2211LETTERS

children with traumatic cataract.2–4 Verma et al.5

observed a much higher rate of VAO in eyes in whicha primary posterior capsulotomy was not performed.Did the authors encounter any VAO at 1 year andwas any intervention done for it, as it can affect the fi-nal visual results? It would be more informative hadthe authors mentioned the type of resurgeries thatwere performed in 106 cases.

Jaspreet Sukhija, MDJagat Ram, MDChandigarh, India

REFERENCES1. ShahMA, Shah SM, Applewar A, Patel C, Patel K. Ocular trauma

score as a predictor of final visual outcomes in traumatic cataract

cases in pediatric patients. J Cataract Refract Surg 2012;

38:959–965

2. Eckstein M, Vijayalakshmi P, Killedar M, Gilbert C, Foster A. Use

of intraocular lenses in children with traumatic cataract in south

India. Br J Ophthalmol 1998; 82:911–915. Available at: http://

www.ncbi.nlm.nih.gov/pmc/articles/PMC1722709/pdf/v082p009

11.pdf. Accessed September 14, 2012

3. Koenig SB, Ruttum MS, Lewandowski MF, Schultz RO. Pseudo-

phakia for traumatic cataracts in children. Ophthalmology 1993;

100:1218–1224

4. BenEzra D, Cohen E, Rose L. Traumatic cataract in children:

correction of aphakia by contact lens or intraocular lens. Am

J Ophthalmol 1997; 123:773–782

5. Verma N, Ram J, Sukhija J, Pandav SS, Gupta A. Outcome of

in-the-bag implanted square-edge polymethyl methacrylate

intraocular lenses with and without primary posterior capsuloto-

my in pediatric traumatic cataract. Indian J Ophthalmol 2011;

59:347–351. Available at: http://www.ncbi.nlm.nih.gov/pmc/arti-

cles/PMC3159314/. Accessed September 14, 2012

Reply : We agree with Drs. Shukhija and Ram’sobservations about our study and the confusiontherein, which arose because of our failure to describeour methodology adequately. We would like to ad-dress the issue and add the details of the protocol wefollowed. We reiterate that the purpose was validityof the OTS as a predictor of final visual outcome intraumatic cataract cases in a pediatric age group.

In addition to a thorough history of ocular traumafor each patient younger than 18 years enrolled inour study, we obtained details of the injuries. Datafor the initial and follow-up reports were collected us-ing the online Birmingham Eye Trauma TerminologySystem format of the International Society of OcularTrauma.

Anterior segment examination was done accordingto protocol using torch light or hand-held slitlamp.Preoperativeworkup included an assessment of visualfunction according to the American Academy of Pedi-atrics vision check protocol; examinationwas done un-der anesthesia for uncooperative children. Fundus

J CATARACT REFRACT SURG - V

evaluation was done by indirect ophthalmoscope.B-scan (Ophthalmic Technologies, Inc.)was performed in children in whom the fundus viewwas obscured due to media opacities. Keratometrywas performed using a handheld keratometer (NidekCo. Ltd.). Three consecutive readings were taken.Axial lengthmeasurement was done byA/B Sonomedwith an average of 3 or more good readings.

A standardized examination protocol was followedfor every patient in the presence of a team of pediatricophthalmologists, anesthetists, optometrist, tech-nicians, and supporting staff present during the exam-ination under anesthesia. Ocular pressure wasmeasured using a Perkin’s handheld tonometer; thisprocedure was omitted for eyes with open-globe in-juries. Details of the surgery or any interventionwere collected using a specified pretested onlineform. All eyes were scored during the initial assess-ment according to the operational definitions OTS cal-culated according to guidelines.

As described in “Patients and Methods,” in allglobe-rupture patients, primary repair was per-formed first followed by cataract surgery so thecontact method of biometry could be used.1 Thesurgical technique was based on cataract morphol-ogy and the position of the lens, the presence of vit-reous in the lens and /or in anterior chamber, andthe conditions of the surrounding structures. Sur-gery was done by the anterior or pars plana route(20-gauge and/or 23-gauge) in most cases. In mem-branous variety of our cases, effort was made to sep-arate the fused capsule with an OVD; in select cases,an IOL was placed in the bag and through the parsplana, anterior vitrectomy and a primary posteriorcapsulorhexis were performed using a vitrectomycutter.

As detailed in the article, in the small number ofcases with an unstable bag or inadequate posteriorcapsule support but adequate peripheral capsulesupport, the poly(methyl methacrylate) (PMMA)IOL was placed in the ciliary sulcus, with adequateviscodissection and meticulous clearing of all poste-rior synechiae between the iris and the residualcapsule.

As described in the article, the secondary surgerywas done after 3 to 6weeks per the protocol and longerdelays were avoided in children who were amblyopic.The operated patients were reexamined after 24 hours;3 days; and 1, 2, and 6 weeks to enable refractive cor-rection. Follow-up examination was done according tostandard format. All children younger than 5 yearswere treated by patching for amblyopia.

Many of the points raised by Drs. Shukhija and Ramshould be clarified by the details and references pro-vided above. The biometry was performed when the

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patient came for secondary IOL implantation. Sinceglobe-rupture repair was done, the contact biometryprocedure was possible. The IOLMaster was used asneeded. Keratometrywas performed using a handheldkeratometer. Axial length measurement was done byA/B Sonomed. Keratometry and A-scan biometrywere performed for both eyes at our center. The IOLpower calculation was done using the SRK/II formulaand Dahan’s criteria were used while consideringIOLs in our pediatric patients and with the aim ofattaining emmetropia or to match the refractive errorin the fellow eye.1

In response to the point raised, the second surgerywas done 6 weeks after the primary repair of the cor-nea and corneoscleral wound repair, as mentioned inthe article. In all of our cases, secondary IOL implanta-tion was performed after the said period.

We apologize for the unintended typing mistakeabout the 219/290 cases.

We agree with Drs. Shukhija and Ram’s statementabout lensectomy and vitrectomy not being a preferredmethod, but in the literature variable views exist aboutthepreferredmethodof traumaticpediatric cataract sur-gery in children younger than 2 years. When this studywas done in 2002 and 2003, lensectorywas still awidelypopular method. As mentioned, we do not use it rou-tinely but lensectomy is the preferred method in casesof soft and fluffy or other cataract in which vitreouswas confirmed or suspected to have prolapsed into thelens. Lensectomy is very safe and can be combinedwith IOL implantation on retained anterior capsule.2,3

As mentioned in the article, the mean follow-upwasup to a year but the range was variable and up to10 years. We found sulcus-fixated PMMA IOLs arewell tolerated.4–10 We regret not mentioning in detailthat our aim was to validate the predictive value ofthe OTS in children with traumatic cataract. Our otherpublications covering the mentioned query have beensubmitted for publication.dMehul Shah, MD,Shreya Shah, MD, Pramod Upadhyay, MD

REFERENCES1. Shah M, Shah S, Shah S, Prasad V, Parikh A. Visual recovery

and predictors of visual prognosis after managing traumatic

cataracts in 555 patients. Indian J Ophthalmol 2011; 59:217–

222. Available at: http://www.ncbi.nlm.nih.gov/pmc/articles/

PMC3120243/?reportZprintable. AccessedSeptember 20, 2012

2. Thouvenin D. Prise en charge des cataractes de l’enfant: tech-

niques chirurgicales et choix de l’implant [Management of in-

fantile cataracts: surgical technics and choices in lens

implantation]. J Fr Ophtalmol 2011; 34:198–202.

3. Taylor D. Choice of surgical technique in the management of

congenital cataract. Trans Ophthalmol Soc UK 1981;

101:114–117

4. Kamlesh Dadeya S. Management of paediatric traumatic cata-

ract by epilenticular intraocular lens implantation: long-term

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visual results and postoperative complications. Eye 2004;

18:126–130. Available at: http://www.nature.com/eye/journal/

v18/n2/pdf/6700605a.pdf. Accessed September 20, 2012

5. Ahmadieh H, Javadi MA, Ahmady M, Karimian F, Einollahi B,

Zare M, Dehghan MH, Mashyekhi A, Valaei N, Soheilian M,

Sajjadi H. Primary capsulectomy, anterior vitrectomy, lensec-

tomy, and posterior chamber lens implantation in children:

limbal versus pars plana. J Cataract Refract Surg 1999;

25:768–775

6. Basti S, Ravishankar U, Gupta S. Results of a prospective eval-

uation of three methods of management of pediatric cataracts.

Ophthalmology 1996; 103:713–720

7. Gupta AK, Grover AK, Gurha N. Traumatic cataract surgery with

intraocular lens implantation in children. J Pediatr Ophthalmol

Strabismus 1992; 29:73–78

8. Bustos FR, Zepeda LC, Cota O. Intraocular lens implantation

in children with traumatic cataract. Ann Ophthalmol 1996;

28:153–157

9. Eckstein M, Vijayalakshmi P, Killedar M, Gilbert C, Foster A.

Aetiology of childhood cataract in south India. Br J Ophthalmol

1996; 80:628–632. Available at: http://www.ncbi.nlm.nih.

gov/pmc/articles/PMC505557/pdf/brjopthal00007-0048.pdf.

Accessed September 20, 2012

10. Pandey SK, Ram J, Werner L, Brar GS, Jain AK, Gupta A,

Apple DJ. Visual results and postoperative complications of cap-

sular bag and ciliary sulcus fixation of posterior chamber intraoc-

ular lenses in children with traumatic cataracts. J Cataract

Refract Surg 1999; 25:1576–1584

Instruments for ab externo scleral-fixatedintraocular lens

Slade et al.1 recently published an excellent descrip-tion of their technique for ab externo scleral fixation ofan intraocular lens. I use a very similar technique andhave 2 suggestions that may help anterior segmentsurgeons who operate at facilities that do not haveretinal instruments (microvitreoretinal blade and25-gauge disposable internal limiting membrane[ILM] forceps) readily available. First, a 22- or 23-gauge needle is an inexpensive substitute for makingthe sclerotomy incisions. Second, instead of the ILMforceps, a Kuglen hook can be passed through the scle-rotomy to easily retrieve the suture loops. Althoughthe Kuglen hook is not malleable like the ILM forceps,I find it to be very effective and it is virtually alwaysavailable.

Seth W. Meskin, MDMilford, Connecticut, USA

REFERENCE1. Slade DS, Hater MA, Cionni RJ, Crandall AS. Ab externo scleral

fixation of intraocular lens. J Cataract Refract Surg 2012;

38:1316–1321

Glistenings and retinal straylightIn the editorial about microvacuoles in hydrophobic

acrylic intraocular lenses (IOLs), 1 Dr. Mamalis

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