Primary posterior capsulorhexis with optic capture and intracameral heparin in paediatric cataract surgery

Full-Diffractive Multifocal Intraocular Lens Posterior Optic Capture for Selected Pediatric Cataracts

PURPOSE

To evaluate the short-term outcomes of implantation of a full-diffractive multifocal intraocular lens (IOL) with optic capture for selected pediatric cataracts.

METHODS

In this prospective study, patients with pediatric cataract aged 3 to 14 years were selected to receive multifocal IOL (Tecnis ZMB00; Abbott Medical Optics) posterior optic capture. Visual acuity, stereopsis, visual quality, and complications were assessed.

RESULTS

Forty-five patients (66 eyes) were recruited with a follow-up of 9.09 ± 5.93 months (range: 6 to 24 months). The cataract was bilateral in 21 patients and unilateral in 24 patients. At the last follow-up visit, the mean distance-corrected distance, intermediate, and near visual acuity was 0.28 ± 0.25, 0.43 ± 0.24, and 0.39 ± 0.27 logMAR, respectively. Among the patients with bilateral cataract, postoperative corrected distance visual acuity (CDVA) was 20/40 or better in 79% (33 of 42) of the eyes and 20/20 in 26% (11 of 42) of the eyes. Of the patients with unilateral cataract, 54% (13 of 24) achieved a CDVA of 20/40 or better but none obtained a CDVA of 20/20. All patients developed stereopsis postoperatively (P < .05). There was no significant difference in modulation transfer function cut-off and Strehl ratio between the eyes with a multifocal IOL and the healthy eyes of patients with unilateral cataract (P > .05). Objective Scatter Index values were significantly better in the healthy eyes (P < .05). No posterior capsule opacification, posterior synechiae, secondary glaucoma, pigmentary IOL deposits, or IOL decentration was observed during the follow-up period.

CONCLUSIONS

Short-term follow-up results suggest full-diffractive multifocal IOL optic capture may benefit appropriately selected patients with pediatric cataract. [J Refract Surg. 2021:37(6):390-397.].

Intraocular lens optic capture in pediatric cataract surgery

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

Effect of low molecular weight heparin (enoxaparin) on congenital cataract surgery

AIM

To assess the efficacy of intracameral enoxaparin (a low-molecular-weight heparin) infusion, in variable doses on postoperative inflammatory response in congenital cataract surgery.

METHODS

It is a prospective, randomized controlled trial. Eighty eyes of 53 children with congenital cataract were enrolled in this study. Every eye had primary posterior capsulorrhexis and intraocular lens (IOL) implantation after lens aspiration. The eyes were divided into 4 equal groups. In group 1 balanced salt solution (BSS) without enoxaparin was used as an irrigation solution. Whereas in group 2, 3 and 4, 40mg, 20mg and 10mg enoxaparin in 500mL BSS was used respectively. The inflammatory response in the anterior chamber was compared among the groups with slit-lamp biomicroscopy.

RESULTS

The mean follow-up period was (17.75±3.95) months in group 1, (18.00±5.15) months in group 2, (19.20±5.47) months in group 3 and (18.65±5.16) months in group 4. Mean number of inflammatory cells in the anterior chamber in group 1 was significantly higher than that of group 2, 3, 4 (P<0.001). There was fibrin formation in the anterior chambers of 3 eyes in group 1 and one eye in group 4. There was synechiae formation in 3 eyes of group 1 and one eye of group 4. There was no significant difference among the groups by means of fibrin or synechiae formation (P>0.05). There were IOL precipitates in 4 eyes of group 1 and 2 eyes of group 4. IOL precipitate formation was significantly higher in group 1 than that of group 2 and 3 in which there was no IOL precipitate (P=0.048). There was IOL subluxation in only one eye of group 1, 3 and 4 while no subluxation was observed in group 2 (P>0.05). There was no statistically significant difference detected about IOL subluxation occurance in all 4 groups (P>0.05).

CONCLUSION

Complications of cataract surgery in congenital cataract patients associated with postoperative inflammatory response found to be decreased with the use of enoxaparin in intraocular infusion solutions. Furthermore according to our results the anti-inflammatory effect of enoxaparin was dose dependant.

Anti-inflammatory effect of low-molecular-weight heparin in pediatric cataract surgery: a randomized clinical trial

PURPOSE

To determine if intraocular infusion of low-molecular-weight heparin (enoxaparin) reduces postoperative inflammation in pediatric eyes undergoing cataract surgery with IOL implantation.

DESIGN

Prospective masked randomized controlled trial.

METHODS

setting: Private, institutional practice. study population: Twenty children (40 eyes) undergoing bilateral cataract surgery with IOL implantation were randomized to receive enoxaparin in the intraocular infusion fluid (BSS) (Group I) or not to receive enoxaparin (Group II). The first eye was randomly assigned to 1 of the 2 groups and the second eye received alternate treatment. observation procedure: Patients were followed up in the first week and 1 and 3 months after surgery. main outcome measures: Anterior chamber flare and cells (Hogan's criteria), cell deposits on IOL, posterior synechiae.

RESULTS

One week postoperatively, no eyes had >grade 2 flare/cells. Proportion of eyes with grade 2 cells was higher in eyes that did not receive enoxaparin (Group II: 80% vs Group I: 40%, P = .009). In the first week >10 small cell deposits were noted in the eyes that received enoxaparin (Group I: 20%, Group II: none, P = .005). Large cell deposits first appeared at 1 month in 40% of eyes in Group I and 55% of eyes in Group II (P = .34) and increased at 3 months (60% in both groups, P > .999). Posterior synechiae were seen in 10% of eyes in Group I at 1 month, which persisted at 3 months; no eyes in Group II showed posterior synechiae (P = .14).

CONCLUSION

The results of our study suggest that there does not seem to be a benefit of using enoxaparin in the infusion fluid with respect to early postoperative inflammation.

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

Intraoperative enoxaparin minimizes inflammatory reaction after pediatric cataract surgery

PURPOSE

To evaluate the effect of intraocular infusion of enoxaparin, a low-molecular-weight heparin, on postoperative inflammatory response in pediatric cataract surgery.

DESIGN

Prospective, comparative, consecutive interventional case series.

METHODS

Seventeen consecutive eyes (11 patients) underwent pediatric cataract surgery in two tertiary medical centers. During the procedure, balanced salt solution with enoxaparin (40 mg in 500 ml) was infused into the anterior chamber. Eleven consecutive eyes (eight patients) received balanced salt solution without enoxaparin in the infusion bottle. The inflammatory response in the anterior chamber was compared between the two groups by semiquantification with slit-lamp biomicroscopy. Postoperative inflammatory complications, including fibrin formation, intraocular lens precipitates, anterior and posterior synechiae, cyclitic and pupillary membrane formation, and anterior subluxation of the intraocular lens, were also compared. The follow-up period after surgery was between 3 and 36 months (average 12.3 months).

RESULTS

The number of cells and the degree of flare were minimal in the group with enoxaparin in the infusion bottle (P < .001). The total number of postoperative inflammation-related complications was also lower in the enoxaparin-treated group (P = .007). All corneas remained clear, and the endothelial cell count, which was performed in two patients, did not show substantial decrease in their density or changes in shape and size. No other enoxaparin-related complications were observed.

CONCLUSIONS

Infusion of enoxaparin during pediatric cataract surgery may minimize the postoperative inflammatory response and decrease the number of postoperative inflammatory related complications. Enoxaparin should also be evaluated for cataract surgery in other conditions where postoperative inflammation may be exacerbated.

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.

Heparin in the intraocular irrigating solution in pediatric cataract surgery

PURPOSE

To investigate the antiinflammatory effects of adding heparin sodium to the irrigating solution to prevent fibrinoid reaction and related long-term complications after pediatric cataract surgery.

SETTING

Department of Ophthalmology, Inonu University, Turgut Ozal Medical Center, Malatya, Turkey.

METHODS

Thirty eyes of 18 children who had cataract or other ocular surgery were included in the study. Bilateral cataract surgery was performed in 20 eyes of 10 children and bilateral secondary intraocular lens (IOL) implantation in 4 eyes of 2 children (Group 1). Four eyes of 4 children had unilateral cataract surgery and 2 eyes of 2 children with previous perforating eye injury had synechiotomy and pupilloplasty (Group 2). Heparin sodium was added to the irrigating solution during surgery in 12 left eyes of children with bilateral surgery (Group 1a) and in all eyes in Group 2. Heparin sodium was not added during surgery in 12 right eyes of children having bilateral surgery (Group 1b, control). Early and late postoperative intraocular reactions were recorded and compared.

RESULTS

In Group 1a (heparin added), 6 eyes had less fibrinoid reaction and fewer related complications such as posterior synechias, pupil irregularity, and intraocular lens (IOL) decentration than the fellow right eyes. No eye in Group 1a having primary cataract surgery had hyphema or intraocular bleeding. Hyphema occurred on the first postoperative day in 1 eye in Group 1a that had secondary IOL implantation.

CONCLUSIONS

Adding heparin sodium to the irrigating solution decreased postoperative inflammatory and fibrinoid reactions and related complications such as synechias, pupil irregularity, and IOL decentration in pediatric cataract surgery. However, the use of heparin during surgery can be risky in eyes with a defective blood-aqueous barrier such as after previous ocular surgery.

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

PURPOSE

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

SETTING

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

METHODS

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

RESULTS

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

CONCLUSIONS

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