Glaucoma following congenital cataract surgery--the role of early surgery and posterior capsulotomy

Nationwide incidence of and risk factors for undergoing incisional glaucoma surgery following infantile cataract surgery

Nationwide incidence and risk factors for incisional glaucoma surgery post-infantile cataract (IC) surgery in children remain poorly understood. We conducted a population-based cohort study using the Korean national health claims database to identify IC patients diagnosed before age 1 who had IC surgery among all Korean born between 2008 and 2018 (n = 9,593,003). We estimated the annual occurrence of undergoing incisional glaucoma surgery following IC surgery in the general population aged 0-10. The risk factors for incisional surgery including systemic comorbidities and ophthalmic anomalies were analyzed by multivariable logistic regression. Of 650 patients who had undergone IC surgery with a mean (standard deviation [SD]) follow-up period of 6.2 (3.2) years, 92 (14.2%) were diagnosed with glaucoma following infantile cataract surgery (GFICS). Among them, 21 patients (22.8%) underwent incisional glaucoma surgery after a mean (SD) follow-up duration of 5.4 (2.8) years from the diagnosis of GFICS. Median (InterQuartile Range) age at incisional surgery was 4 (2,6) years old. Twenty of 21 patients (95.2%) underwent incisional glaucoma surgery within 3 years of diagnosis of GFICS. No factors, except younger age at glaucoma diagnosis (P = 0.03), were associated with undergoing incisional surgery. These findings can better understand the epidemiologic features and clinical courses of GFICS.

Combined trabeculotomy-trabeculectomy for glaucoma after congenital cataract surgery: long-term results

OBJECTIVE

The aim of this study was to report on the long-term (>5 years) results of surgery for glaucoma after congenital cataract surgery.

DESIGN

Retrospective.

METHODS

A chart review was conducted of all children operated on for glaucoma after congenital cataract surgery in the Pediatric Ophthalmology Service of the Ophthalmology Department of Alexandria main University Hospital in Alexandria, Egypt, between 2005 and 2014 who completed 5 years of follow-up. Demographic, clinical, and operative data were retrieved from the medical records. Success was defined by stability and (or) reversal of optic nerve cupping in relation to presentation and, if this information was not available, by an intraocular pressure (IOP) less than the presenting IOP and less than 16 mm Hg with (true) or without (qualified) IOP-lowering therapy.

RESULTS

The records of 48 children were reviewed. Thirty-two eyes of 24 children had completed at least 5 years of follow-up and were included in the study. The mean age (±SD) of the study children was 11.6 ± 11.3 months (range, 3.2-52.0 months) at presentation, and the mean (±SD) follow-up was 105.5 ± 31.4 months (range, 60-156 months). Of 47 glaucoma surgical procedures in total, combined angle and filtering surgery with antimetabolite was the most common procedure performed (n = 30;63.8%). Annual success percentages from the fifth year onward to the thirteenth year were 69.6%, 68.8%, 77.8%, 50.0%, 71.4%, 60.0%, 50.0%, 83.3%, and 50.0%, respectively.

CONCLUSIONS

Surgery for glaucoma after congenital cataract surgery remains safe and successful for 13 years after surgery.

Nationwide incidence of congenital and infantile cataract requiring surgery in Korea

Congenital and infantile (CI) cataract is one of the most important and preventable cause of blindness in children, but the incidence has not been studied in Korea. We collected data from the national claims database of the National Health Insurance Service of Korea from 2002 through 2019. We identified children who underwent cataract surgery within the age of 5 years, and cumulative incidence rates were calculated for each of the three age criteria. 989 patients out of 4,221,459 births underwent surgery with CI cataract during the period. The cumulative incidence rates per 10,000 births were 1.60 (0-1 years), 2.38 (0-3 years), and 2.95 (0-5 years), respectively. The incidence peaked in the 2007 birth cohort, which coincides with the start of the national screening program for infants/children. Primary intraocular lens implantation was performed in 439 patients (44%). Strabismus and glaucoma requiring surgery occurred in 291 patients (29.4%) and 32 patients (3.2%), respectively, within 8 years after cataract surgery. The incidence rates of CI cataract in Korea appear to be comparable to previous studies in other regions. The early screening program for infants may reduce delayed diagnosis and increase the proportion of patients undergoing surgery at a critical time for visual development.

Risk Factors for Glaucoma Diagnosis and Surgical Intervention following Pediatric Cataract Surgery in the IRIS® Registry

PURPOSE

To compare demographic and clinical factors associated with glaucoma following cataract surgery (GFCS) and glaucoma surgery rates between infants, toddlers, and older children using a large, ophthalmic registry.

DESIGN

Retrospective cohort study.

PARTICIPANTS

Patients in the IRIS® Registry (Intelligent Research in Sight) who underwent cataract surgery at ≤ 17 years old and between January 1, 2013 and December 31, 2020.

METHODS

Glaucoma diagnosis and procedural codes were extracted from the electronic health records of practices participating in the IRIS Registry. Children with glaucoma diagnosis or surgery before cataract removal were excluded. The Kaplan-Meier estimator was used to determine the cumulative probability of GFCS diagnosis and glaucoma surgery after cataract surgery. Multivariable Cox regression was used to identify factors associated with GFCS and glaucoma surgery.

MAIN OUTCOME MEASURES

Cumulative probability of glaucoma diagnosis and surgical intervention within 5 years after cataract surgery.

RESULTS

The study included 6658 children (median age, 10.0 years; 46.2% female). The 5-year cumulative probability of GFCS was 7.1% (95% confidence interval [CI], 6.1%-8.1%) and glaucoma surgery was 2.6% (95% CI, 1.9%-3.2%). The 5-year cumulative probability of GFCS for children aged < 1 year was 22.3% (95% CI, 15.7%-28.4%). Risk factors for GFCS included aphakia (hazard ratio [HR], 2.63; 95% CI, 1.96-3.57), unilateral cataract (HR, 1.48; 95% CI, 1.12-1.96), and Black race (HR, 1.61; 95% CI, 1.12-2.32). The most common surgery was glaucoma drainage device insertion (32.6%), followed by angle surgery (23.3%), cyclophotocoagulation (15.1%), and trabeculectomy (5.8%).

CONCLUSIONS

Glaucoma following cataract surgery diagnosis in children in the IRIS Registry was associated with young age, aphakia, unilateral cataract, and Black race. Glaucoma drainage device surgery was the preferred surgical treatment, consistent with the World Glaucoma Association 2013 consensus recommendations for GFCS management.

FINANCIAL DISCLOSURE(S)

Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.

Paediatric cataract surgery with 27G vitrectomy instrumentation: the Ghent University Hospital Experience

Objective

To describe a cohort of paediatric patients who underwent unilateral or bilateral lens extractions at Ghent University hospital using the Dutch Ophthalmic Research Center (D.O.R.C.) ultra-short 27G vitrectomy system.

Methods

Retrospective analysis of the medical and surgical records of all children that underwent lens extraction between September 2016 and September 2020 using the D.O.R.C. ultra-short 27G vitrectomy system.

Results

Seventy-two eyes of 52 patients were included. The most important aetiologies in this study were of secondary (25.5%), developmental (13.7%), or genetic (13.7%) nature. No definitive cause could be established in more than a quarter of cases (27.5%) despite extensive work-up, them being deemed idiopathic. The remainder of cases (19.6%) was not assigned a final aetiologic designation at the time of the study due to contradicting or missing diagnostic data. This study could not identify any cataract cases related to infection or trauma. Surgical complications rate was 61.1% of which posterior capsule opacification was the most frequent with a rate of 25%. A significant short-term postoperative best-corrected visual acuity gain (≤ -0.2 LogMAR) was observed in 60.5% of eyes for which usable acuity data were available (n = 38).

Conclusion

Many different instruments and techniques have been described and used in the context of paediatric lens extractions, each with its advantages and disadvantages. This study illustrates that an ultra-short 27G vitrectomy system can be used to perform paediatric lens extractions with good surgical outcomes. Further studies and comparative trials are needed to ascertain this further.

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.

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.

Cataract in retinopathy of prematurity - A review

Preterm babies with retinopathy of prematurity (ROP) can become blind if they do not receive appropriate timely intervention. The presence of cataract in these individuals in addition to visual deprivation amblyopia, also delays proper screening, adequate treatment, and makes follow-up assessment difficult. Anatomical differences in these infants and amblyopia management, especially in unilateral cataract, are other important concerns, and hence, management of these cases with cataract and ROP is challenging. In this review, studies where ROP cases were associated with cataract, were evaluated with a focus on preterm individuals less than 6 months age. Preterm babies are at increased risk of developing cataract because of systemic factors. In addition, those with ROP may have cataract associated with retinal detachment or treatment received. The type of cataract, risk factors, and pathophysiology associated with each cause varies. This review highlights these different aspects of cataract in ROP including causes, pathophysiology, types of cataracts, and management. The management of these cases is critical in terms of the timing of cataract surgery and the challenges associated with surgery and posterior segment management for ROP. Anatomical differences, preoperative retina status, pupillary dilatation, neovascularization of iris in aggressive posterior ROP, fundus examination, amblyopia, and follow-up are various important aspects in the management of the same. The preoperative workup, intraoperative challenges, postoperative care, and rehabilitation in these individuals are discussed.

Outcomes of the infantile cataract surgery: case series with a 5-year follow-up

PURPOSE

To present the 5-year outcomes obtained from the infantile cataract surgery in pediatric population.

METHODS

Medical records of all patients with unilateral or bilateral infantile cataract who had undergone lensectomy and anterior vitrectomy with or without intraocular lens implantation before 10 years of age were evaluated. Patients with any history of ocular trauma, retinal or corneal dystrophy, ocular or orbital surgery, retinopathy of prematurity, raised intraocular pressure at the time of diagnosis, or incomplete follow-up sessions were excluded from the research.

RESULTS

A total of 85 eyes belonged to 52 patients were analyzed. Bilateral and unilateral diseases were present in 33 (63.5%) and 19 (36.5%) patients, respectively. After performing the first operation, 43 (50.6%) eyes still remained aphakic. The mean corrected distance visual acuity (CDVA) of the aphakic and pseudophakic eyes was estimated as 0.77 ± 0.52 and 0.43 ± 0.39 logMAR with no statistical difference. The age at the time of performing the cataract surgery was not associated with the final CDVA in either group. Complications in the anterior segment structures were noted in 39 (45%) eyes. Strabismus and amblyopia were noted in 52 (61%) and 75 (88.2%) eyes, respectively. Glaucoma was found in 17 (20%) eyes with no correlation with the final CDVA, age at the time of cataract surgery, or the status of the lens.

CONCLUSION

Due to high prevalence rates of amblyopia, strabismus, and glaucoma after the infantile cataract surgery, specific attention should be paid to these complications in each follow-up examination.

Incidence and Risk Factors of Glaucoma Following Pediatric Cataract Surgery With Primary Implantation

PURPOSE

To determine the incidence and risk factors for glaucoma after pediatric cataract surgery with intraocular lens (IOL) implantation.

DESIGN

Retrospective, consecutive case series.

METHODS

In this single-center study, we reviewed 136 children (199 eyes) who underwent pediatric cataract surgery before 1 year of age with a minimum of 1 year of follow-up. The intervention used was pediatric cataract surgery with IOL implantation, and the primary outcome measure was the presence or absence of secondary glaucoma.

RESULTS

The mean age at surgery was 148 ± 93 days (range 30-359 days) with a mean follow-up of 6.3 ± 3.6 years (range 1.1-12.8 years). Glaucoma developed in 31 eyes (16%) with 5- and 10-year incidence rates of 12% and 28%, respectively. The incidence of glaucoma seemed to be bimodal, with a first peak occurring after a mean delay of 2.5 months (range 1.6-4.1 months) and a second peak occurring after a mean delay of 5.7 years (range 2.6-11.7 years). Younger age at surgery, shorter axial length, longer follow-up, use of trypan blue, reintervention, and bilateral surgery were associatied with a higher incidence of glaucoma. Multivariate analysis including the aforementioned variables indentified longer follow-up (odds ratio [OR] = 1.3 [95% confidence interval {CI} 1.1-1.6], P = .001), reintervention (OR = 4.1 [95% CI 1.2-13.4], P = 0.02), and the use of trypan blue (OR = 4.1 [95% CI 1.3-13.1], P = .02) as predictors for the development of glaucoma.

CONCLUSION

Glaucoma is a common complication after pediatric cataract surgery. It seemed to have a bimodal incidence. Risk factors for glaucoma development were reintervention, the use of trypan blue, and a long follow-up.

Angle Surgery in Pediatric Glaucoma Following Cataract Surgery

Glaucoma is a common and sight-threatening complication of pediatric cataract surgery Reported incidence varies due to variability in study designs and length of follow-up. Consistent and replicable risk factors for developing glaucoma following cataract surgery (GFCS) are early age at the time of surgery, microcornea, and additional surgical interventions. The exact mechanism for GFCS has yet to be completely elucidated. While medical therapy is the first line for treatment of GFCS, many eyes require surgical intervention, with various surgical modalities each posing a unique host of risks and benefits. Angle surgical techniques include goniotomy and trabeculotomy, with trabeculotomy demonstrating increased success over goniotomy as an initial procedure in pediatric eyes with GFCS given the success demonstrated throughout the literature in reducing IOP and number of IOP-lowering medications required post-operatively. The advent of microcatheter facilitated circumferential trabeculotomies lead to increased success compared to traditional <180° rigid probe trabeculotomy in GFCS. The advent of two-site rigid-probe trabeculotomy indicated that similar results could be attained without the use of the more expensive microcatheter system. Further studies of larger scale, with increased follow-up, and utilizing randomization would be beneficial in determining optimum surgical management of pediatric GFCS.

Clinical Characteristics and Treatment of Secondary Glaucoma After Pediatric Congenital Cataract Surgery in a Tertiary Referral Hospital in Spain

PURPOSE

To analyze clinical characteristics, treatment, and long-term outcomes of pediatric patients with glaucoma after congenital cataract surgery at a single tertiary care hospital.

METHODS

Medical records of pediatric patients diagnosed as having glaucoma secondary to congenital cataract surgery between 1996 and 2016 were reviewed retrospectively.

RESULTS

A total of 58 eyes of 42 patients were included with a median follow-up time of 55 months (interquartile range [IQR]: 27 to 128) after glaucoma diagnosis. Mean time of glaucoma onset after cataract surgery was 35 months (IQR: 5 to 96). At diagnosis, 81% of the eyes were aphakic and the majority presented with an open angle (86%). Multivariate analysis demonstrated that glaucoma diagnosis was made earlier in eyes with persistent fetal vasculature (β = -0.334, P = .006) and aphakic eyes (β = 0.404, P = .001). Two-thirds of eyes required surgical treatment for glaucoma. Seventy percent had an Ahmed glaucoma valve (New World Medical, Inc) implantation as their primary procedure, followed by trabeculectomy (24%) and synechiolysis with peripheral iridotomy (6%). All medically treated eyes and 78% of the surgically treated eyes achieved intraocular pressure (IOP) control at the final visit.

CONCLUSIONS

Diagnosis of glaucoma after congenital cataract surgery seems to follow a bimodal distribution (years 1 and 5 after cataract surgery). Two-thirds of the eyes required surgical hypotensive treatment to achieve IOP control. Ahmed glaucoma valve implantation is a safe and effective surgical option to be considered as both first- and second-line treatment. Functional outcome was more favorable in those eyes with medically controlled glaucoma. [J Pediatr Ophthalmol Strabismus. 2020;57(5):292-300.].

Cataract management in children: a review of the literature and current practice across five large UK centres

Congenital and childhood cataracts are uncommon but regularly seen in the clinics of most paediatric ophthalmology teams in the UK. They are often associated with profound visual loss and a large proportion have a genetic aetiology, some with significant extra-ocular comorbidities. Optimal diagnosis and treatment typically require close collaboration within multidisciplinary teams. Surgery remains the mainstay of treatment. A variety of surgical techniques, timings of intervention and options for optical correction have been advocated making management seem complex for those seeing affected children infrequently. This paper summarises the proceedings of two recent RCOphth paediatric cataract study days, provides a literature review and describes the current UK 'state of play' in the management of paediatric cataracts.

Secondary glaucoma and visual axis opacification in aphakic and pseudophakic patients following congenital cataract surgery: A 28-year longitudinal case series

Purpose:

To determine the incidence, timing and risk factors for glaucoma and visual axis opacification development following surgery for congenital cataract in the first year of life.

Methods:

A prospective case series of all cataract surgery performed in Temple Street Children’s University Hospital over a 28-year period was conducted. A total of 93 subjects (135 eyes) were analysed. Sixty-two eyes had a primary intraocular lens inserted at the time of surgery; 73 eyes were aphakic. We recorded patient demographics, age at surgery, length of follow-up, rates and time to diagnosis of glaucoma and rates of visual axis opacification. Relative risk analysis was performed to identify potential risk factors for secondary glaucoma and visual axis opacification.

Results:

Mean length of follow-up was 160.02 ± 64.42 months (13.3 years), range 40–336 months. Final mean LogMAR across all groups was 0.85 ± 0.51 (0.90). Overall 45 (33.33%) eyes developed secondary glaucoma, 12 (19.4%) in pseudophakic eyes and 33 (45.21%) in aphakic eyes. The incidence of glaucoma was highest in bilateral aphakia (relative risk 1.96, p = 0.0240) and in eyes with corneal diameter <9.5 mm (relative risk 1.93, p = 0.0364). There was no significant difference in glaucoma rates between pseudophakia and aphakia in those operated on less than 2.5 months of age. Secondary glaucoma occurred between 3 months to 16.5 years post surgery. Rates of visual axis opacification were lower in aphakia compared to pseudophakia (relative risk 0.59, p = 0.0098).

Conclusion:

Overall glaucoma rates of one-third are similar to those recorded in the infantile aphakic treatment study. It can occur up to 17 years post cataract surgery, evidence that long-term follow-up is imperative.

Risk of aphakic glaucoma after pars plana-lensectomy with and without removal of the peripheral lens capsule

BACKGROUND

The etiology of aphakic glaucoma is unclear. It has been suggested that remaining lens epithelium releases cytokines transducing trabecular meshwork cells. Therefore, we compared two cohorts of children undergoing lensectomy. In cohort 1, the entire lens including its capsule was removed, in cohort 2 the peripheral lens capsule was left intact, also to facilitate secondary intraocular lens implantation later on.

METHODS

We included children with uni- or bilateral congenital cataract who underwent lensectomy during the first year of life with subsequent contact lenses fitting. Group 1 comprised 41 eyes, group 2 comprised 33 eyes. In group 1, the median age at surgery was 4.0 months in unilateral and 3.0 months in bilateral cases 1, in group 2, 8.1 months and 2.4 months, respectively. The mean follow-up was 12.8 years in group 1 and 9.3 years in group 2. All cases were analyzed for the prevalence of aphakic glaucoma, for visual acuity and for compliance in visual rehabilitation (contact lens/occlusion therapy).

RESULTS

We found no significant difference in glaucoma prevalence between group 1 and group 2 (p = 0.68). The overall glaucoma rate was 26% after the mean follow-up of 11 years in both groups. In unilateral cases, the median visual acuity was logMAR 0.7 in both groups. In bilateral cases it was logMAR 0.4 in group 1 and logMAR 0.2 in group 2 (p = 0.05).

CONCLUSIONS

Leaving the peripheral lens capsule intact had no negative effect on the incidence of glaucoma and on resulting visual acuity.

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.

Five-Year Postoperative Outcomes of Bilateral Aphakia and Pseudophakia in Children up to 2 Years of Age: A Randomized Clinical Trial

PURPOSE

Comparative evaluation of complications and visual outcomes following bilateral congenital cataract surgery in children up to 2 years of age with and without primary intraocular lens (IOL) implantation at 5 years follow-up.

DESIGN

Randomized controlled clinical trial.

METHODS

Sixty children (120 eyes) up to 2 years of age undergoing bilateral congenital cataract surgery were randomized to Group 1, primary aphakia (n = 30), or Group 2, primary IOL implantation (pseudophakia) (n = 30). A single surgeon performed surgeries with identical surgical technique. All patients were followed up regularly until 5 years postoperatively. At each follow-up, glaucoma, visual axis obscuration (VAO) requiring surgery, and inflammation (cell deposits, posterior synechiae) were assessed. Visual acuity was assessed until 5 years follow-up. The first operated eye was selected for statistical analysis.

RESULTS

Median age of the patients at time of surgery was 5.11 months (aphakia group) and 6.01 months (pseudophakia group) (P = .56). Five years postoperatively, incidence of glaucoma was 16% and 13.8% in Groups 1 and 2 (P = .82). Incidence of posterior synechiae was significantly higher in the pseudophakia group (27.6%) compared to the aphakia group (8%) (P = .004). VAO requiring surgery was seen in 8% and 10.3% of eyes in Groups 1 and 2 (P = .76). Mean logMAR visual acuity at 5 years follow-up was 0.59 ± 0.33 and 0.5 ± 0.23 in Groups 1 and 2, respectively (P = .79). However, more eyes in the pseudophakic group started giving documentable vision earlier in their postoperative follow-ups.

CONCLUSIONS

Incidence of postoperative complications was comparable between the groups, except for a higher incidence of posterior synechiae in pseudophakic eyes. Visual rehabilitation was faster in the pseudophakic group.

Phacoemulsification and primary implantation with bag-in-the-lens intraocular lens in children with unilateral and bilateral cataract

PURPOSE

To report outcome in a paediatric cohort with cataract extraction and implantation of bag-in-the-lens intraocular lens (BIL-IOL).

METHODS

Children younger than 16 years of age subjected to phacoemulsification with primary implantation of BIL-IOL during 2009 through 2013 were analysed retrospectively. Exclusion criteria were uveitis or ≤6 months of follow-up.

RESULTS

In total, 109 eyes of 84 children were included; 40 unilateral and 44 bilateral cataracts. For all eyes, median age at surgery was 2.5 years (range 2 weeks to 14.1 years) and 16 children (24 eyes) were ≤6 weeks. Coexisting systemic disease was more common in children with bilateral cataract (24 patients, 54.5%) compared to unilateral cataract (6 patients, 15.0%, p < 0.0001). Ocular comorbidity was more common in unilateral cataracts; n = 14 eyes (35.0%) compared to bilateral cataracts; n = 10 eyes (14.5%; p = 0.017). Median follow-up was 2.8 years (range 7 months to 5.8 years). During the follow-up period, 15 (13.8%) eyes developed glaucoma and five (4.6%) eyes required treatment for visual axis opacification (VAO). Corrected distance visual acuity (CDVA) for bilateral cataracts at last follow-up was 0.42 ± 0.45 (logMAR; mean±SD) with 35 (55.6%) eyes attaining a CDVA of ≥0.5 (dec). For unilateral cataracts mean CDVA was significantly poorer; 0.67 ± 0.51 (p = 0.010) with 15 (37.5%) eyes attaining a CDVA of ≥0.5.

CONCLUSION

For children having cataract surgery with primary implantation of BIL-IOL, VAO is rare and visual outcome overall good. Unilateral cataracts are associated with a higher proportion of ocular comorbidity and poorer visual outcome.

The Profile and Management of Glaucoma in Adult Aphakic Patients Following Complicated Cataract Surgery

Objectives

To determine the profile and clinical course of glaucoma in adult aphakic patients following complicated cataract surgery.

Materials and Methods

Retrospective chart review of 22 adult aphakic patients (29 eyes) with glaucoma.

Results

Mean age was 57.69±14.18 years when aphakia occurred. Mean age at time of presentation to our glaucoma clinic was 62.57±12.47 years. Mean follow-up time was 42.83±57.04 months. Changes between the first and last follow-up visits were as follows: mean intraocular pressure decreased from 26.21±13.86 mmHg to 18.14±9.63 mmHg (p=0.003); mean number of glaucoma medications used increased from 1.41±1.27 to 2.07±1.04 (p=0.005); and mean vertical cup/disc ratio increased from 0.69±0.25 to 0.78±0.24 (p=0.024). Glaucoma was managed using medications in 26 eyes (89.7%), whereas 3 eyes underwent surgical treatment. However, surgery alone was not sufficient to control intraocular pressure and additional glaucoma medications were needed.

Conclusion

Prevention of glaucomatous optic neuropathy in aphakic patients is challenging both medically and surgically. Although a significant decrease in intraocular pressure can be achieved with glaucoma medications, glaucomatous disc changes may progress.

Glaucoma following childhood cataract surgery: the South India experience

PURPOSE

To determine the characteristics and risk factors for the development of glaucoma after cataract surgery in children seen at a major referral tertiary eye centre in South India.

METHODS

This is a retrospective review of the medical records of consecutive patients seen at the glaucoma/paediatric eye clinic of the centre, with a diagnosis of glaucoma secondary to aphakia/pseudophakia over a 5-year period.

RESULTS

There were 21 eyes of 14 children that developed glaucoma and 23 eyes of 12 children were selected as control. The mean age (standard deviation SD) at the time of cataract surgery for the glaucoma group was 7.4 (± 10.1) months and 39.13 (± 41.2) months for the control. The mean follow-up (SD) period was 114.29 (± 61.9) months and 97.61 (± 43.5) months for the glaucoma and control, respectively. The mean duration from cataract surgery to onset of glaucoma was 81.19 (± 52.4) months (median 66 months, range 21-172 months). Multivariate analysis detected age at surgery younger than 12 months (OR 10.45, 95%CI 1.76-62.03, p = 0.010) and ocular anomalies mainly microcornea (OR 7.11, 95%CI 1.14-44.46, p = 0.036) as risk factors for development of glaucoma after paediatric cataract surgery.

CONCLUSION

Glaucoma can develop several years after childhood cataract surgery. Surgery in the first year of life and microcornea are risk factors for the development of glaucoma post-surgery. Signs of glaucoma should specifically be looked for during follow-up visits.

Twenty-five-gauge sutureless lensectomy in infants with congenital cataract

PURPOSE

To evaluate the incidence of intra- and postoperative complications of transconjunctival 25-gauge (25G) sutureless pars plicata lensectomy.

METHODS

The medical records of patients <12 months of age with congenital cataracts who underwent 25G sutureless lensectomy were reviewed retrospectively. Patients were evaluated at postoperative days 1, 7, 15, 30, 60, and 90 and every 3 months thereafter. Visual acuity outcomes and intra- and postoperative complications were described and analyzed.

RESULTS

A total of 72 eyes of 44 infants were included; 28 patients (64%) had bilateral cataract. Median follow-up was 28 months (range, 12-93 months). In 47 eyes (81%) there was improved visual acuity after surgery. Intraoperative adverse events occurred in 9 eyes (13%). Postoperative complications occurred in 14 eyes (19%): 6 eyes (8%) had secondary visual axis opacification, 6 eyes (8%) had secondary glaucoma, 1 eye (1%) had posterior synechiae, and 1 eye (1.4%) had retinal detachment.

CONCLUSIONS

Transconjunctival pars plicata 25G sutureless lensectomy is a minimally invasive technique for congenital cataract treatment. No postoperative complications were observed in 81% of eyes. Visual acuity improved in 81% of the operated eyes.

Second intraocular surgery after primary pediatric cataract surgery: indications and outcomes during long-term follow-up at a tertiary eye care center

PurposeAlthough pediatric cataract surgery has become standardized and safe, further surgical interventions are not uncommon. The purpose of this study was to analyze the incidence of complications in children who required an intraocular intervention.MethodsA retrospective review of medical records of children (<7 years) with cataract who underwent cataract surgery with or without primary posterior chamber intraocular lens (IOL) placement between January 2006 and December 2014 was carried out. Data were collected regarding visual axis opacification (VAO), glaucoma, IOL decentration, intraocular infections, and other indications that required a second intraocular surgery.ResultsOut of 814 (570 pseudophakic and 244 aphakic) eyes of 620 operated children, 45 eyes of 40 children (5.5%, 45/814) needed a second surgery. The most common indication being VAO (2.9%, 24/814), followed by glaucoma (0.73%, 6/814). Incidence of complications was higher in children <1 year (VAO 6.1%, 19/308 and glaucoma 6%, 6/308). Among all children, repeat interventions and VAO were slightly less frequent in pseudophakics (4.91%, 28/570) vs aphakics (6.91%, 17/244) (P=0.31). As VAO was more common in pseudophakic eyes in infants, glaucoma was equally common in both groups. Best-corrected visual acuity improved from 1.6±0.56 LogMAR preoperatively to 0.80±0.50 LogMAR postoperatively.ConclusionsOur study suggests that overall incidence of second intraocular surgery is low after primary pediatric cataract surgery. VAO remains the most common indication followed by secondary glaucoma. Incidence of complications is higher in children <1 year of age at initial surgery.

Visual Outcomes of Congenital Cataract Surgery in a Tertiary Public Hospital in Bangladesh

PURPOSE

The purpose of this study was to look at the visual outcomes of bilateral congenital cataract surgery.

DESIGN

A prospective study was conducted.

METHODS

A total of 102 eyes of 51 children aged between 2 and 12 months undergoing bilateral congenital cataract surgery from January 2008 to December 2008 with a 3-year follow-up were included in this study. The study was performed at a tertiary public hospital. Data were analyzed using SPSS version 17. Chi-square (χ²) tests were performed to identify the association between visual outcome and age at surgery. P values less than 0.05 were considered statistically significant.

RESULTS

Among the 102 eyes, 32 (31.4%) eyes were operated on when the subjects were aged between 2 and 3 months, and 70 (68.6%) eyes were operated on at the age of 3 to 12 months. The subjects were followed up for 3 years after surgery. Postoperative best-corrected visual acuity was measured. Visual outcomes were significantly poor in children aged 3 months or older (P < 0.001) as compared with children aged between 2 and 3 months.

CONCLUSIONS

Early detection and treatment with long-term postoperative rehabilitation is vital to improve visual outcomes of children with congenital cataract.

Surgical Management of Glaucoma After Congenital Cataract Surgery

PURPOSE

Cataract surgery in children is a difficult entity with possible complications, glaucoma being particularly common. The purpose of this study was to explore the results of surgical intervention for glaucoma after congenital cataract surgery in Alexandria University, Egypt.

METHODS

The study was a retrospective chart review of 32 children with glaucoma after congenital cataract surgery between 2005 and 2012. Preoperative, operative, and postoperative data were collected. Complications were noted. Success was studied at the end of follow-up.

RESULTS

The study included 41 (36 aphakic, 5 pseudophakic) eyes of 32 children undergoing 57 glaucoma surgical procedures. The mean ± standard deviation age at the time of surgery was 17.2 ± 21.6 months (range: 3.0 to 103.5 months) and the mean follow-up period was 39.1 ± 25.2 months (range: 1 to 75 months). The most common (78%) primary glaucoma surgical procedure was combined trabeculotomy-trabeculectomy with mitomycin C. The mean preoperative intraocular pressure, corneal diameter and thickness, cup-disc ratio, and axial length of the study eyes was 22.3 ± 6.1 mm Hg (range: 10 to 34 mm Hg), 11.4 ± 0.9 mm (range: 10 to 13 mm) and 617.6 ± 66.8 µm (range: 538 to 758 µm), 0.5 ± 0.3 mm (range: 0 to 1 mm), and 22.85 ± 2.75 mm (range: 18.55 to 29.17 mm), respectively, and postoperatively at last follow-up was 11.0 ± 7.3 mm Hg (range: 1 to 36 mm Hg), 11.5 ± 0.9 mm (range: 10 to 13 mm) and 576.8 ± 83.3 µm (range: 461 to 736 µm), 0.4 ± 0.3 mm (range: 0 to 1 mm), and 24.62 ± 2.81 mm (range: 19.70 to 32.81 mm), respectively. Success was reported in 34 (82.9%) eyes. Complications included endophthalmitis, hypotony disc edema, and retinal detachment.

CONCLUSIONS

Glaucoma after congenital cataract surgery is a difficult entity, often requiring more than one surgical procedure to control it. Long-term follow-up is mandatory to detect any failure of treatment at any time point and manage accordingly.

Cataract surgery outcomes in bangladeshi children

PURPOSE

To measure visual acuity (VA) outcomes, complication rates, and the social impact of cataract surgery in a cohort who underwent surgery as children in Bangladesh.

DESIGN

Case series.

PARTICIPANTS

A total of 471 of 850 children from 6 Bangladeshi districts who had been identified as cataract blind using key informants (KIs) between 2004 and 2009 during the Bangladesh Childhood Cataract Campaign (BCCC) together with all those children not included in the BCCC database but in the Child Sight Foundation (CSF) database who had been identified as cataract blind.

METHODS

The subjects and families were contacted again by KIs and transported to local examination centers, where parents and subjects were administered a questionnaire and subjects underwent full ocular examination. Where operative data were available (15%), they were analyzed in conjunction with questionnaire and examination findings. Statistical analysis was performed using SPSS Statistics (IBM, Armonk, NY).

MAIN OUTCOME MEASURES

Presenting and best-corrected visual acuities (BCVAs), cause(s) of poor outcome, postoperative refraction, and school attendance.

RESULTS

A total of 407 of the participants had undergone bilateral surgery as children, with a mean follow-up of 8.8 years. The mean age at examination was 16 years (range, 5-28 years; standard deviation [SD], 4.6 years); 63% of those examined were male; 22% had a binocular presenting VA of >20/60; and 53% were severely visually impaired or blind (VA <20/200). After refraction, 33% had VA >20/60 in their better eye and 33% had VA <20/200. Factors that predicted poor VA in multivariate logistic regression analysis were nystagmus (P < 0.001), longer delay in presentation (P < 0.001), and magnitude of absolute spherical equivalent refractive error (P<0.001). Some 50% had nystagmus, and 69% of those currently aged ≤16 years were attending school. Better acuity was associated with school attendance (P < 0.001), whereas gender was not.

CONCLUSIONS

Approximately one third of all participants had a BCVA of ≥20/60 in their better eye. Amblyopia and nystagmus limited visual outcome, indicating the need for earlier detection and treatment. This is the first study to show the link between pediatric cataract outcome and access to education, a millennium development goal.

Optimal screening interval for intraocular pressure measurement for Asian glaucoma patients

AIM: To explore the optimal interval of intraocular pressure (IOP) measurement for screening glaucoma in healthy people.

METHODS: From January to December 2005, we consecutively enrolled all participants (> 20 years old) attending the Center for Preventive Medicine at St. Luke’s International Hospital in Tokyo, Japan, for the annual health check program. The program promoted the early detection of chronic diseases and their risk factors. We excluded people who had glaucoma or a high IOP (≥ 22 mmHg) at baseline. The annual health check-ups collected all demographic information and medical history with an initial evaluation, including IOP measurement. IOP was measured in both eyes with a full auto-tonometer TX-F (Canon, Tokyo, Japan). Participants with an IOP ≥ 22 mmHg in either eye were considered to require additional evaluation for glaucoma. We divided the participants into two groups based on age: under 65 years old and over 65 years old. The United States Department of Health and Human Services Centers for Medicare and Medicaid Services guideline was used as a reference.

RESULTS: From January 2005 to July 2008, 12 385 participants underwent check-ups each year. The mean ± SD IOP in the higher eye at baseline was 13.4 (2.6) in 2005, 13.2 (2.7) in 2006, 13.3 (2.6), and 12.8 (2.6) in 2008. In addition, we analyzed the differences with an analysis of variance (ANOVA), and additional analysis was performed with Bonferroni’s correction. The difference between the 4 years was significant (P < 0.01) with ANOVA. Bonferroni analysis revealed significant differences between 2005 and 2006 (P < 0.01), 2005 and 2008 (P < 0.01), 2006 and 2007 (P < 0.01), 2006 and 2008 (P < 0.01), and 2007 and 2008 (P < 0.01). Only the difference between 2005 and 2007 was not significant (P = 0.1). Logistic regression suggested that only age (P < 0.01) and baseline IOP (P < 0.01) were associated with high IOP; the presence of diabetes, HgbA1c level, gender, systolic blood pressure, diastolic blood pressure, low-density lipoprotein and family history were non-significant.

CONCLUSION: Annual IOP check-ups may be recommended for participants aged ≥ 65 years with baseline IOPs of 17-21 mmHg. A check-up every 3 years or more may be recommended for patients with IOPs < 17 mmHg.

[Aphakic and pseudophakic glaucoma following pediatric cataract surgery]

Modern surgical techniques allow congenital cataract surgery to be performed much more successfully. The development of a secondary glaucoma is the most dreaded postoperative complication (one third of all pediatric secondary glaucomas). Due to the limited value of the available literature, data on prevalence are unreliable. A 10-year postoperative incidence of 10-25% is given in the literature for developing secondary glaucoma and the frequency increases with the duration of follow-up. A major risk factor seems to be the age at the time of surgery. The younger the patient is at the time of surgery the higher the risk of secondary glaucoma. A microcornea seems to be another risk factor in multivariate analysis. The following postoperative changes might be involved in the pathogenesis: peripheral anterior synechia, high iris insertion and membranous material over the trabecular meshwork. Additionally postoperative inflammation, reaction to lens epithelial cells, perioperative barotrauma and loss of anterior segment architecture might also be responsible. In order to evaluate the optimal age window for congenital cataract surgery and risk factors for the development of secondary glaucoma, a prospective longitudinal study is mandatory.

Cataract surgery in the first year of life: aphakic glaucoma and visual outcomes

OBJECTIVE

To report the incidence of aphakic glaucoma following lensectomy in infants in their first year of life and examine the impact of this diagnosis on visual outcome.

DESIGN

Retrospective cohort study.

PARTICIPANTS

All patients who had lensectomy for congenital cataract during the first year of life at British Columbia Children's Hospital between 1995 and 2006.

METHODS

Retrospective review of medical records.

RESULTS

Seventy-five eyes of 46 patients (29 bilateral, 17 unilateral) were included. The mean age at lensectomy was 93 days (range, 2-364 days) with a mean follow-up of 77.5 months (range, 36-166 months). Patients with bilateral cataracts had a better visual outcome than those with unilateral cataracts (p < 0.032). Of the patients with measurable visual acuity (VA), 34 of 45 eyes (75.6%) with bilateral cataracts and only 3 of 16 eyes (18.8%) with unilateral cataract achieved a VA of 20/40 or better. Eighteen of 75 eyes (24%) developed aphakic glaucoma at a mean of 30 months following lensectomy. Nine patients (50%) achieved final vision of 20/40 or better. The development of aphakic glaucoma was not associated with worse visual outcomes (p < 0.315). The mean intraocular pressure (IOP) at diagnosis was 28.6±5.9 mm Hg and mean final IOP was 14.1 ± 3.0 mm Hg, a significant reduction (p < 0.0001). Fifteen of 18 eyes with aphakic glaucoma (83.3%) required surgical intervention to achieve IOP control.

CONCLUSIONS

Children with aphakic glaucoma may have good visual outcomes if it is recognized early and managed appropriately. A significant proportion of patients required surgical intervention to control IOP.

Secondary in-the-bag intraocular lens implantation in children who have been aphakic since early infancy

PURPOSE

To report the results of secondary in-the-bag intraocular lens (IOL) implantation compared to secondary sulcus IOL implantation in eyes that received cataract extraction during early infancy.

METHODS

This was a comparative retrospective study. Data were collected for the ages at cataract extraction and at secondary IOL implantation, the length of follow-up, the reasons for IOL insertion, postoperative complications, and pre- and postoperative best-corrected visual acuity. Eyes with less than 6 months of follow-up were excluded from the analysis of postoperative outcome but were included in the rest of the analysis.

RESULTS

Thirty-three eyes received in-the-bag secondary IOL implantation at the Storm Eye Institute, Medical University of South Carolina, during the past 10 years and were compared with 21 eyes that received secondary sulcus IOL implantation during the same time period. Both groups had cataract extraction during the first 4 months of life. The 2 groups were comparable in terms of age at secondary IOL implantation, sex, ethnicity, laterality, and eye measurements except for a longer mean axial length for the eyes implanted in the sulcus. The complications were comparable in both groups. The last follow-up best-corrected visual acuity clustered around a median of 20/40 and was not significantly different between the 2 groups or from the median preoperative best-corrected visual acuity of 20/50.

CONCLUSIONS

Secondary in-the-bag IOL implantation has comparable early results with sulcus IOL implantation while still allowing the use of single-piece acrylic IOLs and offering the chance, in suitable eyes, for implanting a secondary IOL in the anatomical space of the capsular bag.

Aphakic glaucoma after cataract surgery for isolated nontraumatic pediatric cataract

PURPOSE

To compare eyes diagnosed with aphakic glaucoma to those that were not after pediatric cataract surgery (age <12 years) without intraocular lens implantations for isolated (e.g., no microcornea) nontraumatic cataract with at least 5 years follow-up.

METHODS

Institutional retrospective institutional series (1985-2003).

RESULTS

Of 269 aphakic eyes, 62 (23%) were diagnosed with glaucoma (36 of 130 patients, 27.7%) an average of 59.0 months [m] (standard deviation +/- 44 months; median 33.5 months; range 1 to 227 months) postoperatively with an average intraocular pressure at diagnosis of 34.6 mm Hg (standard deviation +/- 5.3). Eyes diagnosed with glaucoma had lower mean age at cataract diagnosis (6.9 months versus 11.1 months) and surgery (9.2 months vs. 13.3 months), more frequent need for a second surgery to clear the visual axis (23% [8/62] versus 5.3% [11/207]), a higher percentage of eyes operated before 10 months of age (88.7% [55/62] versus 74.5% [155/207]), and a longer mean follow-up (160.4 months versus 112.7 months). The incidence of diagnosed aphakic glaucoma in eyes operated at or before 10 months of age was more than double (26.2% versus 11.9% P<0.00001).

CONCLUSIONS

Independent of obvious ocular abnormality other than cataract, earlier cataract diagnosis and surgery and second surgery to clear the visual axis more frequently occurred in aphakic children who were diagnosed with aphakic glaucoma. The incidence was more than double in eyes that had surgery at or before 10 months of age. A number of cases likely have delayed diagnosis because of difficulties in assessing young patients for early glaucoma.

Outcome of angle surgery in children with aphakic glaucoma

PURPOSE

To investigate the outcome of trabeculotomy and/or goniotomy for pediatric aphakic glaucoma.

METHODS

Retrospective chart review of consecutive children who had congenital cataract surgery between 1990 and 2006 and required goniotomy and/or trabeculotomy for aphakic glaucoma. Treatment success was defined as postoperative intraocular pressure of <or=24 mm Hg despite topical medication use, avoidance of trabeculectomy or shunt placement, and no visually significant complications in the follow-up period. Exclusion criteria included a diagnosis of anterior segment dysgenesis, microcornea, and glaucoma at the time of cataract surgery, and follow-up less than 1 year.

RESULTS

A total of 14 eyes of 11 patients met inclusion criteria, with a mean follow-up of 4.7 years. Of theses, 2 eyes had goniotomy alone, 3 eyes had goniotomy followed by trabeculotomy, and 9 eyes had trabeculotomy alone. Mean IOP before angle surgery was 35 +/- 10 mm Hg. Mean IOP at the last recorded visit was 22 +/- 4 mm Hg (p = 0.0005). Treatment success was observed in 8 of the 14 eyes (57.1%), with a mean number of angle procedures of 1.4 per eye: 6 eyes (42.8%) were successful after a single angle surgery, each involving an initial trabeculotomy; 3 eyes (21.4%) underwent subsequent shunt placement after initial goniotomy at 6 months, 1.3 years, and 5.5 years after the last angle surgery.

CONCLUSIONS

When intraocular surgery is indicated to control IOP in pediatric aphakic glaucoma, trabeculotomy and/or goniotomy can be successful in the majority of eyes and may decrease the need for filtering and shunting procedures.

The incidence of glaucoma following paediatric cataract surgery: a 20-year retrospective study

AIMS

To analyse the incidence of glaucoma in children undergoing cataract surgery and determine whether early surgery is associated with increased risk of glaucoma.

METHODS

A retrospective chart review of all children aged 14 years or less who had surgery for congenital or developmental cataract at one unit over the last 20 years. The children were divided into three groups; group 1 consisting of children aged < or =50 days at surgery, group 2 those aged 51 days to 1 year, and group 3 aged 1-14 years.

RESULTS

We identified a total of 104 eyes of 74 children. The medical records for 100 eyes (71 children) were available for review. In all, 17 eyes (12 children) were aged < or =50 days at surgery, none of which have developed glaucoma. Group 2 consisted of 28 eyes (17 children) with one patient developing glaucoma in both eyes 11 years after surgery. Group 3 consisted of 55 eyes (42 children), none of which have developed glaucoma. After a median follow-up period of 4.9 years (range 0.6-19.6 years, mean 6.4 +/- 5.2 years) 2% of eyes had developed glaucoma. There was no significant difference in the length of follow-up between groups (H=2.979, P=0.22, Kruskal-Wallis Test).

CONCLUSIONS

There was a low incidence of glaucoma in our series and this was not increased in those having surgery in the first 6 weeks of life. Our findings contribute further evidence for the variability in prevalence of glaucoma after paediatric cataract extraction in the literature and suggest that factors other than age at surgery are important risk factors for this condition.

Glaucoma in aphakic and pseudophakic eyes following surgery for congenital cataract in the first year of life

PURPOSE

To determine the incidence and risk factors for glaucoma in pseudophakic and aphakic eyes following surgery for congenital cataract within the first year of life.

METHODS

We conducted a review of all cataract surgery performed at our unit over a 23-year period. Age at surgery, corneal diameter, intraocular lens implantation, presence of persistent foetal vasculature and visual axis opacification (VAO) were documented. Time to development of glaucoma, management and outcome were determined. One eye was selected randomly for analysis in cases of bilateral cataract.

RESULTS

Duration of follow-up was significantly longer (p < 0.001) in the aphakic (113 +/- 69 months) compared to the pseudophakic group (56 +/- 44 months). Age at surgery was significantly less (p = 0.01) in the aphakic group. The incidence of glaucoma was significantly greater (p = 0.02) in the aphakic (15 eyes, 33%) compared to the pseudophakic (seven eyes, 13%) group. Each eye that developed glaucoma underwent cataract extraction aged < or = 2.5 months. Analysis of all eyes that underwent surgery aged < or = 2.5 months revealed no statistical difference (p = 0.08) in the incidence of glaucoma. Smaller corneal diameter and VAO were not associated with increased risk of glaucoma development. Ahmed valves proved effective in controlling intraocular pressure but visual outcome was poor in the majority of cases.

CONCLUSION

Surgery for congenital cataract at an early age increases the risk of glaucoma development, regardless of whether the eye is aphakic or pseudophakic. Intraocular pressure control with Ahmed valves is frequently required. Glaucomatous damage and dense amblyopia contribute to poor visual outcome in these eyes.

Age at the time of cataract surgery and relative risk for aphakic glaucoma in nontraumatic infantile cataract

PURPOSE

To report the relative risk for aphakic glaucoma as a function of age at surgery in infants who underwent cataract surgery before 10 months of age for nontraumatic infantile cataract without microcornea.

METHODS

This was an institutional retrospective case series (January 1985 to February 2003) of children who underwent cataract surgery without intraocular lens implantation for nontraumatic infantile cataract before 10 months of age. Patients with less than 5 years' postsurgical follow-up, microcornea, persistent fetal vasculature, and/or other significant anterior segment abnormality were excluded.

RESULTS

The surgical procedure in all cases was lens aspiration, posterior capsulotomy, and anterior vitrectomy with anterior small-incision techniques. Of 210 eyes (121 patients), 55 eyes (26.2%; 31 patients [25.6%]) developed aphakic glaucoma. Relative risk for later aphakic glaucoma as a function of age at the time of surgery decreased from 1.85 (95% CI, 0.88-3.86) at 0-1 months of age to a nadir at 3-4 months of age (0.22 [95% CI, 0.05-0.96]) and then increased again to peak at 3.17 (95% CI, 1.1-9.11) at 5-6 months of age.

CONCLUSIONS

The lowest relative risk for later aphakic glaucoma in our cohort was for surgery performed at 3-4 months of age, for which the 95% CI remained less than 1.0. Further conclusions are limited by overlapping confidence intervals. However, because of amblyopia issues, we do not recommend delaying congenital cataract surgery beyond 4 weeks of life.

[The latest on amblyopia treatment]

In recent years there has been a lively discussion on the benefits of early detection and treatment of amblyopia, as well as large prospective randomized controlled studies. Furthermore, we now have the opportunity to measure effective occlusion time. This leads to a better scientific base for discussion of amblyopia therapy.