Pediatric cataract
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ANN OPHTHALMOL. 2006; 38 (2) .....................................................97 Consultation Section PEDIATRIC CATARACT Questions: What Workup Do You Use With Pediatric Cataracts? What Are the Misconceptions and Mistakes With Pediatric Cataracts? Answer: Pediatric cataract has varied presentations. A congenital cataract may be isolated or hereditary; it may be unilat- eral or bilateral; it may be the only abnormality or there may be microcornea and/or nystagmus; it may be a part of a syndrome. The anterior chamber may be normal, shallow, or deep. The chamber is deep when the cataract is mostly absorbed and membranous. The pupil may be normal or small, and it might dilate with diffi- culty. Dilatation of the pupil helps to study the cataract itself, so that a surgical approach can be planned. Trau- matic pediatric cataract has varied presentations as well, depending on the type and direction of injury. Marfan syndrome cases need special mention. They usually present after many years, when the child has difficulty in school. A B-scan ocular ultrasound, which can detect a flaw in the posterior capsule that allows the lens matter to escapes posteriorly, is done in every case. Cataract with pre-existing posterior capsule defect/rup- ture needs to be handled very carefully. Intraocular power in non-cooperative young patients is calculated on the operating table using A-scan ocular ultrasound and a hand-held Ortho-K instrument. Many times the calculated power of the intraocular lens (IOL) is so high that a matching lens cannot be found. The highest power lens that we have is +36-diopter iris claw lens. The goal in congenital cataract surgery is to clear the optical axis at the earliest age and also provide gross correction of the refractive error. We have performed numerous operations at the age of 2 months. Many of these patients have been followed for more than 10 years. We have not yet compared visual results with the results obtained in patients operated at a later age, for example, 4 months, 6 months, or 1 year. Pleoptic exer- cises help improve the visual acuity of a majority of the pediatric patients. Our most important finding in the past two decades of unilateral congenital surgery is that a vast majority of these patients develop good vision after visual exercises. F. Hampton Roy, MD, FACS, OOSS, AAO Dennis Shepard, MD, FACS EDITED BY DENNIS SHEPARD, MD, FACS, F. HAMPTON ROY, MD, FACS, OOSS, AAO
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Transcript of Pediatric cataract
ANN OPHTHALMOL. 2006;38 (2) .....................................................97
Consultation Section
PEDIATRIC CATARACT
Questions: What Workup Do You Use With Pediatric Cataracts? What Are theMisconceptions and Mistakes With PediatricCataracts?
Answer:Pediatric cataract has varied presentations. A congenitalcataract may be isolated or hereditary; it may be unilat-eral or bilateral; it may be the only abnormality or theremay be microcornea and/or nystagmus; it may be a partof a syndrome. The anterior chamber may be normal,shallow, or deep. The chamber is deep when thecataract is mostly absorbed and membranous. The pupilmay be normal or small, and it might dilate with diffi-culty. Dilatation of the pupil helps to study the cataractitself, so that a surgical approach can be planned. Trau-matic pediatric cataract has varied presentations as well,depending on the type and direction of injury.
Marfan syndrome cases need special mention. Theyusually present after many years, when the child hasdifficulty in school. A B-scan ocular ultrasound, whichcan detect a flaw in the posterior capsule that allows thelens matter to escapes posteriorly, is done in every case.Cataract with pre-existing posterior capsule defect/rup-ture needs to be handled very carefully.
Intraocular power in non-cooperative young patientsis calculated on the operating table using A-scan ocularultrasound and a hand-held Ortho-K instrument. Manytimes the calculated power of the intraocular lens (IOL)is so high that a matching lens cannot be found. Thehighest power lens that we have is +36-diopter irisclaw lens.
The goal in congenital cataract surgery is to clear theoptical axis at the earliest age and also provide grosscorrection of the refractive error. We have performednumerous operations at the age of 2 months. Many ofthese patients have been followed for more than 10years. We have not yet compared visual results with theresults obtained in patients operated at a later age, forexample, 4 months, 6 months, or 1 year. Pleoptic exer-cises help improve the visual acuity of a majority of thepediatric patients. Our most important finding in thepast two decades of unilateral congenital surgery is thata vast majority of these patients develop good visionafter visual exercises.
F. Hampton Roy, MD, FACS, OOSS, AAO
Dennis Shepard, MD, FACS
EDITED BY DENNIS SHEPARD, MD, FACS, F. HAMPTON ROY, MD, FACS, OOSS, AAO
The choice of IOL is either an in-the-bag hydrophilicsquare edge lens or an iris-fixated claw lens. When poste-rior capsular support is lacking for any reason, the iris-claw lens is a better choice. Sulcus fixated IOL are proneto many early and late postoperative problems. A suffi-ciently large iridectomy is required after iris-claw lensimplantation. A postoperative closure of iridectomy shalllead to pupil block and iris bombe with all the adverseconsequences. In the past, an iris-claw lens gave theoption of an easy explanation and exchange in case of aresultant undesirable refractive error. Currently, ratherthan exchange the lens, it is easy to correct the residualrefractive error with refractive laser surgery, even at ayoung age.
Pediatric cataract surgery is not difficult, provided theanterior chamber is not allowed to collapse at any timeduring surgery. Hypotony and shallow anterior chamberallow a quick appearance of fibrin from near the angleand less so from the surface of the iris. A planned cleananterior vitrectomy does no harm, but a lens vitreousmix may be the start of a chronic inflammation. Whateverthe size and configuration of the incision line, it shouldnot be left unsutured. Make sure that every incision lineis water-tight. To minimize postoperative reaction, dilutedkenacort in saline is injected into the anterior chamber
after which the chamber is washed. Some kenacort parti-cles remain attached to the iris. This amount is sufficientto prevent postoperative reaction. We do no not find anydifference in ocular reaction between rubella-positiveand rubella-negative patients. The surgery of the othereye is delayed for 2 months, or until we are sure of a suc-cessful procedure in the first eye.
The operated eyes need atropinization and anti-inflammatory steroid and nonsteroid drops for manyweeks and months. Every case needs to be watched forthe development of a secondary cataract. Whereas thinsecondary cataracts can be managed with Yag laser, thethicker membranes need to be removed by surgery. TheFugo Blade™ performs this function well without trac-tion on the tissues.
A successful surgery or re-surgery followed by anuneventful recovery is not the end of the story. It is thebeginning of long-term pediatric patient care with care-ful refraction, management of amblyopia, managementof strabismus, and orthoptic treatment to achieve thebest (i.e., three-dimensional) vision. It requires a greatorganization and a dedicated staff. Mere patching is notenough to achieve good results.
Daljit Singh, MDAmritsar, India
ANN OPHTHALMOL. 2006;38 (2).....................................................98
