Strabismusaftercongenitalcataractssurgery 窑ClinicalResearch窑 Factorsassociatedwithstrabismusaftercataract extractionandprimaryintraocularlensimplantationin congenitalcataracts

DepartmentofOphthalmology,HaeundaePaikHospital, DOI:10.3980/j.issn.2222-3959.2014.03.25 Busan1435,Korea Correspondence to: SooJungLee. Departmentof LeeSJ,KimWS.Factorsassociatedwithstrabismusaftercataract Ophthalmology, HaeundaePaikHospital,Jwa-dong, extractionandprimaryintraocularlensimplantationincongenital Haeundae-gu,Busan1435,[email protected] cataracts. 2014;7(3):522-527 Received:2013-06-24 Accepted:2013-11-25 INTRODUCTION Abstract ongenitalcataractisaconditionobservedin2.2-3of C 10000newborninfantsandisresponsiblefortheloss AIM: To evaluate factors associated with the · [1-3] ofsightin10%ofchildrenworldwidewhobecomeblind . . developmentofstrabismusaftercataractextractionand Unlikecataractsinadults,earlydetection,methodandtime primaryintraocularlensimplantation. ofoperation,timeofintraocularlens(IOL)implantation, ·METHODS:Themedicalrecordsof122patients,aged properIOLpower,andopticaltreatmentforamblyopiaafter 1.5moto9y,whohadundergonecataractextractionwith surgeryareimportantforvisualoutcomesinchildrenwith primaryintraocularlensimplantationbetweenJanuary congenitalcataracts [4].Excessiveinflammatoryreaction, 1993andAugust2011werereviewed.Fourteenpatients secondarycataract,glaucoma,andstrabismuscanoccurafter (17eyes)withstrabismusbeforecataractsurgerywere surgery.Especially,therateofstrabismusassociatedwith excluded. Patients were divided into those with congenitalbilateralcataracts(64patients,128eyes)and congenitalcataracthasbeenreportedto rangefrom [5-8] thosewithunilateralcataracts(44patients,44eyes).The 20.5%-86%beforeandaftercataractsurgery .Strabismus associationsbetweenthedevelopmentofstrabismusand occursmorefrequentlyinpatientswithunilateralthan age at cataract surgery, pre- and post-cataract bilateralcataracts[7,8]. extraction corrected distance visual acuity (CDVA), AstudyofpatientswhounderwentprimaryIOLimplantation interocular CDVA difference, nystagmus, surgical forcongenitalcataractfoundthatcorrecteddistancevisual method,andsecondarycataractwereevaluated. acuity(CDVA)beforeandafteroperation,theformof · RESULTS:Factorssignificantlyassociatedwiththe strabismusandthepresenceorabsenceofamblyopiaafter [7] developmentofstrabismusincludedageatcataract surgerywereassociatedwiththeoccurrenceofstrabismus . surgery ( 1y), preoperative mean CDVA 20/100, Factorsrelatedtotheonsetofpostoperativestrabismusin 臆 臆 presenceofnystagmusinthebilateralcataractgroup aphakicorpseudophakicpatientsaftersurgeryforcongenital andpostoperativeinterocularCDVAdifference 跃20/70in cataractincludedolderageatsurgery,developmentof theunilateralgroup.PostoperativeCDVA 20/100and 臆 secondarycataracts,poorvisualrehabilitationaftersurgery, preservation of posterior capsule, and presence of andunilateralcataract [8].Toourknowledge,however,no secondarycataract weresignificant factors in both studyhasassessedfactorsassociatedwithnewlydeveloped groups. strabismusafterprimaryIOLimplantationexceptthecases · CONCLUSION: Children with congenital cataracts withstrabismuswhichalreadyexistedpreoperatively.We shouldbemonitoredcarefullyaftercataractsurgeryfor thereforeanalyzedthefactorsassociatedwiththeonsetof thedevelopmentofstrabismus,especiallywhenthey strabismusaftercataractremovaland primaryIOL underwent surgery at age 1y, and they have 臆 implantationinpatientswithunilateralandbilateral nystagmus, large postoperative interocular CDVA congenitalcataracts. difference,poorpreoperativeandpostoperativeCDVA, SUBJECTSANDMETHODS preservationoftheposteriorcapsule,orsecondary Thisretrospectiveanalysisincluded189eyesof cataract. Subjects 122patientswhounderwentcataractremovalandprimary ·KEYWORDS: strabismus;congenitalcataract;nystagmus IOLimplantationforcongenitalcataractbyonesurgeonat

522 陨灶贼允韵责澡贼澡葬造皂燥造熏灾燥造援 7熏晕燥援 3熏 Jun.18, 圆园14 www.IJO.cn 栽藻造押8629原愿圆圆源缘员苑圆 8629-82210956 耘皂葬蚤造押ijopress岳员远猿援糟燥皂 Table 1 Characteristics of patients with congenital cataracts Bilateral cataract (n=64) Unilateral cataract (n=44) Variables Postop. orthotropia Postop. strabismus Postop. orthotropia Postop. strabismus P P (n=53) (n=11) (n=31) (n=13) M:F 26:27 7:4 20:11 6:7 Mean age at surgery (a) 3.7±2.5 (0.2-9) 2.4±1.7 (0.1-5) 0.074 3.1±2.1 (0.5-6) 1.2±0.6 (0.7-2) 0.119 Follow-up period (a) 4.8±2.5 (2-12) 4.9±2.2 (2.8-8) 0.624 4.1±3.8 (2-16) 4.3±2.0 (2-9) 0.671

T able 2 Associations between age at surgery and postoperative onset of strabismus Bilateral cataract (n=64) Unilateral cataract (n =44) Variables Postop. orthotropia Postop. strabismus Postop. orthotropia Postop. strabismus P P (n =53) (n =11) (n =31) (n =13) Age at surgery (a)

≤1 10 6 (37.5%) 0.013 2 3 (60.0%) 0.113

>1 43 5 (10.4%) 29 10 (25.6%)

MaryknollhospitalfromJanuary1993toAugust2011.The fixationoftheIOLperformedaftercataractremoval.In patientswithaccompanyingabnormalityoftheeyeswere patientswithbilateralcataracts,itwasregardedasthe excluded.Angleofdeviationwasmeasuredbeforeandafter presenceofsecondarycataractifoneofthebotheyeshad operation,andallincludedpatientswerefollowed-upforat secondarycataract. least2y.Seventeeneyesof14patients(6eyesof3patients StatisticalAnalysis Allstatisticalanalyseswereperformed withbilateralcataractsand11eyesof11patientswith usingSPSSversion12.0.Pearson'sChi-squaretestwas unilateralcataracts)whohadstrabismusbeforesurgerywere employedtocomparediscretevariablesbetweengroups.A excluded.Theremaining108patientsweredividedinto2 two-sample testwasemployedtocomparecontinuous groups:128eyesof64patientswithbilateralcataractsand variablessuchasageatsurgerybetweenthetwogroups.A 44eyesof44patientswithunilateralcataracts,witheach -valuelessthan0.05wasconsideredsignificant.Ethical groupfurthersubdividedintothosewithpreoperative approvalwasobtainedbytheInstitutionalReviewBoardof orthotropiaandpostoperativestrabismusandthosewithpre- MaryknollHospital,andthestudyconductedadheredtothe andpost-operativeorthotropia.Diagnosticcriteriafor DeclarationofHelsinki. congenitalcataractincludedpatientswithcataractobserved RESULTS within1yafterbirth,patientswithafamilyhistoryof Wefoundthat11(17.2%)of64patientswithbilateral congenitalcataract,andpatientswithsystemicdiseaseor cataractsand13(29.5%)of44patientswithunilateral cataractshapesuspectedofbeingcongenital( anterior cataractshadpostoperativeonsetofstrabismus( =0.100) polar,nuclear,lamellar,andsuturalcataract)[9-12]. (Tables1,2). Methods Factorsassessedfortheircorrelationwith PreoperativeCDVAwasdefinedasthemeanCDVAofboth postoperativeonsetofstrabismusincludedageatcataract eyesinpatientswithbilateralcataracts.Patientsinwhom surgery,CDVAbeforeandaftersurgery,interocularCDVA CDVAcouldbemeasuredonlybyCSMorinwhom differencebeforeandaftersurgery,nystagmusbeforeand measurementwasimpossiblewereexcludedfromevaluation aftersurgery,surgicalmethods,andsecondarycataract. of theassociation betweenpreoperativeCDVAand CDVAwasmeasuredwithaSnellenchart,or,with postoperativestrabismus.CDVAwasmeasuredin45 evaluationofcentral,steady,andmaintained (CSM)visual patientswithbilateralcataractsand23withunilateral behaviorinnon-verbalchildren.Surgicalmethodwas cataracts(Tables3,4). dichotomizedbypreservationoftheposteriorcapsule(PC; PostoperativeCDVAatlastfollow-upinpatientswith yes no).Inpatientswithbilateralcataracts,PCremoval bilateralcataractswasmeasuredastheaverageforbotheyes wasdefinedasremovalfrombotheyes.Patientswith in63patients(Table5).Whentheassociationbetween bilateralcataractswhohadunilateralPCremovalwere strabismusandpostoperativeinterocularCDVAdifferenceat regardedasthegroupofintactPC.Ofthe172eyes,131 lastfollow-upwasassessedinpatientswithbilateral underwentposteriorcontinuouscurvilinearcapsulorhexis cataracts(Table6). (PCCC),with107undergoingopticcaptureoftheIOLand Noneofthepatientswithunilateralcataractshadnystagmus 24eyesundergoingIOLimplantationinthebagafter beforeoraftersurgery.Onepatientwithbilateralcataracts anteriorvitrectomyusingavitreouscutter.Ofthe41eyes showedthedisappearanceofnystagmusaftersurgeryand notundergoingPCCC,16hadlensdecentration,withscleral onenewlydevelopednystagmusaftersurgery(Table7).

523 Strabismusaftercongenitalcataractssurgery Table 3 Associations between preoperative visual acuity and postoperative onset of strabismus Bilateral cataract (n =64) Unilateral cataract (n =44) Variables Postop. orthotropia Postop. strabismus Postop. orthotropia Postop. strabismus P P (n=53) (n =11) (n=31) (n =13) -20/100 13 4 11 4 20/80-20/40 19 1 7 1 20/32-20/25 8 0 0 0

≤20/100 13 4 (23.5%) 11 4 (26.7%) 0.039 0.433 >20/100 27 1 (3.6%) 7 1 (12.5%) CSM (-) 2 3 12 7 CSM (+) 6 1 1 1 CSM(-), CSM (+) 5 2 CSM: Central, steady, maintained.

Table 4 Associations between preoperative visual acuity difference between eyes and postoperative onset of strabismus Bilateral cataract (n=64) Unilateral cataract (n=44) Variables Postop. orthotropia Postop. strabismus Postop. orthotropia Postop. strabismus P P (n=53) (n=11) (n=31) (n=13) -20/70 36 4 5 1

20/63-20/40 3 1 5 4

20/32-20/25 1 0 3 1 20/20- 0 0 4 0

≤20/70 36 4 (10.0%) 5 1 (16.7%) 0.461 0.541 >20/70 4 1 (20.0%) 12 5 (29.4%) Unable to measure 13 6 14 7

Table 5 Associations between postoperative visual acuity and postoperative onset of strabismus Bilateral cataract (n=64) Unilateral cataract (n=44) Variables Postop. orthotropia Postop. strabismus Postop. orthotropia Postop.strabismus P P (n=53) (n=11) (n=31) (n=13) -20/100 3 5 2 9 20/80-20/40 9 3 14 3 20/32-20/25 24 3 14 1 20/20 16 0 0 0

≤20/100 3 5 (62.5%) 2 9 (81.8%) 0.003 0.000 >20/100 49 6 (10.9%) 28 4 (12.5%) CSM (+) 1 0 1 0

Themeanageatsurgeryofpatientswithbilateralcataracts cataractsandthreewithunilateralcataracts,respectively, wassimilarinthosewithintactandremovedPC [2.8 1.8y developedsecondarycataracts.ThepreservationofPC 依 (range0.1-6y) 3.5 2.1y(range0.2-9y), =0.421],as affectedtheprevalenceofsecondarycataracts( =0.000and 依 wasthemeanageofpatientswithunilateralcataractswith =0.000,respectively).All35patientsinwhomsecondary intactandremovedPC[1.5 0.4y(range0.6-2y) 2.2 1.4y cataractsdeveloped,underwentclearanceofthevisualaxis 依 依 (range0.5-6y), =0.132]. at2.4 1.9y (range2moto6y)aftercataractsurgery. 依 Secondarycataractsdevelopedinall26patientswho Thirteen (37.1%)underwentNd:YAGlaserposterior underwentIOLimplantationwithpreservationofthePC.Of capsulotomyand22(62.9%)secondaryopticcaptureafter patientswithPCCC,sixinthepatientswithbilateral PCCC(Table8).

524 陨灶贼允韵责澡贼澡葬造皂燥造熏灾燥造援 7熏晕燥援 3熏 Jun.18, 圆园14 www.IJO.cn 栽藻造押8629原愿圆圆源缘员苑圆 8629-82210956 耘皂葬蚤造押ijopress岳员远猿援糟燥皂

Table 6 Associations between postoperative visual acuity difference between eyes and postoperative onset of strabismus Bilateral cataract (n=64) Unilateral cataract (n=44) Variables Postop. orthotropia Postop. strabismus Postop. orthotropia Postop. strabismus P P (n=53) (n=11) (n=31) (n=13)

-20/200 35 3 0 0 20/160-20/70 13 6 8 0 20/63-20/40 4 2 7 3 20/32-20/25 0 0 13 6 20/20- 0 0 2 4

≤20/70 48 9 (15.8%) 8 0 (0%) 0.282 0.039 >20/70 4 2 (33.3%) 22 13 (37.1%) Unable to measure 1 0 1 0

Table 7 Associations between nystagmus and postoperative onset of strabismus in patients with bilateral cataracts Variables Postop. orthotropia (n=53) Postop. strabismus (n=11) P

Nystagmus (+) 4 8 (66.7%) 0.000

Nystagmus (-) 49 3 (5.8%)

Table 8 Associations between posterior capsule removal, other ocular diseases, and secondary cataract and postoperative onset of strabismus Bilateral cataract (n=64) Unilateral cataract (n=44) Variables Postop. orthotropia Postop. strabismus Postop. orthotropia Postop. strabismus P P (n=53) (n=11) (n=31) (n=13) Intact PC 8 7 (46.7%) 3 8 (72.7%) 0.002 0.000 Removed PC 45 4 (8.2%) 28 5 (15.2%) Secondary cataract (+) 13 8 (38.1%) 7 7 (50.0%) 0.002 0.042 Secondary cataract (-) 40 3 (7.0%) 24 6 (20.0%) PC: Posterior capsule.

DISCUSSION higherfrequencyofstrabismusinpatientswithunilateral Thevisualprognosisofpatientswithcongenitalcataractshas thanbilateralcataractsisthoughttobetheresultfromthe beenimprovedbyearlyoperation,advancedoperativeskill, higherdegreeofhypoplasiaincellsofthelateralgeniculate andactivevisualrehabilitation.Anteriorvitrectomyafter bodyontheaffectedsidecomparedtotheoppositesidein PCCCoropticcaptureofIOLhasbeenfoundtoreducethe patientswithunilateralcataracts,adifferencethatmay occurrence ofsecondarycataract,themostfrequent damagethevisualcortexandlateralgeniculatebody.The complicationaftersurgeryforcongenitalcataract [5,6,12-14]. greaterdifficultyinfusionresultsinahigherfrequencyof However,thefrequencyofstrabismusishigherinthese amblyopiabycompetitionbetweenthetwoeyes,withlower patientsthaninthenormalpopulation(1.3%-4.5%)[15-17].For compliancewithocclusivetreatmentcausingsecondary example,thefrequencyofstrabismuswasreportedtobe strabismusmorefrequently[19-21]. 70.6%aftersurgeryforunilateralcataractsand39%in Weassessedtherelationshipbetweenseveralfactorsand childrenwhounderwentprimaryIOLimplantation [7,18]. onsetofstrabismus,includingageatcataractsurgery, Anotherstudyreportedthatthefrequencyofstrabismuswas preoperativeandpostoperativeCDVA,preoperativeand 34%beforesurgeryand65%atfinalfollow-up [8].Wefound postoperativeinterocularCDVAdifference,nystagmus thatthefrequencyofstrabismuswas17.2%inchildrenwith beforeandaftersurgery,operativemethod(preserved bilateraland29.5%inthosewithunilateralcongenital removedPC),andsecondarycataract. cataracts, similartofrequenciesof22%and50%, Wefoundthatageatthetimeofsurgery( 1 ＞1y)was 臆 respectively,and20.5%and34.8%,respectively [5,8].The relatedtoonsetofstrabismusinbilateralcataracts,butwas

525 Strabismusaftercongenitalcataractssurgery notrelatedinunilateralcataracts.Althoughoneprevious patientshadpreoperativenystagmus,withthiscondition studyfoundnoassociationbetweenageatsurgeryand disappearingin1patientbutdevelopingin5[5]. developmentofstrabismus,anotherreportedthatstrabismus Wefoundthatthefrequencyofstrabismuswassignificantly occurredin8%ofchildrenundergoingsurgeryatage ＜3y lowerinpatientswhodidthandidnotundergoPCCC,both andin32%ofthoseaged ＞3y[7,8]. inpatientswithunilateralandbilateralcataracts.The However,inourstudy,thepatientswithearliersurgical incidenceofstrabismuswassignificantlyhigherinpatients timinghadhigherrateofpostoperativeonsetofstrabismusin withthanwithoutsecondarycataract. bilateralcataracts.Thereasonforthisoppositeresultis PCCChasbeenassociatedwithalowerrateofsecondary thoughttheexistenceofnystagmusenabledearlierdiagnosis cataractandahigherrateofopticcaptureofIOL.Secondary forcongenitalcataracts.Inunderdevelopedcountries, cataractspreventthemaintenanceoftheclearvisualaxis, congenitalcataractcannotbenoticeduntilalatertime, andcancauseamblyopia.Amblyopiaisreportedtobea leadingtodelayofsurgeryoraggressivemanagementfor predisposingfactorforthedevelopmentofstrabismus[7,8]. amblyopia.Nystagmushadastrongrelationshipwith Inourcases,secondarycataractsoccurredinallpatientsin developmentofstrabismuslikeotherstudy[22].Ofthepatients whomthePCwaspreserved.8of35patientswithsecondary whounderwentbilateralcataractsurgeryatage 1y, cataractshadnotbeenfollowed-upcontinuously,thus 臆 nystagmuswasobservedin5of6patientswithpostoperative managementforsecondarycataractswasdelayed.Evenafter strabismus,comparedwith3of10patientswithout ND:YAGposteriorcapsulotomyorsecondaryopticcapture strabismus( =0.039). forsecondarycataract,asignificantrelationshipwasevident Intermsofunilateralcataractswithoutnystagmus,the between secondarycataractsandthedevelopmentof optimaltimeofsurgeryforcongenitalcataractsisage strabismus.Therefore,eitheropticcaptureoranterior 6-8wk,aperiodessentialforthedevelopmentofvisual vitrectomyafterPCCCduringcataractremovalmayhelp acuity [6,23].However,theageatcataractsurgeryinour preventonsetofthepostoperativestrabismusbyminimizing presentstudywasover8wkinallthecases;ageatsurgery theriskofdevelopmentofsecondarycataracts. thuslikelyhadlittleimpactondevelopmentofstrabismusin Inconclusion,theprevalenceofstrabismusaftersurgeryfor thepatientswithunilateralcataracts. bilateralcongenitalcataractswassignificantlyhigherwhen Therewassignificantrelationshipsbetweenmean surgerywasperformedatage 1y,whenpreoperative 臆 preoperativeCDVA( 20/100)andstrabismusinbilateral CDVAwaslower,andnystagmusdevelopedbeforeorafter 臆 cataracts.Nystagmuswasnotedin4of17patients(23.5%) surgery.Theprevalenceofstrabismuswashigherinpatients withpoorpreoperativeCDVA 20/100,andinnopatient withunilateralcataractswithalargerpostoperative 臆 withCDVA>20/100. interocularCDVAdifference.Theoccurrenceofstrabismus Weobservednosignificantrelationshipsbetweenpreoperative wassignificantlyhigherinbothsetsofpatientswhen interocularCDVAdifference(20/70 ＞ 20/70)and postoperativeCDVAwaslower,whenPCCCwasnot 臆 strabismus,bothinpatientswithbilateralandunilateral performed,andwhensecondarycataractdeveloped. cataracts. ACKNOWLEDGEMENTS Strabismus,however,wassignificantlymorefrequentin Foundation: SupportedbyInjeUniversity,2013. patientswithpostoperativeCDVA 20/100thaninthose ConflictsofInterest:LeeSJ, None; KimWS, None. 臆 withpostoperativeCDVA ＞20/100,bothinpatientswith REFERENCES unilateralandbilateralcataracts.Moreover,strabismuswas 1KrishnaiahS,SubbaRaoB,LakshmiNarasammaK,AmitG.Asurveyof significantlymorefrequentinunilateralcataractpatients severevisualimpairmentinchildrenattendingschoolsfortheblindina withpostoperativeinterocularCDVAdifference>20/70than coastaldistrictofAndhraPradeshinSouthIndia. 2012;26(8): 20/70.Strabismushasbeenreportedmorefrequentwhen 1065-1070 臆 2PiLH,ChenL,LiuQ,KeN,FangJ,ZhangS,XiaoJ,YeWJ,XiongY, goodCDVAafteroperationwasnotachieved.Improper ShiH,ZhouXY,YinZQ.Prevalenceofeyediseasesandcausesofvisual postoperativetreatmentof amblyopiainpatientswith impairmentinschool-agedchildreninWesternChina. 2012; unilateralcataractshasbeenreportedtoincreaseinterocular 22(1):37-44 [7,8] CDVAdifference,leadingtostrabismus . 3HaargaardB,WohlfahrtJ,RosenbergT,FledeliusHC,MelbyeM.Risk Noneofourpatientswithunilateralcataractshadnystagmus, factorsforidiopathiccongenital/infantilecataract. comparedwith18.8%ofpatientswithbilateralcataractspre- 2005;46(9):3067-3073 orpostoperatively,similartotherateof24%observedina 4SteinertRF. previousstudy [6].Anotherstudyreportedthat8of139 .2nd ed.Philadelphia:WBSaunders2004;273

526 陨灶贼允韵责澡贼澡葬造皂燥造熏灾燥造援 7熏晕燥援 3熏 Jun.18, 圆园14 www.IJO.cn 栽藻造押8629原愿圆圆源缘员苑圆 8629-82210956 耘皂葬蚤造押ijopress岳员远猿援糟燥皂 5LedouxDM,TrivediRH,WilsonMEJr,PayneJF.Pediatriccataract andeyealignmentinchildrentreatedfordensecongenitalordevelopmental extractionwithintraocularlensimplantation:visualacuityoutcomewhen cataracts. 2012;16(2):156-160 measuredatagefouryearsandolder. 2007;11:218-224 16AutrataR,RehurekJ,Vodickov K.Visualresultsafterprimary 觃 6BirchEE,ChengC,StagerDRJr,WeakleyDRJr,StagerDRSr.The intraocularlensimplantationorcontactlenscorrectionforaphakiainthe criticalperiodforsurgicaltreatmentofdensecongenitalbilateralcataracts. firstyearofage. 2005;219(2):72-79 2009;13:67-71 17KimDH,KimJH,KimSJ,YuYS.Long-termresultsofbilateral 7WeisbergOL,SprungerDT,PlagerDA,NeelyDE,SondhiN.Strabismus congenitalcataracttreatedwithearlycataractsurgery,aphakicglassesand inpediatricpseudophakia. 2005;112(9):1625-1628 secondaryIOLimplantation. 2012;90(3):231-236 8OhMJ,MinWK,MinBM.TheAssociationofStrabismusandCongenital 18BothunED,ClevelandJ,LynnMJ,ChristiansenSP,VanderveenDK, Cataract. 1989;30:611-615 NeelyDE,KrugerSJ,LambertSR;InfantAphakicTreatmentStudy. 9KhannaRC,FosterA,KrishnaiahS,MehtaMK,GogatePM.Visual One-yearstrabismusoutcomesintheinfantaphakiatreatmentstudy. outcomesofbilateralcongenitalanddevelopmentalcataractsinyoung 2013;120(6):1227-1231 childreninsouthIndiaandcausesofpooroutcome. 19DickmannA,AlibertiS,RebecchiMT,AprileI,SalerniA,PetroniS, 2013;61(2):65-70 ParrillaR,PerrottaV,DiNardoE,BalestrazziE.Improvedsensorystatus 10SkutaGL,CantorLB,WeissJS.Pediatricophthalmologyand andquality-of-lifemeasuresinadultpatientsafterstrabismussurgery. strabismus. 2010:250 2013;17(1):25-28 11MaX,LiFF,WangSZ,GaoC,ZhangM,ZhuSQ.Anewmutationin 20HessRF,MansouriB,ThompsonB.Restorationofbinocularvisionin BFSP2(G1091A)causesautosomaldominantcongenitallamellarcataracts. amblyopia. 2011;19(3):110-118 2008;14:1906-1911 12Zetterstr mC,LundvallA,KugelbergM.Cataractsinchildren.J 21ChiaA,LinX,DiraniM,GazzardG,RamamurthyD,QuahBL,Chang 觟 2005;31(4):824-840 B,LingY,LeoSW,WongTY,SawSM.Riskfactorsforstrabismusand 13GimbelHV,DeBroffBM.Intraocularlensopticcapture. amblyopiainyoungsingaporechinesechildren. 2004;30(1):200-206 2013;20(3):138-147 14GuoS,WagnerRS,CaputoA.Managementoftheanteriorandposterior 22FranceTD,FrankJW.Theassociationofstrabismusandaphakiain lenscapsulesandvitreousinpediatriccataractsurgery. children. 1984;21(6):223-226 2004;41(6):330-337 23LambertSR.Treatmentofcongenitalcataract. 2004; 15BirchEE,WangJ,FeliusJ,StagerDRJr,HertleRW.Fixationcontrol 88(7):854-855

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