Results of a prospective evaluation of three methods of management of pediatric cataracts

Surgical interventions for bilateral congenital cataract in children aged two years and under

BACKGROUND

Congenital cataracts are lens opacities in one or both eyes of babies or children present at birth. These may cause a reduction in vision severe enough to require surgery. Cataracts are proportionally the most treatable cause of visual loss in childhood, and are a particular problem in low-income countries, where early intervention may not be possible. Paediatric cataracts provide different challenges to those in adults. Intense inflammation, amblyopia (vision is obstructed by cataract from birth which prevents normal development of the visual system), posterior capsule opacification and uncertainty about the final trajectory of ocular growth parameters can affect results of treatment. Two options currently considered for children under 2 years of age with bilateral congenital cataracts are: (i) intraocular lens (IOL) implantation; or (ii) leaving a child with primary aphakia (no lens in the eye), necessitating the need for contact lenses or aphakic glasses. Other important considerations regarding surgery include the prevention of visual axis opacification (VAO), glaucoma and the route used to perform lensectomy.

OBJECTIVES

To assess the effectiveness of infant cataract surgery or lensectomy to no surgery for bilateral congenital cataracts in children aged 2 years and under.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL; which contains the Cochrane Eyes and Vision Trials Register; 2022, Issue 1); Ovid MEDLINE; Ovid Embase; the ISRCTN registry; ClinicalTrials.gov and the WHO ICTRP. The date of the search was 25 January 2022.

SELECTION CRITERIA

We included all randomised controlled trials (RCTs) that compared infant cataract surgery or lensectomy to no surgery, in children with bilateral congenital cataracts aged 2 years and younger. This update (of a review published in 2001 and updated in 2006) does not include children over 2 years of age because they have a wider variety of aetiologies, and are therefore managed differently, and have contrasting outcomes.

DATA COLLECTION AND ANALYSIS

We used standard methods expected by Cochrane. Two review authors extracted data independently. We assessed the risk of bias of included studies using RoB 1 and assessed the certainty of the evidence using GRADE.

MAIN RESULTS

We identified three RCTs that met our inclusion criteria with each trial comparing a different aspect of surgical intervention for this condition. The trials included a total of 79 participants under 2 years of age, were conducted in India and follow-up ranged from 1 to 5 years. Study participants and outcome assessors were not masked in these trials. One study (60 children) compared primary IOL implantation with primary aphakia. The results from this study suggest that there may be little or no difference in visual acuity at 5 years comparing children with pseudophakia (mean logMAR 0.50) and aphakia (mean logMAR 0.59) (mean difference (MD) -0.09 logMAR, 95% confidence intervals (CIs) -0.24 to 0.06; 54 participants; very low-certainty evidence), but the evidence is very uncertain. The evidence is very uncertain as to the effect of IOL implantation compared with aphakia on visual axis opacification (VAO) (risk ratio (RR) 1.29, 95% CI 0.23 to 7.13; 54 participants; very low-certainty evidence). The trial investigators did not report on the cases of amblyopia. There was little evidence of a difference betwen the two groups in cases of glaucoma at 5 years follow-up (RR 0.86, 95% CI 0.24 to 3.10; 54 participants; very low-certainty evidence). Cases of retinal detachment and reoperation rates were not reported. The impact of IOL implantation on adverse effects is very uncertain because of the sparse data available: of the children who were pseudophakic, 1/29  needed a trabeculectomy and 8/29 developed posterior synechiae. In comparison, no trabeculectomies were needed in the aphakic group and 2/25 children had posterior synechiae (54 participants; very low-certainty evidence).  The second study (14 eyes of 7 children under 2 years of age) compared posterior optic capture of IOL without vitrectomy versus endocapsular implantations with anterior vitrectomy (commonly called 'in-the-bag surgery'). The authors did not report on visual acuity, amblyopia, glaucoma and reoperation rate. They had no cases of VAO in either group. The evidence is very uncertain as to the effect of in-the-bag implantation in children aged under 1 year. There was a higher incidence of inflammatory sequelae: 4/7 in-the-bag implantation eyes and 1/7 in optic capture eyes (P = 0.04, 7 participants; very low-certainty evidence). We graded the certainty of evidence as low or very low for imprecision in all outcomes because their statistical analysis reported that a sample size of 13 was needed in each group to achieve a power of 80%, whereas their subset of children under the age of 1 year had only 7 eyes in each group. The third study (24 eyes of 12 children) compared a transcorneal versus pars plana route using a 25-gauge transconjunctival sutureless vitrectomy system. The evidence is very uncertain as to the effect of the route chosen on the incidence of VAO, with no cases reported at 1 year follow-up in either group. The investigators did not report on visual acuity, amblyopia, glaucoma, retinal detachment and reoperation rate. The pars plana route had the adverse effects of posterior capsule rupture in 2/12 eyes, and 1/12 eyes needing sutures. Conversely, 1/12 eyes operated on by the transcorneal route needed sutures. We graded the outcomes with very low-certainty because of the small sample size and the absence of a priori sample size calculation.

AUTHORS' CONCLUSIONS

There is no high level evidence for the effectiveness of one type of surgery for bilateral congenital cataracts over another, or whether surgery itself is better than primary aphakia. Further RCTs are required to inform modern practice about concerns, including the timing of surgery, age at which surgery should be undertaken, age for implantation of an IOL and development of complications, such as reoperations, glaucoma and retinal detachment. Standardising the methods used to measure visual function, along with objective monitoring of compliance with the use of aphakic glasses/contact lenses would greatly improve the quality of study data and enable more reliable interpretation of outcomes.

Aged Lens Epithelial Cells Suppress Proliferation and Epithelial–Mesenchymal Transition-Relevance for Posterior Capsule Opacification

Posterior capsule opacification (PCO) is a frequent complication after cataract surgery, and advanced PCO requires YAG laser (Nd: YAG) capsulotomy, which often gives rise to more complications. Lens epithelial cell (LEC) proliferation and transformation (i.e., epithelial–mesenchymal transition (EMT)) are two critical elements in PCO initiation and progression pathogenesis. While PCO marginally impacts aged cataract surgery patients, PCO incidences are exceptionally high in infants and children undergoing cataract surgery. The gene expression of lens epithelial cell aging and its role in the discrepancy of PCO prevalence between young and older people have not been fully studied. Here, we conducted a comprehensive differentially expressed gene (DEG) analysis of a cell aging model by comparing the early and late passage FHL124 lens epithelial cells (LECs). In vitro, TGFβ2, cell treatment, and in vivo mouse cataract surgical models were used to validate our findings. We found that aged LECs decelerated rates of cell proliferation accompanied by dysregulation of cellular immune response and cell stress response. Surprisingly, we found that LECs systematically downregulated epithelial–mesenchymal transition (EMT)-promoting genes. The protein expression of several EMT hallmark genes, e.g., fibronectin, αSMA, and cadherin 11, were gradually decreased during LECs aging. We then confirmed these findings in vitro and found that aged LECs markedly alleviated TGFβ2-mediated EMT. Importantly, we explicitly confirmed the in vitro findings from the in vivo mouse cataract surgery studies. We propose that both the high proliferation rate and EMT-enriched young LECs phenotypic characteristics contribute to unusually high PCO incidence in infants and children.

Pars plana subcapsulotomy to remove condense subcapsular opacification in combined surgery of silicone oil removal and phacoemulsification

PURPOSE

Because of the direct contact of intravitreal silicone oil (SO) with the subcapsular membrane, cataract is one of the main SO-related complications. In a group of patients, condense subcapsular opacification occurs, which adds difficulty and risk when having sequential treatment of it. The aim of the current study is to assess the long-term outcomes of pars plana subcapsulotomy to remove condense subcapsular opacification in combined surgery of SO removal and phacoemulsification.

METHODS

Retrospective cohort study. Consecutive patients who were scheduled to have combined surgery of SO removal and phacoemulsification, and with condense subcapsular opacification were included. After phacoemulsification and SO removal, circular subcapsulotomy (diameter = 3-5 mm) was performed with a 23-/25-gauge vitrectomy probe on each subject during the combined surgery. Main outcomes were pre- and postoperative best-corrected visual acuity (BCVA), intra- and postoperative complications.

RESULTS

One hundred and twenty patients (120 eyes) were included. Postoperative logMAR BCVA at day 1, week 1, month 1, and final follow-up examinations was 1.0 ± 0.5, 0.7 ± 0.4, 0.6 ± 0.4, and 0.6 ± 0.3, respectively. Statistically significant median differences of logMAR BCVA occurred between the preoperative examination and each postoperative follow-up examination (all p < 0.001). The sharpest median increase in logMAR BCVA occurred between the day 1 and week 1 postoperative examinations (p < 0.001).

CONCLUSIONS

For condense subcapsular opacification caused by SO tamponade, pars plana subcapsulotomy with a 23-/25-gauge vitrectomy probe during combined surgery of SO removal and phacoemulsification is effective and safe to have surgical management of it. The systemic approach enables patients to experience rapid and long-lasting vision rehabilitation in a single procedure.

Efficacy of intracameral preservative-free triamcinolone acetonide in pediatric cataract surgery: a meta-analysis

PURPOSE

The aim of this study is to evaluate the efficacy of intracameral preservative-free triamcinolone acetonide (TA) on reducing inflammatory reactions after pediatric cataract surgery.

METHODS

Researches were comprehensively searched in PubMed, Embase, and the Cochrane Central Register of Controlled Trials up to 30 November, 2019. Data of interest were extracted and analyzed by Review Manager 5.2. The primary outcome was cell deposits. The secondary outcomes included posterior synechias, fibrinous anterior chamber reaction, visual axis obscuration, and posterior capsule opacification. The odds ratio (OR), weight mean difference (WMD), and their 95% confidence intervals (95% CI) were used to assess the strength of the association.

RESULTS

In total, 45 articles were obtained. Finally, 5 studies with a total of 308 eyes were enrolled in this meta-analysis. Among these, 134 eyes underwent intracameral TA treatment and 174 eyes did not. In intracameral TA treatment group, the incidence of cell deposits (OR = 0.35, 95% CI 0.16-0.76, P = 0.008), posterior synechias (OR = 0.44, 95% CI 0.23-0.86, P = 0.02), and fibrinous anterior chamber reaction (OR = 0.12, 95% CI 0.01-1.05, P = 0.05) were lower compared to those in patients without intracameral TA treatment. Meanwhile, the incidence of visual axis obscuration (OR = 0.10, 95% CI 0.01-0.85, P = 0.04) and posterior capsule opacification (OR = 0.09, 95% CI 0.02-0.55, P = 0.009) were also reduced significantly. The intraocular pressure (IOP) was evaluated at the first month postoperatively (WMD = 0.84 mmHg, 95% CI 0.14-1.53, P = 0.02), but within the normal range. There was no difference of IOP between two groups at 6 months or above after operation (P = 0.93).

CONCLUSIONS

The intracameral preservative-free TA in pediatric cataract surgery contributed to much less inflammatory reaction with the normal IOP range.

Simultaneous Bilateral Pediatric and Juvenile Cataract Surgery Under General Anesthesia: Outcomes and Safety

PURPOSE

To evaluate the surgical approach, outcome, and safety of bilateral simultaneous cataract surgery (BS-Cat) compared with unilateral cataract surgery (US-Cat) and bilateral 2-timed cataract surgery (BT-Cat) in children.

DESIGN

Retrospective, interventional case series.

METHODS

Setting: Department of Ophthalmology, Medical University, Vienna, Austria.

PARTICIPANTS

Children aged 0-18 years who received cataract extraction owing to a unilateral or bilateral cataract between January 2003 and December 2018 were included. Main Outcomes and Measures: Information regarding the type and duration of surgery and total anesthesia time were recorded. Additionally, intraoperative and postoperative complications including retreatments were evaluated.

RESULTS

A total of 220 eyes of 147 patients were included in this analysis (US-Cat: n = 74 patients; BS-Cat: n = 63 patients; BT-Cat: n = 10 patients). The mean age at surgery was 15.94 ± 27.10 months in the US-Cat group, 33.47 ± 58.20 months in the BS-Cat group, and 41.91 ± 55.09 months in the BT-Cat group. The main surgical approach was lensectomy combined with anterior vitrectomy ± IOL implantation (US-Cat: 98.65%; BS-Cat: 95.24%; BT-Cat: 100%; P = .08). Initial intraocular lens implantation was not commonly performed in all groups (US-Cat: 27.03%; BS-Cat: 23.02%; BT-Cat: 50.00%). The mean anesthesia time was shortest in the US-Cat (91.62 ± 26.12 min), followed by the BS-Cat (123.81 ± 30.11 min) and BT-Cat groups (186.00 ± 42.34 min; P < .001), contrary to the duration of surgery (US-Cat: 37.56 ± 15.69 min; BS-Cat: 32.33 ± 17.31 min; BT-Cat: 37.50 ± 18.67; P = .087). An accidental oxygen decrease below 93% was rare in all groups (US-Cat: 6.76%; BS-Cat: 17.46%; BT-Cat: 10.00%). Intraoperative surgical complications occurred rarely (P = .95) and involved mainly the iris. The number of postoperative complications (P = .17) and interventions (P = .10) was similar in all groups. Visual axis obscuration (US-Cat: 28.38%; BS-Cat: 23.81%; BT-Cat: 20.00%; P = .67) and glaucoma (US-Cat: 6.76%; BS-Cat: 15.87%; BT-Cat: 15.00%; P = .20) showed no difference between the groups. However, nystagmus was more pronounced in the BS-Cat group (US-Cat: 12.16%; BS-Cat: 49.21%; BT-Cat: 20.00%; P < .001), whereas strabismus was more pronounced in the US-Cat group (US-Cat: 68.92%; BS-Cat: 33.33%; BT-Cat: 40.00%; P < .001).

CONCLUSION

Simultaneous removal of bilateral cataract in children showed no statistically significant differences regarding intraoperative and postoperative complications when compared to unilateral and 2-timed bilateral cataract surgery. Anesthesia time was longer in simultaneous bilateral than in unilateral cataract surgery, but only by the surgery time of the second eye. However, prolonged anesthesia time was not accompanied by a decrease of oxygen saturation.

The role of primary intraocular lens implantation in the risk of secondary glaucoma following congenital cataract surgery: A systematic review and meta-analysis

Objective

This meta-analysis aims to evaluate the incidence of secondary glaucoma in patients under the age of 2 years who underwent congenital cataract surgery with or without primary intraocular lens (IOL) implantation.

Methods

An electronic literature search was performed in Medline, EMBASE, and Web of Science databases to retrieve studies between January 2011 and November 2018. Patients with congenital cataract who did primary IOL implantation, aphakia, or secondary IOL implantation followed by receiving extraction surgery were included in this study. Relevant studies meeting defined eligibility criteria were selected and reviewed systematically by meta-analysis. Long-term incidences of secondary glaucoma, which developed at least one year after cataract surgery, were considered and discussed as clinical outcomes in each cohort. The pooled data were analyzed according to a random effects model.

Results

Eight publications involving 892 eyes were included in the current meta-analysis. In the general population of eyes with congenital cataract, the long-term incidence of secondary glaucoma was lower (P = 0.06) in eyes with primary IOL (9.5%) than in eyes without primary IOL (15.1%), including aphakia and secondary IOL. The pooled risk ratio (RR) favors primary IOL implantation in all patients (RR = 0.63). For bilateral congenital cataract, the incidence was 6.7% in eyes with primary IOL implantation, which is significantly lower than the 16.7% in eyes with aphakia and secondary IOL implantation (P<0.05, RR = 0.44). However, for unilateral congenital cataract surgery, the incidence was very similar in eyes with and without primary IOL (12.4% vs 12.0%, P = 0.61, RR = 0.87).

Conclusions

In patients under 2 years of age, primary IOL implantation for bilateral congenital cataract surgery is associated with a lower risk of secondary glaucoma.

Comparison of Two Intraocular Lens Implantation Techniques in Pediatric Cataract Surgery in Terms of Postoperative Complications

Background:

Pediatric cataract surgery differs substantially from adult cataract surgery. Numerous studies have focused on reducing the development of postoperative complications.

Aims:

To compare two intraocular lens implantation techniques used in pediatric cataract surgery in terms of postoperative complications.

Study Design:

Case-control study.

Methods:

Patients who underwent pediatric cataract surgery and intraocular lens implantation between 2008 and 2016 were evaluated in this retrospective study. Patients aged 3-15 years with unilateral or bilateral cataract and without corneal pathology were included in the study. The patients were categorized into the following two groups: those who underwent posterior capsulorhexis and anterior vitrectomy using in-the-bag intraocular lens implantation (group 1) and those who underwent posterior capsulorhexis and intraocular lens implantation with the optic fixed behind the posterior capsulorhexis (group 2). Rates of postoperative visual axis opacification and complications (glaucoma, posterior synechiae, uveitic reaction, and intraocular lens decentration) were evaluated in these groups. The implanted intraocular lenses were either monoblock (AcrySof SN60AT intraocular lens), triple-piece (AcrySof MA60BM intraocular lens) foldable hydrophobic acrylic lenses, or multifocal lenses (AcrySof IQ ReSTOR).

Results:

This retrospective study included 52 eyes of 37 patients. Group 1 comprised 26 eyes of 20 patients and group 2 comprised 26 eyes of 17 patients. During the follow-up, visual axis opacification was observed in two patients in group 1 but no patients in group 2. Regarding postoperative complications, there was no uveitic reaction, posterior synechiae, or intraocular lens decentration in either group. There was no significant difference between the groups in terms of the postoperative complications (p>0.05).

Conclusion:

There was no significant difference between in-the-bag intraocular lens implantation after posterior capsulorhexis and intraocular lens optic capture through posterior capsulorhexis in terms of the complications.

Effect of intracameral triamcinolone acetonide on postoperative intraocular inflammation in pediatric traumatic cataract

PURPOSE

To study the effect of a single intracameral injection of triamcinolone acetonide at the end of pediatric traumatic cataract surgery on postoperative inflammation.

METHODS

This prospective interventional study comprised 40 eyes of children with unilateral traumatic cataract. Patients were classified into 2 groups: the study group, in which intraoperative intracameral triamcinolone acetonide (2 mg) was used at the end of surgery; and a control group, which did not receive intracameral triamcinolone acetonide.

RESULTS

The study group included 20 eyes of patients with an average age of 6 ± 2.8 years. The control group included 20 eyes of patients with an average age of 6 ± 2.1 years. No serious intraoperative complications occurred. In the immediate postoperative period, 3 eyes of the control group (15.0%) developed a fibrinous anterior chamber reaction. None of the study group eyes developed a similar reaction. There were no cases of endophthalmitis. In addition, 3 eyes (15%) in the control group had obscuration of the visual axis at the last follow-up. This complication was not encountered in the study group. Posterior synechiae and cellular deposits were observed in 4 eyes (20%) in the study group and 8 eyes (40%) in the control group at 1 month and at the last follow-up.

CONCLUSIONS

The use of intracameral triamcinolone decreased anterior segment inflammation postoperatively in children who had surgery for traumatic cataract.

Long-Term Visual Outcomes of Secondary Intraocular Lens Implantation in Children with Congenital Cataracts

Aim

The aim of this study was to evaluate the long-term visual outcomes and factors affecting visual results in children undergoing secondary intraocular lens (IOL) implantation following primary congenital cataract extraction.

Methods

Children with congenital cataracts who underwent secondary IOL implantation for aphakia at the Eye and ENT Hospital of Fudan University between January 1, 2001, and December 31, 2007, were retrospectively reviewed. One eye was randomly selected in children with bilateral cataracts. Laterality, type of cataract (total or partial opacity), sex, age at primary and secondary surgeries, visual axis opacity (VAO), compliance with amblyopia therapy, postoperative ocular complications, refractive error, ocular alignment, and best corrected visual acuity (BCVA) at last follow-up were recorded; potential factors that might have affected the visual results were evaluated.

Results

Seventy-six bilateral and 34 unilateral congenital cataract cases were analyzed; the mean ages of the children were 12.70±5.06 and 12.50±2.71 years at final follow-up, the mean follow-up periods from IOL implantation were 94.93±24.22 and 109.09±18.89 months, and the mean BCVA (Log MAR) values were 0.51±0.37 and 1.05±0.46, respectively. Final BCVA after secondary IOL implantation was significantly associated with laterality, type of cataract, age at primary cataract extraction, compliance with amblyopia therapy, and refractive correction after surgery. No significant associations were found between BCVA and sex, age at secondary IOL implantation, VAO, or other ocular complications. The most common ocular complications were VAO and elevated intraocular pressure after surgery. There were no other complications, with the exception of one eye with IOL dislocation.

Conclusions

The results indicate that the important determinants of long-term visual outcomes in children with congenital cataracts undergoing secondary IOL implantation are laterality, cataract type, age at initial cataract extraction, compliance with amblyopia therapy, and refractive error.

Visual outcomes of bilateral congenital and developmental cataracts in young children in south India and causes of poor outcome

CONTEXT

Bilateral pediatric cataracts are important cause of visual impairment in children.

AIM

To study the outcome of bilateral pediatric cataract surgery in young children.

SETTING AND DESIGN

Retrospective case series in a tertiary center.

MATERIALS AND METHODS

Records of pediatric cataracts operated between January 2001 and December 2003, with a minimum follow-up of 3 months, were reviewed retrospectively.

STATISTICAL METHODS

Independent sample t-test, Fisher's exact test, and logistic regression using SPSS (Statistical Package for Social Science, Chicago, USA) version 12.

RESULTS

215/257 (83.7%) patients had a minimum follow-up of 3 months. The mean age of presentation to the hospital was 53 months (range: 0-168 months). Congenital cataract was present in 107 patients (58.2%) and developmental cataract in 77 patients (41.8%). The mean age at surgery was 55.2 months (range: 1-168 months). Out of 430 eyes, 269 (62.6%) had an intraocular lens implanted. The mean duration of follow-up was 13.1 months (range: 3-38 months). Pre-operatively, 102 patients (47.3%) had visual acuity <6/60, in the better eye, compared to 37 patients (17.2%) post-operatively ( P < 0.001). Eighty-five patients (39.5%) had visual acuity >6/18. The most common early post-operative complication was fibrinous uveitis in 57 eyes (13.3%) and the most common delayed post-operative complication was posterior capsular opacification in 118 eyes (27.4%). The most important prognostic factor for poor outcome was congenital cataract (odds ratio [OR]: 26.3; 95% confidence interval [CI], 4.4-158.5) and total cataract (OR: 4.8; 95% CI, 1.3-17).

CONCLUSION

Nearly half of the eyes had visual acuity >6/18. The outcome was poorer in congenital cataracts, especially those operated after >1 year of age.

Comparison of hospital versus rural eye cAMP based pediatric cataract surgery

Purpose:

To compare the outcomes of pediatric cataract surgery with intraocular lens (IOL) implantation in an eye camp setting and tertiary care center.

Materials and Methods:

Children aged 5-16 years with visually significant cataract underwent phacoaspiration with IOL implantation in an eye camp (eye camp group) or tertiary care center (TCC group). All surgeries incorporated contemporary microsurgical techniques with implantation of polymethyl-methacrylate (PMMA) IOL. Major postoperative complications were managed at a tertiary care center. Postoperative complications, visual acuity and compliance were evaluated using the Chi-square test. A P value less then 0.05 was considered as statistically significant.

Results:

The cohort comprised 59 children in the eye camp group and 48 children in the TCC group. Thirty two of fifty nine (54.23%) eyes in the eye camp group and 30/48 (62.5%) eyes in the TCC group achieved 20/40 or better best corrected visual acuity (BCVA) postoperatively. Postoperatively, 36 (61%) eyes in the eye camp group and 22 (45.83%) eyes in the TCC group required Nd: YAG laser capsulotomy or a pars plana membranectomy. (P> 0.05) The most striking feature was loss to follow up. In the eye camp group, loss to follow was 20% at one year, 49% at two years, 62% at 3 years and 67% at 4 years compared to 12.5, 21, 27 and 33% respectively in the TCC group (P<0.05, all cases).

Conclusions:

The outcomes of camp and tertiary care center (hospital) based pediatric cataract surgery were similar. However, the major drawback of camp based surgery was loss to follow up which eventually affected the management of amblyopia and postoperative complications.

Corneal endothelial morphologic assessment in pediatric cataract surgery with intraocular lens implantation: a comparison of preoperative and early postoperative specular microscopy

PURPOSE

To observe longitudinal changes in the corneal endothelium after pediatric cataract surgery with intraocular lens implantation.

DESIGN

Prospective, longitudinal study.

METHODS

settings: Iladevi Cataract and IOL Research Centre, Ahmedabad, India. study population: This study included 100 pediatric eyes undergoing cataract surgery with intraocular lens implantation. Posterior capsule management was based on the status of the posterior capsule. Two-port anterior limbal vitrectomy was carried out after posterior capsule plaque peeling. observation procedures: Corneal endothelial morphologic features: endothelial cell density (cell/mm(2)), coefficient of variation, percentage of hexagonality, and central corneal thickness were assessed. main outcome measures: To evaluate whether there is a difference in endothelial cell morphologic features before surgery and 3 months after surgery and also whether pediatric cataract surgery with and without anterior vitrectomy has any impact on the endothelial cell morphologic features.

RESULTS

A comparison of preoperative and postoperative specular microscopy is given here: endothelial cell density, 3225.1 ± 346.8 cells/mm(2) versus 3057.7 ± 330.1 cells/mm(2) (P < .001); coefficient of variation, 27.5 ± 10.6 versus 37.7 ± 16.3 (P < .001); percentage of hexagonality, 58.1 ± 15.3 versus 48.6 ± 13.4 (P < .001); and central corneal thickness, 529 ± 30 μm versus 527 ± 34 μm (P = .64). There was 5.1% decrease in mean endothelial cell loss at 3 months after surgery. No statistically significant difference was noted in the percentage decrease in mean endothelial cell density between eyes undergoing cataract surgery with intact posterior capsules, eyes undergoing manual posterior capsulorrhexis without anterior limbal vitrectomy, and eyes undergoing anterior limbal vitrectomy (P = .543).

CONCLUSIONS

Endothelial cell loss with currently practiced techniques of pediatric cataract surgery is within acceptable limits by adhering to the principles of close chamber technique.

Long-term results of bilateral congenital cataract treated with early cataract surgery, aphakic glasses and secondary IOL implantation

PURPOSE

To evaluate the long-term visual outcome after early surgery of bilateral dense congenital cataracts, aphakic correction with glasses and secondary intraocular lens (IOL) implantation around 2 years of age.

METHODS

The medical records of paediatric patients who underwent cataract extraction, aphakic correction and secondary IOL implantation from 1993 to 2004 at Seoul National University Children's Hospital were reviewed retrospectively. Age at secondary IOL implantation, axial length (AL), best corrected visual acuity (BCVA), refractive error, ocular alignment, stereopsis, and postoperative ocular complications were recorded.

RESULTS

Thirty-seven paediatric bilateral pseudophakic patients were identified with a mean follow-up period of 81.4 months. Best corrected visual acuity of 20/40 or better were attained in 44.0% of eyes, and the median BCVA was 20/50. Preoperative factors associated with poor visual prognosis included cataract surgery after 8 weeks of age, interocular AL difference of 0.5 mm or more, and glaucoma. Amblyopic eyes showed more myopic change compared to fellow eyes. Good or moderate binocular function was achieved in 18.9% of all patients. Incidences of strabismus, glaucoma, posterior capsular opacity formation were 46.0%, 32.4% and 4.0%, respectively.

CONCLUSION

Good postoperative BCVA and binocular function were achieved in most healthy children with bilateral dense congenital cataract and no posterior segment pathology. Early cataract surgery, aphakic correction with glasses and secondary IOL implantation around 2 years of age appears to be appropriate methods.

Long-term outcome of primary versus secondary intraocular lens implantation after simultaneous removal of bilateral congenital cataract

BACKGROUND

Long-term outcomes of intraocular lens (IOL) implantation for congenital cataract in children under 2 years old are still undetermined.

METHODS

We retrospectively reviewed all cases of bilateral congenital cataract who had undergone simultaneous bilateral cataract removal with posterior capsulotomy and central anterior vitrectomy between 1990 and 2010. Patients randomly underwent primary IOL implantation or secondary IOL implantation after a period of contact lens wear. The two groups were compared for visual outcome and complications during follow-up.

RESULTS

Cataract removal and primary IOL implantation was performed in 30 eyes (15 patients; nine males, six females) at a mean age of 6.8 ± 4.2 months. After 79.31 ± 63.4 months, best-corrected visual acuity (BCVA) was 0.53 ± 0.36 EDTRS LogMAR. In 36 eyes (18 patients, 11 males, seven females) the lens was removed at a mean age of 5.42 ± 2.80 months, and after 32.0 ± 6.1 months of contact lens utilization, secondary IOL implantation was performed. After 109.0 ± 33.8 months, BCVA was 0.54 ± 0.4 ETDRS LogMAR. The association between age at surgery and final visual acuity and the difference between the two groups concerning type of cataract at baseline, BCVA and refractive error at last visit, incidence of posterior capsular opacification, glaucoma, strabismus, and nystagmus during follow-up were not significant (p > 0.05). Myopic shift was more frequent in eyes undergone primary IOL implantation (p < 0.001).

CONCLUSIONS

Similar visual outcome and complications were observed during long-term follow-up after both primary and secondary IOL implantation following simultaneous bilateral congenital cataract removal with posterior capsulotomy and central anterior vitrectomy.

Delayed presentation of cataracts in children: are they worth operating upon?

PURPOSE

Childhood cataract is an important cause of avoidable blindness in children. The study aimed to investigate the outcome of surgery in cataracts with delayed presentation which had been operated upon as new pediatric ophthalmology centers were set up in India.

METHODS

This was a retrospective interventional case series from a community eye care center in Western India. Demographic, surgical, pre-operative and post-operative details were obtained from the patients records and entered into Microsoft excel and statistical analysis conducted using SPSS-11 software (SPSS, Chicago, IL). Vision was tested 6 weeks after surgery. The predictors of good vision (> or =6/18) were identified by regression analysis. If the interval between detection of cataract in children and their presentation for surgery was more than 18 months for developmental and 6 months for congenital the cataract was defined having a delayed presentation.

RESULTS

Five hundred and twenty nine eyes of 437 children aged 2 months to 16 years were operated upon in 2004-2006. Preoperative vision was <3/60 in 405 (76.6%) eyes with cataract. Of these 529, 242 eyes were with delayed presentation of cataract (83 congenital and 149 other). 102 had up to 5 years, 91 had 6-10 years and 49 had >11 yrs delay in presentation. At 6 weeks following surgery, vision was > or = 6/18 in 36/93 (38.7%) of eyes with delayed presenting cataracts, as compared to 94/244 (38.5%) > or =6/18 in those without.

CONCLUSION

Surgery for cataracts with delayed presentation helps to regain functional vision, which can be used for navigation and low vision aids.

Pars plana capsulectomy and vitrectomy for posterior capsular opacification in pseudophakic children

PURPOSE

To evaluate the safety and efficacy of pars plana capsulectomy and vitrectomy for posterior capsular opacification (PCO) in pseudophakic children.

METHODS

Pars plana capsulectomy and vitrectomy was performed for PCO in 63 pseudophakic eyes of 57 children with an infusion through sutureless clear cornea. The patients' ages ranged from 3 to 12 years (mean: 5.8 +/- 1.9 years). Surgical technique, intraoperative and postoperative complications, visual acuity, intraocular pressure (IOP), and corneal endothelial cell density were recorded.

RESULTS

The surgical procedure was performed uneventfully in all patients. The mean follow-up was 2.4 +/- 1.4 years (range: 6 months to 5.2 years). During the follow-up period, no incision leakage or other complications were noted and no eye developed recurrent PCO. All eyes had an improvement of visual acuity. Mean postoperative IOP was 13.8 +/- 2.6 mm Hg (range: 8 to 19 mm Hg). Mean overall endothelial cell loss was 3.4%.

CONCLUSIONS

Pars plana capsulectomy and vitrectomy with an infusion through sutureless clear cornea appears to be a safe and effective approach for thick PCO in pseudophakic children.

Primary posterior capsulorhexis with anterior vitrectomy in preventing posterior capsule opacification in pediatric cataract microsurgery

Our study was performed to investigate the operative effects of pediatric cataract surgery with anterior vitrectomy. The study comprised of 38 pediatric patients aged 2-5 years and involved a total of 60 eyes with congenital cataracts. The study was done between March 2004 and December 2005. Posterior capsulorhexis with anterior vitrectomy was performed on 34 eyes of 20 children, and cataract extraction was performed on 26 eyes of 18 children. The percentages of various complications and rate of neodymium YAG (Nd:YAG) laser capsulotomy were followed up for 12-36 months. There were significant differences in the percentages of posterior capsule opacification (PCO) and rate of neodymium YAG (Nd:YAG) capsulotomy between the anterior vitrectomy group and cataract extraction group (P < 0.01). The anterior vitrectomy group was associated with less posterior capsular opacification (11.8%) than the cataract extraction group (76.9%). The YAG capsulotomy rate was 2.9% for the anterior vitrectomy group, and 57.7% for the cataract extraction group. After operation the fibrous exudates in anterior chamber and the intraocular lens subluxation or capture were 5.9% and 2.9% for the anterior vitrectomy group while for the cataract extraction group they were 23.1% and 15.4%; the difference was statistically significant (P < 0.05). The results suggest that primary posterior capsulorhexis with anterior vitrectomy in pediatric cataract surgery who are between 2 and 5 years old is necessary and effective procedure with low PCO rate.

Determinants of pediatric cataract program outcomes and follow-up in a large series in Mexico

PURPOSE

To report determinants of outcomes and follow-up in a large Mexican pediatric cataract project.

SETTING

Hospital Luis Sanchez Bulnes, Mexico City, Mexico.

METHODS

Data were collected prospectively from a pediatric cataract surgery program at the Hospital Luis Sanchez Bulnes, implemented by Helen Keller International. Preoperative data included age, sex, baseline visual acuity, type of cataract, laterality, and presence of conditions such as amblyopia. Surgical data included vitrectomy, capsulotomy, complications, and use of intraocular lenses (IOLs). Postoperative data included final visual acuity, refraction, number of follow-up visits, and program support for follow-up.

RESULTS

Of 574 eyes of 415 children (mean age 7.1 years +/- 4.7 [SD]), IOLs were placed in 416 (87%). At least 1 follow-up was attended by 408 patients (98.3%) (mean total follow-up 3.5 +/- 1.8 months); 40% of eyes achieved a final visual acuity of 6/18 or better. Children living farther from the hospital had fewer postoperative visits (P = .04), while children receiving program support had more visits (P = .001). Factors predictive of better acuity included receiving an IOL during surgery (P = .04) and provision of postoperative spectacles (P = .001). Predictive of worse acuity were amblyopia (P = .003), postoperative complications (P = .0001), unilateral surgery (P = .0075), and female sex (P = .045).

CONCLUSIONS

The results underscore the importance of surgical training in reducing complications, early intervention before amblyopia (observed in 40% of patients) can develop, and vigorous treatment if amblyopia is present. The positive impact of program support on follow-up is encouraging, although direct financial support may pose a problem for sustainability. More work is needed to understand reasons for worse outcomes in girls.

Five-year experience of the 2-incision push-pull technique for anterior and posterior capsulorrhexis in pediatric cataract surgery

PURPOSE

To describe the authors' 5-year experience of the 2-incision push-pull (TIPP) technique for pediatric anterior and posterior capsulorrhexis formation.

DESIGN

Retrospective descriptive study over a 5-year period.

PARTICIPANTS

A total of 84 eyes of 63 patients who had undergone cataract surgery in 1 center.

METHODS

Retrospective review of all consecutive patients who underwent pediatric cataract extraction with planned intraocular lens implantation and TIPP rhexis between January, 1999, and August, 2004. Any lost capsulorrhexis, or capsular tears at any stage of the operation, and the relation of optic size to anterior capsulorrhexis size were noted.

MAIN OUTCOME MEASURES

Complications during TIPP rhexis formation and any late complications at last visit.

RESULTS

The mean age at operation was 70.21 months (range, 4 weeks-18 years). All eyes had anterior TIPP rhexis; 41 eyes also had posterior TIPP rhexis, and there were no anterior or posterior capsulorrhexis loss or tears while performing the technique. In no patient in whom TIPP rhexis was performed for the posterior capsule was there an inadvertent vitreous loss during rhexis formation. All eyes had anterior rhexis diameters that were smaller than the optic diameter (5.5-6.0 mm), approximately 4 to 4.5 mm in diameter. Four capsular tears were reported; 1 tear occurred during irrigation and aspiration and the others during rigid lens insertion. No late complications were noted.

CONCLUSIONS

Our 5-year experience with the TIPP rhexis in pediatric cataract surgery has shown this to be a reliable method for producing a consistent-size capsulorrhexis opening in both anterior and posterior capsulorrhexis.

Completion rate of primary posterior continuous curvilinear capsulorhexis and vitreous disturbance during congenital cataract surgery

PURPOSE

We sought to document the completion rate of primary posterior continuous curvilinear capsulorhexis during congenital cataract surgery and determine the incidence of disruption of vitreous face during this procedure.

METHODS

One hundred six consecutive eyes of patients undergoing posterior continuous curvilinear capsulorhexis (PCCC) during congenital cataract surgery were evaluated prospectively for completion of PCCC and disruption of vitreous face. PCCC was performed under high-viscosity sodium hyaluronate (Healon GV 1.4%) initiated with 26 g of cystotome and later completed with Kraff-Uttrata forceps by frequent grasping and regrasping of the flap. Completion of PCCC and disruption of vitreous face during the procedure was noted. Even in cases of disrupted vitreous face, PCCC was performed and completed with forceps and, later, disruption of vitreous face was managed with 2-port automated limbal anterior vitrectomy. The size of PCCC was measured. An Alcon AcrySof SA30AL was implanted in-the-bag if the PCCC was 4 mm or smaller and in the sulcus when the PCCC was larger than 4 mm.

RESULTS

The mean age of the 106 pediatric patients was 17 +/- 26 months (median, 6 months; range, 1 month to 8 years). PCCC was completed in all the eyes. Disruption of vitreous face during PCCC was noted in 5 of 106 (4.7%) eyes. The mean size of PCCC was 3.6 +/- 0.7 mm. A total of 98 (92.5%) had in-the-bag, and 8 (7.5%) eyes had sulcus implantation of IOL.

CONCLUSION

PCCC was completed in all eyes with minimal disruption of vitreous face in a well-controlled manner under high-viscosity viscoelastics.

Surgical interventions for bilateral congenital cataract

BACKGROUND

Congenital cataracts are opacities of the lens in one or both eyes of children that cause a reduction in vision severe enough to require surgery. Cataract is the largest treatable cause of visual loss in childhood. Paediatric cataracts provide different challenges to those in adults. Intense inflammation, amblyopia and posterior capsule opacification can affect results of treatment. Two treatments commonly considered for congenital cataract are lensectomy and lens aspiration.

OBJECTIVES

The objective of this review was to assess the effects of surgical treatments for bilateral symmetrical congenital cataracts. Success was measured according to the vision attained and occurrence of adverse events.

SEARCH STRATEGY

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) on The Cochrane Library, which contains the Cochrane Eyes and Vision Group Trials Register (2005, Issue 2), MEDLINE (1966 to June 2005), EMBASE (1980 to June 2005, week 27), LILACS (6 July 2005), the Science Citation Index and the reference list of the included studies. We also contacted trial investigators and experts in the field for details of further studies.

SELECTION CRITERIA

We included all prospective, randomised controlled trials that compared one type of cataract surgery to another, or to no surgery, in children with bilateral congenital cataracts aged 15 years or younger.

DATA COLLECTION AND ANALYSIS

Two authors extracted data. No meta-analysis was performed.

MAIN RESULTS

Four trials met the inclusion criteria. All trials were concerned with reducing the development of visual axis opacification (VAO). This was achieved with techniques that included an anterior vitrectomy or optic capture. Posterior capsulotomy alone was inadequate except in older children.

AUTHORS' CONCLUSIONS

Evidence exists for the care of children with congenital or developmental bilateral cataracts to reduce the occurrence of visual axis opacification. Further randomised trials are required to inform modern practice about other concerns including the timing of surgery, age for implantation of an intraocular lens and development of long-term complications such as glaucoma and retinal detachment.

The effectiveness of Nd:YAG laser capsulotomy for the treatment of posterior capsule opacification in children with acrylic intraocular lenses

INTRODUCTION

Acrylic intraolcular lenses (IOLs) may result in lower rates of posterior capsular opacification (PCO) than poly(methyl methacrylate) lenses in children. Nonetheless, PCO frequently occurs eventually, especially in younger children. Here, we evaluated the success of neodymium-doped yttrium-aluminum-garnet (Nd:YAG) laser capsulotomy for the management of PCO after acrylic IOL implantation without primary capsulectomy.

METHODS

We reviewed 73 eyes in 57 children (age 23 months to 12 years; median, 6.4 years) who underwent Nd:YAG laser capsulotomy after AcrySof IOL implantation and who had at least 3 months follow-up (range, 3-92 months; median, 25 months). The effectiveness of laser treatment was evaluated in terms of the need for repeat laser procedures or intraocular surgery to clear the visual axis.

RESULTS

Fifty-one eyes (70%) maintained a clear visual axis after a single Nd:YAG procedure, 10 eyes (84% cumulative) after 2 Nd:YAG procedures, and another 3 eyes (88% cumulative) after 3 Nd:YAG procedures. Six eyes (8%) required pars plana membrane removal to clear the visual axis, whereas 3 eyes (4%) continue to need treatment. Life table analysis showed that the probability of continuing success after 24 months with a single Nd:YAG procedure is 68% (95% confidence interval 53-83%). In younger children (age<4 years), this rate probability was lower than in older children (35% vs. 74%; P=0.022). Two eyes developed mild transient elevated intraocular pressure. In 1 eye, the IOL was dislocated and replaced.

DISCUSSION

Nd:YAG laser capsulotomy is an acceptable option for the management of PCO after AcrySof IOL implantation in children and produces complications infrequently.

Efficacy of trypan blue in posterior capsulorhexis with optic capture in pediatric cataracts [ISRCTN48221688]

Background

To evaluate the efficacy of trypan blue (0.06%) in posterior capsulorhexis with optic capture in pediatric cataracts.

Methods

In this prospective randomized controlled study, trypan blue dye assisted posterior capsulorhexis with optic capture was performed in 18 eyes (group 1) and no dye was used for posterior capsulorhexis (group 2) in 17 eyes.

Results

The mean size of the posterior capsulorhexis was 4.6 +/-1.77 mm and 4.0 +/- 0.93 mm in the group 1 and 2 respectively. Optic capture was possible in 17 eyes in the group 1 and 11 eyes in the group 2.

Conclusion

Trypan blue facilitates posterior capsulorhexis with optic capture of AcrySof IOL in cases of pediatric cataracts.

Posterior vertical capsulotomy with optic entrapment of the intraocular lens in congenital cataracts--prevention of capsule opacification

PURPOSE

To present a modified surgical technique for preventing posterior capsule opacification (PCO) in children with congenital cataracts and to evaluate its long-term efficacy.

SETTING

Department of Ophthalmology, Medical University of Southern Africa, Medunsa, South Africa.

METHODS

Anterior and posterior vertical capsulotomy, with optic entrapment of the intraocular lens (IOL) by maintaining the anterior hyaloid, was performed in 68 cataractous eyes of children aged 2 months to 8 years (mean 3 years, 1 month). The posterior capsule was evaluated for at least 5 years for secondary opacification, IOL position, pigmentary deposits on the IOL optic, and the presence of synechias.

RESULTS

Sixty-eight eyes maintained a clear visual axis for 5 to 12 years (mean 9 years, 1 month) postoperatively. No secondary procedure was necessary. In all eyes, the IOL remained well centered and entrapped.

CONCLUSIONS

Posterior capsulotomy with optic entrapment of the IOL proved to be a safe and efficient surgical procedure for preventing PCO in children with congenital cataracts. Uniting the anterior and posterior capsule in front of the IOL limits the proliferation and migration of Elschnig pearls. An intact anterior hyaloid does not induce capsule opacification in association with optic entrapment; therefore, a vitrectomy is not indicated even in infants under age 5 years. Clear visual axis, centered IOL, and intact vitreous were achieved in this series; this enables a promising long-term prognosis for binocular visual development, especially because surgery was performed early.

Cataracts in children

Bilateral congenital cataract is the most common cause of treatable childhood blindness. Nuclear cataract is usually present at birth and is nonprogressive, whereas lamellar cataract usually develops later and is progressive. Surgery must be performed promptly in cases with dense congenital cataract; if nystagmus has developed, the amblyopia is irreversible. A treatment regimen based on surgery within 2 months of birth combined with prompt optical correction of the aphakia and aggressive occlusion therapy with frequent follow-up has been successful in unilateral and bilateral cases. Both anterior and posterior capsulorhexes are performed in most children. Intraocular lens implantation can be performed safely in children older than 1 year. Anterior dry vitrectomy is recommended in preschool children to avoid after-cataract. Opacification of the visual axis is the most common complication of cataract surgery in children. Secondary glaucoma is the most sight-threatening complication and is common if surgery is performed early. Life-long follow-up is essential in these cases.

Cataract extraction and primary hydrophobic acrylic intraocular lens implantation in infants

PURPOSE

We sought to report the incidence of visual axis opacification and to evaluate the complication and reoperation rates after intraocular lens implantation in infants.

METHODS

Twenty-one infants (31 eyes) who had cataract extraction with primary hydrophobic acrylic IOL implantation between October 1996 and May 2002 were reviewed. Posterior capsule was left intact in 14 eyes (group A); posterior capsulorrhexis or capsulotomy with anterior vitrectomy was performed in 17 eyes (group B). Complication and reoperation rates were compared with an age-matched control group of 17 patients (33 eyes) who were left aphakic after pars plicata lensectomy. Mean follow-up period was 41 months (range, 22-75 months) in group A, 37 months (range, 10-75 months) in group B, and 52 months (range, 7-97 months) in the control group.

RESULTS

Mean age of the patients was 6.8 months (range, 3-10 months) in group A, 8.9 months (range, 3-18 months) in group B, and 4.9 months (range, 1-15 months) in the control group. Visual axis opacification was significantly higher in group A (86%) when compared with group B (17.6%; P < 0.0001). No significant difference was found in terms of pupillary irregularities and peripheral anterior synechiae formation between pseudophakic and aphakic group ( P = 0.43 and P = 0.306, respectively), whereas pigment dispersion and fibrinous reaction were significantly more common in the pseudophakic group ( P = 0.002). Serious complications, such as retinal detachment, pseudophakic bullous keratopathy, and secondary glaucoma, did not develop in any eye. Reoperation rate was significantly higher in group A (78%) when compared with group B (17%) and the control group (12%; P = 0.0011 and P < 0.0001, respectively).

CONCLUSIONS

Visual axis opacification requiring a reoperation was significantly more common in patients with an intact posterior capsule. To decrease the reoperation rate and maintain a clear visual axis, posterior capsulorrhexis with anterior vitrectomy should be performed. Even although early complications were quite frequent, serious late complications were not encountered in any eye. Therefore, under appropriate conditions, IOL implantation is a suitable alternative in infants.

Accuracy of intraocular lens calculations in infants and children undergoing cataract surgery

PURPOSE

We sought to evaluate the accuracy of intraocular lens calculations in children undergoing cataract extraction with intraocular lens (IOL) implantation.

METHODS

This was a retrospective review of 101 consecutive cases of pediatric cataract extraction with posterior chamber IOL. Median age at the time of surgery was 4.8 years, and 23 of the children were younger than 2 years of age. Initial IOL calculations were made using either the SRK II or SRK T formulas. Preoperative predictive data were compared with the refractive result obtained at the 2-month postoperative visit. Prediction error was calculated for each patient, and lens calculation errors were back-calculated for each of 4 commonly used IOL calculation formulas, including the SRK II, SRK T, Holladay I, and Hoffer Q.

RESULTS

The mean prediction error for all patients was 0.30 D. Despite this level of overall accuracy, significant variability did occur with outcomes ranging from -4.06 D to + 3.86 D of the desired spherical equivalent. Mean absolute prediction error was 1.16 D with no significant difference between the SRK II and SRK T formulas. Lens calculation errors predicted by each of the 4 formulas studied demonstrated a high degree of variability with the SRK II being the least variable and the Hoffer Q being the most variable, particularly among the youngest group of children with the axial lengths less than 19 mm.

CONCLUSIONS

The accuracy of commonly used IOL calculation formulas is generally reasonable but highly variable within the pediatric population, Newer theoretic IOL calculation formulas did not outperform older regression models.

Preventing recurrent opacification of the visual pathway after pediatric cataract surgery

PURPOSE

To determine the rate of secondary opacification of the visual pathway following pediatric cataract surgery in children between the ages of 10 months and 7 years.

METHODS

The medical records of children less than 7 years old who underwent lens aspiration, posterior chamber intraocular lens (IOL) implantation, primary pars plana posterior capsulectomy, and anterior vitrectomy were reviewed retrospectively. Twenty-six eyes in 19 children were included in the study. All procedures were performed by an anterior segment surgeon and a vitreoretinal surgeon. Main outcome measures were the prevalence of re-opacification of the visual pathway and of early postoperative complications.

RESULTS

The visual pathway remained clear in 25 of 26 eyes (96%) after pediatric cataract surgery combined with primary pars plana posterior capsulectomy and anterior vitrectomy. The mean age at surgery was 46 +/- 23 months (+/-SD). Secondary opacification of the visual pathway occurred in one eye (4%), requiring another surgical procedure. At last follow-up (mean, 26 months; range, 6 to 79 months), the visual pathway was clear in all 26 eyes (100%). No cases of clinically significant IOL displacement or of retinal detachment were noted.

CONCLUSIONS

For children undergoing pediatric cataract surgery between the ages of 10 months and 7 years, IOL implantation combined with primary pars plana posterior capsulectomy and anterior vitrectomy is effective in preventing re-opacification of the visual pathway.

Management of the anterior and posterior lens capsules and vitreous in pediatric cataract surgery

PURPOSE

To review and discuss the advantages and disadvantages of various methods of managing anterior and posterior lens capsules and anterior vitreous in pediatric cataract surgery.

METHODS

We reviewed the literature related to pediatric cataract surgery on PubMed and subclassified the subject into subtopics for managing the anterior lens capsule, posterior lens capsule, and anterior vitreous.

RESULTS

After a review of the literature, we summarized the advantages and disadvantages of various approaches related to surgical managements of the anterior lens capsule, posterior lens capsule, and anterior vitreous in pediatric cataract surgery. We discussed recommendations from the literature and commented on our experiences related to the above subtopics.

CONCLUSION

In the surgical management of pediatric cataract, anterior continuous curvilinear capsulorhexis provides the most reliable and tear-resistant capsular opening. Vitrectorhexis and radiofrequency diathermy, on the other hand, are alternative approaches (depending on the surgeon's personal preference). Primary posterior continuous curvilinear capsulorhexis may delay the onset of posterior capsule opacification. Anterior vitrectomy may be necessary to prevent or eliminate the onset of posterior capsule opacification in young children.

Removal of dense posterior capsule opacification after congenital cataract extraction using the transconjunctival sutureless vitrectomy system

We report a case of posterior capsule opacity and anterior hyaloid opacity after congenital cataract extraction that was successfully and easily removed using the transconjunctival sutureless vitrectomy system (TSV 25, Bausch & Lomb Surgical). With the TSV25 system, clear axes were maintained.

Pediatric cataract surgery in Nepal

PURPOSE

To describe the first pediatric cataract surgery case series report from Nepal.

SETTING

Tilganga Eye Center, Kathmandu, Nepal.

METHODS

This study comprised a consecutive series of 112 eyes of 85 children having cataract surgery with intraocular lens (IOL) implantation. General anesthesia of ketamine combined with peribulbar block was used in all patients. Patients' demographics, cataract type and presenting symptoms, surgical intervention, preoperative and postoperative visual acuities, and follow-up clinical examinations were recorded.

RESULTS

Seventy-three eyes (65.2%) of 53 patients had extracapsular cataract extraction with posterior capsulotomy, anterior vitrectomy, and posterior chamber IOL implantation (ECCE+PCAP+AV+PCIOL), and 39 eyes (34.8%) of 32 patients had cataract extraction and IOL implantation with an intact posterior capsule (ECCE+PCIOL). Of all patients, the mean age at surgery was 6.2 years +/- 4.3 (SD). The median age in the ECCE+PCAP+AV+PCIOL group was 4.7 years and in the ECCE+PCIOL group, 11.0 years. The mean follow-up was 5.4 +/- 5.3 months. The most common postoperative complication in the ECCE+PCIOL group was visual axis/posterior capsule opacification, which was seen in 18 eyes (46.2%) compared to 4 eyes (5.5%) in the ECCE+PCAP+AV+PCIOL group. Visual acuity improved with surgery in both groups. The leading cause of poor outcomes was deprivation amblyopia. There were no anesthesia-related complications.

CONCLUSIONS

Implantation of an IOL at the time of cataract extraction under combined systemic ketamine and peribulbar lidocaine anesthesia appeared to be well tolerated and produced significant visual improvement in pediatric patients in Nepal. Primary posterior capsulotomy and AV helped prevent visual axis opacification without a significant increase in complications.

Histology and immunohistochemistry of fibrous posterior capsule opacification in an infant

We report the histological findings in posterior capsule opacification (PCO) in 2 eyes of a 10-month-old infant 8 months after cataract extraction and intraocular lens (IOL) implantation. The PCO in the right eye had a regenerated lenticular structure; in the left eye, it was fibrotic. The PCO in the right eye was soft and aspirated with Simcoe's irrigation/aspiration cannula; in the left eye, it was excised surgically. Paraffin sections of the fibrous PCO tissue from the left eye were examined histologically. Hematoxylin-eosin staining showed extracellular matrix (ECM) accumulation and the presence of elongated fibroblastic cells, presumed to be lens epithelial cells (LECs). Immunohistochemistry revealed the presence of fibrous collagen types and cellular fibronectin. The presumed LECs amid the ECM were positive for vimentin and alpha-smooth muscle actin. Histology of the fibrous PCO tissue from this infant was similar to that in adult patients.

Visual axis opacification after AcrySof intraocular lens implantation in children

PURPOSE

To evaluate visual axis opacification after AcrySof intraocular lens (IOL) (Alcon) implantation in pediatric eyes.

SETTING

Iladevi Cataract and IOL Research Centre, Ahmedabad, India.

METHODS

This prospective study evaluated 103 consecutive eyes of 72 children with congenital cataract. Two groups were formed based on age at surgery: Group 1, younger than 2 years, and Group 2, older than 2 years. All eyes in Group 1 (n = 37) had primary posterior continuous curvilinear capsulorhexis (PCCC) with anterior vitrectomy. In Group 2 (n = 66), management of the posterior capsule was assigned randomly to no PCCC (Group 2A, n = 37) or PCCC (Group 2B, n = 29). The PCCC group was further randomized into 2 subgroups: no vitrectomy (Group 2BN, n = 14) or vitrectomy (Group 2BV, n = 15). The primary outcome measures were visual axis opacification and the resulting need for a secondary procedure. Statistical analysis was performed using SPSS for Windows (version 11.0.1).

RESULTS

The mean age of the patients was 5.2 years +/- 5.0 (SD) (range 0.2 to 16.0 years) and the mean follow-up, 2.3 +/- 0.9 years (range 1.0 to 4.0 years). Overall, 41 eyes (39.8%) developed visual axis opacification and 14 (13.6%) required secondary intervention. In Group 1, 4 eyes (10.8%) developed visual axis opacification and 3 (8.1%) had a secondary pars plana vitrectomy. In Group 2A, 31 eyes (83.8%) developed posterior capsule opacification (PCO) and 10 eyes (27.7%) had secondary intervention. Children 8 years or younger at the time of surgery developed significantly greater PCO than older children (P =.01). Five eyes (37.5%) in Group 2BN had opacification of the anterior vitreous face, 1 of which required a secondary procedure. One eye (6.7%) in Group 2BV had visual axis opacification that did not require a secondary procedure.

CONCLUSIONS

AcrySof IOL implantation with appropriate management of the posterior capsule maintained a clear visual axis in 60.2% of eyes. Of the 39.8% of eyes with visual axis opacification, 13.6% had visually significant opacification and required a secondary procedure.

Opacification of the visual axis after cataract surgery and single acrylic intraocular lens implantation in the first year of life

PURPOSE

To report the incidence and risk factors for secondary surgical intervention to treat visual axis opacification (VAO) after cataract surgery and acrylic intraocular lens (IOL) implantation during the first year of life.

METHODS

A retrospective review of 29 eyes of 20 patients receiving a hydrophobic acrylic (AcrySof; Alcon, Fort Worth, TX) IOL implantation was conducted. All eyes underwent primary posterior capsulectomy and anterior vitrectomy. Statistical analysis was performed using SPSS for Windows (SPSS, Chicago, IL).

RESULTS

Average age at surgery was 4.8 +/- 3.7 months, and average follow-up was 33.4 +/- 16.1 months. Eleven of 29 (37.9%) eyes developed VAO requiring secondary surgical intervention at a median of 4.8 months (95% confidence interval 3.4 to 6.2). Average age at surgery for eyes that subsequently opacified was 3.8 +/- 3.0 months compared with 5.4 +/- 4.0 months for those whose visual axis remained clear (P = 0.26). The relative risk of subsequent VAO surgery was 2.7 for primary surgery performed at or before the first 6 months of life. Opacification was significantly related to eyes with associated ocular anomalies (eg, anterior segment dysgenesis, iris hypoplasia, or persistent fetal vasculature) with a relative risk of 8.6 (P < 0.001). Proliferation of cortex was the most common form of VAO, followed by mixed-type with predominantly fibrous, fibrous alone, or Elschnig pearls. When secondary surgery was required, it occurred primarily during the first 6 months (ie, 9 of 11 patients) after the initial cataract surgery.

CONCLUSIONS

When cataract and IOL surgery was undertaken within the first year of life, a secondary surgical procedure was required in 37.9% of eyes to maintain a clear visual axis. Most secondary surgery for VAO occurred within the first 6 months after surgery. Postoperative opacification was most common in eyes with associated ocular anomalies.

Anterior and posterior capsulorhexis in pediatric cataract surgery with or without trypan blue dye: randomized prospective clinical study

PURPOSE

To evaluate the clinical efficacy of trypan blue 0.1% dye (Blurhex) in creating a complete anterior and posterior capsulorhexis during pediatric cataract surgery.

SETTING

Tertiary eyecare center, Postgraduate Institute of Medical Education and Research, Chandigarh, India.

METHODS

In a prospective randomized study, an anterior (ACCC) and posterior (PCCC) continuous curvilinear capsulorhexis were performed in pediatric patients. In Group 1 (n = 19), the ACCC and PCCC were created without use of trypan blue dye. In Group 2 (n = 23), intracameral trypan blue dye was used to stain the anterior and posterior capsules.

RESULTS

In Group 1, 14 eyes (73.6%) had a complete ACCC and 10 (52.6%) had a complete PCCC. In Group 2, 21 eyes (91.3%) had a complete ACCC and 19 (82.6%) had a complete PCCC.

CONCLUSION

In cases of pediatric cataract, staining the anterior and posterior capsules with trypan blue 0.1% allowed recognition of capsule flaps and facilitated the creation of complete ACCCs and PCCCs.

Anterior vitreous face behavior with AcrySof in pediatric cataract surgery

PURPOSE

To describe anterior vitreous face behavior when AcrySof (Alcon, Fort Worth, TX) intraocular lenses come in contact with the anterior vitreous face after posterior continuous curvilinear capsulorhexis without anterior vitrectomy in pediatric patients undergoing cataract surgery.

METHODS

This study comprised 14 eyes of 12 children whose mean age was 9.6 years (range, 2.3 to 16.0). All eyes underwent primary posterior continuous curvilinear capsulorhexis without anterior vitrectomy and had AcrySof IOLs implanted in the bag. Changes on the anterior vitreous face were documented, and visual acuity was recorded. Statistical analysis was performed using Student group t and Mann Whitney tests.

RESULTS

Mean length of follow-up was 21.1 +/- 7.4 months (range, 15.0 to 36 months). Nine eyes (64.3%) had a clear visual axis, whereas 5 eyes (35.7%) developed anterior vitreous face changes. Of those with anterior vitreous face changes, 60% (3 of 5) eyes showed a fine meshwork-like reticular response termed "anterior vitreous reticular response" (AVR); 20% (1 of 5) eyes showed a scaffold response; and 20% (1 of 5) eyes showed a mixed response at the last follow-up examination. The difference in visual acuity before and after the development of the AVR response was not significant (P =.712). The mean age of patients with eyes having a clear visual axis was 12.1 +/- 2.3 years (median = 11.0; range, 9.1 to 16.0), and the mean age of patients with eyes having anterior vitreous face changes was 5.1 +/- 3.4 years (median = 3.6; range, 2.3 to 11.6) (P =.0098).

CONCLUSION

The results suggest that when the AcrySof intraocular lenses come in contact with the anterior vitreous face, they produce the AVR response during the early postoperative period in younger eyes. This does not seem to have any significant impact on visual acuity.

Results and complications of hydrophobic acrylic vs PMMA posterior chamber lenses in children under 17 years of age

PURPOSE

To compare results and complications of implantation of hydrophobic acrylic foldable intraocular lenses in children with those of polymethylmethacrylate (PMMA) intraocular lenses.

METHODS

In a retrospective study, we analyzed results of cataract surgery with posterior chamber lens implantation in 30 eyes of 30 patients aged 1-16 years. In 10 eyes, acrylic (Alcon AcrySof) intraocular lenses, and in 20 eyes, single-piece PMMA posterior chamber lenses were implanted. Indications for cataract surgery (blunt or penetrating trauma, zonular cataract, cataracta polaris posterior, posterior lenticonus) and mean age at implantation were comparable in the two groups. Mean patient age at surgery was 8.6+/-4.6 years (range 3-16 years) for the acrylic vs 6.3+/-4.3 years (range 1-16 years) for the PMMA group. Mean follow-up was 1.0+/-0.7 years (range 0.1-2.2 years) in the acrylic group and 1.8+/-1.5 years (range 0.1-5.7 years) in the PMMA group. Primary anterior vitrectomy was performed in 7 eyes in the PMMA group and in 3 eyes in the acrylic group. In addition, one additional posterior capsulorhexis without anterior vitrectomy was performed in each group. Primary outcome measure was the occurrence of postoperative "complications" (fibrin, synechiae, posterior capsular opacification). For statistical evaluation, the Fisher exact test was used.

RESULTS

When evaluating all complications together (at least one complication vs no complication), there were significantly less complications in the acrylic group (2 of 10 vs 15 of 20; p=0.007. For early complications (postoperative fibrin, synechiae) the difference was also significant (1 of 10 in the acrylic vs 11 of 20 in the PMMA group; p=0.02). The rate of posterior capsular opacification necessitating YAG capsulotomy was lower in the acrylic group (1 of 10 eyes) than in the PMMA group (7 of 20 eyes), but the difference did not reach statistical significance ( p=0.67). The postoperative time point of YAG capsulotomy was 21 months in the acrylic group and 19+/-10 months (range 6-33 months) in the PMMA group. IOL dislocation was not observed in any of the patients. Postoperative visual acuity was comparable in the two groups: 0.57+/-0.35 (0.03-1.0) in the acrylic vs 0.39+/-0.34 (0.001-0.9) in the PMMA group ( p=0.83).

CONCLUSIONS

Implantation of hydrophobic acrylic intraocular lenses in the capsular bag in children may be associated with less postoperative complications compared with implantation of PMMA lenses. This appears also to be true in children under age 6 years. The visual results seem comparable and correspond mainly to the underlying ocular pathology.

Morphological and functional results of AcrySof intraocular lens implantation in children: prospective randomized study of age-related surgical management

PURPOSE

To evaluate the prevalence and severity of posterior capsule opacification (PCO) in pediatric eyes with a foldable acrylic AcrySof (Alcon) intraocular lens (IOL) and age-related surgical methods.

SETTING

Department of Ophthalmology, University of Vienna, Medical School, Vienna, Austria.

METHODS

This prospective randomized study comprised 50 eyes of 34 children aged between 2 and 16 years. Eyes of children between 2 and 5.9 years were consecutively randomized to Group 1a (primary posterior capsulotomy and anterior vitrectomy) or Group 1b (optic capture in addition). Eyes of children between 6 and 16 years were consecutively randomized to Group 2a (primary posterior capsulotomy without anterior vitrectomy), Group 2b (optic capture in addition), or Group 2c (in-the-bag IOL implantation without opening the posterior capsule). Main outcome parameters were the incidence and severity of PCO formation, early postoperative complications, pigmented cell deposits on the IOL surface, and cataract morphology.

RESULTS

The visual axis was clear at the last follow-up in all eyes in Groups 1a, 1b, 2a, and 2b except in 1 eye in Group 1a. Sixty-percent of eyes in Group 2c had PCO. The incidence of early postoperative complications was significantly higher in eyes that developed PCO than in those that maintained a clear visual axis. There was no evidence that cataract morphology influenced PCO rates.

CONCLUSIONS

The AcrySof IOL was well tolerated in pediatric eyes. Optic capture was not necessary to ensure a clear visual axis. Primary posterior capsulotomy should be performed in preschool and uncooperative children and in eyes expected to have relatively high postoperative inflammation. Implanting the AcrySof in the bag and leaving the posterior capsule intact is acceptable for school children and juveniles with isolated developmental cataract.

Paediatric cataract blindness in the developing world: surgical techniques and intraocular lenses in the new millennium

Paediatric cataract blindness presents an enormous problem to developing countries in terms of human morbidity, economic loss, and social burden. Managing cataracts in children remains a challenge: treatment is often difficult, tedious, and requires a dedicated team effort. To assure the best long term outcome for cataract blind children, appropriate paediatric surgical techniques need to be defined and adopted by ophthalmic surgeons of developing countries. The high cost of operative equipment and the uneven world distribution of ophthalmologists, paediatricians, and anaesthetists create unique challenges. This review focuses on issues related to paediatric cataract management that are appropriate and suitable for ophthalmic surgeons in the developing world. Practical guidelines and recommendations have also been provided for ophthalmic surgeons and health planners dealing with childhood cataract management in the developing world.

Posterior capsule staining and posterior continuous curvilinear capsulorhexis in congenital cataract

We report 2 cases of indocyanine green (ICG) staining used for posterior continuous curvilinear capsulorhexis (PCCC) in congenital cataract combined with anterior vitrectomy. In the first case, because of corneal opacity, the visibility of the posterior capsule was poor without staining. After the extraction of the cataract, a PCCC was performed after ICG staining of the posterior capsule. In the second case, after cataract removal, ICG staining was used to better visualize the posterior capsule. In both cases, the PCCC was successfully completed because of better visualization of the stained posterior capsule flap against the transparent anterior hyaloid face of the vitreous. Clear visual axes have been maintained.

Pediatric cataract surgery with or without anterior vitrectomy

PURPOSE

To evaluate after-cataract formation in children having cataract surgery with or without dry anterior vitrectomy and possible differences according to age.

SETTING

St. Erik's Eye Hospital, Stockholm, Sweden.

METHODS

This retrospective study comprised 85 eyes of 85 patients from 0 to 15 years old who had cataract surgery with or without anterior vitrectomy after the implantation of an intraocular lens (IOL). All patients had primary posterior capsulorhexis but no optic capture. Thirty-five patients received a heparin-surface-modified poly(methyl methacrylate) IOL (809C, Pharmacia & Upjohn) and 50 patients, a foldable acrylic IOL (AcrySof(R), Alcon). The records from follow-up visits at the patients' home clinics were used for analysis.

RESULTS

Significantly fewer children were operated on for after-cataract if they had cataract surgery with anterior vitrectomy (P <.05). This applied to both IOL types. In the children older than 7 years in the AcrySof IOL group, there was no difference in the frequency of after-cataract surgery (P >.05).

CONCLUSION

In children younger than 7 years with an AcrySof IOL, the rate of after-cataract surgery was significantly less in those who had an anterior vitrectomy at the time of cataract surgery (P <.05). In younger children, it is advantageous to perform cataract surgery with anterior vitrectomy to help prevent after-cataract formation; however, vitrectomy is not necessary in older children.