Surgical Considerations in Children with Corneal Opacities and Cataracts

Abstract

In the past, pediatric corneal opacities have been grouped into congenital and acquired causes. We discuss corneal opacities and group them based on the treatment, including penetrating keratoplasty, endothelial keratoplasty, and optical iridectomy. Modern surgery for pediatric corneal opacities is following the trend in adult corneal surgery, namely, to replace only the diseased corneal layers. Little definitive surgical advice can be easily gleaned from prior publications on pediatric penetrating keratoplasty, due to the inclusion of diverse patients, techniques, and surgical timing. Visual development, or the lack of it – deprivation amblyopia – is an ever-present issue for the pediatric corneal surgeon, in contrast to the surgical considerations of adult corneal opacity. Each of the three above modalities has its distinct pros and cons in children. For example, while pediatric endothelial keratoplasty requires fewer examinations under anesthesia for suture removal, fewer suture-related complications, and less induced astigmatism compared with penetrating keratoplasty, surgery in children must be altered from the adult technique due to the child’s shallower anterior chamber and relative positive posterior pressure. Optical iridectomy should be considered when the central opacity is associated with at least several millimeters of clear peripheral cornea. The treatment of pediatric corneal opacities, while challenging, can bring tremendous rewards, especially when the relatively recent techniques of selective corneal replacement may be applied. This chapter discusses surgical treatment options for pediatric corneal opacities, including penetrating, endothelial, and lamellar keratoplasties. Attention will also be given to the use of Boston keratoprostheses as well as a less frequent, but highly valuable, optical iridectomy. The management of coincident glaucoma will also be discussed.