Pediatric cataract Surgical challenges and postoperative complications Nikos Kozeis MD, PhD, FICO, FEBO, MRCOphth Consultant Paediatric Ophthalmologist Thessaloniki, Greece
Pediatric Cataract 2.4 / 10000 live births by age 1 3.6 / 10000 by age 15 200000 blind due to cat * Congenital (present at birth) * Infantile (present at 1 year) * Juvenile (develop later) Unilateral or bilateral Causes : Idiopathic Inherited Metabolic Intrauterine infection Syndromes Systemic diseases Trauma- Medications etc.
Morphology Main types: Zonular Polar Lenticonus
Associations With ocular diseases Microphthalmia (the most common) PHPV ROP Aniridia With systemic conditions Myotonic dystrophy Hypoparathyroidism Down s. Lowe s. Rubella Hallermann stieff Trauma Metabolic
Deprivation Amblyopia Cause profound visual loss deprivation amblyopia The sensitive period of visual development Animal studies have informed much of what we now know
The main treatment of pediatric cataract is surgical Aim : Clear visual axis and a focused retinal image Benefits vs. Risks Your decision has a lifetime effect
Challenges - Preoperative (What & When to operate) - Intraoperative (How to operate) - Postoperative (complications)
What to operate? Visually significant cataract Opacity > 3 mm Dense nuclear Invisible fundus Strabismus / Nystagmus Inability to fix & follow Wait and see when Eccentric opacity Major retinal vessels visible Anterior polar No abnormal visual behavior RAPD
When to operate? Congenital, 8 to 10 w of age Surgery before 4 w, risk of glaucoma & pupillary membrane Infantile or late benefits vs. risks Treat amblyopia & operate In bilateral, same time or not?
Intraoperative challenges step by step
Pre operative good plan Child s eye is different
Surgical steps Incision: small / suture Anterior capsule: capsulotomy / vitrectorexis / CCC Lens: aspiration / lensectomy, no hydrodelineation - no phaco, multi- hydrodissection, PI Posterior capsule + ant. Vitreous: capsulectomy x<7 yo capsulectomy + ant. vit x>7 yo no capsulectomy IOL: x > 12 mo, x < 12 mo debatable No - ant segment dysgenesis, PHPV, Glaucoma, Al < 16 mm, Corneal < 10 mm
About IOLs Types: Acrylic, PMMA optic size : 6.00 mm (11 mm) Multifocal/Accommodating IOL Biometry: SRK-T formula (SRK II, Hoffer-Q, Holladay) less accurate in : x < 36 mo, in eye < 20 mm IOL power: 1-2 y.o.= IOL formula - 20% (8-2D) 2-4 y.o.= IOL formula 15% 4-8 y.o.= IOL formula 10% X>8 y.o. = IOL formula Secondary IOL Implantation / traumatic 3 pieces IOL (sulcus), AC IOL, scleral fixated, iris fixated IOL
Key points IOL implantation can be carried out in infancy allow for axial growth be prepared for secondary (capsular) procedures hydrophilic acrylic is in our opinion not suitable for children! more predictable in normal eyes surgery at tertiary centre with specialist optometric/orthoptic support
Postoperative complications - Aggressive inflammation - Synechiae & pupil abnormalities - Membrane formation / PCO - Decentration of IOL - Amblyopia - Glaucoma (30%) - Retinal detachment - Nystagmus - Strabismus - Endophthalmitis
Visual Results Bilateral Median final VA : 6/18 (6/5-6/36) Visual acuity (at five years of age) decrease with increasing initial age at surgery However Early surgery leads to better outcomes
Severity & duration visual deprivation affect eye alignment and ocular stability? Cataract morphology and amblyogenic potential varies Most studies have looked at Va Fixation stability has major impact on visual function
Early onset visual deprivation and eye alignment and ocular stability Binocularity/fixation stability have critical period Timing of surgery/duration of deprivation are factors in development of nystagmus? Only 20% with surgery for bilateral after 10 months developed nystagmus But Eye movement systems not used - prevalence unknown Nystagmus amplitude, frequency, waveform, beat direction not quantified
Ocular Motor Outcomes in children with infantile cataracts: Summary Major form deprivation causes nystagmus in approx 75% this is MLN Minor form deprivation usually steady Large amplitude Saccadic intrusions affected most of the cohort Critical period for fixation stability may be as short as 3 weeks Preoperative CN can convert to MLN after successful surgery
Conclusions Aphakic/pseudophakic children are neurophysiologically disadvantaged - thus at high risk of amblyopia (deprivation, ametropic, anisometropic and strabismic) Early surgery (where indicated), prompt optical correction and rigorous follow up produce best results Aggressive occlusion therapy is often needed in unilaterals
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