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

Influence of posterior capsule abnormalities in pediatric cataract surgery

PURPOSE

To report how to manage posterior capsule abnormalities (PCAs) in pediatric cataracts and evaluate the influence of PCAs during intraocular lens (IOL) optic implantation in Berger space surgeries.

SETTING

Qingdao Eye Hospital of Shandong First Medical University, Qingdao, China.

DESIGN

Retrospective case series study.

METHODS

Pediatric patients with PCAs who underwent cataract surgery were evaluated. A video-based analysis of the surgical interventions included the type of crystalline lens opacification, types and management of PCAs, complications during primary posterior continuous curvilinear capsulorhexis (PCCC), need for anterior vitrectomy (AV), and feasibility of IOL optic capture.

RESULTS

There were 227 pediatric cataract surgeries performed during the study period, and 76 eyes of 66 children with PCAs were evaluated (33.5%, 76/227). Unilateral cataract with PCAs were found in 50 eyes (22.0%, 50/227) and bilateral were found in 26 eyes (11.5%, 26/227). The PCAs were posterior capsule plaque (19.8%, 45/227), posterior capsule defect (6.2%, 14/227), posterior lenticonus (3.1%, 7/227), and persistent fetal vasculature (4.4%, 10/227). In the PCA cases, primary PCCC was successful in 44.7% of the cases (34/76). An unplanned AV during the surgeries was performed in 47.4% (36) of the 76 eyes. IOL optic implantation in Berger space was achieved in 63.2% of the eyes (48/76).

CONCLUSIONS

PCAs are often encountered during pediatric cataract surgeries, especially in unilateral cases. The presence of PCAs may complicate a primary PCCC procedure, resulting in an unplanned AV in some cases. IOL optic implantation in Berger space can also be performed fortunately with well-designed and skilled operation.

Optic Capture Without Anterior Vitrectomy in Pediatric Cataract Surgery

PURPOSE

To compare outcomes of 2 surgical techniques in children undergoing cataract surgery with intraocular lens (IOL) implantation: optic capture of IOL without anterior vitrectomy (AV) or in-the-bag IOL with AV.

DESIGN

Prospective randomized controlled trial.

METHODS

Patients were randomized to 2 groups: optic capture without AV (group 1) or in-the-bag implantation with AV (group 2). The following variables were compared: visual axis opacification (VAO), inflammatory deposits on IOL surface, anteroposterior synechia, IOL tilt and decentration, lenticular astigmatism, refractive prediction error, and posterior segment complications.

RESULTS

Fifty-one eyes of 37 children were investigated with a mean follow-up of 20.1±8.5 months. Group 1 and group 2 had mean ages of 59.2±32.6 and 46.5±21.9 months, respectively (P = .104). Three eyes in group 1 and 2 eyes in group 2 developed VAO (P = .656). Two eyes in group 1 and 5 eyes in group 2 developed anteroposterior synechia (P = .291). Six eyes in group 1 and 11 eyes in group 2 had inflammatory deposits on the IOL (P = .233). Both groups had similar IOL tilt and decentralization (for all meridians, P > .05). The absolute refractive prediction error was 0.55±0.34 diopter (D) and 0.53±0.3 D, respectively (P = .294). Each group had 1 eye with intraocular hypertension (P = .932).

CONCLUSION

The optic capture method was similar to the conventional technique in the quantitative evaluation of comprehensive data such as visual axis opacification, inflammatory sequelae, refractive outcomes, and IOL stability. The optic capture technique is an appealing option for pediatric cataract surgery because it eliminates the requirement for vitrectomy.

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.

Posterior continuous curvilinear capsulorhexis with anterior vitrectomy versus optic capture buttonholing without anterior vitrectomy in pediatric cataract surgery

PURPOSE

To investigate long-term complications following pediatric cataract surgery with implantation of a heparin-coated PMMA IOL and posterior continuous curvilinear capsulorhexis (PCCC) with anterior vitrectomy versus PCCC without anterior vitrectomy with optic capture buttonholing.

SETTING

Department of Ophthalmology, Goethe University, Frankfurt, Germany.

DESIGN

Prospective randomized clinical trial.

METHODS

Eyes with unilateral or bilateral congenital cataract without further pathologies or former surgeries were randomly assigned in two groups: cataract removal, IOL implantation and PCCC with anterior vitrectomy (AV; group A) or posterior optic buttonholing without anterior vitrectomy (optic capture, OC; group B). The main outcome measures were posterior capsule opacification (PCO), complication rates and refractive development.

RESULTS

58 eyes of 41 pediatric cataract surgery patients were included. The mean age at time of operation was 66.05 months (± 29.39). In group A (n=26), two eyes required treatment for posterior capsule opacification, whereas the optic axis remained clear in all eyes in group B (n=30), which was not statistically significant. Additionally, group B had a slightly lower rate of complications. Mean SE after a mean postoperative follow-up of 6.5 years was -0.11 ± 2.51 D (-5.0 to +4.0 D) in group A and -0.08 ± 2.14 D (-5.0 to +4.0 D) in group B, which was not statistically significant either.

CONCLUSION

Optic capture with a heparin-coated PMMA IOL proved to be a safe technique in the prevention of secondary cataract formation without a higher rate of complications and the necessity of vitrectomy.

Outcome of cataract surgery in children affected by malignancies other than retinoblastoma with eye-lens radiation exposure

PURPOSE

To describe, retrospectively, the visual outcome, feasibility, and safety of cataract surgery in a pediatric population affected by iatrogenic cataract, secondary to systemic oncological treatment for malignancies other than retinoblastoma.

METHODS

Young patients, affected by radiation-induced cataract, who were referred to the San Paolo Ophthalmic Center in Padova between 2010 and 2017, were included in the study. All patients had previously received radiotherapy and/or chemotherapy treatment for malignancies, between 2004 and 2013. All medical records of infants who underwent cataract surgery were accurately reviewed.

RESULTS

Eighteen eyes out of 11 patients included in the study underwent cataract surgery. The mean age at surgery was 9.7 ± 3.6 years. The interval between tumor diagnosis and cataract development was around 3 years. Mean follow-up after surgery was 15.4 ± 6.3 months. All eyes underwent posterior chamber intraocular lens implantation, posterior capsulotomy, and anterior vitrectomy in one time surgery. No intraoperative complications were shown. Post-operatively, only one eye received laser capsulotomy due to posterior capsule opacification. At the end of follow up, best-corrected visual acuity was 20/20 (LogMAR 0) in all eyes and significantly improved (p < 0.01) compared to baseline.

CONCLUSIONS

Iatrogenic-cataract surgery in pediatric oncological patients is a safe and effective way to improve visual acuity. Posterior capsulotomy and anterior vitrectomy at the time of surgery reduce the rate of posterior lens opacification and guarantee an excellent visual acuity in these patients.

[Frequency and type of macular edema after cataract surgery in patients with glaucoma]

Cataract is one of the common causes of reversible vision loss in people older than 50 years. Currently, the only way to treat it effectively is phacoemulsification with simultaneous implantation of an intraocular lens - a method that minimizes the amount of surgical trauma and the number of intra- and postoperative complications. Nevertheless, the problem of prevention and timely diagnosis of pathological changes in the retina, which may develop after extraction of cataracts, and in particular - macular edema, remains relevant. This problem becomes especially important when it comes to patients with concomitant cataract and glaucoma who use local antihypertensive drugs - in particular, prostaglandin analogues - for a long time. Having common properties with inflammatory mediators, in some cases they can cause vasodilation, increase vascular permeability and contribute to the development of exudative processes. Drugs of this group can cause impairment of the hematophthalmic and hematoretinal barriers provoking the development of cystoid macular edema, including in the early postoperative period after cataract extraction. As described by S. Irvine in 1953, macular edema is related to late postoperative complications and remains one of the main causes of visual impairment after lens removal. The review provides information about some studies concerning the effect of prostaglandin derivatives on the postoperative period after phacoemulsification. At this time, there is no consensus on this matter.

Intraocular lens optic capture in pediatric cataract surgery

Posterior capsule opacification (PCO) remains the most common complication of pediatric cataract surgery despite continuous efforts to reduce its incidence. For this reason, pediatric cataract surgeons have expended considerable effort into preventing and mitigating PCO. The intraocular lens (IOL) optic capture technique has been used for the prevention of PCO after pediatric cataract surgery for more than 20y, but there is still no professional consensus. However, recent research has shown encouraging results. The IOL optic capture technique can be performed without anterior vitrectomy to prevent PCO, even in younger children. The type and characteristics of IOLs used for optic capture technique, the location of IOL and the complications of IOL optic capture in children are here reviewed.

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.

Surgical management of severe complications arising from uveitis in juvenile idiopathic arthritis

PURPOSE

Evaluate outcomes from severe ocular complications of juvenile idiopathic arthritis following surgery.

METHODS

Eleven eyes of 7 patients underwent complete vitrectomy and peeling of the inner limiting membrane. Inclusion criteria were: anteroposterior segment involvement, hypotony, inflammation control of less than 3 months, compliance issues, rapidly progressive disease. Phacoemulsification was allowed if the patient was >6 years old and inflammation free >3 months. The alternative was a complete lensectomy.

RESULTS

Visual acuity improved from a logMAR of 1.48 to 0.37 (p < 0.0001), and 0.20 at 6 and 12 months (p < 0.0001). No flare-up was observed within the first 6 months. Five eyes developed inflammation between 7 and 19 months. Glaucoma developed in 5 eyes at a median of 16 months. No patient developed cystoid macular edema.

CONCLUSION

Extensive pars plana vitrectomy and cataract extraction can lead to significant improvement in visual acuity. Patients continue to require long-term immunosuppression and adequate follow-up.

Macular structural characteristics in children with congenital and developmental cataracts

PURPOSE

To investigate macular structural characteristics in children with congenital or developmental cataracts.

METHODS

Children 5-16 years of age with a history of surgery for congenital or acquired cataract were enrolled. Eligible patients had visual acuity of 20/400 or better and ≥37 weeks gestational age at birth. Patients were divided into two groups: unilateral (n = 22) and bilateral (n = 19). Fourier domain optical coherence tomography (FD-OCT) was used to image the retinal structure. Retinal volume scans centered on the fovea were obtained. Using the instrument's segmentation software, central subfield thickness (CST) and the thickness of the inner and outer retinal layer regions were measured.

RESULTS

In the unilateral group, 1 child with persistent fetal vasculature had unidentifiable retinal structure and was excluded. Most unilateral eyes (20/21) had a CST within the normal range. However, the CST, superior, nasal, inferior, and temporal sectors were all significantly thicker in the cataractous eye compared to the noncataractous eye (all P < 0.01 [paired t test]). The interocular difference for CST was not associated with age at surgery or interocular difference for visual acuity. In the bilateral group, although 34 of 38 eyes were within the normal range, the average CST of this group was significantly thicker than the noncataractous eye in the unilateral group.

CONCLUSIONS

Following cataract extraction during infancy or childhood, most cataractous eyes had normal macular structure. Cataractous eyes of both unilaterally and bilaterally affected children have thicker CST values compared to the noncataractous eye.

Advances in the management of the surgical complications for congenital cataract

The greatest concern in children with cataracts is irreversible visual loss. The timing of congenital cataract surgery is critical for the visual rehabilitation. Cataract surgery in children remains complex and challenging. The incidence of complications during or after operation is higher in children than adults. Some complications could be avoided by meticulous attention to surgical technique and postoperative care, and others were caused by more exuberant inflammatory response associated with surgery on an immature eye or the intrinsic eyes abnormalities. Utilizing of advanced techniques and timely applying topical corticosteroids and cycloplegic agents can reduce the occurrence of visual axis opacification. Operation on children with strabismus or nystagmus, and applying occlusion therapy on amblyopic eyes can balance the visual inputs to the two eyes. Diagnosis of glaucoma following congenital cataract surgery requires lifelong surveillance and continuous assessment of the problem. So cataract surgeries in children are not the end of journey, but one step on the long road to visual rehabilitation. This paper describes recent evidence from the literature regarding the advance of management after congenital cataract surgery.

Update of intraocular lens implantation in children

Cataract is a common problem that affects the vision in children and a major cause of amblyopia in children. However, the management of childhood cataract is tenuous and requires special considerations especially with regard to intraocular lens (IOL) implantation. Age at which an IOL can be implanted is a controversial issue. Implanting an IOL in very young children carries the risk of severe postoperative inflammation and posterior capsule opacification that may need other surgeries and may affect the vision permanently. Accuracy of the calculated IOL power is affected by the short eyes and the steep keratometric values at this age. Furthermore, choosing an appropriate IOL power is not a straight forward decision as future growth of the eye affects the axial length and keratometry readings which may result in an unexpected refractive error as children age. The aim of this review is to cover these issues regarding IOL implantation in children; indications, timing of implantation, types of IOLs, site of implantation and the power calculations.

Macular thickness changes after phacoemulsification combined with primary posterior curvilinear capsulorhexis

PURPOSE

To evaluate the changes in central macular thickness measured with optical coherence tomography (OCT) after cataract surgery combined with primary posterior continuous curvilinear capsulorhexis (PCCC).

METHODS

Forty-six eyes of 40 consecutive patients who had uneventful phacoemulsification and in-the-bag intraocular lens implantation surgery with primary PCCC, taking place between August 2005 and January 2006 in Beyoglu Eye Training and Research Hospital, were enrolled. Patients with a history of previous ocular surgery, eye trauma, uveitis, or glaucoma, or any systemic disease such as diabetes mellitus, were excluded from the study. None of the cases had macular pathology before surgery. OCT was performed in all patients preoperatively and postoperatively on the first day, first week, and first, third, and sixth months.

RESULTS

Significant quantitative changes from the preoperative examination were observed in the postoperative first week, first month, and third month (p<0.05). The difference between the mean preoperative and postoperative sixth month central macular thickness was not statistically significant (p=0.20). The greatest change in mean macular thickness was noted in the first month visit. No patient developed cystoid macular edema.

CONCLUSIONS

Because primary PCCC does not have an adverse effect on macular integrity, this procedure may be preferred especially in patients with a high risk of posterior capsular opacification.

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.

Management of paediatric traumatic cataract by epilenticular intraocular lens implantation: long-term visual results and postoperative complications

PURPOSE

This study was carried out to evaluate the postoperative visual results and complications following epilenticular intraocular lens implantation in paediatric traumatic cataracts.

MATERIALS AND METHODS

A total of 30 patients undergoing epilenticular intraocular lens implantation for traumatic pediatric cataract were evaluated prospectively for visual results and complications. After-cataract formation was the prime area of interest. Follow-up of patients ranged from 2 to 8 years (mean 5 years). In all, 90% of eyes had a visual acuity of 6/60 or worse at the time of presentation.

RESULTS

In total, 80% of our patients achieved a visual acuity of 6/12 or better postoperatively after a mean follow-up of 5 years. None of our patients had after-cataract formation and the visual axis remained clear until the last follow-up in all the patients.

CONCLUSION

Epilenticular intraocular lens implantation in paediatric traumatic cataracts is associated with favourable anatomic and visual results.

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.

Visual loss in uveitis of childhood

AIMS

To investigate the manifestations and severity of uveitis in children and to identify the risk and specific causes of blindness in this population.

METHODS

Retrospective study of data of 123 consecutive patients examined with active uveitis and the onset of ocular disease before the age of 16 years. Numerous variables were assessed including age and sex distribution, laboratory data, the presence of systemic diseases, onset and course of ocular inflammation, clinical features and complications, therapeutic strategies and their outcomes, final visual acuity, and characteristics associated with poor visual outcome.

RESULTS

Systemic disease was observed in 36/123 patients (29%), with juvenile idiopathic arthritis being the most frequent (25/123, 20%). Toxoplasma retinochoroiditis was diagnosed in 12/23 patients with posterior uveitis (52%; 10% of all with uveitis). Severe intraocular inflammation required systemic drugs in 57 (46%) patients. Ocular complications were observed in 93 patients (76%), of which the most common was cataract (43/123, 35%). Intraocular surgery was required in 35 patients (28%; in total 75 procedures). Three patients (2%) became legally blind and an additional 20/121 (17%) had one legally blind eye caused by uveitis. The most frequent causes of blindness were chorioretinal scars in the macular area and glaucoma in contrast with cystoid macular oedema (CMO) in adults.

CONCLUSIONS

Uveitis in childhood is a potentially blinding disease, in the majority of patients characterised by a chronic course and a high complication rate.

Management of pediatric cataract and lens opacities

The diagnosis and surgical management of cataracts in children has benefitted from improvements in microsurgical techniques. Intraocular lens placement has become standard in children 2 years of age and older. Initial experience with intraocular lens implantation in infants found a high rate of surgical complications. However, refinements in surgical techniques may lesson these complications. Posterior capsule opacification is a frequent postoperative problem after pediatric cataract surgery. Posterior continuous curvilinear capsulorhexis with anterior vitrectomy is an effective means to prevent opacification of the visual axis in children.