Update on pediatric cataract surgery and intraocular lens implantation

Anterior Chamber Depth and Lens Thickness Measurements in Pediatric Eyes: Ultrasound Biomicroscopy Versus Immersion A-Scan Ultrasonography

OBJECTIVE

To compare anterior chamber depth (ACD) and lens thickness (LT) measurements by ultrasound biomicroscopy (UBM), A-scan cross vector (CV) overlay with UBM, and immersion A-scan technique in pediatric eyes.

METHODS

This prospective comparative cohort study comprised 43 eyes of 25 pediatric participants (mean age: 2.3±2.2 y). UBM and immersion A-scan biometry were performed prior to dilation and intraocular surgery. ACD and LT were measured by UBM image analysis, A-scan CV UBM overlay, and immersion A-scan technique.

RESULTS

ACD and LT measurements obtained using immersion A-scan were significantly greater than with UBM image analysis with mean differences of 0.52 mm and 0.62 mm, respectively (p < 0.001). Immersion A-scan and UBM measurements were moderately correlated (r = 0.70 and 0.64, p < 0.001). ACD and LT measurements obtained using CV overlay were not significantly different than UBM measurements and the values were strongly positively correlated (r = 0.95 and 0.93, p < 0.001).

CONCLUSION

Immersion A-scan may overestimate ACD and LT compared to UBM in pediatric patients due to oblique placement of the A-scan probe relative to the optical axis. Supplemental use of UBM and/or CV overlay is indicated to improve measurement accuracy in pediatric patients who cannot reliably fixate due to the ability to confirm proper alignment of the probe with the pupil by visualizing the anterior segment.

Reopening the capsular bag by removing the capsular proliferative membrane to enable secondary in-the-bag intraocular lens implantation in pediatric aphakic eyes

PURPOSE

To present a surgical technique for reopening the capsular bag in pediatric aphakia.

SETTING

Zhongshan Ophthalmic Center, Guangzhou, China.

DESIGN

Case series study.

METHODS

Consecutive pediatric patients with bilateral aphakia requiring secondary intraocular lens (IOL) implantation between July 2021 and June 2022 were included. The diameter of the capsular proliferative membranous ring (PMR) and position of IOL implantation were documented. Various parameters of capsular bag opening during primary cataract removal and secondary surgery were also analyzed.

RESULTS

48 eyes were included with a mean follow-up of 8.1 ± 4.4 months. Using the surgical technique developed in this study, the capsular bag was successfully reopened with in-the-bag (ITB) implantation in 43 eyes (89.6%). ITB implantation was accomplished in all eyes with an outer diameter of PMR ≤5.5 mm and in 3 of 8 eyes (37.5%) with an outer diameter of PMR >5.5 mm. A positive correlation was observed between the primary and secondary anterior capsular opening diameters (ACODs) ( r = 0.422, P = .007) and the primary and secondary posterior capsular opening diameters (PCODs) ( r = 0.619, P < .001). The inner diameter of PMR was found to be positively correlated with secondary PCOD ( r = 0.728, P < .001) and the outer diameter with secondary ACOD ( r = 0.669, P < .001).

CONCLUSIONS

This was a safe and effective surgical technique for pediatric secondary IOL implantation with maximum preservation of the peripheral capsule. Aphakic eyes with an outer diameter of PMR ≤5.5 mm are preferred for secondary ITB implantation.

Multifocal intraocular lens implantation in children with unilateral congenital cataracts

PURPOSE

To evaluate the vision recovery, reconstruction of binocular visual function, and influencing factors after multifocal intraocular lens implantation in children with unilateral congenital cataracts.

SETTING

University hospital.

DESIGN

Prospective clinical study.

METHODS

In the prospective clinical study, 55 children aged 3 to 14 with unilateral congenital cataracts received multifocal intraocular lenses (TECNIS ZMB00) posterior optic capture from 2019 to 2022. Corrected distance visual acuity (CDVA; 5 m), distance-corrected intermediate visual acuity (DCIVA; 66 cm), distance-corrected near visual acuity (DCNVA; 33 cm), stereoscopic vision, visual quality (objective scatter index [OSI] and modulation transfer function [MTF]), axial length (AL), keratometry (K), and contrast sensitivity (CS), as well as postoperative occlusion compliance were evaluated before and after surgery.

RESULTS

At the final follow-up, 90.91% (50/55) patients showed significant improvement in visual acuity (VA) after surgery. CDVA, DCIVA and DCNVA were 0.23 ± 0.17, 0.39 ± 0.15, and 0.44 ± 0.15 logMAR, respectively. 69.09% (38/55) patients achieved good VA (better than 0.3 logMAR).52.76% (25/48) patients had a positive Titmus test. OSI and MTF were 1.24 ± 0.91 and 42.45 ± 12.30, respectively. 73.68% (28/38) of the patients (better than 0.3 logMAR) underwent strict occlusion therapy. Postoperative VA is correlated with preoperative CDVA ( r = -0.829, P < .001), corneal astigmatism ( r = 0.384, P = .036), △AL (difference between the cataract eyes and contralateral eyes, r = -0.490, P = .006), and occlusion compliance ( r = -0.806, P < .001).

CONCLUSIONS

Multifocal intraocular lens implantation could obtain relatively satisfactory VA (CDVA, DCIVA and DCNVA) and the binocular visual function of children with unilateral congenital cataracts. Postoperative VA is related to preoperative VA, corneal astigmatism, △AL, and occlusion compliance.

Visual Function in Children With Posterior Lens Opacities Before and After Surgery

PURPOSE

To evaluate the visual function before and after cataract surgery in children with congenital posterior lens opacities as well as the factors associated with a good visual outcome.

DESIGN

Perspective case-series study.

METHODS

Pediatric patients with posterior lens opacities who underwent cataract surgery were recruited in this study. The cataract type, location, area of opacities, and strabismus were examined perioperatively. Moreover, visual acuity, modulation transfer function (MTF), ocular aberrations, and stereopsis were measured before and after cataract surgery.

RESULTS

Sixty-nine eyes of 63 patients were studied. The mean age of patients at surgery was 6.5 ± 2.9 years. Visual function including corrected distance visual acuity (CDVA), MTF cutoff frequency, and ocular aberrations were significantly affected in eyes with posterior lens opacities. Postoperatively, CDVA was significantly improved from 0.81 ± 0.53 logMAR to 0.40 ± 0.40 logarithm of the minimum angle of resolution (logMAR) (P < .001). Thirty-nine patients (56.5%) achieved a final VA of 20/40 or better. Moreover, MTF cutoff values were significantly improved, and total ocular aberrations were decreased after cataract removal (both P < .001). The stereopsis was also improved postoperatively (P < .001). The multivariate analysis of the risk factors for postoperative CDVA showed that worse preoperative CDVA, larger size of lens opacities, and mean keratometry were the risk factors (all P < .05).

CONCLUSIONS

Visual function can be significantly decreased in children with posterior lens opacities, and surgery was effective in improving visual function. Patients with a CDVA of 0.52 logMAR or better, a size of lens opacity <6.5 mm² and smaller mean keratometry had a greater CDVA postoperatively.

Intraoperative OCT for the assessment of posterior capsular integrity in pediatric cataract surgery

PURPOSE

To study the morphology of the posterior lens cortex and posterior capsules (PCs) in pediatric patients with posterior lens opacities using intraoperative optical coherence tomography (iOCT).

SETTING

Zhongshan Ophthalmic Center, Sun Yat-sen University, Guangzhou, China.

DESIGN

Prospective observational study.

METHODS

Pediatric patients with posterior lens opacities were imaged using iOCT during cataract surgery. The morphology of the posterior lens cortex and PC, along with the common patterns to indicate PC integrity, was assessed. Moreover, PC rent during surgery was observed.

RESULTS

A total of 62 eyes from 53 patients were included. The mean age of patients was 3.8 years. 4 morphological variants of posterior lens opacity were observed: type I (34/62 [54.8%]) with an intact PC; type II (20/62 [32.3%]) with an intact PC, which protruded into the anterior vitreous; type III (3/62 [4.8%]) with a deficient PC and an inability to delineate the PC; and type IV (5/62 [8.1%]) with dense opacity and an inability to characterize the posterior cortex and PC. Phacoemulsification could be performed in types I and II. In types III and IV, manual nucleus removal was performed instead of phacoemulsification. 3 cases (100%) of type III PC dehiscence developed during surgery, whereas no cases developed PC dehiscence of other types.

CONCLUSIONS

The morphology of the PC and posterior lens cortex in pediatric posterior lens opacities could be categorized, and PC integrity could be assessed using iOCT, which was useful to guide surgical strategies and increase safety in pre-existing PC dehiscence in pediatric cataract surgery.

Comparative analysis of visual outcomes of multifocal and monofocal intraocular lenses in congenital cataract surgery

PURPOSE

To assess the impact on visual development of multifocal versus monofocal intraocular lenses (IOLs) implantation in children following congenital cataract surgery.

DESIGN

Retrospective interventional consecutive case series.

METHODS

We reviewed the records of 56 eyes of 43 pediatric patients who underwent congenital cataract surgery with phacoaspiration and simultaneous implantation of IOL under one year of age. Corrected distance visual acuity (CDVA), refractive error and ocular motility disorders were evaluated after a follow-up greater than 4 years.

RESULTS

We implanted 32 multifocal (18unilateral, Group A and 14bilateral, Group B) and 24monofocal IOLs (12unilateral, Group C and 12bilateral, Group D). Mean follow-up was 6.67 years. Mean CDVA of the eyes with multifocal IOL was 0.75±0.46 logMAR in unilateral cataract surgery and 0.34±0.25logMAR in bilateral ones; with monofocal IOLs was 0.71±0.52logMAR in unilateral and 0.53±0.43logMAR in bilateral ones. No statistically significant difference in CDVA between Groups A and B and Groups C and D has been recorded. Final mean spherical equivalent was -3.88±4.73D; in Group A it was -2.74±4.22D, in Group C was -1.08±1.45D, in Group B was -4.82±4.64D and in Group D was -6.81 ± 4.61D.The difference was statistically significant between Group B and D (p=0.01), but not between Group A and C (p=0.14).Twenty-six patients (60.4%) showed post-operative strabismus. Its surgical correction occurred more in patients with multifocal IOL implanted (p=0.038).

CONCLUSIONS

Our findings suggest that the use of multifocal IOLs did not show significant advantages in visual development in children following congenital cataract extraction under one year of age if compared with monofocal IOLs.

Precision of bag-in-the-lens intraocular lens power calculation in different age groups of pediatric cataract patients: Report of the Giessen Pediatric Cataract Study Group

PURPOSE

To evaluate the precision of bag-in-the-lens intraocular lens (BIL IOL) power calculation in different age groups of pediatric cataract patients.

SETTINGS

Department of Ophthalmology, Justus-Liebig-University Giessen, University Hospital Giessen and Marburg GmbH, Campus Giessen, Giessen, Germany.

DESIGN

Retrospective nonrandomized consecutive case series.

METHODS

Pediatric patients diagnosed with cataract and operated with BIL IOL implantation were divided into 4 age groups: Group 1 (0 to 3 months), Group 2 (>3 months, <12 months), Group 3 (12 to 36 months), and Group 4 (>36 months to 17 years). BIL IOL power was calculated with the SRK/T formula. The prediction error (PE) was defined as the absolute difference between the preoperative selected target and postoperative achieved refraction. The impact of age at the time of surgery, axial length (AL), keratometry, and corneal astigmatism on PE was analyzed.

RESULTS

The study comprised 87 eyes of 56 pediatric patients. The mean and median PEs for the entire group were 1.79 diopters (D) and 1.23 D, respectively. The mean PE in each age group was: 3.43 D in Group 1, 2.14 D in Group 2, 1.60 D in Group 3, and 1.33 D in Group 4. The mean PE in eyes with ALs shorter than 20 mm was 2.67 D, and 1.44 D in eyes with an AL of 20 mm or longer. The mean PE in eyes with corneal radii less than 7.3 mm was 2.45 D, and 1.66 D in eyes with corneal radii of 7.3 mm or more. In the age and AL subgroups, the PE differences were statistically significant (P < .05).

CONCLUSIONS

The PE was larger in the youngest study group, and it decreased gradually with age and in eyes with ALs shorter than 20 mm. The PE has to be considered during BIL IOL power calculation in children.

Femtosecond laser - Assisted cataract surgery in pediatric pyramidal anterior polar cataract

PURPOSE

The purpose of this report is to describe the successful utilization of femtosecond laser assisted cataract surgery (FLACS) in a rare case of pyramidal anterior polar cataract in a female child.

OBSERVATIONS

The patient is a 6 years old girl that presented to the cornea clinic with a unilateral pyramidal cataract that was deemed to be visually significant, and therefore required cataract extraction and intraocular lens implantation surgery. FLACS was proposed and mother consented to proceed with the surgery. The femtosecond laser technology enabled precise completion of a central capsulotomy around the protruding pyramidal capsular lesion.

CONCLUSIONS AND IMPORTANCECONCLUSION

Various capsulorhexis techniques have been described and are used in pediatric cataracts including manual, can opener, vitrectorhexis, and laser, but none has become a standard. We propose the use of femtosecond laser for cataract extraction in cases of pediatric pyramidal cataracts, and hereby provide the first case report of such. The laser is a safe method for capsulorhexis construction and offers an additional advantage of intraoperative anterior segment OCT image guidance with visualization of the pyramidal lesion.

Pediatric cataract

Pediatric cataract is a leading cause of childhood blindness. Untreated cataracts in children lead to tremendous social, economical, and emotional burden to the child, family, and society. Blindness related to pediatric cataract can be treated with early identification and appropriate management. Most cases are diagnosed on routine screening whereas some may be diagnosed after the parents have noticed leukocoria or strabismus. Etiology of pediatric cataract is varied and diagnosis of specific etiology aids in prognostication and effective management. Pediatric cataract surgery has evolved over years, and with improving knowledge of myopic shift and axial length growth, outcomes of these patients have become more predictable. Favorable outcomes depend not only on effective surgery, but also on meticulous postoperative care and visual rehabilitation. Hence, it is the combined effort of parents, surgeons, anesthesiologists, pediatricians, and optometrists that can make all the difference.

Capsular Outcomes After Pediatric Cataract Surgery Without Intraocular Lens Implantation: Qualitative Classification and Quantitative Measurement

The objective of this study was to investigate capsular outcomes 12 months after pediatric cataract surgery without intraocular lens implantation via qualitative classification and quantitative measurement.This study is a cross-sectional study that was approved by the institutional review board of Zhongshan Ophthalmic Center of Sun Yat-sen University in Guangzhou, China.Digital coaxial retro-illumination photographs of 329 aphakic pediatric eyes were obtained 12 months after pediatric cataract surgery without intraocular lens implantation. Capsule digital coaxial retro-illumination photographs were divided as follows: anterior capsule opening area (ACOA), posterior capsule opening area (PCOA), and posterior capsule opening opacity (PCOO). Capsular outcomes were qualitatively classified into 3 types based on the PCOO: Type I-capsule with mild opacification but no invasion into the capsule opening; Type II-capsule with moderate opacification accompanied by contraction of the ACOA and invasion to the occluding part of the PCOA; and Type III-capsule with severe opacification accompanied by total occlusion of the PCOA. Software was developed to quantitatively measure the ACOA, PCOA, and PCOO using standardized DCRPs. The relationships between the accurate intraoperative anterior and posterior capsulorhexis sizes and the qualitative capsular types were statistically analyzed.The DCRPs of 315 aphakic eyes (95.8%) of 191 children were included. Capsular outcomes were classified into 3 types: Type I-120 eyes (38.1%); Type II-157 eyes (49.8%); Type III-38 eyes (12.1%). The scores of the capsular outcomes were negatively correlated with intraoperative anterior capsulorhexis size (R = -0.572, P < 0.001), but no significant correlation with intraoperative posterior capsulorhexis size (R = -0.16, P = 0.122) was observed. The ACOA significantly decreased from Type I to Type II to Type III, the PCOA increased in size from Type I to Type II, and the PCOO increased from Type II to Type III (all P < 0.05).Capsular outcomes after pediatric cataract surgery can be qualitatively classified and quantitatively measured by acquisition, division, definition, and user-friendly software analyses of high-quality digital coaxial retro-illumination photographs.

Evaluating the evidence for and against the use of IOLs in infants and young children

Congenital cataracts account for 5-20% of childhood blindness worldwide. In the US, the prevalence of visually significant infantile cataracts is anywhere from 3-4 per 10,000 live births. Infantile cataracts need to be removed early in life in order to prevent the onset of deprivation amblyopia. As a result, cataract surgery is usually performed between age 4-8 weeks depending on the laterality and severity of the cataract. Given advances in the field, pediatric cataract surgery is now a safe and effective intervention for infants, but good visual outcomes require occlusion therapy and optical correction. This review will address current perspectives on the use of intraocular lenses to optically correct infants and young children after cataract surgery, as well as novel designs for intraocular lenses and directions for future research.

Capsular Outcomes Differ with Capsulorhexis Sizes after Pediatric Cataract Surgery: A Randomized Controlled Trial

Capsular outcomes of anterior/posterior capsulorhexis opening (ACO/PCO) are essential for performing a secondary in-the-bag intraocular lens implantation. To compare the capsular outcomes with different primary capsulorhexis sizes, Thirty-eight eligible patients (45 eyes) were randomly assigned to three groups by anterior capsulorhexis diameter (Group A: 3.0-3.9, Group B: 4.0-5.0, and Group C: 5.1-6.0 mm). The areas of ACO/PCO and posterior capsule opening opacity (PCOO) as primary outcomes, while, the incidence of visual axis opacity (VAO) as secondary outcome were measured at follow-up visits. Among the thirty eyes included in the final analysis, the mean area of the ACO decreased significantly, whereas the PCO enlarged with time. Group A had the highest anterior capsule constriction and percentage reduction, which increased with time. There were significant differences in the percentage reductions at 6 months and 1 year compared to 1 month in Group A and B. Group C had the highest posterior capsule enlargement. The percentage of PCOO to PCO area and the incidence of VAO was highest in Group A and lowest in Group C. Thus, Capsulorhexis diameter of 4.0-5.0 mm may yield better capsular outcomes, considering moderate contraction of ACO, moderate enlargement of PCO, and lower percentage of PCOO and VAO.

Retropupillary Fixation of Iris-Claw Intraocular Lens for Aphakic Eyes in Children

Purpose

To report outcome, complications and safety of retropupillary fixated iris-claw intraocular lenses in a pediatric population.

Design

Retrospective study.

Patients and Methods

Ten consecutive pediatric patients (15 eyes) underwent placement of retropupillary fixated iris-claw intraocular lenses between October 2007 and July 2013 at the Department of Ophthalmology, Medical University Graz and General Hospital Klagenfurt, Austria. Postoperative visual acuity and complications were analyzed.

Results

Median final best-corrected visual acuity improved by 0.12 logMAR from preoperative baseline. Mean postoperative spherical equivalent was -0.05 ± 1.76 D. No serious complications were observed intra- or postoperatively during the entire follow-up period of up to 40 months. One patient experienced a haptic disenclavation with IOL subluxation immediately after a car accident.

Conclusion

Our study demonstrates that iris-claw intraocular lens implantation behind the iris is safe in children with lack of capsular support and yields excellent visual outcome with low complication rate.

[Iris suture fixation of posterior chamber lenses. New perspectives for an old technique]

BACKGROUND

Intraocular approaches to correct aphakia in cases of inadequate capsular support include an anterior chamber intraocular lens, fixation of a posterior chamber lens to the sclera or iris by suturing or iris claw, respectively.

OBJECTIVES

This article reviews the indications and contraindications for iris fixation with sutures and gives an overview of surgical techniques, potential complications and outcomes.

METHODS

Based on a selective search of pertinent literature in PubMed the information from original articles and reviews are analyzed, summarized and discussed.

RESULTS

New surgical techniques have imparted an impetus to iris suture fixation with encouraging functional and morphological results offering a new promising alternative to the established options. Improved aspects arise for repositioning of a decentered intraocular lens and for a minimally invasive method for repair of late in-the-bag lens dislocation as seen more frequently by cataract surgeons.

CONCLUSION

A final evaluation of the proposed techniques is not possible because none has clearly emerged as the optimal method. Precise determination of small differences in visual outcome or complication rates requires a large prospective, randomized clinical trial.

Multi-component adjustable intraocular lenses: a new concept in pediatric cataract surgery

PURPOSE

The multi-component intraocular lens (IOL) (IVO; SAS, Strasbourg, France) is a novel approach to the treatment of pediatric cataract. Because the refractive requirements for pediatric eyes often change over time, current IOL technology does not easily allow refractive adjustments after the primary surgical intervention. The multi-component IOL concept allows easy, surgical refractive adjustments to the initial surgical implantation at any postoperative time period. Thus, both surgical implantation and enhancement surgery have been successfully accomplished in adult patients.

METHODS

A novel surgical approach to pediatric cataract surgery is described. At the time of the primary surgery, a two component IOL was implanted. At any postoperative time period, the front lens component, located in front of the capsular bag, could be easily surgically exchanged because the dioptric power requirements of the pediatric eye changed over time.

RESULTS

Both primary and enhancement surgeries have been done in adult patients with good results. Implantations have occurred uneventfully in all cases with no intraoperative or postoperative complications. There was no statistically significant difference in the endothelial cell density, anterior chamber depth, and pachymetry readings preoperatively and 2 years postoperatively. There was no interlenticular fibrosis present.

CONCLUSION

The multi-component IOL should provide a unique and greatly needed surgically adjustable approach to the treatment of pediatric cataract.

In-the-bag intraocular lens placement via secondary capsulorhexis with radiofrequency diathermy in pediatric aphakic eyes

Pediatric ophthalmologists increasingly recognize that the ideal site for intraocular lens (IOL) implantation is in the bag for aphakic eyes, but it is always very difficult via conventional technique. We conducted a prospective case series study to investigate the success rate and clinical outcomes of capsular bag reestablishment and in-the-bag IOL implantation via secondary capsulorhexis with radiofrequency diathermy (RFD) in pediatric aphakic eyes, in which twenty-two consecutive aphakic pediatric patients (43 aphakic eyes) enrolled in the Childhood Cataract Program of the Chinese Ministry of Health were included. The included children underwent either our novel technique for secondary IOL implantation (with RFD) or the conventional technique (with a bent needle or forceps), depending on the type of preoperative proliferative capsular bag present. In total, secondary capsulorhexis with RFD was successfully applied in 32 eyes (32/43, 74.4%, age 5.6±2.3 years), of which capsular bag reestablishment and in-the-bag IOL implantation were both achieved in 30 eyes (30/43, 70.0%), but in the remaining 2 eyes (2/32, 6.2%) the IOLs were implanted in the sulcus with a capsular bag that was too small. Secondary capsulorhexis with conventional technique was applied in the other 11 eyes (11/43, 25.6%, age 6.9±2.3 years), of which capsular bag reestablishment and in-the-bag IOL implantation were both achieved only in 3 eyes(3/43, 7.0%), and the IOLs were implanted in the sulcus in the remaining 8 eyes. A doughnut-like proliferative capsular bag with an extensive Soemmering ring (32/43, 74.4%) was the main success factor for secondary capsulorhexis with RFD, and a sufficient capsular bag size (33/43, 76.7%) was an additional factor in successful in-the-bag IOL implantation. In conclusion, RFD secondary capsulorhexis technique has 70% success rate in the capsular bag reestablishment and in-the-bag IOL implantation in pediatric aphakic eyes, particularly effective in cases with a doughnut-like, extensively proliferative Soemmering ring.

Update of intraocular lens implantation in children

Cataract is a common problem that affects the vision in children and a major cause of amblyopia in children. However, the management of childhood cataract is tenuous and requires special considerations especially with regard to intraocular lens (IOL) implantation. Age at which an IOL can be implanted is a controversial issue. Implanting an IOL in very young children carries the risk of severe postoperative inflammation and posterior capsule opacification that may need other surgeries and may affect the vision permanently. Accuracy of the calculated IOL power is affected by the short eyes and the steep keratometric values at this age. Furthermore, choosing an appropriate IOL power is not a straight forward decision as future growth of the eye affects the axial length and keratometry readings which may result in an unexpected refractive error as children age. The aim of this review is to cover these issues regarding IOL implantation in children; indications, timing of implantation, types of IOLs, site of implantation and the power calculations.

An ROP screening dilemma: hereditary cataracts developing in a premature infant after birth

A female infant born prematurely at 23 weeks' gestational age developed bilateral hereditary cataracts at post-menstrual age 33 weeks, which precluded retinopathy of prematurity screening. The infant underwent right cataract extraction 1 week later, and retinopathy of prematurity was monitored by examining the right eye. In the seventeenth week of life (post-menstrual age 40 weeks), the cataract was removed from the left eye. Visual outcome at 19 months of age was good in both eyes. Very early cataract extraction may be necessary in premature infants to allow ROP evaluations.

Postcataract surgical inflammation

PURPOSE OF REVIEW

To describe the epidemiology, pathogenesis, and recent developments in the diagnosis and management of postcataract surgery inflammation.

RECENT FINDINGS

In patients with pre-existing uveitis, control of inflammation with topical and/or systemic therapy for 3 months preoperatively continues to be important in lessening the risk of postoperative inflammation and complications. During cataract surgery, intraocular lens selection in these patients is important. Recent literature suggests that modern intraocular lenses (IOLs), particularly hydrophilic or hydrophobic acrylic lenses, generally have good uveal biocompatibility in uveitic patients. The postoperative course can be complicated by inflammation and cystoid macular edema (CME), and in uveitic patients, intensive perioperative steroid treatment can lessen these complications. Recent studies show that in uveitic patients, the improvement in CME and inflammation after intravitreal triamcinolone is better than after orbital floor triamcinolone injection, but that a single intraoperative orbital floor injection of triamcinolone is as effective as a 4-week course of postoperative oral prednisolone. Although postoperative inflammation in uveitic patients may be due to recurrence of uveitis, one must recognize other important potential causes of postoperative inflammation and treat accordingly.

SUMMARY

Most patients with postcataract inflammation have good visual outcomes provided that the cause is recognized and that there is adequate perioperative planning in patients predisposed to inflammation.

Long-term follow-up of changes in corneal endothelium after primary and secondary intraocular lens implantations in children

BACKGROUND

To evaluate long-term changes in corneal endothelial cell count and morphology after congenital cataract extraction and intraocular lens implantation.

METHODS

Cataract extraction and posterior chamber intraocular lens (IOL) implantation was performed on 54 congenital cataract patients (83 eyes). The corneal endothelial cell density (ECD), coefficient of variation (CV), hexagonality, and central corneal thickness (CCT) were measured for a retrospective analysis of long-term changes in corneal endothelial characteristics.

RESULTS

The mean age at the time of IOL implantation was 5.00 (3.62) years [mean (SD)], and the mean follow-up period was 8.83 (1.49) years. In a comparison of the treated and normal eyes of patients who underwent unilateral surgery, the treated eyes showed a significantly greater CCT (p < 0.05), and there was no significant difference in ECD, CV, and hexagonality (p > 0.05). In addition, there was no statistically significant difference in the ECD and CCT between the primary and secondary IOL implantation groups.

CONCLUSIONS

Our results did not show any significant corneal endothelial cell loss in congenital cataract patients; however, their CCTs were increased.

Long-term corneal endothelial cell changes in pediatric intraocular lens reposition and exchange cases

PURPOSE

To evaluate long-term corneal endothelial cell changes of intraocular lens (IOL) reposition and exchange in children.

SETTING

State key Laboratory of Ophthalmology, Zhongshan Ophthalmic Center, Sun Yat-sen University, Guangzhou, 510060, China

METHODS

In this retrospective study, all IOL reposition and exchange procedures performed in patients under 14 years old between January 1999 and April 2009 were included. Follow-up outcomes included corneal endothelial cell density, hexagonality, coefficient of variance, average cell size.

RESULTS

IOL reposition procedures in 12 eyes (12 cases) (reposition group, RPG), and IOL exchanges in eight eyes (eight cases) (exchange group, EXG) were performed because of IOL pupillary capture or IOL dislocation. Median of follow-up was 44.5 months in RPG and 66.2 months in EXG. The density of corneal endothelial cells in RPG (2,053 ± 493/mm(2)) and EXG (2,100 ± 758/mm(2)) was significantly decreased in comparison to the control eyes (3,116 ± 335/mm(2)). Hexagonality of corneal endothelial cells and coefficient of variance showed no difference among the control group, RPG and EXG (P > 0.05).

CONCLUSIONS

The density of corneal endothelial cells was conspicuously decreased after IOL reposition or exchange procedures in childhood cases. Longer follow-up must be conducted in these cases.

Secondary intraocular lens implantation after pediatric aphakia

PURPOSE

To describe our technique for secondary intraocular lens (IOL) implantation in aphakic children and report patient outcomes.

PATIENTS AND METHODS

In our technique for in-the-bag IOL implantion, we used a microvitreoretinal (MVR) blade to separate the capsular leaflets for aspiration of reproliferated lens material within Soemmering's ring. When sufficient capsular opening was not possible or capsular support deemed inadequate, an IOL was implanted in the sulcus. Records of patients with secondary IOL implantation between 1999 and 2009 were retrospectively reviewed with regard to intra- and postoperative complications and visual and refractive outcomes.

RESULTS

A total of 50 consecutive eyes of 32 patients were evaluated. Mean age at secondary IOL implantation was 9.1 years. Of these, 26 eyes had in-the-bag IOLs and 24 had sulcus IOLs. Forty-four eyes (88%) had an AcrySof IOL (Alcon Inc, Ft. Worth, TX). The prevalence of any corneal edema (54% vs 19%, P = 0.04) and uveal inflammation >2+ (92% vs 31%, P < 0.05) in immediate postoperative period was greater with sulcus IOL than in-the-bag placement. Late inflammation at 6 months developed in 1 eye, and glaucoma developed in 2 eyes with sulcus IOLs. All eyes maintained or gained lines of best-corrected visual acuity. Mean absolute prediction error was 0.9 ± 0.9 with no significant difference between in-the-bag and sulcus placement.

CONCLUSIONS

Eyes achieving secondary in-the-bag IOL showed less inflammation and corneal edema in the early postoperative period partly as the result of greater surgical and anatomic challenges in some eyes receiving sulcus IOL. Visual and refractive outcomes were satisfactory in eyes with secondary IOL implantation. Mean prediction error was similar for in-the-bag and sulcus IOLs.

Technological advances in pediatric cataract surgery

PURPOSE

Managing pediatric cataracts is often challenging. It is technically difficult to perform surgery in these small complaint eyes and there is higher prevalence of postoperative complications. The outcomes of surgery depend on technique and technology. The purpose of this study is to review the current literature on technological advances in pediatric cataract surgery.

METHODS

Review of literature on management of pediatric cataract surgery.

RESULTS

The advent of vitrectomy machines and intraocular lenses (IOLs) has revolutionized pediatric cataract surgery. "Vitrectorhexis" has become a good alternative to manual capsulorhexis. Primary management of posterior capsule and limited anterior vitrectomy has reduced the incidence of visual axis opacification. Primary IOL implantation is becoming a standard of care in the youngest children. Single piece Acrysof® is preferred for in-the-bag implantation and 3-piece Acrysof® for sulcus implantation. Newer IOLs are being evaluated in pediatric eyes. Precise measurement of intraocular lens power and predicting refractive change are major challenges in long term care of children after surgery.

CONCLUSION

New technology and surgical techniques have refined pediatric cataract surgery. It is critical to focus our efforts on precise biometry measurements, IOL power calculation, and designing IOLs that may address refractive changes in the growing pediatric eye.