Long-term results of bilateral congenital cataract treated with early cataract surgery, aphakic glasses and secondary IOL implantation

Complications, Visual Acuity, and Refractive Error Three Years After Secondary Intraocular Lens implantation for Pediatric Aphakia

OBJECTIVE

To report the cumulative incidence of complications and describe refractive error and visual acuity (VA) outcomes in children undergoing secondary intraocular lens (IOL) implantation following previous surgery for non-traumatic cataract.

DESIGN

Pediatric cataract registry.

PARTICIPANTS

80 children (108 eyes: 60 bilateral, 48 unilateral) undergoing lensectomy at <13 years of age, followed by secondary IOL implantation at median age (range) of 2.7 (0.6 to 5.0) years for bilateral and 2.1 (0.5 to 6.4) for unilateral cases.

METHODS

Annual data collection from medical record review through 5 years following lensectomy.

MAIN OUTCOME MEASURES

Cumulative incidence of newly emergent complications following secondary IOL implantation; refractive error and VA by 5 years after lensectomy.

RESULTS

Median (interquartile range [IQR]) follow-up following secondary IOL implantation was 2.5 years (0.8 to 3.3 years). A common complication following secondary IOL implantation was a glaucoma-related adverse event (GRAE: glaucoma or glaucoma suspect); the cumulative incidence was 17% (95% CI: 3%-29%) in bilateral and 12% (95% CI: 0%-23%) in unilateral cases. The cumulative incidence of surgery for visual axis opacification was 2% (95% CI: 0%-7%) for bilateral and 4% (95% CI: 0%-10%) for unilateral cases. Median prediction error (IQR) within 90 days of implantation was 0.88 D (-0.50 D to +3.00 D) less hyperopic than intended among 21 eyes for bilateral cases and 1.50 D (-0.25 D to +2.38 D) less among 19 unilateral cases. Median (IQR) spherical equivalent refractive error at 5 years (median 5.1 years of age) in eyes receiving a secondary IOL was +0.50 D (-2.38 D to +2.94 D) for 48 bilateral and +0.06 D (-2.25 D to +0.75 D) for 22 unilateral cases. Median (IQR) monocular VA at 5 years was 20/63 (20/50-20/100) for bilateral (n=42) and 20/400 (20/160-20/800) for unilateral (n=33) cases.

CONCLUSIONS

Eyes with secondary IOL implantation have an ongoing risk of new glaucoma-related adverse events. Five years after lensectomy (approximately 2.5 years after secondary IOL implantation), average refractive error was less hyperopic than desired given the anticipated further myopic shift before refraction stabilizes.

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 3,151 patients (4,717 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 < 0.01). A correlation was identified between the age at cataract surgery and the incidence of secondary glaucoma (p = 0.0215).

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.

Prevalence of Glaucoma Following Paediatric Cataract Surgery in an Australian Tertiary Referral Centre

Purpose

Secondary glaucoma following childhood cataract surgery remains the most common complication in the paediatric population. This study aimed to determine the incidence, time to progression and risk factors associated with the development of secondary glaucoma following childhood cataract surgery in a paediatric population. Outcome measures were the detection of secondary glaucoma, postoperative time frame to development of glaucoma and risk factors in its development.

Patients and Methods

A retrospective case series was conducted between 2003 and 2017 at a tertiary children's hospital in Sydney. The patient population included those 16 years or less of age who underwent congenital cataract extraction, with or without an intraocular lens implantation and who had been followed up for a minimum of six months following surgery. Patients were excluded if they had cataract aetiology other than congenital idiopathic cataract. Multivariate Cox Regression analysis was used to determine relevant risk factors.

Results

A total of 320 eyes in 216 patients were included in the study. Secondary glaucoma developed in 11.9% of eyes. In those that developed secondary glaucoma, the average time to onset from surgery was 3.2 years (median 2.75 years). The mean age of diagnosis of secondary glaucoma was 4.58 years (median 3.5 years, range 2.5 months to 13.23 years). Microcornea was the only adverse characteristic significantly associated with an increased risk of secondary glaucoma (HR 6.30, p 0.003).

Conclusion

Despite modern surgical techniques, glaucoma remains a significant long-term sequela in children following cataract surgery.

Stereopsis following surgery in children with congenital and developmental cataracts: A systematic review and meta-analysis

We estimated the proportion of children with stereopsis following surgery in congenital and developmental cataracts by systematic review and meta-analysis and also considered the factors influencing stereopsis, such as intervention age and presence of strabismus. Stereopsis is directly related to quality of life, and investigating its levels following cataract surgery in children may help decide the right time to intervene, particularly in the context of brain plasticity. We conducted a systematic literature search using Scopus, PubMed, and Web of Science and found 25 case series, 3 cohorts, and 3 clinical trial studies from 1/1/1995 to 31/12/2020. Study-specific proportions of stereopsis from 923 children were pooled using a random-effects model, and stratified analyses were conducted based on intervention age and pre-existing strabismus as a confounder. We appraised the risk of bias using tools published by National Institutes of Health and evaluated publication bias with funnel plots and the Egger test. The pooled proportions of stereopsis based on 8 unilateral and 6 bilateral congenital cataract studies were 0.37 (95% CIs: [0.24, 0.53]) and 0.45 (95% CIs: [0.24,0.68]) when patients with preexisting strabismus were excluded as a confounder. When the intervention age was ≤6 months, proportions in unilateral congenital cataract group significantly increased to 0.52 (95% CIs: [0.37, 0.66]; P = 0.49) compared to 0.26 (95% CIs: [0.14, 0.44]; P = 0.16) otherwise. A similar increase in proportions was found when intervention age ≤4 months. In both unilateral and bilateral congenital cataract groups, proportions increased significantly when the confounder was excluded. Overall, proportions in bilateral congenital cataracts were significantly greater than unilateral cases (irrespective of confounder). Eight unilateral and 5 bilateral developmental cataract studies resulted in pooled proportions of 0.62 (95% CIs: [0.27, 0.88] and 0.82 (95% CIs: [0.4, 0.97]), respectively. Although proportions for bilateral developmental cataracts were greater than unilateral cataracts (irrespective of confounder), results were not statistically significant. Finally, proportions in unilateral developmental cataracts were significantly greater than unilateral congenital cataracts (Z = 7.413, P = 6.173694e-14). We conclude that surgical intervention within first 4-6 months can significantly affect postoperative outcomes in unilateral congenital cataracts. Analysis of existing data does not show a significant effect of intervention age on stereopsis outcomes for developmental cataracts.

Outcomes of Bilateral Congenital and Developmental Cataracts Following IOL Implantation in Preschool Children

PURPOSE

To evaluate the different ocular outcomes and the potential factors affecting visual acuity in bilateral congenital cataracts and developmental cataracts after intraocular lens implantation in preschool children.

METHODS

In a retrospective study, 86 eyes (51 congenital and 35 developmental cataract cases) of 43 children aged 6 years and younger who were diagnosed as having bilateral cataracts and underwent cataract aspiration combined with primary or secondary foldable intraocular lens implantation between 2003 and 2018 were reviewed. A minimum of 1 year of follow-up was required. The best corrected visual acuity (BCVA) and the factors associated with visual results were explored.

RESULTS

The postoperative BCVA in the developmental cataract group (0.20 ± 0.19 logarithm of the minimum angle of resolution [logMAR]) was significantly better than that in the congenital cataract group (0.57 ± 0.31 logMAR) (P < .001). The mean refractive error was 3.61 ± 3.03 diopters in the congenital cataract group and 2.15 ± 1.82 diopters in the developmental cataract group. All cases of strabismus and nystagmus were found in the congenital cataract group. In the congenital cataract group, the variables age at cataract extraction and refractive error were significantly associated with BCVA (P < .001, P = .001, respectively). These variables had little effect on the developmental cataract group (P = .971, P = .576, respectively). Postoperative complications were recorded in 18 eyes: 4 in the developmental cataract group and 14 in the congenital cataract group.

CONCLUSIONS

The BCVA in the developmental cataract group was significantly better than that in the congenital cataract group. The therapeutic effects of patients with congenital cataracts and developmental cataracts should be evaluated separately. [J Pediatr Ophthalmol Strabismus. 2021;58(3):180-187.].

The Swedish National Pediatric Cataract Register (PECARE): incidence and onset of postoperative glaucoma

PURPOSE

The aim was to report cumulative incidence and time of onset of postoperative glaucoma in a paediatric early cataract surgery cohort.

METHODS

Data were retrieved from the Pediatric Cataract Register (PECARE), a prospective register of Swedish cataract operations before 8 years of age. All eyes with surgery between January 2007 and December 2014 and a registered follow-up were included. Cataracts caused by uveitis, trauma or coexisting congenital glaucoma were excluded. Glaucoma was defined as early onset if diagnosed within a year after surgery and late onset if diagnosed later.

RESULTS

The study included 288 eyes in 207 children (106 girls), 81 with bilateral and 126 with unilateral cataracts, with a mean follow-up of 3.31 ± 1.77 years. Of the 288, 168 (58.3%) had surgery before 3 months of age; most of these 92.3% (155/168) were defined as dense, 208 (72.2%) were below 1 year of age. Cumulative incidence of surgically treated glaucoma among individuals was 23.7% (49/207). Median time to glaucoma onset was 0.91 years (range: 0.05-4.97 years) for eyes. Early-onset glaucoma was found in 98 % (63/64), and late onset in 2% (1/64).

CONCLUSION

In this paediatric cataract cohort, a majority of eyes had surgery before 3 months of age (58.3%). Secondary glaucoma-onset peaked within the first postoperative year, with a cumulative incidence of 23.7%. Surgery performed after the first month of life, resulted in a lower glaucoma rate. Long-term follow-up will reveal whether the low rate of late-onset glaucoma with early surgery will last, and if so, the consequences.

Recent developments in the management of congenital cataract

Congenital cataract is a rare eye disease, one of the leading treatable causes of low vision in children worldwide. Hereditary cataracts can be divided in syndromic and non-syndromic cataracts. Early diagnosis in congenital cataracts is key to reach good visual function. Current surgical techniques, that combine microincision cataract extraction and primary intraocular lens (IOL) implantation, have improved childhood cataract outcome. Complications include posterior capsule opacification (PCO), aphakic or pseudophakic glaucoma, uveitis, pupil displacement and IOL decentration. A recent study using a modified Delphi approach identified areas of consensus and disagreement in the management of pediatric cataract. A consensus or near consensus was achieved for 79% of the questions, however 21% of the questions remained controversial, as for IOL implantation strategy. Congenital cataracts show a highly variable phenotype and genotype, and can be related to different mutations, genetic variance, and other risk factors. Congenital cataracts can be associated with other ocular developmental abnormalities, including microphthalmia, microcornea, or aniridia and with systemic findings. Next-generation sequencing (NGS) and forthcoming new ultra-high-throughput sequencing represent excellent tools to investigate the genetic causes of congenital cataracts. A better recognition of different clinical presentations and underlying etiologies of congenital cataracts may lead to the development of new approaches to improve visual outcome after cataract surgery and promote early detection of systemic associated syndromes.

Changes in intraocular pressure control in the first year after secondary intraocular lens implantation in children

PURPOSE

To compare intraocular pressure (IOP) control before and during the first year after secondary intraocular lens (IOL) implantation in children.

METHODS

This was a retrospective chart review of children who received secondary IOL implantation. We analyzed IOP and antiglaucoma medications before and after implantation. The latest exam with IOP measurement found within the 2-15 month period after IOL implantation was used for the postoperative data. Failure to maintain IOP control was defined as either the addition of antiglaucoma medication(s) or a rise in IOP > 4 mm Hg. Statistical analyses were performed to assess risk factors for failure to control IOP after surgery, namely age at IOL implantation, preoperative glaucoma status, and IOL fixation location.

RESULTS

A total of 100 eyes were included. The mean duration of follow-up was 7.74 months (SD = 3.11). Twenty-three of one hundred eyes failed to maintain IOP control according to our definition. Eyes with a history of having had a traumatic cataract (n = 3) had a more than threefold increased risk of failure (P = 0.015). Although not statistically significant, very young age at initial cataract surgery (<2 months old) had a twofold increased risk of failure compared to an older age (>12 months old) (P = 0.213). No other risk factors were found to have statistical significance.

CONCLUSION

Secondary IOL implantation carries a modest risk of worsening IOP control in the first year after implantation, for which, a history of ocular trauma or young age at initial cataract surgery seems to present the highest risk.

[Timing of congenital cataract surgery : Amblyopia versus aphakic glaucoma]

A congenital cataract is a rare disorder, which is associated with a high risk of amblyopia. Ophthalmologists are faced with many diagnostic and surgical challenges in the management of this disease. Older children can undergo primary treatment with an intraocular lens, whereas children younger than 12 months of age usually initially remain aphakic. The most frequent long-term complication of aphakic eyes following congenital cataract surgery in connection with posterior capsulorrhexis and anterior vitrectomy is aphakic glaucoma, which in individual cases can lead to substantial impairment of vision. Many factors have been reported to increase the risk of postoperative glaucoma, including microphthalmos, fetal nuclear cataract, conspicuous family history and associated ocular malformations, such as persistent fetal vasculature (PFV). Cataract surgery during early infancy is well-established to be the most important factor for the formation of postoperative aphakic glaucoma. In individual treatment planning it has to be considered that although younger age at the time of cataract removal can provide better prerequisites for prophylaxis of amblyopia, it also confers a higher risk of development of aphakic glaucoma. Children undergoing congenital cataract surgery have to be regularly monitored given the lifelong risk for postoperative complications, such as aphakic glaucoma.

Analysis and management of intraoperative and early postoperative complications of bag-in-the-lens intraocular lens implantation in different age groups of paediatric cataract patients: report of the Giessen Paediatric Cataract Study Group

PURPOSE

To report the rate and management of intra- and early postoperative complications of bag-in-the-lens intraocular lens (IOL) implantation technique for cataract treatment in paediatric patients of different age groups.

SETTINGS

Department of Ophthalmology, Justus-Liebig-University Giessen, University Hospital Giessen and Marburg GmbH, Campus Giessen, Giessen, Germany.

DESIGN

Retrospective non-randomized consecutive case series.

METHODS

Ninety eyes of 60 paediatric cataract patients were enrolled to this retrospective non-randomized observational consecutive case series single-centre study. All patients underwent cataract surgery with bag-in-the-lens IOL implantation between January 2008 and December 2018, performed by two experienced surgeons. The entire cohort was divided into four age groups: first - 0-<3 months, second - 3-<12 months, third - 12-<36 and fourth - >36 months-17 years of age. The intra- and postoperative complications were based on the clinical records. The description of management of complications related specifically to bag-in-the-lens IOL technique was based on the 39 consecutive cases operated since 1 Jan 2016 by one single surgeon that were all video documented. The early postoperative period was defined as 12 months after surgery.

RESULTS

Overall, there were 27 unilateral and 33 bilateral surgical cases of 24 female and 36 male children. The mean age at surgery was 45.25 months (range 1-200 months). The most common intraoperative events were vitreous prolapse and anterior capsule rupture with 28.9% and 13.3%, respectively. Within 12 months of follow-up, five eyes (5.6%) were re-operated because of visual axis reo-pacification (VAR). Intraocular hypertension was diagnosed in seven eyes (7.8%), including two cases that required surgical treatment. In all cases with intra- and early postoperative complications related specifically to bag-in-the-lens technique, it was possible to manage them and successfully implant bag-in-the-lens IOL.

CONCLUSIONS

Implementation of bag-in-the-lens technique in the treatment of paediatric cataract was associated with a relatively low rate of intra- and postoperative complications, including rare cases of VAR. The correct management of complications related specifically to bag-in-the-lens IOL implantation technique shall to be considered during the learning curve.

Incidence and Risk Factors for Glaucoma Development After Bilateral Congenital Cataract Surgery in Microphthalmic Eyes

PURPOSE

To evaluate the long-term incidence and risk of glaucoma after bilateral congenital cataract surgery in microphthalmic eyes.

DESIGN

Retrospective, observational case series.

METHODS

Subjects: Children with microphthalmic eyes who had undergone surgery for bilateral congenital cataract within 6 months of birth and been followed up for at least 5 years.

PROCEDURES

Review of medical records at our institution.

MAIN OUTCOME MEASURES

Probability of an eye's developing glaucoma after bilateral congenital cataract surgery and associated risk factors.

RESULTS

Thirty-eight eyes of 19 children with bilateral congenital cataract were included. The mean age at surgery was 3.2 ± 1.7 months, and the mean follow-up duration was 7.79 ± 2.61 years. After cataract surgery, 11 eyes (29.0%) developed glaucoma at the age of 4.0 ± 1.4 years. Three of these eyes underwent Ahmed glaucoma valve implantation surgery. The probability of an eye's developing glaucoma was estimated to be 32.0% by 10 years after surgery. In a multivariate analysis, axial length was significantly associated with glaucoma development (odds ratio = 0.364, P = .025). Age at the time of cataract surgery, corneal diameter, and aphakia did not affect the risk of glaucoma (P > .10). Eyes without glaucoma had a better final visual outcome than those with glaucoma (0.75 ± 0.60 and 1.47 ± 1.10 logMAR, respectively, P = .049).

CONCLUSIONS

The long-term cumulative risk of postoperative glaucoma development was 32.0% by 10 years after bilateral congenital cataract surgery. Because the risk of developing glaucoma persists for several years after surgery, careful monitoring and control of intraocular pressure is needed to preserve vision in such patients.

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.

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.

Relationship between preoperative axial length and myopic shift over 3 years after congenital cataract surgery with primary intraocular lens implantation at the National Institute of Ophthalmology of Peru, 2007-2011

Objective

To determine the relationship between the preoperative axial length and the myopic shift over 3 years after congenital cataract surgery with primary intraocular lens implantation and other related factors.

Methods

In this retrospective cohort study, the axial length was measured and assigned into 2 groups (>21.5 mm and ≤21.5 mm), visual axis obscuration, laterality of cataract, age of surgery and follow-up time were assessed and compared to the myopic shift.

Results

The mean myopic shift was 3.6 (standard deviation [SD]: 2.3) diopters (D) in all patients; 3.2 (3.3) and 3.9 (3.2) D for each group respectively (p=0.359). In unilateral cataracts the mean myopic shift was 6.3 D and in bilateral cases was 3.0 D (p=0.001). In bilateral cataracts, the shift was 2.6 D (SD: 2.0) and 3.4 D (SD: 1.8), respectively (p=0.098).

Conclusion

There was no relationship between the initial axial length and the myopic shift in all patients. Unilateral cataracts had a greater myopic shift over 3 years.

[Impact of timing of surgery on outcome in children with bilateral congenital cataract]

BACKGROUND

The optimal time for surgical intervention in bilateral congenital cataract is still a matter of controversy.

OBJECTIVES

Herein, we evaluated clinical and functional results after bilateral congenital cataract surgery and performed subgroup analysis based on the age at the time of surgery.

MATERIALS AND METHODS

We retrospectively reviewed the records of 52 eyes of 26 children who underwent surgery for bilateral congenital cataract without intraocular lens implantation within the first 12 months of life; 16 eyes underwent phacoaspiration within the first 10 weeks of life (group A) and 26 eyes had cataract extraction at an age of >10 weeks (group B). We defined the primary outcome measure to be the prevalence of mild, moderate, and severe amblyopia in relationship to age-dependent visual acuity norms after a mean follow-up of 59.7 ± 43.2 months. Secondary outcome measures were interocular difference of visual acuity and the presence of strabismus, nystagmus, posterior capsule opacification, and aphakic glaucoma.

RESULTS

The prevalence of amblyopia was not statistically different between the two age groups. Of all children, 62.5 % (A) and 61.1 % (B) developed age-dependent normal visual acuity or mild amblyopia. However, the younger cohort developed significantly less strabismus than the older cohort (P = 0.03). There was a strong relationship between cataract surgery within the first 14 weeks of life and the development of aphakic glaucoma. All children developing secondary cataract formation underwent cataract surgery in the first 20 weeks of life.

CONCLUSIONS

Our results suggest that long-term prevalence of mild, moderate, and severe amblyopia is similar between the two cohorts of bilateral congenital cataract eyes based on the age ≤ or >10 weeks at the time of surgery. Because there is a strong relationship between postoperative complications and a young age at the time of cataract surgery, close postoperative follow-up is essential. Strabismus is less likely to develop in infants after bilateral cataract surgery within the first 10 weeks of life.

Interocular suppression in children with deprivation amblyopia

In patients with anisometropic or strabismic amblyopia, interocular suppression can be minimized by presenting high contrast stimulus elements to the amblyopic eye and lower contrast elements to the fellow eye. This suggests a structurally intact binocular visual system that is functionally suppressed. We investigated whether suppression can also be overcome by contrast balancing in children with deprivation amblyopia due to childhood cataracts. To quantify interocular contrast balance, contrast interference thresholds were measured using an established dichoptic global motion technique for 21 children with deprivation amblyopia, 14 with anisometropic or mixed strabismic/anisometropic amblyopia and 10 visually normal children (mean age mean=9.9years, range 5-16years). We found that interocular suppression could be overcome by contrast balancing in most children with deprivation amblyopia, at least intermittently, and all children with anisometropic or mixed anisometropic/strabismic amblyopia. However, children with deprivation amblyopia due to early unilateral or bilateral cataracts could tolerate only very low contrast levels to the stronger eye indicating strong suppression. Our results suggest that treatment options reliant on contrast balanced dichoptic presentation could be attempted in a subset of children with deprivation amblyopia.

Visual Outcome and Related Factors in Bilateral Total Congenital Cataract Patients: A Prospective Cohort Study

This study is to evaluate the visual outcome and identify its crucial related factors in children undergoing cataract surgery for bilateral total congenital cataract (CC). This prospective study included consecutive bilateral total cataract patients undergoing primary surgery at Zhongshan Ophthalmic Center (ZOC), Guangzhou, China from Jan 2010 to May 2014. Visual outcome was estimated by best-corrected visual acuity (BCVA) at last follow-up. Potential related factors, including gender, age at last follow-up, age at primary surgery, surgical procedure, postoperative complications (PCs), frequency of follow-up and changes in spectacles were evaluated. Eighty-eight children (176 eyes) were included in the cohort. The mean post-operative BCVA (logMAR) was 1.07 ± 0.53 at the mean follow-up duration 31.07 ± 19.36 months. Multivariable generalized estimating equations (GEEs) showed BCVA was significantly associated with PCs, age at last follow-up and age at primary surgery. Partial correlation analysis indicated age at primary surgery was positively correlated with BCVA controlling for the other factors, both for the whole age range (R = 0.415, P < 0.001) and age >6 months (R = 0.867, P < 0.001). Better visual acuity was related to early primary surgery and low PC occurrence in children with bilateral total CC. Timely surgical intervention and strict control of PCs would be potential steps to achieving better visual outcome.

Visual acuity and its predictors after surgery for bilateral cataracts in children

PurposeThe objective of this study was to investigate preoperative factors associated with postoperative visual acuity outcomes and to develop a model to predict visual acuity prognosis.MethodsA retrospective study was conducted by reviewing clinical charts of pediatric patients who underwent bilateral cataract surgery by a single surgeon (MEW) at the Storm Eye Institute. A multiple logistic regression model was constructed to predict the odds of poor postoperative visual acuity, that is, worse than 20/40, based on age at surgery, gender, primary intraocular lens (IOL) placement, ethnicity, and preoperative nystagmus.ResultsA sample size of 157 children (314 eyes) was investigated with median duration of follow-up of 6.4 years. A total of 78% of children with bilateral cataract had postoperative visual acuity of 20/40 or better. The presence of preoperative nystagmus was highly correlated with poor postoperative visual acuity (OR=6.0; 95% CLs, 2.5-14.1; P-value<0.0001). Children of age <1 year at time of cataract extraction (OR=3.2; 95% CLs, 1.4-7.6; P-value=0.0073), male gender (OR=2.3; 95% CLs, 1.1-4.5; P-value=0.02), the absence of primary IOL placement (OR=3.0; 95% CLs, 1.05-8.4; P-value=0.04), and non-Caucasian ethnicity (OR=2.0; 95% CLs, 1.02-4.03; P-value 0.0447) were associated with poor visual acuity postoperatively.ConclusionsSatisfactory visual outcomes occurred in 78% of children operated on for bilateral cataracts. Preoperative nystagmus, age <1 year at time of cataract extraction, absence of primary IOL placement, male gender, and non-Caucasian ethnicity, were all factors associated with poor postoperative visual acuity.

Long-Term Visual Outcomes of Secondary Intraocular Lens Implantation in Children with Congenital Cataracts

Aim

The aim of this study was to evaluate the long-term visual outcomes and factors affecting visual results in children undergoing secondary intraocular lens (IOL) implantation following primary congenital cataract extraction.

Methods

Children with congenital cataracts who underwent secondary IOL implantation for aphakia at the Eye and ENT Hospital of Fudan University between January 1, 2001, and December 31, 2007, were retrospectively reviewed. One eye was randomly selected in children with bilateral cataracts. Laterality, type of cataract (total or partial opacity), sex, age at primary and secondary surgeries, visual axis opacity (VAO), compliance with amblyopia therapy, postoperative ocular complications, refractive error, ocular alignment, and best corrected visual acuity (BCVA) at last follow-up were recorded; potential factors that might have affected the visual results were evaluated.

Results

Seventy-six bilateral and 34 unilateral congenital cataract cases were analyzed; the mean ages of the children were 12.70±5.06 and 12.50±2.71 years at final follow-up, the mean follow-up periods from IOL implantation were 94.93±24.22 and 109.09±18.89 months, and the mean BCVA (Log MAR) values were 0.51±0.37 and 1.05±0.46, respectively. Final BCVA after secondary IOL implantation was significantly associated with laterality, type of cataract, age at primary cataract extraction, compliance with amblyopia therapy, and refractive correction after surgery. No significant associations were found between BCVA and sex, age at secondary IOL implantation, VAO, or other ocular complications. The most common ocular complications were VAO and elevated intraocular pressure after surgery. There were no other complications, with the exception of one eye with IOL dislocation.

Conclusions

The results indicate that the important determinants of long-term visual outcomes in children with congenital cataracts undergoing secondary IOL implantation are laterality, cataract type, age at initial cataract extraction, compliance with amblyopia therapy, and refractive error.

Factors associated with strabismus after cataract extraction and primary intraocular lens implantation in congenital cataracts

AIM

To evaluate factors associated with the development of strabismus after cataract extraction and primary intraocular lens implantation.

METHODS

The medical records of 122 patients, aged 1.5mo to 9y, who had undergone cataract extraction with primary intraocular lens implantation between January 1993 and August 2011 were reviewed. Fourteen patients (17 eyes) with strabismus before cataract surgery were excluded. Patients were divided into those with congenital bilateral cataracts (64 patients, 128 eyes) and those with unilateral cataracts (44 patients, 44 eyes). The associations between the development of strabismus and age at cataract surgery, pre- and post-cataract extraction corrected distance visual acuity (CDVA), interocular CDVA difference, nystagmus, surgical method, and secondary cataract were evaluated.

RESULTS

Factors significantly associated with the development of strabismus included age at cataract surgery (≤1y), preoperative mean CDVA ≤20/100, presence of nystagmus in the bilateral cataract group and postoperative interocular CDVA difference >20/70 in the unilateral group. Postoperative CDVA ≤20/100 and preservation of posterior capsule, and presence of secondary cataract were significant factors in both groups.

CONCLUSION

Children with congenital cataracts should be monitored carefully after cataract surgery for the development of strabismus, especially when they underwent surgery at age ≤1y, and they have nystagmus, large postoperative interocular CDVA difference, poor preoperative and postoperative CDVA, preservation of the posterior capsule, or secondary cataract.

[Treatment of pediatric cataracts. Part 2: IOL implantation, postoperative complications, aphakia management and postoperative development]

There is a lot of uncertainty concerning intraocular lens (IOL) implantation for pediatric cataracts. The appropriate age which ocular abnormalities are contraindications and according to which formula IOL should be calculated are controversial. In addition to the imperative of identifying postoperative complications, such as secondary cataract formation and secondary glaucoma in a sufficiently timely manner, a modern management of aphakia with refractive compensation and occlusion is necessary. Some easy rules can help prevent pitfalls.

Advances in the management of the surgical complications for congenital cataract

The greatest concern in children with cataracts is irreversible visual loss. The timing of congenital cataract surgery is critical for the visual rehabilitation. Cataract surgery in children remains complex and challenging. The incidence of complications during or after operation is higher in children than adults. Some complications could be avoided by meticulous attention to surgical technique and postoperative care, and others were caused by more exuberant inflammatory response associated with surgery on an immature eye or the intrinsic eyes abnormalities. Utilizing of advanced techniques and timely applying topical corticosteroids and cycloplegic agents can reduce the occurrence of visual axis opacification. Operation on children with strabismus or nystagmus, and applying occlusion therapy on amblyopic eyes can balance the visual inputs to the two eyes. Diagnosis of glaucoma following congenital cataract surgery requires lifelong surveillance and continuous assessment of the problem. So cataract surgeries in children are not the end of journey, but one step on the long road to visual rehabilitation. This paper describes recent evidence from the literature regarding the advance of management after congenital cataract surgery.

Combined pars plana and limbal approach for removal of congenital cataracts

We describe a combined pars plana-limbal approach using a 25-gauge transconjunctival sutureless vitrectomy system for removal of congenital cataracts in a 5-month-old boy. The operated eye had anterior capsulotomy, lensectomy, posterior capsulotomy, and anterior vitrectomy through a pars plana transconjunctival incision created with a 25-gauge trocar. A limbal port incision was used to introduce an infusion micro cannula to maintain the anterior chamber. Incisions did not require suture closure. Following the procedure, inflammation was mild, the pupil was circular and centric, and the intraocular pressure (IOP) was stable. The eyes were left aphakic, and vision was corrected with spectacles. Amblyopia treatment ensued. This surgical technique appears to be safe and effective for the removal of congenital cataracts. Advantages include a more precise capsulotomy and more sufficient lensectomy and anterior vitrectomy, stable intraoperative IOP, and reduced surgical trauma and inflammation.

FINANCIAL DISCLOSURE

No author has a financial or proprietary interest in any material or method mentioned.