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

Posterior Capsulotomy Size Affects the Formation of Significant Visual Axis Opacification in Congenital and Developmental Cataract

PURPOSE

To assess the relationship between posterior capsulotomy size and significant visual axis opacification (VAO) in congenital and developmental cataract.

METHODS

The charts of children aged 7 years and younger who underwent cataract surgery including primary posterior capsulotomy (PPC) and limited anterior vitrectomy between 2012 and 2022 were retrospectively reviewed. Eyes with PPC size smaller than the anterior capsulotomy size were considered as group 1. Eyes with PPC size larger than the anterior capsulotomy size were considered as group 2. Clinical characteristics, the need for Nd:YAG laser treatment or further surgery for significant VAO, and other postoperative complications were compared between the groups.

RESULTS

Sixty eyes of 41 children were included in the study. The median age at the time of surgery was 5.5 and 3 years in groups 1 and 2, respectively (P = .076). Primary intraocular lens implantation was performed in 23 (85.2%) eyes in group 1 and 25 (75.8%) eyes in group 2 (P = .364). There was no difference between the groups in terms of postoperative visual acuity (P = .983) and refractive errors (P = .154). Eight (29.6%) pseudophakic eyes received Nd:YAG laser treatment in group 1, but none of the eyes in group 2 (P = .001). Four (14.8%) eyes in group 1 and 1 (3%) eye in group 2 underwent further surgery for VAO (P = .100). The need for further intervention for significant VAO was statistically higher in group 1 (44.4% vs 3%, P < .001).

CONCLUSIONS

Larger PPC size in pediatric cataract may reduce the need for further intervention for significant VAO. [J Pediatr Ophthalmol Strabismus. 2023;60(6):441-447.].

Outcome of Surgical Membranectomy With a Vitrector via Limbal Approach for Posterior Capsular Opacity in Children

PURPOSE

To evaluate the safety and efficacy of surgical membranectomy with a vitrector via a limbal approach for posterior capsular opacification (PCO) in children.

METHODS

In this retrospective analytical interventional study, medical records of children younger than 17 years who underwent surgical membranectomy with anterior vitrectomy via a limbal approach were analyzed. Time lag for PCO formation after cataract surgery was assessed. Any adverse events during surgery, rate of successful completion of membranectomy, postoperative complications, improvement in visual acuity, and intraocular lens (IOL) centration were recorded.

RESULTS

A total of 60 eyes of 58 children were included: 26 had traumatic etiology and 34 had developmental cataract. Mean time duration for PCO formation was 27.83 ± 39.83 months for traumatic cases and 53.53 ± 52.20 months for developmental cataract (P = .04). A satisfactory opening in the center of the membrane was achieved in 47 cases (n = 47, 78.3%). The complications encountered were uveitis (5 eyes), corneal edema (3 eyes), pigment deposition over IOL (2 eyes), raised intraocular pressure (1 eye), IOL drop (1 eye), and broken haptic (1 eye). Membranectomy with posterior optic buttonholing of the IOL in 9 aphakic eyes resulted in good IOL centration, no anterior chamber reaction, and no iris optic capture in the postoperative period. Mean visual acuity improved from 1.16 ± 0.52 to 0.73 ± 0.55 logMAR (P < .001).

CONCLUSIONS

Surgical membranectomy with a vitrector via a limbal approach is a safe and effective method for managing PCO in the pediatric population. Posterior optic buttonholing of the IOL during membranectomy or secondary IOL implantation results in good IOL centration and fewer complications. [J Pediatr Ophthalmol Strabismus. 2020;57(1):33-38.].

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.

Comparative analysis of non-absorbable 10-0 nylon sutures with absorbable 10-0 Vicryl sutures in pediatric cataract surgery

Purpose:

The purpose of the study is to compare the efficiency as well as the rate and type of suture-related complications between 10-0 monofilament nylon (Aurolab Nylon Sutures, double arm, Aurolab) and 10-0 polyglactin 910 sutures (Vicryl, single arm, Aurolab) for pediatric cataract surgery.

Methods:

It is a prospective, comparative study performed in children who underwent surgery for congenital or developmental cataract from March 2013 to February 2016. Patients underwent suturing with either nylon or Vicryl in unilateral cases, but in most bilateral surgeries, one eye received Vicryl sutures while the other eye received nylon. The sutures were compared for their complications and the need for suture removal.

Results:

Forty-one children (72 eyes) were included in the study, of which 31 children (62 eyes) underwent bilateral surgery while 10 (10 eyes) underwent unilateral surgery. Sixty-four nylon sutures were placed in 32 children (34 eyes), of which 22 (34.4%) were removed due to suture-related complications, whereas 14 (19.7%) (P = 0.03) of the 71 Vicryl sutures placed in 32 children (38 eyes) needed suture removal at an average of 2.9 weeks with the earliest at 6 days postoperatively. The odds of Vicryl suture being removed was 0.42 times with respect to nylon. The most common reason encountered for suture removal in both the materials was sutures becoming loose (16.3%), followed by vascularization (14.1%), infiltration (1.5%), and opacification (4.4%).

Conclusion:

Absorbable suture such as 10-0 Vicryl is preferred over nonabsorbable suture 10-0 nylon for suturing incisions in pediatric cataract surgery, to avoid subjecting the child to repeated anesthesia.

Outcomes of pediatric cataract surgery with triamcinolone-assisted vitrectomy

BACKGROUND/PURPOSE

To evaluate outcomes in pediatric patients undergoing lensectomy, posterior capsulotomy, and triamcinolone-assisted vitrectomy for congenital cataract.

METHODS

This retrospective study included 34 patients younger than 72 months who underwent lensectomy, posterior capsulotomy, and triamcinolone-assisted vitrectomy with or without intraocular lens (IOL) implantation for cataract at the National Taiwan University Hospital from July 2006 to December 2012.

RESULTS

Fifty-one eyes from 34 patients with cataract (unilateral in 17 patients, bilateral in 17 patients) were included. The mean age at surgery was 26.74 months (range: 2-72 months). The mean postoperative follow-up was 27.8 months (range: 6-72 months). Primary IOL implantation was performed in 25 eyes, 21 of which had the IOL implanted in the capsular bag. Fifty eyes had a central round pupil. The median logarithm of the minimum angle of resolution visual acuity was 0.3 in patients with unilateral cataract and 0.1 in those with bilateral cataract. Three eyes (5.9%) developed visual axis opacification (VAO) and required further surgery. Univariate analysis using Fisher's exact test indicated that surgery in the first 12 months of life was significantly associated with development of VAO (p=0.047). The incidence of postoperative VAO was approximately 15.8% in this age group.

CONCLUSION

Triamcinolone-assisted vitrectomy can be used in pediatric cataract surgery without serious long-term adverse effects. While the incidence of VAO is low, it appears unavoidable in approximately one-sixth of patients who undergo surgery before 12 months of age.

Cataract surgery with intraocular lens implantation in children aged 5-15 in local anaesthesia: visual outcomes and complications

The aim of this study was to report feasibility, the visual outcomes and complications of pediatric cataract surgery with primary intraocular lens implantation in children aged 5 to15 years in local anesthesia. This retrospective interventional case series included 62 eyes from 50 children who underwent pediatrc cataract surgery with primary intraocular lens implantation at the Mana eye Clinic Nkongsamba between 2006 and 2015 Main outcome measures were: best-corrected post operative visual acuity, and intraoperative and postoperative complications. Mean age at surgery was 10.18 ± 3.21 years. Mean follow up length was 15.75 ± 3.36 weeks. Etiology included: 10 congenital cataracs (16.12%). 35 developmental cataracts (56.45%) and 17 traumatic cataracts (27.41%). The mean preoperative BCVA was logMAR 1.19 ± 0.33. (range 0.6-2.3). After cycloplegia refraction 2 weeks after surgery, the mean postoperative BCVA was log MAR 0.58 ± 0.88 ( range 0.5-1.8). The mean implanted IOL power was 22.01 ±3.16 D. IOL was succefuly implanted in 54 eyes (87.07%). Eight eyes (9.67%) were left aphakic. Increase in BCVA of 4 logMAR lines and above was recorded in 27 patients (43.55%). Intraoperative complications included: 4 posterior capsule holes with vitrous lost, 3 lenses subluxation and 1 case of iris dialyse. Late postoperative complications included: posterior capsular opacity which occurred in 16 patients, 3 posterior synechia, 2 retinal detachment. Peribulbar anaesthesia can be considered as a viable option in selected patients presenting developmental cataract undergoing cataract surgery in developing countries. Effort should be made to improve the early identification of congenital cataract and its early surgical intervention and prompt optical rehabilitation to prevent amblyopia.

Posterior Capsular Opacification in Preschool- and School-Age Patients after Pediatric Cataract Surgery without Posterior Capsulotomy

Objectives:

We aimed to evaluate the development of posterior capsular opacification (PCO) in preschool- and school-age children with cataract who underwent cataract surgery without posterior capsulotomy and anterior vitrectomy.

Materials and Methods:

The records of 30 eyes of 21 patients who underwent pediatric cataract surgery and intraocular lens (IOL) implantation were retrospectively reviewed. Patients’ age, PCO status and duration, need for neodymium-doped yttrium aluminium garnet (Nd:YAG) laser treatment based on coverage of visual axis, and follow-up period were recorded.

Results:

The mean age of the patients was 7.6±2.83 (4-12) years. Unilateral cataract surgery and IOL implantation were performed in 12 patients (57.14%) and bilateral cataract surgery and IOL implantation were performed in nine patients (42.86%). Average follow-up time was 17.7±22.67 (3-83) months. PCO developed in 21 eyes (70%) and covered the visual axis in 15 eyes (50%), which therefore required Nd:YAG laser posterior capsulotomy. The mean duration of postoperative PCO development was 8.91±18.7 months (1 week-71 months).

Conclusion:

We believe that with adequately experienced surgeons, performing both cataract surgery and posterior capsulotomy with anterior vitrectomy in the same session is appropriate for selected preschool- and school-age children with cataract.

Corneal approach 20 Guage vitrectomy system for the management of congenital cataract

Objective:

To evaluate the efficacy and complications of 20 gauge vitrectomy via corneal approach for the management of congenital cataract.

Method:

We performed anterior capsular vitreorhexis, lens matter aspiration (LMA), primary posterior vitrectorhexis and anterior vitrectomy via corneal approach using 20 gauge vitrectomy system in children younger than two years of age with congenital cataract between January 2014 to December 2014. The intra and postoperative complications were observed.

Results:

Twenty nine eyes of 21 children were included in this study. Congenital cataract surgery using 20 gauge vitrectomy system via corneal approach did not reveal any intra operative complication. Post operatively all children were able to freely open their operated eyes. Conjunctival congestion at the incision site in four eyes and mild anterior chamber reaction in 8 eyes were seen on 1^st daywhich resolved at one week follow up. Other major post operative complications such as inflammatory membrane, irregular pupil, posterior/anterior syneache and opacification of visual axis were not seen during follow up period.

Conclusion:

The 20-gauge vitrectomy system via corneal approach is easy to perform, is less time consuming, safe and effective for the management of congenital cataract in younger children.

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.

Dual approach using vitrectorhexis combined with anterior vitrectomy in pediatric cataract surgery

Purpose. To evaluate efficacy and safety of vitrectorhexis method for both anterior and posterior capsules combined with anterior vitrectomy in children with cataract. Methods. A retrospective chart review was performed for 19 children with cataract operated at a tertiary referral center. Dual approach including anterior and posterior segments was used during the surgery in terms of capsulotomy, intraocular lens (IOL) implantation, and anterior vitrectomy. Results. A total of 23 eyes of 19 patients were enrolled in the study. The mean age of the children was 39.4 ± 2.2 months (5–78). The mean postoperative followup duration was 20.6 ± 7.8 months (3–32). Intraoperative tear was observed only in one of 23 (4.3%) eyes during anterior capsulotomy. All of the patients had a clear visual axis and showed no IOL decentration. Conclusions. Dual approach using vitrectorhexis and anterior vitrectomy is an easy-to-perform technique that seems safe and effective in the short term for younger children.

[Assessment of intra-operative techniques to prevent visual axis opacification in congenital cataract surgery]

OBJECTIVE

To evaluate the effectiveness of various surgical procedures in the management of posterior capsule and anterior vitreous on the prevention of visual axis opacification.

SUBJECTS, MATERIAL AND METHODS

We retrospectively reviewed 120 eyes operated for unilateral congenital cataracts, with a median age at the time of cataract surgery of 21 months (interquartile range, 6-52 months). The eyes were divided into 3 groups: group 1 (eyes with intact posterior capsule, n=39), group 2 (eyes with posterior continuous curvilinear capsulorhexis, n=38), group 3 (eyes with posterior continuous curvilinear capsulorhexis and anterior vitrectomy, n=43).

RESULTS

To determine the effect of posterior continuous curvilinear capsulorhexis on visual axis opacification we compared group 2 with group 1 (chi-square Pearson test, P=.281), therefore in this study the implementation of the posterior continuous curvilinear capsulorhexis did not show any decreases in the incidence of visual axis opacification. To study the effect of posterior continuous curvilinear capsulorhexis associated anterior vitrectomy, we compared group 3 with group 1 (chi-square Pearson test, P=.014), demonstrating that the combination of both techniques (posterior continuous curvilinear capsulorhexis and anterior vitrectomy) decreases the incidence of visual axis opacification.

CONCLUSION

Posterior continuous curvilinear capsulorhexis as a single technique did not show any decrease in the incidence of visual axis opacification. Posterior continuous curvilinear capsulorhexis together with anterior vitrectomy are required to prevent visual axis opacification and to decrease reoperation rate.

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

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

Prevention and management of cataracts in children with juvenile idiopathic arthritis-associated uveitis

Juvenile idiopathic arthritis (JIA)-associated uveitis can be associated with vision-compromising complications such as cataracts, glaucoma, synechiae, and band keratopathy. Of these, cataracts are one of the most common sequelae of JIA-associated uveitis and can result in significant visual disability. Risk factors for cataracts include posterior synechiae and longstanding ocular inflammation. Prevention of cataract development is crucial through appropriate control of uveitis. However, not all preventive measures are successful, and further management consisting of medical and surgical techniques is often necessary. Various factors should be taken into consideration when deciding on cataract management, including timing of surgery and placement of an intraocular lens. Continued partnership between pediatric rheumatologists and pediatric ophthalmologists can help ensure favorable visual outcomes.

Triamcinolone-assisted vitrectomy in pediatric cataract surgery: intraoperative effectiveness and postoperative outcome

PURPOSE

To evaluate intraoperative effectiveness and postoperative outcome of intracameral, preservative-free triamcinolone acetonide in pediatric cataract surgery.

METHODS

A prospective, interventional, observational case series was performed in children undergoing congenital cataract surgery. Three standardized applications of triamcinolone acetonide were used. Postoperatively, IOP, pachymetry, glaucoma, posterior synechiae, cell deposits, and posterior capsule opacification were studied at 1 week, 1 month, and 12 months after surgery.

RESULTS

Mean age at the time of surgery was 14.8 +/- 12.2 months. Of 43 eyes, 5 were kept aphakic and 38 received IOL implantation. After manual posterior continuous curvilinear capsulorhexis and the first injection of triamcinolone, the anterior vitreous face disturbance was visualized as free-floating vitreous strands going into the incision in 18.6% of eyes (8 of 43). Triamcinolone was injected a second time after anterior vitrectomy: residual vitreous strands were identified and removed in 7 of these 8 eyes. Triamcinolone was used for a third time after IOL implantation: residual vitreous strands were identified in 5.3% of eyes (2 of 38). Mean IOP was 12.2 +/- 2.2 mm Hg preoperatively and was 13.6 +/- 3.2 at the 1 week follow-up visit, 12.8 +/- 2.8 at 1 month, and 12.4 +/- 2.0 mm Hg at 12 months.

CONCLUSIONS

Preservative-free triamcinolone acetonide improved visualization of the vitreous during pediatric cataract surgery, thereby ensuring thorough and complete anterior vitrectomy. IOP was not affected, and no adverse postoperative results were observed.

Delayed presentation of cataracts in children: are they worth operating upon?

PURPOSE

Childhood cataract is an important cause of avoidable blindness in children. The study aimed to investigate the outcome of surgery in cataracts with delayed presentation which had been operated upon as new pediatric ophthalmology centers were set up in India.

METHODS

This was a retrospective interventional case series from a community eye care center in Western India. Demographic, surgical, pre-operative and post-operative details were obtained from the patients records and entered into Microsoft excel and statistical analysis conducted using SPSS-11 software (SPSS, Chicago, IL). Vision was tested 6 weeks after surgery. The predictors of good vision (> or =6/18) were identified by regression analysis. If the interval between detection of cataract in children and their presentation for surgery was more than 18 months for developmental and 6 months for congenital the cataract was defined having a delayed presentation.

RESULTS

Five hundred and twenty nine eyes of 437 children aged 2 months to 16 years were operated upon in 2004-2006. Preoperative vision was <3/60 in 405 (76.6%) eyes with cataract. Of these 529, 242 eyes were with delayed presentation of cataract (83 congenital and 149 other). 102 had up to 5 years, 91 had 6-10 years and 49 had >11 yrs delay in presentation. At 6 weeks following surgery, vision was > or = 6/18 in 36/93 (38.7%) of eyes with delayed presenting cataracts, as compared to 94/244 (38.5%) > or =6/18 in those without.

CONCLUSION

Surgery for cataracts with delayed presentation helps to regain functional vision, which can be used for navigation and low vision aids.

[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.

Long-term results of pars plana lensectomy with double-capsule-supported intraocular lens implantation in children

BACKGROUND

To report the long-term results of the pars plana lensectomy with double-capsule-supported intraocular lens implantation technique for the treatment of pediatric cataracts.

METHODS

A lensectomy and an anterior vitrectomy were performed through the pars plana approach, followed by implantation of a posterior chamber intraocular lens (IOL) to the sulcus over the capsules. Patients with a minimum follow-up of 5 years were included in the study and patient data were collected retrospectively from the patient reports.

RESULTS

Sixteen eyes of 10 patients with a mean age of 4.3 (SD 1.1) years were included in the study. Only one case was traumatic, and the others were congenital cataract cases. A 6.5 mm polymethyl methacrylate posterior chamber IOL was used in all cases. The visual axis was clear in all the cases through the mean follow-up period of 79.2 (SD 14.1) months. IOL decentration was observed in 1 eye at postoperative month 24, and it needed to be repositioned. There was no posterior capsular opacification in any of the cases. Best-corrected visual acuity was 20/40 or better in 81.3% of the eyes.

INTERPRETATION

The pars plana lensectomy with double-capsule-supported intraocular lens implantation technique seems to be a safe and easy method in children, limiting postoperative IOL-related complications and posterior capsule opacification in the long term.

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

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

Determinants of pediatric cataract program outcomes and follow-up in a large series in Mexico

PURPOSE

To report determinants of outcomes and follow-up in a large Mexican pediatric cataract project.

SETTING

Hospital Luis Sanchez Bulnes, Mexico City, Mexico.

METHODS

Data were collected prospectively from a pediatric cataract surgery program at the Hospital Luis Sanchez Bulnes, implemented by Helen Keller International. Preoperative data included age, sex, baseline visual acuity, type of cataract, laterality, and presence of conditions such as amblyopia. Surgical data included vitrectomy, capsulotomy, complications, and use of intraocular lenses (IOLs). Postoperative data included final visual acuity, refraction, number of follow-up visits, and program support for follow-up.

RESULTS

Of 574 eyes of 415 children (mean age 7.1 years +/- 4.7 [SD]), IOLs were placed in 416 (87%). At least 1 follow-up was attended by 408 patients (98.3%) (mean total follow-up 3.5 +/- 1.8 months); 40% of eyes achieved a final visual acuity of 6/18 or better. Children living farther from the hospital had fewer postoperative visits (P = .04), while children receiving program support had more visits (P = .001). Factors predictive of better acuity included receiving an IOL during surgery (P = .04) and provision of postoperative spectacles (P = .001). Predictive of worse acuity were amblyopia (P = .003), postoperative complications (P = .0001), unilateral surgery (P = .0075), and female sex (P = .045).

CONCLUSIONS

The results underscore the importance of surgical training in reducing complications, early intervention before amblyopia (observed in 40% of patients) can develop, and vigorous treatment if amblyopia is present. The positive impact of program support on follow-up is encouraging, although direct financial support may pose a problem for sustainability. More work is needed to understand reasons for worse outcomes in girls.

Pediatric cataract extraction with intraocular lens implantation: visual acuity outcome when measured at age four years and older

PURPOSE

Assessment of visual outcome of pediatric eyes that underwent cataract extraction with primary intraocular lens (IOL) implantation at a single center.

METHODS

A retrospective review of charts of 510 consecutive pediatric patients that underwent cataract extraction was performed. Exclusion criteria were traumatic cataract, secondary IOL implantation, retinopathy of prematurity, severe developmental delay, age less than 4 years at last follow-up, and follow-up less than 6 months. In bilateral cases, only right eye data were included.

RESULTS

One hundred thirty-nine eyes met inclusion criteria. Median age at surgery was 5.12 years (range, 0.03-16.92); median age at last follow-up was 9.05 years, and median follow-up was 3.65 years. Sixty-six of 139 (47.5%) patients had unilateral cataracts compared with 73/139 (52.5%) bilateral cases. The median visual acuity of all eyes was 20/30, with median visual acuity of unilateral and bilateral cases being 20/40 and 20/25, respectively. Older patients achieved better visual acuity (unilateral cases: p = 0.003; bilateral cases: p = 0.07). Eyes with a greater interocular axial length difference achieved poorer visual acuity. Forty-five patients had a final visual acuity worse than 20/40. Of these, 34 (76%) had a diagnosis of amblyopia as the sole cause. Nineteen of 139 (13.7%) eyes had final visual acuity worse than 20/200. Eighteen patients required strabismus surgery, and 22 required additional intraocular surgery.

CONCLUSIONS

Better visual acuity was associated with bilateral cataract, older age at surgery, and normal interocular axial length difference. Amblyopia was the major cause of residual visual deficit.

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.

Completion rate of primary posterior continuous curvilinear capsulorhexis and vitreous disturbance during congenital cataract surgery

PURPOSE

We sought to document the completion rate of primary posterior continuous curvilinear capsulorhexis during congenital cataract surgery and determine the incidence of disruption of vitreous face during this procedure.

METHODS

One hundred six consecutive eyes of patients undergoing posterior continuous curvilinear capsulorhexis (PCCC) during congenital cataract surgery were evaluated prospectively for completion of PCCC and disruption of vitreous face. PCCC was performed under high-viscosity sodium hyaluronate (Healon GV 1.4%) initiated with 26 g of cystotome and later completed with Kraff-Uttrata forceps by frequent grasping and regrasping of the flap. Completion of PCCC and disruption of vitreous face during the procedure was noted. Even in cases of disrupted vitreous face, PCCC was performed and completed with forceps and, later, disruption of vitreous face was managed with 2-port automated limbal anterior vitrectomy. The size of PCCC was measured. An Alcon AcrySof SA30AL was implanted in-the-bag if the PCCC was 4 mm or smaller and in the sulcus when the PCCC was larger than 4 mm.

RESULTS

The mean age of the 106 pediatric patients was 17 +/- 26 months (median, 6 months; range, 1 month to 8 years). PCCC was completed in all the eyes. Disruption of vitreous face during PCCC was noted in 5 of 106 (4.7%) eyes. The mean size of PCCC was 3.6 +/- 0.7 mm. A total of 98 (92.5%) had in-the-bag, and 8 (7.5%) eyes had sulcus implantation of IOL.

CONCLUSION

PCCC was completed in all eyes with minimal disruption of vitreous face in a well-controlled manner under high-viscosity viscoelastics.

Comparison of epilenticular IOL implantation vs technique of anterior and primary posterior capsulorhexis with anterior vitrectomy in paediatric cataract surgery

PURPOSE

To compare the functional outcome of epilenticular intraocular lens (IOL) implantation vs the technique of anterior continuous curvilinear capsulorhexis (ACCC), posterior continuous curvilinear capsulorhexis (PCCC) with vitrectomy and in-the-bag IOL implantation in paediatric cataract surgery.

METHODS

Forty eyes of 33 children with developmental or traumatic cataract, whose mean age was 2-12 years, were randomly divided into two groups A and B. Group A patients underwent epilenticular IOL implantation while in group B patients, ACCC, PCCC with anterior vitrectomy with in-the-bag IOL implantation was performed. Equal number of eyes (10 each) with developmental cataracts (subgroups A1 and B1) and traumatic cataracts (subgroups A2 and B2) were allotted to both the groups. Postoperative visual acuity, opacification of the visual axis, and possible complications were observed and analysed.

RESULTS

Four eyes in subgroup B2 had fibrous or ruptured capsules, and were managed by epilenticular IOL implantation technique. One eye in subgroup B2 developed central posterior capsular opacification and hence required a secondary capsulotomy. All cases in group A maintained a clear visual axis at the last follow-up. Minimal postoperative inflammation was noticed in all groups, which subsided with anti-inflammatory medication. At the last follow-up, all eyes in group A gained visual acuity >/=6/18. Whereas in group B, visual acuity >/=6/18 was obtained in 85.7% cases with the epilenticular IOL implantation technique and in 83.3% cases with ACCC and PCCC with anterior vitrectomy technique.

CONCLUSION

Epilenticular IOL implantation offers a safe and effective alternative for management of paediatric cataract. In selected cases of traumatic cataract, it is the preferred treatment modality.

Modification of the high-speed vitrectomy system TSV 25 for pediatric cataract surgery

Modifications of a transconjunctival sutureless vitrectomy system (TSV 25, Bausch & Lomb Surgical) for removing cataracts and performing poster capsulotomy-anterior vitrectomy in children are reported.

Opacification of the visual axis after cataract surgery and single acrylic intraocular lens implantation in the first year of life

PURPOSE

To report the incidence and risk factors for secondary surgical intervention to treat visual axis opacification (VAO) after cataract surgery and acrylic intraocular lens (IOL) implantation during the first year of life.

METHODS

A retrospective review of 29 eyes of 20 patients receiving a hydrophobic acrylic (AcrySof; Alcon, Fort Worth, TX) IOL implantation was conducted. All eyes underwent primary posterior capsulectomy and anterior vitrectomy. Statistical analysis was performed using SPSS for Windows (SPSS, Chicago, IL).

RESULTS

Average age at surgery was 4.8 +/- 3.7 months, and average follow-up was 33.4 +/- 16.1 months. Eleven of 29 (37.9%) eyes developed VAO requiring secondary surgical intervention at a median of 4.8 months (95% confidence interval 3.4 to 6.2). Average age at surgery for eyes that subsequently opacified was 3.8 +/- 3.0 months compared with 5.4 +/- 4.0 months for those whose visual axis remained clear (P = 0.26). The relative risk of subsequent VAO surgery was 2.7 for primary surgery performed at or before the first 6 months of life. Opacification was significantly related to eyes with associated ocular anomalies (eg, anterior segment dysgenesis, iris hypoplasia, or persistent fetal vasculature) with a relative risk of 8.6 (P < 0.001). Proliferation of cortex was the most common form of VAO, followed by mixed-type with predominantly fibrous, fibrous alone, or Elschnig pearls. When secondary surgery was required, it occurred primarily during the first 6 months (ie, 9 of 11 patients) after the initial cataract surgery.

CONCLUSIONS

When cataract and IOL surgery was undertaken within the first year of life, a secondary surgical procedure was required in 37.9% of eyes to maintain a clear visual axis. Most secondary surgery for VAO occurred within the first 6 months after surgery. Postoperative opacification was most common in eyes with associated ocular anomalies.

Paediatric cataract blindness in the developing world: surgical techniques and intraocular lenses in the new millennium

Paediatric cataract blindness presents an enormous problem to developing countries in terms of human morbidity, economic loss, and social burden. Managing cataracts in children remains a challenge: treatment is often difficult, tedious, and requires a dedicated team effort. To assure the best long term outcome for cataract blind children, appropriate paediatric surgical techniques need to be defined and adopted by ophthalmic surgeons of developing countries. The high cost of operative equipment and the uneven world distribution of ophthalmologists, paediatricians, and anaesthetists create unique challenges. This review focuses on issues related to paediatric cataract management that are appropriate and suitable for ophthalmic surgeons in the developing world. Practical guidelines and recommendations have also been provided for ophthalmic surgeons and health planners dealing with childhood cataract management in the developing world.