During this live webinar, Dr. Kalaivani will cover paediatric cataract management in situations like cataract associated with persistent fetal vasculature, uveitis, posterior polar cataracts and trauma.

Lecturer: Dr. Kavitha Kalaivani, Pediatric Ophthalmologist, Chennai, India.

Transcript

DR KALAIVANI: So we’re talking about a few situations. Specifically complex pediatric cataract management. So generally pediatric cataract management as such is complex, as a routine, compared to another cataract surgery. In the way that it differs in etiology, the age of onset, whether it is unilateral, bilateral, whether to operate or not, when to operate, who operates it, what about IOLs, what formula, what A-constant, and postoperative inflammation, complications after the surgery, and rehabilitation. So like I keep telling, small things that we think are not small in a routine cataract surgery — even a routine cataract surgery, everything really matters. Right from the cystotome, side port incisions, whether we make our rhexis clockwise, anticlockwise, pupil dilatation, the depth of the anterior chamber, the red glow, and was viscoelastics we use. For our routine surgery, this is how we do. We stain the capsule. And I generally use an Utrata forceps, but here in this video, you can use micro capsular forceps as well. The advantage of micro capsular forceps being you can use it in both side ports. So this is a very simple, routine pediatric cataract surgery, where the anterior rhexis and posterior rhexis were done. Posterior rhexis — the small tip here — you can switch off the main light of the microscope and use a little brighter retroillumination, which really gives a very good red glow, and Utrata is the best instrument to do this. In some places, people can use vitrectomy cutter also. So now we go to the complex situations as pediatric ophthalmologists sometimes we have to face. So one situations that I might be covering during this talk is trauma, which all of us would be facing every now and then. Especially when there is iris involvement. How do we manage? I will be discussing a few situations. Uveitic cataract management. I see that a lot of us have questions regarding how we manage uveitis and cataract in children. Posterior polar cataracts, which is again a common pediatric entity. Fetal vasculature, along with cataract, how we manage, and some resurgeries. What we come across. So traumatic cataracts — it is very challenging in the way that it presents in multiple types of presentations. Like the way — the type of injury, the age of the child, the mode of injury, and the chronology. Like, when the injury happened. Was it a fresh injury, or was it an already sutured wound? So because the presentation to us can be very varied, the management also has to be really tailor made, and according to each situation we have to face. The age is a very important factor here. So basically collecting all situations, the protocols of how to manage traumatic cataracts in children is: When there is a primary wound intact, and there is a cataract, it is best to avoid cataract management during the time of the primary repair, and there are of course a few exceptions. Like if there is already a huge breach in the capsule and the cortex is coming out, then you have to remove the cortex. But ideally, in a primary wound repair setting, better not to manage the cataract. And if you don’t manage at that time, then you will manage the cataract from one week to one month of trauma, depending on how dense the opacity is. And then the amblyogenic age — you have to remember, it is crucial to clear the visual axis and not hurriedly place the intraocular lens. So if there is a corneal wound, that decides when we place the IOL. If the corneal wound is in the center and you have sutured it, obviously — and there is a total cataract inside, and it’s a very small child, like a two-year-old, then here you can’t wait for the corneal wound to heal, remove the sutures, and place the IOL. Here the IOL can be placed later. You have to clear the visual axis early. And primary IOL implantation, if possible, is the best in all age groups. And concurrent issues like iris trauma, glaucoma if it is present, and retinal issues need planning and management. And whenever required, you have to do it simultaneously. And long-term management, like glaucoma, retinal complications, and of course sympathetic ophthalmia, has to be kept in mind when we manage trauma in children. So a small clipping of how we manage trauma with iris issues. So this is a video collection of three different situations where there was iris management required during the time of cataract management in a child with trauma. So the first scenario is: This was a very small one-year-old child, a battered baby. When we examined the child in the OPD, we could not see exactly what the problem was. But we were able to make out a small limbal scar, and the iris had been entirely stretched, and the AC was flat. So we had to enter the anterior chamber from the AC and literally found the pupil. The pupil had to be cut and made. We had to make a pupilloplasty, and then the cataract was removed, and we had to use hooks to visualize. So this child currently actually required a glaucoma procedure as well. And doing a little okay. Not very good vision now. The second situation — here, again, it was a sutured, almost a central irregular corneal wound. And the iris is entirely plastered to that wound. But this child came at four years of age with a knife injury. So there was a dense corneal scar. So as we did the surgery, we were planning what to do. The aim here is to create a visual axis. So since the corneal center is — the scar is there, but the scar is reasonably localized, and there is a little peripheral clear cornea. So after clearing the membrane, we made an irido-membranectomy, and iridectomy, to create the visual axis. So that later, at least, a phakic correction is possible. And I have left a rim, in case the situation improves. We can even put a secondary IOL later. And this third situation, where sometimes iris can be involved, at its attachment, like iridodialysis can be there. Here the irido is first — better to do the cataract surgery. When you use hooks here, it’s very useful. It clears you a way. It gives you a good visibility. And the iridodialysis does not come in the way of cataract surgery. So you do all the cataract procedure, including IOL implantation. Remove the hooks. And then we can repair the iridodialysis. I’m sorry the text is probably hiding it a bit. So you remove the hooks. And then with the 10-0 prolene suture, I had to take two bites. Iridodialysis surgery is initially a little technically difficult, but it’s a very rewarding surgery. So this is how we manage in trauma. And there is a cataract along with iris-related issues. How do you reconstruct the anterior segment? So the second issue that everybody faces when you manage pediatric cataracts is the uveitic cataracts. Uveitic cataract in the young can present — the cataract can be due to the disease process itself. Or many times we can have drug-induced or steroid-induced cataract. So these cataracts are generally — the cataracts as such are generally very soft. The main clinch here is how you do the rhexis. That is the most important step. Before even doing the cataract surgery, what all do we have to be prepared for? So the systemic disease control. Luckily, we have a very good uvea backup. So all we do is see the patient only when the cataract becomes significant and it requires surgery. And when you are alone and you are practicing, then good systemic disease control is most important. You can’t have active disease going on and doing the cataract surgery. You will really end up in a problem. And intraoperatively, like I said, management of the pupil is really crucial. Anterior capsule management is also very important. And IOL decisions, whether we are putting or not, and where we are putting, is very crucial. And again, it doesn’t stop with surgery. Postoperatively, inflammation control continues to — it has to continue to happen. Follow-up, along with the uvea specialist, continues lifelong, as long as the disease is active. And we continue treating the disease. So a small checklist, preoperatively: Like I said, disease activity. The eye should be quiet for at least two to three months. Prior to planning the surgery. And we have to really make sure if the cataract is the cause for the media opacity, because many of these children may have a vitreous haze or so. So adequate perioperative steroid and immuno. So during the surgery, just before the surgery, we need to hike up the immunosuppression and steroid therapy, anticipating an inflammatory response to the surgery. And additional procedures, if required. A vitrectomy, if media haze is there or not. So along with that, you need to take a position. So like we can’t understate: That pediatric uveitic cataract surgery does not begin at the table. It begins much before, when you plan. So the surgery as such. Really important factors: How do you manage the pupil? How do you manage the capsule? And intraocular lens implantation. So pupil management in pediatric cataract is very challenging. It always has a bound-on, totally syneched pupil. Here we use Grieshaber’s hooks. It’s the most ideal hook. And a small clipping of how we do it. So like I said, the first step is to remove the synechiae. Sometimes you may have to use scissors, if the synechiae are very adherent. And gently, because the eye will be very flimsy and very — you have to be careful when you put hooks. And like this, what I’m removing — there is a small membrane. You can even have sometimes a total membrane over the cataract, over the lens, before we actually see the capsule. So once we remove that, then you need to stain and proceed with the rest of the surgery. So like I said, capsule in uveitic cataracts are very soft and can be friable. And they can easily run, even worse than a general pediatric cataract. You always have to stain the capsule. And you always have to use a heavy viscoelastic. It gives you a good tamponade and flattens the anterior surface of the lens. And if the lens is intumescent, like sometimes you can have a steroid-induced uveitic cataract, where the lens can be intumescent, so you have to puncture it. And keep in mind the flag sign. Deflate the lens pressure. And then proceed with the surgery. Like I said, a forceps is always better. With a good staining. The anterior rhexis was done. Then the cataract surgery was done. And a posterior capsulorrhexis is also done. So this was a very unique type of pediatric cataract. With an extreme fibrosed capsule. None of the standard instruments were able to pierce the capsule. So I had to use the MVR knife. And then with the help of scissors, cutter, and all sorts of instruments, the capsule could be opened. Sometimes in uveitic cataracts, we may have these kinds of situations. Especially in older children. And now comes the cataract. Removing the cataract is hardly anything. It’s usually very soft. IOP may be low, so you have to remember: Zonules may be weak. So that also you have to keep in mind. And a very thorough cortical wash is necessary. So that you don’t give a ground for inflammation and PC fibrosis later. The posterior rhexis, like in all pediatric cataracts, it is a must, up to the age of at least 6 or 7. Anterior vitrectomy — again, we do anterior vitrectomy, along with posterior capsulorrhexis. But yes, you can take a decision to see whether there are a lot of traction — because incomplete and improper anterior vitrectomy in a uveitic situation can lead to traction, CME, et cetera. So in older children, maybe if the vitreous is not disturbed, you can just do a PPC and wait and see. And you can consider not doing a PPC in older children. Like I said, when you think the child may cooperate for a YAG later. So children with postuveitis, even the PC can be fibrotic, like in this situation. The PC was a little fibrotic. So here, when you use a forceps, there is a lot of traction. You have to stop and continue with the cutter. You cannot continue if the bag seems to come. But here we’re able to manage with the forceps itself. So IOL decisions in uveitic cataract — again, younger children, very young children, lens aspiration without IOL — if it is intermittent uveitis, they do better with IOL than do JIA children. And IOL is strictly contraindicated in very young children with JIA. And older children — yes, IOL can be implanted, but definitely in the bag. There is no role of IOL implantation in uveitis in the sulcus. Or any other position, for that matter. So if you’re not able to intraoperatively — where we don’t get a good bag, or we are not having a good reliable bag — better leave the child aphakic rather than implant the lens in the sulcus. So as I said, surgery over? It’s not over at that. So inflammation — postoperatively, immediately, also. IOP control, IOP monitoring, is very important. Despite a good PC opening, there are lots of incidents where we continue to get PC opacification and even anterior opacification, so that you have to keep watching. CME has to be looked for. And continued treatment with the systemic illness with steroids and immunosuppressants, as and when required. So, to summarize, pediatric uveitic cataract management — they need special attention. And it’s not just another cataract surgery in the child. A long inflammation-free period is a must. It’s mandatory that you have a quiet eye for at least two to three months. Adequate perioperative steroids and immunosuppressive cover is necessary. And pupil and capsular management is most important. And IOL implantation with caution, with the help of your uveitic specialist. Whether it is indicated or not, you have to decide. And post-op follow-up is: Continually manage the uveitic entity, and of course, hand in hand, amblyopia therapy, since it is a child. The third scenario, we’ll see today, is another common condition of posterior polar cataracts in children. So it’s not very uncommon. If it is very small, sometimes they may be asymptomatic. You can just watch. And very often, they’re bilateral. And here the clinch is: They have preexisting, weak, or sometimes absent posterior capsule. So what do you look for with these children? So they usually have very dense central core of cataract. Close to the PC. And there is a very posterior opacity, like I said. And the ring-like opacity in the PC, like we see in adults, sometimes even in children we can make out. So that’s the clue. So this is one pediatric posterior polar cataract. So here we see the anterior lens is relatively quite clear. So the other steps are all — good pupil dilatation is extremely important. Now you’ll see, once the pupil got dilated, you can see a small ring behind. So that’s a clue. So you stain well. Anterior rhexis… As per the routine procedure here. You can make a smaller anterior rhexis than you normally would, because you’re not sure about the posterior capsular status. As you complete the anterior rhexis, the cortical aspiration should be very, very cautiously done. You can even aspirate using a cutter itself. In the cutter, many of the good machines have a vitrectomy cutter. I/A cutter option. Like, the first setting is irrigation/aspiration, and the second setting is cutter. So you can use that. So that’s in here, if you see the cortex that I’m aspirating. And below that, there is no PC. And if you can see carefully, there is a small — there is a nice circumscribed PC rim. So it’s like an already made posterior capsulotomy. We have to be very careful. You can see the vitreous a little liquefied and all. So this is a preexisting, very well circumscribed posterior capsular dehiscence in a posterior polar cataract. So luckily for us, many times in pediatric cataracts, the vitreous is dense. The nucleus and the cataract doesn’t drop down. But yes, it can happen. So you have to be aware, and you have to keep your fluid settings and all very low and cautious. So I’m using a cutter for aspiration, as well as so that if vitreous keeps disturbing you, you can keep cutting the vitreous. So this was a small child. So we decided not to implant an IOL. But if you have to implant an IOL in this situation, I would do a sulcus implantation. That is why I said smaller rhexis is important. So for a PPC in a child, how do you tackle? You anticipate always a weak or an absent PC. A dilated pupil is a must. If it’s not dilating, you have to use hooks. You have to stain the anterior capsule. That, again, is a must. And a little smaller anterior rhexis. Low IOP setting. And aspiration with the help of a cutter. And you keep a three-piece IOL on standby. But if the PPC is small, you can manage an in-the-bag single-piece IOL also. So the fourth situation that we’ll be seeing today is cataract with a persistent fetal vasculature. Again, this is not so uncommon. It’s probably a very common type of unilateral congenital cataract we see in children. Very commonly, it is associated with a smaller eye, smaller cornea. They have a very dense amblyopia. And we always have a little dilemma, whether to do anterior or a posterior approach in these situations. We’ve decided, based on the ultrasound findings, and sometimes how the size of the eye is, the stalk can be very thick and vascular. Sometimes you can see an associated RD in ultrasound. Then you can have a backup of a posterior segment surgeon or a posterior segment surgeon can do the surgery anteriorly, and if there is any problem, and proceed with the retina procedure as required. An IOL, whether it be a planning, if it is not a very dense PFV, then the anterior approach is better. So during the anterior approach, what do you have to be prepared for? You have to be prepared for a very thick, fibrous posterior capsule. So you need all sorts of instruments, like special scissors, cutter, et cetera. And you have to be prepared for the stalk being vascular, and it can give rise to bleed during the surgery. So you need an intraocular cautery when you are going to do a surgery on these children. And it’s ideal to have, if possible, a backup retina surgeon, especially if there is a bleed and the bleed goes into the retina during the surgery, and you’re not able to see the retina properly. And a good fundus examination, after removing the cataract, is very important. One is to see if anything has to be done then and there. And to predict the prognosis. So this is not a PHPV, but I’m showing this video because this was a trauma, but this had a very similar posterior capsule block, along with vascularity. So this is how we manage a PFV also. Because many of the times, the stalk will be peripheral. Not exactly in the center. And most of the time, the anterior lens — there’ll be hardly any real lens matter. It’ll only be fused capsule. Again, you’ll stain the capsule. Anterior rhexis. Thinking of implanting an IOL. Then anterior rhexis, again, here, it’s more important. As we remove the cortex, you can notice that there is a stalk, a vascular stalk coming. This is exactly how the PFV stalk will be. And you see that reddish tinge. So then you have to be really, really careful. It may bleed. I’m using an intraocular cautery. Before you cut, you have to use the cautery. And once it is avascular, you have to cut the stalk. And this is how the PC will be. Thick. And you remove the rest of the capsule. Membranous capsule. Do an anterior vitrectomy. If there is no other problem, then you can put a lens in the sulcus. So prognosis is very guarded, usually. Because it is unilateral. Secondly, because it has a separate retinal pathology. And densely amblyopic. So actually, even in older children, if they present very late, you can even consider leaving them alone, if you think the visual prognosis would be extremely guarded. So the fifth scenario that we’ll be discussing here is a few resurgeries. Like many of the times, we do see children requiring surgeries, resurgeries, for various reasons. And what are the common situations? The commonest situation we do is planned aphakia management. We do lensectomy in infancy. So we plan a secondary IOL implantation later in childhood. Or if there is a visual axis opacification, we sometimes have to do membranectomies. And if there are IOL issues, like IOLs can be decentered, there can be pupil captured, so all these situations — we may have to do resurgeries. And rarely, if there is glaucoma, they have to have glaucoma surgeries and retinal surgeries. Of course, those two will be dealt with by their respective surgeons. But this is a short video of how we do a secondary IOL implantation routinely following up lensectomy in childhood. So you’ll see a nice PC rim. So a three-piece foldable IOL is the best choice here. There are people who attempt or who open the bag and try to implant a secondary IOL also in the bag. I have personally not done it ever. And it’s technically probably very difficult. But yes, if you are able to do it, the best that you can do — the only thing is then there will be cortex. There will always be some amount of cortex between the capsules. So once you open the PC rim and the residual bag is there, you have to remove that cortex before you implant the lens into the bag. But otherwise, a safe sulcus IOL implantation is also a very good option. So postlensectomy aphakia. If you are planned — secondary IOL managing, if you’re doing, ideally above the age of 3 or 4, sulcus placement. If sulcus is not adequate or anything, then scleral fixation can be done, but only after the age of 8, ideally. And trauma sometimes — like I was discussing, we have situations where we have done a cataract surgery and we need a secondary IOL implantation. Again, routinely it is done in the sulcus. Very rarely, but if it’s not there, we can do it in the — fixate the lens. So this is another surgery. It’s a resurgery. The patient presented from elsewhere. You can see a captured IOL, partly in the anterior chamber. And there is a very dense membrane in the visual axis. So here the plan was to do a membranectomy and position the IOL into its place. So again, you need good instruments. You have to clear the synechiae. Scissors are a very useful instrument. Scissors, along with a cutter. So once there is a good sulcus and you have cleared — the rest of the sulcus is clear in this child, you have to confirm that there’s a good sulcus — so since the lens otherwise is looking fine, I tried to redial the lens into the sulcus. So I was successful in redialing this haptic. So when I was positioning, I just think and see: What do I notice? See? I’m noticing that the haptic has broken. So here again you have to anticipate — you have to — luckily for me, I had a DBR done, because if that lens was not viable, I was planning to exchange it. So that is the key here. These kinds of situations, when we are not sure what you may face during the surgery, you have to keep things, really. So that lens, because the haptic was broken — I don’t know. Maybe due to the surgery. During the manipulation, it may have gotten broken, or it was broken. That is where it got captured. Anyway, it had to be explanted, and a three-piece foldable lens was implanted and put in the sulcus. So here the tips, like I said, is: Anticipation is the key. So you have to have DBR done, whenever you’re planning a manipulation of an already placed IOL. So that in case you need to replace it, you have a DBR ready. And keep important instruments ready. And very judicial manipulation. So maybe the previous patient — if I had not — since the cornea was good, there may have been a role of not just doing the membranectomy and not redialing the lens. It would have been an option also. But I thought the sulcus was good, so I redialed it. So I don’t know. As minimal a manipulation, whenever you’re doing a resurgery. Because resurgery is always more challenging. Especially when a lot of handling is there. So, to summarize, pediatric cataract management can be complicated with other issues. So good preoperative assessment is very, very important. You anticipate and have a good preparedness. And there is no compromise on instruments. So thank you very much. If the IOL is undercorrected, should the proper correction be completed using contact lenses or spectacles? Yes. The answer would be yes. And that is the reason — I mean, the undercorrect — so allowing myopic shift over the growth period — but yes, you have to correct the child — make the child emmetropic with the contact lens or spectacles. That is the idea. So undercorrection is only for the IOL. Another question is: How long would you wait after inflammation subsided, doing cataract surgery in children? So we use six weeks of tapering of steroids in a routine pediatric cataract surgery. And even trauma. So usually — and only topical steroids. And usually, by six weeks, the children — inflammation, all that would subside. If it is a special situation, like significant trauma or uveitic conditions, then the inflammation control will be required longer, and we can take the help of a uveitic specialist to advise us how to continue the inflammation control. But routinely, it is six weeks, tapering of steroids. Topical steroids. Can you please tell why limited anterior vitrectomy is — in pediatric cataract? Limited anterior vitrectomy has a similar role to posterior capsulotomy. It is because in children, anterior vitrectomy is also prone to have opacification later. So that is the same reason why we do a PPC. We combine it along with the limited anterior vitrectomy to prevent PC opacification. Another question. A child, two months old, with congenital NLDO and posterior polar cataract in the same eye. How to proceed? It’s a very good question. Very common situation, actually. So very small children — yes, you have to make sure that there’s no NLD obstruction, because infants are prone to have NLD obstruction as well. So what we do here is we first have to manage the NLD obstruction by syringing and probing. Usually here in our institute, we wait for one or two weeks. Once you do a syringing and probing, many times the NLD obstruction clears. They massage and use antibiotic cover, and after one or two weeks of syringing and probing, if the patency is restored, we can proceed with cataract surgery. And two months syringing and probing. Otherwise, we can wait up to six months of age, but because there’s an impending cataract surgery, yes, we can do an early probing and syringing in these children. And if you ensure patency of the duct, the risk of endophthalmitis is not higher. What immunosuppressive agent do you recommend? For a cataract surgery, it is steroid all the time. But if they’re already on an immunosuppressive agent, as for the uveitic entity, then they continue it, and that continues. But for a cataract surgery, during perioperatively and postoperatively, steroid is the best immunosuppressive. Having encountered severe post-op inflammation in cataracts with iris injury, status post trauma, dense membrane formation, especially in cases where we repair iris tissue in the same setting, or once we create a visual axis by removing iris. How to manage? I agree. This is a very common situation, postoperative inflammation, especially if it’s a recent injury, and we handle the iris a lot. If you are very sure that the inflammation is only because of iris handling, and you rule out infection completely, a short course of systemic steroids also can help. Atropine helps. And very rarely, if there is a thick membrane, there are one or two situations where, after the surgery you do — and there is a thick fibrin which is occluding the visual axis, you may have to go and do a vitrectomy — remove it with a cutter. Surgically, if it’s a very small child. Otherwise, we can YAG it later, if it is YAG-able, in an older child. But yes, that is a very common condition. Your second question is: In postuveitis cataract, how to avoid or deal with postoperative hypotony? Presurgery, we prefer if the IOP is around more than 4 to 6. You have to make sure. And postsurgery, usually with very poor hypotony, they don’t do well. But before the surgery, if you’re anticipating you have to wait and postpone surgery, you can give intravitreal steroids. Wait and see if IOP is at least 4 to 6, before you do the cataract surgery. Have you placed iris claw lens in children with compromised bag? This is a very good point. Yes, I missed discussing it. Now there is a very good role of posterior iris claw lenses in children who are younger, for sclerally fixated lenses, but older enough to have a secondary IOL implantation. Yes, in experienced hands, the posterior iris claw lens is having a role. A definite role. I have not still had a personal experience with that. What is the recommended age for surgery of a child that is congenital or traumatic non-penetrating? Surgery… Congenital cataracts, like if it is bilateral, minimum age is ideally above 3 months now. Because looking into other aspects, like glaucoma, all that incidence is much, much higher in very young children. So above the age of 2 to 3 months, if it is a bilateral congenital cataract, unless it is total cataract, and that age you have to do a lensectomy and not implant IOL. If it is unilateral cataract, again, a little above six weeks is the cutoff. If it’s within six weeks, better to avoid surgery. And trauma at any age, you have to do the surgery. If the cataract is significant. Whether it is penetrating or non-penetrating. Here age is not a factor. When do you do a scleral incision? What is your preferred incision? Clear corneal or scleral incision? That’s a good question. The scleral incisions nowadays — scleral incisions are definitely safer, with respect to wound strength and infection point of view. So if you — younger children, you can, if you are implanting an IOL, you can do a scleral incision. But now if you’re very sure that the patient will be following up properly, and you’re going to close the wound anyway, a corneal incision is well also. So now almost we have switched to clear corneal incisions. We no longer do scleral incisions. Unless the child is one-eyed or there are specific reasons like that. Otherwise, corneal incisions are as good, provided you are closing it with the suture. And another question: Do you perform simultaneous bilateral surgery in ordinary pediatric cataracts? Thank you for bringing this question. Yes, we never do bilateral surgery in ordinary pediatric cataracts. In our institute, and I’m sure in most of the institutes and most of the places in the world, bilateral simultaneous cataract surgeries in children are done only for anesthesia-related issues. Only when there is a high anesthesia-related reason, that a second general anesthesia can be deleterious to life, in those situations, we do bilateral simultaneous cataract surgeries in children. Otherwise, we never do. So it’s a strong no here. Do you have topical atropine and systemic steroids post… Yes. No systemic steroids. We always give only topical steroids, topical home atropine, and antibiotic. For all pediatric cataract surgery. Routine pediatric cataract surgery. Systemic steroids are reserved only for uveitic cataracts, and in very special cases where it is trauma and there is significant inflammation after the surgery. But not routinely. Routinely, only topical steroids. What type of IOL to be placed in uveitis patients if IOL is indicated? Very good question. Again, here, if it is in the bag, like I said, it’s only in the bag. We use a hydrophilic acrylic single-piece IOL in the bag. So any brand, anything which you have access to, works well. Our next question: How do you manage the severe inflammation after you use iris hooks to manipulate the iris a lot? What’s your topical steroid regime? So topical steroid regime: We start with hourly prednisolone acetate. For one week. Followed by 8 times, 6 times, followed for 6 weeks, and if there is a very severe inflammation, you add a strong cycloplegic, even atropine, and if there is still a lot of reaction and there is no infection, then you can use a short course of systemic steroid, based on the weight of the patient. How to calculate IOL in traumatic cataract. Yes, it’s very challenging if cornea has a scar in the center. Otherwise, like in a routine situation only. So if there is a corneal scar in the center, if the sutures are removed, you wait for at least 2 to 3 weeks — 2 weeks of suture removal and do a keratometry. If keratometry is not helping, it’s not freezing, then you have to do a topography.. Usually topography combined will give us some clue. Some idea. And calculate the IOL based on that. Very rarely, if the scar is really very significant, and you’re not able to get a good topo value also, then you can try using a standard keratometry. 44/44. And calculate and put an IOL, and correct the vision. Residual astigmatism. With glasses or contact lens. Large refractive errors, which are detected much later in life — which is the best approach if IOL already placed primarily? Yeah. This is a recent important question. So there are a few options we have. If it’s a very large refractive error, and the child is well above the age of refractive change, then there are options of IOL exchanges. Or (inaudible) IOLs nowadays. We are thinking of that as an option. I don’t have personal experience with both. But yes, IOL exchange would come as an option here, if there is a very large refractive error. Provided the child has come out of the — beyond the age of 16 or 18. Very minimal refractive error beyond that age — sometimes even a cornea LAS refractive procedure can be done. Just within 2 or 3 diopters. Otherwise, contact lens is the safest. When do you decide to stop anterior vitrectomy? Or, in other words, what is a good anterior vitrectomy? Anterior vitrectomy, like many of the times — it’s a good question. We can’t really see how much anterior vitrectomy. So it’s time, basically. Half a minute or so. And at the end, you have to make sure that there is no vitreous in the anterior chamber or in the bag. So both the capsule rims are nice and round, and there are no vitreous tags. That is the endpoint. But otherwise, you stop after less than a minute or so of doing the vitrectomy. How long after an infant cataract surgery would you expect glaucoma or PCO to occur? Sadly, there is no clear time guide for this. But for a glaucoma to occur, the age when you operate on an infant is very, very crucial. So most of the studies have proved that the younger the child, the younger than 2 to 3 months, if you operate, chance of glaucoma is very high. So the older the child, the glaucoma chances actually keep becoming lesser and lesser. And many times, these glaucoma — they develop because they have associated angle anomalies also. PCO occurs after an infant cataract surgery — yeah. If you have not been able to do a very sufficient big good enough opening in the cataract, or not able to completely remove the cortex, then PCO occurrence can be quite early. And if the eye is also smaller, like a little small microcornea, a little microphthalmia, those eyes also — the membrane forms earlier than another situation. With glaucoma, age is a very important factor. Age of surgery. So beyond 2 months, the chances significantly keep reducing. That is why it is recommended that we do wait for surgery after 2 months, at least. Capsulorrhexis in children. What is the best approach? In children, can opener is not an option, if you’re planning an IOL. And if you’re starting to do cataracts in children, then you always stain your capsules. Use a higher density viscoelastics. Like a Healon GV or something. So that it flattens your cornea. And you use — instead of a cystotome, it is better to use a forceps. Like a capsular forceps, or an Utrata forceps. The forceps gives you a very good control. So when do we prescribe glasses, postpediatric cataract surgery? That’s a very important question. As soon as possible, if we have to prescribe glasses. If it is an aphakic child, if you’re leaving the child aphakic, then as early as the next visit, when you’re going to send them away. Within the first 2 or 3 days of surgery, you can do a refraction and prescribe glasses, if it is bilateral. If it is unilateral, and you’re going to give contact lenses, then two weeks is the ideal time. For prescribing in unilateral lensectomy children. If it is pseudophakic, yeah, 2 to 3 weeks is ideal. So as early as possible, you have to rehabilitate them. In unilateral cataract, age less than 5, would you choose emmetropia or undercorrection? Undercorrection only. The undercorrection, even if it is unilateral, you have to undercorrect. It’s depending on the age. And you can always give the glasses for the residual hyperopia. Because at 5 years, you are going to anyway implant IOLs, so the difference can be managed and tolerated well with glasses. And another question on combining strabismus surgery with cataract surgery on unilateral pediatric cataracts with sensory squint. The answer is no. In children, we do not combine these two surgeries for a lot of reasons. Do you recommend PA in all sulcus-placed IOLs in children? If we place sulcus IOLs in children… I mean, foldable sulcus IOLs in children — we don’t recommend PA in every situation. We don’t routinely do. Thank you.

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April 7, 2020

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