Incidence and predictors of glaucoma following surgery for congenital cataract in the first year of life in Victoria, Australia

Timing of Diagnosis and Treatment of Glaucoma following Infantile Cataract Surgery

PURPOSE

To report timing of diagnosis and treatment of glaucoma following cataract surgery (GFCS) in a large cohort of infants undergoing cataract surgery at a tertiary care center.

STUDY DESIGN

Cross-sectional study.

PARTICIPANTS

All consecutive infants that underwent cataract surgery over a 30-year period from January 1991 to December 2021 were included if they had at least 1 year follow-up.

METHODS

The data collection included age at time of cataract surgery, presence of associated ocular or systemic conditions, age at diagnosis of GFCS, and treatment required to control GFCS. Glaucoma diagnosis required intraocular pressure (IOP) > 21 mmHg on > 2 visits with glaucomatous optic nerve head changes and/or visual field changes, or in young children, other anatomic changes such as corneal enlargement or haze or accelerated axial elongation and myopic shift.

MAIN OUTCOME MEASURES

The incidence of GFCS was calculated. Linear regression was performed to assess the effect of age at time of cataract surgery. Analysis of risk factors and treatment modalities was performed using univariate and multivariate analysis.

RESULTS

Three hundred eighty-three eyes (260 patients) were analyzed. Median age at surgery was 52 days and median follow-up, 8 years. Glaucoma following cataract surgery was noted in 27% (104/383 eyes; median age at surgery, 45 days; median follow-up, 13 years.) Young age at surgery (< 3 months) was the greatest risk factor (P = 0.001) but the incidence was similar for infants operated in the first, second, or third month of life (25%, 36%, 40%, respectively, P = 0.4). Microcornea (41%, P < 0.0001), poorly dilating pupils (25%, P = 0.001), persistent fetal vasculature (PFV, 13%; P = 0.8), or anterior segment dysgenesis (3%, P = 0.02) were considered as additional risk factors. Surgical intervention was needed for 73% (24/33) eyes with early-onset GFCS compared with 14% (10/71) eyes with later-later onset GFCS (P < 0.0001). Medical treatment was effective in 86% with later-onset GFCS (P = 0.006).

CONCLUSIONS

The incidence of GFCS was 27%, and timing of diagnosis occurred in a bimodal fashion. Early-onset GFCS usually requires surgical intervention; medical treatment is effective for later-onset GFCS. Cataract surgery within the first 3 months of life, microcornea, and poorly dilating pupils were major risk factors.

FINANCIAL DISCLOSURE(S)

The authors have no proprietary or commercial interest in any materials discussed in this article.

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.

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 of Glaucoma-Related Adverse Events in the First 5 Years After Pediatric Lensectomy

Importance

Glaucoma can develop following cataract removal in children.

Objective

To assess the cumulative incidence of glaucoma-related adverse events (defined as glaucoma or glaucoma suspect) and factors associated with risk of these adverse events in the first 5 years after lensectomy prior to 13 years of age.

Design, Setting, and Participants

This cohort study used longitudinal registry data collected at enrollment and annually for 5 years from 45 institutional and 16 community sites. Participants were children aged 12 years or younger with at least 1 office visit after lensectomy from June 2012 to July 2015. Data were analyzed from February through December 2022.

Exposures

Usual clinical care after lensectomy.

Main Outcomes and Measures

The main outcomes were cumulative incidence of glaucoma-related adverse events and baseline factors associated with risk of these adverse events.

Results

The study included 810 children (1049 eyes); 443 eyes of 321 children (55% female; mean [SD] age, 0.89 [1.97] years) were aphakic after lensectomy, and 606 eyes of 489 children (53% male; mean [SD] age, 5.65 [3.32] years) were pseudophakic. The 5-year cumulative incidence of glaucoma-related adverse events was 29% (95% CI, 25%-34%) in 443 eyes with aphakia and 7% (95% CI, 5%-9%) in 606 eyes with pseudophakia; 7% (95% CI, 5%-10%) of aphakic eyes and 3% (95% CI, 2%-5%) of pseudophakic eyes were diagnosed as glaucoma suspect. Among aphakic eyes, a higher risk for glaucoma-related adverse events was associated with 4 of 8 factors, including age less than 3 months (vs ≥3 months: adjusted hazard ratio [aHR], 2.88; 99% CI, 1.57-5.23), abnormal anterior segment (vs normal: aHR, 2.88; 99% CI, 1.56-5.30), intraoperative complications at time of lensectomy (vs none; aHR, 2.25; 99% CI, 1.04-4.87), and bilaterality (vs unilaterality: aHR, 1.88; 99% CI, 1.02-3.48). Neither of the 2 factors evaluated for pseudophakic eyes, laterality and anterior vitrectomy, were associated with risk of glaucoma-related adverse events.

Conclusions and Relevance

In this cohort study, glaucoma-related adverse events were common after cataract surgery in children; age less than 3 months at surgery was associated with elevated risk of the adverse events in aphakic eyes. Children with pseudophakia, who were older at surgery, less frequently developed a glaucoma-related adverse event within 5 years of lensectomy. The findings suggest that ongoing monitoring for the development of glaucoma is needed after lensectomy at any age.

Management of cataract surgery in Lowe syndrome

AIM

To evaluate the ophthalmic and anesthesiologic management of cataract surgery in children with Lowe syndrome receiving lens removal, the development and management of secondary glaucoma.

METHODS

This retrospective case series included 12 eyes of 6 children with genetically verified Lowe syndrome receiving cataract removal. Information regarding the type and duration of surgery and total anesthesia time were recorded. Additionally, intra- and postoperative complications were noted as well as clinical examinations such as visual acuity and funduscopy.

RESULTS

All children received simultaneous bilateral cataract surgery at the mean age of 8.98±3.58wk. Lensectomy combined with posterior capsulotomy and anterior vitrectomy was performed in all children. The mean time for cataract surgery per eye was 35.83±8.86min, whereas the total time of surgery was 153.33±22.11min. The mean extubation time and duration at recovery room was 42.33±22.60min and 130.00±64.37min, respectively. During surgery, a decrease of oxygen saturation below 93% was found in only one child. During the postoperative follow-up, nystagmus (6 children) and strabismus (5 children) was commonly found in contrast to no case of visual axis opacification. Secondary glaucoma developed in five eyes of three children, which was treated with topical eye drops in only one child. A trabeculectomy was performed in both eyes of one child, whereas removal of syechia and an iridectomy in one eye of one child.

CONCLUSION

Bilateral simultaneous cataract surgery under general anesthesia is a safe surgical procedure in Lowe syndrome children. The glaucoma screening with intraocular pressure measurements is crucial in the postoperative management of Lowe syndrome patients to avoid additional visual impairment.

Approach to childhood glaucoma: A review

Childhood glaucoma represents a heterogenous group of rare ocular conditions that may result in significant sight threatening complications related to elevated intraocular pressure (IOP). It can be classified as either primary or secondary and the latter may have systemic associations. This review will be based on the work of the childhood glaucoma research network (CGRN) and will focus on the diagnosis and management of the most common types of childhood glaucoma. These include primary congenital glaucoma (PCG) and juvenile open angle glaucoma (JOAG) as well as secondary causes of glaucoma associated with non-acquired ocular anomalies (Axenfeld-Rieger anomaly; Peters anomaly and Aniridia), glaucoma associated with systemic disease (Sturge Weber syndrome and Neurofibromatosis), those due to acquired conditions (Uveitic glaucoma, trauma and tumours) and importantly glaucoma following cataract surgery.

The Swedish National Pediatric Cataract Register (PECARE): incidence and onset of postoperative glaucoma

PURPOSE

The aim was to report cumulative incidence and time of onset of postoperative glaucoma in a paediatric early cataract surgery cohort.

METHODS

Data were retrieved from the Pediatric Cataract Register (PECARE), a prospective register of Swedish cataract operations before 8 years of age. All eyes with surgery between January 2007 and December 2014 and a registered follow-up were included. Cataracts caused by uveitis, trauma or coexisting congenital glaucoma were excluded. Glaucoma was defined as early onset if diagnosed within a year after surgery and late onset if diagnosed later.

RESULTS

The study included 288 eyes in 207 children (106 girls), 81 with bilateral and 126 with unilateral cataracts, with a mean follow-up of 3.31 ± 1.77 years. Of the 288, 168 (58.3%) had surgery before 3 months of age; most of these 92.3% (155/168) were defined as dense, 208 (72.2%) were below 1 year of age. Cumulative incidence of surgically treated glaucoma among individuals was 23.7% (49/207). Median time to glaucoma onset was 0.91 years (range: 0.05-4.97 years) for eyes. Early-onset glaucoma was found in 98 % (63/64), and late onset in 2% (1/64).

CONCLUSION

In this paediatric cataract cohort, a majority of eyes had surgery before 3 months of age (58.3%). Secondary glaucoma-onset peaked within the first postoperative year, with a cumulative incidence of 23.7%. Surgery performed after the first month of life, resulted in a lower glaucoma rate. Long-term follow-up will reveal whether the low rate of late-onset glaucoma with early surgery will last, and if so, the consequences.

Secondary glaucoma and visual outcome after paediatric cataract surgery with primary bag-in-the-lens intraocular lens

PURPOSE

To determine predictors of secondary glaucoma and poor visual outcome in children undergoing cataract surgery with bag-in-the-lens (BIL)-IOL implantation.

METHODS

Medical records were retrospectively analysed for children with primary implantation with BIL-IOL during 2009-2013.

RESULTS

The study included 109 eyes. Median age at surgery was 2.5 years (range 2 weeks-14.1 years), 26.6% being ≤12 weeks of age (= early group). Median follow-up time was 2.8 years (7 months-5.8 years). 15 eyes (13.8%) developed glaucoma, 14 (48.3%) in the early group and 1 (1.3%) in the late group (p < 0.001). Within the early group, mean time for surgery differed significantly. Patients developing glaucoma had cataract surgery at 3.5 ± 1.1 weeks (mean ± SD) and the non-glaucoma patients at 5.7 ± 3.3 weeks (p = 0.024). In the entire cohort, 21 eyes (19.3%) had conditions associated with glaucoma; 57.1% of these developed glaucoma compared to 3.4% without these conditions (p < 0.001). Corrected distance visual acuity (CDVA) (decimal) of ≥0.5 was seen in 50 eyes (48.5%), median 0.63 in the late group and 0.15 in the early group. Glaucoma eyes in the early group (surgery at 3.5 weeks) achieved 0.56 median (range, 0.4-1.0) logMAR, (0.28 decimal) CDVA, whereas non-glaucoma eyes (surgery at 5.7 weeks) achieved 0.89 median (range 0.7-1.6) logMAR (0.13 decimal) CDVA; p = 0.016. Glaucoma development in infants between 5 weeks and 2 years of age was 6.7% (n = 2/30).

CONCLUSIONS

Comorbidity strongly increases the risk of secondary glaucoma. Surgery during the first month is correlated with better CDVA outcome and glaucoma. After 5 weeks of age, glaucoma rate is low with the BIL-IOL.

Prospective analysis of the predictors of glaucoma following surgery for congenital and infantile cataract

PURPOSE

A prospective longitudinal cohort study was performed to assess the incidence of and risk factors for the development of glaucoma following surgery for congenital/infantile cataract.

METHODS

One hundred and one eyes of one hundred and one children, ≤12 years of age who had follow-up of ≥24 months were included. Group I included those who underwent surgery using an anterior approach, group II included those who underwent surgery using a posterior approach, and group III included those who underwent surgery using an anterior approach along with foldable intraocular lens implantation. Standard definitions for glaucoma and glaucoma suspect were used. The Cox proportional hazard model was used to analyze risk factors for glaucoma.

RESULTS

Group I: 30 eyes (29.7%); group II: 11 eyes (10.9%); group III 60 eyes (59.4%). The incidence of glaucoma + glaucoma suspect was 7.9% (95% CL: 2.6, 13.2%) in the entire group. The incidence in group I was 16.7% (95% CL 3%, 30%), in group II was 18.2% (95% CL: 0, 41%) and in group III was 1.7% (95% CL: 0, 4.9%). Gonioscopy revealed high iris insertion with grade I (modified Shaffer grading) in one eye each in the glaucoma and glaucoma suspect group and open angles in the rest. Age at surgery of ≤3 months (HR: 6.6, 95% CL: 1.4, 30.6, p = 0.01) was found to be a significant risk factor within the aphakic group.

CONCLUSIONS

Younger age at the time of surgery was the only identifiable risk factor for glaucoma.

Outcome of Pediatric Cataract Surgeries in a Tertiary Center in Switzerland

Purpose

To determine and to analyze the outcome of pediatric cataract surgery.

Methods

A retrospective chart review of individuals aged up to 10 years who underwent cataract surgery between January 1, 2004, and December 31, 2014, at the UniversityHospital Zurich, Switzerland.

Results

63 children (94 affected eyes) with bilateral (68/94) or unilateral (26/94) cataract were identified. Surgery was performed at a median age of 1.5 months (IQR: 1.3–2.6 months) for the aphakic group (45/94) and of 50.7 months (IQR: 38.0–78.4 months) for the IOL group (49/94). At the last follow-up visit (median 31.1 months, IQR: 18.4–50.2 months), visual acuity was better in bilateral than in unilateral cataract cases. Posterior capsular opacification (PCO) was diagnosed in 30.9% of eyes without a significant difference in the IOL and aphakic groups (p = 0.12). Aphakic glaucoma was diagnosed in 12/45 eyes at a median of 6.8 months (IQR 2.1–13.3 months) after surgery. Microcornea (5/12) and anterior segment anomalies (8/12) were associated with glaucoma development (p < 0.05).

Conclusion

Laterality and timing of surgery influence the outcome of pediatric cataract surgery. PCO was the most frequent postoperative complication. Aphakic glaucoma is often associated with ocular developmental abnormalities and a poor visual outcome.

Surgical, medical and developmental outcomes in patients with Down syndrome and cataracts

BACKGROUND

Individuals with Down syndrome have an increased risk for congenital cataracts, but descriptions of surgical, medical and developmental outcomes are sparse.

MATERIALS AND METHODS

Retrospective review of medical charts of patients with Down syndrome with visits to Cincinnati Children's Hospital from 1988 to 2013 was performed. A case series of five patients with Down syndrome and cataracts is presented. A total of 47 patients with Down syndrome without cataracts were used as a developmental control. Developmental quotients were compared using an independent-sample, unequal variance t-test.

RESULTS

Post-operative cataract complication rates ranged from 20% to 60%. Visual outcomes were varied; significant associations between complication rate and visual outcome were not found. Developmental quotients did not show an association with number of complications, but were lower for children with Down syndrome with cataracts requiring surgery compared to children with Down syndrome without cataracts.

CONCLUSION

In children with Down syndrome and congenital cataract, surgical intervention has risk for post-operative complications. Further investigation is needed to determine if there is an association between surgical complications and visual or developmental outcomes.

Outcome of surgical treatment of primary and secondary glaucoma in young children

PURPOSE

To describe a paediatric cohort surgically treated for primary or secondary glaucoma (PG/SG), with regard to incidences, visual outcome and control of intraocular pressure (IOP).

METHODS

All children (n = 29, 42 eyes in total) surgically treated for PG or SG at the age of 4 years or younger between January 2002 and December 2010 at Sahlgrenska University Hospital in Mölndal were retrospectively studied through medical records. Median follow-up time after initial surgery was 5.9 years (range 2.4-11.2 years).

RESULTS

The incidence of primary congenital glaucoma was 4.3 cases per 100 000 live births in the county of Västra Götaland. For glaucoma secondary to cataract surgery, the incidence was 13% with a median postoperative duration to diagnosis of glaucoma of 3.8 months (range 1.6 months to 4.3 years). Preoperative mean IOP was 31.5 (SD 8.1) mmHg, and mean IOP at last visit was 17.1 (SD 4.4) mmHg. For the entire cohort, 30% of the glaucoma eyes required more than two IOP-lowering surgical procedures during the study period. BCVA was ≥0.3 (decimal) in 45% of glaucomatous eyes at last follow-up with no statistically significant difference between PG and SG. Analysis of functional visual outcome, that is BCVA in the better eye, showed that 83% of all patients attained a BCVA of ≥0.5.

CONCLUSIONS

The incidences and outcome of surgically treated paediatric glaucoma were in accordance with previous studies. Chamber angle surgery, and if necessary, tube implantation without the use of antimetabolites, is a favourable approach leaving most sites needed for future glaucoma surgery unaffected.

Exome sequencing identifies novel and recurrent mutations in GJA8 and CRYGD associated with inherited cataract

BACKGROUND

Inherited cataract is a clinically important and genetically heterogeneous cause of visual impairment. Typically, it presents at an early age with or without other ocular/systemic signs and lacks clear phenotype-genotype correlation rendering both clinical classification and molecular diagnosis challenging. Here we have utilized trio-based whole exome sequencing to discover mutations in candidate genes underlying autosomal dominant cataract segregating in three nuclear families.

RESULTS

In family A, we identified a recurrent heterozygous mutation in exon-2 of the gene encoding γD-crystallin (CRYGD; c.70C > A, p.Pro24Thr) that co-segregated with 'coralliform' lens opacities. Families B and C were found to harbor different novel variants in exon-2 of the gene coding for gap-junction protein α8 (GJA8; c.20T > C, p.Leu7Pro and c.293A > C, p.His98Pro). Each novel variant co-segregated with disease and was predicted in silico to have damaging effects on protein function.

CONCLUSIONS

Exome sequencing facilitates concurrent mutation-profiling of the burgeoning list of candidate genes for inherited cataract, and the results can provide enhanced clinical diagnosis and genetic counseling for affected families.

Congenital cataract: prevalence and surgery age at Zhongshan Ophthalmic Center (ZOC)

Congenital cataract (CC) is the primary cause of treatable childhood blindness. Population-based assessments of prevalence and surgery age of CC, which are critical for improving management strategies, have been unavailable in China until now. We conducted a hospital-based, cross-sectional study of the hospital charts of CC patients younger than 18 years old from January 2005 to December 2010 at Zhongshan Ophthalmic Center (ZOC) in Guangzhou, China. Residence, gender, age at surgery, hospitalization time, and the presence of other ocular abnormalities were extracted and statistically analyzed in different subgroups. The search identified 1314 patients diagnosed with CC from a total of 136154 hospitalizations, which accounted for 2.39% of all the cataract in-patients and 1.06% of the total in-patients over the six-year study period. Of the identified CC patients, 9.2% had ≥ 2 hospitalizations due to the necessity of additional surgeries, with a total ratio of boys to girls of 1.75 ∶ 1. Based on a subgroup analysis according to age, patients 2-6 years old constituted the highest proportion (29.22%) of all hospitalized CC patients, and those 13-18 years old constituted the lowest proportion (13.47%) of the total number. The average age at surgery was 27.62 ± 23.36 months, but CC patients ≤ 6 years old (especially ≤ 6 months old) became increasingly prevalent throughout the 6-year study period. A total of 276 cases (20.93%) of CC were associated with one or more other ocular abnormalities, the highest incidence rates were observed for exotropia (6.24%), nystagmus (6.16%), and refractive error (3.65%). In conclusion, CC patients accounted for 2.39% of all cataract in-patients in a review of 6 years of hospitalization charts from ZOC. The age at the time of surgery decreased over the 6-year study period, which probably reflects the continuing improvement of public awareness of children's eye care in China.