Evaluation of whether intracameral dexamethasone predisposes to glaucoma after pediatric cataract surgery

Glucocorticoid-Induced Ocular Hypertension and Glaucoma

Glucocorticoid (GC) therapy is indicated in many diseases, including ocular diseases. An important side-effect of GC therapy is GC-induced ocular hypertension (GIOHT), which may cause irreversible blindness known as GC-induced glaucoma (GIG). Here, we reviewed the pathological changes that contribute to GIOHT including in the trabecular meshwork and Schlemm's canal at cellular and molecular levels. We also discussed the clinical aspects of GIOHT/GIG including disease prevalence, risk factors, the type of GCs, the route of GC administration, and management strategies.

A Comprehensive Review of Pediatric Glaucoma Following Cataract Surgery and Progress in Treatment

Glaucoma following cataract surgery (GFCS) remains a serious postoperative complication of pediatric cataract surgery. Various risk factors, including age at lensectomy, intraocular lens implantation, posterior capsule status, associated ocular/systemic anomaly, additional intraocular surgery, and a family history of congenital cataract and GFCS, have been reported. However, the optimal surgical approach remains unclear. This review evaluates the diagnostic criteria, classification, risk factors, mechanism, and surgical management, especially the efficacy of minimally invasive glaucoma surgery, in GFCS, and aims to propose an optimal clinical management strategy for GFCS. The results of our review indicate that ab interno trabeculotomy (goniotomy) may be the most appropriate first-line treatment for GFCS.

Outcomes and prognostic factors of cataract surgery in cytomegalovirus-related anterior uveitis

PURPOSE

To evaluate the outcomes of cataract surgery in patients with cytomegalovirus (CMV) anterior uveitis and factors associated with final visual outcome.

SETTING

Hong Kong Eye Hospital, Hong Kong.

DESIGN

Retrospective case series.

METHODS

History, clinical characteristics, corrected distance visual acuity (CDVA), medications, and complications of CMV anterior uveitic eyes that underwent cataract surgery between 2010 and 2020 were reviewed.

RESULTS

This study included 26 eyes of 26 patients undergoing phacoemulsification. The median duration of disease was 4.8 years, and the median quiescent period preoperatively was 2.3 years. None required pupil manipulation or had significant intraoperative complications. The median CDVA improved from 20/100 (interquartile range [IQR] 20/200 to 20/50) preoperatively to 20/30 (IQR 20/40 to 20/25) at 1 year and 20/35 (IQR 20/50 to 20/30) at the last follow-up at a median of 4.9 years postoperatively ( P < .001). CDVA improved in 19 eyes (73.1%) and was ≥20/40 in 18 eyes (69.2%). In the multivariate regression model, preoperative use of topical 0.15% ganciclovir (β = 0.33, 95% CI 0.17 to 0.48, P < .001) and adjunctive intraoperative intracameral dexamethasone 0.4 mg (β = 0.19, 95% CI 0.01 to 0.36, P = .043) were associated with a better final CDVA. Loss of CDVA and poor postoperative CDVA visual acuity were mostly attributed to uveitic glaucoma, but preoperative glaucoma or the number of antiglaucoma medications did not affect final CDVA.

CONCLUSIONS

Cataract surgery in eyes with CMV anterior uveitis was safe and CDVA significantly improved and remained sustained postoperatively. Topical ganciclovir 0.15% preoperatively and intracameral corticosteroid intraoperatively seem to maximize the final visual outcome.

Infantile Aphakic Glaucoma: A Proposed Mechanism

PURPOSE

To review information pertaining to secondary glaucoma following infant lensectomy and provide evidence to support the mechanism responsible for this condition.

METHODS

Reported risk factors and proposed mechanisms for infantile aphakic glaucoma are reviewed. Laboratory studies and clinical observations in affected patients with glaucoma are described. Evidence of postoperative anterior chamber fibrosis is reviewed and interpreted.

RESULTS

Clinical evidence demonstrated the development of anterior chamber fibrosis following infant cataract surgery. Laboratory studies showed liberated lens epithelial cell transition to fibroblasts.

CONCLUSIONS

The review and assessment of laboratory and clinical evidence support the proposal that infantile aphakic glaucoma is caused, in part, by postoperative anterior chamber fibroization related to lens cell dispersion, cytokine activation, and epithelial-mesenchymal transition with resultant filtration angle fibrosis and secondary loss of filtration function. [J Pediatr Ophthalmol Strabismus. 2022;59(4):236-242.].

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.

[Cataract surgery in children with non-infectious uveitis: Review of current practices in France]

PURPOSE

To evaluate the medical-surgical management of cataract surgery in children with chronic uveitis in various French pediatric ophthalmology centers.

MATERIALS AND METHODS

Two-part study: first, a descriptive observational segment on the evaluation of French practices. A questionnaire was sent to the various pediatric ophthalmologists in France. A second retrospective chart review, including children with non-infectious chronic uveitis who had cataract surgery in the pediatric ophthalmology department of Bordeaux University Hospital from 2008 to 2017.

RESULTS

Twenty-one ophthalmologists responded to the questionnaire. Only 23.8% systematically initiated immunosuppressive drugs (aside from corticosteroids) before surgery. A total of 88.2% prescribed oral corticosteroid treatment preoperatively. Eleven surgeons administered intravenous corticosteroid boluses during the surgery, and primary lens implantation is the most common method used in 95.2%. A total of 76.2% initiated oral steroid therapy after surgery. Postoperatively, all surgeons started local therapy with high-dose corticosteroids. At one year, 100% achieved improvement of visual acuity greater than or equal to 2 lines. On our service, 10 eyes (7 children) underwent cataract surgery. Seven were treated with systemic immunosuppressive drugs (aside from corticosteroids) and 80% of cases received oral corticosteroid therapy a few days before surgery. An intravenous corticosteroid bolus was administered preoperatively in 8 cases, and primary lens implantation was performed in 100% of cases. Postoperatively, 5 children received oral corticosteroid treatment. All were treated with local high dose steroids. At one year, the mean best-corrected visual acuity was 0.18 LogMar (0-0.7, SD: 0.25).

CONCLUSION

When performed with an aggressive anti-inflammatory protocol, cataract surgery leads to a good visual outcome in selected children with chronic uveitis.

The role of Dexamethasone in clinical pharmaceutical treatment for patients with cataract surgery

The aim of the present study is to determine the efficacy of dexamethasone (DEX) vs. indomethacin (IND) and ciprofloxacin (CIP) in modulating immediate inflammation following cataract surgery. A total of 644 patients with cataract were recruited and inflammation was investigated during the perioperative period. The management protocol was similar in both groups. Each drug was given four times a day for 30 days starting 7 days prior to surgery. The primary efficacy criteria for evaluation were the reduction in anterior chamber (AC) flare and AC inflammation score, in addition, a different secondary efficacy and safety evaluation criteria were maintained. The results demonstrated that the average inflammation score was 1.2±0.8 in the DEX group, which was significantly lower compared with the IND (1.9±0.7) and CIP (1.8±0.6) groups. Intra-ocular pressure was decreased following treatment with DEX, while intra-ocular pressure was slightly increased in the IND (1.9±0.7) and CIP (1.8±0.6) groups. The final visual outcomes for patients postcataract surgery were clinically superior in the DEX group compared with that of the IND and CIP groups (P=0.034 and P=0.042, respectively), but there was no significant difference between the ND and CIP groups (P=0.78). Outcomes indicated that AC inflammation, conjunctival hyperaemia, corneal and lid oedema, ocular infection, pain, photophobia, and tearing were significantly improved in each group. No significant poor local tolerance or adverse reaction was observed in the DEX, IND and CIP groups. In conclusion, the outcomes of the present study suggest that DEX serves an important role in the clinical pharmaceutical treatment of patients with cataract surgery.

Cataract

Cataract is the leading cause of reversible blindness and visual impairment globally. Blindness from cataract is more common in populations with low socioeconomic status and in developing countries than in developed countries. The only treatment for cataract is surgery. Phacoemulsification is the gold standard for cataract surgery in the developed world, whereas manual small incision cataract surgery is used frequently in developing countries. In general, the outcomes of surgery are good and complications, such as endophthalmitis, often can be prevented or have good ouctomes if properly managed. Femtosecond laser-assisted cataract surgery, an advanced technology, can automate several steps; initial data show no superiority of this approach over current techniques, but the results of many large clinical trials are pending. The greatest challenge remains the growing 'backlog' of patients with cataract blindness in the developing world because of lack of access to affordable surgery. Efforts aimed at training additional cataract surgeons in these countries do not keep pace with the increasing demand associated with ageing population demographics. In the absence of strategie that can prevent or delay cataract formation, it is important to focus efforts and resources on developing models for efficient delivery of cataract surgical services in underserved regions. For an illustrated summary of this Primer, visit: http://go.nature.com/eQkKll.

Complications of pediatric cataract surgery

PURPOSE

Cataract surgery in young children poses different challenges and potential complications compared to those encountered in adult populations. We performed a literature review of the complications of pediatric cataract surgery.

METHODS

Literature review of complications of pediatric cataract surgery.

RESULTS

Complications in children vary based on the age of the patient at surgery and the cause of the cataract. Common events discussed include increased inflammatory response, opacification of the posterior capsule, lens reproliferation, pupillary membrane, and amblyopia; less common events include infections, significant bleeding, and retinal detachment.

CONCLUSION

Complications after cataract surgery in children are often associated with a robust inflammatory reaction or secondary opacity and, in infants, glaucoma. Late complications can occur decades later, so that long-term follow-up is required. Though surgery carries significant risks, the consequences of no surgery and irreversible deprivation amblyopia in very young children should be considered.

Pediatric cataract: challenges and future directions

Cataract is a significant cause of visual disability in the pediatric population worldwide and can significantly impact the neurobiological development of a child. Early diagnosis and prompt surgical intervention is critical to prevent irreversible amblyopia. Thorough ocular evaluation, including the onset, duration, and morphology of a cataract, is essential to determine the timing for surgical intervention. Detailed assessment of the general health of the child, preferably in conjunction with a pediatrician, is helpful to rule out any associated systemic condition. Although pediatric cataracts have a diverse etiology, with the majority being idiopathic, genetic counseling and molecular testing should be undertaken with the help of a genetic counselor and/or geneticist in cases of hereditary cataracts. Advancement in surgical techniques and methods of optical rehabilitation has substantially improved the functional and anatomic outcomes of pediatric cataract surgeries in recent years. However, the phenomenon of refractive growth and the process of emmetropization have continued to puzzle pediatric ophthalmologists and highlight the need for future prospective studies. Posterior capsule opacification and secondary glaucoma are still the major postoperative complications necessitating long-term surveillance in children undergoing cataract surgery early in life. Successful management of pediatric cataracts depends on individualized care and experienced teamwork. We reviewed the etiology, preoperative evaluation including biometry, choice of intraocular lens, surgical techniques, and recent developments in the field of childhood cataract.

Treatment of diabetic macular edema with sustained-release glucocorticoids: intravitreal triamcinolone acetonide, dexamethasone implant, and fluocinolone acetonide implant

INTRODUCTION

Diabetic macular edema (DME) can be treated with intravitreal glucocorticoids, particularly triamcinolone acetonide, dexamethasone (DEX), and fluocinolone acetonide (FA).

AREAS COVERED

The pathophysiology of DME includes multiple growth factors such as VEGF and also inflammatory mediators. Glucocorticoids act on DME through multiple pathways, and current research into their efficacy, safety, and therapeutic potential when administered intravitreally is discussed.

CONCLUSION

The intravitreal route of administration minimizes systemic side effects of glucocorticoids. Furthermore, sustained-release low-dose delivery via the DEX implant or the FA implant will limit frequent intravitreal injection and possibly some cost associated with intravitreal anti-VEGF therapy. In addition, the durable action of these treatments facilitates combination therapy. Patients can receive these implants as foundational therapy, and then receive additional treatment with laser or intravitreal anti-VEGF agents as combination therapy, which may conceivably provide some synergistic benefit. While the FA implant lasts much longer than the DEX implant, potentially decreasing the visit and treatment burden on patients and their families, the FA implant appears to have a greater risk of inducing ocular hypertension and cataract. However, these modalities have not been directly compared in a clinical trial and there is insufficient evidence to draw more elaborate conclusions.