Strabismus developing after unilateral and bilateral cataract surgery in children

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.

Posterior Capsulotomy Size Affects the Formation of Significant Visual Axis Opacification in Congenital and Developmental Cataract

PURPOSE

To assess the relationship between posterior capsulotomy size and significant visual axis opacification (VAO) in congenital and developmental cataract.

METHODS

The charts of children aged 7 years and younger who underwent cataract surgery including primary posterior capsulotomy (PPC) and limited anterior vitrectomy between 2012 and 2022 were retrospectively reviewed. Eyes with PPC size smaller than the anterior capsulotomy size were considered as group 1. Eyes with PPC size larger than the anterior capsulotomy size were considered as group 2. Clinical characteristics, the need for Nd:YAG laser treatment or further surgery for significant VAO, and other postoperative complications were compared between the groups.

RESULTS

Sixty eyes of 41 children were included in the study. The median age at the time of surgery was 5.5 and 3 years in groups 1 and 2, respectively (P = .076). Primary intraocular lens implantation was performed in 23 (85.2%) eyes in group 1 and 25 (75.8%) eyes in group 2 (P = .364). There was no difference between the groups in terms of postoperative visual acuity (P = .983) and refractive errors (P = .154). Eight (29.6%) pseudophakic eyes received Nd:YAG laser treatment in group 1, but none of the eyes in group 2 (P = .001). Four (14.8%) eyes in group 1 and 1 (3%) eye in group 2 underwent further surgery for VAO (P = .100). The need for further intervention for significant VAO was statistically higher in group 1 (44.4% vs 3%, P < .001).

CONCLUSIONS

Larger PPC size in pediatric cataract may reduce the need for further intervention for significant VAO. [J Pediatr Ophthalmol Strabismus. 2023;60(6):441-447.].

Strabismus development after pediatric cataract surgery associated with age at surgery, intraocular lens implantation, and visual acuity outcome

PURPOSE

Approximately half of the children operated on for cataracts develop strabismus. We determined what factors predict its development.

METHODS

In a retrospective, cross-sectional study, children who underwent cataract surgery before age 5 between 2010 and 2017 in a tertiary center in Brazil were identified from medical records. Subsequently, patients were invited for an ophthalmological examination to assess visual acuity, refraction, and strabismus (constant or intermittent heterotropy of any magnitude). In addition, age at surgery, cataract laterality, intraocular lens implantation, surgical complications, nystagmus, anisometropia, and elapsed time between surgery and the present examination were assessed using logistic regression.

RESULTS

Surgery was performed in 74 eyes of 46 patients (21 males). The median age at surgery was 6.4 (3.7-29.6) months, and the interval between surgery and this examination was 32.5 (18.0-53.0) months. Strabismus was present in 33 (72%) patients, 35% had esotropia and 33% exotropia. One patient had strabismus surgery before the examination. Age at surgery (OR 0.95; p-value .018), IOL implantation (OR 0.08; p-value .027), and current visual acuity on the worse eye (OR 1.16; p-value .036) were associated with strabismus.

CONCLUSIONS

Strabismus development after pediatric cataract surgery is associated with age at surgery, intraocular lens implantation, and visual-acuity outcomes of the worse eye.

Risk Ractors for Strabismus Surgery after Pediatric Cataract Surgery in the United States

Purpose

To determine the cumulative incidence of strabismus surgery after pediatric cataract surgery and identify the associated risk factors.

Design

US population-based insurance claims retrospective cohort study.

Participants

Patients ≤ 18 years old who underwent cataract surgery in 2 large databases: Optum Clinformatics Data Mart (2003-2021) and IBM MarketScan (2007-2016).

Methods

Individuals with at least 6 months of prior enrollment were included, and those with a history of strabismus surgery were excluded. The primary outcome was strabismus surgery within 5 years of cataract surgery. The risk factors investigated included age, sex, persistent fetal vasculature (PFV), intraocular lens (IOL) placement, nystagmus and strabismus diagnoses before cataract surgery, and cataract surgery laterality.

Main Outcome Measures

Kaplan-Meier estimated cumulative incidence of strabismus surgery 5 years after cataract surgery and hazard ratios (HRs) with 95% confidence intervals (CIs) from multivariable Cox proportional hazards regression models.

Results

Strabismus surgery was performed on 271/5822 children included in this study. The cumulative incidence of strabismus surgery within 5 years after cataract surgery was 9.6% (95% CI, 8.3%-10.9%). Children who underwent strabismus surgery were more likely to be of younger age at the time of cataract surgery, of female sex, have a history of PFV or nystagmus, have a pre-existing strabismus diagnosis, and less likely to have an IOL placed (all P < 0.001). Factors associated with strabismus surgery in the multivariable analysis included age 1 to 4 years (HR, 0.50; 95% CI, 0.36-0.69; P < 0.001) and age > 5 years (HR, 0.13; 95% CI, 0.09-0.18; P < 0.001) compared with age < 1 year at time of cataract surgery, male sex (HR, 0.75; 95% CI, 0.59-0.95; P < 0.001), IOL placement (HR, 0.71; 95% CI, 0.54-0.94; P = 0.016), and strabismus diagnosis before cataract surgery (HR, 4.13; 95% CI, 3.17-5.38; P < 0.001). Among patients with strabismus diagnosis before cataract surgery, younger age at cataract surgery was the only factor associated with increased risk of strabismus surgery.

Conclusions

Approximately 10% of patients will undergo strabismus surgery within 5 years after pediatric cataract surgery. Children of younger age, female sex, and with a pre-existing strabismus diagnosis undergoing cataract surgery without IOL placement are at greater risk.

Financial Disclosures

The author(s) have no proprietary or commercial interest in any materials discussed in this article.

Comparative analysis of visual outcomes of multifocal and monofocal intraocular lenses in congenital cataract surgery

PURPOSE

To assess the impact on visual development of multifocal versus monofocal intraocular lenses (IOLs) implantation in children following congenital cataract surgery.

DESIGN

Retrospective interventional consecutive case series.

METHODS

We reviewed the records of 56 eyes of 43 pediatric patients who underwent congenital cataract surgery with phacoaspiration and simultaneous implantation of IOL under one year of age. Corrected distance visual acuity (CDVA), refractive error and ocular motility disorders were evaluated after a follow-up greater than 4 years.

RESULTS

We implanted 32 multifocal (18unilateral, Group A and 14bilateral, Group B) and 24monofocal IOLs (12unilateral, Group C and 12bilateral, Group D). Mean follow-up was 6.67 years. Mean CDVA of the eyes with multifocal IOL was 0.75±0.46 logMAR in unilateral cataract surgery and 0.34±0.25logMAR in bilateral ones; with monofocal IOLs was 0.71±0.52logMAR in unilateral and 0.53±0.43logMAR in bilateral ones. No statistically significant difference in CDVA between Groups A and B and Groups C and D has been recorded. Final mean spherical equivalent was -3.88±4.73D; in Group A it was -2.74±4.22D, in Group C was -1.08±1.45D, in Group B was -4.82±4.64D and in Group D was -6.81 ± 4.61D.The difference was statistically significant between Group B and D (p=0.01), but not between Group A and C (p=0.14).Twenty-six patients (60.4%) showed post-operative strabismus. Its surgical correction occurred more in patients with multifocal IOL implanted (p=0.038).

CONCLUSIONS

Our findings suggest that the use of multifocal IOLs did not show significant advantages in visual development in children following congenital cataract extraction under one year of age if compared with monofocal IOLs.

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.

Persistent Fetal Vasculature With Elongated Ciliary Processes in Children

PURPOSE

Outcomes and reoperation rates in infants with unilateral persistent fetal vasculature (PFV) with elongated or stretched ciliary processes have not been extensively studied and were excluded from the Infant Aphakia Treatment Study (IATS). The purpose of this study is to analyze the preoperative measurements, reoperation rates, and complications after surgery in unilateral anterior PFV with stretched processes.

DESIGN

Retrospective case series.

METHODS

Inclusion criteria consisted of unilateral cataract surgery prior to 7 months of age and anterior PFV with elongated ciliary processes. Eyes with posterior retinal involvement and less than 6 months of follow-up were excluded. All patients underwent lensectomy, posterior capsulectomy, and vitrectomy.

RESULTS

Eleven eyes of 11 patients were included. Patients had a mean age at surgery of 2.4 ± 1.4 months. Average follow-up was 4.5 ± 3.7years. Globe axial lengths were 18.6 ± 1.9 mm. Ten patients (91%) were initially left aphakic. Three patients (27%) later received a secondary intraocular lens (IOL), and 1 patient underwent an IOL exchange. Six out of 10 (60%) aphakic patients developed visual axis opacification. One aphakic patient required topical therapy for glaucoma. One additional patient developed neovascular glaucoma and retinal detachment. The eye was subsequently enucleated. Three patients underwent strabismus surgery. Two patients underwent pupilloplasty. Two patients (18.2%) had a final visual acuity better than 20/200.

CONCLUSION

Eyes operated for PFV with elongated ciliary processes are unlikely to have a final visual acuity greater than 20/200 and many will need additional surgery. Postoperative visual axis opacification occurred in 60% and glaucoma developed in 18%.

Long-term results of secondary intraocular lens implantation in children under 30 months of age

Purpose

To report the long-term outcome of early secondary intraocular lens (IOL) implantation following congenital cataract extraction in a large number of eyes.

Methods

Data of aphakic children under 30 months of age who underwent secondary IOL implantation and had at least one year of follow-up after the surgery was reviewed. In all of the patients, a foldable three-piece acrylic IOL was implanted in the ciliary sulcus by the same surgeon using the same technique. The database studied included refractive and visual acuity (VA) outcomes and complications.

Results

Fifty patients (75 eyes) were included. The average age at the time of cataract extraction was 94.20 ± 44.94 days and 20.7 ± 6.0 months in the secondary IOL implantation. After 82.32 ± 48.91 months, the VA was 0.58 ± 0.35 LogMAR and the spherical equivalent was −2.20 ± 4.19 D. There was a negative correlation between a longer follow-up period and myopia at the SE measured (P = .001). The most frequent complications included glaucoma and corectopia. Performing the secondary IOL implantation ≤ 20 months of age was not a risk factor for glaucoma development (P = 0.095).

Conclusion

Secondary IOL implantation under 30 months of age is an option for children with unsatisfactory management of the optic treatment. A predictable IOL power calculation and satisfactory visual outcomes compared to results of later secondary IOL implantation are possible.

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.

Clinical features of strabismus and nystagmus in bilateral congenital cataracts

AIM

To evaluate the prevalence, clinical features, and the factors affecting onset of strabismus and nystagmus in patients with bilateral congenital cataracts.

METHODS

This study evaluated 116 eyes of 58 patients who underwent lens removal for the treatment of bilateral congenital cataracts between January 1999 and January 2011. The presence and type of strabismus and nystagmus were determined before and after surgery. Type of strabismus and final visual acuity were compared in patients with and without nystagmus. Patients were divided into three groups (orthotropia/orthotropia, orthotropia/strabismus, and strabismus/strabismus) according to their preoperative and postoperative ocular alignment. Age at cataract surgery and associations of nystagmus and primary intraocular lens (IOL) implantation with strabismus were analyzed.

RESULTS

Six patients (10.3%) had strabismus preoperatively and an additional 11 (19.0%) developed postoperative strabismus. Exotropia was more common than esotropia both preoperatively and postoperatively. Eighteen patients (31.0%) had postoperative nystagmus, with sensory nystagmus being the most common type. Of the 18 patients with nystagmus, 10 had strabismus, with exotropia being more common than esotropia. Postoperative visual acuity was poor in patients with nystagmus. Age at cataract surgery and rate of primary IOL implantation were significantly lower, and postoperative nystagmus was more common, in the orthotropia/strabismus group than in the other two groups.

CONCLUSION

Exotropia and sensory nystagmus are common in patients with bilateral congenital cataracts. Age at cataract surgery and rate of IOL implantation are lower and nystagmus more common in patients with postoperative onset of strabismus. Nystagmus is associated with poor visual prognosis.