Risk of Glaucoma after Pediatric Cataract Surgery

Timing of Diagnosis and Treatment of Glaucoma following Infantile Cataract Surgery

PURPOSE

To report timing of diagnosis and treatment of glaucoma following cataract surgery (GFCS) in a large cohort of infants undergoing cataract surgery at a tertiary care center.

STUDY DESIGN

Cross-sectional study.

PARTICIPANTS

All consecutive infants that underwent cataract surgery over a 30-year period from January 1991 to December 2021 were included if they had at least 1 year follow-up.

METHODS

The data collection included age at time of cataract surgery, presence of associated ocular or systemic conditions, age at diagnosis of GFCS, and treatment required to control GFCS. Glaucoma diagnosis required intraocular pressure (IOP) > 21 mmHg on > 2 visits with glaucomatous optic nerve head changes and/or visual field changes, or in young children, other anatomic changes such as corneal enlargement or haze or accelerated axial elongation and myopic shift.

MAIN OUTCOME MEASURES

The incidence of GFCS was calculated. Linear regression was performed to assess the effect of age at time of cataract surgery. Analysis of risk factors and treatment modalities was performed using univariate and multivariate analysis.

RESULTS

Three hundred eighty-three eyes (260 patients) were analyzed. Median age at surgery was 52 days and median follow-up, 8 years. Glaucoma following cataract surgery was noted in 27% (104/383 eyes; median age at surgery, 45 days; median follow-up, 13 years.) Young age at surgery (< 3 months) was the greatest risk factor (P = 0.001) but the incidence was similar for infants operated in the first, second, or third month of life (25%, 36%, 40%, respectively, P = 0.4). Microcornea (41%, P < 0.0001), poorly dilating pupils (25%, P = 0.001), persistent fetal vasculature (PFV, 13%; P = 0.8), or anterior segment dysgenesis (3%, P = 0.02) were considered as additional risk factors. Surgical intervention was needed for 73% (24/33) eyes with early-onset GFCS compared with 14% (10/71) eyes with later-later onset GFCS (P < 0.0001). Medical treatment was effective in 86% with later-onset GFCS (P = 0.006).

CONCLUSIONS

The incidence of GFCS was 27%, and timing of diagnosis occurred in a bimodal fashion. Early-onset GFCS usually requires surgical intervention; medical treatment is effective for later-onset GFCS. Cataract surgery within the first 3 months of life, microcornea, and poorly dilating pupils were major risk factors.

FINANCIAL DISCLOSURE(S)

The authors have no proprietary or commercial interest in any materials discussed in this article.

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.

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

PURPOSE

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

DESIGN

Retrospective cohort study.

PARTICIPANTS

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

METHODS

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

MAIN OUTCOME MEASURES

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

RESULTS

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

CONCLUSIONS

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

FINANCIAL DISCLOSURE(S)

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

The prevalence of visual axis opacification in the Swedish Pediatric Cataract Register

PURPOSE

To report on the occurrence of postoperative visual axis opacification (VAO) in children younger than 5 years of age operated for cataract in Sweden, and to analyse correlations with age at surgery and surgical method.

METHODS

Data were derived from the Swedish Pediatric Cataract Register (PECARE). All children operated on between 1 January 2007 and 31 December 2020 were included. Follow-ups at 1, 2 and 5 years of age were analysed.

RESULTS

Cataract surgery were performed on 770 eyes belonging to 549 children (n = 282 boys, 51.4%); 327/770 (42.5%) of the children underwent surgery before 3 months of age and 216/770 (28%) before 6 weeks of age. Data on 881 follow-up visits were registered. At the follow up-visits at 1, 2 and 5 years of age, VAO was present in 154/349 (44.1%), 41/323 (12.7%) and 25/208 (12%). The majority of the children with VAO underwent cataract surgery before age 6 months, with a predominance before age 2 months. Primary IOL was implanted in 601/770 (78%) of eyes; 40.8% had an acrylic one-piece lens, 31.8% had a bag-in-the-lens IOL, 21.9% were aphakic and 5.2% had an acrylic three-piece lens. Implantation of a bag-in-the-lens IOL was related to a significantly lower occurrence of VAO compared to other types of IOL, including aphakia (p < 0.0002).

CONCLUSION

Our results are in accordance with the literature. Primary bag-in-the-lens IOL implantation before 2 years of age seems adequate and safe, with a low occurrence of VAO, and can thus be continued as routine in Sweden.

Long-term risk of glaucoma after cataract surgery in childhood

PURPOSE

To examine the long-term risk of glaucoma after cataract surgery in childhood.

METHODS

This study took place from January 2022 until December 2022 and included patients from a large family with hereditary childhood cataract who had cataract surgery before 18 years of age. Patients underwent an ophthalmologic examination to determine the presence of glaucoma or ocular hypertension (OHT). Patients who did not want to participate in the examination could contribute with a medical journal from their treating ophthalmologist. The risk of long-term glaucoma was determined using survival analysis, and risk factors were assessed using a Cox proportional hazards regression model.

RESULTS

We included 68 patients (133 eyes) with a median age at cataract surgery of 7 years (IQR: 5-10). The median follow-up time after cataract surgery to glaucoma/OHT or the latest ophthalmologic examination was 35 years (IQR: 15-48). Twelve patients (18 eyes) had glaucoma, and five patients (eight eyes) had OHT, resulting in 15 patients with glaucoma/OHT. The long-term risk of glaucoma/OHT diagnosed in adulthood was 47.7% (CI: 21.8-70.9) at the age of 70 years of patients who were free of glaucoma before their 18th year. We could not confirm or dismiss an association between glaucoma/OHT and sex, age at surgery, number of ocular interventions before 18 years of age or glaucoma after cataract surgery in a first-degree relative.

CONCLUSION

Cataract surgery in childhood is associated with a high risk of late-onset glaucoma. Regular lifelong follow-up is important to ensure early diagnosis and prevent extensive vision loss.

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

Objective

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

Methods

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

Results

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

Conclusion

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

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.

Evolution and trends of childhood cataract research in the past 10 years: A scientometric analysis

Purpose

To present a panoramic review of childhood cataract knowledge networks, hotspots and trends.

Methods

The Web of Science Core Collection was used to retrieve the global literature on childhood cataract published between 2012 and 2021. Scientometric data were analyzed and visualized using VOSviewer and CiteSpace for metrics including publication count, citation count, country, journal, author, cited reference, subject category and their temporal trends.

Results

A total of 3395 analyzed publications showed an inconsistent annual increasing trend. The USA (n = 939) was the leading contributor among countries. The Journal of American Association for Pediatric Ophthalmology and Strabismus (n = 113) had the highest number of publications among journals. Eight clusters of author collaboration network including 183 authors were identified. Gene mutation, cataract surgery management, intraocular lens implantation complications, prevalence, and glaucoma were identified as the research hotspots. Pediatric cataract surgery, new mutations, artificial intelligence, and cerebrotendinous xanthomatosis were identified as frontier research topics. "Biochemistry and molecular biology", "neurosciences", and "radiology, nuclear medicine and medical imaging" had the highest betweenness centrality values (0.38, 0.32, and 0.22). Multidisciplinary (burst years: 2020 to 2021; strength = 4.32) had the greatest strength as of 2021.

Conclusions

Childhood cataract research intensely focuses on revealing the genetic background and pheno-spectrum of the diseases, innovating and/or optimizing surgical techniques, and preventing and treating postoperative complications. Artificial intelligence has shed light on the diagnosis and treatment of childhood cataracts. The advance in the research on molecular mechanisms of childhood cataracts depends on multidisciplinary cooperation.

Analysis of age at detection and outcomes of dense unilateral congenital cataract surgery for children on the paediatric cataract register

AIM

Analysis of age at time of detection and surgery of dense unilateral cataract and investigation of best-corrected visual acuity (BCVA) in a nationwide register-based cohort study, based on the routine of maternity ward eye screening.

METHODS

Data were derived from the Paediatric Cataract Register (PECARE). All children (n = 54) diagnosed with dense congenital unilateral cataract between January 2007 and September 2014 who had surgery before 1 year of age, and for whom 5-year follow-up records were available, were included.

RESULTS

The majority, 35/54 (65%), were detected and operated on before age 6 weeks and 30/35 (86%) were referred from maternity wards. Visual acuity (VA) ≥ 0.5 (decimal, 0.3 logMAR) was found in 7/53 (13%) of the cohort at age 5 years; further, 19 children achieved VA ≥ 0.1 (decimal, 1.0 logMAR) (36%) and 19 children VA < 0.05 (decimal, 1.30 logMAR) (36%). Ten-year follow-up records were available for 17/53 (32%) children; 1/17 (6%) achieved VA ≥ 0.5 (decimal, 0.3 logMAR), 4/17 (24%) VA ≥ 0.3-<0.5 (decimal, 0.52-0.30 logMAR), 3/17 (18%) VA ≥ 0.05-0.1 (decimal, 1.30-1.0 logMAR) and 10/17 (59%) VA < 0.05 (decimal, 1.30 logMAR).

CONCLUSION

A total of 90% of the children were detected with cataract within 100 days of birth and 80% were operated on within this period. This study showed better visual acuity in those treated for dense unilateral cataracts than previously reported in an earlier Swedish cohort study.

Management of cataract surgery in Lowe syndrome

AIM

To evaluate the ophthalmic and anesthesiologic management of cataract surgery in children with Lowe syndrome receiving lens removal, the development and management of secondary glaucoma.

METHODS

This retrospective case series included 12 eyes of 6 children with genetically verified Lowe syndrome receiving cataract removal. Information regarding the type and duration of surgery and total anesthesia time were recorded. Additionally, intra- and postoperative complications were noted as well as clinical examinations such as visual acuity and funduscopy.

RESULTS

All children received simultaneous bilateral cataract surgery at the mean age of 8.98±3.58wk. Lensectomy combined with posterior capsulotomy and anterior vitrectomy was performed in all children. The mean time for cataract surgery per eye was 35.83±8.86min, whereas the total time of surgery was 153.33±22.11min. The mean extubation time and duration at recovery room was 42.33±22.60min and 130.00±64.37min, respectively. During surgery, a decrease of oxygen saturation below 93% was found in only one child. During the postoperative follow-up, nystagmus (6 children) and strabismus (5 children) was commonly found in contrast to no case of visual axis opacification. Secondary glaucoma developed in five eyes of three children, which was treated with topical eye drops in only one child. A trabeculectomy was performed in both eyes of one child, whereas removal of syechia and an iridectomy in one eye of one child.

CONCLUSION

Bilateral simultaneous cataract surgery under general anesthesia is a safe surgical procedure in Lowe syndrome children. The glaucoma screening with intraocular pressure measurements is crucial in the postoperative management of Lowe syndrome patients to avoid additional visual impairment.

Infantile Aphakic Glaucoma: A Proposed Mechanism

PURPOSE

To review information pertaining to secondary glaucoma following infant lensectomy and provide evidence to support the mechanism responsible for this condition.

METHODS

Reported risk factors and proposed mechanisms for infantile aphakic glaucoma are reviewed. Laboratory studies and clinical observations in affected patients with glaucoma are described. Evidence of postoperative anterior chamber fibrosis is reviewed and interpreted.

RESULTS

Clinical evidence demonstrated the development of anterior chamber fibrosis following infant cataract surgery. Laboratory studies showed liberated lens epithelial cell transition to fibroblasts.

CONCLUSIONS

The review and assessment of laboratory and clinical evidence support the proposal that infantile aphakic glaucoma is caused, in part, by postoperative anterior chamber fibroization related to lens cell dispersion, cytokine activation, and epithelial-mesenchymal transition with resultant filtration angle fibrosis and secondary loss of filtration function. [J Pediatr Ophthalmol Strabismus. 2022;59(4):236-242.].

Glaucoma following Infant Lensectomy: 2021 Update

PURPOSE

To review information pertaining to glaucoma following infant lensectomy surgery and to provide evidence to support the responsible mechanism of this condition.

METHODS AND RESULTS

Described risk factors and proposed mechanisms for infantile aphakic glaucoma were assessed. The clinical evidence observed in affected glaucoma patients was analyzed, and evidence of postoperative anterior chamber fibrosis was reviewed and interpreted.

CONCLUSION

The review and assessment of laboratory and clinical evidence support the proposal that infantile aphakic glaucoma is caused, in part, by postoperative anterior chamber fibroization related to lens cell dispersion and active epithelial-mesenchymal transition with resultant filtration angle tissue injury and loss of function.

Advisability of primary intraocular lens implantation for infants under 2: A systematic review and meta-analysis

PURPOSES

The present meta-analysis compared the postoperative visual performance of primary intraocular lens (IOL) implantation and primary aphakia in cataract infants.

METHODS

PubMed, Embase, Science Direct and Cochrane Library were searched, and postoperative visual acuity (VA) and complications were extracted and pooled.

RESULTS

Three randomised controlled trails (RCTs) and five retrospective studies were included. The postoperative VA of children younger than 4.5 years in primary IOL group was better than that in primary aphakia group [MD = -0.14, 95% CI: (-0.23, -0.06), P = .90]. The subgroup analysis based on RCTs and on unilateral cataract surgery revealed the same result. There was no significant difference in the incidence of glaucoma, strabismus, retinal detachment and nystagmus between primary IOL group and primary aphakia group [OR = 1.02, 95% CI: (0.62, 1.68), P = .48 for glaucoma; OR = 0.76, 95% CI: (0.30, 1.90), P = .05 for strabismus; OR = 0.49, 95% CI: (0.07, 3.30), P = .34 for retinal detachment; OR = 1.26, 95% CI: (0.68, 2.36), P = .92 for nystagmus]. The proportion of patients requiring postoperative visual axis opacification (VAO) clearing was higher in primary IOL group than that in primary aphakia group [OR = 9.22, 95% CI: (4.74, 17.96), P = .16].

CONCLUSION

For infants under 2 years of age, primary IOL implantation would provide more visual benefits compared with primary aphakia did, though the benefits would taper off with the age reaching 4.5 years. Moreover, the current study revealed a higher VAO incidence r in primary IOL implantation group.

Treatment of congenital and early childhood cataract

The successful outcome of treatment for infant and childhood cataract depends on many factors. It is crucial that the treatment falls into a phase in which neither the eye nor the visual pathway and visual cortex are fully developed. This review summarizes the current state of knowledge and provides an overview of the epidemiology, causes and clinical forms, early detection and, above all, treatment options. Special attention is paid to time-critical stages of development, according to which the therapeutic concepts are based. Complications, such as amblyopia and glaucoma are discussed in detail. In addition to surgical aspects, much emphasis is placed on orthoptic-refractive aftercare, the quality and execution of which is the essential predictor of a good functional outcome.

Angle Surgery in Pediatric Glaucoma Following Cataract Surgery

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

Clinical characteristics and treatment of secondary glaucoma, glaucoma suspects and ocular hypertension after congenital cataract surgery

OBJECTIVE

To evaluate changes in intraocular pressure after congenital cataract surgery in a real-world setting.

METHODS

This retrospective case series included all children aged 0-2 years undergoing lens extraction due to congenital cataract. Development of an elevated intraocular pressure was divided into three groups: secG, suspG and OHT. Further, risk factors for IOP changes, the therapeutic approach and functional outcome were assessed during follow-up.

RESULTS

One hundred and sixty-one eyes of 110 patients aged 0-2 years were included, whereof 29 eyes of 17 children developed secondary glaucoma (secG; 11 eyes/8 patients), glaucoma suspect (suspG; three eyes/three patients) or ocular hypertension (OHT; 15 eyes/10 patients). No difference in surgrical procedure (p = 0.62) was found, but age at cataract surgery differed significantly (p = 0.048), with the secG group (1.74 ± 1.01 months) being the youngest (suspG: 3.93 ± 1.80 months; OHT group: 5.91 ± 5.36 months).Secondary surgical intervention was significantly higher in the secG (4.64 ± 3.41) followed by the suspG (2.00 ± 2.65) and OHT groups (0.40 ± 0.74; p < 0.001). Postoperative complications including nystagmus (p = 0.81), strabismus (p = 0.98) and amblyopia (p = 0.73) showed no difference, in contrast to visual axis obscuration which was more common in the secG group (p = 0.036).

CONCLUSION

Initial lensectomy and anterior vitrectomy procedure together with or without IOL implantation seems to have no influence for the development of IOP changes after pediatric cataract surgery. However, children who developed secondary glaucoma had cataract surgery significantly earlier, within the first 2-3 months of life. Glaucoma surgery was required to achieve final IOP control in most eyes. The development of secondary glaucoma was also associated with a significant increase in surgical re-treatments.

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.

[Treatment of congenital and early childhood cataract]

The successful outcome of treatment for infant and childhood cataract depends on many factors. It is crucial that the treatment falls into a phase in which neither the eye nor the visual pathway and visual cortex are fully developed. This review summarizes the current state of knowledge and provides an overview of the epidemiology, causes and clinical forms, early detection and, above all, treatment options. Special attention is paid to time-critical stages of development, according to which the therapeutic concepts are based. Complications, such as amblyopia and glaucoma are discussed in detail. In addition to surgical aspects, much emphasis is placed on orthoptic-refractive aftercare, the quality and execution of which is the essential predictor of a good functional outcome.

Secondary glaucoma and visual outcome after paediatric cataract surgery with primary bag-in-the-lens intraocular lens

PURPOSE

To determine predictors of secondary glaucoma and poor visual outcome in children undergoing cataract surgery with bag-in-the-lens (BIL)-IOL implantation.

METHODS

Medical records were retrospectively analysed for children with primary implantation with BIL-IOL during 2009-2013.

RESULTS

The study included 109 eyes. Median age at surgery was 2.5 years (range 2 weeks-14.1 years), 26.6% being ≤12 weeks of age (= early group). Median follow-up time was 2.8 years (7 months-5.8 years). 15 eyes (13.8%) developed glaucoma, 14 (48.3%) in the early group and 1 (1.3%) in the late group (p < 0.001). Within the early group, mean time for surgery differed significantly. Patients developing glaucoma had cataract surgery at 3.5 ± 1.1 weeks (mean ± SD) and the non-glaucoma patients at 5.7 ± 3.3 weeks (p = 0.024). In the entire cohort, 21 eyes (19.3%) had conditions associated with glaucoma; 57.1% of these developed glaucoma compared to 3.4% without these conditions (p < 0.001). Corrected distance visual acuity (CDVA) (decimal) of ≥0.5 was seen in 50 eyes (48.5%), median 0.63 in the late group and 0.15 in the early group. Glaucoma eyes in the early group (surgery at 3.5 weeks) achieved 0.56 median (range, 0.4-1.0) logMAR, (0.28 decimal) CDVA, whereas non-glaucoma eyes (surgery at 5.7 weeks) achieved 0.89 median (range 0.7-1.6) logMAR (0.13 decimal) CDVA; p = 0.016. Glaucoma development in infants between 5 weeks and 2 years of age was 6.7% (n = 2/30).

CONCLUSIONS

Comorbidity strongly increases the risk of secondary glaucoma. Surgery during the first month is correlated with better CDVA outcome and glaucoma. After 5 weeks of age, glaucoma rate is low with the BIL-IOL.

Iridocorneal Angle and Anterior Segment Structure of Eyes in Children with Cataract

OBJECTIVE

To evaluate the morphology of iridocorneal angle and anterior segment in eyes of children with cataract.

METHODS

In this prospective cross-sectional study, we included eyes of children with bilateral cataract as well as unilateral cataract and fellow eyes. The iridocorneal angle was evaluated using gonioscopy. We compared the preoperative structures of iridocorneal angle and anterior segment between cataractous eyes and fellow eyes. The grading of iridocorneal angle and anatomical changes were analyzed.

RESULTS

We finally recruited 55 eyes of 55 children with bilateral cataract and 41 cataractous eyes and 33 fellow eyes of 41 children with unilateral cataract. The fellow eyes were used as a control group. The iridocorneal angle was open in eyes with pediatric cataract when compared to control eyes. The eyes with cataract exhibited more pigments on the trabecular meshwork than control eyes did (unilateral cataract vs. control, p = 0.013; bilateral cataract vs. control, p = 0.002). The eyes with cataract exhibited a smaller cornea than control eyes (unilateral cataract vs. control, p = 0.031; bilateral cataract vs. control, p < 0.001).

CONCLUSIONS

The iridocorneal angle is open in the eyes of children with cataract. Eyes with increased pigments on the trabecular meshwork need to be carefully monitored and surgeons should to be on the alert for postoperative glaucoma.

Glaucoma following cataract surgery in the first 2 years of life: frequency, risk factors and outcomes from IoLunder2

Background

We investigated glaucoma related adverse events, predictors and impact at 5 years following surgery in the IoLunder2 cohort

Methods

Population based observational cohort study of children undergoing cataract surgery aged 2 years or under between January 2009 and December 2010. Glaucoma was defined using internationally accepted taxonomies based on the consequences of elevated intraocular pressure (IOP). Glaucoma related adverse events were any involving elevated IOP. Multivariable analysis was undertaken to investigate potential predictors of secondary glaucoma with adjustment for within-child correlation in bilateral cataract. Unilateral and bilateral cataract were analysed separately.

Results

Complete follow-up data were available for 235 of 254, 93% of the inception cohort. By 5 years after primary cataract surgery, 20% of children with bilateral cataract and 12% with unilateral had developed secondary glaucoma. Glaucoma related complications had been diagnosed in 24% and 36% of children, respectively. Independent predictors of glaucoma were younger age at surgery (adjusted OR for reduction of week in age: 1.1, 95%C I 1.1 to 1.2, p<0.001); the presence of significant ocular comorbidity (adj OR 3.2, 95% CI 1.1 to 9.6, p=0.01); and shorter axial length (adj OR for each mm 1.7, 95% CI 10.0 to 1, p=0.05) for bilateral cataract. Shorter axial length was the single independent factor in unilateral disease (adj OR 9.6, 95% CI 1.7 to 52, p=0.009)

Conclusions

Both younger age at surgery (the strongest marker of ocular ‘immaturity’) and smaller ocular size (a marker of both immaturity and developmental vulnerability) can be used to identify those at greatest risk of glaucoma due to early life cataract surgery.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Intraocular lens implantation as an isolated risk factor for secondary glaucoma in pediatric patients

OBJECTIVE

To evaluate the effect of intraocular lens (IOL) implantation on the development of secondary glaucoma after cataract surgery in pediatric patients.

DESIGN

Retrospective case series study.

METHODS

This study reviewed the medical records of children under 16 years of age who had undergone cataract surgery from 1996 to 2016 for congenital or developmental cataract. In every child an IOL was implanted in the primary surgery. Data collected included demographic information, age at cataract diagnosis and at surgery, surgical procedure, and postoperative follow-up of refraction, cup-to-disc ratio (C/D), intraocular pressure (IOP), and associated systemic and ocular anomalies. Patients with risk factors for glaucoma were excluded from the study.

RESULTS

Of the 255 children below age 16 years who underwent cataract extraction surgery with primary IOL implantation, 73 (124 eyes) met the inclusion criteria. Follow-up ranged from 4 to 18 years. Only 1 patient (0.8% of the 124 eyes) developed glaucoma in 1 of his 2 operated eyes; the surgeries were performed at 10 months, 1 week apart, and glaucoma was diagnosed 4 months later. One patient had suspected glaucoma in both eyes (incidence of 1.6%). Both these children were of Bedouin origin.

CONCLUSION

IOL implantation, by itself, is not a risk factor for development of secondary glaucoma after cataract surgery in a population below 16 years of age.

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.

Incidence and Risk Factors of Early-onset Glaucoma following Pediatric Cataract Surgery in Egyptian Children: One-year Study

Aim

To study the incidence and risk factors of glaucoma occurring within 1 year following pediatric cataract surgery in Egyptian children.

Materials and methods

This is a prospective nonrandomized study conducted at Aburich Children’s Hospital, over a period of 1 year on a cohort of Egyptian patients with congenital and infantile cataract. One hundred and fifty eyes of 88 patients were enrolled in this study. All the patients underwent anterior approach removal of lens matter, whereas primary intraocular lens (IOL) implantation was carried at the age of 1 and 2 years for unilateral and bilateral cases respectively. Intraocular pressure (IOP) was measured at 1 week, 1 month, 3 months, 6 months, 9 months, and 1 year. For those who developed glaucoma, time of diagnosis and associated risk factors were reported.

Results

The incidence of glaucoma was 11.33% (17 of 150 eyes), while incidence of glaucoma suspect was 0.67% (1 of 150 eyes) in the first year following cataract surgery. The majority of the cases (66.7%) were discovered in the first 3 months postcataract surgery. Age at time of cataract surgery, the state of aphakia/pseudophakia, persistent fetal vasculature (PFV), and microphthalmia were not found to be significant predictors of early-onset glaucoma in our study.

Conclusion

Aphakic glaucoma continues to be a devastating condition with high incidence during first year following cataract surgery.

Clinical significance

Regular follow-up should start as early as possible following cataract surgery. Further prospective studies with larger study population are required.

How to cite this article: Gawdat GI, Youssef MM, Bahgat NM, Elfayoumi DM, Eddin MAS. Incidence and Risk Factors of Early-onset Glaucoma following Pediatric Cataract Surgery in Egyptian Children: One-year Study. J Curr Glaucoma Pract 2017;11(3):80-85.

Primary Congenital Glaucoma Versus Glaucoma Following Congenital Cataract Surgery: Comparative Clinical Features and Long-term Outcomes

PURPOSE

To report and compare visual and glaucoma outcomes in primary congenital glaucoma (PCG) vs glaucoma following congenital cataract surgery (GFCS).

DESIGN

Retrospective, observational, comparative case series.

METHODS

Setting: Emory Eye Center, Atlanta, Georgia.

STUDY POPULATION

Pediatric glaucoma patients (age 0-18 years) treated at Emory by 1 clinician with ≥2-year follow-up. Glaucoma was defined according to the 9th Consensus Report of the World Glaucoma Association.

MAIN OUTCOME MEASURES

Snellen-equivalent logMAR visual acuity (VA) and glaucoma control (IOP ≤21, no devastating complications, no recommendation for further glaucoma surgery). Asymptotic Wilcoxon-Mann-Whitney rank sum tests were employed to compare glaucoma subgroups.

RESULTS

Included were 72 PCG and 56 GFCS cases, with mean follow-up time of 7.4 ± 4.1 and 8.0 ± 3.8 years, respectively. At last follow-up, PCG showed better median VA than GFCS in worse-seeing eyes (20/60 [interquartile range (IQR) 20/30-20/200] vs 20/400 [IQR 20/70-hand motion], respectively, P < .0001) and in better-seeing eyes of bilaterally-affected children (20/30 [IQR 20/20-20/60] vs 20/70 [IQR 20/35-20/100], respectively, P = .024).The following variables characterized the PCG and GFCS groups' glaucoma status, respectively: mean age at diagnosis (years), 0.70 ± 1.3 vs 3.3 ± 3.5 (P < .0001); median IOP (mm Hg), 15.50 [IQR 12.1-19.4] vs 17.50 [IQR 14.9-22], P = .037; median number of glaucoma medications at last follow-up, 1.49 [IQR 0-2] vs 2.54 [IQR 1-4], P < .0001; median number of glaucoma surgeries, 1.0 [IQR 1-2] vs 1.25 [IQR 0.5-2.0], P = .09.

CONCLUSIONS

Children with PCG (vs those with GFCS) presented earlier, had better vision, required fewer medications to control disease, and had lower IOP at last follow-up.

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

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

Surgical outcomes of congenital and developmental cataracts in Japan

PURPOSE

To retrospectively analyze the surgical outcomes of congenital/developmental cataracts in Japan.

METHODS

A mail questionnaire was sent to facilities engaged in surgical treatment of congenital cataracts.

RESULTS

Twenty-nine facilities reported on 809 eyes of 508 patients with congenital/developmental cataracts. Three hundred fifty-nine eyes underwent intraocular lens implantation (pseudophakia group), while 450 eyes were left aphakic (aphakia group). The average age at surgery was significantly higher in the pseudophakia group (70 ± 53 months) than in the aphakia group (14 ± 24 months) (P < 0.0001). A significantly larger proportion of patients with unilateral cataract (52.0 %) received IOL implantation than did those with bilateral cataracts (42.6 %) (P = 0.0224). The prevalence of associated ocular disorders, such as nystagmus, microcornea, nanophthalmos, and persistent fetal vasculature, was significantly higher in the aphakia group than in the pseudophakia group. Postoperatively, glaucoma developed more frequently in the aphakia group (5.8 %) than in the pseudophakia group (0.7 %) (P = 0.0003). Posterior capsule opacification developed more frequently in the pseudophakic eyes even when both posterior capsulotomy and anterior vitrectomy were performed, especially in patients aged 1 year or younger. Postoperative visual acuity was significantly better in the pseudophakia group than in the aphakia group, both in the unilateral and in the bilateral cases.

CONCLUSIONS

Surgeons tended to select IOL implantation, rather than to leave the eye aphakic, in patients who were older at the time of surgery, had fewer coexisting ocular disorders, and suffered from unilateral cataract. Under such circumstances, pseudophakic eyes obtained significantly better postoperative visual acuity than did aphakic eyes.

Complications of pediatric cataract surgery

PURPOSE

Cataract surgery in young children poses different challenges and potential complications compared to those encountered in adult populations. We performed a literature review of the complications of pediatric cataract surgery.

METHODS

Literature review of complications of pediatric cataract surgery.

RESULTS

Complications in children vary based on the age of the patient at surgery and the cause of the cataract. Common events discussed include increased inflammatory response, opacification of the posterior capsule, lens reproliferation, pupillary membrane, and amblyopia; less common events include infections, significant bleeding, and retinal detachment.

CONCLUSION

Complications after cataract surgery in children are often associated with a robust inflammatory reaction or secondary opacity and, in infants, glaucoma. Late complications can occur decades later, so that long-term follow-up is required. Though surgery carries significant risks, the consequences of no surgery and irreversible deprivation amblyopia in very young children should be considered.

Intraocular pressure control with echothiophate iodide in children's eyes with glaucoma after cataract extraction

PURPOSE

To report the intraocular pressure (IOP)-lowering ability and side-effect profile of echothiophate iodide (EI) in the control of glaucoma in aphakic and pseudophakic eyes of children.

METHODS

The medical records of all aphakic and pseudophakic children treated with EI for IOP lowering after developing glaucoma were retrospectively reviewed.

RESULTS

A total of 32 eyes of 21 children were included. Mean age at cataract removal was 3.9 months (range, 5 days-2.7 years). Mean age of glaucoma diagnosis was 3.2 years (range, 40 days-12 years). Mean duration from cataract removal and diagnosis of glaucoma was 2.9 years (range, 16 days-12 years). EI reduced IOP in 31 of 32 eyes. Mean baseline IOP (29.1 ± 5.3 mm Hg) dropped to 19.6 ± 6.7 mm Hg. Six eyes had IOP spikes that could not be controlled with other medications when commercial unavailability led to discontinuation of EI. Average duration of use was 3.5 years. Mean final IOP on an average of 2.2 medications was 16.9 ± 5.1 mm Hg 7.9 years following initial glaucoma diagnosis. Four eyes required surgery for uncontrolled IOP. Side-effects included transient redness (3/32 eyes), not necessitating discontinuation of EI.

CONCLUSIONS

EI lowered IOP to within an acceptable range with no significant adverse events. In several patients it was the only pharmacologic agent that was successful.

Expression of the HSF4 DNA binding domain-EGFP hybrid gene recreates early childhood lamellar cataract in transgenic mice

PURPOSE

The clinical management of cataracts in infancy involves surgical removal of the lens to ensure transmission of light to the retina, which is essential for normal neural development of the infant. This surgery, however, entails a lifelong follow-up and impaired vision. To our knowledge, no animal models recapitulate human lamellar opacities, the most prevalent form of early childhood cataracts. We present data on the recreation of the human lamellar cataract phenotype in transgenic mice.

METHODS

Mutations in the DNA binding domain (DBD) of the heat shock transcription factor 4 (HSF4) are known to be associated with early childhood autosomal dominant lamellar cataract. We used bacterial artificial chromosome (BAC) transgenesis to express a hybrid gene: Hsf4 (DBD)-enhanced green fluorescent protein (EGFP), by recombineering EGFP sequences into the DBD of the Hsf4 gene, to interfere with the DNA binding properties of Hsf4.

RESULTS

We recapitulated the human lamellar cataract, in its temporal as well as spatial presentation, within the transgenic mouse lens. This phenotype was reproduced faithfully using four different BACs, indicating that EGFP can be used to target transcription factor function in transgenic mice. Molecular and cell biological examination of early postnatal transgenic lens reveals impairment of secondary fiber cell differentiation.

CONCLUSIONS

Recreation of the human lamellar cataract phenotype in mice allows investigation of this human pathology at a level not possible previously and points to the relevance of fiber cell heterogeneity dictated by fiber cell-specific gene activity in the biogenesis of the lamellar cataract.

Comparison of contact lens and intraocular lens correction of monocular aphakia during infancy: a randomized clinical trial of HOTV optotype acuity at age 4.5 years and clinical findings at age 5 years

IMPORTANCE

The efficacy and safety of primary intraocular lens (IOL) implantation during early infancy is unknown.

OBJECTIVE

To compare the visual outcomes of patients optically corrected with contact lenses vs IOLs following unilateral cataract surgery during early infancy.

DESIGN, SETTING, AND PARTICIPANTS

The Infant Aphakia Treatment Study is a randomized clinical trial with 5 years of follow-up that involved 114 infants with unilateral congenital cataracts at 12 sites. A traveling examiner assessed visual acuity at age 4.5 years.

INTERVENTIONS

Cataract surgery with or without primary IOL implantation. Contact lenses were used to correct aphakia in patients who did not receive IOLs. Treatment was determined through random assignment.

MAIN OUTCOMES AND MEASURES

HOTV optotype visual acuity at 4.5 years of age.

RESULTS

The median logMAR visual acuity was not significantly different between the treated eyes in the 2 treatment groups (both, 0.90 [20/159]; P = .54). About 50% of treated eyes in both groups had visual acuity less than or equal to 20/200. Significantly more patients in the IOL group had at least 1 adverse event after cataract surgery (contact lens, 56%; IOL, 81%; P = .02). The most common adverse events in the IOL group were lens reproliferation into the visual axis, pupillary membranes, and corectopia. Glaucoma/glaucoma suspect occurred in 35% of treated eyes in the contact lens group vs 28% of eyes in the IOL group (P = .55). Since the initial cataract surgery, significantly more patients in the IOL group have had at least 1 additional intraocular surgery (contact lens, 21%; IOL, 72%; P < .001).

CONCLUSIONS AND RELEVANCE

There was no significant difference between the median visual acuity of operated eyes in children who underwent primary IOL implantation and those left aphakic. However, there were significantly more adverse events and additional intraoperative procedures in the IOL group. When operating on an infant younger than 7 months of age with a unilateral cataract, we recommend leaving the eye aphakic and focusing the eye with a contact lens. Primary IOL implantation should be reserved for those infants where, in the opinion of the surgeon, the cost and handling of a contact lens would be so burdensome as to result in significant periods of uncorrected aphakia.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT00212134

HSF4 mutation p.Arg116His found in age-related cataracts and in normal populations produces childhood lamellar cataract in transgenic mice

The p.Arg116His mutation in the heat shock transcription factor-4 (HSF4) has been associated with age-related cataracts, but it is also seen in 2% of the normal population, indicating either reduced penetrance or that the normal subjects were not old enough to express the phenotype. Based on the proximity of p.Arg116His to two known mutations in the DNA-binding domain of HSF4, namely, p.Leu114Pro and p.Arg119Cys, which segregate with childhood lamellar cataract, we tested the possibility that this phenotype may have been missed by the ophthalmologist and/or that it did not spread to the visual axis so as to affect vision significantly. Here, we demonstrate via BAC (bacterial artificial chromosome) transgenesis that p.Arg116His recreates the childhood lamellar cataract in mice suggesting that incomplete penetrance associated with early cataracts may not be an absence but a limitation of the detection of the phenotype.

Long-term risk of glaucoma after congenital cataract surgery

PURPOSE

To report the long-term risk of glaucoma development in children following congenital cataract surgery.

DESIGN

Retrospective interventional consecutive case series.

METHODS

We retrospectively reviewed the records of 62 eyes of 37 children who underwent congenital cataract surgery when <7 months of age by the same surgeon using a limbal approach. The Kaplan-Meier method was used to calculate the probability of an eye's developing glaucoma and/or becoming a glaucoma suspect over time.

RESULTS

The median age of surgery was 2.0 months and the median follow-up after cataract surgery was 7.9 years (range, 3.2-23.5 years). Nine eyes (14.5%) developed glaucoma a median of 4.3 months after cataract surgery and an additional 16 eyes (25.8%) were diagnosed as glaucoma suspects a median of 8.0 years after cataract surgery. The probability of an eye's developing glaucoma was estimated to be 19.5% (95% CI: 10.0%-36.1%) by 10 years after congenital cataract surgery. When the probability of glaucoma and glaucoma suspect were combined, the risk increased to 63.0% (95% CI: 43.6%-82.3%).

CONCLUSIONS

Long-term monitoring of eyes after congenital cataract surgery is important because we estimate that nearly two thirds of these eyes will develop glaucoma or become glaucoma suspects by 10 years after cataract surgery.

Results of congenital cataract surgery with and without intraocular lens implantation in infants and children

BACKGROUND

Operations for congenital cataract in children in the past had resulted in aphakia. Improvement in surgical tools and techniques as well as in intraocular lens (IOL) implantation has led to correction of the aphakia by IOL implantation. We report the outcome of cataract surgery with and without IOL on these children in our institution between 1991-2008.

METHODS

In this retrospective cohort study, the medical records of all children who underwent surgery for congenital cataract were reviewed. The final study group included 144 children (218 eyes). Postoperative visual acuity (VA) was tested either by Teller Acuity Cards (in preverbal children) or by the Snellen chart. Data on VA status and postoperative complications were retrieved.

RESULTS

Patients with bilateral cataract had better postoperative VA than patients with unilateral cataract (logMAR 0.559 ± 0.455 vs. 0.919 ± 0.685, respectively, P < 0.001). Children who underwent IOL implantation had better postoperative VA than those who did not, but the type of surgery had no significant effect after correction for the child's age at surgery (P = 0.346). Secondary cataract occurred more frequently in the extra-capsular cataract extraction (ECCE) + IOL implantation group than in the ECCE only group (20.6 % vs. 8.3 %, respectively, P = 0.018).

CONCLUSIONS

Patients with bilateral cataract had better postoperative VA compared with those with unilateral cataract. The type of surgery had no effect on final VA, but there was a higher rate of secondary cataract in the ECCE + IOL patients compared to the ECCE only patients.

Glaucoma after pediatric cataract surgery in a population with limited access to care

BACKGROUND

Cataract is a leading cause of childhood blindness in eastern Africa and other resource-constrained regions around the world, and high-quality surgical centers are increasingly responding to this challenge. Despite evidence concerning the ongoing risk of postoperative glaucoma after lensectomy, little is known of the incidence of glaucoma after pediatric cataract surgery in Africa. We sought to evaluate the frequency and predictors of postoperative glaucoma in this setting.

METHODS

The medical records of all children who underwent surgery for congenital or developmental cataract between 2003 and 2005 at the Kilimanjaro Christian Medical Centre were retrospectively reviewed to determine the incidence of postoperative glaucoma. Potential risk factors were evaluated by means of logistic regression.

RESULTS

Cumulative incidence of glaucoma at 3 years was 6.5% (95% CI, 2.5-16.0), and the annual incidence rate was 2.0 cases per 100 operated eyes (95% confidence interval, 0.74-4.37). Total time of follow-up and absence of primary intraocular lens implantation correlated with risk for postoperative glaucoma, but multivariate analysis could not confirm independent associations.

CONCLUSIONS

As cataract surgical rates continue to increase and pediatric ophthalmology centers in Africa progress toward the goals of Vision 2020: The Right to Sight, renewed efforts must be directed toward the long-term postoperative care of all children undergoing operation for pediatric cataract.

Management and outcomes of cataract in children: the Toronto experience

PURPOSE

To review the management and outcomes of pediatric patients with cataract who were managed by one of two surgeons at a single institution.

METHODS

An observational series of consecutive cases identified from the hospital's outpatient billing records and surgical data program were used. Visual acuity was measured with the Snellen or Allen charts. Glaucoma was defined as IOP >20 mm Hg with clinical signs of glaucoma or visual field loss. Procedures for aphakic/pseudophakic glaucoma were excluded from analysis of additional surgeries performed subsequent to cataract extraction.

RESULTS

The search identified 778 patients (1,122 eyes) diagnosed with cataract over 10 years. Of these, 74% of eyes were treated surgically. Those patients with total, nuclear, and lamellar cataracts were significantly more likely than the overall population to undergo surgery. Additional surgeries were required in 12% of surgically treated eyes, with pseudophakic eyes representing more than one-half. Aphakic and pseudophakic glaucoma prevalence were 12% and 1%, respectively. Cataract morphology was not found to be a predisposing factor in the development of glaucoma. Visual outcomes were significantly better for posterior subcapsular (P = 0.0001), nuclear (P = 0.025), lamellar (P = 0.03), and traumatic cataracts (P = 0.005) than for other morphological types at all ages. Visual acuity was 20/30 or better in 63% of children with unilateral pseudophakia, 45% of children with unilateral aphakia, and approximately 75% of children with bilateral aphakia and pseudophakia.

CONCLUSIONS

Patients with total, nuclear, and lamellar cataracts were more likely to undergo surgery. Approximately 10% of patients required additional surgeries. No cataract morphology predisposed patients to developing glaucoma. Good visual outcomes were attained in bilaterally pseudophakic/aphakic and unilaterally pseudophakic children.

[Aphakic and pseudophakic glaucoma following pediatric cataract surgery]

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

Glaucoma following infantile cataract surgery

PURPOSE

To examine incidence, risk factors, and outcomes of glaucoma following infantile cataract extraction.

METHODS

A retrospective chart review of all patients who underwent cataract extraction between January 1, 1993, and December 31, 2006, at the Children's Medical Center in Dallas.

RESULTS

Sixty-four eyes met inclusion criteria, of which 11 eyes (17.2%) developed glaucoma during a mean follow-up of 65.1 ± 4.3 months. Age younger than 3 months at cataract diagnosis (odds ratio 4.89, P = .05) or cataract extraction (odds ratio 4.4, P = .047) and the presence of anterior chamber anomalies (odds ratio 8.0, P = .01) were the only risk factors found to have statistical significance for the development of glaucoma. Eight of 11 eyes with glaucoma (72.2%) required at least one surgical intervention. Three of 10 eyes (30%) had a final best-corrected visual acuity below 20/400 and another 4 eyes (40%) demonstrated some degree of amblyopia.

CONCLUSION

Despite modern microsurgical techniques, infantile cataract surgery continues to pose a risk of secondary glaucoma. This was particularly true when cataract was diagnosed and/or extracted in patients younger than 3 months of age. Most eyes that developed glaucoma required surgical management and visual outcomes continue to be poor in this group.

[Results and complications of surgery of congenital cataract]

Results of surgery for congenital cataract were studied according to age of implantation, type and polarity. Each forms combined, visual acuity in logMAR is divided by a median of 0.45 (5/10) in bilateral cataracts and 0.7 (2/10) in the unilateral. The precocity of the surgery allows a better prognosis, but exposes to more complications, especially glaucoma. Complications as inflammatory diseases, glaucoma, capsular opacification, refractive error, residual myopic shift, and retinal complications are discussed.

Infantile aphakic glaucoma: a proposed etiologic role of IL-4 and VEGF

PURPOSE

To identify the factors secreted by lens epithelial cells (LECs) responsible for the altered trabecular meshwork (TM) cells and to compare their effect on monocultured TM cells with that of TM cells co-cultured with LECs.

METHODS

Such factors were isolated using cytokine antibody array membranes, and their effect on TM cells was assessed by analyzing changes in morphology and gene expression. In addition, inhibition of the isolated factors was performed in the co-culture model by adding specific antibodies to the cell culture media.

RESULTS

Transforming growth factor beta-2, interleukin-4 (IL-4), and vascular endothelial growth factor (VEGF) are presented as candidate cytokines responsible for the observed changes in LEC-TM co-cultures. Culturing TM cells in the presence of VEGF and IL-4 triggered alterations closely reflecting those observed in the LEC-TM co-culture model, where their inhibition significantly hindered the alteration of the TM cells.

CONCLUSION

These findings suggest a possible explanation for the development of infantile aphakic glaucoma, based on residual LECs secreting IL-4 and VEGF after removal of congenital cataract, which then alter trabecular meshwork cell morphology and gene expression.

Acquired central corneal thickness increase following removal of childhood cataracts

PURPOSE

To evaluate central corneal thickness (CCT) in children with congenital/developmental cataracts before and after cataract removal, to correlate CCT with corneal diameters before cataract surgery in this same group, and to evaluate CCT over time in a separate group of children who were already aphakic or pseudophakic at study entry.

DESIGN

Longitudinal study.

METHODS

Children with cataract (Group 1, with pre-cataract-removal CCT) and aphakia/pseudophakia (Group 2, presenting after cataract removal) were included. CCT measurements were performed using ultrasound pachymetry. Normal fellow eyes of unilaterally affected cases served as controls. In bilateral cases, right eyes were used for analyses.

RESULTS

Group 1 comprised 66 children. Before cataract surgery, unilateral cases (n = 31) showed similar CCT and strong association between the affected and fellow eyes (552.0 ± 32.9 μm vs 550.9 ± 40.4 μm, respectively; r(2) = 0.71, P = .0001). After cataract surgery, affected eyes (n = 13) showed mean CCT increase of 29.7 ± 43.1 μm (P = .03) while fellow eyes remained unchanged. Similarly, before cataract surgery, bilateral cases (n = 35) showed similar CCT between the right and left eyes. After cataract surgery, mean CCT increase was 27.4 ± 39.4 μm for first operated eyes of bilateral cases (n = 17, P = .01). Group 2 comprised 50 aphakic/pseudophakic children lacking pre-cataract-removal CCT. CCT was higher in eyes with glaucoma vs those without, at both first and last measurements (ΔCCT 58.9 ± 27.0 μm at first examination, P = .034, and 56.4 ± 27.1 μm at last examination, P = .043, respectively). There was no statistically significant CCT change over the study interval (median 28 months) for either Group 2 eyes with or those without glaucoma.

CONCLUSIONS

CCT in children with cataracts increases after cataract surgery while the fellow eye remains stable. This increase seems to occur early after surgery, likely remaining stable thereafter, though glaucoma can accentuate the increase.

Simultaneous vs sequential bilateral cataract surgery for infants with congenital cataracts: Visual outcomes, adverse events, and economic costs

OBJECTIVES

To compare the incidence of adverse events and visual outcomes and to compare the economic costs of sequential vs simultaneous bilateral cataract surgery for infants with congenital cataracts.

METHODS

Retrospective review of simultaneous vs sequential bilateral cataract surgery for infants with congenital cataracts who underwent cataract surgery when 6 months or younger at our institution.

RESULTS

Records were available for 10 children who underwent sequential surgery at a mean age of 49 days for the first eye and 17 children who underwent simultaneous surgery at a mean age of 68 days (P = .25). We found a similar incidence of adverse events between the 2 treatment groups. Intraoperative or postoperative complications occurred in 14 eyes. The most common postoperative complication was glaucoma. No eyes developed endophthalmitis. The mean (SD) absolute interocular difference in logMAR visual acuities between the 2 treatment groups was 0.47 (0.76) for the sequential group and 0.44 (0.40) for the simultaneous group (P = .92). Payments for the hospital, drugs, supplies, and professional services were on average 21.9% lower per patient in the simultaneous group.

CONCLUSIONS

Simultaneous bilateral cataract surgery for infants with congenital cataracts is associated with a 21.9% reduction in medical payments and no discernible difference in the incidence of adverse events or visual outcomes. However, our small sample size limits our ability to make meaningful comparisons of the relative risks and visual benefits of the 2 procedures.

Lack of glaucoma following infantile cataract surgery with primary posterior chamber intraocular lens implantation

BACKGROUND AND OBJECTIVE

To determine the incidence of glaucoma following infantile cataract surgery with primary posterior chamber lens (PC-IOL) implantation for isolated non-traumatic cataract.

PATIENTS AND METHODS

Retrospective institutional medical record review.

RESULTS

Thirty-six eyes of 31 patients were identified. Small incision surgery (including posterior capsulotomy and anterior vitrectomy) was performed at a mean age of 7.6 months (median: 7 months; range: 5 to 10 months) with in-the-bag PC-IOL placement in 27 eyes and sulcus PC-IOL placement in 9 eyes. Last follow-up examination was a mean 67.1 months postoperatively (median: 65 months; range: 60 to 84 months). No eye was diagnosed as having glaucoma. In a similar population (same methods, age range, and ethnic group) that was left aphakic, the incidence of glaucoma was 22 of 57 eyes (38.6%).

CONCLUSION

Primary PC-IOL implantation may confer protection against delayed-onset glaucoma following cataract surgery between 5 and 10 months of age.