Eye (2016) 30, 1229–1233 © 2016 Macmillan Publishers Limited, part of Springer Nature. All rights reserved 0950-222X/16 www.nature.com/eye 1,2 1 3 Visual acuity and its LA Bonaparte , RH Trivedi , V Ramakrishnan CLINICAL STUDY and ME Wilson1 predictors after surgery for bilateral cataracts in children Abstract Purpose The objective of this study was to Introduction investigate preoperative factors associated Early treatment of cataract can be beneficial with postoperative visual acuity outcomes as it is a treatable cause of visual handicap in and to develop a model to predict visual children.1 Visually significant cataracts, if left acuity prognosis. untreated, can lead to poor vision, which can Methods A retrospective study was adversely affect a child’s education, occupation, conducted by reviewing clinical charts of and socio-economic status for life.2 Early pediatric patients who underwent bilateral detection through screening mechanisms and cataract surgery by a single surgeon (MEW) at prompt treatment are imperative to prevent the Storm Eye Institute. A multiple logistic poor vision and blindness.3,4 Understanding regression model was constructed to predict the odds of poor postoperative visual acuity, certain clinical factors and their roles in affecting that is, worse than 20/40, based on age at visual acuity after cataract surgery helps surgery, gender, primary intraocular lens determine visual outcomes. (IOL) placement, ethnicity, and preoperative Many clinical factors have been suggested 1Department of fl nystagmus. in previous studies to be important in uences Ophthalmology, Results of visual outcomes for pediatric patients with Storm Eye Institute, A sample size of 157 children – unilateral and bilateral cataracts.4 7 Previous Medical University of (314 eyes) was investigated with median South Carolina, studies have determined that age at time of duration of follow-up of 6.4 years. A total of Charleston, SC, USA 78% of children with bilateral cataract had cataract extraction, method of postoperative postoperative visual acuity of 20/40 or better. optical correction, and presence of nystagmus 2Department of The presence of preoperative nystagmus was are all factors that may help predict Ophthalmology, Nassau highly correlated with poor postoperative postoperative visual outcomes. Preoperative University Medical Center, East Meadow, NY, USA visual acuity (OR = 6.0; 95% CLs, 2.5–14.1; nystagmus has been associated with poor P-valueo0.0001). Children of age o1 year at postoperative visual acuity in bilateral cataract 3 5,6 Public Health Sciences, time of cataract extraction (OR = 3.2; 95% CLs, cases. Postoperative glaucoma patients also Medical University of South 7,8 1.4–7.6; P-value = 0.0073), male gender have lower rates of good visual acuity results. Carolina, Charleston, SC, (OR = 2.3; 95% CLs, 1.1–4.5; P-value = 0.02), The presence of systemic disorders have been USA the absence of primary IOL placement associated with poor visual acuity in bilateral (OR = 3.0; 95% CLs, 1.05–8.4; P-value = 0.04), cases, reflecting additional causes of poor Correspondence: = vision.4 Many previous studies have included ME Wilson, Department of and non-Caucasian ethnicity (OR 2.0; 95% Ophthalmology, Storm Eye CLs, 1.02–4.03; P-value 0.0447) were both unilateral and bilateral cataracts within the Institute, Medical University associated with poor visual acuity same study. However, there have been limited of South Carolina, Rm 218, postoperatively. studies based solely on bilateral cataracts in 167 Ashley Avenue, Conclusions Satisfactory visual outcomes children,9 and to our knowledge, a model to MSC 676, Charleston, SC 29425-6760, USA predict visual acuity before surgery has yet occurred in 78% of children operated on for Tel: +1 84 3792 7622; bilateral cataracts. Preoperative nystagmus, to be developed. Fax: +1 84 3792 8289. age o1 year at time of cataract extraction, There is a paucity of data regarding E-mail: wilsonme@musc. absence of primary IOL placement, male preoperative factors that predict postoperative edu gender, and non-Caucasian ethnicity, were visual outcomes in the pediatric bilateral cataract all factors associated with poor postoperative population. In this study, we report visual acuity Received: 27 February 2016 Accepted in revised form: visual acuity. outcomes when childhood cataracts present 4 July 2016 Eye (2016) 30, 1229–1233; doi:10.1038/eye.2016.166; bilaterally. The objective of this study was to Published online: published online 29 July 2016 acquire a better understanding of the factors that 29 July 2016 Visual acuity in pediatric bilateral cataracts LA Bonaparte et al 1230 are associated with postoperative visual acuity outcomes performed using SAS software, version 9.3 (SAS Institute and to develop a model to predict visual acuity prognosis Inc., Cary, NC, USA). Logistic regression analysis was preoperatively. Specifically, the relationship between performed to investigate the influence of age at time preoperative variables and visual outcomes after bilateral of cataract surgery, gender, ethnicity, preoperative pediatric cataract extraction was investigated. nystagmus, and primary vs secondary/no IOL implantation on postoperative visual function. A Materials and methods multivariate model was constructed to predict the odds of worse visual acuity based on the preoperative A retrospective study was conducted by reviewing variables. P-values of o0.05 were considered to be clinical charts of pediatric patients who underwent of statistical significance. bilateral cataract surgery by a single surgeon (MEW) In addition, we compared our postoperative visual at the Storm Eye Institute from January 1991 to October outcomes with the required visual acuity to qualify for a 2012. The institutional review board at the Medical driving license in the US; conventionally, best-corrected University of South Carolina approved the study protocol visual acuity must be 20/40 in at least one eye for the according to the tenets of the Declaration of Helsinki. majority of states in the US. Patients from birth to 18 years of age with visually significant bilateral cataracts who had bilateral cataract extraction with or without intraocular lens (IOL) Results implantation were included in this study. Children in In all, 314 eyes of 157 children fitted inclusion criteria. whom cataracts were acquired as a result of trauma, Approximately 61% of children were Caucasian (n = 96), patients with additional ocular pathology, such as lens 34% African-American (n = 53), 3% Hispanic (n = 5), and subluxation or congenital glaucoma, and children o5 2% other (n = 3). Race was classified as ‘Caucasian’ years of age at last follow-up were excluded from and ‘non-Caucasian’ during regression analysis this study. In addition, patients with postoperative (61% Caucasian vs 39% non-Caucasian). In all, 53% of our follow-up period of o6 months were excluded. patient database was male (n = 83) and 47% was female The following preoperative data were reviewed: cause (n = 74). Median age at surgery was 3.91 years, with a and type of cataract, age at surgery, duration between range of 0.01–17.5. Median follow-up was 6.4 years. first eye cataract surgery to second eye cataract surgery, The distributions of the variables, nystagmus, associated ocular conditions, associated systemic conditions, past medical history, including developmental preoperative strabismus, and IOL placement were as delay, nystagmus (if present, yes or no), strabismus follows: 23% of eyes were noted to have nystagmus and (if present, yes or no), and best-corrected distance 19% had strabismus preoperatively. A total of 80% of eyes visual acuity (BCDVA). The initial surgical technique was had primary IOL placed at time of surgery, 9% had a reviewed and whether the patient was treated with IOLs secondary IOL placed, and 11% remained aphakic. or contact lenses was determined. If IOLs were implanted, Median visual acuity of the eye with better vision was power of the IOLs and the targeted refractions were best in children older than 4 years of age with a Snellen noted. The following data were collected from visual acuity of 20/25. Median visual acuity of the eye postoperative follow-up notes and dictations: age at with poor vision was worse for children younger than 1 last follow-up, postoperative complications, such as year of age with a Snellen visual acuity of 20/60 (Table 1). glaucoma, and BCDVA at 1 month and last follow-up. Furthermore, median visual acuity in the eye with better If BCDVA was o20/100 at the last follow-up exam, vision was 20/40 for children in the amblyogenic age causes for poor visual outcome were determined. Data group, that is, ≤ 5 years of age (n = 94), and 20/25 for collected also included demographic information, consisting of gender and ethnicity. The primary outcome measure was postoperative Table 1 Median VA and range for age at surgery BCDVA using Snellen linear optotypes. The geometric Age at N Median VA of Median VA of Driving visual acuity was then converted to a logarithm of the surgery eye with better eye with worse license in the minimal angle of resolution units for statistical analysis. (years) vision vision US (%) Visual acuity was also categorized as better than or equal o1 51 20/40 20/60 61 to 20/40 and worse than 20/40, creating a dichotomous 1–4 28 20/30 20/40 93 outcome for visual acuity. 4–8 40 20/25 20/30 80 Statistical analyses were performed on eyes that met the 48 38 20/25 20/25 90 inclusion criteria. Descriptive statistics were calculated for Total 157 20/30 20/40 78 case characteristics. A multivariate analysis was Abbreviations: N, number of patients; VA, visual acuity. Eye Visual acuity in pediatric bilateral cataracts LA Bonaparte et al 1231 those above 5 years of age (n = 63). Median visual acuity Table 2 Multivariate (joint effects) analysis of factors associated in the eye with worse vision was 20/50 for children in with poor acuity as dichotomous outcome ≤ the amblyogenic age group, that is, 5 years of age Preoperative variable Relative odds of having P-value and 20/30 for children above 5 years of age.