Management Of Pediatric Cataract Research Articles

A case series on small incision cataract surgery + PMMA IOL with primary posterior capsulorrhexis: A safe and cheaper alternative in management of pediatric cataracts

Pediatric cataracts, a significant cause of childhood blindness, present pronounced challenges in low-income countries where conventional phacoemulsification with hydrophobic foldable IOLs may be economically unfeasible. In resource-limited settings, the conventional method of employing phacoemulsification with hydrophobic foldable IOLs is often impractical. This case series explores an economically pragmatic alternative, centering on Small-incision cataract surgery (SICS) paired with rigid polymethyl methacrylate (PMMA) intraocular lenses (IOLs). This study delves into the visual outcomes of SICS with in-the-bag PMMA IOLs, Primary Posterior Capsulorrhexis (PPC), and anterior vitrectomy to mitigate Posterior Capsule Opacification (PCO) formation in the Visual Axis (VA). The evaluation, conducted at specific postoperative intervals spanning from Post-op Day 01 to the 6th month, provides a comprehensive understanding of the efficacy and safety of this approach. Findings underscore PMMA IOLs as both durable and cost-effective substitutes, with an emphasis on SICS with PPC as a reliable technique for cataract removal. This research delivers a practical solution to enhance visual outcomes, tackling the distinct challenges confronted in resource-limited settings and contributing to the broader global endeavor to alleviate preventable childhood blindness.

A review of paediatric cataract surgery techniques and practices: Past, present and future

Background: The management of paediatric cataract has always been unique, challenging and complex for ophthalmologists. The pursuit of expertise to enhance outcomes for affected children has driven the scientific and ophthalmic community, from the years preceding Christ to the present-day 21st century, to refine surgical techniques for visual restoration in these children. Methods: This is a review article looking into the evolution, historical progression and advancement of cataract surgical techniques in children through extensive online literature search utilising internet search engines, journals, textbooks, PubMed, Cross-references, ResearchGate, Medscape and Web of Science. Search terms used included “history of Paediatric Cataract Surgery,” “Paediatric cataract surgical techniques,” “Couching,” “Discission,” “Irrigation & Aspiration’, ‘Phacoemulsification’, ‘Femtolaser’, Visual rehabilitation and Optic capture”. Results: The management of paediatric cataract has witnessed remarkable transformation over the years. The historical context illustrates a continuous dedication towards improving visual outcome. Refined techniques have culminated in diverse array of methods and practices used to take care of unique or specific challenges encountered in the care of paediatric cataracts. Conclusion: This article highlights the various methods employed to achieve the goal of visual restoration in paediatric cataract cases by considering factors such as the age of the child, the extent and impact of cataract and advancements in technology. Therefore, it provides insight into the ongoing efforts to enhance the quality of life for children affected by cataract.

Artificial intelligence in cataract and refractive surgery

Artificial intelligence (AI) technology is proving to be promising in the field of healthcare, especially in the areas relying on big data and image‐based analysis. In Ophthalmology, AI was already tested in majority of subspecialities, including cataract and refractive surgery. There were interesting studies showing the benefits of using AI algorithms in early keratoconus detection, to predict the outcomes of laser refractive surgery, and to cataract surgery training and monitoring. Moreover, AI models using fundus images to diagnose and grade cataract have been developed. New intraocular lens (IOL) formulas are applying big data and computational methodologies to achieve better prediction of targeted refraction and simplify the IOL selection process. Recent developments in AI have shown their potential possibility for the diagnosis and management of paediatric cataract using slit‐lamp images.

Systemic and ocular associations in pediatric patients undergoing cataract surgery.

Evaluation for systemic diagnosis is an important part of pediatric cataract management. While there are reports on associated systemic and ocular associations in children with infantile cataracts, reports specifying associations in large cohorts of children undergoing cataract surgery are lacking. Retrospective chart review of consecutive patients undergoing cataract surgery at a pediatric tertiary referral center during 30-year period was performed. Associated systemic and ocular associations were recorded. The etiologies were analyzed depending on laterality, age, and gender. Seven-hundred twenty-seven patients (1135 eyes) were included for analysis: 408 (56%) with bilateral and 319 (44%) with unilateral cataract. An identifiable cause for cataract was identified in 66% (270/408) bilateral and 55% (176/319) unilateral cataract patients. Hereditary cataract accounted for 22% of bilateral cataracts. An underlying syndrome or genetic diagnosis was found in 24% bilateral (97/408, 86 genetic/syndromic, 11 metabolic) but only in 2% of unilateral cases (5/319). Cataracts were the result of treatment for cancer, or other systemic conditions requiring steroids, in 60/408 bilateral (15%) and 15/319 (5%) unilateral cataract patients. In contrast, unilateral cataracts had higher ocular associations (49%, 156/319) than bilateral cataracts (6%, 23/408) primarily ocular trauma (20%, 64/319) and persistent fetal vasculature (20%, 62/319). Clinicians should be aware of potential systemic and ocular associations among children with visually significant cataracts. Those with no family history of juvenile cataract should be evaluated for systemic associations, and referral to genetics may be warranted in select cases.

Bilateral cataract in a child with blepharophimosis-ptosis-epicanthus inversus syndrome: A surgical challenge

IntroductionBlepharophimosis-ptosis-epicanthus inversus syndrome (BPES) is a rare autosomal dominant genetic disorder characterized by complex orbito-palpebral anomalies. We report a rare case of BPES associated with bilateral congenital cataract.ObservationThis study reports the case of a 6-month-old infant with BPES in whom a bilateral congenital cataract was diagnosed, after the parents noticed leukocoria and signs of poor vision in their child. No other ophthalmologic manifestations commonly associated with this syndrome were found. The infant underwent cataract surgery first, with lens phacoaspiration and posterior capsulotomy coupled with anterior vitrectomy and placement of a 3-piece foldable hydrophobic posterior chamber lens in the capsular bag. The surgery was a real challenge due to the orbito-palpebral anomalies that limited a small surgical space, and the placement of the IOL was a matter of discussion.DiscussionPublications on the association of congenital cataract with BPES are very rare. The link between these two anomalies is difficult to establish since different genes on different chromosomes code for the two diseases. A lateral canthotomy can be considered to overcome the surgical difficulties due to the reduced working space. The surgical management of pediatric cataract varies in the literature.ConclusionThis case highlights the difficulty of cataract surgery in children, even more so when associated with BPES, and the challenge of improving vision in these children given the high risk of amblyopia.

Challenges in Management of Pediatric Cataract

Challenges in Management of Pediatric Cataract

Pediatric cataract - Evaluation and management

Management of pediatric cataracts remains a challenge. Increased intraoperative difficulties, low scleral rigidity, high vitreous pressure, propensity for increased postoperative inflammation, changing refractive state of the eye, very high incidence of visual axis opacification, and a tendency to develop amblyopia, all add to the difficulty in achieving a good visual outcome in a pediatric patient. This article focuses on the major aspects in the management of pediatric cataract and the literature.

Commentary: Pediatric cataract management during the COVID-19 era.

Commentary: Pediatric cataract management during the COVID-19 era.

Recent developments in the management of congenital cataract.

Congenital cataract is a rare eye disease, one of the leading treatable causes of low vision in children worldwide. Hereditary cataracts can be divided in syndromic and non-syndromic cataracts. Early diagnosis in congenital cataracts is key to reach good visual function. Current surgical techniques, that combine microincision cataract extraction and primary intraocular lens (IOL) implantation, have improved childhood cataract outcome. Complications include posterior capsule opacification (PCO), aphakic or pseudophakic glaucoma, uveitis, pupil displacement and IOL decentration. A recent study using a modified Delphi approach identified areas of consensus and disagreement in the management of pediatric cataract. A consensus or near consensus was achieved for 79% of the questions, however 21% of the questions remained controversial, as for IOL implantation strategy. Congenital cataracts show a highly variable phenotype and genotype, and can be related to different mutations, genetic variance, and other risk factors. Congenital cataracts can be associated with other ocular developmental abnormalities, including microphthalmia, microcornea, or aniridia and with systemic findings. Next-generation sequencing (NGS) and forthcoming new ultra-high-throughput sequencing represent excellent tools to investigate the genetic causes of congenital cataracts. A better recognition of different clinical presentations and underlying etiologies of congenital cataracts may lead to the development of new approaches to improve visual outcome after cataract surgery and promote early detection of systemic associated syndromes.

Epidemiology of pediatric cataracts – A 5 year retrospective study

To determine the epidemiology, diagnosis and management of pediatric cataracts and to identify preventable factors and improve the visual prognosis in these patients. A retrospective study was conducted after reviewing the details of 87 patients of pediatric cataract aged between 3 months and 15 years who underwent cataract surgery in our institute from January 2014 to December 2018. A team of ophthalmologists and pediatricians attached to the center examined all the patients preoperatively. The type of cataract was determined using slit lamp biomicroscopy or operating microscope. Congenital cataracts were 71.26% and acquired cataracts were 27.9%. Congenital cataract includes idiopathic (77.41%), hereditary (12.90%), associated with syndromes (8.06%) and rubella (1.61%). In congenital cataract group, 41 patients had bilateral cataract and 21 had unilateral cataract. In acquired cataract group, 23 had unilateral and 2 had bilateral cataract. Traumatic cataract was most common in boys in the age group of 11-15 years and most common cause of trauma was wooden stick injury (45%). All patients underwent surgery and were left either aphakic (planned for secondary IOL implantation) or pseudophakic and had post operative visual rehabilitation. Early diagnosis and treatment of pediatric cataracts in a high percentage of cases is the key for good visual outcome. Given the high proportion of idiopathic pediatric cataracts, prevention of the disease remains a challenge worldwide.

A Cross-Sectional Online Survey Identifies Subspecialty Differences in the Management of Pediatric Cataracts Associated with Uveitis.

IntroductionTo determine if differences exist between pediatric ophthalmologists and uveitis ophthalmologists in the treatment of pediatric uveitic cataracts and placement of intraocular lenses.MethodsUveitis ophthalmologists and pediatric ophthalmologists were surveyed via an online poll regarding their therapeutic management of pediatric uveitic cataract and intraocular lens (IOL) placement.ResultsSixty-two responses from uveitis ophthalmologists and 47 responses from pediatric ophthalmologists were recorded. According to 79% of all responses, uveitis was not a contraindication for primary IOL implantation in patients with controlled intraocular inflammation. Pediatric ophthalmologists were more likely to respond that the presence of chronic juvenile idiopathic arthritis-associated iridocyclitis, pars planitis, or recurrent acute anterior uveitis is a contraindication for primary IOL implantation in pediatric cases with full control of intraocular inflammation. There was no consensus within either specialty with regard to the preferred IOL material for lens implantation. Uveitis ophthalmologists were more likely to report the use of intravenous and intravitreal steroids for perioperative treatment. In cataract surgery for a child with recurrent acute anterior uveitis, a higher percentage of uveitis ophthalmologists (71%) than pediatric ophthalmologists (50%) responded that the posterior capsule should be primarily opened. A higher percentage of uveitis ophthalmologists also stated that anterior vitrectomy should be performed at the time of cataract surgery in all three uveitis types.ConclusionsPediatric ophthalmologists and uveitis ophthalmologists have similar approaches to the management of pediatric uveitic cataract removal and IOL insertion, but several differences remain between these subspecialties. Continued collaboration between the subspecialties would be helpful to better develop consistent criteria to improve patient care.Electronic supplementary materialThe online version of this article (10.1007/s40123-020-00245-x) contains supplementary material, which is available to authorized users.

Paradigms for Pediatric Cataract Surgery.

Pediatric cataract surgery has seen several advances in techniques, technologies, and conceptual practices. Pediatric cataract management heavily depends on a combined effort, not only from the ophthalmologist, but also the parents, the anesthetists, and the supporting staff members (eg, optometrists, orthoptists, patient coordinators). Surgical management, though critical, is not the only consideration for these children. Continuing visual rehabilitation and monitoring for complications remain key elements even after the surgery is done. Pediatric cataract surgery is a complex issue best left to surgeons who are familiar with the surgical paradigms and its long-term complications. Key components of surgery are management of posterior capsule and anterior vitreous and intraocular lens (IOL) implantation. It is a preferred practice today to perform a primary posterior capsulorhexis with anterior vitrectomy in younger children (up to 3 to 5 years old). Even in older children (up to the age of 8 years), performing a posterior capsulorhexis without anterior vitrectomy is the preferred approach. Above the age of 8 years, the posterior capsule can be left intact. In-the-bag IOL implantation is almost becoming a norm for children above the age of 1 year. Though there is no universal consensus regarding the earliest age for primary IOL implantation, many surgeons increasingly prefer primary IOL implantation even in infants. Alternate approaches that can avoid anterior vitrectomy like optic capture through the posterior capsulorhexis and bag-in-the-lens are also gaining more and more popularity.

Update on Pediatric Cataract Surgery and the Delphi Panel Paper

We review the Delphi panel paper and address topics of non-consensus in the preoperative, intraoperative, and postoperative management of pediatric cataract. The Infant Aphakia Treatment Study expanded our understanding of unilateral cataract surgery in infants 6 months and younger. While primary IOL implantation is accepted for children older than 2 years, long-term data is required to determine the optimal age for primary IOL. Primary management of the posterior capsule should consider the child’s unique risks and benefits. Recent benchmarking papers confirmed higher refractive prediction error than adults and there is a need for IOL calculation formulas that cater to the pediatric eye. The impact of next-generation sequencing, bag-in-the-lens, optic capture, and femtosecond laser are yet to be determined. Pediatric cataract management is challenging and questions remain on the best approach to some surgical aspects. Future long-term randomized trials will help us move toward consensus globally.

Comparative study of 25- versus 20-gauge pars plana capsulotomy and vitrectomy in pediatric cataract surgery.

To compare 25- and 20-gauge pars plana vitrectomy (PPV) for the management of pediatric cataract. 20 eyes of 15 patients were randomly divided into two groups to undergo pars plana capsulotomy and vitrectomy by either 25-gauge (group A) or 20-gauge (group B) PPV after lens aspiration and IOL implantation. The two groups were compared for total surgical time, time taken in doing pars plana capsulotomy and vitrectomy, and the size of posterior capsulotomy. Post-operative astigmatism was compared at 3months. The mean total surgical time in group A was 49.2±6.7min, while mean total surgical time in group B was 62.5+5.48min (p=0.001). The mean time taken for pars plana capsulotomy and vitrectomy was 4.1±1.19min in group A and 5.0±0.73min (p=0.03) in group B. The mean size of the PCCC in group A was 3.3±0.34mm, while in group B it was 4.0±0.33mm (p=0.001). The mean astigmatism at 3months in group A was 0.65±0.31 diopters, while in group B it was 1.45±0.92 diopters (p=0.019). 25-gauge transconjunctival sutureless PPV can be an attractive alternative to 20-gauge system in the management of pediatric cataracts.

Innovations in pediatric cataract surgery.

Advances in technology have made surgery in children safer and faster. The management of pediatric cataract has made rapid progress in the past decade with the availability of safer anesthesia, newer technique's, more predictable intraocular lens (IOL) power calculation, a better understanding of neurobiology, genetics, amblyopia management, improved IOL designs for preventing visual axis opacification, and adjuvant postoperative care. Modern vitrectomy machines with minimally invasive instruments, radiofrequency, diathermy, and plasma blades help immensely in complicated cases. Preoperative evaluation with ultrasound biomicroscopy and optical coherence tomography (OCT) allows better planning of surgical procedure. The future holds good for stem cell research, customized OCT, and Zepto (precision pulse capsulotomy).

Update on congenital cataract surgery management.

The basic procedure of pediatric cataract surgery has not dramatically changed over the past few years. Recent multicenter study results along with technological innovations, however, have increased our understanding and armamentarium of techniques and devices used to improve outcomes. We review surgical techniques that have been recently applied to the management of pediatric cataracts and describe newer intraocular lenses that have become available for use in the pediatric population. The 5-year results of the Infant Aphakia Treatment Study, including visual outcomes and complications, as well as other studies comparing intraocular lens implants with contact lenses for infants have shaped our management of congenital cataract. We also discuss how ocular imaging with optical coherence tomography has enhanced our understanding of the microstructural effects on pediatric eyes after cataract surgery and touch on other future innovations. We review updates in the management of congenital cataract, which remains a major cause of preventable childhood blindness.

Delphi Process in the Management of Pediatric Cataract.

Delphi Process in the Management of Pediatric Cataract.

Comprehensive management of pediatric cataract in Africa

Worldwide, childhood blindness is 0.75/1000 children giving an estimated number of 1.4 million suffering from blindness worldwide. Of the blind children worldwide, congenital cataract is the major cause in African countries. The management of cataract in children poses a challenge to the African ophthalmologist, and the earlier in life cataract develops, the more difficult it is to manage. A description of the common causes, clinical presentation, methods of modern surgical removal, and suggested typical postoperative management of this condition is given along with common complications and challenges that may be encountered.

Use of the Delphi process in paediatric cataract management

PurposeTo identify areas of consensus and disagreement in the management of paediatric cataract using a modified Delphi approach among individuals recognised for publishing in this field.DesignA modified Delphi method.ParticipantsInternational paediatric...

Pediatric Cataract

Paediatric cataract is one of the most important surgically treatable causes of childhood blindness. Treating pediatirc cataract has a large impact on society as ‘lost blind years’ can be saved. Various morphological types are known of which zonular has the best visual prognosis. Rubella accounts for the most common preventive cause for pediatrc cataract. Intraoperative biometry plays an important role though in coperative children optical biometry may be suitable option. Since the pediatric eye and pediatric lens is not a minature adult eye and lens repsectively, surgical steps needs to be modified. Intraocular lenses (IOL) provide the best available option for visual rehabilitation after removal of cataract because of the constant visual input provided. Poor intraocular lens power predictability, increased inflammation, postoperative complications and the technical difficulty of surgery are the main concerns for IOL implantation. Surgery is just a step towards management of pediatric cataract, amblyopia therapy, glasses correction, and log term follwup are essetinal for better outcomes.