Radiofrequency diathermy capsulorhexis of the anterior and posterior capsules in pediatric cataract surgery: preliminary results

Techniques of anterior capsulotomy in cataract surgery

Optimal outcomes of a cataract surgery largely depend on the successful performance of an anterior capsulotomy. It is one of the most important steps of modern cataract surgery which reduces the risk of capsular tears and ensures postoperative stable intraocular lens (IOL). Anterior capsulotomy is considered ideal if it is round, continuous, well-centered, and overlaps the implanted IOL around its circumference. If any of these features is missing, it can be a cause of impedance for desired surgical and visual outcomes. Manual can opener and manual capsulorhexis are the routine standard techniques employed for manual extracapsular cataract extraction and phacoemulsification, respectively. Recent increasing use of femtosecond laser cataract surgery has allowed cataract surgeons to obviate inherent inaccuracies of manual anterior capsulotomy techniques. There is an ongoing quest to find an ideal, risk free, and surgeon-friendly technique of anterior capsulotomy that can be employed for surgery in all types of cataracts.

Updates on managements of pediatric cataract

Purpose

A comprehensive review in congenital cataract management can guide general ophthalmologists in managing such a difficult situation which remains a significant cause of preventable childhood blindness. This review will focus on surgical management, postoperative complications, and intraocular lens (IOL)-related controversies.

Methods

Electrical records of PubMed, Medline, Google Scholar, and Web of Science from January 1980 to August 2017 were explored using a combination of keywords: "Congenital", "Pediatric", "Childhood", "Cataract", "Lens opacity", "Management", "Surgery", "Complication", "Visual rehabilitation”, and "Lensectomy". A total number of 109 articles were selected for the review process.

Results

This review article suggests that lens opacity obscuring the red reflex in preverbal children and visual acuity of less than 20/40 is an absolute indication for lens aspiration. For significant lens opacity that leads to a considerable risk of amblyopia, cataract surgery is recommended at 6 weeks of age for unilateral cataract and between 6 and 8 weeks of age for bilateral cases. The recommended approach in operation is lens aspiration via vitrector and posterior capsulotomy and anterior vitrectomy in children younger than six years, and IOL implantation could be considered in patients older than one year. Most articles suggested hydrophobic foldable acrylic posterior chamber intraocular lens (PCIOL) for pediatrics because of lower postoperative inflammation. Regarding the continuous ocular growth and biometric changes in pediatric patients, under correction of IOL power based on the child's age is an acceptable approach. Considering the effects of early and late postoperative complications on the visual outcome, timely detection, and management are of a pivotal importance. In the end, the main parts of post-operation visual rehabilitation are a refractive correction, treatment of concomitant amblyopia, and bifocal correction for children in school age.

Conclusions

The management of congenital cataracts stands to challenge for most surgeons because of visual development and ocular growth. Children undergoing cataract surgery must be followed lifelong for proper management of early and late postoperative complications. IOL implantation for infants less than 1 year is not recommended, and IOL insertion for children older than 2 years with sufficient capsular support is advised.

Capsulorhexis: Pearls and pitfalls

A critical step in phacoemulsification (as well as extracapsular cataract extraction) is making a window in anterior capsule wall (i.e. anterior capsulotomy). Continuous Curvilinear Capsulorhexis (CCC) has become recognized as the standard method of anterior capsulectomy. Techniques employed for CCC have undergone sustained evolution. The present review evaluates elementary principles of CCC. Management of CCC in the presence of small pupil and pseudoexfoliation syndrome is discussed. Main differences of pediatric CCC from its adult-style counterpart and finally several techniques of rescue of an extending capsulorhexis are also reviewed.

In-the-bag intraocular lens placement via secondary capsulorhexis with radiofrequency diathermy in pediatric aphakic eyes

Pediatric ophthalmologists increasingly recognize that the ideal site for intraocular lens (IOL) implantation is in the bag for aphakic eyes, but it is always very difficult via conventional technique. We conducted a prospective case series study to investigate the success rate and clinical outcomes of capsular bag reestablishment and in-the-bag IOL implantation via secondary capsulorhexis with radiofrequency diathermy (RFD) in pediatric aphakic eyes, in which twenty-two consecutive aphakic pediatric patients (43 aphakic eyes) enrolled in the Childhood Cataract Program of the Chinese Ministry of Health were included. The included children underwent either our novel technique for secondary IOL implantation (with RFD) or the conventional technique (with a bent needle or forceps), depending on the type of preoperative proliferative capsular bag present. In total, secondary capsulorhexis with RFD was successfully applied in 32 eyes (32/43, 74.4%, age 5.6±2.3 years), of which capsular bag reestablishment and in-the-bag IOL implantation were both achieved in 30 eyes (30/43, 70.0%), but in the remaining 2 eyes (2/32, 6.2%) the IOLs were implanted in the sulcus with a capsular bag that was too small. Secondary capsulorhexis with conventional technique was applied in the other 11 eyes (11/43, 25.6%, age 6.9±2.3 years), of which capsular bag reestablishment and in-the-bag IOL implantation were both achieved only in 3 eyes(3/43, 7.0%), and the IOLs were implanted in the sulcus in the remaining 8 eyes. A doughnut-like proliferative capsular bag with an extensive Soemmering ring (32/43, 74.4%) was the main success factor for secondary capsulorhexis with RFD, and a sufficient capsular bag size (33/43, 76.7%) was an additional factor in successful in-the-bag IOL implantation. In conclusion, RFD secondary capsulorhexis technique has 70% success rate in the capsular bag reestablishment and in-the-bag IOL implantation in pediatric aphakic eyes, particularly effective in cases with a doughnut-like, extensively proliferative Soemmering ring.

Subtle signs of an intact anterior vitreous face during pediatric cataract surgery

We describe the subtle signs of the anterior vitreous face as a bulging structure, a homogenous staining pattern of 3 buttonholes, and a lamellar or fibrillar pattern intact. This should help surgeons correctly recognize the intact anterior vitreous face.

Vitrectorhexis versus forceps capsulorhexis for anterior and posterior capsulotomy in congenital cataract surgery

PURPOSE

To compare the results of anterior and posterior continuous curvilinear capsulorhexis created using forceps with those created using vitrector in eyes suffering from congenital cataract.

METHODS

Twenty-eight eyes with congenital cataract were included in the study. The anterior and posterior continuous curvilinear capsulorhexes were created using microforceps in 17 eyes or through a vitrector in 11 eyes.

RESULTS

Corneal edema (P = .56) and anterior chamber flare (P = 1.0) were comparable in both groups. In addition, the time for optical axis clarity was also similar between the groups (P = .98).

CONCLUSION

The current results suggest that the use of both techniques appears to be equally safe and effective for the achievement of anterior and posterior capsulorhexis.

Subtle signs of anterior vitreous face disturbance during posterior capsulorhexis in pediatric cataract surgery

In 4 patients with congenital cataract, subtle signs of anterior vitreous face (AVF) disturbance were documented during posterior continuous curvilinear capsulorhexis. The signs were vitreous strands in the anterior chamber, vitreous strands attached to the capsule flap, and distortion of the anterior and posterior capsulorhexis margins; the latter is considered a pathognomonic sign of AVF disturbance. As a result of the early recognition, modifications to the cataract surgery technique were made.

Updates on the Surgical Management of Paediatric Cataract with Primary Intraocular Lens Implantation

With the advent of modern surgical techniques, paediatric cataract has become much more manageable. Intraocular lens (IOL) implantation is the standard of care for patients over the age of 2 years. The use of IOL in young infants is still controversial. In addition, there are still unresolved issues, such as the minimum age at which IOL can be safely implanted, IOL power selection and IOL power calculation. The current trends in the management of the above challenges are discussed. Although numerous reports on the prevention and management of posterior capsule opacification have been published, there are ongoing intensive debates and research. Long-term postoperative complications like glaucoma and rhegmatogenous retinal detachment are problems that cannot be overemphasised and these issues are also reviewed. Key words: Congenital cataract, Intraocular lens, Posterior capsule opacification

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.

Extensibility and scanning electron microscopy evaluation of 5 pediatric anterior capsulotomy techniques in a porcine model

PURPOSE

To compare the extensibility and scanning electron microscopy (SEM) of 5 currently used pediatric anterior capsulotomy techniques: vitrectorhexis, manual continuous curvilinear capsulorhexis (CCC), can-opener, radio frequency diathermy, and plasma blade in a porcine model.

SETTING

Storm Eye Institute, Medical University of South Carolina, Charleston, South Carolina, USA.

METHODS

Extensibility was determined by stretching each capsulotomy until it ruptured and measuring it by calculating the mean stretch-to-rupture circumference of each capsulotomy (20 eyes per technique) as a percentage of its baseline circumference. Edge characteristics were evaluated using SEM.

RESULTS

The mean extensibility of each technique tested (vitrectorhexis 161%, CCC 185%, can opener 149%, radio frequency 145%, plasma blade 170%) was significantly different (P<.001, 1-way analysis of variance). The SEM examination found that the vitrectorhexis had a scalloped edge with the whole edge rolled over, presenting a smooth surface toward the inside of the capsulotomy; the manual CCC produced the smoothest edge, with no irregularities noted; the can-opener edge was irregular, showing each puncture of the needle had created a small arc, with occasional regions of the edge rolled over in a "hit-and-miss" fashion; the radio-frequency diathermy capsulotomy edge was ragged, rough, and irregular; and the plasma blade capsulotomy edge was rougher than the manual CCC, but there were fewer irregularities than the radio-frequency diathermy edge had.

CONCLUSIONS

The manual CCC technique produced the most extensible porcine capsulotomy, followed by the plasma blade, vitrectorhexis, can-opener, and radio-frequency techniques, in a porcine model. The manual CCC technique also produced the smoothest anterior capsulotomy edge according SEM evaluation.

Update on the surgical management of pediatric cataracts

The treatment of pediatric cataracts is rapidly evolving, and the visual prognosis for infants and children with cataracts is improving, due in part to earlier surgery, increased frequency of intraocular lens (IOL) implantation, more effective amblyopia therapy following surgery, and better forms of optical correction. A surgeon treating a child with a cataract is faced with An assortment of therapeutic dilemmas such as whether an IOL should be implanted, whether foldable lenses are appropriate, and whether the posterior capsule should be opened during surgery. Although the surgery can be technically difficult in small and unforgiving eyes, it is often the easy part as treatment decisions and results have lifelong implications. The visual system, which is immature at birth, has a latent period of approximately 6 weeks before it becomes sensitive to deprivation, and binocular vision first appears at approximately 3 months of age. It is therefore imperative that infants with visually significant congenital cataracts receive prompt treatment during the sensitive periods to decrease the risk of developing amblyopia or binocular abnormalities. An ideal time for early surgical intervention resulting in few complications and maximal visual outcome has not been identified with certainty. Perhaps the greatest overall change in the approach to the surgical treatment of pediatric cataracts has been the adaptation of techniques used in adult cataract surgery. This article focuses on the methods currently used in the management 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.

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.

Enhanced visualization of capsulorhexis with indocyanine green staining in pediatric white cataracts

PURPOSE

To evaluate the enhancement of the visualization of the anterior lens capsule with indocyanine green (ICG) in pediatric dense, mature cataracts.

PATIENTS AND METHODS

Six children (10 eyes) 4 to 9 years old with complete, white cataracts underwent ICG-enhanced cataract surgery.

RESULTS

All of the eyes showed a complete continuous curvilinear capsulorhexis and a well-centered intracapsular implant. No surgical or postoperative complications were encountered.

CONCLUSION

Staining the anterior capsule with ICG is an excellent way to facilitate performance of an anterior capsulorhexis in pediatric white cataracts.

Clinical outcomes of pars plana capsulotomy with anterior vitrectomy in pediatric cataract surgery

PURPOSE

The management of the posterior capsule in pediatric cataract surgery remains challenging. The purpose of our study was to evaluate the role and clinical outcomes of primary pars plana capsulotomy and pars plana anterior vitrectomy during pediatric cataract surgery with intraocular lens (IOL) implantation.

METHODS

Consecutive cases of pars plana capsulotomy and anterior vitrectomy during pediatric cataract surgery were retrospectively reviewed. The surgical technique was the same in all patients and involved pars plana capsulotomy with anterior vitrectomy after the IOL was implanted in the capsular bag.

RESULTS

Seventy-six pediatric cataract cases in 61 patients performed from 1994 through 1999 used the pars plana posterior capsulotomy technique and were included in this analysis. A posterior chamber IOL was implanted in all cases. There were no intraoperative complications associated with the surgery. Median age at the time of surgery was 21 months. All patients had at least 1 year of follow-up and mean follow-up was 29.4 months. Among patients old enough to read Snellen's letters (53 eyes), final best-corrected visual acuity was 20/40 or better in 32 eyes (60%) and 20/50 to 20/200 in 21 eyes (40%). Poor final visual acuity was associated with deprivation amblyopia or optic nerve dysplasia or hypoplasia. There were no postoperative retinal complications or cases of IOL dislocation during the follow-up period. Seven eyes (9.2%) of five patients with a median age of 2.5 months developed reopacification of the visual axis at a mean of 4.1 months postoperatively. This event occurred in 6 of 28 eyes with an age of 6 months or less (21.4%), versus only 1 of 48 eyes with an age greater than 6 months (2.0%) (P =.006, Fisher exact test). The visual axis was restored by pars plana membranectomy in 6 eyes and 1 eye of one patient underwent neodymium:YAG laser membrane discission.

CONCLUSIONS

Pars plana capsulotomy with pars plana anterior vitrectomy is a safe, effective method of managing the posterior capsule in pediatric cataract surgery with IOL implantation. Visual axis reopacification is associated with a very young age at the time of surgery. Continued follow-up of these patients is important to assess the long-term outcomes of this surgical approach.

Visual outcomes and complications of posterior chamber intraocular lens implantation in the first year of life

PURPOSE

To document the visual outcome and postoperative complications in infants who had congenital cataract surgery with posterior chamber intraocular lens (PC IOL) implantation in the first year of life.

SETTING

The Children's Hospital, Dublin, Ireland.

METHODS

Twenty-seven eyes of 20 infants were reviewed. Seven infants (14 eyes) had bilateral congenital cataract and 13 (13 eyes), uniocular cataract. The mean age at surgery was 4 months (range 3 weeks to 11 months). A standard surgical technique involved anterior capsulorhexis, phacoemulsification with or without posterior capsulorhexis with in-the-bag PC IOL implantation, and no anterior vitrectomy. Surgery was performed by 1 surgeon. The mean follow-up was 41 months (range 6 to 88 months).

RESULTS

The main complication was lens reproliferation into the visual axis. Of the 11 eyes that did not have a primary posterior capsulorhexis, 10 had 1 or more capsulotomies. Seven required a neodymium:YAG (Nd:YAG) laser capsulotomy a mean of 6 months postoperatively, and 2 had 2 Nd:YAG capsulotomies. Six eyes also had a surgical capsulotomy when the membrane was deemed too thick for further laser treatment. Fourteen of 25 eyes had a primary posterior capsulorhexis; 8 had no further intervention. Four eyes had persistent hyperplastic primary vitreous (PHPV), 3 required a surgical capsulotomy, 2 had an Nd:YAG laser capsulotomy, 2 had an anterior vitrectomy, and 1 developed open-angle glaucoma. There was a mean refractive shift of 6.0 diopters after a mean follow-up of 41 months, with most of the myopic shift occurring in the first 24 months.

CONCLUSIONS

Visual axis reopacification was the main complication of IOL implantation in infants, with PHPV leading to more complications and repeat procedures. Anterior vitrectomy appeared to reduce the reoperation rate. Results indicate that primary posterior capsulorhexis is important and Nd:YAG capsulotomy is not satisfactory in infants. In addition, the reduction in glaucoma with IOL implantation, if borne out over the long term, is a significant advantage in cases of congenital cataract.

Visual outcome and complications of bilateral intraocular lens implantation in children

PURPOSE

To determine the safety and efficacy of bilateral intraocular lens (IOL) implantation in children.

SETTING

Tertiary referral pediatric ophthalmology department.

METHODS

This retrospective study comprised 13 children (26 eyes) who had bilateral cataract surgery with IOL implantation. Patients were divided into 2 groups: congenital cases, diagnosed during the first year of life, and developmental cases, diagnosed after 1 year of age. All patients had small incision phacoemulsification with primary implantation of a poly(methyl methacrylate) or a foldable acrylic IOL. Primary posterior capsulotomy was performed in 16 eyes (61.5%).

RESULTS

Age at surgery ranged from 1 week to just under 8 years. Seven patients (53.8%) had a systemic diagnosis: Down's syndrome (n = 4); developmental delay or cerebral atrophy (n = 3). Five children with systemic problems could not cooperate with formal vision testing; 2 could fix and follow bilaterally, and 3 had central, steady, and maintained vision bilaterally. In the congenital group, 37.5% of eyes attained a visual acuity of 20/20 and 87.5%, 20/120 or better. In the developmental group, formal vision testing was possible in 4 children. Five eyes (83.3%) attained a visual acuity of 20/40 or better. Thirteen eyes (50.0%) required posterior capsulotomy. Primary posterior capsulotomy reduced the incidence of posterior capsule opacification (PCO), but there was no correlation between PCO and IOL material. One patient developed glaucoma bilaterally.

CONCLUSION

Bilateral IOL implantation was safe and produced good visual results in children of all ages with bilateral cataract.

Pars plana lensectomy with double-capsule-supported intraocular lens implantation in children

An alternative technique to manage pediatric cataracts comprises a pars plana lensectomy and anterior vitrectomy with anterior and posterior capsulotomies and posterior chamber heparin-surface-modified intraocular lens (IOL) implantation in the ciliary sulcus through a scleral tunnel. The surgical results in 7 eyes of 6 consecutive patients between 3.5 and 12.0 years old with developmental or traumatic cataract who had surgery using this technique were evaluated prospectively. Follow-up ranged from 12 to 19 months. All 7 eyes maintained a clear pupillary axis and a well-centered IOL from immediately after surgery to the last follow-up. Final best corrected visual acuity was 20/40 or better in 71% of cases.

Silicone intraocular lens implantation in children: preliminary results

PURPOSE

To evaluate the safety and outcome of foldable silicone intraocular lens (IOL) implantation in children.

SETTING

Department of Ophthalmology, University of Giessen, Giessen, Germany.

METHODS

The results of cataract extraction and silicone IOL implantation in children having surgery between 1992 and 1997 were retrospectively analyzed in 8 eyes (7 patients). All IOLs were implanted in the capsular bag through a 3.5 mm clear corneal incision. In 4 eyes, primary posterior capsulectomy and anterior vitrectomy were performed.

RESULTS

Mean patient age at the time of surgery was 5.1 years (range 8 months to 15 years). The surgeries were uneventful. All IOLs remained anatomically stable and well centered during the mean follow-up of 29.6 months (range 18 to 46 months). Postoperative inflammatory reaction was minimal. Neither fibrinoid exudation nor posterior synechias occurred postoperatively. Postoperative best spectacle-corrected visual acuity ranged from 20/800 to 20/20. All eyes with an intact posterior capsule developed posterior capsule opacification. In the 4 eyes that had primary posterior capsulectomy and anterior vitrectomy, the visual axis remained clear.

CONCLUSIONS

These preliminary results suggest that silicone IOL implantation in children is a safe procedure with good and stable short-term anatomic results. Longer follow-up is necessary to answer questions about the long-term safety of silicone lens implantation in a child's eye.

Implantation of the modified endocapsular bending ring in pediatric cataract surgery using a viscoadaptive viscoelastic agent

Cataract surgery and intraocular lens (IOL) implantation in pediatric eyes remain controversial. Using a viscoadaptive viscoelastic agent, we implanted a modified capsular bending ring (CBR) as well as an acrylic IOL with a sharp-optic-edge design in the capsular bag. All operated eyes demonstrated a low postoperative inflammatory reaction and a clinically well-centered IOL. The band-shaped, sharp-edged CBR facilitates the creation of a sharp, discontinuous bend in the equatorial capsule, which prevents anterior and posterior capsule opacification. Combining the viscoadaptive viscoelastic agent and the CBR enhances the safety of primary and secondary posterior chamber IOL implantation in pediatric cataract surgery, reduces capsule opacification, and may facilitate IOL exchange.

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

PURPOSE

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

SETTING

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

METHODS

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

RESULTS

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

CONCLUSION

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

Small peripheral anterior continuous curvilinear capsulorhexis

Cataract surgery is routinely performed using an anterior continuous curvilinear capsulorhexis (CCC). A manual surgical technique is described for performing a small (less than 1.5 mm diameter) anterior CCC. This technique's applications extend from Phaco-Ersatz, a cataract surgical technique designed to restore accommodation to pediatric cataract surgery. An experimental rabbit study was conducted to determine the feasibility of the technique. Up to 9 small peripheral anterior CCCs were made in the same lens capsule without the capsule tearing. The mean diameter of the CCCs was 1.1 mm +/- 0.3 (SD). A 30 gauge needle and Utrata capsulorhexis forceps were used to construct the CCC. This technique shows promise for the successful performance of small CCCs in Phaco-Ersatz procedures and pediatric cataract surgery.

Primary posterior capsulorhexis without anterior vitrectomy in pediatric cataract surgery: longer-term outcome

PURPOSE

To assess the effectiveness of primary posterior capsulorhexis without anterior vitrectomy in preventing posterior capsule opacification (PCO) in pediatric cataract surgery.

SETTING

Children's Hospital, Dublin, Republic of Ireland.

METHODS

The study comprised 32 eyes of 22 pediatric patients who had cataract extraction between 1994 and 1998. Extracapsular cataract extraction was performed using radiofrequency diathermy capsulorhexis to the anterior and posterior capsules without an anterior vitrectomy. Posterior chamber intraocular lens implantation was performed in 20 eyes. There were 23 congenital, 6 developmental, and 3 traumatic cataracts.

RESULTS

Patient age ranged from 1 month to 12 years. Mean follow-up was 19 months (range 6 to 50 months). Twenty-seven of 32 eyes (84.4%) had a clear visual axis at last follow-up. Five eyes required a neodymium: YAG capsulotomy, which was performed a mean of 5 months postoperatively (range 1 to 9 months). The incidence of PCO requiring capsulotomy was 15.6%.

CONCLUSION

Primary posterior capsulorhexis without anterior vitrectomy was safe and effective, with a low reopacification rate. Long-term follow-up of this patient cohort is necessary.