Does primary intraocular lens implantation prevent "aphakic" glaucoma in children?

Nationwide incidence of and risk factors for undergoing incisional glaucoma surgery following infantile cataract surgery

Nationwide incidence and risk factors for incisional glaucoma surgery post-infantile cataract (IC) surgery in children remain poorly understood. We conducted a population-based cohort study using the Korean national health claims database to identify IC patients diagnosed before age 1 who had IC surgery among all Korean born between 2008 and 2018 (n = 9,593,003). We estimated the annual occurrence of undergoing incisional glaucoma surgery following IC surgery in the general population aged 0-10. The risk factors for incisional surgery including systemic comorbidities and ophthalmic anomalies were analyzed by multivariable logistic regression. Of 650 patients who had undergone IC surgery with a mean (standard deviation [SD]) follow-up period of 6.2 (3.2) years, 92 (14.2%) were diagnosed with glaucoma following infantile cataract surgery (GFICS). Among them, 21 patients (22.8%) underwent incisional glaucoma surgery after a mean (SD) follow-up duration of 5.4 (2.8) years from the diagnosis of GFICS. Median (InterQuartile Range) age at incisional surgery was 4 (2,6) years old. Twenty of 21 patients (95.2%) underwent incisional glaucoma surgery within 3 years of diagnosis of GFICS. No factors, except younger age at glaucoma diagnosis (P = 0.03), were associated with undergoing incisional surgery. These findings can better understand the epidemiologic features and clinical courses of GFICS.

Ten-year outcomes of congenital cataract surgery performed within the first six months of life

PURPOSE

To investigate the long-term outcomes of congenital cataract surgery performed within the first 6 months of life.

SETTING

11 ophthalmic surgical sites in Japan.

DESIGN

Retrospective chart review.

METHODS

Medical charts were retrospectively reviewed for 216 eyes of 121 patients. The age at surgery was 2.9 ± 1.7 months, with follow-up duration 13.0 ± 2.3 years. The cohort consisted of 83 cases with bilateral aphakia, 12 with bilateral pseudophakia, 20 with unilateral aphakia, and 6 with unilateral pseudophakia.

RESULTS

Surgical intervention within the critical period of visual system development (10 weeks for bilateral and 6 weeks for unilateral cases) led to significantly better final visual acuity than surgery conducted after this time frame. The incidence of secondary glaucoma was similar between groups while the occurrence of visual axis opacification was more frequent with earlier surgery. A forward stepwise multiple regression analysis revealed that the final visual acuity was significantly associated with laterality of cataract (better outcomes in bilateral cases), phakic status (with pseudophakia outperforming aphakia), presence of systemic and ocular comorbidities, and development of secondary glaucoma. Secondary glaucoma was significantly more prevalent in aphakic eyes than pseudophakic eyes.

CONCLUSIONS

In patients with genuine congenital cataract, surgery within the critical period of visual development results in better final visual acuity, albeit with an increased risk of visual axis opacification. The use of IOL with sophisticated surgical techniques shows promise even in congenital cataract surgery.

Timing of Diagnosis and Treatment of Glaucoma following Infantile Cataract Surgery

PURPOSE

To report timing of diagnosis and treatment of glaucoma following cataract surgery (GFCS) in a large cohort of infants undergoing cataract surgery at a tertiary care center.

STUDY DESIGN

Cross-sectional study.

PARTICIPANTS

All consecutive infants that underwent cataract surgery over a 30-year period from January 1991 to December 2021 were included if they had at least 1 year follow-up.

METHODS

The data collection included age at time of cataract surgery, presence of associated ocular or systemic conditions, age at diagnosis of GFCS, and treatment required to control GFCS. Glaucoma diagnosis required intraocular pressure (IOP) > 21 mmHg on > 2 visits with glaucomatous optic nerve head changes and/or visual field changes, or in young children, other anatomic changes such as corneal enlargement or haze or accelerated axial elongation and myopic shift.

MAIN OUTCOME MEASURES

The incidence of GFCS was calculated. Linear regression was performed to assess the effect of age at time of cataract surgery. Analysis of risk factors and treatment modalities was performed using univariate and multivariate analysis.

RESULTS

Three hundred eighty-three eyes (260 patients) were analyzed. Median age at surgery was 52 days and median follow-up, 8 years. Glaucoma following cataract surgery was noted in 27% (104/383 eyes; median age at surgery, 45 days; median follow-up, 13 years.) Young age at surgery (< 3 months) was the greatest risk factor (P = 0.001) but the incidence was similar for infants operated in the first, second, or third month of life (25%, 36%, 40%, respectively, P = 0.4). Microcornea (41%, P < 0.0001), poorly dilating pupils (25%, P = 0.001), persistent fetal vasculature (PFV, 13%; P = 0.8), or anterior segment dysgenesis (3%, P = 0.02) were considered as additional risk factors. Surgical intervention was needed for 73% (24/33) eyes with early-onset GFCS compared with 14% (10/71) eyes with later-later onset GFCS (P < 0.0001). Medical treatment was effective in 86% with later-onset GFCS (P = 0.006).

CONCLUSIONS

The incidence of GFCS was 27%, and timing of diagnosis occurred in a bimodal fashion. Early-onset GFCS usually requires surgical intervention; medical treatment is effective for later-onset GFCS. Cataract surgery within the first 3 months of life, microcornea, and poorly dilating pupils were major risk factors.

FINANCIAL DISCLOSURE(S)

The authors have no proprietary or commercial interest in any materials discussed in this article.

Incidence of and risk factors for suspected and definitive glaucoma after bilateral congenital cataract surgery: a 5-year follow-up

AIMS

To report the incidence and associated risk factors for developing suspected and definitive glaucoma after bilateral congenital cataract (CC) removal with a 5-year follow-up.

METHODS

Secondary analysis of a prospective longitudinal cohort study. Bilateral CC patients who had undergone cataract surgery between January 2011 and December 2014 at Zhongshan Ophthalmic Centre were recruited. Suspected glaucoma was defined as persistent ocular hypertension requiring medical treatment. Definitive glaucoma was defined as accompanied by the progression of glaucomatous clinical features. According to postoperative lens status in 5 years follow-up: 130 eyes in the aphakia group; 219 in the primary intraocular lens (IOL) implantation group and 337 in the secondary IOL implantation group. The Kaplan-Meier survival and Cox regression analyses were used to explore the cumulative incidence and risk factors for suspected and definitive glaucoma.

RESULTS

Three hundred fifty-one children (686 eyes) with bilateral CCs were enrolled in the study. The mean age at surgery was 1.82±2.08 years, and the mean follow-up duration was 6.26±0.97 years. Suspected and definitive glaucoma developed at a mean time of 2.84±1.75 years (range 0.02-7.33 years) postoperatively. The cumulative incidence of suspected and definitive glaucoma was 9.97% (35 of 351 patients), including 6.12% (42 eyes) for definitive glaucoma and 2.48% (17 eyes) for suspected glaucoma. Microcornea (HR 4.103, p<0.0001), CC family history (HR 3.285, p=0.001) and initial anterior vitrectomy (HR 2.365 p=0.036) were risk factors for suspected and definitive glaucoma. Gender, age at surgery, intraocular surgery frequency, length of follow-up and frequency of neodymium-doped yttrium aluminumaluminium garnet laser were non-statistically significant. Primary IOL implantation was a protective factor (HR 0.378, p=0.007).

CONCLUSIONS

Identifying suspected and definitive glaucoma after bilateral CC surgery can lower the risk of secondary blindness in children. Patients with related risk factors need to pay more attention and thus reach early intervention and treatment during clinical practice. Primary IOL implantation may be a potential protective factor, need more clinical trials to be verified.

TRIAL REGISTRATION NUMBER

NCT04342052.

Long-term surgical outcomes of pediatric cataract-multivariate analysis of prognostic factors

We assessed the 10-year postoperative outcomes of pediatric cataract patients who underwent surgery at the age of 6 years or younger. A retrospective review of medical charts was conducted for 457 eyes of 277 patients, with the age at surgery averaging 1.3 ± 1.5 years (mean ± SD) and the follow-up duration averaging 12.8 ± 2.4 years (ranging from 10 to 17 years). The cohort included 250 eyes of 125 cases with bilateral aphakia (age at surgery 0.5 ± 0.8 years), 110 eyes of 55 cases with bilateral pseudophakia (1.9 ± 1.6 years), 42 cases with unilateral aphakia (1.1 ± 1.3 years), and 55 cases with unilateral pseudophakia (2.6 ± 1.7). A forward stepwise multiple regression analysis revealed that the best-corrected visual acuity at the final visit was significantly associated with laterality of cataract (with bilateral cases showing better results compared to unilateral cases), presence of systemic comorbidities, presence of ocular comorbidities, development of glaucoma, and phakic status (with better results in the pseudophakia group than the aphakia group). The age at surgery did not significantly affect visual acuity outcomes. A multiple logistic regression analysis demonstrated that the incidence of secondary glaucoma was significantly linked to younger age at surgery, phakic status (higher in aphakic than pseudophakic eyes), and presence of systemic comorbidities. In conclusion, after pediatric cataract surgery, final visual acuity was better in patients with bilateral cataracts, those treated with an intraocular lens, and cases without systemic or ocular comorbidities and secondary glaucoma. The development of secondary glaucoma was linked to younger age at surgery, aphakic status, and presence of systemic comorbidities.

10-Year Outcomes of Pediatric Cataract Surgery with Foldable Intraocular Lens Implantation and Posterior Continuous Curvilinear Capsulorhexis

INTRODUCTION

We investigated the long-term outcomes of pediatric cataract surgeries performed with modern surgical techniques involving in-the-bag implantation of a foldable intraocular lens (IOL).

METHODS

Data were retrospectively collected from 42 eyes in 30 patients who underwent surgery at 6 years and younger (average 2.5 ± 2.3 years) and were followed up for an average of 12.2 ± 2.4 years (10-17 years). Surgical procedures included anterior continuous curvilinear capsulorhexis (CCC), lens removal, posterior CCC, anterior vitrectomy, and in-the-bag IOL implantation. There were 18 unilateral (2.7 ± 2.3 years) and 12 bilateral cases (2.3 ± 2.3 years), with no significant age difference between groups (p = 0.462).

RESULTS

The mean best-corrected visual acuity (BCVA) at the final visit was 0.453 ± 0.488 (logMAR), correlating significantly with the age at surgery (r = -0.307, p = 0.048). The unilateral group had a worse BCVA (0.658 ± 0.615) than the bilateral group (0.298 ± 0.294) (p < 0.001). On average, eyes showed a myopic shift of -6.0 ± 6.3D, which significantly correlated with surgical age (r = 0.402, p = 0.008). While the myopic shift was -8.2 ± 6.1 D in the unilateral group and -4.9 ± 6.4 D in the bilateral group, the net shift for unilateral cases (comparing pseudophakic and fellow eyes) was -4.8 D. Three eyes (7.1%) exhibited suspected glaucoma (increased intraocular pressure), but no glaucoma or other severe complications were noted. IOL exchange surgery was necessary in two eyes (4.8%) due to pronounced myopic drift and significant IOL decentration. Three eyes (7.1%) required surgery for significant visual axis opacification.

CONCLUSIONS

Contemporary surgical strategies appear to yield promising long-term outcomes in patients with infantile cataracts.

Nationwide Incidence of Infantile Cataract Surgery and Risk of Secondary Glaucoma in a Population-based Birth Cohort

PURPOSE

To determine the nationwide birth cohort incidence of infantile cataract (IC) surgery and the risk of secondary glaucoma in a Korean population.

DESIGN

A population-based, retrospective cohort study.

METHODS

We accessed the Korean National Health Claims database to identify patients with IC who were diagnosed before 1 year of age and who underwent IC surgery among all Koreans born between 2008 and 2018 (n = 9,593,003). We estimated IC surgery incidence in a birth cohort. The incidence rates of post-IC surgery glaucoma were estimated per 100 person-years, based on the Poisson distribution. The risk factors for post-IC surgery glaucoma, including ophthalmic and systemic comorbidities, were analyzed by multivariable logistic regression analysis.

RESULTS

During the 11-year study period, 692 patients underwent IC surgery. The annual birth cohort incidence of IC surgery in the general population ranged from 5.10 to 9.29 cases per 100,000 individuals. Among patients who had been followed up for longer than 1 year (n = 650), 92 (14.2%) developed glaucoma, and its incidence rate was 2.29 (95% confidence interval, 1.86-2.80) per 100 person-years. The mean time from IC surgery to glaucoma development was 4.7 ± 3.5 years. No factors were identified as being associated with post-IC surgery glaucoma risk other than primary or secondary intraocular lens implantation, which reduces the risk (all P < .05). In patients without primary intraocular lens implantation, the risk of glaucoma increased steeply during the first 2 years after IC surgery.

CONCLUSION

This study identified the birth cohort incidence of IC surgery and secondary glaucoma risk in individuals of East Asian ethnicity. These estimates may help to better understand the epidemiologic features and clinical courses of patients with IC.

A Comprehensive Review of Pediatric Glaucoma Following Cataract Surgery and Progress in Treatment

Glaucoma following cataract surgery (GFCS) remains a serious postoperative complication of pediatric cataract surgery. Various risk factors, including age at lensectomy, intraocular lens implantation, posterior capsule status, associated ocular/systemic anomaly, additional intraocular surgery, and a family history of congenital cataract and GFCS, have been reported. However, the optimal surgical approach remains unclear. This review evaluates the diagnostic criteria, classification, risk factors, mechanism, and surgical management, especially the efficacy of minimally invasive glaucoma surgery, in GFCS, and aims to propose an optimal clinical management strategy for GFCS. The results of our review indicate that ab interno trabeculotomy (goniotomy) may be the most appropriate first-line treatment for GFCS.

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.

Experiences of Treatment With Contact Lenses in Aphakic Children With Unilateral Congenital Cataract: A Retrospective Study

BACKGROUND AND OBJECTIVES

Congenital cataract is a condition compromising the eye's crystalline lens in infants and is usually diagnosed at birth. It can lead to irreversible vision loss if not promptly detected and treated, especially in unilateral cases. Nowadays, children with congenital cataracts can undergo surgical removal of their opacified crystalline lenses, and visual rehabilitation is mandatory to prevent deep amblyopia. Contact lenses, predominantly of rigid gas-permeable (GP) type, are gaining more popularity for this matter.

METHOD

In this retrospective cohort study, unilateral aphakic children younger than 6 years referred to the Contact Lens Clinic at Farabi Eye Hospital from November 2011 to September 2019 were included.

RESULTS

Seventy-six unilateral aphakic children with congenital cataracts (57.9% boys and 42.1% girls) rehabilitated with GP were studied. The mean age of diagnosis and referral to the contact lens clinic were 20.0±19.8 and 32.0±24.4 weeks, respectively, while the mean follow-up time was 12.44±26.28 months. The mean visual acuity for children capable of cooperating at the last follow-up was 0.98±0.62 log MAR. Among the participants, eight children (9.7%) were diagnosed as glaucoma suspects. The mean initial base curve and power of GP lenses were 7.86±0.39 mm and 23.29±5.52 diopters, respectively. Only 21 parents (27.6%) reported nonadherence to the scheduled part-time patch program.

CONCLUSION

The results of this study showed GP-based optical treatment after early diagnosis, surgical removal of congenital cataracts, and a long-term close follow-up to be well tolerated by children and their parents, with acceptable parents' compliance and can thus be introduced as a safe and effective method to achieve desirable visual outcomes.

Visual outcomes and complications in infantile cataract surgery: a real - world scenario

Objective

To evaluate visual outcomes and complications of infantile cataract surgery through a 1-year follow-up period in a real world scenario.

Methods and analysis

Prospective observational study evaluating infants with cataract undergoing surgery.

Results

We analysed 173 eyes of 97 infants (76 bilateral); median age 18.7 weeks, (IQR: 11–33.9 weeks). Toxoplasmosis, rubella, cytomegalovirus and herpes infection was the most common aetiology in both unilateral 10 (47.6%) and bilateral 43 (55.1%) cases, followed by familial and syndromic cases. Fifty-four eyes (29.5%) received primary intraocular lens (IOL) implantation.

Seventy-five infants (76%) were less than 6 months of age. At 1-year follow-up, mean log MAR best-corrected visual acuity was 1.00±0.08 and 1.21±0.03 in unilateral and bilateral cases respectively (p=0.012), which was not statistically significant. At 1-year follow-up, pseudophakic(1.09±0.05) eyes had a better mean log MAR visual acuity comparing aphakes(1.24±0.04) clinically but was not statistically significant after the application of Bonferroni correction (p=0.012). The mean myopic shift of −2.9 D±0.39 and −4.53 D±0.55 over 1 year was noted in aphakes and pseudophakes, respectively (p=0.016). Visual axis opacification and glaucoma were the most common complications noted in pseudophakes and aphakes, respectively.

Conclusion

Primary IOL implantation in selected cases of infantile cataract is a feasible option, particularly in cases when optimal aftercare and refractive rehabilitation of aphakia are not possible.

Management of Childhood Glaucoma Following Cataract Surgery

Glaucoma remains a frequent serious complication following cataract surgery in children. The optimal approach to management for 'glaucoma following cataract surgery' (GFCS), one of the paediatric glaucoma subtypes, is an ongoing debate. This review evaluates the various management options available and aims to propose a clinical management strategy for GFCS cases. A literature search was conducted in four large databases (Cochrane, PubMed, Embase, and Web of Science), from 1995 up to December 2021. Thirty-nine studies-presenting (1) eyes with GFCS; a disease entity as defined by the Childhood Glaucoma Research Network Classification, (2) data on treatment outcomes, and (3) follow-up data of at least 6 months-were included. Included papers report on GFCS treated with angle surgery, trabeculectomy, glaucoma drainage device implantation (GDD), and cyclodestructive procedures. Medical therapy is the first-line treatment in GFCS, possibly to bridge time to surgery. Multiple surgical procedures are often required to adequately control GFCS. Angle surgery (360 degree) may be considered before proceeding to GDD implantation, since this technique offers good results and is less invasive. Literature suggests that GDD implantation gives the best chance for long-term IOP control in childhood GFCS and some studies put this technique forward as a good choice for primary surgery. Cyclodestruction seems to be effective in some cases with uncontrolled IOP. Trabeculectomy should be avoided, especially in children under the age of one year and children that are left aphakic. The authors provide a flowchart to guide the management of individual GFCS cases.

Outcomes of the infantile cataract surgery: case series with a 5-year follow-up

PURPOSE

To present the 5-year outcomes obtained from the infantile cataract surgery in pediatric population.

METHODS

Medical records of all patients with unilateral or bilateral infantile cataract who had undergone lensectomy and anterior vitrectomy with or without intraocular lens implantation before 10 years of age were evaluated. Patients with any history of ocular trauma, retinal or corneal dystrophy, ocular or orbital surgery, retinopathy of prematurity, raised intraocular pressure at the time of diagnosis, or incomplete follow-up sessions were excluded from the research.

RESULTS

A total of 85 eyes belonged to 52 patients were analyzed. Bilateral and unilateral diseases were present in 33 (63.5%) and 19 (36.5%) patients, respectively. After performing the first operation, 43 (50.6%) eyes still remained aphakic. The mean corrected distance visual acuity (CDVA) of the aphakic and pseudophakic eyes was estimated as 0.77 ± 0.52 and 0.43 ± 0.39 logMAR with no statistical difference. The age at the time of performing the cataract surgery was not associated with the final CDVA in either group. Complications in the anterior segment structures were noted in 39 (45%) eyes. Strabismus and amblyopia were noted in 52 (61%) and 75 (88.2%) eyes, respectively. Glaucoma was found in 17 (20%) eyes with no correlation with the final CDVA, age at the time of cataract surgery, or the status of the lens.

CONCLUSION

Due to high prevalence rates of amblyopia, strabismus, and glaucoma after the infantile cataract surgery, specific attention should be paid to these complications in each follow-up examination.

Clinical Outcomes After Ahmed Glaucoma Valve Implantation for Pediatric Glaucoma After Congenital Cataract Surgery

PRCIS

Ahmed valve success for glaucoma following congenital cataract surgery lasts at least 5 years in most eyes, and >10 years in some cases. The procedure is a valuable option for these patients.

PURPOSE

The aim of the study was to report on the results of Ahmed valve implantation in children with glaucoma following congenital cataract surgery.

PATIENTS AND METHODS

Medical records were reviewed for 41 pediatric eyes (27 patients) with glaucoma after congenital cataract surgery with Ahmed glaucoma valve (AGV) implantation between 2007 and 2018. The primary outcome measure was surgical success, defined as intraocular pressure (IOP) ≤22 mm Hg (with or without glaucoma medications) on 2 consecutive follow-up visits, without glaucoma reoperation, and without significant visual complications during the follow-up period.

RESULTS

Median age at the time of AGV implantation was 80 months (range: 14 to 146 mo) and the mean follow-up period was 61.1±46.5 months. The cumulative probability of surgical success was 95.1%, 89.8%, 83.1%, and 72.6% at 12, 24, 60, and 84 months, respectively. IOP significantly decreased from 35.8±7.4 mm Hg before valve implantation to 18.7±6.5 mm Hg at the last recorded visit (51.4% decrease; P<0.0001). Most eyes (79%) required medications for pressure control. Complications occurred in 14 eyes (34%), with 12 of these remaining successful. Early hypotony was the most common complication (19.5%). Retinal detachment occurred in 1 eye.

CONCLUSIONS

Despite a decrease in surgical success over time, AGV implantation was successfully used for IOP control in the majority of our pediatric eyes with glaucoma after congenital cataract surgery. Most complications were managed effectively and surgical success was maintained.

Commentary review: challenges of intraocular lens implantation for congenital cataract infants

As an indispensable part of congenital cataract surgery, intraocular lens (IOL) implantation in infantile patients has long-term positive impacts on visual rehabilitation, as well as postoperative complications inevitably. Timing of IOL implantation in infantile congenital cataract patients is not simply a point-in-time but a personalized decision that comprehensively takes age at surgery, risks of postoperative complications, and economic condition of family in consideration, and combines with choosing suitable IOL type and power. For infants with well-developed eyeballs and good systemic conditions, IOL implantation at six months of age or older is safe and effective. Otherwise, secondary IOL implantation may be a safer choice.

Glaucoma-Related Adverse Events at 10 Years in the Infant Aphakia Treatment Study: A Secondary Analysis of a Randomized Clinical Trial

Importance

Glaucoma-related adverse events constitute serious complications of cataract removal in infancy, yet long-term data on incidence and visual outcome remain lacking.

Objective

To identify and characterize incident cases of glaucoma and glaucoma-related adverse events (glaucoma + glaucoma suspect) among children in the Infant Aphakia Treatment Study (IATS) by the age of 10.5 years and to determine whether these diagnoses are associated with optic nerve head (ONH) and peripapillary retinal nerve fiber layer (RNFL) assessment.

Design, Setting, and Participants

Analysis of a multicenter randomized clinical trial of 114 infants with unilateral congenital cataract who were aged 1 to 6 months at surgery. Data on long-term glaucoma-related status and outcomes were collected when children were 10.5 years old (July 14, 2015, to July 12, 2019) and analyzed from March 30, 2019, to August 6, 2019.

Interventions

Participants were randomized at cataract surgery to either primary intraocular lens (IOL), or aphakia (contact lens [CL]). Standardized definitions of glaucoma and glaucoma suspect were created for IATS and applied for surveillance and diagnosis.

Main Outcomes and Measures

Development of glaucoma and glaucoma + glaucoma suspect in operated-on eyes up to age 10.5 years, plus intraocular pressure, axial length, RNFL (by optical coherence tomography), and ONH photographs.

Results

In Kaplan-Meier analysis, for all study eyes combined (n = 114), risk of glaucoma after cataract removal rose from 9% (95% CI, 5%-16%) at 1 year, to 17% (95% CI, 11%-25%) at 5 years, to 22% (95% CI, 16%-31%) at 10 years. The risk of glaucoma plus  glaucoma suspect diagnosis after cataract removal rose from 12% (95% CI, 7%-20%) at 1 year, to 31% (95% CI, 24%-41%) at 5 years, to 40% (95% CI, 32%-50%) at 10 years. Risk of glaucoma and glaucoma plus glaucoma suspect diagnosis at 10 years was not significantly different between treatment groups. Eyes with glaucoma (compared with eyes with glaucoma suspect or neither) had longer axial length but relatively preserved RNFL and similar ONH appearance and visual acuity at age 10 years.

Conclusions and Relevance

Risk of glaucoma-related adverse events continues to increase with longer follow-up of children following unilateral cataract removal in infancy and is not associated with primary IOL implantation. Development of glaucoma (or glaucoma suspect) after removal of unilateral congenital cataract was not associated with worse visual acuity outcomes at 10 years.

Trial Registration

ClinicalTrials.gov Identifier: NCT00212134.

Clinical characteristics and treatment of secondary glaucoma, glaucoma suspects and ocular hypertension after congenital cataract surgery

OBJECTIVE

To evaluate changes in intraocular pressure after congenital cataract surgery in a real-world setting.

METHODS

This retrospective case series included all children aged 0-2 years undergoing lens extraction due to congenital cataract. Development of an elevated intraocular pressure was divided into three groups: secG, suspG and OHT. Further, risk factors for IOP changes, the therapeutic approach and functional outcome were assessed during follow-up.

RESULTS

One hundred and sixty-one eyes of 110 patients aged 0-2 years were included, whereof 29 eyes of 17 children developed secondary glaucoma (secG; 11 eyes/8 patients), glaucoma suspect (suspG; three eyes/three patients) or ocular hypertension (OHT; 15 eyes/10 patients). No difference in surgrical procedure (p = 0.62) was found, but age at cataract surgery differed significantly (p = 0.048), with the secG group (1.74 ± 1.01 months) being the youngest (suspG: 3.93 ± 1.80 months; OHT group: 5.91 ± 5.36 months).Secondary surgical intervention was significantly higher in the secG (4.64 ± 3.41) followed by the suspG (2.00 ± 2.65) and OHT groups (0.40 ± 0.74; p < 0.001). Postoperative complications including nystagmus (p = 0.81), strabismus (p = 0.98) and amblyopia (p = 0.73) showed no difference, in contrast to visual axis obscuration which was more common in the secG group (p = 0.036).

CONCLUSION

Initial lensectomy and anterior vitrectomy procedure together with or without IOL implantation seems to have no influence for the development of IOP changes after pediatric cataract surgery. However, children who developed secondary glaucoma had cataract surgery significantly earlier, within the first 2-3 months of life. Glaucoma surgery was required to achieve final IOP control in most eyes. The development of secondary glaucoma was also associated with a significant increase in surgical re-treatments.

The impact of late-treated pediatric cataract on intraocular pressure

PURPOSE

To assess the intraocular pressure and visual acuity before and after pediatric congenital cataract surgery performed at a relatively older age.

METHODS

A retrospective analysis of all consecutive pediatric patients diagnosed and operated for bilateral congenital cataracts during a seven-year period (2012-2018) in rural southern Ethiopia. Non-ambulatory vision was defined as hand motion or worse. The main outcome measures were intraocular pressure (IOP) and visual acuity.

RESULTS

Thirty-two children were included, 17 females (53.1%), with a mean age of 11 years (± 2.83) [range, 7-18]. A total of 59 eyes were operated on. The mean follow-up was 4.8 ± 1.8 years (range, 2-8). VA improved from 20/1400 preoperatively to 20/440 postoperatively OD and 20/540 OS (p < 0.001). More eyes had ambulatory vision after cataract surgery than pre-surgery (56 eyes [95%] vs. 29 eyes [49%], p < 0.001). The IOP decreased from a mean preoperative value of 18.4 ± 7.1 mmHg to 14.5 ± 2.9 postoperatively OD (p < 0.001) and 16.3 ± 5.9 mmHg to 13.9 ± 3.5 OS (p < 0.001). Fifteen eyes (24%) had increased IOP (> 21 mmHg) preoperatively, of which three remained high after surgery. Positive correlations were found between IOP, axial length and cup-to-disc ratio. None of the patients required pressure-lowering procedures.

CONCLUSION

Bilateral congenital cataracts may be associated with ocular hypertension, with possible progression to glaucoma if left untreated. Surgery at a relatively older age often was associated with a significant improvement in intraocular pressure and ambulatory vision.

The Swedish National Pediatric Cataract Register (PECARE): incidence and onset of postoperative glaucoma

PURPOSE

The aim was to report cumulative incidence and time of onset of postoperative glaucoma in a paediatric early cataract surgery cohort.

METHODS

Data were retrieved from the Pediatric Cataract Register (PECARE), a prospective register of Swedish cataract operations before 8 years of age. All eyes with surgery between January 2007 and December 2014 and a registered follow-up were included. Cataracts caused by uveitis, trauma or coexisting congenital glaucoma were excluded. Glaucoma was defined as early onset if diagnosed within a year after surgery and late onset if diagnosed later.

RESULTS

The study included 288 eyes in 207 children (106 girls), 81 with bilateral and 126 with unilateral cataracts, with a mean follow-up of 3.31 ± 1.77 years. Of the 288, 168 (58.3%) had surgery before 3 months of age; most of these 92.3% (155/168) were defined as dense, 208 (72.2%) were below 1 year of age. Cumulative incidence of surgically treated glaucoma among individuals was 23.7% (49/207). Median time to glaucoma onset was 0.91 years (range: 0.05-4.97 years) for eyes. Early-onset glaucoma was found in 98 % (63/64), and late onset in 2% (1/64).

CONCLUSION

In this paediatric cataract cohort, a majority of eyes had surgery before 3 months of age (58.3%). Secondary glaucoma-onset peaked within the first postoperative year, with a cumulative incidence of 23.7%. Surgery performed after the first month of life, resulted in a lower glaucoma rate. Long-term follow-up will reveal whether the low rate of late-onset glaucoma with early surgery will last, and if so, the consequences.

Changes in intraocular pressure control in the first year after secondary intraocular lens implantation in children

PURPOSE

To compare intraocular pressure (IOP) control before and during the first year after secondary intraocular lens (IOL) implantation in children.

METHODS

This was a retrospective chart review of children who received secondary IOL implantation. We analyzed IOP and antiglaucoma medications before and after implantation. The latest exam with IOP measurement found within the 2-15 month period after IOL implantation was used for the postoperative data. Failure to maintain IOP control was defined as either the addition of antiglaucoma medication(s) or a rise in IOP > 4 mm Hg. Statistical analyses were performed to assess risk factors for failure to control IOP after surgery, namely age at IOL implantation, preoperative glaucoma status, and IOL fixation location.

RESULTS

A total of 100 eyes were included. The mean duration of follow-up was 7.74 months (SD = 3.11). Twenty-three of one hundred eyes failed to maintain IOP control according to our definition. Eyes with a history of having had a traumatic cataract (n = 3) had a more than threefold increased risk of failure (P = 0.015). Although not statistically significant, very young age at initial cataract surgery (<2 months old) had a twofold increased risk of failure compared to an older age (>12 months old) (P = 0.213). No other risk factors were found to have statistical significance.

CONCLUSION

Secondary IOL implantation carries a modest risk of worsening IOP control in the first year after implantation, for which, a history of ocular trauma or young age at initial cataract surgery seems to present the highest risk.

Paediatric cataract in the uveitis setting

BACKGROUND/AIMS

Cataract formation is common in uveitis and is visually more threatening in the paediatric cohort due to the risk of amblyopia. In addition, paediatric uveitis can often be difficult to manage. We report our experience with IOL placement in cataract surgery in the setting of paediatric uveitis.

METHODS

This non-comparative, retrospective interventional case series examined our cases of paediatric cataract occurring in patients with uveitis from 2003 to 2016. Parameters examined included visual acuity (VA), underlying diagnosis, immunosuppression status, intra-operative complications and requirement for further surgery.

RESULTS

In total, 10 eyes of seven patients were identified. The mean age at diagnosis of uveitis was 7.7 years (range 5.2-14 years) with onset of cataract at a mean of 29.3 months later (range 0-66 months). Three cases were bilateral and four cases were unilateral. Final visual outcomes were excellent with 80% showing improvement in VA achieving greater than 6/9.5 (p < 0.05). These patients had significant co-morbidities with concurrent glaucoma, band keratopathy and cystoid macular oedema. Uveitis was quiet for a minimum of 6 months in all cases prior to surgery with augmentation of immunosuppression pre-operatively as well as intra-operative local or intra-venous steroids. Tight post-operative care was necessary as 80% developed further flare-up of uveitis requiring increased immunosuppression and surgical interventions to manage their uveitis.

CONCLUSION

Paediatric uveitis patients who develop cataract can have good visual outcomes with IOL insertion at the time of surgery when there is aggressive control of uveitis in the pre, peri and post-operative period.

Clinical Characteristics and Treatment of Secondary Glaucoma After Pediatric Congenital Cataract Surgery in a Tertiary Referral Hospital in Spain

PURPOSE

To analyze clinical characteristics, treatment, and long-term outcomes of pediatric patients with glaucoma after congenital cataract surgery at a single tertiary care hospital.

METHODS

Medical records of pediatric patients diagnosed as having glaucoma secondary to congenital cataract surgery between 1996 and 2016 were reviewed retrospectively.

RESULTS

A total of 58 eyes of 42 patients were included with a median follow-up time of 55 months (interquartile range [IQR]: 27 to 128) after glaucoma diagnosis. Mean time of glaucoma onset after cataract surgery was 35 months (IQR: 5 to 96). At diagnosis, 81% of the eyes were aphakic and the majority presented with an open angle (86%). Multivariate analysis demonstrated that glaucoma diagnosis was made earlier in eyes with persistent fetal vasculature (β = -0.334, P = .006) and aphakic eyes (β = 0.404, P = .001). Two-thirds of eyes required surgical treatment for glaucoma. Seventy percent had an Ahmed glaucoma valve (New World Medical, Inc) implantation as their primary procedure, followed by trabeculectomy (24%) and synechiolysis with peripheral iridotomy (6%). All medically treated eyes and 78% of the surgically treated eyes achieved intraocular pressure (IOP) control at the final visit.

CONCLUSIONS

Diagnosis of glaucoma after congenital cataract surgery seems to follow a bimodal distribution (years 1 and 5 after cataract surgery). Two-thirds of the eyes required surgical hypotensive treatment to achieve IOP control. Ahmed glaucoma valve implantation is a safe and effective surgical option to be considered as both first- and second-line treatment. Functional outcome was more favorable in those eyes with medically controlled glaucoma. [J Pediatr Ophthalmol Strabismus. 2020;57(5):292-300.].

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.

Outcomes of Ahmed glaucoma valve in paediatric glaucoma following congenital cataract surgery in persistent foetal vasculature

PURPOSE

To evaluate the outcomes of primary Ahmed glaucoma valve in refractory secondary glaucoma following congenital cataract surgery, particularly in persistent foetal vasculature.

METHOD

Retrospective review of paediatric patients after Ahmed glaucoma valve implantation for refractory post-lensectomy glaucoma in a tertiary referral centre in Spain. Surgical complications, additional and/or replacements of Ahmed glaucoma valve, intraocular pressure, cup-to-disc ratio, glaucoma medications and final visual acuity were studied.

RESULTS

A total of 29 eyes, 41% with persistent foetal vasculature and 59% with non-persistent foetal vasculature were included with mean follow-up of 105 ± 67 and 74 ± 45 months, respectively, after first Ahmed glaucoma valve implant. Median survival time for the first Ahmed glaucoma valve was significantly lower in persistent foetal vasculature (7.0 ± 3.2 months) compared to non-persistent foetal vasculature (over 129 months), p = 0.001. The cumulative probability of success in persistent foetal vasculature and non-persistent foetal vasculature eyes with Ahmed glaucoma valve were, respectively, 37.5% and 88.2% at year 1 and 28.1% and 71.9% at year 5. Cox regression model suggested persistent foetal vasculature as predictive risk factor of time to Ahmed glaucoma valve failure (hazard ratio: 5.77, p = 0.004). Four eyes developed phthisis bulbi. Mean intraocular pressure prior glaucoma surgery was 32.66 ± 6.73 mmHg and decreased to 16.54 ± 2.75 mmHg (p < 0.001) at final visit. The most frequent early postoperative complication was severe hypotony (32.6%) which tended to be self-limiting. Vitreous haemorrhage was associated with persistent foetal vasculature (p = 0.024). Ahmed glaucoma valve replacements after complications and additional Ahmed glaucoma valve implantations due to unsatisfactory intraocular pressure were more common in the persistent foetal vasculature group.

CONCLUSION

Eyes with persistent foetal vasculature and secondary glaucoma after congenital cataract surgery followed by AGV implantation had a higher number of complications and a decreased probability of success compared to the non-persistent foetal vasculature group. Both groups achieved a significant decrease in intraocular pressure; thus, Ahmed glaucoma valve may be considered as first-line treatment in refractory glaucoma following congenital cataract surgery.

Comparison of visual acuity and complications between primary IOL implantation and aphakia in patients with congenital cataract younger than 2 years: a meta-analysis

To analyze the visual acuity and complications between primary intraocular lens (IOL) implantation and contact lens wearing, this literature search was performed with data on patients with congenital cataract younger than 2 years published in March 2019. Seven identified studies enrolling 675 eyes were selected for analysis. Patients with primary IOL implantation owned better visual acuity than those with aphakia who wore the contact lens (weighted mean difference = 0.161; 95% CI, 0.108-0.214). For visual axis opacification (VAO), primary IOL implantation increases the incidence of VAO compared with contact lens wearing (relative risk = 0.23; 95% CI, 0.13-0.42). No statistically significant difference was found between the 2 groups about the prevalence of glaucoma and strabismus. Primary IOL implantation achieved better visual outcomes after cataract extraction in patients younger than 2 years. In addition, no higher risk for complications among primary IOL implantation compared with contact lens wearing was noted. Therefore, implanting a primary IOL during congenital cataract surgery is a better therapy for children younger than 2 years than wearing a contact lens.

Incidence and Risk Factors for Glaucoma Development After Bilateral Congenital Cataract Surgery in Microphthalmic Eyes

PURPOSE

To evaluate the long-term incidence and risk of glaucoma after bilateral congenital cataract surgery in microphthalmic eyes.

DESIGN

Retrospective, observational case series.

METHODS

Subjects: Children with microphthalmic eyes who had undergone surgery for bilateral congenital cataract within 6 months of birth and been followed up for at least 5 years.

PROCEDURES

Review of medical records at our institution.

MAIN OUTCOME MEASURES

Probability of an eye's developing glaucoma after bilateral congenital cataract surgery and associated risk factors.

RESULTS

Thirty-eight eyes of 19 children with bilateral congenital cataract were included. The mean age at surgery was 3.2 ± 1.7 months, and the mean follow-up duration was 7.79 ± 2.61 years. After cataract surgery, 11 eyes (29.0%) developed glaucoma at the age of 4.0 ± 1.4 years. Three of these eyes underwent Ahmed glaucoma valve implantation surgery. The probability of an eye's developing glaucoma was estimated to be 32.0% by 10 years after surgery. In a multivariate analysis, axial length was significantly associated with glaucoma development (odds ratio = 0.364, P = .025). Age at the time of cataract surgery, corneal diameter, and aphakia did not affect the risk of glaucoma (P > .10). Eyes without glaucoma had a better final visual outcome than those with glaucoma (0.75 ± 0.60 and 1.47 ± 1.10 logMAR, respectively, P = .049).

CONCLUSIONS

The long-term cumulative risk of postoperative glaucoma development was 32.0% by 10 years after bilateral congenital cataract surgery. Because the risk of developing glaucoma persists for several years after surgery, careful monitoring and control of intraocular pressure is needed to preserve vision in such patients.

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

Background

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

Methods

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

Results

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

Conclusions

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

Secondary glaucoma and visual axis opacification in aphakic and pseudophakic patients following congenital cataract surgery: A 28-year longitudinal case series

Purpose:

To determine the incidence, timing and risk factors for glaucoma and visual axis opacification development following surgery for congenital cataract in the first year of life.

Methods:

A prospective case series of all cataract surgery performed in Temple Street Children’s University Hospital over a 28-year period was conducted. A total of 93 subjects (135 eyes) were analysed. Sixty-two eyes had a primary intraocular lens inserted at the time of surgery; 73 eyes were aphakic. We recorded patient demographics, age at surgery, length of follow-up, rates and time to diagnosis of glaucoma and rates of visual axis opacification. Relative risk analysis was performed to identify potential risk factors for secondary glaucoma and visual axis opacification.

Results:

Mean length of follow-up was 160.02 ± 64.42 months (13.3 years), range 40–336 months. Final mean LogMAR across all groups was 0.85 ± 0.51 (0.90). Overall 45 (33.33%) eyes developed secondary glaucoma, 12 (19.4%) in pseudophakic eyes and 33 (45.21%) in aphakic eyes. The incidence of glaucoma was highest in bilateral aphakia (relative risk 1.96, p = 0.0240) and in eyes with corneal diameter <9.5 mm (relative risk 1.93, p = 0.0364). There was no significant difference in glaucoma rates between pseudophakia and aphakia in those operated on less than 2.5 months of age. Secondary glaucoma occurred between 3 months to 16.5 years post surgery. Rates of visual axis opacification were lower in aphakia compared to pseudophakia (relative risk 0.59, p = 0.0098).

Conclusion:

Overall glaucoma rates of one-third are similar to those recorded in the infantile aphakic treatment study. It can occur up to 17 years post cataract surgery, evidence that long-term follow-up is imperative.

Elevated intraocular pressure in paediatric cataract surgery in a reference centre

OBJECTIVE

To study elevated postoperative intraocular pressure (PIOP) after paediatric cataract surgery in a reference centre and to compare the results obtained with the most relevant world literature.

MATERIALS AND METHODS

A retrospective observational study was conducted, collecting information from clinical records of 99 patients (142 eyes) operated on due to unilateral or bilateral paediatric cataracts between 2000 and 2008.

RESULTS

The proportion of eyes with PIOP≥20mmHg and bilateral cataracts was higher, 79.3%, than the proportion of eyes with PIOP≥20mmHg and a unilateral cataract, 20.7% (P=.032). The proportion of eyes with PIOP≥20mmHg between the eyes with cataract surgery before one month of age was higher, 50%, than between the eyes in which the cataract surgery was performed after one month of age, 17.2% (P=.009). PIOP values≥20mmHg were associated with a lower best corrected visual acuity at 5 years after cataract surgery (P=.020). The proportion of eyes with PIOP≥20mmHg and without intraocular lenses was higher, 69%, than the proportion of eyes with PIOP≥20mmHg and intraocular lenses, 31% (P<.001).

CONCLUSIONS

A PIOP>20mmHg was observed in 20.4% of eyes in a 5-year follow-up period, appearing more frequently in eyes with bilateral cataract than unilateral, and in aphakic eyes more than pseudophakic eyes. Elevation of the PIOP was associated with the performance of cataract surgery at early ages.

Intraocular lens implantation as an isolated risk factor for secondary glaucoma in pediatric patients

OBJECTIVE

To evaluate the effect of intraocular lens (IOL) implantation on the development of secondary glaucoma after cataract surgery in pediatric patients.

DESIGN

Retrospective case series study.

METHODS

This study reviewed the medical records of children under 16 years of age who had undergone cataract surgery from 1996 to 2016 for congenital or developmental cataract. In every child an IOL was implanted in the primary surgery. Data collected included demographic information, age at cataract diagnosis and at surgery, surgical procedure, and postoperative follow-up of refraction, cup-to-disc ratio (C/D), intraocular pressure (IOP), and associated systemic and ocular anomalies. Patients with risk factors for glaucoma were excluded from the study.

RESULTS

Of the 255 children below age 16 years who underwent cataract extraction surgery with primary IOL implantation, 73 (124 eyes) met the inclusion criteria. Follow-up ranged from 4 to 18 years. Only 1 patient (0.8% of the 124 eyes) developed glaucoma in 1 of his 2 operated eyes; the surgeries were performed at 10 months, 1 week apart, and glaucoma was diagnosed 4 months later. One patient had suspected glaucoma in both eyes (incidence of 1.6%). Both these children were of Bedouin origin.

CONCLUSION

IOL implantation, by itself, is not a risk factor for development of secondary glaucoma after cataract surgery in a population below 16 years of age.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Five-Year Postoperative Outcomes of Bilateral Aphakia and Pseudophakia in Children up to 2 Years of Age: A Randomized Clinical Trial

PURPOSE

Comparative evaluation of complications and visual outcomes following bilateral congenital cataract surgery in children up to 2 years of age with and without primary intraocular lens (IOL) implantation at 5 years follow-up.

DESIGN

Randomized controlled clinical trial.

METHODS

Sixty children (120 eyes) up to 2 years of age undergoing bilateral congenital cataract surgery were randomized to Group 1, primary aphakia (n = 30), or Group 2, primary IOL implantation (pseudophakia) (n = 30). A single surgeon performed surgeries with identical surgical technique. All patients were followed up regularly until 5 years postoperatively. At each follow-up, glaucoma, visual axis obscuration (VAO) requiring surgery, and inflammation (cell deposits, posterior synechiae) were assessed. Visual acuity was assessed until 5 years follow-up. The first operated eye was selected for statistical analysis.

RESULTS

Median age of the patients at time of surgery was 5.11 months (aphakia group) and 6.01 months (pseudophakia group) (P = .56). Five years postoperatively, incidence of glaucoma was 16% and 13.8% in Groups 1 and 2 (P = .82). Incidence of posterior synechiae was significantly higher in the pseudophakia group (27.6%) compared to the aphakia group (8%) (P = .004). VAO requiring surgery was seen in 8% and 10.3% of eyes in Groups 1 and 2 (P = .76). Mean logMAR visual acuity at 5 years follow-up was 0.59 ± 0.33 and 0.5 ± 0.23 in Groups 1 and 2, respectively (P = .79). However, more eyes in the pseudophakic group started giving documentable vision earlier in their postoperative follow-ups.

CONCLUSIONS

Incidence of postoperative complications was comparable between the groups, except for a higher incidence of posterior synechiae in pseudophakic eyes. Visual rehabilitation was faster in the pseudophakic group.

Long-term results of secondary intraocular lens implantation in children under 30 months of age

Purpose

To report the long-term outcome of early secondary intraocular lens (IOL) implantation following congenital cataract extraction in a large number of eyes.

Methods

Data of aphakic children under 30 months of age who underwent secondary IOL implantation and had at least one year of follow-up after the surgery was reviewed. In all of the patients, a foldable three-piece acrylic IOL was implanted in the ciliary sulcus by the same surgeon using the same technique. The database studied included refractive and visual acuity (VA) outcomes and complications.

Results

Fifty patients (75 eyes) were included. The average age at the time of cataract extraction was 94.20 ± 44.94 days and 20.7 ± 6.0 months in the secondary IOL implantation. After 82.32 ± 48.91 months, the VA was 0.58 ± 0.35 LogMAR and the spherical equivalent was −2.20 ± 4.19 D. There was a negative correlation between a longer follow-up period and myopia at the SE measured (P = .001). The most frequent complications included glaucoma and corectopia. Performing the secondary IOL implantation ≤ 20 months of age was not a risk factor for glaucoma development (P = 0.095).

Conclusion

Secondary IOL implantation under 30 months of age is an option for children with unsatisfactory management of the optic treatment. A predictable IOL power calculation and satisfactory visual outcomes compared to results of later secondary IOL implantation are possible.

Long-term outcomes following primary intraocular lens implantation in infants younger than 6 months

Purpose:

To study the long-term safety profile and visual outcomes of primary intraocular lens (IOL) implantation in infants <6 months of age.

Methods:

This was a retrospective observational study conducted at a tertiary eye care center in South India. Infants under 6 months meeting the selection criteria who underwent cataract surgery (lens aspiration, primary posterior capsulorhexis, and anterior vitrectomy) with primary IOL implantation between January 2008 and December 2011 and minimum 3-year follow-up were included. Patient demographics, serial refractions, visual acuity, complications, and associated amblyopia/strabismus were reviewed. Visual acuity, myopic shift, and complications were the outcome measures.

Results:

Sixty-nine eyes of 38 infants (31 bilateral; mean age: 4.6 months) were reviewed. Mean follow-up was 51 months (range: 36–84). Median logMAR best-corrected visual acuity at the final visit was 0.74 (interquartile range [IQR]: 0.50–0.98) in eyes with bilateral cataracts and 0.87 (IQR: 0.60–1.14) in eyes with unilateral cataracts with an average myopic shift of 6.7 diopters over 4.2 years. Most common postoperative complication was visual axis opacification (VAO) (13 eyes, 18%), necessitating membranectomy followed by pigmentary IOL deposits (11 eyes, 15%), and IOL decentration and glaucoma in four eyes each (5.6%). Mixed linear effect model found no significant association of age, gender, laterality, and postoperative complications with final visual acuity (P ≥ 0.05). Eyes with unilateral cataracts had a greater myopic shift than bilateral cases (P = 0.03).

Conclusion:

Primary IOL implantation in infants <6 months is reasonably safe in appropriately selected infants. VAO was the most common postoperative complication, and a large myopic shift was observed.

Predicting Factor of Visual Outcome in Unilateral Idiopathic Cataract Surgery in Patients Aged 3 to 10 Years

Purpose

To report the surgical results of unilateral pediatric cataracts from uncertain causes in relatively older children and to identify factors related to better visual outcomes.

Methods

We retrospectively evaluated the medical records of 39 patients who underwent surgery between the ages of 3 and 10 years for unilateral pediatric cataracts of no known cause. All patients underwent primary intraocular lens implantation and postoperative amblyopia treatment. A postoperative final visual acuity better than 20 / 30 was considered to be a good visual outcome.

Results

The mean age of patients was 6.0 ± 1.8 years at the time of surgery. The mean preoperative visual acuity was 1.07 ± 0.71 logarithm of the minimum angle of resolution (range, 0.15 to 3.00), while the mean final postoperative visual acuity was 0.47 ± 0.54 logarithm of the minimum angle of resolution (range, 0.00 to 2.00). Of 39 patients, 18 (46.2%) achieved a good visual outcome. Only the preoperative visual acuity maintained a significant association with a good visual outcome according to our multivariate analysis (p = 0.040). A preoperative visual acuity of 20 / 100 or better was found to increase the chance of achieving a good visual outcome by 13.79-fold (95% confidence interval, 1.13 to 167.58).

Conclusions

The visual outcome of unilateral pediatric cataract surgery for cataracts with no specific cause identified in patients after three years of age could be satisfactory, especially with a preoperative visual acuity of 20 / 100 or better.

Effect of Exogenous Alpha-B Crystallin on the Structures and Functions of Trabecular Meshwork Cells

Purpose

Secondary open-angle glaucoma may develop as a postoperative complication of early childhood cataract surgery. Its mechanism is poorly understood. Surgical removal of cataracts is typically incomplete, and we estimate that this disease is associated with alpha-B crystallin (CRYAB) secreted from the retained lens material. This study, for the first time, focused on the role of CRYAB in undesired changes of the structures and functions in trabecular meshwork (TM) cells.

Methods

Cell proliferation and migration were assessed using a cell counting kit-8 (CCK8) and transwell assay analysis, respectively. Immunofluorescence (IF), quantitative real-time PCR (Rt-qPCR), and Western blot were performed to determine the effect of CRYAB on F-actin, tight junctions, and the expression of epithelial to mesenchymal transition- (EMT-) associated proteins in TM cells.

Results

CRYAB promoted proliferation (p < 0.0001), migration (p < 0.001), and F-actin reorganization in TM cells. There were statistically significant increases in the mRNA and protein levels of zo-1, cadherin-N, and vimentin (all p < 0.0001) and cadherin-E decreased (p < 0.0001) and the mRNA level of claudin-1 increased (p < 0.0001) compared to those of the control group.

Conclusion

All of the changes in structures and functions first observed in the TM cells after exposure to CRYAB resembled alterations seen in primary open-angle glaucoma, suggesting that CRYAB might be related to the pathogenesis of secondary open-angle glaucoma after congenital cataract surgery.

Incidence and Risk Factors of Early-onset Glaucoma following Pediatric Cataract Surgery in Egyptian Children: One-year Study

Aim

To study the incidence and risk factors of glaucoma occurring within 1 year following pediatric cataract surgery in Egyptian children.

Materials and methods

This is a prospective nonrandomized study conducted at Aburich Children’s Hospital, over a period of 1 year on a cohort of Egyptian patients with congenital and infantile cataract. One hundred and fifty eyes of 88 patients were enrolled in this study. All the patients underwent anterior approach removal of lens matter, whereas primary intraocular lens (IOL) implantation was carried at the age of 1 and 2 years for unilateral and bilateral cases respectively. Intraocular pressure (IOP) was measured at 1 week, 1 month, 3 months, 6 months, 9 months, and 1 year. For those who developed glaucoma, time of diagnosis and associated risk factors were reported.

Results

The incidence of glaucoma was 11.33% (17 of 150 eyes), while incidence of glaucoma suspect was 0.67% (1 of 150 eyes) in the first year following cataract surgery. The majority of the cases (66.7%) were discovered in the first 3 months postcataract surgery. Age at time of cataract surgery, the state of aphakia/pseudophakia, persistent fetal vasculature (PFV), and microphthalmia were not found to be significant predictors of early-onset glaucoma in our study.

Conclusion

Aphakic glaucoma continues to be a devastating condition with high incidence during first year following cataract surgery.

Clinical significance

Regular follow-up should start as early as possible following cataract surgery. Further prospective studies with larger study population are required.

How to cite this article: Gawdat GI, Youssef MM, Bahgat NM, Elfayoumi DM, Eddin MAS. Incidence and Risk Factors of Early-onset Glaucoma following Pediatric Cataract Surgery in Egyptian Children: One-year Study. J Curr Glaucoma Pract 2017;11(3):80-85.

Visual outcomes of dense pediatric cataract surgery in eastern China

Purpose

To evaluate the visual outcomes of dense pediatric cataract surgery in eastern China.

Methods

Medical records of children who underwent surgery for dense unilateral or bilateral pediatric cataract in Shandong Provincial Hospital between January 2007 and December 2012 were collected. Patients who cooperated with optical correction and aggressive patching of the sound eye and who had a minimum postoperative follow-up of more than 2 years were included. Risk factors for poor visual outcomes were analyzed.

Results

Of the 105 eligible patients (181 eyes), 76 had bilateral cataract, and 29 unilateral. With a mean follow up of 46.77 mo (range 24.0~96.0 mo), the final best corrected visual acuity (BCVA) of 158 eyes were recorded, and 4.43% (7/158) achieved 0.1 logarithm of the minimum angle of resolution (logMAR) or better; 15.19% (24/158) obtained a BCVA between 0.1 logMAR and 0.3 logMAR; 18.99%, (30/158) between 0.3 logMAR and 0.5 logMAR; 46.84% (74/158), between 0.5 logMAR and 1 logMAR; 14.55%, worse than 1 logMAR. The mean BCVA of the patients who underwent lensectomy before 3 months of age was significantly better than that of patients who underwent lensectomy between 3 and 12 months (p = 0.001). In the same lensectomy age groups, the final BCVA of the children in the bilateral and unilateral groups did not differ significantly (P>0.05). Lensectomy after 3 months of age, postoperative complications, strabismus and nystagmus were shown to be risk factors for poor visual outcomes.

Conclusions

Lensectomy before 3 months of age, IOL implantation, proper managing of postoperative complications, early optical correction and aggressive postoperative patching of the sound eye would increase the final BCVA for patients with dense pediatric cataract.

Long-term outcomes of ciliary sulcus versus capsular bag fixation of intraocular lenses in children: An ultrasound biomicroscopy study

Purpose

To evaluate the long-term outcomes of ciliary sulcus versus capsular bag fixation of intraocular lenses (IOLs) in children after pediatric cataract surgery.

Methods

IOL was implanted in the ciliary sulcus in 21 eyes of 14 children, and in the capsular bag in 19 eyes of 12 children for the treatment of pediatric cataract in an institutional setting. Ultrasound biomicroscopy (UBM) was performed. Main outcome measures included IOL decentration, IOL tilt, anterior chamber depth (ACD), angle-opening distance at 500 μm (AOD₅₀₀), trabecular-iris angle (TIA), best-corrected visual acuity (BCVA), intraocular pressure (IOP), and incidence of postoperative complications.

Results

The mean follow-up period was 6.81 ± 1.82 years. Comparing to the capsular bag fixation group, the ciliary sulcus fixation group had higher vertical IOL decentration, horizontal IOL tilt, and vertical IOL tilt (p = 0.02, 0.01,0.01, respectively), higher incidence of iris-IOL contact and peripheral anterior synechia (p = 0.001, 0.03, respectively), smaller ACD, AOD₅₀₀, and TIA (p = 0.02, 0.03, 0.04, respectively), higher mean IOP (17.10 ±6.06 mmHg vs.14.15± 4.74 mmHg, p = 0.01), and higher incidence of secondary glaucoma (28.57% vs. 10.53%, p = 0.007).There was no significant difference between the two groups with regard to the BCVA, refractive errors, incidence of myopic shift, nystagmus, strabismus, and visual axis opacity.

Conclusions

Ciliary sulcus fixation of IOLs in pediatric eyes may increase IOL malposition and crowding of the anterior segment, and may associate with a higher risk of secondary glaucoma compared to capsular bag fixation of IOLs.

The long-term anterior segment configuration after pediatric cataract surgery and the association with secondary glaucoma

Secondary glaucoma constitutes major sight-threatening complication of pediatric cataract surgery, yet the etiology remains unclear. The purpose of this study was to investigate the long-term anterior segment configuration and the association with secondary glaucoma in pediatric pseudophakia. Ultrasound biomicroscopy (UBM) was performed on 40 eyes of 26 children underwent pediatric cataract surgery and intraocular lens (IOL) implantation. The anterior chamber depth (ACD), angle-opening distance at 500 μm (AOD500), trabecular-iris angle (TIA), central corneal thickness (CCT), structural abnormities, IOL position, IOP, and incidence of glaucoma were evaluated. High insertion of iris, in which the iris root is attached more anteriorly than normal, was seen in 13 eyes (32.50%). IOL was located in the capsular bag in 19 eyes and in the ciliary sulcus in 21 eyes. Logistic regression analysis identified high insertion of iris (OR 3.40, 95% CI 1.03-11.17, p = 0.03) and IOL implantation in sulcus (OR 1.39, 95% CI 1.07-4.85, p = 0.04) as independent risk factors for glaucoma. The presence of high insertion of iris and IOL implantation in ciliary sulcus may increase the long-term risk of the development of secondary glaucoma after pediatric cataract surgery.

Current Status of IOL implantation in pediatric eyes: an update

INTRODUCTION

Pediatric cataracts are a huge problem worldwide, and with improving techniques and technology, the surgical treatment and postoperative visual rehabilitation are improving. Despite intraocular lenses(IOLs) being the standard of care for adult cataract surgery, this issue is still somewhat controversial, particularly in young children and infants due to lack of unequivocal evidence. This review therefore summarises the findings from recent studies on the aspect of IOL implantation in pediatric eyes. Areas covered: An extensive literature search was undertaken for published articles on congenital/developmental pediatric cataracts, and IOL implantation, where literature pertinent to traumatic and subluxated cataracts was not included in the review. Pubmed was used for literature search, and keywords entered were : pediatric, cataract surgery, intraocular lens, persistent fetal vasculature, outcomes, complications, visual performance with intraocular lenses. Expert commentary: Recent literature supports IOL implantation in most cases of congenital / developmental pediatric cataracts, and it seems like the way forward. However, the jury is still out on IOL implantation in infants, particularly in bilateral cataracts. Thus, surgeons must be extremely cautious in planning primary IOL implantation in infant eyes, and if they do perform IOL implantation, rigorous followup is mandatory.

Diagnosis of pupillary block glaucoma after removal of congenital cataracts with intraoperative ultrasound biomicroscopy: a case report

Background

Aphakic glaucoma is a common complication after congenital cataract extraction, especially in those who have surgery during infancy. This case report describes a case of bilateral pupillary block glaucoma diagnosed with intraoperative ultrasound biomicroscopy (UBM) after removal of congenital cataract.

Case presentation

We present a case report of a 9-month-old infant with bilateral corneal enlargement and ocular hypertension after uneventful removal of congenital cataracts. Initial and follow-up examination findings were reviewed. The infant was suspected to have developmental glaucoma and schemed to have bilateral trabeculotomy until pupillary obstruction by vitreous herniation and angle closure with iris bombé were detected by intraoperative UBM. Anterior vitrectomy and goniosynechialysis were then performed as treatment.

Conclusion

Pupillary block glaucoma is a rare type of infantile aphakic glaucoma. Application of intraoperative UBM can assist in the differential diagnosis of aphakic glaucoma in infants.

Visual Outcomes and Complications of Piggyback Intraocular Lens Implantation Compared to Aphakia for Infantile Cataract

Purpose:

To evaluate the long-term visual outcomes and complications of the piggyback intraocular lens (IOL) implantation compared to aphakia for infantile cataract.

Patients and Methods:

In a comparative study from 1998 to 2007, piggyback IOL implantation (piggyback IOL group) was performed for 14 infants (23 eyes) with infantile cataract and 20 infants (32 eyes) who were aphakic (aphakia group) after infantile cataract surgery. Data were collected on logMAR visual acuity, and postoperative complications over a mean follow-up time of 6.2 ± 1.7 years and 5.8 ± 1.7 years.

Results:

The mean age at surgery was 7.5 ± 0.6 months and 6.0 ± 3.3 months for the piggyback and the aphakic group respectively (P > 0.05). At the last follow-up visit, visual acuity was 0.85 ± 0.73 (median = 0.70, interquartile range = 0.3–1.32) in the piggyback IOL group and 0.89 ± 0.56 (median = 0.86, interquartile range = 0.50–1.24) in the aphakic group (P > 0.05). There was a positive relationship between age and visual outcomes in the aphakic group (r = 0.4, P = 0.04) but not in the piggyback IOL group (P = 0.48). There was no significant difference between the mean myopic shift in the piggyback IOL group (∑5.28 ± 1.06 D) and the aphakic group (∑5.10 ± 1.02 D) (P > 0.05). The incidence of reoperation due to complications in piggyback IOL group was higher than aphakic group (%48 vs. %16, respectively, P ≤ 0.01). However, in patients older than 6 months, this risk was not significantly different compared to the aphakic group.

Conclusions:

Although piggyback IOL implantation for infantile cataract is optically acceptable as a treatment option, there is no significant difference in visual outcomes compared to aphakia. The incidence in reoperation due to complications in patients aged 6 months or younger is higher than those treated with aphakia.