Evaluation for cystoid maculopathy after pars plicata lensectomy-vitrectomy for congenital cataracts

Central macular thickness and subfoveal choroidal thickness changes on spectral domain optical coherence tomography after cataract surgery in pediatric population

Purpose

To evaluate the central macular thickness (CMT) and subfoveal choroidal thickness (SFCT) changes on spectral domain optical coherence tomography (SD-OCT) after cataract surgery with intraocular lens (IOL) implantation in a pediatric population.

Methods

This was a longitudinal, prospective, interventional study which included 90 pediatric patients who underwent cataract extraction with IOL implantation. Serial SD-OCT scans were done at postoperative day 1, 1-month, and 3-month follow-up. CMT and SFCT were measured at each visit.

Results

A statistically significant increase in CMT was noted at 1 month (from 199.3 μm to 210.04 μm) post surgery, which declined over a 3-month period (202.70 μm, P = 0.0001). In case of SFCT, a constant increase was observed for over 3 months of follow-up (baseline: 296.52 μm; 1 month: 309.04 μm; and 3 months: 319.03 μm, P = 0.0001). The traumatic cataract group showed more pronounced changes in CMT and SFCT than the non-traumatic cataract group. No significant difference was observed regarding these parameters between those who underwent primary posterior capsulotomy (PPC) versus those who did not. None of the patients in the study group developed cystoid macular edema. These posterior segment-related anatomical changes did not affect the final visual outcomes.

Conclusion

Cataract surgery induces potential inflammatory changes in the macula and choroid in pediatric patients. Such changes are more pronounced in trauma-related cases; however, they are not significant enough to affect the visual outcomes. Similarly, the additional surgical step of PPC does not induce significant anatomical or functional changes.

Longitudinal changes of the macular structure after lens removal combined with anterior vitrectomy after pediatric cataract surgery

PURPOSE

To explore the macular thickness changes after lens removal combined with anterior vitrectomy for pediatric cataract surgery.

SETTING

The Eye Hospital of Wenzhou Medical University, Zhejiang, China.

DESIGN

Prospective study.

METHODS

Thirty children (40 eyes) aged between 3 years and 9 years with pediatric cataracts, including 20 children (20 eyes) with unilateral cataracts and 10 children (20 eyes) with bilateral cataracts, were enrolled. Spectral-domain optical coherence tomography was used to obtain macular images. Central subfield thickness (CST) and retinal thickness in the Early Treatment Diabetic Retinopathy Study subfields (inner 1.0 to 3.0 mm annulus and outer 3.0 to 6.0 mm annulus) were recorded preoperatively as well as at 1, 3, 6, and 12 months postoperatively.

RESULTS

Forty eyes of 30 children were included. Retinal thickness in every subfield significantly thickened at 3 months postoperatively (all P < .05). CST significantly thickened compared with preoperative levels (228.03 ± 18.58 vs 240.35 ± 17.41, P = .005) at 3 months postoperatively; macular thickness gradually decreased in the following months. At 6 months postoperatively, retinal thickness in inner nasal, inferior, temporal, and outer nasal subfields remained significantly thicker compared with preoperative levels (P = .048, P = .036, P = .029, and P = .017, respectively). At 12 months, the retinal thickness in all subfields reached the preoperative level.

CONCLUSIONS

The influence on macular thickness lasted until 12 months after pediatric cataract surgery. The inner macular thickness increased for a longer time than the outer macular thickness postoperatively.

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.

Spectral-domain optical coherence tomography measurements of central foveal thickness before and after cataract surgery in children

PURPOSE

To compare macular thickness before and after cataract surgery and intraocular lens (IOL) implantation in pediatric eyes.

DESIGN

Retrospective cohort study.

SETTING

University Eye Clinic, San Giuseppe Hospital, University of Milan, Milan, Italy.

METHODS

The study analyzed spectral-domain optical coherence tomography (SD-OCT) images of the macula in pediatric eyes in which cataract surgery had been performed and that were examined preoperatively and 1, 3, 6, 9, and 12 months postoperatively.

RESULTS

The mean age of the 11 patients (11 eyes) was 5.8 years ± 2.2 (SD) (range 3 to 14 years). The mean macular thickness at 1 month and 3 months was significantly higher than at baseline (273.7 ± 26.8 μm and 266.0 ± 22.8 μm, respectively, versus 244.8 ± 19.5 μm; P < .0001). It reached the baseline value after 3 months and remained stable over the 12-month follow-up. The mean thicknesses at 6, 9, and 12 months were 249.1 ± 17.6 μm, 245.7 ± 18.5 μm, and 246.2 ± 18.1 μm, respectively (P > .05 versus baseline).

CONCLUSIONS

Spectral-domain OCT was useful in evaluating the macular changes in the eyes of a cohort of pediatric patients 3 years and older. Cystoid macular edema was not observed during the 12-month follow-up.

FINANCIAL DISCLOSURE

No author has a financial or proprietary interest in any material or method mentioned.

Cystoid macular oedema in paediatric aphakia and pseudophakia

AIM

To assess the incidence of cystoid macular oedema (CMO), following lensectomy, anterior vitrectomy (limbal and pars plicata), and primary posterior capsulorhexis following surgery for congenital and developmental cataract.

METHODS

A prospective study was carried out involving 30 eyes (20 children) with cataract. Lensectomy, primary posterior capsulorhexis, and anterior vitrectomy were performed on all eyes. Vitrectomy was performed using either a limbal or pars plicata approach. Fluorescein angiography was carried out 4-7 weeks after surgery. Fluorescein was administered intravenously and visualised using the Retcam.

RESULTS

Anterior vitrectomy was carried out via the limbal approach in 12 eyes and, of these, six were implanted with an intraocular lens. The pars plicata approach was carried out in 18 eyes and 10 received an implant. CMO was not detected in any eye.

CONCLUSION

CMO was not detected in the early postoperative period irrespective of approach to anterior vitrectomy or presence of an intraocular lens. Intravenous fluorescein angiography was performed without complication.

Pars Plana Lensectomy and Intraocular Lens Implantation in Pediatric Radiation-Induced Cataracts in Retinoblastoma

OBJECTIVE

To investigate visual outcomes, surgical complications, and tumor recurrence among children with retinoblastoma (RB) undergoing pars plana lensectomy, vitrectomy, and simultaneous intraocular lens insertion for radiation-related cataract secondary to external beam radiotherapy (EBRT).

DESIGN

Retrospective, noncomparative, consecutive case series.

METHODS

The medical records for all patients treated with pars plana lensectomy, vitrectomy, and posterior chamber intraocular lens implantation for radiation-induced cataract after EBRT for RB at a single institution between January 1, 1990, and December 31, 2000, were reviewed.

PARTICIPANTS

The study included 16 eyes of 12 children with Reese-Ellsworth stage V RB.

MAIN OUTCOME MEASURES

Visual acuity, surgical and postoperative complications, postoperative refraction, and tumor recurrence.

RESULTS

The median age at diagnosis of RB was 6 months (range, 1-49 months). All patients received EBRT as primary treatment and experienced radiation-induced cataracts. The median interval from RB diagnosis to cataract surgery was 42 months (range, 28-95 months). Preoperative mean visual acuity was 20/400, with 12 of 16 eyes (75%) having macular tumor involvement. All patients underwent pars plana lensectomy, vitrectomy, and posterior chamber intraocular lens insertion. Vitreous samples were evaluated by cytopathologic examination, and no viable tumor cells were identified in any of the vitreous specimens. Postoperative complications included transient cystoid macular edema in 5 eyes (31%) and iridocyclitis in 3 eyes (19%). The mean follow-up after cataract surgery was 66 months (range, 30-94 months). Final visual acuity was 20/40 or better in 11 of 16 eyes (69%). No late intraocular recurrence, orbital tumors, or metastatic disease was noted in this study.

CONCLUSIONS

Pars plana lensectomy, vitrectomy, and simultaneous intraocular lens implantation is an effective means of managing EBRT-induced cataracts in eyes with previously treated RB. There was no evidence of active tumor in eyes undergoing surgery at least 28 months after the diagnosis and commencement of therapy for RB, and no late intraocular, orbital, or metastatic tumors were detected. Visual acuity was limited by the presence of primary macular tumor pathologic features in a subset of patients, but final vision better than 20/400 may be achieved in these eyes.

Necessity of vitrectomy when optic capture is performed in children older than 5 years

PURPOSE

To determine whether anterior vitrectomy is necessary when optic capture is performed in children between 5 and 12 years old with congenital cataract.

SETTING

Iladevi Cataract and IOL Research Center, Ahmedabad, India.

METHODS

This prospective randomized controlled study comprised 41 eyes of 25 children whose mean age was 83.57 months (range 60 to 144 months). Intraocular lens (IOL) implantation with optic capture through a primary posterior continuous curvilinear capsulorhexis was performed in all the eyes. The IOL haptics were bag fixated. Patients were randomly assigned to 1 of 2 groups. Vitrectomy was performed in 1 group (n = 21 eyes) and not performed in the other group (n = 20 eyes). The mean follow-up was 21.04 months. A Student t test and chi-square test were used for statistical analysis.

RESULTS

All eyes in the vitrectomy group and 30% in the no-vitrectomy group had a clear visual axis at the last follow-up (P <.001) The visual axis was obscured as a result of anterior vitreous fibrosis in 70% of eyes in the no-vitrectomy group. High-contrast visual acuity was not significantly different between groups (P =.28). Low-contrast sensitivity was significantly better in the vitrectomy group (P =.02). Eighteen eyes (85.7%) in the vitrectomy group and 16 eyes (80%) in the no-vitrectomy group developed deposits on the IOL (P =.62). The deposits were present at the last follow-up in 4 eyes (19.0%) in the vitrectomy group and in 6 eyes (30.0%) in the no-vitrectomy group (P =.85). Three eyes (14.3%) in the vitrectomy group and 8 eyes (40.0%) in the no-vitrectomy group developed synechias (P =.06).

CONCLUSION

The results suggest that anterior vitrectomy is necessary with optic capture in children with congenital cataract who are between 5 and 12 years old.

Cystoid macular edema after pediatric intraocular lens implantation: fluorescein angioscopy results and literature review

PURPOSE

To evaluate the occurrence of cystoid macular edema (CME) after lens extraction, anterior vitrectomy, and intraocular lens implantation (IOL) in children using angioscopy after administration of oral fluorescein.

SETTING

Centers in Tamil Nadu, India, and Hong Kong, China.

METHODS

This study comprised 18 children (28 eyes) who had cataract extraction, posterior capsulorhexis, anterior vitrectomy, and in-the-bag IOL implantation. The presence of CME was evaluated 1 week and 4 to 6 weeks after surgery using fluorescein angioscopy.

RESULTS

Anterior chamber fibrin occurred in 4 eyes (14.3%). Fluorescein angioscopy was performed 1 week after surgery in all eyes and after 1 month in 25 eyes (89.3%). No eye demonstrated the presence of CME on fluorescein angioscopy.

CONCLUSIONS

Cystoid macular edema did not occur in the early period after pediatric cataract surgery using current surgical techniques. Longer follow-up is required to ascertain the incidence of CME in the late postoperative period.

Ischaemic heart disease may predispose to pseudophakic cystoid macular oedema

PURPOSE

Pseudophakic macular oedema (PMO) is uncommon following uncomplicated phacoemulsification and lens implantation and the cause of infrequent cases is rarely understood. This study was undertaken to determine whether a relationship exists between ischaemic heart disease (IHD) and PMO.

METHODS

Retrospective case note review was carried out of 177 (252 eyes) consecutive patients without pre-existing retinal disease who underwent phacoemulsification and intraocular lens implantation during a 12 month period. Patients with a post-operative best corrected visual acuity < 6/9 underwent slit-lamp biomicroscopy and fluorescein angiography to identify PMO. IHD was defined on clinical and electrocardiographic grounds. The incidence of IHD was compared in patients with and without PMO and statistical analysis performed using the Fisher's exact test.

RESULTS

PMO occurred in 4 patients (6 eyes), all of whom had IHD, whereas no PMO occurred in the remaining 173 patients (246 eyes) (p = 0.04).

CONCLUSIONS

Pseudophakic macular oedema represents an important complication following modern phacoemulsification and intraocular lens implantation and is associated significantly with ischaemic heart disease.

Primary capsulectomy, anterior vitrectomy, lensectomy, and posterior chamber lens implantation in children: limbal versus pars plana

PURPOSE

To compare the results of a limbal versus a pars plana approach for primary posterior capsulectomy and anterior vitrectomy in the management of childhood cataract.

SETTING

Department of Ophthalmology, Labbafinejad Medical Center, Tehran, Iran.

METHODS

A randomized, controlled, double-masked clinical trial of 45 eyes was conducted. After being matched, 38 eyes were included in the study and were divided into 2 equal groups for data analysis. All eyes had lensectomy and posterior chamber intraocular lens (PC IOL) implantation. Primary posterior capsulectomy and anterior vitrectomy were performed through the limbus in half of the eyes and the pars plana in the other half. Main outcome measures included visual acuity, estimated red reflex, postsurgical inflammatory reaction, corneal clarity, posterior synechias, iris capture, IOL position, capsulectomy size, glaucoma, cystoid macular edema, retinal tear, and postoperative refraction.

RESULTS

No statistically significant differences were found between the 2 approaches in the outcome measures.

CONCLUSION

The anatomic and visual results were encouraging when posterior capsulectomy and anterior vitrectomy, using a limbal or pars plana approach, were combined with lensectomy and PC IOL implantation in children. The application of these techniques depends on surgeon experience and skill.

Infantile cataracts

Cataracts are one of the most treatable causes of visual impairment during infancy. Recent epidemiological studies have shown that they have a prevalence of 1.2 to 6.0 cases per 10,000 infants. The morphology of infantile cataracts can be helpful in establishing their etiology and prognosis. Early surgery and optical correction have resulted in an improved outcome for infants with either unilateral or bilateral cataracts. While contact lenses continue to be the standard means of optically correcting an infant's eyes after cataract surgery, intraocular lenses are gaining in popularity as an alternative means of optically correcting these eyes. Post-operative complications occur more commonly after infantile than adult cataract surgery and many of these complications do not develop until years later. As a result, it is critical that children be followed closely on a long term basis after infantile cataract surgery.

Pediatric cataracts

The presentation, etiology, diagnostic examination, and management of pediatric cataracts are discussed in this article. If untreated, cataracts result in significant visual deprivation. Evaluation of the pupillary light reflex should become an integral part of every pediatrician's physical examination. Patients should be referred for a complete eye examination whenever a cataract is suspected because early intervention may be the most important factor in determining a good visual outcome.

Cyclo-oxygenase inhibitors in ophthalmology

Cyclo-oxygenase inhibitors, which are formulated as ophthalmic eyedrop preparations, have recently become commercially available for use by ophthalmologists in the United States to inhibit intraoperative miosis during cataract surgery and to prevent postoperative inflammation. In addition, they are available worldwide as ocular antiinflammatory drugs and are used in the prevention and treatment of pseudophakic and aphakic cystoid macular edema. Understanding the rationale behind the use of these agents requires an understanding of the pathophysiology of the cyclo-oxygenase inhibitors. In this review recent advances in laboratory and clinical science are emphasized. The role of COIs during and following surgery is examined.

Pars plicata lensectomy/vitrectomy for developmental cataract extraction: surgical results

Fifty-two cases of developmental cataracts extracted using the pars plicata lensectomy/vitrectomy technique were reviewed. Eyes with additional ocular anomaly other than microphthalmos were not included. No early complications were detected in a postoperative period ranging from 1.5 to 7 years with a median of 4 years, and late complications were limited to secondary membranes occurring in small eyes. Since secondary membranes occurred only in eyes in which the axial length was less than or equal to 17.4 mm and the corneal diameter was less than or equal to 9.5 mm, we suggest that eyes that are small by the absolute dimensions cited here are at greater risk of developing secondary membranes postoperatively. Small eyes by absolute dimensions should be distinguished from microphthalmic eyes, since the relative term microphthalmic is less predictive of risk of complication than are absolute dimensions. Linear Snellen acuity in 15 patients capable of response ranged as follows: 20/20-20/80 with a median of 20/40 in eyes with partial bilateral cataracts; 20/25-20/80 with a median of 20/50 in eyes with complete bilateral cataracts; 20/30-20/400 with a median of 20/200 in eyes with unilateral partial cataracts; and 20/60-CF with a median of 20/400 in eyes with complete unilateral cataracts. Mean patient ages at surgery were 3 months for those with bilateral complete cataracts, 5 months for those with unilateral complete cataracts, 18 months for those with bilateral partial cataracts, and 25 months for those with unilateral partial cataracts. The earliest possible removal of visually significant opacities must be combined with aggressive postoperative visual rehabilitation to obtain the best possible visual outcome.

Cystoid macular edema in pediatric aphakia

The presence of cystoid macular edema (CME) after cataract extraction in the pediatric age group could adversely affect rapid visual rehabilitation of the eye by contributing to irreversible amblyopia. Several previous studies, including one by our group, have addressed this problem. Hoyt's observations of CME in ten of 27 eyes undergoing lensectomy-vitrectomy procedures have stirred renewed interest in this topic. The current study includes 12 eyes undergoing lensectomy-vitrectomy procedures, five eyes undergoing manual extracapsular procedures (ECCE) with discission of the posterior capsule, three eyes undergoing ECCE without discission of the posterior capsule, and three eyes undergoing secondary discissions. No CME was found angiographically on postoperative evaluation.

Long-term visual results after pars plicata lensectomy-vitrectomy for congenital cataracts

We performed a pars plicata lensectomy-vitrectomy on 32 patients (47 eyes) with congenital cataracts. Ocular abnormalities, mainly nystagmus, strabismus, and microphthalmia, were present in 29 patients. No complications occurred intraoperatively or postoperatively in 39 eyes with up to 8 1/2 years' follow-up (average 2.2 years). The pars plicata approach is a good surgical technique for the management of congenital cataracts.

Results of vitrectomy in children

Though vitrectomy results in the general population are being well established, the results in children particularly of amblyopic age are still largely unknown. This paper details the results in 44 children aged one month to 13 years, of whom 28 were seven years of age or less. The most frequent indication for vitrectomy was penetrating ocular trauma (61%). Of the total 44 cases, 28 (63%) were rendered unilaterally aphakic, 18 of these being less than 7 years old. Improvement in vision occurred in 34 (77%) of the 44 patients, and 10 (23%) remained unchanged. In the 18 children aged one month to seven years who became unilaterally aphakic, 11 (61%) improved and seven (39%) remained unchanged. The management of amblyopia and contact lenses in children is stressed. These results indicate that vitreous surgery plays a significant role in the restoration of vision in children.

Prophylaxis and therapy of aphakic cystoid macular edema

Aphakic cystoid macular edema (ACME) can be a visually significant complication of modern cataract surgery. Prophylaxis of ACME is preferable to therapy of established ACME. Selection of the appropriate cataract operation, control of systemic factors, avoidance of topical catecholamines, control of intraocular inflammation and use of topical or systemic pharmacologic agents may play a role in the prevention of ACME. If it is proven that light toxicity influences the development of ACME, filters in operating microscopes or in intraocular lenses, cataract glasses, or contact lenses may be helpful. Once ACME is present, antiinflammatory therapy has been the main intervention, although its longterm value remains uncertain. Surgical approaches of unproven value have included photocoagulation, vitrectomy, and removal of an intraocular lens.