Incidence of and Risk Factors for Suspected Glaucoma and Glaucoma After Congenital and Infantile Cataract Surgery: A Longitudinal Study in China

Long-term risk of glaucoma after cataract surgery in childhood

PURPOSE

To examine the long-term risk of glaucoma after cataract surgery in childhood.

METHODS

This study took place from January 2022 until December 2022 and included patients from a large family with hereditary childhood cataract who had cataract surgery before 18 years of age. Patients underwent an ophthalmologic examination to determine the presence of glaucoma or ocular hypertension (OHT). Patients who did not want to participate in the examination could contribute with a medical journal from their treating ophthalmologist. The risk of long-term glaucoma was determined using survival analysis, and risk factors were assessed using a Cox proportional hazards regression model.

RESULTS

We included 68 patients (133 eyes) with a median age at cataract surgery of 7 years (IQR: 5-10). The median follow-up time after cataract surgery to glaucoma/OHT or the latest ophthalmologic examination was 35 years (IQR: 15-48). Twelve patients (18 eyes) had glaucoma, and five patients (eight eyes) had OHT, resulting in 15 patients with glaucoma/OHT. The long-term risk of glaucoma/OHT diagnosed in adulthood was 47.7% (CI: 21.8-70.9) at the age of 70 years of patients who were free of glaucoma before their 18th year. We could not confirm or dismiss an association between glaucoma/OHT and sex, age at surgery, number of ocular interventions before 18 years of age or glaucoma after cataract surgery in a first-degree relative.

CONCLUSION

Cataract surgery in childhood is associated with a high risk of late-onset glaucoma. Regular lifelong follow-up is important to ensure early diagnosis and prevent extensive vision loss.

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.

Incidence of and risk factors for suspected and definitive glaucoma after bilateral congenital cataract surgery: a 5-year follow-up

AIMS

To report the incidence and associated risk factors for developing suspected and definitive glaucoma after bilateral congenital cataract (CC) removal with a 5-year follow-up.

METHODS

Secondary analysis of a prospective longitudinal cohort study. Bilateral CC patients who had undergone cataract surgery between January 2011 and December 2014 at Zhongshan Ophthalmic Centre were recruited. Suspected glaucoma was defined as persistent ocular hypertension requiring medical treatment. Definitive glaucoma was defined as accompanied by the progression of glaucomatous clinical features. According to postoperative lens status in 5 years follow-up: 130 eyes in the aphakia group; 219 in the primary intraocular lens (IOL) implantation group and 337 in the secondary IOL implantation group. The Kaplan-Meier survival and Cox regression analyses were used to explore the cumulative incidence and risk factors for suspected and definitive glaucoma.

RESULTS

Three hundred fifty-one children (686 eyes) with bilateral CCs were enrolled in the study. The mean age at surgery was 1.82±2.08 years, and the mean follow-up duration was 6.26±0.97 years. Suspected and definitive glaucoma developed at a mean time of 2.84±1.75 years (range 0.02-7.33 years) postoperatively. The cumulative incidence of suspected and definitive glaucoma was 9.97% (35 of 351 patients), including 6.12% (42 eyes) for definitive glaucoma and 2.48% (17 eyes) for suspected glaucoma. Microcornea (HR 4.103, p<0.0001), CC family history (HR 3.285, p=0.001) and initial anterior vitrectomy (HR 2.365 p=0.036) were risk factors for suspected and definitive glaucoma. Gender, age at surgery, intraocular surgery frequency, length of follow-up and frequency of neodymium-doped yttrium aluminumaluminium garnet laser were non-statistically significant. Primary IOL implantation was a protective factor (HR 0.378, p=0.007).

CONCLUSIONS

Identifying suspected and definitive glaucoma after bilateral CC surgery can lower the risk of secondary blindness in children. Patients with related risk factors need to pay more attention and thus reach early intervention and treatment during clinical practice. Primary IOL implantation may be a potential protective factor, need more clinical trials to be verified.

TRIAL REGISTRATION NUMBER

NCT04342052.

Safety and efficacy in pediatric secondary intraocular lens implantation, in-the-bag versus sulcus implantation: a multicenter, single-blinded randomized controlled trial

BACKGROUND

Treatment of pediatric cataract remains challenging because of the extremely high incidence of postoperative adverse events (AEs), especially the AEs related to the locations of secondary implanted intraocular lens (IOL). There are two common locations for secondary IOL implantation in pediatric aphakic eyes: ciliary sulcus or in-the-bag implantation. However, there are currently no large, prospective studies comparing complication rates and visual prognosis of in-the-bag versus ciliarysulcus secondary IOL implantation in pediatric patients. Whether or how much secondary in-the-bag IOL implantation benefits the pediatric patients more than sulcus implantation and deserves to be performed routinely by surgeons remains to be elucidated. Here, we describe the protocol of a randomized controlled trial (RCT) designed to evaluate the safety and efficacy of two approaches of IOL implantation in pediatric aphakia.

METHODS

The study is a multicenter, single-blinded RCT with 10 years of follow-up. Overall, a minimum of 286 eyes (approximately 228 participants assuming 75% have two study eyes) will be recruited. This study will be carried out in four eye clinics across China. Consecutive eligible patients are randomized to undergo either secondary in-the-bag IOL implantation or secondary sulcus IOL implantation. Participants with two eyes eligible will receive the same treatment. The primary outcomes are IOL decentration and the incidence of glaucoma-related AEs. The secondary outcomes include the incidence of other AEs, IOL tilt, visual acuity, and ocular refractive power. Analysis of the primary and secondary outcomes is to be based on the intention-to-treat and per-protocol analysis. Statistical analyses will include the χ² test or Fisher's exact test for the primary outcome, mixed model and generalized estimated equation (GEE) model for the secondary outcome, Kaplan-Meier survival curves for the cumulative probability of glaucoma-related AEs over time in each group.

DISCUSSION

To the best of our knowledge, this study is the first RCT to evaluate the safety and efficacy of secondary IOL implantation in pediatric aphakia. The results will provide high-quality evidence for the clinical guidelines for the treatment of pediatric aphakia.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05136950. Registered on 1 November 2021.

Nationwide Incidence of Infantile Cataract Surgery and Risk of Secondary Glaucoma in a Population-based Birth Cohort

PURPOSE

To determine the nationwide birth cohort incidence of infantile cataract (IC) surgery and the risk of secondary glaucoma in a Korean population.

DESIGN

A population-based, retrospective cohort study.

METHODS

We accessed the Korean National Health Claims database to identify patients with IC who were diagnosed before 1 year of age and who underwent IC surgery among all Koreans born between 2008 and 2018 (n = 9,593,003). We estimated IC surgery incidence in a birth cohort. The incidence rates of post-IC surgery glaucoma were estimated per 100 person-years, based on the Poisson distribution. The risk factors for post-IC surgery glaucoma, including ophthalmic and systemic comorbidities, were analyzed by multivariable logistic regression analysis.

RESULTS

During the 11-year study period, 692 patients underwent IC surgery. The annual birth cohort incidence of IC surgery in the general population ranged from 5.10 to 9.29 cases per 100,000 individuals. Among patients who had been followed up for longer than 1 year (n = 650), 92 (14.2%) developed glaucoma, and its incidence rate was 2.29 (95% confidence interval, 1.86-2.80) per 100 person-years. The mean time from IC surgery to glaucoma development was 4.7 ± 3.5 years. No factors were identified as being associated with post-IC surgery glaucoma risk other than primary or secondary intraocular lens implantation, which reduces the risk (all P < .05). In patients without primary intraocular lens implantation, the risk of glaucoma increased steeply during the first 2 years after IC surgery.

CONCLUSION

This study identified the birth cohort incidence of IC surgery and secondary glaucoma risk in individuals of East Asian ethnicity. These estimates may help to better understand the epidemiologic features and clinical courses of patients with IC.

A Comprehensive Review of Pediatric Glaucoma Following Cataract Surgery and Progress in Treatment

Glaucoma following cataract surgery (GFCS) remains a serious postoperative complication of pediatric cataract surgery. Various risk factors, including age at lensectomy, intraocular lens implantation, posterior capsule status, associated ocular/systemic anomaly, additional intraocular surgery, and a family history of congenital cataract and GFCS, have been reported. However, the optimal surgical approach remains unclear. This review evaluates the diagnostic criteria, classification, risk factors, mechanism, and surgical management, especially the efficacy of minimally invasive glaucoma surgery, in GFCS, and aims to propose an optimal clinical management strategy for GFCS. The results of our review indicate that ab interno trabeculotomy (goniotomy) may be the most appropriate first-line treatment for GFCS.

Efficacy and safety of intraoperative use of tropicamide 0.02%/phenylephrine0.31%/lidocaine1% intracameral combination during pediatric cataract surgery

BACKGROUND

To demonstrate the safety and efficacy of the intracameral use of tropicamide 0.02%/phenylephrine 0.31%/lidocaine 1% in pediatric cataract surgery, a combination widely used in adult patients but still off-label in children.

METHODS

Design: two-center, prospective, observational study.

SETTING

San Giuseppe Hospital, Milan and Meyer Children's Hospital, Florence.

STUDY POPULATION

children from 0 to 4 years of age undergoing cataract surgery with or without intraocular IOL implantation, in the absence of clinically significant systemic conditions, history of ocular surgery, concurrent ocular medication, hypersensitivity to any of the substances and post-traumatic cataracts. During the surgery, patients received the combination drug after the primary access to the anterior chamber. Efficacy was evaluated by achieving an adequate mydriasis in order to perform capsulorhexis, while safety was assessed by recording vital signs (heart rate, blood pressure, respiratory rate, temperature) pre- and post-administration of the substance.

RESULTS

This study included 53 surgical procedures of 36 patients: 41 eyes were left aphakic, while 12 eyes received primary IOL implantation. The pupil size was adequate to safely perform capsulorhexis in 52 procedures of 53. The difference in pupil enlargement was significant (6.0 ± 1.14 mm, P =  < 0.001). There were no notable changes in vital parameters.

CONCLUSIONS

The administration of intracameral tropicamide 0.02%/phenylephrine 0.31%/lidocaine 1% in pediatric cataract surgery is effective for obtaining an adequate mydriasis without any vital parameters changes throughout the procedure.

In-the-Bag Versus Ciliary Sulcus Secondary Intraocular Lens Implantation for Pediatric Aphakia: A Prospective Comparative Study

PURPOSE

To compare outcomes of in-the-bag vs ciliary sulcus secondary intraocular lens (IOL) implantation for pediatric aphakia.

DESIGN

Prospective interventional case series.

METHODS

This institutional study was conducted in 202 children (355 aphakic eyes) diagnosed as having congenital cataracts and who underwent cataract extraction before age 24 months. Pediatric aphakic eyes underwent in-the-bag or ciliary sulcus secondary IOL implantation according to the amount of residual lens capsule and were monitored for 3 years postoperatively. The main outcome measures were adverse events (AEs), IOL tilt and decentration, and best corrected visual acuity (BCVA) in the operative eye.

RESULTS

A total of 144 eyes (40.6%, 89 children) received in-the-bag IOL implantation (capsular group), and 211 eyes (59.4%, 132 children) underwent ciliary sulcus IOL implantation (sulcus group). Kaplan-Meier curves showed that the time-dependent incidence of glaucoma-related AEs (GRAEs) (P = .005) and any AEs (P = .002) were higher in the sulcus group. In-the-bag IOL implantation was a strong protective factor against GRAE (hazard ratio, 0.08; 95% CI, 0.01-0.53; P = .009) and any AEs (hazard ratio, 0.21; 95% CI, 0.08-0.57; P = .002). Clinically significant IOL decentration (>0.4 mm) was more common in the sulcus group compared with the capsular group (vertical decentration: 29.8% vs 15.7%, P = .005; horizontal decentration: 30.3% vs 9.35%, P < .001). BCVA in the capsular group was better than that in the sulcus group (logMAR, 0.56 vs 0.67, P = .014).

CONCLUSIONS

Compared with ciliary sulcus secondary IOL implantation, in-the-bag IOL implantation reduced AEs and yielded better IOL centration and BCVA for pediatric aphakia.

Glaucoma and risk factors three years after congenital cataract surgery

Background

This study aimed to identify the incidence of and risk factors for postoperative glaucoma-related adverse events at various time points after congenital cataract surgery.

Methods

This retrospective cohort study enrolled 259 eyes from 174 patients (surgical age ≤ 7 years) who underwent congenital cataract surgery. All surgical procedures were conducted at the Eye Hospital of Wenzhou Medical University between May 2011 and March 2019. Patients were classified into group 1 [primary intraocular lens (IOL) implantation, N = 111 eyes], group 2 (secondary IOL implantation, N = 85 eyes), and group 3 (no IOL implantation, N = 63 eyes). We recorded demographic factors and incidence and risk factors for glaucoma-related adverse events.

Results

Glaucoma-related adverse events occurred in 21 (8.1%) eyes, whereas 27 (10.4%) eyes developed steroid-induced ocular hypertension. The percentage of glaucoma-related adverse events was 0%, 1.2%, 1.2%, 1.6%, 4.0%, and 8.9% at 1 month, 6 months, 1 year, 2 years, 3 years and 4 years after surgery, respectively. Sixteen (18.8%), five (7.9%), and zero eyes developed glaucoma-related adverse events in groups 2, 3, and 1, respectively. Family history of congenital cataract [hazard ratio (HR), 50.463; 95% confidence interval (CI), 7.051–361.139; P < 0.001], preoperative central corneal thickness (CCT) [HR, 1.021; 95% CI, 1.009–1.034; P = 0.001], preoperative horizontal corneal diameter (HCD) [HR, 3.922; 95% CI, 1.558–9.804; P = 0.004], and preoperative lens thickness (LT) [HR, 3.745; 95% CI, 1.344–10.417; P = 0.012] were identified as predictors of postoperative glaucoma-related adverse events.

Conclusions

Family history of congenital cataract, thicker preoperative CCT, smaller preoperative HCD, and thinner preoperative LT are the main risk factors of postoperative glaucoma-related adverse events. Regular monitoring of children after cataract surgery with these risk factors may help ophthalmologists detect susceptible individuals and provide timely interventions in the clinic.

Incidence and risk factors of glaucoma after surgery for congenital cataract diagnosed under one year of age: Protocol for Korean Nationwide Epidemiological Study for Childhood Glaucoma (KoNEC)

Introduction

Congenital cataract (CC) can cause childhood visual impairment, even after CC surgery, due to subsequent occurrence of glaucoma. The post-CC-surgery glaucoma study results vary, due largely to the lack of a sufficient number of population-based cohort studies. This study herein proposed aims to assess the incidence and risk factors of post-CC-surgery glaucoma in a nationwide cohort. The clinico-demographic factors associated with outcomes of post-CC-surgery glaucoma will be investigated as well.

Materials and methods

This population-based, nested case-control study is planned as part of the Korean Nationwide Epidemiological Study for Childhood Glaucoma (KoNEC). Data for a nationwide retrospective cohort representative of the years 2008 to 2018 will be extracted from the National Institutes of Health database, which includes demographic information, diagnoses and medical visits as well as procedures, records of prescriptions, and comorbidities. Among the patients whose first CC diagnosis was made before age 1, only those who underwent surgery for CC will be included in the study. The rate of occurrence of post-CC-surgery glaucoma will be determined based on a Poisson distribution. Also, for cumulative incidence plotting, the Kaplan-Meier method will be used. To identify risk factors for occurrence and poor outcomes of post-CC-surgery glaucoma, we will perform a multivariable regression analysis of matched samples. The detailed patterns of post-CC-surgery glaucoma management will be studied as well.

OSF registration number

DOI 10.17605/OSF.IO/AWTEC.

Case Report: A Novel Mutation in the CRYGD Gene Causing Congenital Cataract Associated with Nystagmus in a Chinese Family

Purpose: Congenital cataract (CC) is a common disease resulting in leukocoria and the leading cause of blindness in children worldwide. Approximately 50% of congenital cataract is inherited. Our aim is to identify mutations in a Chinese family with congenital cataract.

Methods: A four-generation Chinese family diagnosed with congenital cataract was recruited in West China Hospital of Sichuan University. Genomic DNA was extracted from the peripheral blood of these participants. All coding exons and flanking regions were amplified and sequenced, and the variants were validated using Sanger sequencing. AlphaFold2 was used to predict possible protein structural changes in this variant.

Results: The proband had congenital nuclear cataract with nystagmus. A heterozygous variant c.233C &gt; T was identified in exon 2 of the CRYGD gene in chromosome 2. This mutation resulted in a substitution of serine with phenylalanine at amino acid residue 78 (p.S78F). The variant might result in a less stable structure with a looser loop and broken hydrogen bond predicted by AlphaFold2, and this mutation was co-segregated with the disease phenotype in this family.

Conclusion: We described cases of human congenital cataract caused by a novel mutation in the CRYGD gene and provided evidence of further phenotypic heterogeneity associated with this variant. Our study further extends the mutation spectrum of the CRYGD gene in congenital cataract.

Measurement and Analysis of Central Corneal Thickness at Different Postnatal Stages in Chinese Premature Infants

Purpose

The objective of this study was to evaluate central corneal thickness (CCT) in Chinese premature infants at different postnatal stages to study the peak point and analyze influential factors on CCT development.

Methods

This was a cross-sectional study of premature infants. Initial CCT measurement was taken at 34 weeks of gestational age (GA) and at intervals until 88 weeks of postmenstrual age (PMA) was reached. The comparison and correlation analysis were carried out to access the association of CCT with gender, birth weight (BW), GA, and retinopathy of prematurity (ROP) for each PMA. The premature infants were divided into the thick CCT group and the thin CCT group according to the average CCT at 40 w. And the difference in CCT between the two groups at subsequent 52 w and 64 w was compared.

Results

A total of 1726 premature infants (3463 measurements) with an average of 2.21 ± 1.57 measurements were included in this study. The CCT decreased from 34 w GA to 52 w PMA (R = 92.36, P < 0.0001) and then reached a plateau (R = 2.541, P=0.3567). Male (P < 0.05), low BW (P < 0.05), and low GA (P < 0.05) were associated with thicker CCT at the early stage of PMA. The premature infants who had thick CCT at 40 w would have thick CCT at 52 w and 64 w accordingly.

Conclusions

The CCT values of premature infants decreased over time and plateaued at 52 w PMA. Gender, BW, and GA were considered as the influential factors of CCT at the early stage of PMA. Moreover, CCT at 40 w could forecast its development trend at 52 w or 64 w after birth.