants and in cases with posterior capsular defects.

Risk of visual axis opacification in infants with and without primary IOL implantation after congenital cataract surgery performed during the first 4 months of age

PURPOSE

The study evaluates the rate of postoperative formation of a pupillary membrane (PM) and posterior visual axis opacification (PVAO) in infants with and without primary IOL implantation during the first 4 months of infancy.

METHODS

Medical records for 144 eyes (101 infants) operated between 2005 and 2014 were evaluated. A posterior capsulectomy and anterior vitrectomy were performed. Primary IOL implantation was performed in 68 eyes, while 76 eyes were left aphakic. There were 16 bilateral cases in the pseudophakic group and 27 in the aphakic group. The follow-up period was 54.3 ± 21.05 months and 49.1 ± 18.60 months, respectively. Fisher's exact test was used for statistical analysis. The two-sample t-test with equal variance was used to compare surgery age, follow-up period and time intervals of complications.

RESULTS

The mean age of surgery was 2.1 ± 0.85 months in the pseudophakic and 2.2 ± 1.01 months in the aphakic group. PM was diagnosed in 40% pseudophakic and 7% aphakic eyes. A second surgery for PVAO was performed in 72% pseudophakic and 16% aphakic eyes. Both were significantly higher in the pseudophakic group. In the pseudophakic group, the number of PVAO was significantly higher in infants operated before 8 weeks of age compared to surgery age 9-16 weeks. The frequency of PM was not age-dependent.

CONCLUSION

Although it remains feasible to implant an IOL during the primary surgery, even in very young infants, there should always be solid arguments for this decision since it puts the child at higher risk of repeated surgeries under general anaesthesia.

Predictive Factors of Complications and Visual Outcomes after Pediatric Cataract Surgery: A Single Referral Center Study from Türkiye

Objectives

To evaluate the predictive factors of complications and visual acuity outcomes in pediatric cataract patients.

Materials and Methods

This retrospective, observational clinical study included 80 eyes of 50 patients treated for pediatric cataracts between 2010 and 2020. The eyes were divided into Group I (congenital cataracts, n=38) and Group II (developmental cataracts, n=42). Group II was also divided into Group IIA (aphakic, n=21) and Group IIB (pseudophakic, n=21). The effects of the age, laterality, cataract morphology, intraocular lens implantation, preoperative nystagmus/strabismus, and intraoperative anterior hyaloid rupture on complications and final best-corrected visual acuity (BCVA; logMAR) were evaluated.

Results

The median (interquartile range) age and follow-up time were 28 (5-79) months and 60 (29-84) months, respectively. There was a significant difference in mean final BCVA between Group I (0.79±0.46) and Group II (0.57±0.51) (p=0.047); however, no difference was observed between Group IIA and Group IIB (p=0.541). Having congenital cataract (p=0.045), preoperative nystagmus/strabismus (p=0.042), total/mature cataract (p<0.001), and postoperative complications (p=0.07) were significantly associated with final BCVA. However, in multivariate analysis, only total/mature cataract (β: 0.52, p<0.001) and having any complication (β: 0.24, p=0.018) were associated with final BCVA. Congenital cataract and intraoperative anterior hyaloid rupture were the only significant risk factors of postoperative complications on univariate (p=0.027 and p=0.003, respectively) and binary logistic regression analysis (odds ratio [OR]: 2.95 [95% confidence interval: 1.07-8.15], p=0.036 and OR: 4.28 [95% confidence interval: 1.55-11.77], p=0.005, respectively).

Conclusion

Total/mature cataract and the presence of any postoperative complication adversely affected the final BCVA. Having a congenital cataract and intraoperative anterior hyaloid membrane rupture increased the risk of complications.

What we have learned from the Infant Aphakia Treatment Study: The 49th Annual Frank D. Costenbader Lecture

Unilateral congenital cataracts lead to deprivation amblyopia, which can be severe. Until the 1970s, they were believed to be always associated with poor visual outcomes. However, advances in our understanding of the plasticity of the infant brain and the development of better surgical techniques allowed good visual outcomes to be obtained in a few of these patients. The Infant Aphakia Treatment Study (IATS) was conducted to provide empirical evidence regarding the best type of optical correction to be used following surgical extraction of the cataract. Specifically, infants were randomly assigned to either be left aphakic and to wear contact lenses or an intraocular lens (IOL) was implanted and the residual refractive error was corrected with spectacles. The study found that good visual acuity and stereopsis could be achieved in some patients in both treatment groups. Early cataract surgery, consistent optical correction and part-time patching of the fellow eye are important elements needed to achieve good visual outcomes. However, excess patching of the fellow eye may interfere with the development of stereopsis. More adverse events occurred after IOL implantation, particularly visual axis opacification, compared with the infants who were left aphakic. Glaucoma-related adverse events occurred in 40% of eyes after a 10-year follow-up and were not associated with IOL implantation. Further research is needed to increase the percentage of children with unilateral congenital cataracts who achieve good visual outcomes.

Novel silicone elastomer contact lenses designed for simultaneous viewing of distance and near eye displays

SIGNIFICANCE

As technology advances, there is a need for a safe and well-fitting contact lens that can be utilized to carry embedded components without concerns of decreasing oxygen permeability to the eye.

PURPOSE

The purpose of this study was to assess fitting characteristics, vision and performance of a novel ultra-high Dk silicone elastomer contact lens having a fully encapsulated two-state polarizing filter and a high-powered central lenslet that allows viewing at distance and viewing of a near eye display, while managing the concomitant high water vapor permeability of the material.

METHODS

15 participants were fit with the silicone elastomer study lenses. Biomicroscopy was conducted before and after lens wear. Visual acuity with manifest refraction and visual acuity with an over-refraction while wearing the plano-powered study lenses were measured. Participants wore spectacles with micro-displays at the focal length of the lenslet on each eye. Lens fit was assessed including ease of lens removal. Subjective assessments of viewing the micro-displays were completed on a 1(unable) to 10(immediate/profound/stable) scale.

RESULTS

Biomicroscopy revealed no eyes had moderate or severe corneal staining after study lens wear. Mean (±standard deviation) LogMAR acuity for all eyes was -0.13(0.08) with best corrected refraction and -0.03(0.06) with the study lenses and over-refraction. Mean spherical equivalent of the manifest refraction for both eyes was -3.12 D and was -2.75 D over the plano study lenses. Subjective assessments revealed a mean score of 7.67(1.91) for ease of obtaining fusion; 8.47(1.30) for ease of observing three-dimensional vision, and 8.27(1.49) for stability of the fused binocular display vision.

CONCLUSION

The silicone elastomer study lenses with a two-state polarizing filter and central lenslet allow for vision at distance and on spectacle mounted micro-displays.

Bag-in-the-lens intraocular lens implantation before 12 weeks of age in congenital cataract

PURPOSE

The aim of this study was to evaluate the intra- and postoperative complications, especially the risk of visual axis opacification (VAO), following the implantation of the bag-in-the-lens (BIL) intraocular lens (IOL) in infants with congenital cataract operated on before 12 weeks of age.

METHODS

Infants operated on before 12 weeks of age between June 2020 and June 2021 with a follow-up longer than 1 year were included in the present retrospective study. This was a first-experience cohort of an experienced paediatric cataract surgeon with this type of lens.

RESULTS

Nine infants (13 eyes) with a median age at surgery of 28 days (range, 21-49 days) were included. The median follow-up time was 21.6 months (range, 12.2-23.4 months). The lens was correctly implanted with the anterior and posterior capsulorhexis edges placed into the interhaptic groove of the BIL IOL in seven of 13 eyes; none of these eyes developed VAO. In the remaining six eyes, the IOL was only fixated to the anterior capsulorhexis edge, and in these cases, an anatomical anomaly of the posterior capsule and/or anterior vitreolenticular interface dysgenesis were observed. These six eyes developed VAO. One eye had a partial iris capture in the early postoperative phase. Otherwise, the IOL remained well centred and stable in all eyes. Anterior vitrectomy was necessary in seven eyes due to vitreous prolapse. One patient with unilateral cataract was diagnosed with bilateral primary congenital glaucoma at 4 months of age.

CONCLUSION

Implantation of the BIL IOL is safe even in the youngest age group less than 12 weeks of age. Although being a first-experience cohort, the BIL technique is shown to reduce the risk of VAO and the number of surgical procedures.

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.

Pediatric cataract surgery: considerations and updates in diagnosis and management

PURPOSE OF REVIEW

The purpose of this review is to provide an overview of updates in the diagnosis and management of pediatric cataracts, with an emphasis on recent discoveries in the last two years.

RECENT FINDINGS

Pediatric cataracts remain an infrequent but significant disease with vision threatening consequences. Although much of the management has not changed historically, more recent updates, particularly borrowed from adult cataract management, have influenced the field of cataract management in children. Even these studies emphasize that pediatric cataracts are a distinct clinical entity from adult-onset cataracts, and further research is needed to optimize the diagnosis and management of cataracts in childhood.

SUMMARY

This is an overview of the recent advancements in the diagnosis of management of pediatric cataracts, with advancements that originate from the adult cataract surgery field in addition to studies that challenge classical surgical techniques to make cataract surgery safer and to promote amblyopia therapy.

Long-term strabismus outcomes after unilateral infantile cataract surgery in the Infant Aphakia Treatment Study

PURPOSE

To characterize long-term strabismus outcomes in children in the Infant Aphakia Treatment Study (IATS).

METHODS

This study was a secondary data analysis of long-term ocular alignment characteristics of children aged 10.5 years who had previously been enrolled in a randomized clinical trial evaluating aphakic management after unilateral cataract surgery between 1 and 6 months of age.

RESULTS

In the IATS study, 96 of 109 children (88%) developed strabismus through age 10.5 years. Half of the 20 children who were orthophoric at distance through age 5 years maintained orthophoria at distance fixation at 10.5 years. Esotropia was the most common type of strabismus prior to age 5 years (56/109 [51%]), whereas exotropia (49/109 [45%]) was the most common type of strabismus at 10.5 years (esotropia, 21%; isolated hypertropia, 17%). Strabismus surgery had been performed on 52 children (48%), with 18 of these (35%) achieving microtropia <10^Δ. Strabismus was equally prevalent in children randomized to contact lens care compared with those randomized to primary intraocular lens implantation (45/54 [83%] vs 45/55 [82%]; P = 0.8). Median visual acuity in the study eye was 0.56 logMAR (20/72) for children with orthotropia or microtropia <10^Δ versus 1.30 logMAR (20/400) for strabismus ≥10^Δ (P = 0.0003).

CONCLUSIONS

Strabismus-in particular, exotropia-is common irrespective of aphakia management 10 years following infant monocular cataract surgery. The delayed emergence of exotropia with longer follow-up indicates a need for caution in managing early esotropia in these children. Children with better visual acuity at 10 years of age are more likely to have better ocular alignment.

Outcomes of unilateral cataract surgery in children 2-7 years of age: a comparison to surgery in toddlers and infants

PURPOSE

To compare outcomes of unilateral cataract surgery in children aged 2-7 years with the outcomes reported in younger children.

METHODS

The medical records of patients who underwent unilateral cataract surgery between the ages of 2-7 years were reviewed retrospectively. Traumatic cataracts and ectopia lentis were excluded. Outcomes were compared to those of the Infant Aphakia Treatment Study (IATS) for infants up to 7 months of age and the Toddler Aphakia and Pseudophakia Study (TAPS) for toddlers between 7-24 months of age who underwent unilateral cataract surgery.

RESULTS

A total of 68 children were included, with a mean follow-up of 4.3 years. The proportion of intraoperative complications (7%) was significantly lower than that reported in IATS but not significantly different from that of TAPS. In our older cohort, more children (41%) had visual acuity better than 20/40 compared to infants (23% [P < 0.05]) and toddlers (11% [P < 0.001]), with a final median visual acuity of 20/44. The proportion of adverse events in our older cohort was reduced (7%) compared to that of infants (81%) and toddlers (24%). Additional unplanned intraocular surgeries occurred less often (6%) than in the infant cohort (72%). No patients developed glaucoma.

CONCLUSIONS

Cataract surgery in slightly older children carries less risk of vision-threatening complications and adverse events compared to infants and results in better visual outcomes than in toddlers. Once the decision is made to pursue surgery on a visually significant cataract, the age of the child should determine which relevant risks are emphasized in the informed consent discussion.

Outcomes of bilateral cataract surgery in children 2-7 years of age: a comparison to surgery in toddlers and infants

PURPOSE

To evaluate the outcomes of bilateral cataract surgery in children 2-7 years of age in our institution and to compare them to the bilateral infant and toddler outcomes of the Toddler Aphakia Pseudophakia Study (TAPS) registry.

METHODS

The medical records of children who underwent bilateral cataract surgery between the ages of 2 and 7 years of age with a minimum of 2 years' postoperative follow-up were reviewed retrospectively. Patients with a history of trauma or subluxated lenses were excluded. Main outcome measures were best-corrected visual acuity, strabismus requiring surgery, adverse events, and reoperations.

RESULTS

A total of 114 eyes of 57 children were included. Median age at surgery was 4.4 years. At the visit closest to 10 years of age, the median best-corrected visual acuity of the better-seeing eye was 0.05 logMAR (20/22); of the worse-seeing eye, 0.18 logMAR (20/30). Strabismus surgery was performed in 1 patient. Among first-operated eyes, adverse events occurred in 4 eyes (7%), which was significantly less than in the TAPS cohort of 1-7 months (P = 0.0001) and the TAPS cohort of 7 months to 2 years (P = 0.01). No eye developed glaucoma or was labeled glaucoma suspect. Unplanned intraocular reoperations were needed in 4 first-operated eyes (3 membranectomy/vitrectomy for removal of opacifications and 1 lysis of vitreous wick).

CONCLUSIONS

Compared to infants and toddlers, bilateral cataract surgery performed between 2 and 7 years of age was associated with significantly fewer adverse events and excellent visual acuity.

Femtosecond laser-assisted anterior capsulotomy in children undergoing cataract surgery: a large case series

Objective

To evaluate safety and postoperative visual outcomes of low-energy femtosecond laser-assisted (FLA) anterior capsulotomy in paediatric cataract surgery.

Methods and analysis

We report a retrospective single-centre consecutive case series of 51 eyes of 33 paediatric cataract patients with a mean age of 3.22 years (range: 2 months to 13 years) who underwent cataract surgery with FLA anterior capsulotomy, using FEMTO LDV Z8 femtosecond laser (Ziemer Ophthalmic Systems). Anterior laser capsulotomy, phacoaspiration and intraocular lens implantation were performed in all eyes. Both intraoperative and long-term postoperative complications, along with long-term monocular corrected distance visual acuity (CDVA), were assessed during average follow-up period of 32.96 months (range: 13–69 months).

Results

In 48 out of 51 eyes, a well-sized and well-located anterior capsulotomy was achieved without intraoperative complications. Anterior capsule tears occurred in three eyes; however, they did not extend posteriorly and the intraocular lens were placed in the bags without any further complications. Posterior capsular opacification developed in 45.10% of eyes (23 out of 51) and was subsequently treated with neodymium:yttrium-aluminum-garnet (Nd:YAG) laser capsulotomy. Mean CDVA at final follow-up was 20/40 (range: 20/63 to 20/32) in unilateral cases younger than 12 months, 20/40 (range: 20/1000 to 20/25) in unilateral cases older than 12 months, 20/66 (range: 20/400 to 20/32) in bilateral cases younger than 12 months and 20/40 (range: 20/200 to 20/20) in bilateral cases older than 12 months.

Conclusions

Paediatric cataract surgery with low-energy FLA anterior capsulotomy is a procedure with long-term safety, resulting in significant improvement in CDVA.

Primary intraocular lens implantation in infants with unilateral congenital cataract operated before 12 weeks of age

PURPOSE

The aim of this study was to report visual outcome and safety after cataract surgery with primary intraocular lens implantation before 12 weeks of age.

METHODS

Infants with visually significant unilateral congenital cataract having primary IOL implantation in the capsular bag before 12 weeks of age in 2007-2016 were enrolled for a prospective study examination in 2017. The medical records were also reviewed.

RESULTS

In total, 23 patients with a median age at cataract surgery of 32 days (range, 12-75 days) were included. Seventeen (74%) eyes had persistent foetal vasculature (PFV). After a median follow-up of 6.3 years (range, 1.4-10.9 years), the corrected distance visual acuity was 0.8 logMAR (range, 3.0-0.1 logMAR). All, except one eye, required surgery for visual axis opacification (VAO), with a median of two (range 0-5) additional surgical procedures. Four (17%) eyes developed secondary glaucoma.

CONCLUSION

Cataract surgery with primary IOL implantation before 12 weeks of age resulted in a high number of VAO operations, and the visual outcome varied considerably, showing the range in outcome for this challenging patient group. Co-existent PFV in these young patients was common. The incidence of secondary glaucoma was similar to other studies, despite the young age at surgery, high percentage of PFV and number of surgical procedures for VAO.

Clinical Features and Outcomes of Congenital Cataract Surgery with Primary Intraocular Lens Implantation in a Tunisian Cohort

Purpose

To describe the clinical features of congenital cataract (CC) in a Tunisian cohort and to assess the surgical outcomes of primary intraocular lens implantation in two groups based on the age at surgery.

Methods

This study was a prospective analysis of children under 5 years with CC that were operated between January 2015 and 2020. The surgery consisted of phacoaspiration with posterior capsulorhexis and primary implantation. Group 1 comprised children operated at <2 years of age and Group 2 comprised children operated between 2 and 5 years. Peri and postoperative surgical events as well as refractive and visual outcomes were compared between both the groups.

Results

Fifty-five (84 eyes) infants were enrolled. Group 1 included 30 (48 eyes) children and Group 2 included 25 (36 eyes) patients. The mean follow-up was 27.60 ± 19.89 months. The mean delay between the diagnosis and the cataract surgery was 11.97 ± 13.84 months. Of 14 (16.7%) eyes with postoperative visual axis opacification (VAO), 9 (10.7%) eyes required pars plana membranectomy. The VAO was not statistically associated with the age at surgery (P = 0.112), but significantly correlated with sulcus implantation (P = 0.037). The final mean visual acuity was 0.51 logMAR and comparable between both the groups (P = 0.871). Poor visual outcome was significantly associated with low age at presentation (<6 months; P = 0.039), delay between the diagnosis and time of surgery (P = 0.001), preoperative nystagmus (P = 0.02), and poor parental compliance to amblyopia treatment (P = 0.009).

Conclusions

Primary implantation seems to be safe and efficient. VAO appears to become an avoidable occurrence owing to better surgical techniques. Amblyopia remains the biggest barrier to final visual outcome.

Bag-in-the-lens intraocular lens in paediatric cataract surgery: intraoperative and postoperative outcomes

PURPOSE

To report intra- and postoperative surgical outcome using the bag-in-the-lens (BIL) technique in paediatric cataract surgery.

METHODS

In a retrospective case series, we studied the outcomes of children aged <12 years operated for cataract with the bag-in-the-lens intraocular lens (IOL), with a minimum of 6 months of follow-up.

RESULTS

Since 2013, 50 eyes in 30 patients <12 years (20 bilateral and 10 unilateral) have been operated at our department with the BIL technique, with a median follow-up time of 33.5 months (range 6-77). Median age at surgery was 49.5 months (4-139). In one case, the IOL luxated through the capsulorhexes to the vitreous, but could be secured and repositioned as planned without further difficulties. Anterior vitrectomy was necessary in one case due to prolapse of vitreous to the anterior chamber during surgery. No other intraoperative complications occurred. Visual axis opacification (VAO) developed in four eyes (8%). So far, only one of these has needed a reoperation with clearing of the secondary cataract. A complete absence of VAO was thus seen throughout the study period in 92%. In two eyes, postoperative iris capture occurred. In both cases, surgical repositioning of the iris was needed. No eyes developed secondary glaucoma during the study period.

CONCLUSION

The BIL technique seems to be a safe surgical procedure in paediatric cataract, with significantly less complications and need for additional surgery compared with the conventional lens-in-the-bag technique.

Posterior Capsular Outcomes of Pediatric Cataract Surgery With In-The-Bag Intraocular Lens Implantation

AIM

To investigate the change of posterior capsular outcomes of pediatric cataract surgery with primary in-the-bag intraocular lens (IOL) implantation.

METHODS

We conducted a case series of pediatric cataract children who underwent cataract extraction with primary in-the-bag IOL implantation, posterior capsulorhexis or vitrectorhexis, and limited anterior vitrectomy at the Eye Hospital of Wenzhou Medical University between 2016 and 2019. Digital retro-illumination photographs of pediatric eyes were obtained at baseline and 6 months, 12 months, and the last visit postoperatively. Capsular outcomes of the posterior capsular opening area (PCOA) and lens reprolifration area at those time points were compared. Correlations between the PCOA and influential factors, such as age at surgery, axial growth, and follow-up duration, were analyzed. The study was registered at register.clinicaltrials.gov (NCT04803097).

RESULTS

Data of 23 patients (27 eyes) were used in the final analysis. During follow-up, the PCOA enlarged at a rate of 0.29-0.32 mm²/month during the first six months postoperatively and 0.05-0.08 mm²/month over the next 1-2 years. Six months postoperatively, the PCOA enlargement statistically and positively correlated with the follow-up duration and axial growth. The area of lens reprolifration was 0.46 ± 1.00 mm² at six months postoperatively and then remained stable.

CONCLUSION

The PCOA enlarged rapidly within the first six months after the pediatric cataract surgery with primary IOL implantation. Six months postoperatively, the enlargement of PCOA was positively correlated with follow-up duration and axial growth. Posterior capsulorhexis or capsulectomy should be performed with a diameter of 3.0 to 4.0 mm for good visual axis transparency and the protection of in-the-bag IOL.

Commentary review: challenges of intraocular lens implantation for congenital cataract infants

As an indispensable part of congenital cataract surgery, intraocular lens (IOL) implantation in infantile patients has long-term positive impacts on visual rehabilitation, as well as postoperative complications inevitably. Timing of IOL implantation in infantile congenital cataract patients is not simply a point-in-time but a personalized decision that comprehensively takes age at surgery, risks of postoperative complications, and economic condition of family in consideration, and combines with choosing suitable IOL type and power. For infants with well-developed eyeballs and good systemic conditions, IOL implantation at six months of age or older is safe and effective. Otherwise, secondary IOL implantation may be a safer choice.

Glaucoma-Related Adverse Events at 10 Years in the Infant Aphakia Treatment Study: A Secondary Analysis of a Randomized Clinical Trial

Importance

Glaucoma-related adverse events constitute serious complications of cataract removal in infancy, yet long-term data on incidence and visual outcome remain lacking.

Objective

To identify and characterize incident cases of glaucoma and glaucoma-related adverse events (glaucoma + glaucoma suspect) among children in the Infant Aphakia Treatment Study (IATS) by the age of 10.5 years and to determine whether these diagnoses are associated with optic nerve head (ONH) and peripapillary retinal nerve fiber layer (RNFL) assessment.

Design, Setting, and Participants

Analysis of a multicenter randomized clinical trial of 114 infants with unilateral congenital cataract who were aged 1 to 6 months at surgery. Data on long-term glaucoma-related status and outcomes were collected when children were 10.5 years old (July 14, 2015, to July 12, 2019) and analyzed from March 30, 2019, to August 6, 2019.

Interventions

Participants were randomized at cataract surgery to either primary intraocular lens (IOL), or aphakia (contact lens [CL]). Standardized definitions of glaucoma and glaucoma suspect were created for IATS and applied for surveillance and diagnosis.

Main Outcomes and Measures

Development of glaucoma and glaucoma + glaucoma suspect in operated-on eyes up to age 10.5 years, plus intraocular pressure, axial length, RNFL (by optical coherence tomography), and ONH photographs.

Results

In Kaplan-Meier analysis, for all study eyes combined (n = 114), risk of glaucoma after cataract removal rose from 9% (95% CI, 5%-16%) at 1 year, to 17% (95% CI, 11%-25%) at 5 years, to 22% (95% CI, 16%-31%) at 10 years. The risk of glaucoma plus  glaucoma suspect diagnosis after cataract removal rose from 12% (95% CI, 7%-20%) at 1 year, to 31% (95% CI, 24%-41%) at 5 years, to 40% (95% CI, 32%-50%) at 10 years. Risk of glaucoma and glaucoma plus glaucoma suspect diagnosis at 10 years was not significantly different between treatment groups. Eyes with glaucoma (compared with eyes with glaucoma suspect or neither) had longer axial length but relatively preserved RNFL and similar ONH appearance and visual acuity at age 10 years.

Conclusions and Relevance

Risk of glaucoma-related adverse events continues to increase with longer follow-up of children following unilateral cataract removal in infancy and is not associated with primary IOL implantation. Development of glaucoma (or glaucoma suspect) after removal of unilateral congenital cataract was not associated with worse visual acuity outcomes at 10 years.

Trial Registration

ClinicalTrials.gov Identifier: NCT00212134.

Outcomes of secondary intraocular lens implantation in the Infant Aphakia Treatment Study

PURPOSE

To report outcomes of secondary intraocular lens (IOL) implantation in the Infant Aphakia Treatment Study (IATS).

SETTING

Multicenter clinical practice.

DESIGN

Secondary analysis of patients enrolled in a randomized clinical trial.

METHODS

Details regarding all secondary IOL surgeries conducted in children enrolled in the IATS were compiled. Visual outcomes, refractive outcomes, and adverse events at the age of 10½ years were evaluated. Comparisons were made with eyes that remained aphakic and with eyes randomized to primary IOL placement.

RESULTS

The study included 114 infants, 57 in the aphakic group and 57 in the primary IOL group; 55 of 57 patients randomized to aphakia with contact lens correction were seen for the 10½-year study visit; 24 (44%) of 55 eyes had secondary IOL surgery. Median age at IOL surgery was 5.4 years (range 1.7 to 10.3 years). Mean absolute prediction error was 1.00 ± 0.70 diopters (D). At age 10½ years, the median logarithm of the minimum angle of resolution visual acuity (VA) was 0.9 (range 0.2 to 1.7), similar to VA in the 31 eyes still aphakic (0.8, range 0.1 to 2.9); the number of eyes with stable or improved VA scores between the 4½-year and 10½-year study visits was also similar (78% secondary IOL eyes; 84% aphakic eyes). For eyes undergoing IOL implantation after the 4½-year study visit (n = 22), the mean refraction at age 10½ years was -3.20 ± 2.70 D (range -9.90 to 1.10 D), compared with -5.50 ± 6.60 D (n = 53, range -26.50 to 3.00 D) in eyes with primary IOL (P = .03).

CONCLUSIONS

Delayed IOL implantation allows a more predictable refractive outcome at age 10½ years, although the range of refractive error is still large.

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.

Comparison of posterior optic capture of intraocular lens without vitrectomy vs endocapsular implantation with anterior vitrectomy in congenital cataract surgery: A randomized prospective study

Purpose:

To compare surgical outcome of two procedures in pediatric cataract surgery.

Methods:

Prospective randomised interventional study. Consecutive patients with bilateral congenital cataract who were operated during January 2016 to October 2016 at a tertiary care referral institute were included. One eye of all patients underwent Intraocular lens (IOL) implantation with optic capture through a primary posterior continuous curvilinear capsulorhexis (PPC) without vitrectomy while in the other eye endocapsular IOL implantation was performed along with PPC and anterior vitrectomy. Intraoperative challenges and postoperative complications were noted.

Results:

15/18 children who fulfilled the inclusion criteria were included for follow up analysis. Mean age at the time of surgery was 21 ± 14.7 months. At a mean follow up of 25.69 ± 1.06 months; all eyes in both groups maintained a clinically centred IOL with clear visual axis. One patient with endocapsular IOL implantation developed anterior capsular phimosis. The rate of fibrinous complications (IOL deposits and synechiae) were more in the eyes with IOL in the bag (6 eyes) vs eyes where posterior optic capture was done (1 eye); P = 0.039.

Conclusion:

Posterior optic capture is a safer alternative to conventional pediatric cataract surgery in terms of inflammatory sequelae and lens epithelial cell proliferation. However the two methods work equally well in preventing visual axis obscuration over a long follow-up.

Developmental characteristics of the cytokine profile in aqueous humor and its relationship with the inflammatory response in children

Background

Although influencing the severity of postoperative intraocular inflammation of congenital cataract, the developmental characteristics of cytokine profile in the aqueous humor during childhood had not been described. And its relationship with the inflammatory response after intraocular surgery remained unsolved.

Methods

Preoperative aqueous humor samples were collected from 65 eyes of congenital cataract patients (CC group) and 13 eyes of age-related cataract patients (ARC group) from January 2015 to May 2017. The concentrations of 22 cytokines were measured. Differences in concentrations between the CC and ARC groups were described. Correlation analysis, least absolute shrinkage and selection operator (LASSO) and multivariate linear regression were then used to investigate the dynamic changes in the cytokine profile with age and their relationships with the postoperative inflammatory response.

Results

The concentrations of granulocyte colony stimulating factor (G-CSF), interferon (IFN)-α2, interleukin (IL)-1α and IL-7 were higher in the CC group than in the ARC group, while the concentrations of epidermal growth factor (EGF), granulocyte-macrophage colony stimulating factor (GM-CSF), IL-10, IL-12p70, IL-2, IL-3, IL-4, IL-5, IL-6, IL-8, and tumor necrosis factor (TNF)-α were more abundant in the ARC group (P<0.05). Within the CC group, the concentrations of EGF and IL-3 were positively correlated with age, while negative correlations were observed for monocyte chemotactic protein-1 (MCP-1) and IL-8 (P<0.05). Further multivariate analysis revealed that age was an independent associated factor of MCP-1 (β=−0.337, P<0.001). IL-3 (β=−0.490, P=0.006) and EGF (β=−0.415, P=0.044) were significantly correlated with the postoperative inflammatory response [evaluation of posterior capsule opacification (EPCO)] at 3 and 12 months after surgery, respectively.

Conclusions

This study demonstrated the dynamic change in the cytokine profile of the aqueous humor in children and its relationship with the postoperative inflammatory response. These findings can serve as the foundation for further investigation into the mechanisms that underlie the early development of intraocular immunology.

Intraocular Lenses: Overview of Designs, Materials, and Pathophysiologic Features

This article provides an overview of intraocular lenses (IOLs) currently used in cataract surgery. Aspects presented include design features related to IOL construction and sites of fixation; optic, filter, and haptic materials; as well as pathophysiologic features of uveal biocompatibility, capsular biocompatibility, and postoperative IOL opacification. This overview also includes supplementary (add-on; piggyback) lenses implanted in eyes that are already pseudophakic and considerations on IOLs used in the pediatric population. Different IOLs are made available to surgeons each year, including lenses with increasingly complex design characteristics owing to advancements in manufacturing and surgical techniques.

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.

Long-term Effect of Intraocular Lens vs Contact Lens Correction on Visual Acuity After Cataract Surgery During Infancy: A Randomized Clinical Trial

Importance

Although intraocular lenses (IOLs) are often implanted in children, little is known whether primary IOL implantation or aphakia and contact lens correction results in better long-term visual outcomes after unilateral cataract surgery during infancy.

Objective

To compare long-term visual outcomes with contact lens vs IOL correction following unilateral cataract surgery during infancy.

Design, Setting, and Participants

This multicenter randomized clinical trial enrolled 114 infants with a unilateral congenital cataract who underwent cataract surgery with or without primary IOL implantation between 1 and 6 months of age. Data on long-term visual outcomes were collected when the children were age 10.5 years (July 14, 2015, to July 12, 2019) and analyzed from March 30 through August 6, 2019.

Interventions

Intraocular lens implantation at the time of cataract surgery.

Main Outcomes and Measures

Best-corrected visual acuity using the electronic Early Treatment Diabetic Retinopathy Study (E-ETDRS) testing protocol. Analysis was performed on an intention-to-treat basis.

Results

Best-corrected visual acuity was measured at age 10.5 years for 110 of the 114 patients (96%) enrolled as infants. The participants included 58 girls (53%) and 52 boys (47%). Overall, 27 of the children (25%) had good (logMAR 0.30 [Snellen equivalent, 20/40] or better) visual acuity in the treated eye (12 [22%] in the IOL group and 15 [27%] in the aphakia group), but 50 children (44%) had a visual acuity of logMAR 1.00 (Snellen equivalent, 20/200) or worse (25 [44%] in the IOL group and 25 [44%] in the aphakia group). The median logMAR acuity in the treated eye was similar in children randomized to receive an IOL at the time of cataract extraction (0.89; interquartile range [IQR], 0.33-1.43 [Snellen equivalent, 20/159]) and those who remained aphakic (0.86; IQR, 0.30-1.46 [Snellen equivalent, 20/145]) (IQR, 0.30-1.46; P = .82). Although the overall difference in median visual acuity between the 2 groups was small, the estimate was imprecise (99% CI for the difference in medians was -0.54 to 0.47).

Conclusions and Relevance

As in previous phases of the study, visual acuity outcomes were highly variable with only 27 children (25%) achieving excellent visual acuity in their treated eye and 50 children (44%) having poor vision in the treated eye. Implanting an IOL at the time of cataract extraction was neither beneficial nor detrimental to the visual outcome.

Trial Registration

ClinicalTrials.gov Identifier: NCT00212134.

[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.

Visual Axis Opacity after Intraocular Lens Implantation in Children in the First 2 Years of Life: Findings from the IoLunder2 Cohort Study

PURPOSE

Appropriate correction of aphakia is key to good outcomes. There may be clinical settings where and populations in whom accessing or managing aphakic contact lenses is challenging. Strategies to target the increased risk of visual axis opacity (VAO) after primary intraocular lens (IOL) implantation in infancy are necessary. We describe the predictors of VAO after primary IOL implantation for unilateral or bilateral congenital or infantile cataract in children younger than 2 years of age.

DESIGN

Population-based (United Kingdom and Ireland), prospective, inception cohort study undertaken through a national clinical network.

PARTICIPANTS

A total of 105 children (57 with bilateral cataract, 48 with unilateral cataract, total 162 eyes) undergoing primary IOL implantation in the first 2 years of life between January 2009 and December 2010.

METHODS

Observational longitudinal study with multilevel, multivariable modeling to investigate associations between outcome of interest and child- and treatment-specific factors, including age, axial length, socioeconomic status, IOL model, and postoperative steroid use.

MAIN OUTCOME MEASURES

Postoperative proliferative or inflammatory visual axis opacity (VAO) requiring surgical correction.

RESULTS

Visual axis opacity occurred in 67 eyes (45%), typically within the first postoperative year. Use of a 3-piece IOL model (odds ratio [OR], 0.3; 95% confidence interval [CI], 0.09-0.99, P = 0.03) and increasing age at surgery (OR, 0.97, 95% CI, 0.95-0.99, P = 0.02) were each independently protective against the development of proliferative VAO. Inflammatory VAO was independently associated with socioeconomic deprivation (OR, 5.39; 95% CI, 1.46-19.89; P = 0.01).

CONCLUSIONS

Visual axis opacification is common after IOL implantation in early childhood. The findings of this prospective cohort study suggest that the use of 3-piece IOL models may reduce the risk of pseudophakic VAO in children younger than 2 years of age.

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.

Quantitative proteomic analysis of aqueous humor after rabbit lensectomy reveals differences in coagulation and immunomodulatory proteins

Proteomics of juvenile rabbit aqueous humor was evaluated before and after surgery to determine proteins responsible for postoperative outcomes.

Children with congenital and childhood cataract require frequent follow-up visits and examinations in general anaesthesia: considerations for the strain on families

BACKGROUND

Children with cataract require frequent monitoring to detect complications, adjust refractive correction and treat amblyopia. This is time consuming for the families. The aim of the study was to evaluate how often children with cataract are seen as outpatients or under general anaesthesia during the first 7 years of life.

METHODS

We performed a retrospective chart review of all children with congenital and childhood cataract born between 2000 primo and 2017 seen at our institution. The cumulated number of outpatient visits and examinations and/or surgeries in general anaesthesia was extracted for age 1, 3, 5 and 7 years.

RESULTS

Children who had cataract surgery were seen significantly more often than children without surgery. During the first year of life, children with bilateral surgery had a median of nine outpatient visits, children with unilateral cataract had 11 and children without surgery had five outpatient visits. At 7 years of age, half of the children operated bilaterally before 1 year of age had undergone at least five procedures/examinations in general anaesthesia versus 1/4 of those with unilateral surgery and none of those without surgery. Children were seen less frequently with advancing age.

CONCLUSION

The management, treatment and follow-up of children with cataract are demanding, requiring frequent hospital visits and repeated examinations and/or surgical procedures in general anaesthesia over many years, but mainly during the first year of life. Surgical patients are more complex and require closer follow-up. This message is important to convey to the parents at the onset of the disease.

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.

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.

Unplanned returns to the operating room within three months of pediatric cataract-related intraocular surgery: indications and risk factors

PURPOSE

To evaluate the indications and associated risk factors for unplanned returns to the operating room within 90 days of pediatric cataract-related surgery.

METHODS

The medical records patients undergoing either cataract extraction or secondary intraocular lens (IOL) implantation at a single center from 1991 to 2018 were reviewed retrospectively.

RESULTS

A total of 1,392 eyes of 989 patients were included, with 48 unplanned reoperations in 46 eyes of 43 patients, yielding a reoperation rate of 3.3% (46/1392) for one reoperation and 0.14% (2/1392) for two within 90 days of surgery. Of the 48 reoperations, indications for reoperation were as follows: lens cortex reproliferation (n = 14), elevated intraocular pressure (n = 11), inflammatory pupillary membranes (n = 7), vitreous wick to the cataract surgery wound (n = 6), synechiae (n = 3), uveitis (n = 3), posterior capsule opacification in an eye with intact posterior capsule (n = 1), retained cortex (n = 1), traumatic iris prolapse (n = 1), and foreign body in anterior chamber (n = 1). Risk factors for an unplanned reoperation included a history of traumatic cataract (relative risk, 2.55) or age <1 year at time of first surgery (relative risk, 3.02). In the absence of these risk factors, the reoperation rate was 1.1%.

CONCLUSIONS

Unplanned reoperations after pediatric cataract surgery are uncommon, but when they occur it is often in the setting of trauma or surgery performed before the age of 1 year.

Biometric changes in Indian pediatric cataract and postoperative refractive status

Purpose:

To prospectively evaluate the biometric changes in Indian pediatric cataract and postoperative refractive status.

Methods:

A total of 147 patients were recruited into three groups: age <6 months, age between 7 months and 18 months, and age between 19 and 60 months and prospectively observed for 6 months. Exclusion criteria were preterm birth, microphthalmia, microcornea, megalocornea, uveitis, glaucoma, and traumatic or complicated cataract. Axial length and keratometry, the primary outcome measures, were taken preoperatively under general anesthesia before surgery. These children were followed up for 6 months to look for refractive and biometric changes. T-test and linear regression with the logarithm of independent variables were done.

Results:

All unilateral cataractous eyes (n = 25) and randomly selected bilateral cases (n = 122) were included in the analysis, for a total of 147 eyes. Mean age was 17.163 ± 13.024 months; axial length growth was 0.21, 0.18, 0.06 mm/month, and keratometry decline was 0.083, 0.035, 0.001 D/month in age groups 0–6, 7–18, and 19–60 months, respectively. The visual acuity improved in log MAR from 1.020 to 0.745 at 6 months postoperatively. There was statistically significant (Spearman's correlation coefficient = –0.575, P < 0.001) between age and postoperative refraction. There were no intraocular lens (IOL)-related complications seen in the immediate postoperative period. Peripheral opacification was seen in 102 eyes and central opacification in 1 eye at a 6-month follow-up.

Conclusion:

Indian eyes have a lower rate of axial length growth and keratometry change in comparison with western eyes implying smaller undercorrection in emmetropic IOL power for Indian pediatric eyes to achieve a moderate amount of hyperopia.

Acute angle closure in an aphakic infant: Case report and review of the literature

Purpose

Aphakic pupillary block glaucoma is a rare complication after congenital cataract surgery. We describe the case of an infant with acute angle closure in an aphakic eye following congenital cataract lensectomy with anterior vitrectomy nine months prior. Potential pathophysiology and therapeutic strategies are discussed.

Observations

A one-year-old male infant presented to our emergency unit with right eye injection and pain. At the age of six weeks he had undergone right eye lensectomy with anterior vitrectomy for congenital cataract and was left aphakic with large anterior and posterior capsulorrhexis. Examination was significant for a shallow anterior chamber centrally and iridocorneal touch of the periphery for 360° with intraocular pressure (IOP) measured at 70 mmHg. The child was diagnosed with aphakic pupillary block leading to an acute angle closure event. He underwent emergent anterior vitrectomy with surgical peripheral iridotomy (PI) performed via pars plana approach. This resulted in immediate deepening of the anterior chamber, with resolution of the pupillary block and iridocorneal touch. Thereafter, his ocular exam was normal.

Conclusions and Importance

This unusual case underscores the importance of vigilance in the postoperative management of children after congenital cataract extraction. Unexpected complications remain a threat despite the initial undertaking of preventative measures.