Corneal Changes in Children after Unilateral Cataract Surgery in the Infant Aphakia Treatment Study

Management of childhood cataract: practice patterns among ophthalmologists in Nigeria

OBJECTIVE

To describe the practice patterns for the management of paediatric cataracts among ophthalmologists practising in Nigeria.

METHODS

A cross-sectional study of fully trained Nigerian ophthalmologists who perform cataract surgery in children aged 16 years and below. An online questionnaire was distributed via e-mail and social media platforms to respondents. Data on socio-demographic characteristics, type, location and years of practice, status and preferred approach to management of childhood cataracts were obtained and analysed.

RESULTS

A total of 41 ophthalmologists responded that they perform paediatric cataract surgery. Of these, 25 (61.0%) were paediatric ophthalmologists while 7 (17.0%) were general ophthalmologists. Most respondents (92.7%) practise in urban settings and 30 (73.2%) work in tertiary hospitals. Most respondents (90.2%) routinely insert intraocular lenses (IOLs) in children aged 2 years and above while 32 (78.0%) routinely under-correct the IOL power. Thirty-four (82.9%) have an anterior vitrectomy machine, 31 (75.6%) routinely perform posterior capsulotomy and anterior vitrectomy, and 17 (58.5%) routinely perform same-day sequential bilateral cataract surgery. Twenty-six (63.4%) respondents routinely give near correction in aphakic children, while 24 (58.5%) respondents routinely give bifocals in pseudophakic children. Compared to other sub-specialists, paediatric ophthalmologists were 24 times more likely to routinely under-correct IOL power (p = 0.001) and 4 times more likely to routinely correct near vision in aphakic children (0.036) as well as prescribe bifocals for pseudophakic children respectively (0.029).

CONCLUSION

The practice of paediatric cataract surgery in Nigeria is mainly in line with expected standards, but there is a need for the development of detailed practice guidelines.

Long-term visual outcomes and ocular complications in children with Marner's hereditary cataracts operated in the period 1940-2021

PURPOSE

To investigate visual development and long-term complications after cataract surgery in childhood.

METHODS

This cross-sectional study included patients from a family with Marner's hereditary cataracts who had cataract surgery before 18 years of age. The study was conducted from 1 January 2022 until 31 December 2022. The patients contributed to their medical files and participated in an updated ophthalmologic examination.

RESULTS

We included 52 patients (101 eyes, 34 females). The median age at cataract surgery was 7 years (IQR: 5-10) and the age at examination was 40 years (IQR: 21-54). Primary and secondary intraocular lens implantation had been performed in 47.5% (25 patients, 48 eyes) and 16.8% (10 patients, 17 eyes). Visual acuity was ≤0.3 logMAR in 77% (78 eyes), and <0.5 logMAR in 8% (8 eyes). Glaucoma was present in 17% (9 patients, 12 eyes), ocular hypertension in 6% (3 patients, 4 eyes), and 10% (5 patients, 5 eyes) had prior retinal detachment. Mild visual field loss (2 < mean defect (MD) ≤ 6 dB) was found in 62% (63 eyes) and moderate to advanced visual field loss (MD > 6 dB) in 24% (24 eyes). Thirty-five patients (67%) held a driver's licence, and three were not allowed to drive due to low visual function. All patients were employed.

CONCLUSION

After cataract surgery in childhood, many patients achieve normal visual acuity, but mild visual field loss is common. Long-term follow-up is important due to the high risk of glaucoma.

Corneal characteristics and OCT-angiography findings in pediatric glaucoma and glaucoma suspects

PURPOSE

To analyze corneal biomechanics, specular microscopy, and optical coherence tomography-angiography findings in children with glaucoma.

METHODS

Pediatric patients (<18 years of age) with glaucoma (n = 38), increased cup:disk ratio and normal intraocular pressure (IOP) glaucoma suspects (n = 36), and controls (n = 67) were prospectively enrolled. Patients underwent testing with Ocular Response Analyzer, CellChek Specular Microscope, and Heidelberg OCT-A.

RESULTS

Average age of participants was 12.4 ± 3.5 years, with no difference between groups (P = 0.71). Glaucoma patients had undergone more intraocular surgeries (P < 0.0001) and showed worse logMAR visual acuity (P < 0.0001) than suspects or controls. Central corneal thickness (CCT) was greater in glaucoma patients (642.8 ± 85.9 μm [P < 0.0001]) and suspects (588 ± 43.7 μm [P = 0.003]) compared with controls (561 ± 39.9 μm). Corneal hysteresis (CH) was decreased in eyes with glaucoma (10.4 ± 3.0) compared with controls (11.7 ± 1.5 [P = 0.006]), but not suspects (11.3 ± 2.0 [P = 0.1]). Glaucoma patients had lower endothelial cell density (2028.4 ± 862.7 [P < 0.0001]) and greater average cell area (547.2 ± 332.4 [P < 0.0005]) compared with suspects (2919.3 ± 319.1, 347.5 ± 46.2) and controls (2913.7 ± 399.2, 350.8 ± 57.7), but there was no difference in polymegathism (P = 0.12) or pleomorphism (P = 0.85). No differences in vessel density or vessel skeletal density in the retinal vascular complex (P = 0.3077, P = 0.6471) or choroidal vascular complex (P = 0.3816, P = 0.7306) were detected.

CONCLUSIONS

Children with glaucoma showed thicker corneas with lower endothelial cell density and greater cell area, but no difference in retinal/choroidal vascular densities compared with suspects and controls.

Preoperative central corneal thickness in eyes with pediatric cataract versus normal fellow eyes

PURPOSE

To compare the preoperative central corneal thickness (CCT) in eyes with unilateral cataract with their normal fellow eyes in the pediatric population.

METHODS

A retrospective chart review was conducted using the STORM Kids cataract database. Eyes with traumatic cataract, previous surgery or therapeutic manipulation, or age >18 years were excluded. Only eyes with a normal fellow eye were included. The intraocular pressure, age at time of surgery, race, sex, and type of cataract were also extracted from the record.

RESULTS

A total of 70 eyes with unilateral cataract and 70 fellow normal eyes met inclusion criteria. The mean age at the time of surgery was 3.35 years (range, 0.08-15.05). The mean preoperative CCT in the operated eyes was 577 ± 58 μm (range, 464-898 μm). The mean preoperative CCT in fellow eyes was 570 ± 35 μm (range, 485-643 μm). There was no statistically significant difference between the preoperative CCT in cataract eyes versus unaffected fellow eyes (P = 0.183). When stratified by age, the difference in the CCT between cataract and fellow eyes was greatest in the <1 year age group, but was not statistically significant (P = 0.236). The mean preoperative corneal diameter of operative eyes was 11.0 mm (range, 5.5-12.5 mm [n = 68]). The mean preoperative IOP was 15.1 mm Hg (n = 66).

CONCLUSIONS

In our study cohort, there was no significant difference in mean preoperative CCT between unilateral pediatric cataract eyes and unaffected fellow eyes.

Preoperative Characteristics of Ocular Biometry in Children with Unilateral Congenital Cataracts

The ocular biometry characteristics are clinically significant for children with unilateral congenital cataracts, but there is a lack of data analysis concerning the preoperative measurements. The axial length (AL), mean keratometry (Km), corneal astigmatism (CA), and the anterior chamber depth (ACD) from both eyes before cataract surgery were obtained from 205 patients (410 eyes, 3-15 years of age) with unilateral congenital cataracts. In the congenital cataract eyes, shorter AL (22.44 ± 1.52 mm vs. 22.57 ± 1.04 mm, p = 0.036) and higher CA (- 1.89 ± 0.91 D vs. - 1.24 ± 0.67 D, p < 0.001) were found, and no significant difference was found in the Km and the ACD measurements compared to the contralateral normal eyes. Females had shorter AL and shallower ACD compared to males. However, the Km and CA in the females were significantly larger than that in males. Shorter AL, larger Km, higher CA, and shallower ACD were also found in females who had a binocular axial difference (the value obtained by subtraction of the contralateral normal eye from the congenital cataract eye) that less than zero. The preoperative ocular biometry of shorter AL, larger Km, higher CA, and shallower ACD should be considered in females with unilateral congenital cataracts. The age and the binocular axial differences had a statistically significant correlation (r = -0.192, p = 0.006). Therefore, changes in the binocular axial differences associated with aging may enhance the guidelines for intraocular lens selection and the management of congenital cataracts.

Corneal Structural Changes in Congenital Glaucoma

OBJECTIVE

To identify corneal structure differences on quantitative high-frequency ultrasound biomicroscopy (UBM) among subjects with congenital glaucoma compared with controls.

METHODS

This prospective case-control study evaluated 180 UBM images from 44 eyes of 30 subjects (18 control and 12 glaucoma, mean age 5.2±8.0 years, range 0.2-25.8 years) enrolled in the Pediatric Anterior Segment Imaging and Innovation Study (PASIIS). ImageJ was used to quantify a comprehensive set of corneal structures according to 21 quantitative parameters. Statistical analysis compared corneal measurements in glaucoma subtypes and age-matched controls with significance testing and mixed effects models.

RESULTS

Significant differences between congenital glaucoma cases and controls were identified in 16 of 21 measured parameters including angle-to-angle, central and peripheral corneal thicknesses, scleral integrated pixel density, anterior corneal radius of curvature, and posterior corneal radius of curvature. Eight parameters differed significantly between primary congenital glaucoma and glaucoma following congenital cataract surgery.

CONCLUSION

Multiple measurable corneal structural differences exist between congenital glaucoma and control eyes, and between primary and secondary congenital glaucoma, including but not limited to corneal width and thickness. The structural differences can be quantified from UBM image analysis. Further studies are needed to determine whether corneal features associated with glaucoma can be used to diagnose or monitor progression of congenital glaucoma.

Changes in corneal thickness after vitrectomy-Implications for glaucoma practice

Purpose

To evaluate changes in central corneal thickness (CCT) following vitrectomy.

Methods

All consecutive old and new patients referred to glaucoma services for possible secondary glaucoma after vitrectomy and who had undergone corneal pachymetry between July 2013 to June 2020, were included. The eye that developed elevated intraocular pressure (IOP) and was diagnosed clinically as glaucoma after vitrectomy, was labelled as the “affected” eye. The contralateral eye of the patient with normal IOP and no history of vitrectomy was labelled as the “control” eye. The difference in CCT in the affected eye and the contralateral control eye (ΔCCT) and CCT were compared between different age groups. Correlation of CCT in the affected eye with age, diagnosis, type of surgery done, lens status and pre-existing glaucoma was done using multivariate regression analysis.

Results

Of 127 eyes of 120 patients (M:F = 85:35), the average CCT in the affected eye was significantly higher than the unaffected contralateral control eye (p<0.0001). The ΔCCT in eyes presenting at an age <25 years was higher (median 582, 497–840) than those that presented later (median 518, 384–755), p <0.0001, with maximum ΔCCT seen in eyes that had undergone vitrectomy at age<12 years. The CCT in the affected eye was significantly higher in aphakic eyes (588±81.6 microns) than in pseudophakic eyes (552±79.03 microns), p = 0.03. On multivariate analysis, age<25 years remained as a significant influencer of CCT in the affected eye (β = -1.7, p<0.001, R2 = 28.3%).

Conclusions

Young age group<25 years are more prone to corneal remodelling and CCT changes after vitrectomy.

CLEAR - Medical use of contact lenses

The medical use of contact lenses is a solution for many complex ocular conditions, including high refractive error, irregular astigmatism, primary and secondary corneal ectasia, disfiguring disease, and ocular surface disease. The development of highly oxygen permeable soft and rigid materials has extended the suitability of contact lenses for such applications. There is consistent evidence that bandage soft contact lenses, particularly silicone hydrogel lenses, improve epithelial healing and reduce pain in persistent epithelial defects, after trauma or surgery, and in corneal dystrophies. Drug delivery applications of contact lens hold promise for improving topical therapy. Modern scleral lens practice has achieved great success for both visual rehabilitation and therapeutic applications, including those requiring retention of a tear reservoir or protection from an adverse environment. This report offers a practical and relevant summary of the current evidence for the medical use of contact lenses for all eye care professionals including optometrists, ophthalmologists, opticians, and orthoptists. Topics covered include indications for use in both acute and chronic conditions, lens selection, patient selection, wear and care regimens, and recommended aftercare schedules. Prevention, presentation, and management of complications of medical use are reviewed.

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

Background

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

Methods

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

Results

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

Conclusions

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

Optical Coherence Tomography Findings After Childhood Lensectomy

Purpose

To explore the impact of childhood lensectomy on posterior segment development.

Methods

Cross-sectional observational study at children's eye clinics at a tertiary referral center in London, UK. We included 45 children age 4 to 16 years with healthy eyes and 38 who had undergone lensectomy. We acquired posterior segment optical coherence tomography scans of both eyes. We used parametric and nonparametric tests in SPSS24 for the comparison of parameters between groups and within individuals; a P value less than 0.05 was considered significant. The main outcome measures were foveal pit depth and subfoveal choroidal thickness (CT). Secondary outcomes were inner and outer ring CT and photoreceptor layer parameters, macular and peripapillary retinal nerve fiber layer thickness.

Results

Foveal pit depth and subfoveal CT are significantly reduced in eyes that have undergone lensectomy compared with nonoperated eyes. Inner ring CT and outer ring CT are reduced. Foveal inner retinal layer thickness is increased. Mean inner retinal and outer nuclear layer thickness are not affected.

Conclusions

Childhood lensectomy is associated with a reduction in developmental foveal pit deepening and lack of developmental thickening of the posterior choroid. Mechanical and optical disruption of foveal and subfoveal choroidal development may affect structural foveal development after childhood lensectomy.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Corneal Endothelial Cell Density in Children: Normative Data From Birth to 5 Years Old

PURPOSE

To establish a normative database of endothelial cell density (ECD) using in vivo specular microscopy in children under 5 years old.

DESIGN

Cross-sectional study.

METHODS

Specular microscopy was performed during a clinic visit in cooperative children in the standard upright position. In uncooperative children, specular microscopy was performed in the lateral decubitus position under general anesthesia, before surgery for other reasons. Corneal diameter (CD) was measured in children undergoing general anesthesia and was stratified according to age.

RESULTS

One hundred and eighteen eyes of 118 patients were included in the study. The mean patient age was 2.6 ± 1.4 years (range 0.1-5 years) and the mean ECD was 3746 ± 370 cells/mm² (range 3145-5013 cells/mm²). The mean CD under 2 years of age was 11.85 ± 0.57 mm (n = 40, range 10.50-12.75 mm). Up to 2 years of age, ECD was more inversely correlated with CD than with age (r = -0.61, P < .0001; r = -0.38, P = .01, respectively). In contrast, after the age of 2 years, the ECD was inversely correlated with age but not with CD (r = -0.27, P = .02; r = -0.24, P = .2). Between the first and second year of life, the rate of ECD decrease was significantly higher than between 2 and 5 years of age (8.2%, 334 cells/mm² vs 2.7%, 100 cells/mm² a year, respectively).

CONCLUSION

In the first 2 years of life there is a rapid decline in ECD, which is likely related to growth in CD and hence surface area. After the cornea reaches adult size, the ECD decreases at a rate similar to that reported in adults.