Current Status of IOL implantation in pediatric eyes: an update

Incidence Rate of Secondary Glaucoma Following Congenital Cataract Surgery: An In-Depth Systematic Review and Meta-Analysis

PURPOSE

To assess the incidence of secondary glaucoma in children following congenital cataract surgery.

DESIGN

Systematic review and meta-analysis.

METHODS

The PubMed, Embase, Cochrane Library, and Web of Science databases were searched from inception through March 16, 2023. Studies reporting congenital cataract surgery and glaucoma were enrolled. The quality of the selected studies was assessed using the Newcastle Ottawa Scale, and data analysis was executed utilizing R software.

RESULTS

A total of 36 published studies with 3151 patients (4717 eyes) were included in the analysis. The incidence rate of glaucoma following congenital cataract surgery was 6.6% (95% CI: 3.9%, 9.9%). The incidence of secondary glaucoma in the primary intraocular lens (IOL) implantation group (3.3% [95% CI: 1.5%, 5.8%]) and the secondary IOL implantation group (3.5% [95% CI: 0%, 11.4%]) were lower compared to the aphakia group (13.5% [95% CI: 7.7%, 20.6%]). The incidence rate among children with congenital cataracts from Asia (6.9% [95% CI: 4.1%, 10.4%]) was higher than that in European children (0.9% [95% CI: 0%, 3.0%]; P < .01). A correlation was identified between the age at cataract surgery and the incidence of secondary glaucoma (P = .02).

CONCLUSIONS

This meta-analysis found that the incidence of secondary glaucoma following congenital cataract surgery is approximately 6.6%. Children with IOL implantation exhibit a lower incidence of secondary glaucoma, with a lower incidence noted in European children compared to their Asian counterparts. The age at cataract surgery is an important risk factor to consider.

Pediatric cataract surgery: Rate of secondary visual axis opacification depending on intraocular lens type

PURPOSE

To assess the time course of secondary visual axis opacification (VAO) that led to additional surgery after primary intraocular lens (IOL) implantation in children and to describe further surgical outcomes. Comparison of different lens types.

DESIGN

Single center, retrospective analysis of children aged 1-14 years who underwent cataract surgery with primary IOL implantation. The surgical technique was either in-bag IOL placement with primary posterior capsulotomy and anterior vitrectomy or bag-in-lens IOL placement. We excluded eyes with visually significant ocular comorbidities.

SUBJECTS

Total of 135 eyes of 95 children. Of these, 64 had received an acrylic three-piece IOL, 51 an acrylic single-piece IOL, and 20 an acrylic single-piece bag-in-lens IOL. The median ages at surgery were 53 months (IQR 35-75), 52 months (27-65), and 60 months (40-84) in the 3-piece, 1-piece, and bag-in-lens group, respectively.

METHODS

Analysis of medical records. We used the Kaplan-Meier method and a cox proportional hazards model with pre-defined adjustments for age at surgery, year of surgery, and socioeconomic deprivation (GISD score by postal code) to analyze VAO-free survival by lens type. Patients were invited to attend a clinical visit to achieve longer follow-ups.

MAIN OUTCOME MEASURES

The rate of survival without VAO that required clearing of the visual axis after cataract surgery with primary IOL implantation. Any other surgical complications.

RESULTS

The overall median follow-up was 19 months (IQR 3-58). There were 13 cases of VAO, occurring at a median of 10 months (IQR 10-12) after surgery. Of these, 1 eye had a 3-piece in-bag IOL, 10 eyes had 1-piece in-bag IOLs, and 2 eyes had bag-in-lens IOLs. The adjusted hazard ratio was 32.8 (95% CI: 3.3-327, p=0.003) for 1-piece acrylic IOLs and 19.6 (1.22-316, p=0.036) for bag-in-lens IOLs, compared to 3-piece acrylic in-bag IOLs. Two eyes with bag-in-lens surgery (10%) had an iris capture. There was one case of endophthalmitis. We found no cases of postoperative retinal detachment or new glaucoma.

CONCLUSIONS

Children with secondary visual axis opacification that required a procedure to clear the visual axis generally presented within fifteen months. Opacification rates were lowest when a 3-piece acrylic IOL was used.

Real-time intraoperative OCT imaging of the vitreolenticular interface during pediatric cataract surgery

PURPOSE

To report on the use of intraoperative optical coherence tomography (OCT) imaging of the vitreolenticular interface (VLI) during pediatric cataract surgery and to determine the incidence of VLI dysgenesis and surgical difficulties.

SETTING

Department of Ophthalmology, Antwerp University Hospital, Edegem, Belgium.

DESIGN

Retrospective cohort study.

METHODS

This study included 51 pediatric patients who underwent cataract surgery between April 2016 and December 2018. Video recordings and OCT images of the VLI were analyzed and compared. VLI dysgenesis was considered present when intraoperative OCT images demonstrated partial or total adhesions between the posterior lens capsule and the anterior hyaloid membrane. Video recordings were analyzed to describe surgical difficulties, more specifically: inability to create a calibrated primary posterior continuous curvilinear capsulorhexis (PPCCC), occurrence of vitreous prolapse, need for anterior vitrectomy, and complicated IOL implantation.

RESULTS

Of the 51 patients included, VLI dysgenesis was demonstrated in 27 patients (52.9%). The incidence of VLI dysgenesis was greater in children with unilateral cataract (72.4%), and children with a posterior capsule plaque (90%). PPCCC was challenging in 20 patients. A defect of the anterior hyaloid membrane was found in 16 patients. Anterior vitrectomy or cutting vitreous strands with scissors was necessary in 10 patients.

CONCLUSIONS

Intraoperative OCT images were an excellent tool to evaluate the VLI and to demonstrate the presence of VLI dysgenesis during pediatric cataract surgery. Performing a calibrated PPCCC was more challenging in the presence of VLI dysgenesis. This can subsequently expose a defect in the anterior hyaloid membrane, which may result in vitreous prolapse.

Recent developments in the management of congenital cataract

Congenital cataract is a rare eye disease, one of the leading treatable causes of low vision in children worldwide. Hereditary cataracts can be divided in syndromic and non-syndromic cataracts. Early diagnosis in congenital cataracts is key to reach good visual function. Current surgical techniques, that combine microincision cataract extraction and primary intraocular lens (IOL) implantation, have improved childhood cataract outcome. Complications include posterior capsule opacification (PCO), aphakic or pseudophakic glaucoma, uveitis, pupil displacement and IOL decentration. A recent study using a modified Delphi approach identified areas of consensus and disagreement in the management of pediatric cataract. A consensus or near consensus was achieved for 79% of the questions, however 21% of the questions remained controversial, as for IOL implantation strategy. Congenital cataracts show a highly variable phenotype and genotype, and can be related to different mutations, genetic variance, and other risk factors. Congenital cataracts can be associated with other ocular developmental abnormalities, including microphthalmia, microcornea, or aniridia and with systemic findings. Next-generation sequencing (NGS) and forthcoming new ultra-high-throughput sequencing represent excellent tools to investigate the genetic causes of congenital cataracts. A better recognition of different clinical presentations and underlying etiologies of congenital cataracts may lead to the development of new approaches to improve visual outcome after cataract surgery and promote early detection of systemic associated syndromes.

Comparison of the Accuracy of IOL Power Calculation Formulas for Pediatric Eyes in Children of Different Ages

Purpose

This study aims to compare the accuracy of five intraocular lens (IOL) power calculation formulas (SRK/T, Hoffer Q, Holladay 1, Haigis, and Holladay 2) for pediatric eyes in children of different ages.

Methods

In this prospective study, patients who received cataract surgery and IOL implantation in the capsular bag were enrolled. We compared the calculation accuracy of 5 formulas at 1 month postoperatively and performed subgroup analysis with the patients divided into three groups according to their ages at the time of surgery as follows: group 1 (age ≤ 2 years, 35 eyes), group 2 (2 years < age < 5 years, 38 eyes), and group 3 (age > 5 years, 29 eyes).

Results

75 patients (102 eyes) were enrolled in this study. The Haigis formula got the smallest PE among all formulas in all three groups. With regard to APE, there were no statistical differences among the formulas except group 2, with the SRK/T formula a little smaller, the Holladay 2 formula a little larger in group 1, and the Haigis formula a little smaller in group 3. In group 2, the Haigis formula had the lowest APE (0.87 ± 0.61 D), while the Holladay 2 formula had the largest (1.71 ± 1.20 D, p < 0.001), followed by the Holladay 1 formula (1.51 ± 1.07 D, p=0.002). On comparing the percentage of APE within 0.5 D and 1.0 D obtained with 5 formulas in each group, there were no statistical differences. The SRK/T formula and the Holladay 1 formula showed the highest percentage (40.00% and 60.00%) in group 1. While the Haigis formula got the highest percentage in less than 0.5 D (34.21%) and less than 1 D (60.53%) in group 2. In group 3, the Holladay 2 formula and the Haigis formula got the highest percentage less than 0.5 D (58.62%) and less than 1 D (79.31%). The multiple linear regression indicated that the age at the time of surgery was a significant factor affecting the accuracy of APE; after removing the age, AL was the only factor that affected the accuracy of APE.

Conclusion

The SRK/T and the Holladay 1 formulas were relatively accurate in patients younger than 2 years old, while the Haigis formula performed better in patients older than 2.

A pilot study of intraocular lens explantation in 69 eyes in Chinese patients

AIM

To study the effects of intraocular lens (IOL) explantation and demographic characteristics.

METHODS

Retrospective non-comparative case series. Clinical data recorded from patient charts included the following: demographic, preoperative and postoperative characteristics; complications; surgical methods, and changes in visual acuity.

RESULTS

A total of 69 eyes in 67 Chinese patients who received IOL explants were studied. The patients' mean age at the time of explantation was 46.1 years old [SD 22.5 (6-85)], and 37 patients were female (55.2%). Regarding employment, 47.8% were farmers, 23.9% were retired, 16.4% were students, 4.5% were unemployed, 3% were workers, and 4.5% were other (including staff members, teachers and officers). The main reasons for explantation were dislocation/decentration in 41 cases (59.4%) and retinal detachment in 10 cases (14.5%). The third most prevalent cause was incorrect lens power in 7 eyes (10.1%). The remaining reasons were endophthalmitis in 6 cases (8.7%), posterior capsular opacity in 3 eyes (4.3%), and impacting retinal surgery operation in 2 cases (2.9%). The main comorbidities were high myopia in 18 eyes (26.1%), trauma in 8 eyes (11.6%), retinal detachment in 6 eyes (8.7%), congenital cataracts in 8 eyes (11.6%), and Marfan's syndrome in 2 eyes (2.9%). The mean time from implantation to explantation was 4.0y [SD 4.2 (0.005-15)]. Treatment after explantation included posterior chamber IOL implantation in 44 eyes (63.8%) and aphakia in 25 eyes (36.2%). After surgery, the best corrected visual ability (BCVA) was improved in 50 cases (72.5%), including 28 patients (40.6%) in whom visual ability was improved by more than two lines.

CONCLUSION

Dislocation/decentration is the main cause for explantation, and high myopia is a main risk factor. Posterior chamber IOL implantation remains the most elected treatment after explantation.