Complications in the first year following cataract surgery with and without IOL in infants and older children

Risk of visual axis opacification in infants with and without primary IOL implantation after congenital cataract surgery performed during the first 4 months of age

PURPOSE

The study evaluates the rate of postoperative formation of a pupillary membrane (PM) and posterior visual axis opacification (PVAO) in infants with and without primary IOL implantation during the first 4 months of infancy.

METHODS

Medical records for 144 eyes (101 infants) operated between 2005 and 2014 were evaluated. A posterior capsulectomy and anterior vitrectomy were performed. Primary IOL implantation was performed in 68 eyes, while 76 eyes were left aphakic. There were 16 bilateral cases in the pseudophakic group and 27 in the aphakic group. The follow-up period was 54.3 ± 21.05 months and 49.1 ± 18.60 months, respectively. Fisher's exact test was used for statistical analysis. The two-sample t-test with equal variance was used to compare surgery age, follow-up period and time intervals of complications.

RESULTS

The mean age of surgery was 2.1 ± 0.85 months in the pseudophakic and 2.2 ± 1.01 months in the aphakic group. PM was diagnosed in 40% pseudophakic and 7% aphakic eyes. A second surgery for PVAO was performed in 72% pseudophakic and 16% aphakic eyes. Both were significantly higher in the pseudophakic group. In the pseudophakic group, the number of PVAO was significantly higher in infants operated before 8 weeks of age compared to surgery age 9-16 weeks. The frequency of PM was not age-dependent.

CONCLUSION

Although it remains feasible to implant an IOL during the primary surgery, even in very young infants, there should always be solid arguments for this decision since it puts the child at higher risk of repeated surgeries under general anaesthesia.

Assessment of long-term visual outcomes in aphakic children wearing scleral contact lenses

BACKGROUND

Timely management of aphakic children is critical for the rehabilitation of adequate visual gain. This study aims to evaluate the long-term efficacy of scleral contact lenses in terms of visual outcomes, complications, and compliance in aphakic children.

METHODS

Retrospective data review of children with congenital or acquired cataract, or subluxated crystalline lenses, who underwent lensectomy from 2004 to 2018 and who used scleral contact lenses for refractive correction. Collected data from the follow up period included recorded aphakic refraction and visual acuity, complications following scleral contact lens wear documented in the clinic and ophthalmic emergency room and compliance to lens wear according to parental feedback on every visit in the clinic.

RESULTS

76% of cases, with final best corrected visual acuity (BCVA) of 20/40 or better achieved in seventeen eyes (34%). The rate of amblyopia was 50%. Strabismus developed in 56% of children, and those had less favourable visual outcomes (0.43 ± 0.4 LogMAR without strabismus and 0.8 ± 0.5 LogMAR with strabismus, p = 0.015). No corneal infections were documented during the follow up. Main adverse effect on the ocular surface was superficial punctate keratopathy (n = 16). Compliance was good in 48 children (96%)- except for two cases, the scleral lenses were tolerated well by all children.

CONCLUSION

Scleral contact lenses are an effective means of visual rehabilitation in aphakic children after lensectomy and may be used long-term with good compliance of wear, excellent visual outcomes, and tolerable adverse events.

Pediatric cataract surgery: considerations and updates in diagnosis and management

PURPOSE OF REVIEW

The purpose of this review is to provide an overview of updates in the diagnosis and management of pediatric cataracts, with an emphasis on recent discoveries in the last two years.

RECENT FINDINGS

Pediatric cataracts remain an infrequent but significant disease with vision threatening consequences. Although much of the management has not changed historically, more recent updates, particularly borrowed from adult cataract management, have influenced the field of cataract management in children. Even these studies emphasize that pediatric cataracts are a distinct clinical entity from adult-onset cataracts, and further research is needed to optimize the diagnosis and management of cataracts in childhood.

SUMMARY

This is an overview of the recent advancements in the diagnosis of management of pediatric cataracts, with advancements that originate from the adult cataract surgery field in addition to studies that challenge classical surgical techniques to make cataract surgery safer and to promote amblyopia therapy.

Endophthalmitis after pediatric cataract surgery in the United States: report using an insurance claims database

PURPOSE

To describe the characteristics and incidence of children developing endophthalmitis within the first 90 days following pediatric cataract surgery.

SETTING

Deidentified commercial and Medicare Advantage health claims across the United States.

DESIGN

Population-based retrospective cohort study.

METHODS

In a retrospective review of approximately 58 million charts in Optum's deidentified Clinformatics Data Mart Database, patients aged <13 years who underwent cataract surgery in one or both eyes with or without primary intraocular lens (IOL) implantation between 2003 and 2017 were identified. Excluded were patients with traumatic cataract, <90 days of continuous insurance coverage, a prior diagnosis of endophthalmitis, and a diagnosis of endophthalmitis occurring after 90 days of cataract surgery. The main outcome measure was the incidence of endophthalmitis occurring within the first 90 days of cataract surgery and the odds ratio for developing endophthalmitis according to demographic and intraoperative factors.

RESULTS

Cataract surgery was performed on 789 eyes (52.6% male), with a median age of 4 (interquartile range 1-8) years. The rate of IOL implantation at the time of cataract surgery was 66.8%. Endophthalmitis was diagnosed in 4 of 789 eyes (0.51%). The median time to diagnosis of endophthalmitis was 6.5 days (range: 5-44 days). There was no significant association between endophthalmitis and age, sex, or primary IOL implantation.

CONCLUSIONS

In this large insurance claims database, the incidence of endophthalmitis following pediatric cataract surgery reported was more than the rate previously reported by any study with patients of a similar age.

Advisability of primary intraocular lens implantation for infants under 2: A systematic review and meta-analysis

PURPOSES

The present meta-analysis compared the postoperative visual performance of primary intraocular lens (IOL) implantation and primary aphakia in cataract infants.

METHODS

PubMed, Embase, Science Direct and Cochrane Library were searched, and postoperative visual acuity (VA) and complications were extracted and pooled.

RESULTS

Three randomised controlled trails (RCTs) and five retrospective studies were included. The postoperative VA of children younger than 4.5 years in primary IOL group was better than that in primary aphakia group [MD = -0.14, 95% CI: (-0.23, -0.06), P = .90]. The subgroup analysis based on RCTs and on unilateral cataract surgery revealed the same result. There was no significant difference in the incidence of glaucoma, strabismus, retinal detachment and nystagmus between primary IOL group and primary aphakia group [OR = 1.02, 95% CI: (0.62, 1.68), P = .48 for glaucoma; OR = 0.76, 95% CI: (0.30, 1.90), P = .05 for strabismus; OR = 0.49, 95% CI: (0.07, 3.30), P = .34 for retinal detachment; OR = 1.26, 95% CI: (0.68, 2.36), P = .92 for nystagmus]. The proportion of patients requiring postoperative visual axis opacification (VAO) clearing was higher in primary IOL group than that in primary aphakia group [OR = 9.22, 95% CI: (4.74, 17.96), P = .16].

CONCLUSION

For infants under 2 years of age, primary IOL implantation would provide more visual benefits compared with primary aphakia did, though the benefits would taper off with the age reaching 4.5 years. Moreover, the current study revealed a higher VAO incidence r in primary IOL implantation group.

Visual outcomes following cataract surgery with intraocular lens implantation in vitrectomized eyes among children

Purpose:

To assess the visual outcomes and associated factors in pediatric patients undergoing cataract surgery following pars plana vitrectomy (PPV).

Methods:

A total of 52 eyes of 52 children who underwent cataract surgery and intraocular lens (IOL) implantation in previously vitrectomized eyes between January 2008 and December 2017 were included in this retrospective study. Descriptive and inferential statistical measurements (Chi-square test, Fisher's exact test, odds ratio, multiple logistic regression) were done.

Results:

The mean age at PPV was 11.3 ± 2.9 years. The most common indication for PPV was retinal detachment in 43 eyes (82.69%) and vitreous hemorrhage in 6 eyes (11.53%). The mean preoperative and postoperative best-corrected visual acuity (BCVA) was 1.31 ± 0.48 logMAR (logarithm of the minimum angle of resolution) units (20/400) and 0.69 ± 0.45 logMAR units (20/100), respectively; P < 0.001. The final visual outcome was good in 37 eyes (71.15%) and poor in 15 eyes (28.85%). In mean follow-up of 4 years, 42.3% developed posterior capsular opacification, 13.5% developed glaucoma, and 3.8% had retinal redetachment after cataract surgery. In the presence of macular pathology, the visual outcome was poor (aOR [adjusted odds ratio] = 4.26, P = 0.002).

Conclusion:

Cataract surgery with IOL implantation in vitrectomized eyes among children is a safe procedure and can improve visual acuity and quality of life. However, the extent of improvement is limited by macular pathology.

Accuracy of Intraocular Lens Power Calculation in Children With Vitrectomized Eyes Undergoing Cataract Surgery

PURPOSE

To assess the predictability of desired postoperative refractive outcomes using the SRK-II formula for intraocular lens (IOL) power calculation in children undergoing cataract surgery in eyes with a previous pars plana vitrectomy (PPV).

METHODS

In this retrospective study, 68 eyes of 66 children who underwent cataract surgery and IOL implantation in eyes that had previous vitrectomy between January 2008 and December 2017 were included. Data were collected on preoperative and postoperative characteristics. The Mann-Whitney test, Kruskal-Wallis test, and multinominal logistic regression were used for comparing the results.

RESULTS

Absolute prediction error (APE) in the cohort was 1.29 ± 1.13. Desirable refractive outcome with insignificant prediction error of less than 0.50 diopters (D) was found in approximately one-third of the children. Patients were further subdivided by magnitude of APE as ≥ 0.50 to ≤ 1.00 D and > 1.00 D. Age at the time of surgery, axial length, mean keratometry, silicone oil removal, IOL position, scleral buckle, and corneal suture did not affect APE and there was no significant difference between the groups (P > .05).

CONCLUSIONS

The mean APE of the SRK-II formula for IOL power calculation in pediatric eyes that had vitrectomy is comparable to that reported in the literature for routine pediatric cataract surgeries. Factors such as age, axial length, corneal power, IOL position (bag/sulcus), scleral buckle, corneal suture, and silicone oil removal done prior to surgery or along with cataract surgery did not affect the APE. [J Pediatr Ophthalmol Strabismus. 2021;58(2):126-131.].

Microperipheral Iridectomy for Troublesome Posterior Synechiolysis in Secondary Intraocular Lens Implantation

Purpose

To introduce an effective method for separating extensive posterior synechiae and those located under or adjacent to surgical incisions.

Methods

Pediatric patients who had been subjected to cataract surgery and developed troublesome posterior synechiae requiring secondary intraocular lens (IOL) implantation were recruited. All patients underwent microperipheral iridectomy at the 12 o'clock position. Then, an ophthalmic viscosurgical device was injected into the posterior chamber through the iris fistula to mechanically separate the posterior synechiae, using scissors to cut robust posterior synechiae if necessary. The results of posterior synechiolysis and the position of the implanted IOL were analyzed.

Results

Sixteen patients (median age, 51.56 months; range, 28–80 months) were included. The scope of posterior synechia in clock was 4.42 (range, 1–10). All troublesome posterior synechiae were successfully separated using the microperipheral iridectomy method, and all patients underwent IOL implantation in the ciliary sulcus. There was one case of peripheral iridectomy-related early intraoperative bleeding; no bleeding was observed at the end of surgery.

Conclusions

Microperipheral iridectomy is a useful method for the management of troublesome posterior synechiae during secondary IOL implantation in pediatric patients, which makes secondary IOL implantation an easier and safer method in some challenging cases.

Developmental characteristics of the cytokine profile in aqueous humor and its relationship with the inflammatory response in children

Background

Although influencing the severity of postoperative intraocular inflammation of congenital cataract, the developmental characteristics of cytokine profile in the aqueous humor during childhood had not been described. And its relationship with the inflammatory response after intraocular surgery remained unsolved.

Methods

Preoperative aqueous humor samples were collected from 65 eyes of congenital cataract patients (CC group) and 13 eyes of age-related cataract patients (ARC group) from January 2015 to May 2017. The concentrations of 22 cytokines were measured. Differences in concentrations between the CC and ARC groups were described. Correlation analysis, least absolute shrinkage and selection operator (LASSO) and multivariate linear regression were then used to investigate the dynamic changes in the cytokine profile with age and their relationships with the postoperative inflammatory response.

Results

The concentrations of granulocyte colony stimulating factor (G-CSF), interferon (IFN)-α2, interleukin (IL)-1α and IL-7 were higher in the CC group than in the ARC group, while the concentrations of epidermal growth factor (EGF), granulocyte-macrophage colony stimulating factor (GM-CSF), IL-10, IL-12p70, IL-2, IL-3, IL-4, IL-5, IL-6, IL-8, and tumor necrosis factor (TNF)-α were more abundant in the ARC group (P<0.05). Within the CC group, the concentrations of EGF and IL-3 were positively correlated with age, while negative correlations were observed for monocyte chemotactic protein-1 (MCP-1) and IL-8 (P<0.05). Further multivariate analysis revealed that age was an independent associated factor of MCP-1 (β=−0.337, P<0.001). IL-3 (β=−0.490, P=0.006) and EGF (β=−0.415, P=0.044) were significantly correlated with the postoperative inflammatory response [evaluation of posterior capsule opacification (EPCO)] at 3 and 12 months after surgery, respectively.

Conclusions

This study demonstrated the dynamic change in the cytokine profile of the aqueous humor in children and its relationship with the postoperative inflammatory response. These findings can serve as the foundation for further investigation into the mechanisms that underlie the early development of intraocular immunology.

Postoperative outcomes of intraocular lens implantation in the bag versus posterior optic capture in pediatric cataract surgery

PURPOSE

To compare complications in children up to 4 years old having cataract surgery with intraocular lens (IOL) implantation using 2 techniques: in-the-bag IOL with anterior vitrectomy or optic capture of IOL with no anterior vitrectomy.

SETTING

Iladevi Cataract & IOL Research Centre, Ahmedabad, India.

DESIGN

Prospective randomized control clinical trial.

METHODS

The study included children having cataract surgery with IOL implantation. Patients were randomized to Group 1 (in-the-bag 3-piece hydrophobic acrylic IOL [Acrysof MA60AC] with anterior vitrectomy) or Group 2 (optic capture of the same IOL without anterior vitrectomy). Intraoperative complications were documented. Postoperative visual axis obscuration (VAO), glaucoma, cell deposits on the IOL, and posterior synechiae were compared at 1, 3, 6, and 12 months.

RESULTS

The study comprised 61 children (61 eyes). The mean ages were 14.8 months ±11.47 (SD) in Group 1 (n = 30) and 18.2 ± 11.47 months in Group 2 (n = 31). Overall, only 1 eye in Group 1 developed a VAO requiring membranectomy 4 months postoperatively, and 2 eyes in Group 1 developed glaucoma over 12 months (P = .49). Intraocular lens cell deposits and posterior synechiae were comparable between groups. The IOL could not be captured in 5 eyes (16.1%); no complications occurred in these eyes.

CONCLUSIONS

Optic capture of 3-piece hydrophobic acrylic IOLs could be achieved in most eyes. The VAO, glaucoma, and inflammation were comparable 12 months postoperatively. Thus, optic capture of an IOL is an alternative surgical technique that can be used to avoid vitrectomy, even in children younger than 4 years.

Long-Term Outcome of Nd:YAG Laser Posterior Capsulotomy in Children: Procedural Strategies and Visual Outcome

PURPOSE

To evaluate the long-term outcome of neodymium:yttrium-aluminum-garnet (Nd:YAG) laser posterior capsulotomy after cataract surgery in children.

DESIGN

Retrospective case series.

METHODS

Electronic medical records of pediatric patients who underwent Nd:YAG laser posterior capsulotomy between January 1, 2008, and October 31, 2012, and followed up for more than 5 years were reviewed.

RESULTS

Thirty-one eyes of 25 patients were included. Only compliant patients assessed during slit-lamp examination and anterior segment photography underwent laser treatment. The mean age at the time of initial laser treatment was 9.04 ± 3.51 years (minimum 56 months), and the mean interval between cataract surgery and initial laser treatment was 28.1 ± 22.1 months. Posterior capsular openings were successfully made in 26 (83.9%) eyes with a single attempt and in 3 (9.7%) eyes with a second attempt. Overall success rate was 93.5%. The logMAR best-corrected visual acuity was significantly improved from 0.61 ± 0.36 to 0.19 ± 0.25 at 1 month posttreatment (P < .0001) and well maintained, at least for 5 years of follow-up, without serious complications. The recurrence of posterior capsular opacity was observed in 7 (24.1%) eyes, which was successfully managed by repeated laser procedure or surgical capsulectomy.

CONCLUSIONS

By selecting compliant patients and repeated attempts, Nd:YAG laser posterior capsulotomy can be successfully performed in a pediatric population without serious complications. Laser treatment is also a good option for managing recurred posterior capsular opacity. Restored visual acuity can be maintained for at least 5 years.

Outcomes of cataract surgery in Microophthalmia

Objective

To find out outcomes of cataract surgery with Microophthalmia in children less than two years.

Methods

This cross-sectional study was conducted at Al-Ibrahim Eye Hospital, Karachi from January 2016 to August 2017. It included thirty micro ophthalmic eyes of infants with visually significant cataract of age less than two years who had cataract surgery without intraocular lens implantation. Axial length of globe was 19 mm or less in all thirty eyes of seventeen infants. in which thirteen infants had bilateral cataract and four had unilateral cataract.

Result

Thirty Simple Micro ophthalmic eyes from seventeen patients having visually significant congenital cataract were studied. Thirteen had bilateral cataract and four had unilateral cataract. Mean preoperative IOP was 9.0±1.2 mmHg and postoperative IOP after three months was 10.9±3.2 mmHg. Three patients had secondary capsular opacification 17.6%. Two patients had posterior synachae 11.8% after three months.

Conclusion

The results suggest that cataract surgery in simple microophthalmia is safe procedure. Postoperative complications in this study were within acceptable limits. Long term study with intraocular lens is required to confirm our observation.

Outcome of primary intraocular lens implantation in infants: Complications and rates of additional surgery

PURPOSE

To study the requirement of additional surgery and adverse events in infants having primary intraocular lens (IOL) implantation.

SETTING

Tertiary care institute, Chandigarh, India.

DESIGN

Prospective observational noncomparative case series.

METHODS

Infants who had phacoaspiration, primary posterior capsulotomy, anterior vitrectomy, and primary IOL implantation were evaluated for complications and the need for additional surgery over a 3-year period. The main outcome measures were the rate of complications, adverse events, and need for additional surgery.

RESULTS

Sixty infants (100 eyes) with a mean age of 7.13 months ± 2.32 (SD) (range 3 to 12 months) were studied. The mean follow-up was 41.2 ± 3.5 months. Indication of additional surgery included visual axis opacification in 13 eyes, pupillary membrane/IOL decentration in 4 eyes, and iris prolapse in 4 eyes. Adverse events included pigment on the IOL in 14 eyes and iridolenticular adhesions in 9 eyes. Ocular hypertension was observed in 2 eyes. The IOL was placed in sulcus or by optic capture in 14 eyes. There was no difference in additional surgery and adverse events between infants aged 6 months or younger versus those older than 6 months (P = .734).

CONCLUSION

There was a low incidence of adverse events and additional surgery requirement in infants who had cataract surgery with primary IOL implantation.

FINANCIAL DISCLOSURE

None of the authors has a financial or proprietary interest in any material or method mentioned.

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 in Pediatric Developmental Cataract Surgery with Primary Intraocular Lens Implantation

OBJECTIVES

The aim of this study was to evaluate the outcomes of pediatric developmental cataract surgery with primary intraocular lens (IOL) implantation.

MATERIALS AND METHODS

Patients between 2 and 16 years old who underwent cataract surgery with primary IOL implantation were retrospectively evaluated. Age at time of surgery, pre- and postoperative best corrected visual acuities, postoperative ocular complications, and any accompanying ocular pathologies were obtained from the patients' charts. Mean refractive changes and degree of myopic shift were analyzed according to the age groups. Operated eyes were also compared with the fellow eyes in unilateral cases.

RESULTS

A total of 101 eyes of 65 patients were included. The average age at time of surgery was 76±40 months and the average follow-up period was 44±30 months. Among the 78 eyes that could be assessed for visual acuity improvement, 66 (84.6%) of them showed ≥2 lines of improvement. The difference in the mean refractive change between the 2-5 years old and 8-16 years old age groups was found to be statistically significant. However, the mean refractive change per year was not found to be significant between the same age groups. In unilateral cases, the operated eyes showed a greater myopic change than the fellow eyes, with no statistically significant difference. The most common postoperative complication was visual axis opacity.

CONCLUSION

Good visual outcomes can be achieved following pediatric cataract surgery with primary IOL implantation. Optic axis opacities were the most common postoperative complications. Overall, refractive changes following surgery are inevitable, and more prominent in younger age groups.

Surgical Outcome of Congenital Cataract in Eyes With Microcornea

PURPOSE

To report the intraoperative and postoperative outcomes of congenital cataract surgery in eyes with microcornea.

METHODS

In this retrospective, interventional, comparative case series, the authors reviewed 47 eyes of 26 children with microcornea and congenital cataract (21 bilateral and 5 unilateral) who underwent lens aspiration with primary posterior capsulectomy and anterior vitrectomy between 2008 and 2014 with a minimum follow-up period of 6 months. Demographic profiles and systemic and ocular features were documented. Intraoperative and postoperative complications were studied separately for bilateral and unilateral cases. Patients were also divided into two groups on the basis of their ages at surgery (early surgery group: 3 months or younger; late surgery group: older than 3 months) and postoperative complications were compared. Visual outcome was analyzed in those with a follow-up period of more than 1 year.

RESULTS

Early surgery was performed in 24 eyes of 13 patients (11 bilateral and 2 unilateral) and late surgery in 23 eyes of 13 patients (10 bilateral and 3 unilateral). Intraoperatively, all eyes had poor pupillary dilatation and 6 (12.8%) eyes needed iris hooks. Postoperatively, the most common early complication was transient corneal edema observed in 22 (46.8%) eyes (13 and 8 eyes in the early and late surgery groups, respectively). Late complications included visual axis opacification in 6 (12.76%) eyes (3 in each group), and secondary glaucoma in 5 (10.64%) eyes (2 and 3 eyes in the early and late surgery groups, respectively). Vision was normal for age in 18 (60%) of the bilateral cases with a follow-up period of more than 1 year.

CONCLUSIONS

Early surgical intervention for congenital cataract in eyes with microcornea can result in favorable outcomes with an acceptable rate of postoperative complications. [J Pediatr Ophthalmol Strabismus. 2018;55(1):30-36.].

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.

Second intraocular surgery after primary pediatric cataract surgery: indications and outcomes during long-term follow-up at a tertiary eye care center

PurposeAlthough pediatric cataract surgery has become standardized and safe, further surgical interventions are not uncommon. The purpose of this study was to analyze the incidence of complications in children who required an intraocular intervention.MethodsA retrospective review of medical records of children (<7 years) with cataract who underwent cataract surgery with or without primary posterior chamber intraocular lens (IOL) placement between January 2006 and December 2014 was carried out. Data were collected regarding visual axis opacification (VAO), glaucoma, IOL decentration, intraocular infections, and other indications that required a second intraocular surgery.ResultsOut of 814 (570 pseudophakic and 244 aphakic) eyes of 620 operated children, 45 eyes of 40 children (5.5%, 45/814) needed a second surgery. The most common indication being VAO (2.9%, 24/814), followed by glaucoma (0.73%, 6/814). Incidence of complications was higher in children <1 year (VAO 6.1%, 19/308 and glaucoma 6%, 6/308). Among all children, repeat interventions and VAO were slightly less frequent in pseudophakics (4.91%, 28/570) vs aphakics (6.91%, 17/244) (P=0.31). As VAO was more common in pseudophakic eyes in infants, glaucoma was equally common in both groups. Best-corrected visual acuity improved from 1.6±0.56 LogMAR preoperatively to 0.80±0.50 LogMAR postoperatively.ConclusionsOur study suggests that overall incidence of second intraocular surgery is low after primary pediatric cataract surgery. VAO remains the most common indication followed by secondary glaucoma. Incidence of complications is higher in children <1 year of age at initial surgery.

Delayed sclerotomy wound dehiscence after lensectomy and vitrectomy in Marfan syndrome

Marfan syndrome (MFS) is associated with abnormal fibrillin development that can cause morbidity and mortality. A case of acute onset hypotony due to sclerotomy wound dehiscence 13 years after 20-gauge pars plana vitrectomy and lensectomy is reported in a patient with MFS. Slit lamp examination revealed a leaking sclerotomy wound and intraoperatively the source was noted to be the prior sclerotomy site. On postoperative follow-up, the patient's vision returned to baseline, and intraocular pressure normalized. Twenty-gauge sclerotomy wound dehiscence may occur years after surgery, especially in patients with abnormal collagen as in MFS.

Complications in the first 5 years following cataract surgery in infants with and without intraocular lens implantation in the Infant Aphakia Treatment Study

PURPOSE

To compare rates and severity of complications between infants undergoing cataract surgery with and without intraocular lens (IOL) implantation.

DESIGN

Prospective randomized clinical trial.

METHODS

A total of 114 infants were enrolled in the Infant Aphakia Treatment Study, a randomized, multi-center (12) clinical trial comparing the treatment of unilateral aphakia in patients under 7 months of age with a primary IOL implant or contact lens. The rate, character, and severity of intraoperative complications, adverse events, and additional intraocular surgeries during the first 5 postoperative years in the 2 groups were examined.

RESULTS

There were more patients with intraoperative complications (28% vs 11%, P = .031), adverse events (81% vs 56%, P = .008), and more additional intraocular surgeries (72% vs 16%, P < .0001) in the IOL group than in the contact lens group. However, the number of patients with adverse events in the contact lens group increased (15 to 24) in postoperative years 2-5 compared to the first postoperative year, while it decreased (44 to 14) in years 2-5 compared to the first postoperative year in the IOL group. If only one half of the patients in the contact lens (aphakic) group eventually undergo secondary IOL implantation, the number of additional intraocular surgeries in the 2 groups will be approximately equal.

CONCLUSION

The increased rate of complications, adverse events, and additional intraocular surgeries associated with IOL implantation in infants <7 months of age militates toward leaving babies aphakic if it is considered likely that the family will be successful with contact lens correction.

Comparison of contact lens and intraocular lens correction of monocular aphakia during infancy: a randomized clinical trial of HOTV optotype acuity at age 4.5 years and clinical findings at age 5 years

IMPORTANCE

The efficacy and safety of primary intraocular lens (IOL) implantation during early infancy is unknown.

OBJECTIVE

To compare the visual outcomes of patients optically corrected with contact lenses vs IOLs following unilateral cataract surgery during early infancy.

DESIGN, SETTING, AND PARTICIPANTS

The Infant Aphakia Treatment Study is a randomized clinical trial with 5 years of follow-up that involved 114 infants with unilateral congenital cataracts at 12 sites. A traveling examiner assessed visual acuity at age 4.5 years.

INTERVENTIONS

Cataract surgery with or without primary IOL implantation. Contact lenses were used to correct aphakia in patients who did not receive IOLs. Treatment was determined through random assignment.

MAIN OUTCOMES AND MEASURES

HOTV optotype visual acuity at 4.5 years of age.

RESULTS

The median logMAR visual acuity was not significantly different between the treated eyes in the 2 treatment groups (both, 0.90 [20/159]; P = .54). About 50% of treated eyes in both groups had visual acuity less than or equal to 20/200. Significantly more patients in the IOL group had at least 1 adverse event after cataract surgery (contact lens, 56%; IOL, 81%; P = .02). The most common adverse events in the IOL group were lens reproliferation into the visual axis, pupillary membranes, and corectopia. Glaucoma/glaucoma suspect occurred in 35% of treated eyes in the contact lens group vs 28% of eyes in the IOL group (P = .55). Since the initial cataract surgery, significantly more patients in the IOL group have had at least 1 additional intraocular surgery (contact lens, 21%; IOL, 72%; P < .001).

CONCLUSIONS AND RELEVANCE

There was no significant difference between the median visual acuity of operated eyes in children who underwent primary IOL implantation and those left aphakic. However, there were significantly more adverse events and additional intraoperative procedures in the IOL group. When operating on an infant younger than 7 months of age with a unilateral cataract, we recommend leaving the eye aphakic and focusing the eye with a contact lens. Primary IOL implantation should be reserved for those infants where, in the opinion of the surgeon, the cost and handling of a contact lens would be so burdensome as to result in significant periods of uncorrected aphakia.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT00212134

Hydrophobic acrylic versus polymethyl methacrylate intraocular lens implantation following cataract surgery in the first year of life

PURPOSE

To evaluate complication rates following implantation of hydrophobic acrylic versus polymethyl methacrylate (PMMA) intraocular lens (IOL) with cataract surgery in infants.

METHODS

Records of children undergoing cataract surgery with IOL implantation in first year of life were retrospectively reviewed. Infants were divided into two groups--hydrophobic acrylic IOLs were implanted in group A, and PMMA IOLs in group B. Outcome measures included incidence of complications, additional surgical procedures, and refractive error changes.

RESULTS

One hundred and thirteen eyes of 113 children (75 males) with mean age of 6.49 ± 3.56 months were included. Group A included 62 eyes, and group B included 51 eyes. The two groups did not differ significantly in terms of age and axial length. There was no significant difference between the groups for incidence of posterior capsular opacification (PCO), pupillary membranes, glaucoma, fibrin on IOL surface or IOL malposition (p = 0.09). Development of PCO was delayed in group A (p = 0.049). Thirteen eyes of group A and 18 eyes of group B required additional surgical intervention (p = 0.20) in the follow-up visits.

CONCLUSION

Comparable complications may be expected in infants with PMMA and hydrophobic acrylic lenses. Children implanted with PMMA IOLs may require earlier surgical re-intervention for PCO.

Intraoperative usefulness and postoperative results of the endoilluminator for performing primary posterior capsulectomy and anterior vitrectomy during pediatric cataract surgery

PURPOSE

To analyze the intraoperative usefulness and postoperative results of endoilluminator use during pediatric cataract surgery.

METHODS

Medical records of children <8 years of age who underwent lens aspiration with primary posterior capsulectomy (PPC) and anterior vitrectomy (AV) with or without intraocular lens implantation (IOL) were studied. An endoilluminator was used intraoperatively as an external light source in all cases to ensure the completeness of PPC and adequacy of AV. All children were divided into three groups depending upon the age at surgery and presence of IOL. We included only the first operated eye in bilateral cases. We studied the intraoperative performance for all and postoperative complications for those with >6 months follow-up.

RESULTS

The charts of 79 eyes of 46 children (26 boys, 20 girls: 33 bilateral, 13 unilateral) were reviewed, of which we analyzed 46 eyes of 46 children for intraoperative performance and 42 eyes of 42 children for postoperative complications. The intraoperatively adequate size of PPC was obtained in all cases with no vitreous in the anterior chamber. Two cases in the first group developed peaking of the pupil, and one case developed visual axis contraction requiring membranectomy. None of the cases in the other groups developed any complication.

CONCLUSION

An endoilluminator is a simple, safe, and powerful tool for better visualization of the posterior capsule and anterior vitreous during pediatric cataract surgery. It helps in confirming a good vitrectomy, ensuring its completeness and thereby reducing the chances of any complication due to inadequate AV.

Pediatric infectious endophthalmitis: a review

Infectious endophthalmitis is a rare but severe complication of septecemia, intraocular surgeries, or penetrating eye trauma. The etiology, prognosis, and management of pediatric endophthalmitis resulting from exogenous and endogenous infections are reviewed. Open-globe trauma and glaucoma surgery are the most frequent causes of endophthalmitis in children, whereas endogenous infection is the least common cause. Streptococcus and Staphylococcus species are common bacterial agents in both posttraumatic and postoperative pediatric endophthalmitis, whereas Candida albicans is a commonly reported organism in endogenous endophthalmitis. Additionally, Streptococcus pneumoniae and Haemophilus influenzae appear more likely as pathogens in children than in adults. The clinical manifestations and outcome usually correlate with the virulence of the infecting organism. The visual prognosis of endophthalmitis is generally poor.

Results of congenital cataract surgery with and without intraocular lens implantation in infants and children

BACKGROUND

Operations for congenital cataract in children in the past had resulted in aphakia. Improvement in surgical tools and techniques as well as in intraocular lens (IOL) implantation has led to correction of the aphakia by IOL implantation. We report the outcome of cataract surgery with and without IOL on these children in our institution between 1991-2008.

METHODS

In this retrospective cohort study, the medical records of all children who underwent surgery for congenital cataract were reviewed. The final study group included 144 children (218 eyes). Postoperative visual acuity (VA) was tested either by Teller Acuity Cards (in preverbal children) or by the Snellen chart. Data on VA status and postoperative complications were retrieved.

RESULTS

Patients with bilateral cataract had better postoperative VA than patients with unilateral cataract (logMAR 0.559 ± 0.455 vs. 0.919 ± 0.685, respectively, P < 0.001). Children who underwent IOL implantation had better postoperative VA than those who did not, but the type of surgery had no significant effect after correction for the child's age at surgery (P = 0.346). Secondary cataract occurred more frequently in the extra-capsular cataract extraction (ECCE) + IOL implantation group than in the ECCE only group (20.6 % vs. 8.3 %, respectively, P = 0.018).

CONCLUSIONS

Patients with bilateral cataract had better postoperative VA compared with those with unilateral cataract. The type of surgery had no effect on final VA, but there was a higher rate of secondary cataract in the ECCE + IOL patients compared to the ECCE only patients.

[Aphakic and pseudophakic glaucoma following pediatric cataract surgery]

Modern surgical techniques allow congenital cataract surgery to be performed much more successfully. The development of a secondary glaucoma is the most dreaded postoperative complication (one third of all pediatric secondary glaucomas). Due to the limited value of the available literature, data on prevalence are unreliable. A 10-year postoperative incidence of 10-25% is given in the literature for developing secondary glaucoma and the frequency increases with the duration of follow-up. A major risk factor seems to be the age at the time of surgery. The younger the patient is at the time of surgery the higher the risk of secondary glaucoma. A microcornea seems to be another risk factor in multivariate analysis. The following postoperative changes might be involved in the pathogenesis: peripheral anterior synechia, high iris insertion and membranous material over the trabecular meshwork. Additionally postoperative inflammation, reaction to lens epithelial cells, perioperative barotrauma and loss of anterior segment architecture might also be responsible. In order to evaluate the optimal age window for congenital cataract surgery and risk factors for the development of secondary glaucoma, a prospective longitudinal study is mandatory.

Complications, adverse events, and additional intraocular surgery 1 year after cataract surgery in the infant Aphakia Treatment Study

PURPOSE

To compare rates and severity of complications between infants undergoing cataract surgery with and without intraocular lens (IOL) implantation.

DESIGN

Prospective, randomized clinical trial.

PARTICIPANTS

The Infant Aphakia Treatment Study (IATS) is a randomized, multicenter (n = 12) clinical trial comparing treatment of aphakia with a primary IOL or contact lens in 114 infants with unilateral congenital cataract.

INTERVENTION

Infants underwent cataract surgery with or without placement of an IOL.

MAIN OUTCOME MEASURES

The rate, character, and severity of intraoperative complications (ICs), adverse events (AEs), and additional intraocular surgeries (AISs) during the first postoperative year in the 2 groups were analyzed.

RESULTS

There were more patients with ICs (28% vs. 11%; P = 0.031), AEs (77% vs. 25%; P<0.0001), and AISs (63% vs. 12%; P<0.0001) in the IOL group than the contact lens group. Iris prolapse was the most common IC. The most common AE was visual axis opacification, and the most common additional intraocular reoperation was a clearing of visual axis opacification.

CONCLUSIONS

The rates of ICs, AEs, and AISs 1 year after surgery were numerically higher in the IOL group, but their functional impact does not clearly favor either treatment group.

FINANCIAL DISCLOSURE(S)

The author(s) have no proprietary or commercial interest in any materials discussed in this article.

Soft lens matter recurrence after congenital cataract surgery

We report a case of soft lens matter recurrence 17 years after the original congenital cataract was removed. To our knowledge, this is the longest interval for soft lens matter to recur.

FINANCIAL DISCLOSURE

No author has a financial or proprietary interest in any material or method mentioned.

Visual axis opacification after cataract surgery and hydrophobic acrylic intraocular lens implantation in the first year of life

PURPOSE

To report the incidence of visual axis opacification (VAO) requiring surgery after cataract extraction with hydrophobic acrylic intraocular lens (IOL) implantation during the first year of life.

SETTING

Storm Eye Institute, Charleston, South Carolina, USA; Iladevi Cataract and IOL Research Center, Ahmedabad, India.

DESIGN

Cohort study.

METHODS

Medical records of patients younger than 1 year who had primary posterior capsulectomy, vitrectomy, and in-the-bag hydrophobic acrylic IOL implantation were reviewed. In bilateral cases, 1 eye was randomly chosen. The need for surgery for visually significant VAO was evaluated 12 months after cataract surgery.

RESULTS

Seventy-two eyes were included. The mean age at cataract surgery was 6.0 months. Seventeen eyes (23.6%) required surgery for VAO a mean of 6.2 ± 2.9 months postoperatively. The odds for VAO surgery were 3.5 times greater in eyes of female children than in eyes of male children. For AcrySof MA60AC, SA60AT, SN60AT, or SN60WF IOLs, surgery for VAO was required in 25%, 23%, 23%, and 23% of eyes, respectively. The earliest time between cataract and secondary VAO surgery was relatively later (9.0 months) with the SN60WF IOL than with the MA60AC, SA60AT, or SN60AT IOL (4.4, 2.2, and 2.0 months, respectively).

CONCLUSIONS

Nearly 25% of operated eyes of infants required a secondary surgical procedure for VAO; the rate was higher in eyes of female infants but did not differ between IOL models. The data indicate that surgery for VAO is required later in eyes with an SN60WF IOL than in eyes in which other AcrySof IOLs were used.

FINANCIAL DISCLOSURE

No author has a financial or proprietary interest in any material or method mentioned.

A randomized clinical trial comparing contact lens with intraocular lens correction of monocular aphakia during infancy: grating acuity and adverse events at age 1 year

OBJECTIVE

To compare the visual outcomes and adverse events of contact lens with primary intraocular lens (IOL) correction of monocular aphakia during infancy.

METHODS

In a randomized, multicenter (12 sites) clinical trial, 114 infants with a unilateral congenital cataract were assigned to undergo cataract surgery between 1 to 6 months of age either with or without primary IOL implantation. Contact lenses were used to correct aphakia in patients who did not receive IOLs. Grating visual acuity was tested at 1 year of age by a masked traveling examiner.

MAIN OUTCOME MEASURE

Grating visual acuity at 1 year of age.

RESULTS

The median logMAR visual acuity was not significantly different between the treated eyes in the 2 groups (contact lens group, 0.80; IOL group, 0.97; P = .19). More patients in the IOL group underwent 1 or more additional intraocular operations than patients in the contact lens group (63% vs 12%; P < .001). Most of these additional operations were performed to clear lens reproliferation and pupillary membranes from the visual axis.

CONCLUSIONS

There was no statistically significant difference in grating visual acuity at age 1 year between the IOL and contact lens groups; however, additional intraocular operations were performed more frequently in the IOL group.

APPLICATION TO CLINICAL PRACTICE

Until longer-term follow-up data are available, caution should be exercised when performing IOL implantation in children aged 6 months or younger given the higher incidence of adverse events and the absence of an improved short-term visual outcome compared with contact lens use.

Comparison of intraocular lens power calculation formulae in pediatric eyes

PURPOSE

To evaluate accuracy of intraocular lens (IOL) power calculation formulae (SRK II, SRK/T, Holladay 1, Hoffer Q) in pediatric eyes.

DESIGN

Retrospective case series.

PARTICIPANTS

One hundred thirty-five eyes of 96 children with congenital, developmental, or acquired cataracts who underwent uncomplicated cataract surgery and IOL implantation by a single surgeon over a 10-year period.

METHODS

Axial length (AL), keratometry (K), and manufacturer's A constant were employed in 4 common IOL power calculation formulae to predict the refractive outcome. Retinoscopy was measured at 4 to 8 weeks postoperatively and converted to spherical equivalent. For analysis, eyes were grouped by age at surgery, AL, and mean K.

MAIN OUTCOME MEASURES

We determined the prediction error (PE) = predicted refraction - actual refraction and the absolute PE = |predicted refraction - actual refraction|. The formula that gave the best prediction (minimum PE) was determined.

RESULTS

The mean age at surgery was 6.4 years. Mean absolute PE was 1.11 for the SRK II, 0.84 for SRK/T, 0.76 for Holladay, and 0.76 for Hoffer Q formulae. There was a trend toward greater PE in eyes of younger children (< or =2 years), shorter AL (AL < or = 22 mm) and steeper corneas (mean K > 43.5 diopters [D]). On comparing absolute PE obtained with 4 formulae in each patient, Hoffer Q gave the minimum PE in 46% of eyes compared with 23% with SRK II, 18.5% with SRK/T, and 12.5% with Holladay 1. The SRK/T, Holladay 1, and Hoffer Q were similar in accurately predicting refractive error within +/-0.5 D in about 43% eyes. When clinically significant deviation in PE occurred (>0.5 D), there was usually an undercorrection (72%), except for Hoffer Q, which was almost as likely to overcorrect as undercorrect (44% vs 56%). The PE was lower with office measurements when compared with anesthesia measurements, owing probably to better fixation in older children with higher ALs.

CONCLUSION

The PE was insignificant (PE < or = 0.5 D) in 43% eyes, and similar for all formulae. However, the Hoffer Q was predictable for the highest number of eyes. When the PE was >0.5 D, most formulae gave an undercorrection, except for the Hoffer Q, which the surgeon may want to consider when targeting postoperative refractions.

Visual results and complications of primary intraocular lens implantation in infants aged 6 to 12 months

BACKGROUND

To present the visual results and the complications of primary intraocular lens (IOL) implantation in infants aged 6 to 12 months between January 2002 and July 2007.

METHODS

A total of 26 consecutive eyes, of 16 infants with cataract aged 6 to 12 months, were reviewed in the study. All patients had cataract extraction with anterior and posterior capsulorrhexis combined with anterior vitrectomy and primary hydrophobic acrylic IOL implantation. Six infants (six eyes) had unilateral congenital cataract and ten (20 eyes), bilateral cataract. Visual acuity and complications were recorded throughout the 46.4-month mean follow-up (range 22 to 79 months).

RESULTS

All eyes had primary IOL implantation. The mean best-corrected visual acuity (logMAR) was 0.98 +/- 0.18,0.50 +/- 0.14 and 0.61 +/- 0.25 for unilateral, bilateral and all eyes respectively at the last follow-up. IOLs were implanted in the capsular bag of 25 eyes (96.2%) and in the sulcus of the remaining one eye (3.8%). Seven eyes (26.9%) developed visual axis opacification (VAO), and four eyes required secondary pars plana vitrectomy (PPV). IOL opacification occurred in one eye 54 months after implantation. Late onset open-angle glaucoma developed in one eye, and required trabeculectomy surgery. The predictors of good best-corrected visual acuity (BCVA) included partial cataract, bilateral cataract, absence of strabismus or nystagmus, and good amblyopic treatment. The greatest annual myopic change (5.15 +/- 2.08 D) was observed during the first 12 months after surgery. In unilateral cases, there was no significant difference in the axial length between the cataractous eye and the fellow normal eye both at the time of surgery (P = 0.891) and final follow-up (P = 0.693).

CONCLUSIONS

Primary IOL implantation was safe and effective for infantile cataract surgery. Total or unilateral cataract, nystagmus or strabismus, and inadequate amblyopic therapy were predictors of poor BCVA. Significant myopic shifts occurred especially in infants in the first year of surgery. The pseudophakic eye had a similar growth rate, as measured by axial length, to that of the fellow normal eye, in unilateral cases.

[Advantages of the bag-in-the-lens intraocular lens in pediatric cataract surgery]

OBJECTIVE

Evaluate the advantages of the bag-in-the-lens intraocular lens in children undergoing cataract surgery.

PATIENTS AND METHODS

This prospective study included 54 eyes of 37 children and babies (age, 2 months to 14 years), consecutively operated on between December 1999 and January 2008 for unilateral or bilateral cataract using the "bag-in-the-lens" intraocular lens. Slit-lamp examination, intraocular pressure, visual acuity, and refraction were followed to the best possible degree over time.

RESULTS

The mean age of the 37 children at the last consultation visit was 8.3+/-4.9 years. The mean visual acuity improved from 0.2+/-0.1 to 0.8+/-0.3. On the other hand, visual acuity improvement in children presenting hyperplastic persistence of the vitreous was less favorable with a postoperative average visual acuity of 0.14+/-0.18. The mean postoperative refraction in 13 children (26 eyes) operated on for bilateral cataract was 0.5+/-1.5 D for eyes showing axial lengths with substantial variation. The refraction was stable over time in children over 2 years of age. Once the implant was positioned correctly, the remaining epithelial cells of the lens did not migrate toward the visual axis, which was the case in 93.8% of all eyes and in 100% of children over 1 year of age.

CONCLUSIONS

The "bag-in-the-lens" implant is particularly indicated in children in whom posterior rhexis and optic capture have been recommended since 1994. The implantation minimizes the use of anterior vitrectomy in pediatric cataract surgery, limiting it to those eyes presenting a proliferative hyperplastic vitreous.

Accuracy of biometry in pediatric cataract extraction with primary intraocular lens implantation

PURPOSE

To determine the accuracy of predicted postoperative refractive outcomes in pediatric patients having cataract surgery with intraocular lens (IOL) implantation and to compare them with other variables historically considered important in cataract surgery.

SETTING

Tertiary care referral hospital.

METHODS

This retrospective review comprised 203 eyes of 153 consecutive pediatric patients (< or = 18 years old) having cataract extraction with primary posterior chamber IOL implantation in the capsular bag. All cases were performed by 1 of 2 surgeons, and all refractions were performed manually by an experienced pediatric ophthalmologist using a retinoscope.

RESULTS

In all patients, the mean absolute value (MAE) of the prediction error was 1.08 diopters (D) +/- 0.93 (SD). Age at time of surgery and corneal (K) mean curvature were significantly correlated with the absolute value of the prediction error (P = .0006 and P = .0088, respectively). A multiple regression model showed that age at time of surgery and K mean curvature were the only 2 variables significantly associated with MAE; axial length, formula, surgeon, and A-scan type were not significantly associated with prediction error.

CONCLUSIONS

Data from 203 consecutive primary pediatric IOL implantations showed the heterogeneous nature of the variables involved in predictions of refractive outcomes in this population. The complexities of this issue support the need for specific methods of measurement and an IOL calculation formula for the pediatric population.

Accuracy of IOL calculations in children: a comparison of immersion versus contact A-scan biometery

PURPOSE

To evaluate the accuracy of pediatric IOL calculations performed under general anesthesia by using immersion A-scan biometry and to compare the results to those obtained using contact A-scan biometry.

METHODS

A retrospective review of 203 consecutive cases of pediatric cataract extraction with primary IOL implantation within the capsular bag; mean patient age was 5.52 +/- 4.19 years (range, 18 days to 18 years). Axial length measurements were performed with the contact A-scan biometry in 138 eyes, whereas immersion technique biometry was used in the remaining consecutive 65 eyes. Preoperative predictive target refraction was compared with the refractive result obtained at the 2-month postoperative visit.

RESULTS

The mean of the absolute value lens prediction error for all eyes was 1.08 +/- 0.93 D from the desired postoperative refractive result. Lens prediction error for the contact A-scan subgroup was 1.11 +/- 0.90 D, whereas the immersion A-scan subgroup was less at 1.03 +/- 0.98 D. This result was not statistically significant (p = 0.6442). Statistically significant correlations were found between increased lens prediction error and age at time of surgery or corneal curvature.

CONCLUSIONS

This retrospective, noncomparative pilot study showed no significant difference in IOL prediction error when comparing the postoperative refractive results obtained with immersion versus contact A-scan biometry in pediatric IOL calculations.

Advances in the management of congenital and infantile cataract

Congenital and infantile cataracts produce deprivation amblyopia and can thus cause lifelong visual impairment. Successful management is dependent on early diagnosis and referral for surgery when indicated. Accurate optical rehabilitation and postoperative supervision are essential.The timing of surgery and its relationship to the duration of deprivation is important. Unilateral congenital cataract surgery within 6 weeks of birth produces the best outcomes. The equivalent 'latent' period for bilateral visual deprivation may be longer at around 10 weeks. Visual deprivation has a significant impact on the development of fixation stability. Major form deprivation, even after early surgery, leads to nystagmus. This is mostly manifest latent nystagmus (MLN). The latent period for fixation stability may be as short as 3 weeks. Preoperative congenital nystagmus (CN) can convert to more benign MLN after surgery. Infantile IOL implantation is becoming increasingly accepted. A satisfactory long-term refractive result requires that allowance be made for childhood axial growth and myopic shift. In a series of 25 infants (33 eyes) implanted before 12 months of age, the mean myopic shift at 12 months was 4.83 D. This increased to 5.3 D in infants implanted before 10 weeks. The initial desired refractive outcome following IOL implantation is thus hypermetropia, with the degree dependent on the age of the child. Glaucoma or ocular hypertension is a common complication following paediatric cataract surgery. Microphthalmia and surgery in early infancy are risk factors. Tonometry results may be influenced by the increased corneal thickness seen in aphakic and pseudophakic children. The long-term prognosis of eyes with aphakic glaucoma is not necessarily poor but intraocular pressure control may require three or more medications. Surgical intervention appears to be necessary in over a quarter of eyes. Posterior capsule opacification (PCO) is common in infants undergoing primary lens implantation. Primary capsulotomy and anterior vitrectomy reduce the risk of PCO. In the absence of anterior vitrectomy, primary posterior capsulotomy does not prevent visual axis opacification. Further developments will continue to be driven by clinical research. The prevention of capsule opacification and cellular proliferation may in future be achieved by the use of devices to specifically target epithelial cells at surgery.

Bag-in-the-lens intraocular lens implantation in the pediatric eye

PURPOSE

To study the efficacy, safety, and feasibility of implantation of a bag-in-the-lens intraocular lens (IOL) in children and babies.

SETTING

Departments of Ophthalmology, University Hospital, Antwerp, Belgium, and the University Hospital, Ljubljana, Slovenia, and a private ophthalmology practice, Oudenaarde, Belgium.

METHODS

Thirty-four eyes of 22 children had implantation of a bag-in-the-lens IOL. The ages ranged from 2 months to 14 years. Congenital cataract was present in 26 eyes, and persistent fetal vasculature (PFV) was concomitantly present in 4 eyes. Fifteen patients had bilateral cataract, and 6 had unilateral cataract.

RESULTS

In 3 eyes, the IOL could not be properly implanted. In these cases, secondary intervention was necessary because of early posterior capsule opacification. The mean postoperative follow-up was 17.45 months +/- 17.12 (SD) (range 4 to 68 months). None of the children except those presenting with PFV had anterior vitrectomy during surgery. The optical axis remained clear during the follow-up in all patients who had successful IOL implantation.

CONCLUSIONS

The bag-in-the-lens implantation technique in children and babies was safe and kept the visual axis clear after cataract surgery. In the near future, 4.0 or 4.5 mm IOLs will be available that may improve the success rate of IOL implantation in the small eyes of babies.

Primary intraocular lens implantation in infants: complications and visual results

PURPOSE

To evaluate the complications and visual results in a consecutive series of patients having cataract extraction with intraocular lens (IOL) implantation in the first year of life.

SETTING

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

METHODS

This retrospective study comprised 28 children (31 eyes) who had cataract surgery with primary IOL implantation.

RESULTS

The median age at surgery was 2.5 months (range 8 days to 10 months). The median follow-up was 36 months. Two newborns with persistent fetal vasculature (PFV) who had surgery at 8 days and 17 days, respectively, developed intraoperative vitreous hemorrhage; a retinal detachment developed in 1 of the eyes. Intraocular lens luxation occurred in 2 infants with PFV. Seventy percent of eyes developed opacification of the visual axis that required additional surgery. Chronic glaucoma developed in 2 eyes and transitory glaucoma in 1 eye. Two of the glaucoma cases occurred in eyes with PFV. In 7 eyes of 4 infants with bilateral cataract, the median visual acuity was 20/63 (range 20/25 to 20/100). In 12 infants with unilateral cataract without PFV, 7 achieved a visual acuity between 20/32 and 20/200 (median 20/63), 4 achieved counting fingers (CF), and 1 achieved light perception. In 12 eyes with PFV, 2 achieved a visual acuity of 20/200 and the rest achieved CF or worse.

CONCLUSIONS

After-cataract with membrane formation was the main complication in infants with primary IOL implantation. The glaucoma incidence was low at the last follow-up.

Single-piece AcrySof intraocular lens implantation in children with congenital and developmental cataract

PURPOSE

To evaluate surgical outcomes of 1-piece AcrySof SA30AL intraocular lens (IOL) (Alcon Laboratories) implantation in children having surgery for congenital and developmental cataracts.

SETTING

Iladevi Cataract & IOL Research Centre, Raghudeep Eye Clinic, Ahmedabad, India.

METHODS

This prospective observational study comprised 134 consecutive eyes of 84 children from 2 to 15 years old who had surgery for congenital and developmental cataract. Two groups were formed depending on the age of the child at surgery. Primary posterior continuous curvilinear capsulorhexis (PCCC) was performed in children younger than 6 years (Group 1, 66 eyes), and no PCCC was performed in children older than 6 years (Group 2, 68 eyes). Vitrectomy was not performed. An AcrySof IOL was implanted in the bag in all eyes except 1 in Group 1, which received a sulcus-fixated IOL. The study's primary outcome measures were the incidence of visual axis obscuration and the need for a secondary procedure to clear the axis. Secondary observations included the incidence of posterior synechias, cell deposits, and haptic compression. A test of proportion was applied to determine whether age was a risk factor for the development of visual axis obscuration.

RESULTS

The mean age at surgery was 6.0 years +/- 3.2 (SD). The mean follow-up was 2.6 +/- 0.6 years. In Group 1, 20 eyes (30.3%) developed visual axis obscuration but only 6 (9.1%) required a secondary procedure. In Group 2, 20 eyes (29.4%) developed visual axis obscuration and 10 (14.7%) required secondary procedures. Posterior synechias were observed in 2 eyes (3.0%) in Group 1 and none in Group 2. Cell deposits were seen in 8 eyes (12.1%) in Group 1 and 8 eyes (11.8%) in Group 2. Haptic compression was noted in 1 eye in Group 2. Mild IOL decentration was observed in the 1 eye with a sulcus-fixated IOL.

CONCLUSION

The 1-piece AcrySof IOL provided satisfactory visual axis clarity, produced an acceptable inflammatory response, and maintained centration in pediatric eyes.