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Home , Childhood cataract

JMSCR Vol||08||Issue||11||Page 260-266||November 2020

http://jmscr.igmpublication.org/home/ ISSN (e)-2347-176x ISSN (p) 2455-0450 DOI: https://dx.doi.org/10.18535/jmscr/v8i11.46

Paediatric -Type of Surgery Done in my Current Sample of Cases

Authors Dr N. Suhasini M.S. FIGS1, Dr V. Suryanarayana M.S.,D.O2. 1Asst. Prof-KIMS & RF, Amalapuram, 2Retd. Prof, REH, Visakhapatnam

Abstract Aim: To describe and analyze type of surgery done in the management of paediatric . Materials & Methods: A retrospective study of 68 subjects who had undergone cataract surgery during 2007-08 in Govt. REH. PMMA (12mm) was implanted in the bag for children more than 2 years. Intraocular lenses were not implanted for children aged less than 2 years. Optical correction was given. Results & Discussion: SICS+PCIOL done in 29 subjects, phaco + PCIOL done in 15 subjects, only ECCE in 2 patients, ECCE+ACIOL in 1 patient & ECCE + PPC & PCIOL in 1 patient. Conclusions: 1. Improvement of child health care is needed for early detection of cataract in children. 2. Role of rubella and trauma in childhood cataract should be investigated and addressed. Visual assessment and postoperative care should be further improved. 3. Cataract surgery with unilateral and bilateral IOL implantation can provide a beneficial effect on final visual outcome in children who are operated- on, before abnormal foveolar function develops. 4. Primary posterior chamber lenses are recommended for children six years of age and older 5. Proper case selection and a controlled, skilled surgical approach, the use of an intraocular lens for visual rehabilitation in the pediatric age group is a feasible approach. 6. Intraocular lens implantation for children with congenital or developing cataract is an effective treatment for visual rehabilitation, even for those patients age 2 years and younger. 7. If has developed, the is unfortunately irreversible. 8. Concerted efforts must be made to educate people about the prevention of blindness due to cataract in all age groups in general and the importance of continued follow up in the paediatric age group in particular. 9. Apart from school screening programmes, training programmes must be conducted to equip teachers to identify vision problems and to sensitise them about the significance of early reporting. 10. The facilities at primary Health care institutes need to be upgraded and the staff trained to provide postoperative follow up care to paediatric patients. 11. Although the treatment of childhood cataract has evolved considerably over the years, providing high quality standard eye care still remains a challenge for the providers 12. The eye care providers should collaborate with the programs related to child health care and address the underlying causes of cataract in children 13. For this, the cooperation of parents, paediatricians & ophthalmologists is required. Keywords: PMMA-Poly Methyl Methacrylate; REH: Regional Eye Hospital.

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Management of paediatric cataract general, an IOL is inserted into the eye of older The management of cataract in the child depends babies, and depending on the age of the child, an upon several factors: the child’s age; the extent of IOL power is selected (according to the biometry) visual loss; whether or not there is an associated to make that eye appropriately hypermetropic, and illness or coexisting ; and if the hence allow for the myopic shift which takes place cataract Affects One or both eyes. in the developing eye; the aim is for emmetropia Surgery when the eye is fully grown. In the older child, for Intraocular lens (IOL) implantation is becoming example a seven year old child with bilateral an increasingly accepted procedure in young cataracts which are beginning to significantly children and infants. Awareness of the rate of interfere with visual acuity, the eye with the worst myopic shift which takes place in the developing visual acuity is operated on, followed by the eye, and the use of biometry helps to predict second eye at least three to four weeks later. All appropriate IOL powers to try to ensure eventual surgery has potential complications, and the emmetropia. However, final refraction is variable, parents are warned about all possible such that emmetropia in adulthood cannot be complications pre-operatively (see later). guaranteed, as there are insufficient long-term Complications of lens aspiration and IOL studies. Whether or not an IOL is inserted will implantation include post-operative , depend on the age of the child (recently in some , and retinal centre IOLs are inserted into the eyes of babies as detachment. In addition, there is a greater than young as four weeks of age), whether or not there 90% risk that the posterior capsule will become is any underlying ocular pathology in which IOL thickened within in a year, which requires a implantation is contra-indicated. In some further procedure either with laser or surgical instances, for example, in remote areas in less capsulotomy to clear the visual axis and restore industrialised countries where it is unlikely that visual acuity to what it was initially the child will be able to be brought back for postoperatively. In order to reduce the need for regular follow-up, IOL implantation is not repeated general anaesthetics in order to perform advisable laser and or surgery, a primary posterior Bilateral Cataracts capsulorrhexis (and limited anterior vitrectomy) Surgery is indicated when the cataracts are may be performed. This involves making a hole in interfering with normal visual development. If the the posterior capsule and removing a small vision is good, then surgery is not indicated, and amount of vitreous at the time of the initial the child has regular checkups. If there is a cataract surgery. This procedure significantly significant deterioration in that child’s acuity at reduces the development of posterior capsular any stage, then surgery is considered .If a child opacification. has bilateral dense cataracts, one eye is operated Unilateral Cataract on followed by the second eye one to two weeks In infants with unilateral cataract, the cataract is later. The first eye is occluded post-operatively most likely to be idiopathic and there is usually no until the second eye is operated on, to prevent associated systemic disease. It is important not to amblyopia in the un-operated eye. In very young confuse asymmetric bilateral cataract with babies, an IOL is not inserted; these babies are unilateral cataract and, hence, careful slit lamp given contact lenses one to two weeks post examination is essential in all children with operatively, and if contact lenses are contra- cataract, as there may be very subtle changes in indicated, the child is given aphakicspectacles. In one lens and dense cataract in the other. With some of these children, an IOL may be inserted as regard to the management of unilateral cataract, a secondary procedure when the eye has grown. In the decision to operate depends on the density of

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the lens opacity, whether or not there is any severe microphthalmos or parents who are unable associated microphthalmos, and on the parent’s to cope with contacts), the child is given aphakic motivation to have the surgery performed. spectacles which have the advantage of increasing The parents need to be fully informed that surgery magnification and, therefore, enhancing the alone will not improve their child’s vision, and child’s acuity, and in can make the eyes of that the management of amblyopia is the key to a children with microphthalmia look slightly bigger. successful result. This entails optical correction Pseudophakia and many hours of patching the normal eye every To allow for the future growth of the infant eye day, which as one knows can be extremely (i.e the myopic shift) an IOL power less than that difficult in a small infant or toddler, and needs to to result in emmetropia is used. This makes the be maintained for many years. If occlusion is not child hypermetropic (the amount of hypermetropia performed the eye will remain densely amblyopic. depends on the age of the child), then as the It has been reported extensively in the literature child’s eye grows emmetropia is approached. The that children who have had surgery for bilateral child is then given reading spectacles (and a cataracts have a much better visual outcome than distance prescription if required). children who have had surgery for unilateral Amblyopia management post-operatively cataract. Children with unilateral cataract need The treatment of amblyopia is essential in order to diligent occlusion therapy of the unoperated eye obtain a successful outcome in patients who have together with accurate optical correction of the had both unilateral and bilateral cataract surgery. operated eye to obtain a good visual result. Amblyopia is managed by giving the required optical correction and occluding the eye with Optical correction post-operatively better visual acuity. The occlusion is performed according to a standardized regime (Tayloe, If the child has not had an IOL inserted and is D.S.I., The Doyne Lecture,1998).It is important to therefore aphakic, contact lenses are fitted as soon realize that excessive patching of the phakic eye in as possible after surgery, regardless of age. This is infants with unilateral aphakia may be associated usually done one to two weeks post-operatively. with increased nystagmus and can have adverse The baby is refracted and contact lenses are fitted. effects on the phakic eye, hence it is imperative Contact lenses are relatively safe (Amaya, L., et that these children are reviewed every two weeks. al., 1990), they can be used in combination with Complications of Cataract Surgery spectacles for near, and also to correct Cataract surgery in the child and especially in (Enoch, J.M. and Hamer, R.D.,1983). Rigid gas babies has a higher incidence of complications permeable contact lenses are most suitable for the than those seen after adult cataract surgery. This management of aphakia, as they have a wide may be due to several reasons: cataract surgery is range of powers, can correct , and are technically more difficult in the child’s eye, as the relatively cheap. The disadvantages of contact tissues are more elastic and behave differently to lens wear are similar to those seen in adults, and adult tissues; the child’s eye becomes more include hypoxia and infective . Parents inflamed than an adult eye in response to an IOL; should be educated about contact lens hygiene and the very young child’s is still the signs and symptoms of possible complications developing and is therefore extremely sensitive to associated with contact lens wear. All infants and having a defocused image as is the case in children wearing contact lenses should be kept aphakia; and a young child is less likely to fully under constant review at a specialized unit. If comprehend the importance of keeping dirty contact lenses cannot be fitted (e.g. raised fingers away from the operated eye in the intraocular pressure, external eye disease, dry eye, immediate post-operative period and, therefore,

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may rub the eye too vigorously resulting in wound , and/or reduced vision, and requires urgent dehiscence and prolapse or infection. There hospital admission and treatment. have been many reports of the visual outcome and 5. Posterior capsule opacification complications of posterior chamber lens Posterior capsule opacification occurs in up to implantation inc hildren (Thouvenin, D., 1995). 90% of paediatric eyes after lens aspiration when The most common complications include: the posterior capsule and anterior vitreous face are 1. Glaucoma left intact. These children, having had a good Glaucoma may arise in the first few weeks post- visual result initially, later present with blurred operatively, and may present as a watery eye with vision. The thickened posterior capsule is seen or without . The child is usually using the slit lamp, or simply by examining the irritated or just “not his usual self”. Some children red reflex. These children are admitted as a day are asymptomatic, hence the importance of regular case and a posterior capsulotomy is performed. review with IOP checks post-operatively. Older children can have laser treatment without a Glaucoma may also occur as a late complication general anaesthetic. In some cases, the capsule years later, and this type of glaucoma can be thickens again and may require surgery to clear asymptomatic, therefore all children who have had the visual axis. cataract surgery should be followed up for life. 6. 2. Uveitis Retinal detachment may occur years after cataract All children will develop a certain degree of surgery, and present with reduced vision which uveitis post-cataract surgery. This is kept under may be preceded by flashes and . control with frequent installation of topical steroids, which are given to all children routinely, Methodology and are eventually tailed off and discontinued. Background However, some children (approximately 30%) Early diagnosis of is essential develop inflammation with fibrin formation. This in ensuring treatment, together with parental accumulation of fibrin may result in secondary advice and support, can be provided promptly. membrane formation blocking the visual axis if There is good scope for investigating them using not recognized and treated promptly. many approaches. Many questions can beeasily 3. Irregular addressed through trials and clinical studies. An irregularly shaped pupil after cataract surgery Visual loss in congenital/infantile cataract is may be due to: a) a strand of vitreous coming mainly due to amblyopia. There is limited forwards from the vitreous cavity to the anterior information available about the long-term chamber; b) damage to the iris during surgery; and outcomes in children treated with modern surgical c) iris prolapse, which may be due to accidental techniques. This study is designed to evaluate trauma to the eye post-operatively and requires Paediatric cataracts and its visual out come by urgent attention, as if leftuntreated that eye may using modern techniques among outpatient become infected, and even the other eye may be at population of in and around a risk from sympathetic ophthalmia. Guntur Township of Andhra Pradesh. 4. Endophthalmitis Bacterial infection of the eye is a devastating Objectives complication which can occur in up to 0.4% of 1. To determine functional results after eyes after cataract surgery. It may occur early (i.e. unilateral and bilateral cataract surgery in within days to weeks) or late (months to years) children with different aphakic optical post-operatively and presents with a sore painful correction.

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2. To report treatment of pediatric patients management was obtained in most cases through a with cataract, and evaluate the efficiency central capsulorrhexis measuring around 4 mm. of different surgical interventions. Lensectomy and Anterior vitrectomy were done in children under 2 years and in traumatic cases The specific objectives are: where Posterior capsule was suspected to be To examine does cataract extraction combined ruptured, a limbal approach was taken for with primary IOL implantation, compared with lensectomy and anterior vitrectomy. A primary cataract extraction without IOL implantation, posterior capsulotomy with or without vitrectomy result in: was performed. PMMA lens (12 mm) was  Better overall visual function? implanted in the bag for children above 2 years.  Reduced risk of aphakic glaucoma? Intraocular lenses were not implanted for children  Increased risk of significant myopic shift? aged less than 2 years. Children who did not Random samplingis used to select a nationally receive IOL implants were rehabilitated representative sample of adults. The study design postoperatively using spectacles or contact lenses. and protocol are submitted to NTR University of Patching was done if the cataract was unilateral Health Sciences for approval. and amblyopia was present. Each subject and his parent was interviewed, a The surgical procedures included cataract brief history of the age of onset of visual loss, extraction, intraocular lens implantation, posterior involvement of other members of the family, the capsulorrhexis and anterior vitrectomy in most of place of residence, and whether the parents’ the cases. The visual status of eyes with cataract marriage was consanguineous was recorded. before and 6 weeks after surgery has been Every subject had their visual acuity measured evaluated. and underwent auto refraction and fundus/optic Statistical analysis disc examination. The results thus obtained are analyzed, and An exploration of demographic variables was discussed in comparison with the existing studies conducted using regression modeling. For the in the literature. SPSS Version 10.1 software has study, 60 subjects of cataract, 0- 18 years age been used for statistical analysis. Descriptive groups underwent an extensive ophthalmologic statistics are computed for baseline demographic, screening examination, including measurements clinical and laboratory features according to of visual acuity and the visual field and fundus etiology. Frequency tables were generated to photography. Cause of cataract formation in each reflect the etiology of cataract and all the values subject was investigated using all screening are determined at 5% significance level. information and medical records, to establish the Contingency tables were analyzed through aetiology. chisquared statistics. Univariate type of parametric Surgical Technique type of statistical analysis has been used. Wound construction was done using self-sealing suture less wound in most cases. Capsular

Table No.14 Type of Surgery done in the current sample of subjects

Type of surgery n Percent Only ECCE 2 4.17 SICS with PC IOL 29 60.75 ECCE with PC IOL &PPC 1 2.08 ECCE with ACIOL 1 2.08 Phaco with PC IOL 15 30.92 Total 48 100

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Various types of operations done on the subjects a 4.17% of the cases only ECCE without any IOL of the current study are shown in table No. 14 and implantation was done. ECCE with PC IOL and figure No.11. Among these surgeries majority PPC has been tried in 2.08% of the cases. ECCE 60.75% is SICS with PC IOL. Next commonly with ACIOL has been placed in 2.08% of the done operation 30.92% is Phaco with PC IOL. In cases.

30,92

Phaco with PC IOL 2,08 ECCE with ACIOL 2,08 ECCE with PC IOL &PPC 60,75

SICS with PC IOL

Only ECCE 4,17

0 10 20 30 40 50 60 70

Percent

Figure No.11 Type of Surgery done in the given Sample

Limitations of the study Zhenzhen Liu PhDa† Zhuoling Lin MDa 1. The sample size is small Qianzhong Cao PhDa Xiaohang Wu MDa 2. Only cases attending Hospital were Qiwei Wang PhDa Duoru Lin MDa recruited for the study. Xiaoyan LiMDa Prof Lixia Luo PhDa BoQu PhDa Prof Haotian Lin PhDa Prof Yizhi Liu PhDa- The Lancet- Bibliography October,2016-Elsevier 1. Use of the Delphi process in paediatric 4. Comparing the astigmatic outcome after cataract management Massimiliano paediatric cataract surgery with different Serafino1, Rupal H Trivedi2, Alex V incisions Amit Gupta1, Muralidhar Levin3, M Edward Wilson2, Paolo Ramappa2, Ramesh Kekunnaya1, Pravin Nucci1, Scott R Lambert4, Ken K K Vaddavalli2, Debajit Ray1, Sunita Nischal5, David A Plager6, Dominique Chaurasia2, Harsha L Rao3,Chandra Sekar Bremond-Gignac7, Ramesh Kekunnaya8, Garudadri3 –Bjo.Bmj.com-2012 Sachiko Nishina9, Nasrin N Tehrani10, 5. Outcome of paediatric cataract surgery Marcelo C Ventura11 Bjo.Bmj.com-2016 with primary posterior capsulotomy and 2. Short-term outcomes of dry pars plana anterior vitrectomy using intra‐ operative posterior capsulotomy and anterior preservative‐ free triamcinolone acetonide vitrectomy in paediatric cataract surgery Rohit Gupta ,Jagat Ram ,JaspreetSukhija – using 25-gauge instruments, Y Huang, L Acta ophthalmologica-2014 XieBjo.Bmj.com-2010 6. Improvement for dry pars plana posterior 3. Timing and approaches in congenital capsulotomy and anterior vitrectomy using cataract surgery: a randomised controlled a 25-gauge vitrectomy system in paediatric trial Prof Weirong Chen MDa† Erping cataract surgery Yunhai Dai1,2, Yusen Long MDa† Jingjing Chen MDa† Dr N. Suhasini et al JMSCR Volume 08 Issue 11 November 2020 Page 265

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Huang2, Xiaoming Wu2, Lixin Xie2- British journal of Ophthalmology-2013- Bjo.Bmj.com 7. Long‐ term results of bilateral congenital cataract treated with early cataract surgery, aphakic glasses and secondary IOL implantation Dong‐ Hyun Kim ,Jeong Hun Kim, Seong‐ Joon Kim –Acta Ophthalmologica-2012 8. Precision pulse capsulotomy: an automated alternative to manual capsulorhexis in paediatric cataract Pratik Chougule1, Vivekanand Warkad2, Akshay Badakere1Ramesh Kekunnaya1- BMJ open Ophthalmology-2019.

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