Learn Connect Succeed JCAHPO Regional Meetings 2015
Pediatric Cataracts: Complicated Cases and Controversies M. Edward Wilson, M.D. N. Edgar Miles Professor of Ophthalmology and Pediatrics Storm Eye Institute Department of Ophthalmology Medical University of Ophthalmology Charleston, South Carolina, USA Financial Disclosures Omeros Grant support Springer Book royalties Lippincott, Williams & Wilkins Book royalties Cataract surgery in children Cataract surgery in children General anesthesia is required Postoperative exams are often challenging Postoperative application of anti-inflammatory medications is difficult Postoperative trauma is difficult to control Genetic and metabolic conditions often co-exist with childhood cataracts Microphthalmia may be severe Secondary glaucoma is common Visual acuity Axial length Keratometry Lens power The developing eye Critical period 20/200 20/100 20/60 20/40 20/20 16.0 mm 20.3 mm 21.4 mm 22.7 mm 51.0 45.0 34.5 19.0 Characterizing Cataracts in Children by Type Not all pediatric cataracts are alike Cataract type can be a critical determinate of outcome Refraction +0.5 +2.0 +0.5 Risk of amblyopia High Low 0 12 24 36 48 84 120 Modified from David Yorston Age (months) 1
Cataract surgery with IOL in a child Sudden white cataract in a 6 year-old Oops -this is what can happen in children PHPV Persistence and Hyperplasia of Primary Vitreous PFV Persistent Fetal Vasculature Subluxated Lens 2
Pediatric Anterior Lens Capsule Thin, Strong, and Very Elastic Twice the extensibility Five times the tensile strength Manual tear circular capsulorhexis Vitrectorhexis Manual tear circular capsulorhexis Vitrectorhexis Radiofrequency Diathermy Plasma Blade Radiofrequency Diathermy Plasma Blade Anterior Lens Capsule Intraocular Lens Implantation for children The standard of care for children after uncomplicated cataract surgery at ages beyond infancy. An acceptable alternative for infants, especially those without complex microphthalmia 3
NEI Press Release National Institutes of Health National Eye Institute Contact: National Eye Institute (301) 496-5248 neinews@nei.nih.gov Contacts better than permanent lenses for babies after cataract surgery Permanent lenses lead to more repeat eye surgeries, NIH study finds March 6, 2014 Infants Vitrectorhexis Bimanual I&A Posterior capsulectomy and vitrectomy Silsoft aphakic contact lens placed at the time of surgery developed a customized Silsoft lens constant Aphakia Aphakia - summary Aphakia Aphakia - summary The least traumatic surgery for infancy Two small entries avoids multiple in/out Can place contact lens at conclusion of surgery / No patch & shield needed Can begin post-op drops right away Maximum flexibility for the rapidly changing refractive error of infancy. Dramatically reduced VAO until after after 1 Silsoft CL --- 7.5 base curve in infancy 7.7 base curve after 18-24 months Initial CL power based on biometry Use +32 for axial length <17 mm +29 for 17 to 18.5 mm +26 for 18.5 to 19.5 mm +23 for 19.5 to 20 mm +20 for 20 to 21 mm Lens constant 111.9 4
Cataract Surgery as a Refractive Procedure Cataract Surgery as a Refractive Procedure Adult cataract & IOL surgery not only removes the opacities in the crystalline lens, it also corrects hyperopia, myopia, and astigmatism in a precise and predictable manner. Childhood cataract & IOL surgery not only removes the opacities in the crystalline lens, it also removes an all-important offset to globe axial length irreversibly derailing the eye s natural emmetropization. The developing eye The developing eye Critical period Critical period Visual acuity 20/200 20/100 20/60 20/40 20/20 Visual acuity 20/200 20/100 20/60 20/40 20/20 Axial length 16.0 mm 20.3 mm 21.4 mm 22.7 mm Axial length 16.0 mm 20.3 mm 21.4 mm 22.7 mm Keratometry 51.0 45.0 Keratometry 51.0 45.0 Lens power 34.5 19.0 Lens power 34.5 19.0 Refraction +0.5 +2.0 +0.5 Refraction +0.5 Myopic shift plus permanent presbyopia +0.5 Risk of amblyopia High Low Risk of amblyopia High Low 0 12 24 36 48 84 120 Age (months) 0 12 24 36 48 84 120 Age (months) Normal Eye Growth is Triphasic 4.5mm in first 2 yrs 0.4mm per yr age 2-6 1mm from age 6 to adulthood Cataract Surgery as a Refractive Procedure To best predict the IOL power needed to minimize refractive error at age 20, implantation is best carried out in phase 2 or 3 of the eye growth curve. Secondary IOL implantation can be placed in the capsular bag or in the ciliary sulcus. If possible, avoid IOL in the age of VAO (0-1 year) and the age of most rapid and least predictable eye growth (0-2 years) 5
A xia l Le n g t h - Tr e a t e d Ey e ( m m ) Refractive error Axial Length at Age 5 Histograms of Refractive Error for Patients Treated with an IOL By Whether or not Glaucoma was Diagnosed 2 8 2 6 27.6 27.5 2 4 2 2 2 0 1 8 18.3 18.5 C L IO L n 4 5 4 8 M e a n 2 1.5 2 2.0 S D 1.7 2.0 # Patients Median IQR * Range Without Glaucoma 44-1.69-5.03 to 1.16-18.00 to 5.00 With Glaucoma 11-7.25-16.50 to -3.50-19.00 to -1.50 T h e tw o tr e a tm e n t g r o u p s a r e n o t sta tistic a lly sig n ific a n tly d iffe r e n t ( p = 0.23). Frequently asked questions What postoperative refraction do you aim for at various ages? 1 month +12 5-6 years +3 2-3 months +9 6-7 years +2 4-6 months +8 7-8 years +1.5 6-12 months +7 8-10 years +1 1-2 years +6 10-14 years +0.5 2-4 years +5 > 14 years plano 4-5 years +4 Pediatric Surgery Data Base >1600 cataract and IOL surgeries Pre-op, post-op, refractive changes, VA Serial EUA with axial lengths Polypseudophakia Polypseudophakia 6
Temporary Polypseudophakia (Piggyback IOLs) Permanent IOL in the capsular bag Temporary IOL in the ciliary sulcus Aim for plano or mild hyperopia Yearly biometry remove piggyback IOL when predicted refraction is plano Glasses prescribed when the myopia exceeds 4D. 16 years of experience using this technique is selected cases Piggyback IOL J AAPOS 2001;5:238-245. Ophthalmology 2000;107:1261-1266. J Pediatr Ophthalmol Strabismus 1999;36(5):281-286. Age 3-6 Pediatric Cataract Surgery Secondary IOL In-the-bag In-the sulcus Bimanual closed chamber surgery Vitrectorhexis (age 0-2) / modified CCC Single-piece acrylic IOL Pars plana posterior capsulotomy / vitrectomy Secondary In-the-bag IOL 10.0 Vicryl for wound closure Special Thanks Rupal H. Trivedi Donna W. Wilson 7