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

The association between developmental delay and endophthalmitis after pediatric cataract surgery using an insurance claims database

PURPOSE

To evaluate risk factors for postoperative endophthalmitis in pediatric cataract surgery based on an analysis of a large insurance claims database.

METHODS

We retrospectively analyzed pediatric (0-18 years) cataract surgeries from the IBM MarketScan Research Database from 2004 to 2017. Suspect cases of endophthalmitis were identified by International Classification of Diseases codes; confirmed cases, by Current Procedural Terminology codes within 7 days of diagnosis. Odds ratios (OR) were assessed for age, sex, aphakia, concomitant vitrectomy, open-globe injury, uveitis, lens displacement, developmental delay, trisomy 21, and immunocompromised status.

RESULTS

Among 5,304 eyes of 6,835 patients, the following were factors significantly associated with pediatric cataract surgery-related suspect endophthalmitis: open-globe injury (OR = 7.75; 95% CI, 3.32-18.09; P < 0.001), ocular trauma (OR = 3.64; 95% CI, 1.83-7.24; P < 0.001), aphakia (OR = 2.33, CI 1.15-4.69, P = 0.018), and developmental delay (OR = 4.24, 95% CI, 1.00-18.02; P = 0.05). With univariate analysis of confirmed endophthalmitis cases, the following were identified as statistically significant: open-globe injury (OR = 8.1; 95% CI, 2.64-24.87; P < 0.001), ocular trauma (OR = 4.34, CI 1.72-10.97; P = 0.002), subluxated or dislocated lens (OR = 3.62; 95% CI, 1.04-12.57; P = 0.043), aphakia (OR = 2.86; 95% CI, 1.13-7.26; P = 0.027), and developmental delay (OR = 8.24; 95% CI, 1.86-36.44; P = 0.005). Age, sex, concomitant vitrectomy, and uveitis were not associated with increased risk of endophthalmitis.

CONCLUSIONS

Developmental delay may be a risk factor for postoperative endophthalmitis in pediatric cataract surgery. Surgeons can assess preoperative risk by performing a detailed medical and social history for challenges particular to this population that may complicate the postoperative course.

The Ophthalmic Manifestations of Down Syndrome

Down Syndrome is one of the most common chromosomal conditions in the world, affecting an estimated 1:400-1:500 births. It is a multisystem genetic disorder but has a wide range of ophthalmic findings. These include strabismus, amblyopia, accommodation defects, refractive error, eyelid abnormalities, nasolacrimal duct obstruction, nystagmus, keratoconus, cataracts, retinal abnormalities, optic nerve abnormalities, and glaucoma. These ophthalmic conditions are more prevalent in children with Down Syndrome than the general pediatric population, and without exception, early identification with thoughtful screening in this patient population can drastically improve prognosis and/or quality of life.

Immediately sequential bilateral cataract surgery in Down syndrome

The exponential increase in world population and average human lifespan is expected to result in geriatric population globally. The problem of preventable blindness due to cataract will increase manifold. Simultaneous Bilateral cataract surgery (SBCS) is a viable option in such subset of patients. Despite faster visual recovery, economic benefits to patients and health care providers, decreased risk of complications associated with General anaesthesia, there is significant resistance in accepting SBCS as a routine procedure. Bilateral endophthalmitis is the main deterrent in performing ISBCS. This case highlights successful ISBCS in 36 years old female patient with Down's syndrome.

Immediate sequential bilateral cataract surgery in adults with Down's syndrome

PURPOSE

To describe the cataract surgery outcomes in 34 adult patients with Down's syndrome in our center between 1996 and 2019.

SETTING

Clinical practice, tertiary hospital in Madrid, Spain.

DESIGN

Retrospective, descriptive study in which 34 patients with Down's syndrome who underwent cataract surgery in our center between 1996 and 2019 were included.

METHODS

Socio-demographic and clinical data such as the type of cataract, the keratometry and biometry, the type of surgery, the IOL material, and the complications before and after surgery were recovered.

RESULTS

Fifty-four eyes of 34 patients (23 female, 11 male, mean age 49 ± 8 years) underwent cataract surgery with general anesthesia. Immediately sequential, bilateral cataract surgery was performed in 18 patients (90% of bilateral cases). White cataract was found in 11 eyes (20.4%). Phacoemulsification technique was used in 51 eyes, extracapsular technique in 2 eyes (3.7%), and intracapsular technique in 1 eye (1.85%) (the only aphakic eye after surgery). The mean Km was 48.73 ± 4D, and the mean axial length was 25.2 ± 2.5 mm. The most frequent ocular comorbidity was myopia (27 eyes, 50%) followed by strabismus (11 eyes, 20.4%) and keratoconus (10 eyes, 18.5%). Posterior capsular rupture as a complication during surgery was found in 3 eyes (5.5%). The mean preoperative visual acuity was 0.8 ± 0.2 logMAR, and the mean postoperative visual acuity was 0.5 ± 0.18 logMAR.

CONCLUSIONS

Phacoemulsification technique can be performed in adults with Down's syndrome with an acceptable rate of complications. The lack of patient cooperation, the ocular comorbidities and the challenging biometric estimation must be considered in surgical planning. It seems reasonable to perform immediately sequential, bilateral cataract surgery when possible, in order to reduce the exposure to general anesthesia.

Clinical and therapeutic particularities of congenital cataracts in pediatric patients with Down syndrome

Objective: This study aims to identify clinical and therapeutic surgical particularities and postoperative complications encountered in children suffering from Down syndrome and congenital cataract, as well as the existence of a correlation with associated systemic anomalies. Methods: A retrospective interventional study that analyzes cases of congenital cataracts operated on a group of 14 children with Down syndrome, respectively on 26 eyes, was performed. The age of the children at the time of the surgery, the presence of associated ocular and systemic anomalies, the employed surgical technique, the frequency and the type of postoperative complications, were examined. Results: Cataracts present at birth, with recommendations for surgical treatment, were rare among children suffering from Down syndrome, but their frequency increased with age. Most children had systemic anomalies, but also other, usually multiple, ocular anomalies. The rate of postoperative complications was higher than among children with congenital cataracts, but without Down syndrome. In six cases, more than one complication/ case was identified. It was not possible to establish a clear correlation between the number and type of the postoperative complication and the systemic anomalies, nor was it possible to establish a correlation with the functional visual outcomes, because those children had other important ocular anomalies as well. Conclusions: Congenital cataracts with recommendations for surgical treatment in children suffering from Down syndrome have a low incidence, but an increase in frequency can be noticed with age. The recommended surgical technique is the one that involves maneuvers for the prevention of visual axis re-opacification. Per primam implantation is definitely indicated. The risk of postoperative complications is high, in terms of both frequency and number, with the possibility that more than one complication occurs, unrelated to a particular systemic anomaly, in one patient.

Down Syndrome and Postoperative Complications in Children Undergoing Intestinal Operations

OBJECTIVE

This paper intends to evaluate the association between Down Syndrome (DS) and postoperative medical and surgical complications and inpatient postoperative mortality in pediatric patients undergoing intestinal operations.

METHODS

The 2012 Kids' Inpatient Database was queried to compare short-term postoperative medical and surgical complications and in-patient mortality among patients with DS undergoing intestinal operations to a cohort without DS using inverse probability weighting. Subset analysis was performed for patients undergoing intestinal operations exclusive of gastrostomy placement. Adverse treatment effects were calculated for the outcomes of interest.

RESULTS

Of 17,026 pediatric patients undergoing intestinal operations, 444 had DS. In unadjusted analysis, medical complications (urinary tract infection, deep venous thrombosis, sepsis, pneumonia) occurred in 7.9% of patients with DS, compared to 14.1% of those without (p < 0.001). Surgical complications (wound disruption, hemorrhage, superficial or deep wound infection) occurred in 3.5% of patients with DS, compared to 4.6% of those without (p = 0.34), and in-patient mortality occurred in 0.3% of patients with DS, compared to 2.7% of those without (p = 0.009). Adverse treatment effects (ATE) calculated after inverse probability weighting demonstrated no difference for medical or surgical complications but a significantly decreased mortality with DS.

CONCLUSIONS

Contrary to common perception and data extrapolated from the adult literature, pediatric patients with DS have neither higher medical nor surgical complication rates after intestinal operations. Similar to patients undergoing congenital heart surgery, pediatric patients with DS have a lower postoperative inpatient mortality after these general operations compared to those without DS. Mechanisms influencing risks in DS patient remain unknown.

LEVEL OF EVIDENCE

Level III, retrospective comparative study.