540 Br J Ophthalmol 2001;85:540–542 Outcome of lens aspiration and intraocular lens implantation in children aged 5 years and under Lorraine Cassidy, Jugnoo Rahi, Ken Nischal, Isabelle Russell-Eggitt, David Taylor Abstract However, final refraction is variable, such that Aims—To determine the visual outcome emmetropia in adulthood cannot be guaran- and complications of lens aspiration with teed, as there are insuYcient long term studies. intraocular lens implantation in children There have been many reports of the visual aged 5 years and under. outcome and complications of posterior cham- Methods—The hospital notes of all chil- ber lens implantation in children.4–12 Most of dren aged 5 years and under, who had these have been based on older children, undergone lens aspiration with intraocu- secondary lens implants, a high number of lar lens implantation between January traumatic cataracts, and many have reported 1994 and September 1998, and for whom early outcome. We report visual outcome and follow up data of at least 1 year were avail- complications of primary IOL implantation at able, were reviewed. least 1 year after surgery, in children aged 5 Results—Of 50 children who underwent years and under, with mainly congenital or surgery, 45 were eligible based on the juvenile lens opacities. follow up criteria. 34 children had bilat- eral cataracts and, of these, 30 had surgery Methods on both eyes. Cataract was unilateral in 11 SUBJECTS cases; thus, 75 eyes of 45 children had sur- We reviewed the notes of all children aged 5 gery. Cataracts were congenital in 28 years and under, who had undergone lens aspi- cases, juvenile in 16, and traumatic in one ration with primary posterior chamber in- case. The median age at surgery was 39 traocular lens implantation between January months (range 11–70 months). Follow up 1994 and August 1998 in our hospital. Forty ranged from 12–64 months (median 36 five of these children were eligible for inclusion months). Of 34 children with bilateral dis- in our study, as a minimum of 1 year follow up ease, 25 (73.5%) had a final best corrected data were available for them. Those children visual acuity of 6/12 or better, while seven with uveitis, aniridia, and persistent primary (20.5%) achieved 6/18 or less; in one child hyperplastic vitreous were excluded. the vision improved from UCUSUM to CSM but another, who had only one eye operated on, was unable to fix or follow PREOPERATIVE ASSESSMENT with this eye preoperatively or 2 years All patients had had a full ophthalmic assess- postoperatively. Of 11 children with uni- ment preoperatively. This included visual acu- lateral cataract, five (45.5%) had a final ity (using preferential looking, CardiV acuity best corrected visual of 6/12 or better, and cards, Kay pictures, Sheridan Gardner singles, six (54.5%) 6/18 or less. A mild fibrinous or the Snellen chart as appropriate) slit lamp Department of uveitis occurred in 20 (28.2%) eyes in the examination, dilated funduscopy, retinoscopy, Ophthalmology, Great immediate postoperative period, but re- keratometry, and biometry. B-scan ultrasono- Ormond Street graphy and electrophysiological testing includ- Hospital for Children, solved with topical steroids. One child had a vitreous wick postoperatively requiring ing visual evoked potentials (VEP) and an Great Ormond Street, electroretinogram (ERG) were carried out if London surgical division. Glaucoma, endoph- L Cassidy thalmitis, or retinal detachment have not necessary. The intraocular lens power was cal- J Rahi been observed so far in any patient culated using the SRK II formula, and the K Nischal postoperatively. appropriate IOL power chosen according to I Russell-Eggitt the child’s age using a graph constructed from D Taylor Conclusion—From this series the authors suggest that, in children aged 5 years and the world literature. The pupils were dilated under, lens aspiration with intraocular with cyclopentolate 0.5% and phenylephrine Department of 2.5% inserted at 90, 60, and 30 minutes Paediatric lens implantation is a safe procedure, with Epidemiology, a good visual outcome in the short term. preoperatively. Informed consent was obtained Institute of Child Further studies are needed to investigate from the parents. Health, Guilford Street, London these outcomes in the long term. SURGICAL TECHNIQUE J Rahi (Br J Ophthalmol 2001;85:540–542) After conjunctival periotomy and cautery to Correspondence to: the sclera, a 6 mm scleral tunnel was made in Mr David Taylor, Great Intraocular lens implantation is becoming an all cases, using an angled crescent blade. A Ormond Street Hospital for increasingly accepted procedure in young chil- small opening was then made using a Children, Great Ormond Street, London WC1N 3JH, dren and infants. Awareness of the rate of keratome into the anterior chamber (AC). UK myopic shift which takes place in the develop- Healon GV was then injected to the AC and [email protected] ing eye, and the use of biometry, allows us to an anterior continuous circular capsulorhexis Accepted for publication predict appropriate intraocular lens (IOL) (CCC) performed using a Sutherland rhexis 20 December 2000 powers to try to ensure eventual emmetropia.1–3 forceps. The lens matter was aspirated using a www.bjophthalmol.com Outcome of lens aspiration and IOL implantation in children aged 5 years and under 541 Table 1 The Great Ormond Street occlusion protocol for bilateral and unilateral cataracts Results Of 45 children eligible for inclusion on the Occlusion regime for bilateral cataract Occlusion regime for unilateral cataract minimum follow up criterion, 34 had bilateral (1) 0–1/2 octaves interocular diVerence in (1) The phakic eye is occluded 1hour/day for and 11 unilateral disease. Cataracts were visual acuity, no occlusion each month of life* until 6 months of age. After congenital in 23 cases in the group with 6 months occlusion depends on interocular diVerence (see 2–4 below) bilateral lens opacities, the remaining 11 were (2) 1–2 octaves interocular diVerence in (2) 0–1⁄2 octave interocular diVerence in visual juvenile. In the unilateral group there was one visual acuity, 1–2 hours of occlusion of the acuity, 50% of waking hours traumatic cataract, five congenital cataracts, preferred eye (3) More than 2 octaves interocular (3) 1–2 octaves interocular diVerence in visual and five juvenile cataracts. Five cases in the diVerence in visual acuity, 2–4 hours of acuity, 75% of waking hours unilateral group and two in the bilateral group occlusion of the preferred eye were associated with posterior lenticonus. (4) If no improvement after stage 3, full time (4) More than 2 octaves interocular diVerence in occlusion visual acuity, 100% waking hours Seventy five eyes of 45 children (28 boys, 17 NB To be reviewed every 2 weeks NB To be reviewed every 2 weeks girls) had surgery, 11 eyes in the unilateral group, and 64 eyes in the bilateral group. *That is, a child aged 2 months is patched for 2 hours a day, a 3 month old child for 3 hours/day, etc. Thirty children with bilateral cataracts had bilateral lens aspiration and PC IOL, and four Table 2 Visual outcome and compliance with occlusion therapy in children with unilateral children had uniocular surgery, as the cataract cataract in the second eye was not significant enough to Age at Postop Occlusion Follow up interfere with visual acuity. The median age at Patient Eye surgery Aetiology Preop VA VA concorde* (years) surgery was 39 months (range 11–70 months). 1 R 18/12 C Not fixing 6/12 Good 4 The median follow up period was 36 months or following (range 12–62 months). 2 L 3 y 6/12 C 1/60 6/24 Poor 4 3 L 3 y 6/12 C 6/24 6/9 Good 3.5 4 L 5 y 3/12 J CFs 6/6 Good 2.5 VISUAL OUTCOME 5 R 1 y 2/12 C ? not 6/60 None 1.1 In the bilateral group, final best corrected visual cooperative acuity in the worse eye was 6/12 or better in 25 6 R 5 y J 6/60 6/60 None 3 7 R 14/12 C ? not 6/60 None 2.2 (73.5%) children, 6/18 or less in seven (20.6%), cooperative and in one child whose vision was not assessed 8 R 3 y T PL 6/24 Poor 1.2 using acuity cards, the vision improved from 9 R 5 y 1/12 J 2/60 1/60 Good 1.3 10 R 3 y J PL 6/12 Good 1.3 fixation that was uncentral unsteady and un- 11 R 2 y 1/12 J 3/60 6/6 Good 5 maintained (UCUSUM), to central steady and maintained (CSM). One child from the bilateral C = congenital; J = juvenile; T = traumatic; CF = counting fingers; PL = perception of light. *Concordance was categorised into none (no compliance), poor (less than full), and good (full). group who only had one eye operated on, was not fixing or following with this eye 2 years post- Table 3 Requirement for posterior capsulotomy postoperatively in patients having had operatively; this was because of non-compliance primary posterior capsulotomy without primary vitrectomy with occlusion therapy. Primary posterior Primary In the unilateral group, the final best cor- Eye CCC vitrectomy YAG capsulotomy Surgical capsulotomy rected visual acuity was 6/12 or better in five A Yes No Yes × 2Yes (45.5%) children, 6/18 or less in six (54.5%) B Yes No Yes × 1No cases. Poor vision was attributed, at least in part, C Yes No Yes × 2Yes to poor compliance with occlusion therapy in five of 11 (45%) children (Table 1).