Infectious agents in congenital cataract in a tertiary care referral center in North India

Analysis of postoperative visual and surgical outcome following surgery for absorbed cataract in pediatric age group and the intraoperative difficulties

PURPOSE

To analyze the postoperative visual and surgical outcomes following surgery for pediatric-absorbed cataracts and intraoperative difficulties.

METHODS

This prospective longitudinal study included 43 eyes (30 children) with absorbed cataracts aged between 6 months and 18 years (either sex). All children underwent best-corrected visual acuity (BCVA), anterior and posterior segment evaluation, rubella titer estimation, intraocular lens (IOL) power calculation, superior small incision cataract surgery with or without posterior capsulotomy/anterior vitrectomy/IOL implantation under general anesthesia, visual rehabilitation, and were followed up for 1 year.

RESULTS

The mean age was 7.89 ± 4.84 years. Preoperative BCVA distance: 39 eyes had either perception of light (PL) or counting finger close to face (CFCF); near BCVA: all eyes had either PL or N36. Postoperative (12 months) distant BCVA: a majority of the eyes (27) had 6/60-1/60, 11 eyes had 6/18-6/36; near: N18 in 19 eyes, N6 in 7 eyes. Anterior continuous curvilinear capsulorrhexis (ACCC) was possible in eight eyes. Cortical aspiration was difficult in 16 eyes (peripheral calcified ring). A majority (32 eyes) underwent in the sulcus implantation (in-the-bag: eight eyes); two eyes: no IOL, one eye: secondary IOL. Eleven eyes had early postoperative inflammation. At 12 months, one eye underwent membranectomy for visual axis opacification and 38 eyes had well-centered IOLs.

CONCLUSION

Surgery in absorbed cataracts is challenging because of the anatomic disorganization of the absorbed lens. By adopting appropriate surgical methods and good visual rehabilitation, one can achieve satisfactory surgical and visual outcomes, highlighting the need for surgical intervention.

Anti-Herpes Simplex 1 Activity of Simmondsia chinensis (Jojoba) Wax

Jojoba (Simmondsia chinensis (Link) Schneider) wax is used for various dermatological and pharmaceutical applications. Several reports have previously shown beneficial properties of Jojoba wax and extracts, including antimicrobial activity. The current research aimed to elucidate the impact of Jojoba wax on skin residential bacterial (Staphylococcus aureus and Staphylococcus epidermidis), fungal (Malassezia furfur), and virus infection (herpes simplex 1; HSV-1). First, the capacity of four commercial wax preparations to attenuate their growth was evaluated. The results suggest that the growth of Staphylococcus aureus, Staphylococcus epidermidis, and Malassezia furfur was unaffected by Jojoba in pharmacologically relevant concentrations. However, the wax significantly attenuated HSV-1 plaque formation. Next, a complete dose–response analysis of four different Jojoba varieties (Benzioni, Shiloah, Hatzerim, and Sheva) revealed a similar anti-viral effect with high potency (EC₅₀ of 0.96 ± 0.4 µg/mL) that blocked HSV-1 plaque formation. The antiviral activity of the wax was also confirmed by real-time PCR, as well as viral protein expression by immunohistochemical staining. Chemical characterization of the fatty acid and fatty alcohol composition was performed, showing high similarity between the wax of the investigated varieties. Lastly, our results demonstrate that the observed effects are independent of simmondsin, repeatedly associated with the medicinal impact of Jojoba wax, and that Jojoba wax presence is required to gain protection against HSV-1 infection. Collectively, our results support the use of Jojoba wax against HSV-1 skin infections.

ToRCH-screening in pediatric cataract revisited: A North Indian tertiary care centre study

Purpose:

To analyze and report ToRCH-serology screening profile (Toxoplasma gondii [TOX], rubella [RV], cytomegalovirus [CMV], and herpes simplex virus [HSV-I/II]) in pediatric cataract.

Methods:

In this prospective analytical study, 1,026 consecutive children were screened, of which 46 children with clinically diagnosed congenital (n = 26) and developmental cataract (n = 20) were included. Post-traumatic and familial cataracts were excluded. Sera of all children were tested both qualitatively and quantitatively for IgG/IgM-antibodies against ToRCH agents in a sequential manner.

Results:

Overall, IgM/IgG-seropositivity against ≥1 ToRCH agent was reported in 91.3% (42/46) children. IgM (±IgG) positivity against ≥1 ToRCH agent was reported in 26.08% (12/46) children (nine congenital and three developmental cataract; P = 0.18), which included 8.7% (4/46) children reported positive against ≥2 agents. Finally, 13% (6/46) children were reported to be sero-clinical-positive (three were infants and three were >1 year age, P = 0.55; five congenital and one developmental cataract, P = 0.21). Either alone or combined, RV attributed to the majority (50%; 6/12) of the IgM (±IgG) and sero-clinical-positive (50%; 3/6) children. None of the children were HSV-II IgM-positive. Laboratory-confirmed congenital rubella syndrome was reported in 4.3% (2/46) children. One sero-clinical-positive infant with rare coexisting bilateral persistent fetal vasculature was also reported. IgG-alone positivity was reported highest with CMV in 67.4% (31/46) children, whereas 43.4% (20/46) children were found nonimmune to RV.

Conclusion:

The current study emphasizes the need to interpret ToRCH-screening in pediatric cataract with caution. Interpretation should include both serial qualitative and quantitative assays in tandem with clinical correlation to minimize the diagnostic errors. Clinicians should remain vigilant regarding sero-clinical-positivity in older children too who might pose a threat to the spread of infection.

Nongenetic risk factors for infantile cataracts: Systematic review of observational studies

INTRODUCTION

While infantile cataracts are a major cause of childhood blindness, risk factors remain unknown for approximately two-thirds of cases.

METHODS

We systematically searched electronic databases PubMed, Ovid MEDLINE, Web of Science, and Scopus, from inception through March 2018, to identify relevant cohort, case-control, cross-sectional studies, case reports, and case series. We also manually screened bibliographies and consulted with experts in the field to identify additional publications. We reviewed cross-sectional studies, case reports, and case series and provided a narrative summary of the reported potential risk factors. We evaluated methodological qualities of cohort and case-control studies, extracted relevant data, and described statistically significant associations with infant, maternal, and paternal characteristics. Quality assessment and data extraction were conducted by two reviewers independently. All discrepancies were discussed with the senior author and resolved by consensus.

RESULTS

Overall, 110 publications were included in the review, 33 of which were cohort and case-control studies. Most of these studies (n = 32) used population-based data and had either excellent (n = 31) or good (n = 2) methodological quality. Nine studies reported statistically significant associations with infant characteristics (preterm birth, low birth weight), maternal occupations and diseases during pregnancy (untreated hypertension, infections), and paternal sociodemographics (younger age, employment in sawmill industry during pregnancy).

CONCLUSIONS

This systematic literature review provided a comprehensive summary of the known nongenetic risk factors for infantile cataracts, identified gaps in the literature, and provided directions for future research. Studies identifying modifiable risk factors are warranted to design interventions aimed at primary prevention of infantile cataracts.

Newborn with bilateral congenital cataracts: Never forget congenital rubella syndrome

A term, growth-restricted newborn presented with a sepsis-like picture, persistent pulmonary hypertension and bilateral cataracts. Initial review of prenatal and family history, as well as microbiological investigations were noncontributory. Following lenticular extraction, viral examination of the lenses confirmed the presence of rubella. Congenital rubella syndrome (CRS) presents with a constellation of signs and symptoms that overlap with many other conditions. The presence of bilateral cataracts in a newborn is a rare finding and this case is used to review the broad etiology of congenital cataracts. We propose a structured diagnostic approach for clinicians, remembering that CRS is a rare but possible etiology. The early diagnosis of CRS in this case, allowed us to initiate appropriate management and preventive measurements.

Congenital cataract: a guide to genetic and clinical management

Worldwide 20,000-40,000 children with congenital or childhood cataract are born every year with varying degrees and patterns of lens opacification with a broad aetiology. In most cases of bilateral cataract, a causative genetic mutation can be identified, with autosomal dominant inheritance being most common in 44% of cases. Variants in genes involve lens-specific proteins or those that regulate eye development, thus giving rise to other associated ocular abnormalities. Approximately 15% of cases have systemic features, hence paediatric input is essential to minimise comorbidities and support overall development of children at high risk of visual impairment. In some metabolic conditions, congenital cataract may be the presenting sign, and therefore prompt diagnosis is important where there is an available treatment. Multidisciplinary management of children is essential, including ophthalmic surgeons, orthoptists, paediatricians, geneticists and genetic counsellors, and should extend beyond the medical team to include school and local paediatric visual support services. Early surgery and close follow up in ophthalmology is important to optimise visual potential and prevent amblyopia. Routine genetic testing is essential for the complete clinical management of patients, with next-generation sequencing of 115 genes shown to expedite molecular diagnosis, streamline care pathways and inform genetic counselling and reproductive options for the future.

Lay abstract

Childhood cataract: how to manage patients Cataract is a clouding of the lens in the eye. Cataract occurring in children has many different causes, which may include infections passed from mother to child during pregnancy, trauma, medications and exposure to radiation. In most cases of cataract occurring in both eyes, a genetic cause can be found which may be inherited from parents or occur sporadically in the developing baby itself while in the womb. Cataracts may occur on their own, with other eye conditions or be present with other disorders in the body as part of a syndrome. Genetic testing is important for all children with cataract as it can provide valuable information about cause, inheritance and risk to further children and signpost any other features of the disease in the rest of the body, permitting the assembly of the correct multidisciplinary care team. Genetic testing currently involves screening for mutations in 115 genes already known to cause cataract and has been shown to expedite diagnosis and help better manage children. Genetic counselling services can support families in understanding their diagnosis and inform future family planning. In order to optimise vision, early surgery for cataract in children is important. This is because the brain is still developing and an unobstructed pathway for light to reach the back of the eye is required for normal visual development. Any obstruction (such as cataract) if left untreated may lead to permanent sight impairment or blindness, even if it is removed later. A multidisciplinary team involved in the care of a child with cataract should include ophthalmic surgeons, orthoptists, paediatricians, geneticists and genetic counsellors, and should extend beyond the medical team to include school and local child visual support services. They will help to diagnose and manage systemic conditions, optimise vision potential and help patients and their families access best supportive care.

Molecular genetics of congenital cataracts

Congenital cataracts, the most common cause of visual impairment and blindness in children worldwide, have diverse etiologies. According to statistics analysis, about one quarter of congenital cataracts caused by genetic defects. Various mutations of more than one hundred genes have been identified in hereditary cataracts so far. In this review, we briefly summarize recent developments about the genetics, molecular mechanisms, and treatments of congenital cataracts. The studies of these pathogenic mutations and molecular genetics is making it possible for us to comprehend the underlying mechanisms of cataractogenesis and providing new insights into the preventive, diagnostic and therapeutic approaches of cataracts.

Newborn Glaucoma: Do not Forget Infections

Intrauterine infections can affect various structures of the developing fetal eye. Rubella infection results in congenital cataracts, keratopathy, retinopathy and less commonly, glaucoma. Ophthalmic manifestations of intrauterine cytomegalovirus (CMV) infection have been reported to be chorioretinitis, optic nerve colobomas, and corneal opacities, but have not been implicated in congenital cataract or congenital glaucoma. Concurrent infection with both rubella and CMV virus has not been reported. We report concurrent rubella and CMV infection in a baby born with corneal opacification, severe congenital glaucoma, and congenital cataract. It is important to recognize these babies early and investigate for intrauterine infections rather than assume they are all primary congenital glaucoma. Involvement of the cornea, glaucoma, and cataract make management of these babies a major challenge requiring a multidisciplinary team approach.

Clinical characteristics of young adult cataract patients: a 10-year retrospective study of the Zhongshan Ophthalmic Center

AIM

To investigate the characteristics of young adult cataract (YAC) patients over a 10-year period.

METHODS

This observational study included YAC patients aged 18-49 years who were treated surgically for the first time at the Zhongshan Ophthalmic Center in China. YAC patients were analysed and compared with patients with childhood cataract (CC) in January 2005 to December 2014.

RESULTS

During the 10-year period, 515 YAC patients and 2421 inpatients with CC were enrolled. Among the YAC patients, 76.76% (109/142) of unilateral patients had a corrected distance visual acuity (CDVA) better than 20/40 in the healthy eye, whereas only 20.38% (76/373) of bilateral patients had a CDVA better than 20/40 in the eye with better visual acuity. Compared with the CC group, the YAC group had a higher proportion of rural patients (40.40% vs 31.60%, p=0.001). Furthermore, the prevalence of other ocular abnormalities in YAC patients was higher than that in patients with CC (29.71% vs 17.47%, p<0.001).

CONCLUSIONS

A large proportion coming from rural areas and a high prevalence of complicated ocular abnormalities may be the most salient characteristics of YAC patients. Strengthening the counselling and screening strategy for cataract and health education for young adults are required especially for those in rural areas.

Development and evaluation of multiplex real-time PCR for diagnosis of HSV-1, VZV, CMV, and Toxoplasma gondii in patients with infectious uveitis

Infectious uveitis is a vision threatening inflammatory ocular disease wherein early diagnosis may prevent the loss of vision. The purpose of this study was to develop a multiplex real-time PCR for the diagnosis of Herpes simplex virus-1, Varicella zoster virus, cytomegalovirus and Toxoplasma gondii in patients with suspected infectious uveitis. A total of 126 intraocular samples (aqueous and vitreous humor) were collected and subjected to multiplex real-time PCR. Overall 26.2% (33/126) patients were found to be positive for one or more of the pathogens tested. The overall positivity for VZV, HSV, CMV and T. gondii was found to be 16 (12.7%), 7 (5.6%), 5 (3.9%), and 9 (7.1%); with mean pathogen load of 5.07×10⁵, 9.5×10⁴, 1.08×10⁴ and 394 (copies/μl) respectively. The development of highly sensitive and specific assay for early differentiation of pathogens is important for the early initiation of treatment thereby preventing irreversible damage to the ocular structures.

Screening, genetics, risk factors, and treatment of neonatal cataracts

Neonatal cataracts remain the most common cause of visual loss in children worldwide and have diverse, often unknown, etiologies. This review summarizes current knowledge about the detection, treatment, genetics, risk factors, and molecular mechanisms of congenital cataracts. We emphasize significant progress and topics requiring further study in both clinical cataract therapy and basic lens research. Advances in genetic screening and surgical technologies have improved the diagnosis, management, and visual outcomes of affected children. For example, mutations in lens crystallins and membrane/cytoskeletal components that commonly underlie genetically inherited cataracts are now known. However, many questions still remain regarding the causes, progression, and pathology of neonatal cataracts. Further investigations are also required to improve diagnostic criteria for determining the timing of appropriate interventions, such as the implantation of intraocular lenses and postoperative management strategies, to ensure safety and predictable visual outcomes for children. Birth Defects Research 109:734-743, 2017. © 2017 Wiley Periodicals, Inc.