Management Options in Pediatric Cataract
Clinical examination of the child should include a complete examination of all systems, including respiratory, nervous, and cardiovascular systems. Supportive laboratory investigations should include hemogram, blood sugar, titers for antibodies to TORCH agents (toxoplasmosis, other infections, rubella, cytomegalovirus, and herpes simplex virus), HIV, hepatitis B surface antigen, and X-rays, and echocardiography if required. Special tests to rule out metabolic diseases should be ordered whenever necessary.
Surgical Technique Anterior Capsule Management
Anterior capsulorhexis is the anchor for pediatric cataract management, as it determines the surgical strategy and site of IOL fixation. The anterior capsule in children is very elastic, and therefore it may be difficult to perform a controlled manual continuous curvilinear capsulorhexis (CCC). However, it remains a gold standard for resistance to tearing and should be accomplished whenever possible. Difficulties in performing manual CCC in the infantile eye led researchers and surgeons to search for alternative methods to open the anterior capsule in children. Alternatives to manual CCC currently available include vitrectorhexis, radiofrequency diathermy with a Fugo plasma blade, the two-incision push–pull technique, and the four-incision technique.3–6
Wilson et al. analyzed pediatric anterior
capsulotomy techniques in the porcine model and found that manual capsulorhexis produced the most extensible capsulotomy with the most regular and stable edge.7
In eyes with poor anterior capsule visibility,
trypan blue (0.0125 %) was used to stain the anterior capsule. The shape, size, and edge integrity of anterior capsulotomy are very important for the long-term centration of the IOL (Figure 1).
Management of the Posterior Capsule and Anterior Vitreous Face
The most frequent and significant problem following pediatric cataract surgery is visual axis opacification (VAO).8–13
(Figure 2). Maintenance of a
Posterior capsulotomy can be performed using various approaches, including manual posterior continuous curvilinear capsulorhexis (PCCC), vitrectorhexis, radiofrequency diathermy, and the Fugo plasma blade.21,22
Manual PCCC is performed before IOL
implantation, whereas, if a pars plana vitrectorhexis is performed, it is done after the IOL is implanted.23,24
The size of the posterior
capsulorhexis should be large enough to provide a clear central visual axis, but smaller than the IOL optic, so as to allow stable in-the-bag IOL fixation. Manual PCCC offers the advantage of a controlled size and strong edges, but is more difficult to perform (Figure 3).
A potential complication associated with this procedure is disruption of the anterior vitreous face (AVF).25
The signs of AVF disruption vary from
subtle to obvious, and include: •
• •
the presence of vitreous strands in the anterior chamber; the attachment of the vitreous to the capsular flap; and distortion of the capsulorhexis margin.
US OPHTHALMIC REVIEW
Recently, we described a technique to render the vitreous visible to the anterior segment surgeon. On completion of the PCCC, 0.1 ml of a suspension of preservative free triamcinolone acetonide (Aurocort) was injected for visualizing the AVF as well as the presence and extent of vitreous in the anterior chamber.26,27
After vitrectomy, if the surgeon has
not cleared the residual vitreous strands triamcinolone can now be used second time to identify clearly the superficial vitreous gel, which may have otherwise gone unnoticed. After IOL implantation and removal of the residual ophthalmic viscosurgical device, the surgeon again injects 0.1 ml of the suspension into the anterior chamber. Additional anterior vitrectomy is performed if vitreous strands are identified in the anterior chamber.
45
clear visual axis remains a high priority when planning management of the posterior capsule in the amblyogenic age range. An important question that remains is when should the posterior capsule be left intact? Primary posterior capsulectomy (with or without anterior vitrectomy) are considered ‘routine surgical steps,’ especially in young children.14–20
Figure 3: A Well-centered Primary Posterior Continuous Curvilinear Capsulorhexis Concentric to and Smaller than the Anterior Capsulorhexis Allows Safe in the Bag IOL implantation
Figure 2: Postoperative Images of Posterior Capsule Opacification with Primary Posterior Continuous Curvilinear Capsulorhexis
Figure 1: Well-centered, Symmetric Anterior Capsulorhexis
Page 1 |
Page 2 |
Page 3 |
Page 4 |
Page 5 |
Page 6 |
Page 7 |
Page 8 |
Page 9 |
Page 10 |
Page 11 |
Page 12 |
Page 13 |
Page 14 |
Page 15 |
Page 16 |
Page 17 |
Page 18 |
Page 19 |
Page 20 |
Page 21 |
Page 22 |
Page 23 |
Page 24 |
Page 25 |
Page 26 |
Page 27 |
Page 28 |
Page 29 |
Page 30 |
Page 31 |
Page 32 |
Page 33 |
Page 34 |
Page 35 |
Page 36 |
Page 37 |
Page 38 |
Page 39 |
Page 40 |
Page 41 |
Page 42 |
Page 43 |
Page 44 |
Page 45 |
Page 46 |
Page 47 |
Page 48 |
Page 49 |
Page 50 |
Page 51 |
Page 52 |
Page 53 |
Page 54 |
Page 55 |
Page 56 |
Page 57 |
Page 58 |
Page 59 |
Page 60 |
Page 61 |
Page 62 |
Page 63 |
Page 64 |
Page 65 |
Page 66 |
Page 67 |
Page 68 |
Page 69 |
Page 70 |
Page 71 |
Page 72 |
Page 73 |
Page 74 |
Page 75 |
Page 76