Lecture: Pathogenesis and Management of Pediatric Cataracts

This Live Lecture covers various types and presentations of cataracts in the Pediatric age group. This lecture also elaborates on the investigations, indications for surgical interventions, timing of surgery, type of surgery, IOL options and post surgery rehabilitation.

Lecturer: Dr. Kavitha Kalaivani



(To translate please select your language to the right of this page)

DR KAVITHA KALAIVANI: So first of all, I thank Cybersight/Orbis, especially Mr. Lawrence and Mr. Jonathan here, for providing me this opportunity. So in this talk today, we’ll be trying to cover the basis of approach to a patient — the child with cataract. The pathogenesis and management, basically. So we’ll directly go into the topic. So as we all know, the incidence of pediatric cataract in the world over is 1 to 13 per 10,000 live births, and it affects 200,000 children. 200,000 children become blind due to bilateral cataract. And as we all know, cataract is a treatable cause for blindness, and early treatment ensures near-normal life. And we are talking about children here, which means the life expectancy is going to be 60, 70 years from the onset of the problem. So that is why this talk today is very important. So why pediatric cataract specifically? So as we all know, adult and pediatric cataracts differ in almost every possible way. As we know, a child is not a small adult. So pediatric cataracts are different in etiology, the age of onset, laterality matters in the way we manage, whether to operate or not arises, when to operate, who operates, whether to put intraocular lens implantation or not, the inflammatory response the children’s eyes may be exposed to, the complications that are faced, which may be lifelong, and the rehabilitation which follows. So in all these ways, pediatric cataracts are different, as compared to adult cataracts. So this is the first question. I just wanted to know… Who is, today, registered, and who is watching this lecture? This lecture will probably be of use to practicing pediatric ophthalmologists, general ophthalmologists who invariably get to manage children, of course, ophthalmology residents, and of course, other interested — optometrists also can benefit from this lecture. So the pathogenesis, as we come to pediatric cataracts — pediatric cataracts are basically classified based on their morphological appearance and etiological presentation. So in morphology, the cataract arises due to arrest in the growth or some disturbance during the development of the lens. So depending on which position or which position of the lens opacifies, the cataracts can classified accordingly. And as we all know, because of the structure of the lens, the more anterior the lens opacity is, the less vision-threatening it is, and vice versa. The more posterior and central, the more vision-threatening the opacity becomes. So morphological classification — we see anterior polar, pyramidal, and anterior subcapsular cataracts are common in children. And when it is posterior, it can be posterior subcapsular, posterior lenticonus, it can be associated with persistent fetal vasculature, as part of a developmental abnormality, and Mittendorf’s dots. All these cataracts are posterior. So these are some examples of anterior lens opacities. As we all know, the first one is the anterior polar cataract. The second one is anterior cataract, which are riders. It’s more peripheral. And the third one in the right corner is blue dot cataracts, which — sometimes in the center, but mostly it is in the anterior. Posterior cataracts can be posterior subcapsular opacity, as we see in the first one. A membranous cataract, where the posterior capsule can be opacified for various reasons. And posterior lenticonus, as we see in the final picture. So these are more vision-threatening, because they are in the center and closer to the nodal point of the lens. And central cataracts, which we see more commonly, can be nuclear, lamellar, otherwise called zonular, cortical riders, sutural cataract, pulverulent cataracts, cerulean cataracts, aceuliform or coralliform cataracts. So these are some examples of central cataracts. Which, depending on their density, affect the vision, and hence the need for management. The right side corner cataract is a total cataract. So etiologically, we saw morphologically how cataracts are classified in children. The etiological classification, when it comes to that — we divide them into bilateral presentation and unilateral cataracts. So bilateral, the commonest etiology is no cause. Idiopathic. Which is up to 50% of the cataracts — have no cause. The second commonest is congenital or developmental. Again, here, cause is idiopathic. Hereditary or genetic can be a second reason. And associated with inborn errors of metabolism and TORCH, infection, perinatally, can be a cause of congenital bilateral developmental cataracts. Ocular anomalies, like aniridia, anterior segment dysgenesis syndromes, can also have bilateral cataracts as presentation at birth. And metabolic causes like Loeys syndrome and so many other syndromes, which affect the general metabolism, can also present with cataracts at birth. And steroid-induced — obviously children are more prone for allergic conjunctivitis, and inadvertent chronic use of steroids, either topically or systemically, for children like nephrotic syndrome and other systemic conditions, where steroid is indicated in children, can present with cataracts at a little bit later age. And etiologically, for unilateral cataracts, a specific eye problem has to be first noticed. Trauma probably leads the picture. Traumatic cataract in children. And secondly, it can be part of an anterior or a posterior segment anomaly, like corneal opacities, congenital opacities, can present with cataract. Peter’s or Axenfeld anomalies, when they have unilateral presentation, can also present with cataracts. And commonest in this category can be persistent fetal vasculature. Presenting with a membranous type of cataract, which can be highly vascular, also. And complicated cataract — uveitis can be unilateral or sometimes bilateral. So when it comes to cataracts in children, as compared to adults, the clinical features may be a challenge. Children may not present with complaints as compared to adults, who come with their own complaints. So we need, as parents and as doctors, to pick up the symptoms and signs, which the child may not come complaining about. So what are the symptoms the child may present with? The parents may directly notice a white spot in the pupillary area. Commonly diminution of vision. Very young babies, they may not recognize the mother’s face or objects very close to face, et cetera. Unsteady eyes can be a presentation of congenital cataract. Deviation or squinting of the eyes, and associated symptoms of the systemic disease, if present, can also be a symptom. And what will the signs be? Again, diminution of vision. Less vision. As per age, we can check the vision and we can find out, like, poor fixation, roving eye movements, et cetera. We can see the lenticular opacity. Nystagmus can be present. Strabismus can be present. And other ocular and systemic abnormalities can be present. So when it comes to management — so how would we manage? Do we need investigations in children’s cataracts? As such, do not really specifically need a battery of investigations. A thorough history to find out the cause. Whether it is a genetic cataract. Was there a systemic steroid usage? It’s very important. A thorough ocular examination, to see associated anomalies. A history of trauma or a telltale evidence in the eye of trauma. And in some cases, when you cannot see the posterior segment of the eye, an ultrasound biomicroscopy helps, in case of total cataracts, and a good systemic evaluation. These are the maximum investigations, probably, that we would need, before we decide on the next step. So this would be the next poll question. How do we manage these three situations? So these three situations have all one thing in common: If you see the cataract in the first central picture, the central visual axis is relatively very clear. There are riders in the periphery, but central visual axis is clear. The right corner, where you see the blue dot cataract — again, here we need information about the vision and other symptoms. So these three cataracts are typically non-vision-threatening. So you can just observe. So in children, there is a role for non-specifically no treatment in some of these situations. So these cataracts are usually stationary. They do not progress. All we need to do is correct the associated possible refractive error, et cetera, amblyopia, et cetera, but need not go ahead and manage the cataract specifically. So then that is what? Operate or not to operate? Does this situation occur in children? Definitely. Why is this a question? So when do we face these kinds of questions in a pediatric cataract situation? So no symptoms. Can there be cataract in children with no symptoms? Exactly. So like we just saw these three examples of cataracts where children may not present with any symptoms. And bilateral symmetric cataract in a younger child, where there still may be no symptoms — without any secondary effects, like nystagmus, strabismus, anisometropia. When you’re able to check the vision in a child, and if the visual acuity for near especially is N-6, and extends at least 6 by 12 in both eyes, you can observe the cataract. Because when we operate a child for cataract, once and for all, we remove accommodation. So we have to be very conservative when it comes to providing clarity of vision. The aim of surgery for a pediatric cataract is to give clarity of vision, distance as well as near. So near vision, if it is good, despite having a slight subnormal distance vision, warrants probably a little conservative management. Like, we can wait and watch. And non-progressive — early steroid-induced cataracts may be non-progressive, if we stop the steroid at the time, and we can observe these kinds of cataracts. So in children, there is a role for not operating a cataract. And is there a role of non-surgical management? Is it possible? So this typically — cataract is a little paracentral. It’s affecting the visual axis centrally, but not fully covering the visual axis. The patient may have an associated exotropia, with a -3 cylinder. And a vision of 6/24, N8. So what do we do for this cataract? Do we go ahead and operate? So when cataract may be only one of the reasons for a vision problem, like high anisometropia, strabismus, corneal opacity, macular pathology — so it is part of a multiple problem, so we can still wait by giving management for other problems, like you can give dilating drops, if the opacity is a little paracentral. And of course, glasses and patching. And then if vision improves and we still feel the cataract may also be contributing to the vision problem, we can operate at a later stage. So then we come to surgical management. So how do we decide and how do we manage a child with a cataract? So indications for early surgery. Whenever we talk about children and cataract, we want to know when to go ahead with surgery. So how do we decide? Total cataract. Of course, there is no controversy here. Total cataracts have to be operated as early as they present. And unilateral cataracts in a child is almost like an emergency. You have to operate as early as they present. Asymmetric cataracts behave similar to unilateral cataracts. And presents of secondary effects like nystagmus and strabismus mean there is always a sensory component involved, and already vision getting compromised. And symptoms. A child, a school-going child with vision worse than 6/18, a child with photophobia, all these warrant early surgery. So then early surgery — does it translate into early intraocular lens implantation? So when do we have this question of intraocular lens versus no intraocular lens implantation at the first sitting? So here the prime concern is the age of the child. The first, foremost concern is age of the child, when we plan cataract surgery with an intraocular lens implantation at the primary stage. So why age of the child? Because very young children, very young eyes, the biometry surprises are known to occur at experts’ hands, and myopic shift is supposed to be rapid ’til the age of 24 months. So that is how age is significant, when we plan intraocular lens implantation as a primary procedure. And laterality of the cataract — when you produce a child with a cataract, and you operate and leave the child aphakic, you are producing a huge anisometropia. So we have to weigh the pros and cons of leaving a child aphakic, versus the risks involved in primary intraocular lens implantation. Because visual rehabilitation for unilateral aphakia is very challenging. The diameter of the cornea is a criteria where, when we have to consider intraocular lens implantation in infants — as well as axial length. So these are the criteria we need to look into, when we plan a intraocular lens as a primary procedure during the cataract extraction. So what are the surgical techniques that we have in our hand? So the commonest procedure we follow for pediatric cataracts is lens aspiration with a primary posterior capsulorrhexis with anterior vitrectomy with an intraocular foldable lens implantation in the bag. Or, if we do not plan an intraocular lens in this first sitting, then we can do a lensectomy with an anterior vitrectomy, either the pars plana approach or a limbal route, depending on your expertise and depending on probably the size of the eye and the development of the pars plana. So how to choose IOL in children? So this, again, is a challenge. So every step in a pediatric cataract management poses challenge. So what are the factors influencing intraocular lens power calculation? So the formula — what formula to choose from? The myopic shift, which keeps happening in young infants, the amount of shift proportionate to the age, the axial length and the keratometry measurement, and what we aim for, which is the target diffraction. So all these influences IOL power calculation in children, especially less than 2 years of age. So this is the third question. What is the preferred IOL formula that, if you are a practicing pediatric ophthalmologist, do you prefer? SRK-II, SRK-T, or Hoffer Q? These are the three common formulas used in children. So which one do you prefer? So as per literature, it says that any standard table you can choose from these three. We commonly choose SRK-II if the axial length is above 16 mm. So that is the criteria. Very young axial lengths — better to avoid intraocular lens implantation. So all these three formulas work well. It is a target refraction that you have to look into. And if you are planning both eye surgery, it is always good advise to get a refraction done for the first eye before you plan the second surgery, to have an idea about your biometry value. So what is the target refraction? So in children, compared to an adult, to enable a myopic shift, you aim always at undercorrection, depending on the age. So various methods and various ways over the last 30, 40 years of pediatric cataract surgery evolution — we have found certain guidelines, which can help us choose the target refraction. So there is a rule of 7 for children above 2 years, where the age plus target hyperopia is the intraocular lens power. So if the age is 2, you are to get a number of 7, you add 5. So similarly, the sum should be 7. So you add the age and the target hyperopia. So you choose based on — this is a rough estimation — which is described in literature. For infants, we have two major good studies, the infant aphakia study and the Wilson et al. study, where for less than 6 months, they prefer 3 to 7 diopters of hyperopia as the target refraction, and for 12 months, 0 to 3 diopters of hypermetropia. For 4 to 6 weeks, they aim for 8 diopters, and 6 weeks to 6 months, they aim for 6 diopters. Again, it is still controversial, but this is kind of a guideline, which we try to follow. So what we follow in our Institute is: Age above 4 years, and 2 to 4 years, we aim an undercorrection of up to 10%, and age less than 2 years, about 20% undercorrection. So then you decided the formula of what to use. Now, what is the choice of the IOL? So previously, when we started, it was a single or a multipiece PMMA lens. Polymethylmethacrylate rigid lenses were used. But now it is primarily totally replaced in children by hydrophobic acrylic single piece IOL, if it is in the bag, and acrylic three piece IOL if it is in the sulcus. The prime importance should be to be safe to use, and it should be once and for all, for the long term, and optical diopter should be at least 10.5 to 12 millimeters. So that is the aim when we choose the IOL in children, primarily. So then we go to the steps of surgery. So what are the steps? Basic steps? So general anesthesia, of course, preferred. A scleral tunnel is advised ’til the age of at least 4 years, because the corneal rigidity is very poor, and anterior capsulorrhexis of at least 6 millimeters. A cortical aspiration is done. A posterior capsulorrhexis is mandatory, about 4 millimeters, a limited anterior vitrectomy. Now, this is a little controversial, but we prefer to do anterior vitrectomy up to the age of 6 years. And in-the-bag IOL placement is mandatory, as much as possible, and suturing of the corneal wound is preferred ’til 6 to 8 years of age. So this is how we do a scleral tunnel. And this is how we do a corneal tunnel. Sorry about the right side video. So we make a small conjunctival opening and cauterize those small bleeders. We measure approximately 3 millimeters, and make a small corneal-scleral tunnel, and then enter the cornea. So this is preferred in children less than 4 years of age. Whereas a little older children, you can use a clear corneal entry. So we’ll try to play the video in the end, if possible. So the second most important step is the anterior capsule management. And I would say for a resident or somebody who is learning pediatric cataract surgery now — so this is the single most crucial step, because this determines where you can actually place the IOL. Critical for IOL placement. It is the most challenging step in a pediatric cataract surgery. Even more challenging than a posterior capsule management, because the anterior capsule in a child is very highly elastic. It has a tendency to run, and there is no peripheral red glow. So how do we tackle these three issues? We can use the capsular forceps for a better grip. You always keep holding the rhexis when you do the rhexis. And a capsular staining always helps. So no need to worry about whether to stain or not. It is advisable to always stain the capsule. And a high molecular weight viscoelastic helps you keep the anterior capsule flat, because in children the lens surface is a little more convex. So that is why — that is one of the reasons why there is a tendency to run. So with these three precautions, you can do a very good anterior capsulorrhexis. So you make a side entry with the 15-degree blade. You put an air bubble. You dye the anterior capsule, you stain it with the trypan blue stain. You leave it only for half a minute. You do not at any cost want the posterior capsule to be stained. So you remove the stain comfortably. You make a small nick with the cystotome. And then you use the forceps, capsular forceps, called Utrata forceps. It’s a very comfortable instrument. And you keep grasping and leaving the capsule as you go along. Either clockwise or anticlockwise, as per your convenience. So the mastering the art of anterior capsulorrhexis in a child, using Utrata forceps — probably you have learned most of the surgery. So the technique is to grasp and regrasp. So the third — the next step is the cortical aspiration. So once you have a very good rhexis, you can use the phaco probe, or the inspiration/aspiration cannula, depending on the density of the cortex. And since there is only cortex, all you need to do is a cortical aspiration. You can use a bimanual technique, or you can use a coaxial technique to remove the cortex. And here the tip is to remove every single piece of cortex, because cortex inside the eye can evoke — can throw up a good inflammatory response in very small children. So you have to make a note that the cortex has to be fully aspirated. So the next question for the audience would be: How do you manage the posterior capsule? Do you do a primary posterior capsulorrhexis with the forceps before IOL implantation? Do you do a posterior capsulotomy with a vitrector before IOL implantation? Do you do a posterior capsulotomy with a vitrector after IOL implantation, or do you do a pupillary capture? So I see the answer here. So many of you have said that — more than 50% of you have said that you do a posterior capsulotomy with a vitrector, before implanting the IOL. And some of you with a vitrector after the IOL. And none of you did pupillary capture. Good. Thanks for the response. Now, there are advantages of each. So, like, first the vitrector — I would prefer the first one. The primary — that’s why obviously I have it put it as the first. A primary posterior capsulorrhexis with the Utrata forceps. When you’re comfortable in using these forceps, they have a very good control. And you have a very nice smooth surface of the posterior capsule, and once you learn to do a posterior capsulorrhexis, it is even easier than an anterior capsulorrhexis, and it gives you a very good control. The size management is easier. Of course, vitrector is also a very good way to do. Sometimes the ragged ends, when you put the IOL inside, very, very rarely you can have a tear of the posterior capsule. After intraocular lens implantation with the vitrector, many institutes and many practitioners do this as a first option. It is also a good option — the only thing, when we plan the — see, after IOL implantation, when you do a second procedure after, you do a PPC, you know the bag status. You’re already aware whether the bag is intact and in a good condition, so you can plan a single piece intraocular lens in the bag. Suppose you put the lens inside the bag and you do a vitrector capsulotomy after you do — and you encounter some issue and the capsule ruptures or the posterior capsule gives way or something. Then you already have a single piece foldable lens inside, and it is very difficult to remove through the opening, so it becomes a little messy. But if you are experienced, all the three options are good. Equally good. So thank you for the question. We’ll go to the next slide. So this is a small video on how we do the posterior capsule. So the last piece of the cortex is being removed. This — I chose this video because the posterior capsule is clearly seen. It’s a little membranous. So you can make, again, a small nick with the cystotome. And you can use the Utrata forceps through the main entry. And you can catch with the forceps… And it gives you a good control. Here, again, the tip is not to leave — like an anterior capsulorrhexis, it is good to keep catching the edge of the rhexis. But here, it is better not to leave the rhexis, because once the vitreous comes and gets mixed with the capsule, it is very difficult to retrieve the rhexis. It becomes a little messy. So after that, you place a small anterior vitrectomy, you do, and then place the intraocular lens. So a posterior capsulorrhexis is mandatory ’til the age of 6 years, because we know that the rate of posterior capsular opacification, if we don’t manage the posterior capsule, is almost 100%. And the ideal size should be at least 4 millimeters. So like we said, it can be either manual or with the vitrector. And anterior vitrectomy can be done, along with an anterior posterior capsulorrhexis, up to the age of 6 years. So we saw various clinical scenarios, where we face a pediatric cataract. There’s congenital or developmental cataract, cataract associated with anomalies, associated with systemic conditions, trauma, steroid induced, complicated. Most of it managed based on how dense the opacity is, and depends on all the factors that we just discussed. So these are a few situations we see traumatic cataracts — the upper picture is presurgery, and the lower is picture is postsurgery. The first we see — first two conditions we see — total cataract. The first one, we see an anterior capsule rupture, with cortical disturbance inside. So after the surgery, we have been able to put the lens inside the bag. So there are other types of situations, where like we said, associated with the corneal opacity. So here, to overcome the corneal opacity, the pupilloplasty has also been done, along with the cataract surgery, with IOL implantation. So this was a membranous cataract, what you see there. So the membrane has been trimmed, and the intraocular lens has been placed in the sulcus, because the capsules were found fused. There was no volume to the lens and there was no bag. And uveitic cataract is, again, another challenge, where the uveitic specialist — you have hand in hand — and you manage the uveitis and cataract, during the course of uveitis management, you face cataract in children. So it’s a totally different lecture altogether. The main criteria here is: Lens, if at all you place, it has to be only in the bag. There is no role of a sulcus lens in a child with uveitic cataract. So we saw situations where we were able to place lens or where we decided to place an intraocular lens, primarily. So what are the situations where we decide not to place a lens inside the eye, as a primary procedure? So that situation is called lensectomy. So when do we do lensectomy? When we don’t prefer an IOL. So there are very young children, in some trauma — I chose this video, because it is a very interesting video. We thought at first it was a blunt injury. The iris was fully adherent or closed to the cornea. We could not even see the anterior chamber. Once, after anesthesia only, we realized there was a limbal tear, and there was like an iris bombe. So we made a pupilloplasty. We actually made a pupil, found a total cataract inside, tried to do a rhexis, here we couldn’t complete, because the lens was fully opaque, so we made it with a cutter and removed the capsule. So steps of a lensectomy — a simple lensectomy is — a limbal approach is preferred. You make two limbal openings. At 2:00 and 10:00. You do a capsulotomy, either with a cutter or a forceps, and a good cortical cleanup, and a posterior capsulotomy. Here the idea is to remove the lens and leave a posterior and anterior capsule rim. The size can be the same. So you leave approximately an 8-mm opening in the center, and you have to do an anterior vitrectomy. So if no primary IOL, then what do we do? So we have this unique situation in children. Aphakia. So how do we manage aphakia in children? What do we do? So do we implant a contact lens, like this child? Or do we plan a secondary IOL? So how do we manage aphakia in a child ’til we are able to implant a secondary IOL? So aphakic glasses, single vision glasses, up to the age — if bilateral, good surgery, done in a very small child, the children do very well with single vision aphakic glasses, up to less than… At least 1 year. And you have to start giving bifocals after 2 years of age. So you have to always make sure the near vision is corrected in a very small child. You have to address to the near vision. The need for near vision is very important, the younger the child is. And contact lenses — even in bilateral cases, contact lenses have a very good role, especially — they’re easy to manage. Once you insert, there are extended wear contact lenses, which the compliance is better. The parents in a younger age — but hygiene is very important. And especially in low socio-economic groups, you can try to avoid it in bilateral situations. There is a theoretical saying that if you operate at a very early age, and maybe wearing contact lenses can prevent the onset of nystagmus, but it is to be tested. And secondary IOL implantation, as per age. So unilateral, of course, contact lenses, is the first choice. Rigid gas-permeable contact lenses or the silicon extended wear contact lenses are used. The insertion is difficult. The management is difficult. But you have to always encourage — and that is the best way to manage a unilateral aphakia in a small child. Very, very rare situation, where you’re not able to use contact lens for various reasons, glasses can be tried. And a little earlier, beyond 2 years of age, you can implant a secondary IOL, if all other parameters are normal. So once surgery is over, you can’t sit back and relax in a child, like in an adult. Surgery over — the treatment actually starts. That’s what we tell the parents. The surgery is only the first step in managing a child with a cataract. So surgery is the first step. So what do we have to do? We have to give appropriate glasses, as per age. So infant, like we just saw, single vision glasses for near, with +3 add, actually, and less than 2 years, single vision glasses for 1 meter distance. More than 2 years, you have to start the child on bifocals. So switching the child to bifocals at the correct age is very important. You can assess the child’s visual activity, how active the child is, and start. And amblyopia management goes hand in hand with everything else that we do. And assessment of IOP, if required, under anesthesia, is required lifelong. That cannot be overemphasized. You can see this happy child with unilateral cataract. Nicely patching. Wearing glasses. So what is the latest issue? So when we talk about pediatric cataract management, pediatrics is, again, divided into infant and pediatric. And older children. And so now this is the hard issue here. Since myopic shift is maximum less than 24 months of age, and there is in a very young child associated microcornea, fetal vasculature, and the surgical expertise which is required to manage a little older child is probably a little more challenging when it comes to younger children, and anesthesia issues are very unique to very small children. So when it comes to infantile and pediatric, we have a lot of differences. So in an infant, how early the surgery should be — so in unilateral cataract, as we said, it is an emergency at any age. So up to 8 weeks, or around 8 weeks, we can plan to operate the cataract. And asymmetric cataract, again, 8 weeks. Bilateral dense cataracts, we can wait up to 12 weeks. If there is no nystagmus or other symptoms. And do the surgery. And between the eyes, the spacing should be 1 week. And like we said, secondary effects, if it is there — early surgery is preferred. So now, the next poll question is: How early will you implant IOL in infants? Less than 1 year, less than 6 months, and less than 2 months. Okay. I’m actually happy to see the result. We have more than 86% of you responding to less than 1 year. Which means very less of you do surgery — primary IOL implantation in children less than 2 months and less than 6 months. So we still do not have a consensus here. World over, the threshold for implanting primary IOL keeps reducing as it goes. But what actually we should do? So these are the criteria which have to be extremely strict, when we plan a primary IOL in an infant. The corneal diameter has to be at least 10 millimeters. Intraocular pressure has to be normal by Perkins tonometry, prior to cataract surgery, which is mandatory in all the children, and there should be absolutely absent angle anomalies, which is done by goniometry assessment, prior to the surgery. And axial length should be at least 16 millimeters. So this is a very important criteria, irrespective of age, when we plan intraocular implantation as a primary procedure in infants. So we have this great study to actually guide us. Infant aphakia treatment study. The result of 1 year is: They studied equal number of children with contact lens and intraocular lens. They found visual outcome comparable between the intraocular lens group and the contact lens group. Adverse effects were significantly less in the contact lens group as compared to the intraocular lens group, which is 77%, and number of additional surgeries required were much higher in the intraocular lens group, and additional surgeries were usually required to do visual axis opacification. To improve the visual axis opacification. And intraoperative complications were also slightly higher in the intraocular lens implantation group. And the same group was followed up at the age of 4.5 years. Again, the visual outcome was comparable. Adverse events continued to be higher in the intraocular lens group, though the contact lens group had an increase. This was because of infection related to the contact lens usage. Again, the number of additional surgeries which were required were much more in the intraocular lens group. And glaucoma was found to be comparable, actually. And it was not found to be whether because of intraocular lens implantation or contact lens. It was more associated with younger age in both the groups, and smaller corneas in both the groups. So what is the take-home? Early surgery is always mandatory, but early surgery does not translate to early primary intraocular lens implantation in children. And primary intraocular lens implantation is safe in unilateral cataracts, around the age of 6 months, and bilateral cataracts around the age of 8 months. Choice of IOL poses a challenge. Steps to prevent capsule opacification is mandatory, depending on the age. At least up to the age of 8 years. And timely correction of the residual hyperopia with the near add, lifelong, is very important. Amblyopia management, as long as indicated, goes hand in hand with management. And proper timing of secondary IOL implantation, if the child was aphakic, is very important. So thank you. And now probably we can go back to the — go to the questions. I see some of you could not see the video and some of you have asked me to repeat the video. If there is time, probably I can do that. Which video, to be exact?

>> Dr. Kavitha, only the first video in your presentation played properly for the audience. The remainder of your videos did not play. So we’ll have to follow up after the lecture to see if we can sort that out. Maybe by providing a copy to the audience.

DR KAVITHA KALAIVANI: Sure, sure. I’ll do that. I’m sorry about that. And there is one — Dr. Uchena Novoka, who asks me… The summary of pathogenesis of pediatric cataract. I’m not sure what exactly she wants me to repeat. And her second question is: She wants me to repeat the take-home message. So the take-home — simple. Pediatric cataract surgery: We need to take into all the considerations, and early surgery is mandatory. But the early primary intraocular lens implantation has to be taken with a pinch of salt, depending on all these issues that we talked about. And after cataract surgery, correction with glasses and contact lens for distance and year is very, very mandatory, along with amblyopia treatment, and lifelong monitoring of intraocular pressure, and to look for other cataract surgery-related complications is very important. So cataract surgery management in a child does not stop with the surgery. So there is a question on PCO management by Dr. Soflen Siedel. It just says PCO management. Once we do cataract surgery, we take all the precautions, and we can still get a posterior capsule opacification, even after a good posterior capsulorrhexis. In children, like we said, the cortical — cortex, even if a small few cells are remaining, especially if you place a lens in the bag, there is always a contact, which the lens can proliferate. So we can have, after cataract, called (inaudible), which can start creeping into the visual axis from behind the intraocular lens or even anterior. So older children, older than even 3 years, do cooperate for a capsulotomy. We have had very good cooperation, cooperating children, who can sit in a YAG, in a machine, and we can do a very good YAG capsulotomy, if the opacity is thin and early. If it is a thick membrane, children sometimes, because they present late, can have a very membranous posterior capsule opacification. In that case, capsulotomy might not be a viable option. So in that case, we can do surgery to clear the membrane. Membranectomy we have to do. And very young children, if the opacification is not very dense, we can do a YAG capsulotomy, but in case they do not cooperate, we have some experience with doing a capsulotomy under a general anesthesia. Here the challenge is to give anesthesia and under anesthesia, we have to make the patients sit up for the YAG machine. So it’s a very technically uncomfortable for the child, for the anesthetist, and for us, but it is not… It is an option. So we have had experiences in children, a capsulotomy, under general anesthesia. So PCO management is also as important as managing the cataract. So we have a question from Dr. Mariand Noor Rehma. I’m sorry if I’m not pronouncing the names correctly. How do we manage the visual rehabilitation in children with dislocated lens? Oh, it’s a very important question. So I totally skipped that, actually. So a group of children with pediatric… In pediatric age group present with subluxated and dislocated clear lenses. If that’s what this doctor is asking about. So subluxation in children can be associated with systemic conditions like Marfan’s. Or it can be congenital and it can be hereditary. Isolated, without any other systemic conditions. So many of these children present with high myopia, due to the loss of convexity of the lens. Increase in the curvature of the lens. They can present with high myopic astigmatism, actually. So initially, if the astigmatism is not too high, they do very well with glasses. But if the visual axis is partly phakic and partly aphakic, then correcting these children with myopic correction may be a challenge, and they will have dense amblyopia already. So sometimes we do not go ahead and immediately operate. If the aphakic portion is large, we can give aphakic glasses with the near add, and there are a lot of children who do well with this kind of management. So because surgery for a subluxated lens — lensectomy — has very, very high chances of retinal complications following surgery. So we always try conservative method of glasses. Contact lenses. And then if not able to rehabilitate, we go in for surgery. And nowadays, minimal subluxation — people try rings and segments and try to (inaudible) IOLs. So that can also be tried, if the subluxation is minimal. So there is another question. Do you use intraocular antibiotics at the end of the surgery? No. We don’t use intraocular lens for child or adult after the surgery. There is another question by Dr. Denu Man. How do you manage amblyopia in postcataract surgery patients with nystagmus? That’s a good question. So nystagmus usually is present in a child, presenting with bilateral cataracts. So if there is a clear difference in vision, visual acuity, between the eyes, patching, just like any other — patching for any other amblyopia — is the mode of treatment. But bilateral subnormal vision due to cataracts, presenting with a nystagmus also — we just have to give them glasses. There is no role of patching in that situation. So the child has to have a clear difference between the eyes. The visual acuity has to be clearly different between the eyes, and they do very, very well with the patching regimen. Like any other type of amblyopia. So there is another question by a Dr. Sulfein Saidi. Pars plana lensectomy, versus limbal approach. Like I said, both have a very good — anterior surgeons, pars plana lensectomy, nowadays, pediatric cataracts, even for infants, have come into the hands of pediatric ophthalmologists, rather than retinal surgeons. Previously, when it was a treatment… It was taken care of, a retinal surgeon, pars plana vitrectomy, pars plana lensectomy was probably preferred, but now it is equally preferred. Limbal lensectomy is probably a better choice. Anterior approach is better in most of the situations, except in very small eyes, very small microcornea, where anteriorly there is no space for us to approach, and then pars plana lensectomy can be done. Otherwise, anterior approach is preferred. So there is another question by Dr. Tara Hassan. How to calculate IOLs for infants. Like I said, the SRK-II or SRK-T formula works. So we have the same way — under anesthesia, we have to do a keratometry, a good keratometry, with the handheld keratometer. And the axial length measurement. So if the corneal diameter, keratometry, axial length — if all the three, corneal diameter more than 9.5 or 10, axial length is more than 16 millimeters, then you can apply SRK-II formula and calculate lens — IOL implantation for even infants. But we here in our institute do not prefer a primary intraocular lens implantation for children less than 6 months of age.

>> So to our audience, if you have any additional questions for Dr. Kavitha, please enter them now in the Q and A box. We have about 8 minutes remaining in our time slot, so lots of time for additional questions.

DR KAVITHA KALAIVANI: There is a new question, on multifocal intraocular lenses in children. I’m actually glad you brought it up. Even though we are totally against multifocal lenses in children. As we saw through this lecture, children — especially up to the age of 10 — 8 or 10 — have lots of issues with myopic shifts and challenges in how to calculate intraocular lens power, and all that. So multifocal IOLs in children are still highly debatable. Children, by whom I mean less than 10 years. In many places, many doctors, they have started kind of… Unilateral cataracts, and children with absolutely no other problems. They are considering multifocal intraocular lenses in children. Probably a little older children. But there is still no standard guideline on multifocal lenses in children. And by principle, we still do not advise multifocal lenses in children. Definitely not below the age of 10 years. And there is one more question, on minimum age at surgery. Like we said, age… When we mean minimum age, it’s at least 6 weeks to 8 weeks is the minimum age to manage a cataract which is visually significant. It is when we consider primary intraocular lens implantation, all these other issues arise — like, 6 months, 8 months. So age of surgery, safe from the anesthesia point of view, is 6 weeks, 6 to 8 weeks, for unilateral cataracts, and beyond 8 weeks for bilateral significant cataracts. So how to manage rhexis in membranous cataracts? That’s a very good question. So membranous cataracts — there was actually a picture which I had taken. I don’t have a video. So membranous cataract — sometimes the membrane is a uniform thick membrane. Then we have no choice. We need to use a cutter unit. We need to use a very good curved scissors. And try to make an opening in the center. And with the use of cutter and scissors, we need to try to make a rim. Where there is no other problem, you can place the lens in the sulcus. If one of the capsules is membranous, like the video, which I’m not sure if it played for you — the posterior capsule alone was slightly membranous. So you can manage it in a similar way, like any other rhexis. A capsular forceps, if the membrane is not very thick — otherwise, if a thick membrane, if you use the forceps, the traction on the zonules is a lot, and it can give rise to problem, instability of the bag, so a cutter, a vitrectomy cutter, is preferred. So a cutter, a scissors, curved scissors, along with the forceps, should be your instrumentation. Any difference — Dr. Jay Anathwerma. Any difference in postoperative medication between children and adults? I’m sorry. I really skipped — forgot to actually mention about — exactly. So in adults, probably there is a huge variation of how postoperative inflammation is managed. We normally give a 6 week tapering course of steroids, starting from 6 times a day, to tapering. But in children, we have to give a longer term high dose steroid. We use 1 hourly prednisolone eye drops for the first week, followed by at least for 8 weeks of steroids in a tapering dose, and then in many, we add an antibiotic for 2 weeks. And we use a cycloplegic, like homatropine, in most of the children. Nowadays, in a little older children, we have stopped using homatropine. So cycloplegia, antibiotic, and 8 weeks of steroids, starting with a high frequency, high strength steroid like a prednisolone acetate. Management of central total opacity with cataract-like Peter’s anomaly. This… Central total corneal opacity — see, if the total corneal opacity with cataract — probably if the glaucoma is under control, I think that basically corneal management is — depending on how dense the opacity is, probably penetrating keratoplasty or anything like that — there was a picture in my presentation, where the opacity was paracentral. If there is a paracentral corneal opacity, and you still have a good amount of visual axis, you can manage while doing your cataract surgery, by doing a pupilloplasty or an optical iridectomy, to give enough visual axis. So this is… If it’s a central large total opacity, then there is no option. You have to remove the opacity by penetrating keratoplasty or DSEK, depending on how big the corneal opacity is. But if it is paracentral, or if it is a very small opacity in the cornea, then along with managing the cataract, you can make a pupilloplasty or an optical iridectomy, which works very well. And we have a question — Dr. Tara Hassan. How many diopters subtracted from IOL in infant? Up to 8 — very small infant. Like I said, we do not operate children younger than 6 months for intraocular lens implantation. And we use up to 8 diopters. We undercorrect them by 8 diopters residual. And 6 months to 1 year, we use +6 diopters, and beyond 1 year, we use +4, like that. So less than 6 months, we do not have experience. Not much. So how common is glaucoma, postcataract surgery, and how to monitor? An uneventful cataract surgery, like in older children — the incidence of glaucoma is very, very, very less. We had a study in our institute also — the incidence, like a zonular cataract, operated more than 3, 4 years of age — the incidence of glaucoma following such situations is very less, thankfully. But the single most associated feature for onset of glaucoma is corneal diameter. Microcornea, microphthalmia. The smaller the cornea, the incidence of glaucoma following a cataract surgery is quite high. Especially if these children — we leave them aphakic. So aphakic glaucoma following surgery in a child with microcornea and microphthalmia — microcornea, by which I mean less than 8 millimeters of corneal diameter. The incidence of glaucoma is quite high. And how do we monitor IOP? So we follow a protocol of, after the first surgery, we have a follow-up of about one month, and three months. During the three-month follow-up, we try to calculate the IOP. If the baby, the child, is not cooperative, depending on the age, we have to give anesthesia or sedation. And check interocular pressure with the Perkins tonometer. And beyond after that — every one year. Every one year, along with corneal diameter, pachymetry, axial length measurement, and IOP measurement with Perkins tonometer, and disc evaluation. So this goes hand in hand, invariably of what age the child is, up to lifelong. So the younger the child, you need to probably give gentle anesthesia, but more than 2 years, 3 years, 4 years children — you can give mild sedation on the children that are not cooperative. Beyond that, most of the children are cooperative for applanation tonometer. And at what age do we consider sutured IOL. Dr. Ahmed. So sutured IOL — I assume it is a scleral-fixated IOL. If it is a scleral-fixated IOL, the sclera, rigidity, and the eye size up to the age of 6 — not less than 4 years — scleral-fixated IOLs are not recommended in children less than 6 years of age. So they are done for children maybe following trauma or a subluxated lens, where we had to do a lensectomy, and there is no capsular rim. But it is… We have to wait ’til the age of at least 6 years. So this repeated question on etiology… Etiology and causes of pediatric cataracts in general — that is a question. See, most of the pediatric cataracts which we see are idiopathic. Like we said, more than 50% of the children come into the category of — there is no cause. And the second commonest group is developmental. Congenital. Hereditary. Hereditary. Again, idiopathic. It’s an autosomal dominant inheritance of pediatric cataracts. But other causes… Associated with systemic abnormalities, TORCH infection, inborn errors of metabolism, trauma, all those other causes. But most of the pediatric cataracts, more than 50%, what we see has no cause. Idiopathic.

>> Last call for questions, before we end our lecture.

DR KAVITHA KALAIVANI: Thank you so much.

>> Thank you, Dr. Kavitha, and thank you everyone, for attending.

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February 28, 2017

Last Updated: October 31, 2022

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