Long-term results after primary intraocular lens implantation in children operated less than 2 years of age for congenital cataract

Incidence Rate of Secondary Glaucoma Following Congenital Cataract Surgery: An In-Depth Systematic Review and Meta-Analysis

PURPOSE

To assess the incidence of secondary glaucoma in children following congenital cataract surgery.

DESIGN

Systematic review and meta-analysis.

METHODS

The PubMed, Embase, Cochrane Library, and Web of Science databases were searched from inception through March 16, 2023. Studies reporting congenital cataract surgery and glaucoma were enrolled. The quality of the selected studies was assessed using the Newcastle Ottawa Scale, and data analysis was executed utilizing R software.

RESULTS

A total of 36 published studies with 3151 patients (4717 eyes) were included in the analysis. The incidence rate of glaucoma following congenital cataract surgery was 6.6% (95% CI: 3.9%, 9.9%). The incidence of secondary glaucoma in the primary intraocular lens (IOL) implantation group (3.3% [95% CI: 1.5%, 5.8%]) and the secondary IOL implantation group (3.5% [95% CI: 0%, 11.4%]) were lower compared to the aphakia group (13.5% [95% CI: 7.7%, 20.6%]). The incidence rate among children with congenital cataracts from Asia (6.9% [95% CI: 4.1%, 10.4%]) was higher than that in European children (0.9% [95% CI: 0%, 3.0%]; P < .01). A correlation was identified between the age at cataract surgery and the incidence of secondary glaucoma (P = .02).

CONCLUSIONS

This meta-analysis found that the incidence of secondary glaucoma following congenital cataract surgery is approximately 6.6%. Children with IOL implantation exhibit a lower incidence of secondary glaucoma, with a lower incidence noted in European children compared to their Asian counterparts. The age at cataract surgery is an important risk factor to consider.

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

AIMS

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

TRIAL REGISTRATION NUMBER

NCT04342052.

Accuracy of Intraocular Lens Power Calculation Formulas in Patients With Multifocal Intraocular Lens Implantation With Optic Capture in Berger Space for Pediatric Cataract

PURPOSE

To assess the accuracy of intraocular lens (IOL) calculation formulas in pediatric patients with multifocal IOL implantation with optic capture in Berger space.

METHODS

This prospective observational study enrolled 68 children (101 eyes), aged 3 to 14 years, who received multifocal IOL (Tecnis ZMB00; Abbott Medical Optics) implantation with optic capture in Berger space from June 2019 to June 2020 in Qingdao Eye Hospital. Ocular biometry was performed using the IOLMaster 700 (Carl Zeiss Meditec). The IOL power and intended postoperative refraction were calculated using the Hoffer Q, Barrett Universal II, Holladay, Holladay2, SRK/T, Haigis, and SRKII formulas. The refractive state of patients, prediction error, and absolute prediction error were evaluated.

RESULTS

The mean absolute error of the formulas was significantly different (0.49 diopters [D], Hoffer Q; 0.52 D, Barrett Universal II; 0.47 D, Holladay; 0.54 D, Holladay2; 0.52 D, SRK/T; 0.67 D, Haigis; 0.99 D, SRKII; P < .001). However, the Hoffer Q, Barrett Universal II, Holladay, Holladay2, and SRK/T formulas had a similar accuracy in predicting refractive error within ±0.50 D (62.4%, 59.4%, 62.4%, 62.4%, and 58.4%). There was a trend toward a greater prediction error in eyes with a shorter axial length (≤ 22 mm) or a steeper cornea (> 43.50 D), for which the Hoffer Q and Holladay2 formulas were more accurate. When the axial length was greater than 22 mm or the corneal curvature was 43.50 D or less, the Holladay, Hoffer Q, and Barrett Universal II formulas were more accurate.

CONCLUSIONS

For patients with pediatric cataract treated with multifocal IOL implantation with optic capture in Berger space, the Hoffer Q, Barrett Universal II, Holladay, Holladay2, and SRK/T formulas performed better than the other formulas. [J Pediatr Ophthalmol Strabismus. 20XX;X(X):XX-XX.].

Commentary review: challenges of intraocular lens implantation for congenital cataract infants

As an indispensable part of congenital cataract surgery, intraocular lens (IOL) implantation in infantile patients has long-term positive impacts on visual rehabilitation, as well as postoperative complications inevitably. Timing of IOL implantation in infantile congenital cataract patients is not simply a point-in-time but a personalized decision that comprehensively takes age at surgery, risks of postoperative complications, and economic condition of family in consideration, and combines with choosing suitable IOL type and power. For infants with well-developed eyeballs and good systemic conditions, IOL implantation at six months of age or older is safe and effective. Otherwise, secondary IOL implantation may be a safer choice.

The aging mouse lens transcriptome

Age is a major risk factor for cataract (ARC). However, the influence of aging on the lens transcriptome is under studied. Lens epithelial (LEC) and fiber cells (LFC) were isolated from young (3 month old) and aged (24 month old) C57BL/6J mice, and the transcriptome elucidated via RNAseq. EdgeR estimated differential gene expression in pairwise contrasts, and Advaita's Ipathway guide and custom R scripts were used to evaluate the potential biological significance of differentially expressed genes (DEGs). This analysis revealed age-dependent decreases in lens differentiation marker expression in both LECs and LFCs, with gamma crystallin transcripts downregulating nearly 50 fold in aged LFCs. The expression of the transcription factors Hsf4 and Maf, which are known to activate lens fiber cell preferred genes, are downregulated, while FoxE3, which represses gamma crystallin expression, is upregulated in aged fibers. Aged LECs upregulate genes controlling the immune response, complement pathways, and cellular stress responses, including glutathione peroxidase 3 (Gpx3). Aged LFCs exhibit broad changes in the expression of genes regulating cell communication, and upregulate genes involved in antigen processing/presentation and cholesterol metabolism, while changes in the expression of mitochondrial respiratory chain genes are consistent with mitochondrial stress, including upregulation of NDufa4l2, which encodes an alternate electron transport chain protein. However, age did not profoundly affect the response of LECs to injury as both young and aged LECs upregulate inflammatory gene signatures at 24 h post injury to similar extents. These RNAseq profiles provide a rich data set that can be mined to understand the genetic regulation of lens aging and how this impinges on the pathophysiology of age related cataract.

Comparison of visual acuity and complications between primary IOL implantation and aphakia in patients with congenital cataract younger than 2 years: a meta-analysis

To analyze the visual acuity and complications between primary intraocular lens (IOL) implantation and contact lens wearing, this literature search was performed with data on patients with congenital cataract younger than 2 years published in March 2019. Seven identified studies enrolling 675 eyes were selected for analysis. Patients with primary IOL implantation owned better visual acuity than those with aphakia who wore the contact lens (weighted mean difference = 0.161; 95% CI, 0.108-0.214). For visual axis opacification (VAO), primary IOL implantation increases the incidence of VAO compared with contact lens wearing (relative risk = 0.23; 95% CI, 0.13-0.42). No statistically significant difference was found between the 2 groups about the prevalence of glaucoma and strabismus. Primary IOL implantation achieved better visual outcomes after cataract extraction in patients younger than 2 years. In addition, no higher risk for complications among primary IOL implantation compared with contact lens wearing was noted. Therefore, implanting a primary IOL during congenital cataract surgery is a better therapy for children younger than 2 years than wearing a contact lens.

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.

Medical Management of Children With Congenital/Infantile Cataract Associated With Microphthalmia, Microcornea, or Persistent Fetal Vasculature

PURPOSE

To report the surgical outcomes of children with cataract associated with microphthalmia, microcornea, or persistent fetal vasculature (MMP) and children with isolated cataract.

METHODS

The study included 111 children (cataract associated with MMP: n = 25) who underwent cataract surgery at younger than 16 years. Exclusion criteria were duration of follow-up less than 5 years, intraindividual differences in age at surgery, eye disorders other than MMP, secondary cataract, and syndromal diseases. Main outcome measures were proportion of eyes with glaucoma and best corrected visual acuity (BCVA). Both groups were dichotomized by age at surgery (early intervention group: ≤ 48 days). Descriptive analysis was performed throughout.

RESULTS

Median age at surgery was 3.9 months for cataract associated with MMP and 23.3 months for isolated cataract. The median (interquartile range [IQR]) duration of follow-up was 95.9 months (range: 76.0 to 154.5 months). In children with bilateral cataract associated with MMP, the proportion of eyes with final BCVA worse than 0.3 logMAR was similar regardless of age at surgery (early intervention: 80%, later intervention: 78%). In bilateral isolated cataract, the proportions were 56% and 33%, respectively. Children with cataract associated with MMP had a high prevalence of glaucoma (28%). Glaucoma prevalence was lower in the later intervention group.

CONCLUSIONS

In the presence of MMP, early cataract surgery is associated with a high risk of post-lensectomy glaucoma, but does not offer the benefit of better visual outcomes. [J Pediatr Ophthalmol Strabismus. 2019;56(1):43-49.].

Updates on managements of pediatric cataract

Purpose

A comprehensive review in congenital cataract management can guide general ophthalmologists in managing such a difficult situation which remains a significant cause of preventable childhood blindness. This review will focus on surgical management, postoperative complications, and intraocular lens (IOL)-related controversies.

Methods

Electrical records of PubMed, Medline, Google Scholar, and Web of Science from January 1980 to August 2017 were explored using a combination of keywords: "Congenital", "Pediatric", "Childhood", "Cataract", "Lens opacity", "Management", "Surgery", "Complication", "Visual rehabilitation”, and "Lensectomy". A total number of 109 articles were selected for the review process.

Results

This review article suggests that lens opacity obscuring the red reflex in preverbal children and visual acuity of less than 20/40 is an absolute indication for lens aspiration. For significant lens opacity that leads to a considerable risk of amblyopia, cataract surgery is recommended at 6 weeks of age for unilateral cataract and between 6 and 8 weeks of age for bilateral cases. The recommended approach in operation is lens aspiration via vitrector and posterior capsulotomy and anterior vitrectomy in children younger than six years, and IOL implantation could be considered in patients older than one year. Most articles suggested hydrophobic foldable acrylic posterior chamber intraocular lens (PCIOL) for pediatrics because of lower postoperative inflammation. Regarding the continuous ocular growth and biometric changes in pediatric patients, under correction of IOL power based on the child's age is an acceptable approach. Considering the effects of early and late postoperative complications on the visual outcome, timely detection, and management are of a pivotal importance. In the end, the main parts of post-operation visual rehabilitation are a refractive correction, treatment of concomitant amblyopia, and bifocal correction for children in school age.

Conclusions

The management of congenital cataracts stands to challenge for most surgeons because of visual development and ocular growth. Children undergoing cataract surgery must be followed lifelong for proper management of early and late postoperative complications. IOL implantation for infants less than 1 year is not recommended, and IOL insertion for children older than 2 years with sufficient capsular support is advised.

Outcome of various Hydrophobic Acrylic Intraocular Lens Implantations in Children with Congenital Cataract

PURPOSE

To evaluate performance of different intraocular lenses (IOLs) after cataract surgery in children aged less than 2 years with regards to rates of visual axis opacification (VAO).

METHODS

This was a retrospective chart review of children <2 years of age undergoing cataract surgery with primary posterior capsulotomy, anterior vitrectomy, and IOL over a period of 5 years with minimum follow-up of 1 year at a tertiary care institute. Children with microphthalmos, persistent fetal vasculature, traumatic cataract, aphakia, secondary IOLs, or any other coexisting ocular disease were excluded.

RESULTS

A total of 257 eyes of 159 children were included in the study. The mean age at the time of surgery was 11.63 ± 7.916 months (range 6-23 months). A total of 29 eyes of 16 children underwent phacoaspiration with implantation of SA60 AT (AcrySof, Alcon, Fort Worth, TX); 75 eyes of 45 children received Hoya IOL (Hoya-PS AF-1 Series, Model PC-60AD, Hoya, Japan), 70 eyes of 46 patients received Sensar (Abbott Medical Optics Inc., Santa Ana, CA, USA), and 83 eyes of 52 children received MA60AC (AcrySof). At mean follow-up of 18.31 ± 15.04 months, 22.46% of the patients required resurgery for visual axis obscuration. By multiple regression analysis, the rate of visual axis obscuration was affected by the rate of perioperative complications (p = 0.001) and not affected by age (p = 0.98), type of IOL (p = 0.104), or site of IOL implantation (p = 0.603).

CONCLUSION

Our findings suggest comparable rates of VAO for children less than 2 years of age receiving different types of hydrophobic acrylic IOLs.

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.

Intraocular lens optic capture in pediatric cataract surgery

Posterior capsule opacification (PCO) remains the most common complication of pediatric cataract surgery despite continuous efforts to reduce its incidence. For this reason, pediatric cataract surgeons have expended considerable effort into preventing and mitigating PCO. The intraocular lens (IOL) optic capture technique has been used for the prevention of PCO after pediatric cataract surgery for more than 20y, but there is still no professional consensus. However, recent research has shown encouraging results. The IOL optic capture technique can be performed without anterior vitrectomy to prevent PCO, even in younger children. The type and characteristics of IOLs used for optic capture technique, the location of IOL and the complications of IOL optic capture in children are here reviewed.

Intraocular lens implantation in children with unilateral congenital cataract in the first 4 years of life

PURPOSE

To describe the outcome of phacoaspiration with intraocular lens implantation in children with unilateral congenital cataract in the first 4 years of life.

METHODS

A retrospective chart review of children with visually significant unilateral congenital cataract presenting in the first 4 years of life was done. Children with a minimum postsurgical follow-up of 1 year were included. Outcome measures were mean spherical equivalent, visual axis clarity, visual acuity and complications till the last follow-up.

RESULTS

Ninety-three children met the inclusion criteria. The mean age of surgery was 13.23 ± 11.89 months and the mean follow-up period was 24.37 ± 17.35 months. Nearly 40% of children presented during their first year of life. No difference was noted between the subgroups in terms of age ( p = 0.310), sex ( p = 0.475) or laterality ( p = 0.349). Surgical membranectomy was performed in 22 eyes (23.6%) after an average period of 4.85 ± 2.58 months after surgery. One eye underwent piggy back intraocular lens and four eyes underwent intraocular lens exchange after a mean duration of 50 months (range 40-60 months). The mean visual acuity was 0.79 ± 0.11 (log MAR chart). A total of 60.7% of these children ( n = 31) achieved best corrected visual acuity or 20/80 or better.

CONCLUSION

The results of our study suggest that primary intraocular lens implantation in children with unilateral congenital cataract gives good structural and functional results. Besides a meticulous surgery, visual outcome is affected by the time of presentation and postoperative compliance to amblyopia therapy.

Small lens for a big eye: Successful management of anterior megalophthalmos

We report a case of anterior megalophthalmos and complicated cataract, with apparently smaller lens in both eyes. The right eye had spontaneous retinal detachment. The child underwent cataract surgery in both the eyes with retinal detachment surgery in the right eye. Due to small size of the lenticular bag, a downsized customized intraocular lens (IOL) was implanted. Postoperatively, the IOL was well centered with ambulatory vision till 3 years of follow-up. This case describes this rare disorder and its association with apparently small-sized lens and discusses the course of its management, highlighting the visual rehabilitation with customization of IOLs.

Distribution of Axial Length before Cataract Surgery in Chinese Pediatric Patients

Axial length (AL) is a significant indicator of eyeball development, but reports on the overall status of axial development in congenital cataract (CC) patients and its relationship with patient demographics, such as age, sex, and laterality, are rare. We prospectively investigated the AL of 1,586 patients ≤18 years old and undergoing cataract surgery in China from January 2005 to December 2014. Of these 3,172 eyes, a logarithmic correlation between AL and age in CC patients was calculated, and an age of approximately 2 years was found to be a turning point in the growth rate of AL. A considerable variation was observed in CC patients of the same age. Furthermore, 2–6 years old boys had longer AL than girls. The AL of affected eye in unilateral patients was longer than that of the contralateral eye in 2–6 years age group and longer than that of eye in bilateral CC patients in all age groups. These findings indicate that the development of the length of eyeballs in CC patients is influenced by multiple factors in addition to age. A full understanding of the distribution of AL may provide a useful reference for judging the timing of surgery in CC patients.