Efficacy and safety of vitrectomy for congenital cataract surgery: a systematic review and meta-analysis based on randomized and controlled trials

Comparison of the axial growth with multifocal and monofocal intraocular lenses in unilateral pediatric cataract surgery

PURPOSE

To compare axial growth in pediatric cataract patients who underwent multifocal intraocular lens (IOL) implantation without anterior vitrectomy (AV) with that in pediatric patients who underwent monofocal IOL implantation with or without AV.

METHODS

Patients who had unilateral pediatric cataracts and underwent surgery at 3-6 years of age from June 6, 2019, to June 30, 2020, at our institution were prospectively analyzed. The patients were categorized into Group A: multifocal IOL implantation with optic capture in Berger's space without AV; Group B: monofocal IOL implantation with optic capture in Berger's space without AV; and Group C: bag-in-the-lens monofocal IOL implantation with AV. Groups A', B' and C' consisted of the fellow eyes from the respective groups. Axial growth and monthly growth rates were compared among the 3 treatment groups, as well as between the treated eyes and the fellow eyes.

RESULTS

Thirty-one, 23, and 14 children fulfilling the inclusion criteria, respectively, were included in the final analysis. There were no significant differences in patient age at the time of surgery or preoperative axial length (P > 0.05). After a mean follow-up of 35.57 ± 3.78 months, significant differences in the axial growth and the monthly growth rate were observed (P < 0.05), and Group A had the least axial elongation. Comparing treated eyes with fellow eyes, the amount and rate of axial growth were lower in Group A than in Group A' (P < 0.05), no significant differences were found in Group B (P > 0.05), and Group C had greater growth than did Group C' (P < 0.05).

CONCLUSIONS

The implanting multifocal intraocular lenses and maintenance of vitreous body integrity may be protective factors against excessive axial growth in pediatric cataract patients. Clinical trial registration (prospective study): chiCRT1900023155; 2019-05-14.

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.

Influence of posterior capsule abnormalities in pediatric cataract surgery

PURPOSE

To report how to manage posterior capsule abnormalities (PCAs) in pediatric cataracts and evaluate the influence of PCAs during intraocular lens (IOL) optic implantation in Berger space surgeries.

SETTING

Qingdao Eye Hospital of Shandong First Medical University, Qingdao, China.

DESIGN

Retrospective case series study.

METHODS

Pediatric patients with PCAs who underwent cataract surgery were evaluated. A video-based analysis of the surgical interventions included the type of crystalline lens opacification, types and management of PCAs, complications during primary posterior continuous curvilinear capsulorhexis (PCCC), need for anterior vitrectomy (AV), and feasibility of IOL optic capture.

RESULTS

There were 227 pediatric cataract surgeries performed during the study period, and 76 eyes of 66 children with PCAs were evaluated (33.5%, 76/227). Unilateral cataract with PCAs were found in 50 eyes (22.0%, 50/227) and bilateral were found in 26 eyes (11.5%, 26/227). The PCAs were posterior capsule plaque (19.8%, 45/227), posterior capsule defect (6.2%, 14/227), posterior lenticonus (3.1%, 7/227), and persistent fetal vasculature (4.4%, 10/227). In the PCA cases, primary PCCC was successful in 44.7% of the cases (34/76). An unplanned AV during the surgeries was performed in 47.4% (36) of the 76 eyes. IOL optic implantation in Berger space was achieved in 63.2% of the eyes (48/76).

CONCLUSIONS

PCAs are often encountered during pediatric cataract surgeries, especially in unilateral cases. The presence of PCAs may complicate a primary PCCC procedure, resulting in an unplanned AV in some cases. IOL optic implantation in Berger space can also be performed fortunately with well-designed and skilled operation.

Predictive Factors of Complications and Visual Outcomes after Pediatric Cataract Surgery: A Single Referral Center Study from Türkiye

Objectives

To evaluate the predictive factors of complications and visual acuity outcomes in pediatric cataract patients.

Materials and Methods

This retrospective, observational clinical study included 80 eyes of 50 patients treated for pediatric cataracts between 2010 and 2020. The eyes were divided into Group I (congenital cataracts, n=38) and Group II (developmental cataracts, n=42). Group II was also divided into Group IIA (aphakic, n=21) and Group IIB (pseudophakic, n=21). The effects of the age, laterality, cataract morphology, intraocular lens implantation, preoperative nystagmus/strabismus, and intraoperative anterior hyaloid rupture on complications and final best-corrected visual acuity (BCVA; logMAR) were evaluated.

Results

The median (interquartile range) age and follow-up time were 28 (5-79) months and 60 (29-84) months, respectively. There was a significant difference in mean final BCVA between Group I (0.79±0.46) and Group II (0.57±0.51) (p=0.047); however, no difference was observed between Group IIA and Group IIB (p=0.541). Having congenital cataract (p=0.045), preoperative nystagmus/strabismus (p=0.042), total/mature cataract (p<0.001), and postoperative complications (p=0.07) were significantly associated with final BCVA. However, in multivariate analysis, only total/mature cataract (β: 0.52, p<0.001) and having any complication (β: 0.24, p=0.018) were associated with final BCVA. Congenital cataract and intraoperative anterior hyaloid rupture were the only significant risk factors of postoperative complications on univariate (p=0.027 and p=0.003, respectively) and binary logistic regression analysis (odds ratio [OR]: 2.95 [95% confidence interval: 1.07-8.15], p=0.036 and OR: 4.28 [95% confidence interval: 1.55-11.77], p=0.005, respectively).

Conclusion

Total/mature cataract and the presence of any postoperative complication adversely affected the final BCVA. Having a congenital cataract and intraoperative anterior hyaloid membrane rupture increased the risk of complications.

Optic Capture Without Anterior Vitrectomy in Pediatric Cataract Surgery

PURPOSE

To compare outcomes of 2 surgical techniques in children undergoing cataract surgery with intraocular lens (IOL) implantation: optic capture of IOL without anterior vitrectomy (AV) or in-the-bag IOL with AV.

DESIGN

Prospective randomized controlled trial.

METHODS

Patients were randomized to 2 groups: optic capture without AV (group 1) or in-the-bag implantation with AV (group 2). The following variables were compared: visual axis opacification (VAO), inflammatory deposits on IOL surface, anteroposterior synechia, IOL tilt and decentration, lenticular astigmatism, refractive prediction error, and posterior segment complications.

RESULTS

Fifty-one eyes of 37 children were investigated with a mean follow-up of 20.1±8.5 months. Group 1 and group 2 had mean ages of 59.2±32.6 and 46.5±21.9 months, respectively (P = .104). Three eyes in group 1 and 2 eyes in group 2 developed VAO (P = .656). Two eyes in group 1 and 5 eyes in group 2 developed anteroposterior synechia (P = .291). Six eyes in group 1 and 11 eyes in group 2 had inflammatory deposits on the IOL (P = .233). Both groups had similar IOL tilt and decentralization (for all meridians, P > .05). The absolute refractive prediction error was 0.55±0.34 diopter (D) and 0.53±0.3 D, respectively (P = .294). Each group had 1 eye with intraocular hypertension (P = .932).

CONCLUSION

The optic capture method was similar to the conventional technique in the quantitative evaluation of comprehensive data such as visual axis opacification, inflammatory sequelae, refractive outcomes, and IOL stability. The optic capture technique is an appealing option for pediatric cataract surgery because it eliminates the requirement for vitrectomy.

TGF-β/Smad Signalling Activation by HTRA1 Regulates the Function of Human Lens Epithelial Cells and Its Mechanism in Posterior Subcapsular Congenital Cataract

Congenital cataract is the leading cause of blindness among children worldwide. Patients with posterior subcapsular congenital cataract (PSC) in the central visual axis can result in worsening vision and stimulus deprivation amblyopia. However, the pathogenesis of PSC remains unclear. This study aims to explore the functional regulation and mechanism of HTRA1 in human lens epithelial cells (HLECs). HTRA1 was significantly downregulated in the lens capsules of children with PSC compared to normal controls. HTRA1 is a suppression factor of transforming growth factor-β (TGF-β) signalling pathway, which plays a key role in cataract formation. The results showed that the TGF-β/Smad signalling pathway was activated in the lens tissue of PSC. The effect of HTRA1 on cell proliferation, migration and apoptosis was measured in HLECs. In primary HLECs, the downregulation of HTRA1 can promote the proliferation and migration of HLECs by activating the TGF-β/Smad signalling pathway and can significantly upregulate the TGF-β/Smad downstream target genes FN1 and α-SMA. HTRA1 was also knocked out in the eyes of C57BL/6J mice via adeno-associated virus-mediated RNA interference. The results showed that HTRA1 knockout can significantly upregulate p-Smad2/3 and activate the TGF-β/Smad signalling pathway, resulting in abnormal proliferation and irregular arrangement of lens epithelial cells and leading to the occurrence of subcapsular cataract. To conclude, HTRA1 was significantly downregulated in children with PSC, and the downregulation of HTRA1 enhanced the proliferation and migration of HLECs by activating the TGF-β/Smad signalling pathway, which led to the occurrence of PSC.

Outcomes of paediatric cataract surgery with and without the use of trypan blue

OBJECTIVE

This systematic review was undertaken to answer the research question: "In children with primary cataracts, what are the outcomes (posterior continuous curvilinear capsulorhexis + posterior chamber intraocular lens implantation) of surgery when performed with and without trypan blue staining of the posterior lens capsule?"

METHODS

An electronic search in six biomedical databases was conducted to identify randomised controlled trials that compared trypan blue with no stain during surgery in children 0 -16 years with primary cataracts. Titles and abstracts of studies published between 1946 and 2021 in English language were screened. Data extraction, risk of bias assessment and synthesis of findings were done by two independent reviewers, while conflicts were discussed and resolved with a third.

RESULTS

115 of 153 articles were screened after de-duplication. Of these, 113 were excluded while two randomised controlled trials involving 56 eyes of 42 partcipants were included in the review. The risk of bias was similar across all domains in both. Staining of the capsule led to complete posterior capsulorhexis and optimal placement of the implant in >90% of study eyes, while the control arms had 65% - 80% for both outcomes.

CONCLUSION

Use of trypan blue in paediatric cataract surgery probably leads to better outcomes, but more well-conducted randomised controlled trials on this important topic are needed.

Bag-in-the-lens intraocular lens in paediatric cataract surgery: intraoperative and postoperative outcomes

PURPOSE

To report intra- and postoperative surgical outcome using the bag-in-the-lens (BIL) technique in paediatric cataract surgery.

METHODS

In a retrospective case series, we studied the outcomes of children aged <12 years operated for cataract with the bag-in-the-lens intraocular lens (IOL), with a minimum of 6 months of follow-up.

RESULTS

Since 2013, 50 eyes in 30 patients <12 years (20 bilateral and 10 unilateral) have been operated at our department with the BIL technique, with a median follow-up time of 33.5 months (range 6-77). Median age at surgery was 49.5 months (4-139). In one case, the IOL luxated through the capsulorhexes to the vitreous, but could be secured and repositioned as planned without further difficulties. Anterior vitrectomy was necessary in one case due to prolapse of vitreous to the anterior chamber during surgery. No other intraoperative complications occurred. Visual axis opacification (VAO) developed in four eyes (8%). So far, only one of these has needed a reoperation with clearing of the secondary cataract. A complete absence of VAO was thus seen throughout the study period in 92%. In two eyes, postoperative iris capture occurred. In both cases, surgical repositioning of the iris was needed. No eyes developed secondary glaucoma during the study period.

CONCLUSION

The BIL technique seems to be a safe surgical procedure in paediatric cataract, with significantly less complications and need for additional surgery compared with the conventional lens-in-the-bag technique.

Posterior continuous curvilinear capsulorhexis with anterior vitrectomy versus optic capture buttonholing without anterior vitrectomy in pediatric cataract surgery

PURPOSE

To investigate long-term complications following pediatric cataract surgery with implantation of a heparin-coated PMMA IOL and posterior continuous curvilinear capsulorhexis (PCCC) with anterior vitrectomy versus PCCC without anterior vitrectomy with optic capture buttonholing.

SETTING

Department of Ophthalmology, Goethe University, Frankfurt, Germany.

DESIGN

Prospective randomized clinical trial.

METHODS

Eyes with unilateral or bilateral congenital cataract without further pathologies or former surgeries were randomly assigned in two groups: cataract removal, IOL implantation and PCCC with anterior vitrectomy (AV; group A) or posterior optic buttonholing without anterior vitrectomy (optic capture, OC; group B). The main outcome measures were posterior capsule opacification (PCO), complication rates and refractive development.

RESULTS

58 eyes of 41 pediatric cataract surgery patients were included. The mean age at time of operation was 66.05 months (± 29.39). In group A (n=26), two eyes required treatment for posterior capsule opacification, whereas the optic axis remained clear in all eyes in group B (n=30), which was not statistically significant. Additionally, group B had a slightly lower rate of complications. Mean SE after a mean postoperative follow-up of 6.5 years was -0.11 ± 2.51 D (-5.0 to +4.0 D) in group A and -0.08 ± 2.14 D (-5.0 to +4.0 D) in group B, which was not statistically significant either.

CONCLUSION

Optic capture with a heparin-coated PMMA IOL proved to be a safe technique in the prevention of secondary cataract formation without a higher rate of complications and the necessity of vitrectomy.

Longitudinal changes of the macular structure after lens removal combined with anterior vitrectomy after pediatric cataract surgery

PURPOSE

To explore the macular thickness changes after lens removal combined with anterior vitrectomy for pediatric cataract surgery.

SETTING

The Eye Hospital of Wenzhou Medical University, Zhejiang, China.

DESIGN

Prospective study.

METHODS

Thirty children (40 eyes) aged between 3 years and 9 years with pediatric cataracts, including 20 children (20 eyes) with unilateral cataracts and 10 children (20 eyes) with bilateral cataracts, were enrolled. Spectral-domain optical coherence tomography was used to obtain macular images. Central subfield thickness (CST) and retinal thickness in the Early Treatment Diabetic Retinopathy Study subfields (inner 1.0 to 3.0 mm annulus and outer 3.0 to 6.0 mm annulus) were recorded preoperatively as well as at 1, 3, 6, and 12 months postoperatively.

RESULTS

Forty eyes of 30 children were included. Retinal thickness in every subfield significantly thickened at 3 months postoperatively (all P < .05). CST significantly thickened compared with preoperative levels (228.03 ± 18.58 vs 240.35 ± 17.41, P = .005) at 3 months postoperatively; macular thickness gradually decreased in the following months. At 6 months postoperatively, retinal thickness in inner nasal, inferior, temporal, and outer nasal subfields remained significantly thicker compared with preoperative levels (P = .048, P = .036, P = .029, and P = .017, respectively). At 12 months, the retinal thickness in all subfields reached the preoperative level.

CONCLUSIONS

The influence on macular thickness lasted until 12 months after pediatric cataract surgery. The inner macular thickness increased for a longer time than the outer macular thickness postoperatively.