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 Table of Contents  
ORIGINAL ARTICLE
Year : 2021  |  Volume : 33  |  Issue : 2  |  Page : 151-154

Visual rehabilitation in pediatric cataract with primary intraocular lens implantation


Choithram Netralaya, Indore, Madhya Pradesh, India

Date of Submission03-Sep-2020
Date of Decision05-Sep-2020
Date of Acceptance23-Sep-2020
Date of Web Publication21-Aug-2021

Correspondence Address:
Dr. Dhaivat Shah
Choithram Netralaya, Shriram Talawadi, Dhar Road, Indore, Madhya Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/kjo.kjo_134_20

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  Abstract 


Aim: The aim of this study was to show visual rehabilitation in pediatric cataract with primary intraocular lens implantation. Materials and Methods: 106 eyes of 91 pediatric patients between 2 to 20 years of age who underwent cataract surgery with primary IOL implantation from June 2018 to January 2020 were included in the study. All the surgeries were performed by a single experienced pediatric ophthalmologist. Phacoemulsification, anterior vitrectomy, and primary posterior capsulorhexis with primary IOL implantation were done in all patients. Patients were reviewed 1 week, 1 month, and 6 months postoperatively. Results: Visual acuity improved from 1.7 logarithm of the minimum angle of resolution (logMAR) before the surgery to 0.74 logMAR at the last follow-up. Twelve eyes had postoperative complications which included posterior capsule opacification in 12 eyes, pupillary fibrin membranes in 17 eyes, and corneal edema in 2 eyes. Conclusion: The current study suggests that primary IOL implantation is safe when in an experienced hand for pediatric age group.

Keywords: Anterior vitrectomy, pediatric cataract, phacoemulsification, posterior capsulorhexis, visual rehabilitation


How to cite this article:
Ramteke P, Shah D, Jain H, Vaishnav G, Singh R, Neema A, Vasure R. Visual rehabilitation in pediatric cataract with primary intraocular lens implantation. Kerala J Ophthalmol 2021;33:151-4

How to cite this URL:
Ramteke P, Shah D, Jain H, Vaishnav G, Singh R, Neema A, Vasure R. Visual rehabilitation in pediatric cataract with primary intraocular lens implantation. Kerala J Ophthalmol [serial online] 2021 [cited 2021 Nov 30];33:151-4. Available from: http://www.kjophthal.com/text.asp?2021/33/2/151/324214




  Introduction Top


Cataracts are an opacified intraocular crystalline lens which is the major cause of blindness in children. The prevalence of childhood cataract in developing countries has been reported as 1–15 cases in 10,000 children. Globally estimated data are of 200000 children blind due to bilateral cataract.[1]

Bilateral congenital cataract can be hereditary with a prevalence of 8.3%–25% of cases, with 75% being autosomal dominant in inheritance.[2] Intrauterine infections such as rubella, herpes simplex virus, and varicella are common causative agents. Mostly, all bilateral congenital cataracts are idiopathic. Few metabolic disorders such as galactosemia and hypocalcemia also have an association with congenital cataract. There also occurs a strong association of congenital cataract with myriads of syndrome such as trisomy 21, Turner, trisomy 31, Lowe syndrome, and Alport syndrome. The optimal time for dense congenital cataract removal is 4–8 weeks of life. If the management is done before 4 weeks, there occurs an increased risk of glaucoma, and if after 8 weeks, there is a risk of compromised visual outcome.[3],[4] Management and visual rehabilitation, especially for unilateral cataract, is a daunting task with often disappointing results.


  Materials and Methods Top


Clinical records of 112 eyes of 82 patients aged between 2 and 20 years with congenital, traumatic, and developmental cataract who underwent phacoemulsification with primary intraocular lens (IOL) implantation from June 2018 to February 2020 at a tertiary eye care center in Central India were retrospectively reviewed.

Medical records were analyzed, and the following data were gathered regarding patients' anterior segment examination and type of cataract, which were further categorized nuclear, zonular, posterior subcapsular, polar, and total.

Preoperative and postoperative visual acuity was assessed using fixation patterns and Snellen's acuity chart in preliterate and literate patients, respectively. Ocular biometry included records of axial length, keratometry, and IOL power calculations using IOL Master (Carl Zeiss Meditec, Germany). Routine investigations and B-scan were done in all patients. All the surgeries were performed single handedly by an expert pediatric surgeon under general anesthesia by phacoemulsification, anterior vitrectomy, and primary posterior capsulorhexis with primary IOL implantation in bag; vitreoretinal backup was called for if required. Any intraoperative and postoperative complications and intraoperative difficulties were noted.

Postoperative day 1 detailed anterior segment examination and posterior segment glow were assessed; all the patients were postoperatively advised topical tobramycin 0.3% eye drops four times a day for a week, atropine sulfate 1% eye ointment bedtime or homatropine 2% eye drops twice a day for 2 weeks, and prednisolone acetate 1% 8–12 times per day with gradual tapering in 6 weeks. Patients were reviewed 1 week, 1 month, and 6 months postoperatively. Patients with other organic ocular diseases such as ocular deviations, retinopathy of prematurity, persistent hyperplastic primary vitreous, anterior segment dysgenesis, and raised IOP and those who failed to follow up till 6 months were excluded.

Data were recorded in Microsoft Excel Sheet (version 12.0, Microsoft, Washington, USA), and percentage, proportions, and frequency were analyzed.


  Results Top


A total of 82 patients were included in the study, with 112 eyes accountable. Of the 82 patients, 8 were traumatic cataract which was excluded from the study. Forty-eight patients had unilateral cataract while 28 had bilateral, 60 eyes of 40 patients had congenital cataract, and 44 eyes of 34 patients had developmental cataract. Forty-four patients (59.45%) were male and 30 patients (40.54%) were female. The mean age at surgery was 69.73 months.

Out of 104 eyes operated, 88 eyes (84.6%) had no postoperative complications and 16 eyes had postoperative complications which included posterior capsule opacification (PCO) in 2 eyes (1.9%), pupillary fibrin and membranes in 10 eyes (9.6%), and corneal edema in 4 eyes (3.8%) [Table 1].
Table 1: Eyes with good and poor visual acuity postoperatively in different categorical variants and mean age of patients in both the groups

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The average mean visual acuity was 1.02 logarithm of the minimum angle of resolution (logMAR) following surgery. Visual acuity gain of 6/12 Snellen's acuity or 0.30 logMAR was considered a good visual prognosis. Twenty-eight eyes both of congenital cataract and developmental cataract, 20 eyes with unilateral cataract, and 40 eyes with bilateral cataract had a good mean visual acuity of 0.27 logMAR, 0.24 logMAR, 0.29 logMAR, and 0.21 logMAR, respectively [Table 2].
Table 2: Mean visual acuity in eyes with good and poor visual acuity postoperatively in different categorical variants

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The average mean age of operated unilateral cataract patients was 9.3 years and their mean best-corrected visual acuity (BCVA) improved from 1.91 logMAR preoperatively to 0.93 logMAR postoperatively. The mean age of operated bilateral cataract patients was 7.7 years and their mean BCVA improved from 1.62 logMAR preoperatively to 0.88 logMAR postoperatively [Table 3].
Table 3: Comparison of pre- and postoperative best-corrected visual acuity in unilateral and bilateral cataract

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The average visual acuity improved from 1.7 logMAR before the surgery to 0.74 logMAR at the last follow-up. BCVA improvement was noticed in 84 eyes (80.7%) at the last follow-up compared with their preoperative measurement. In 20 eyes (19.2%), there was little improvement or no change in visual acuity.


  Discussion Top


The results from this study demonstrate that good outcomes are achievable in children undergoing primary IOL implantation following cataract surgery. More than 80% of the eyes had an improvement in visual acuity and more than 50% of the eyes achieved 6/12 Snellen's acuity or 0.3 logMAR visual acuity at the last follow-up. The complication rate can be compared with that previously reported.[5],[6]

Pediatric cataract surgery and aphakia correction after cataract removal presents unique management problems rarely encountered in adult patients. Cataract surgery in children cannot be delayed once a cataract has developed because of the risk of stimulus deprivation amblyopia. With the amblyogenic factor removed, visual development of the operated eye is threatened by anisometropia. Unilateral aphakia correction with glasses produces up to 35% image difference; the use of contact lenses reduces this to 10%. IOL implantation results in aniseikonia of 0%–4%.[7],[8]

As the cataract surgery is evolving with the ability to provide early, effective, and constant optical rehabilitation,[9],[10],[11] several authors have reported a good vision[12],[13],[14],[15],[16] and binocular function[9],[11],[17],[18],[19] in children with unilateral cataract after surgery. Our results showed that 41.6% of children with unilateral cataract who underwent cataract removal and primary IOL implantation between 2 and 20 years of age achieved 0.3 logMAR or better visual acuities, which is a prerequisite for good binocular function. However, good binocular function outcome is limited.

Primary posterior capsulorhexis and anterior vitrectomy are recommended for patients aged 8 years or less.[20] All of our patients underwent anterior vitrectomy and primary posterior capsulorhexis, as strongly recommended in the literature.[21],[22] This can explain why only two patients developed PCO.

In our series, primary IOL implantation was performed in all 104 eyes [Figure 1], [Figure 2], [Figure 3]. The mean visual acuity significantly improved from 1.7 logMAR before the surgery to 0.74 logMAR at the last follow-up. Nystagmus and strabismus were present in six eyes of 11.5% of patients before the surgery. It is a predictive factor for poor postoperative visual acuity.[23] Children with congenital cataracts should ideally be operated on before the development of these factors, which occur in many cases after 10 weeks of age.[23]
Figure 1: (a) Preoperative photo of a 2-year-old male child with right eye total cataract and left eye pseudophakia. (b) Postoperative photo of the same after right eye cataract surgery

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Figure 2: (a) Preoperative photo of a 12-year-old male child with left eye zonular cataract with dense posterior plaque and right eye pseudophakia. (b) Postoperative photo of the same after left eye cataract surgery

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Figure 3: (a) Preoperative photo of a 13-year-old male child with right eye membranous cataract and left eye pseudophakia. (b) Postoperative photo of the same after right eye cataract surgery

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Visual outcome was better in developmental cataract group than congenital cataract group. Severe visual deprivation was suspected to be the cause of poor changes in the postoperative BCVA in congenital cataract group while associated eye comorbidities affected the visual outcome in few cases.

An area of our concern was that after surgery, <20% of patients came for follow-up and visual rehabilitation. A similar situation had been reported in other developing countries where many patients are lost from follow-up after surgery.[24] Reasons for withdrawal include long distance between home and hospital, financial difficulties, poor road infrastructure, ignorance, and lack of awareness to the necessity of long-term follow-up care.

Treatment should not be delayed in pediatric cataract as visual recovery is known to be significantly limited without early intervention. It may be stated that etiology and age at surgery are equally important factors in prognosis for outcome with primary IOL for the treatment of pediatric cataracts.


  Conclusion Top


The current study suggests that primary IOL implantation along with anterior vitrectomy with posterior capsulorhexis is extremely important for pediatric cataract patients. Unilateral cataract has a higher risk of amblyopia. Results come out to be more predictable if early identification, timely referral, and appropriate management protocol are followed. Awareness regarding long-term visual rehabilitation is a must for achieving optimal outcome in such cases.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient (s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initial s will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Acknowledgments

We would like to thank Mrs. Deepika Nagle, Mrs. AnjumZafar Khan, and Mrs. Srishti Sharma.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
World Health Organization. Global Initiative for Eliminating Avoidable Blindness (WHO/PBL/97-61). World Health Organization; 1997.  Back to cited text no. 1
    
2.
Santana A, Waiswo M. The genetic and molecular basis of congenital cataract. Arq Bras Oftalmol 2011;74:136-42.  Back to cited text no. 2
    
3.
Huang B, He W. Molecular characteristics of inherited congenital cataracts. Eur J Med Genet 2010;53:347-57.  Back to cited text no. 3
    
4.
Reddy MA, Francis PJ, Berry V, Bhattacharya SS, Moore AT. Molecular genetic basis of inherited cataract and associated phenotypes. Surv Ophthalmol 2004;49:300-15.  Back to cited text no. 4
    
5.
Trivedi RH, Wilson ME Jr. Single-piece acrylic intraocular lens implantation in children. J Cataract Refract Surg 2003;29:1738-43.  Back to cited text no. 5
    
6.
Faramarzi A, Javadi MA. Comparison of 2 techniques of intraocular lens implantation in pediatric cataract surgery. J Cataract Refract Surg 2009;35:1040-5.  Back to cited text no. 6
    
7.
Katsumi O, Miyajima H, Ogawa T, Hirose T. Aniseikonia and stereoacuity in pseudophakic patients. Unilateral and bilateral cases. Ophthalmology 1992;99:1270-7.  Back to cited text no. 7
    
8.
Rabinowicz IM. Aniseikonia, the bane of binocularity: With views on the management of monocular congenital cataract. Am Orthopt J 1992;42:102-10.  Back to cited text no. 8
    
9.
Helveston EM, Saunders RA, Ellis FD. Unilateral cataracts in children. Ophthalmic Surg 1980;11:102-8.  Back to cited text no. 9
    
10.
Drummond GT, Scott WE, Keech RV. Management of monocular congenital cataracts. Arch Ophthalmol 1989;107:45-51.  Back to cited text no. 10
    
11.
Wheeler DT, Mullaney PB, Awad A, al-Mesfer S, al-Nahdi T, Zwaan J. Pediatric IOL implantation: The KKESH experience. J Pediatr Ophthalmol Strabismus 1997;34:341-6.  Back to cited text no. 11
    
12.
Robb RM, Mayer DL, Moore BD. Results of early treatment of unilateral congenital cataracts. J Pediatr Ophthalmol Strabismus 1987;24:178-81.  Back to cited text no. 12
    
13.
Birch EE, Stager DR. Prevalence of good visual acuity following surgery for congenital unilateral cataract. Arch Ophthalmol 1988;106:40-3.  Back to cited text no. 13
    
14.
Cheng KP, Hiles DA, Biglan AW, Pettapiece MC. Visual results after early surgical treatment of unilateral congenital cataracts. Ophthalmology 1991;98:903-10.  Back to cited text no. 14
    
15.
Kushner BJ. Visual results after surgery for monocular juvenile cataracts of undetermined onset. Am J Ophthalmol 1986;102:468-72.  Back to cited text no. 15
    
16.
Awner S, Buckley EG, DeVaro JM, Seaber JH. Unilateral pseudophakia in children under 4 years. J Pediatr Ophthalmol Strabismus 1996;33:230-6.  Back to cited text no. 16
    
17.
Greenwald MJ, Glaser SR. Visual outcomes after surgery for unilateral cataract in children more than two years old: Posterior chamber intraocular lens implantation versus contact lens correction of aphakia. J AAPOS 1998;2:168-76.  Back to cited text no. 17
    
18.
Gregg FM, Parks MM. Stereopsis after congenital monocular cataract extraction. Am J Ophthalmol 1992;114:314-7.  Back to cited text no. 18
    
19.
Brown SM, Archer S, Del Monte MA. Stereopsis and binocular vision after surgery for unilateral infantile cataract. J AAPOS 1999;3:109-13.  Back to cited text no. 19
    
20.
Wilson ME, Pandey SK, Thakur J. Paediatric cataract blindness in the developing world: Surgical techniques and intraocular lenses in the new millennium. Br J Ophthalmol 2003;87:14-9.  Back to cited text no. 20
    
21.
Alexandrakis G, Peterseim MM, Wilson ME. Clinical outcomes of pars plana capsulotomy with anterior vitrectomy in pediatric cataract surgery. J AAPOS 2002;6:163-7.  Back to cited text no. 21
    
22.
Koch DD, Kohnen T. Retrospective comparison of techniques to prevent secondary cataract formation after posterior chamber intraocular lens implantation in infants and children. J Cataract Refract Surg 1997;23 Suppl 1:657-63.  Back to cited text no. 22
    
23.
Ruit S, Paudyal G, Gurung R, Tabin G, Moran D, Brian G. An innovation in developing world cataract surgery: Sutureless extracapsular cataract extraction with intraocular lens implantation. Clin Exp Ophthalmol 2000;28:274-9.  Back to cited text no. 23
    
24.
Yorston D, Wood M, Foster A. Results of cataract surgery in young children in east Africa. Br J Ophthalmol 2001;85:267-71.  Back to cited text no. 24
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]
 
 
    Tables

  [Table 1], [Table 2], [Table 3]



 

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