2018 Pediatric Cataract Surgery: Pearls for the Non Pediatric Ophthalmologist

Alvina Pauline D. Santiago, MD
June 2, 2018
#pediatriccataractsurgery
©APSantiago 2018 June 5, 2018

No proprietary interest with any of the products mentioned.
©APSantiago 2018 #pediatriccataractsurgery June 5, 2018

§ Is the cataract visually significant?
§ Can vision be improved with surgery?
§ When do I operate?
§ Will I put in an IOL?
§ What formula do I use?
§ What is my target postop refraction?
§ How different is the procedure
compared to adult cataract surgery?
§ How different is postop management?
§ How do I rehabilitate the eye?
http://www.taroticallyspeaking.com

Donahue S,Arnold RW,Ruben JB,
AAPOSVision Screening Committee.
Preschool vision screening: what
should we be detecting and how
should we report it? Uniform
guidelines for reporting results of
preschool vision screening studies.
J AAPOS.2003 Oct;7(5):314-6. PMID:
14566312 DOI:
10.1016/S1091853103001824
§ Anisometropia (sph or cyl) >1.5D
§ Any manifest strabismus
§ Hyperopia >3.5D in any meridian
§ Myopia > 3.0D in any meridian
§ Any media opacity >1mm size
§ Astigmatism
§ >1.5D at 90, 180
- >1.0 D at oblique axis (>10deg of 90, 180)
§ Ptosis </= 1 mm MRD
§ VA per age appropriate standards
AMBLYOPIA = SURGERY

§ In central visual axis, bigger than 3 mm
§ Posterior cataract
§ No clear zones in between
§ Retinal details not visible with direct
ophthalmoscope
§ Nystagmus or strabismus present
§ Poor central fixation after 8 weeks
Jaf HBQ, Diseases of the crystalline lens.
https://www.slideshare.net/AbbasTelakoe/ophthalmologydiseases-of-the-
lensdrbaxtyar. Accessed April 4, 2017

§Check red orange reflex
with the retinoscope to
assess “size” of the
cataract.
§If one can penetrate using
ophthalmoscope or
indirect ophthalmoscope,
reconsider doing the
surgery

Taylor & Hoyt’s Pediatric Ophthalmology 2005
§Usually a smaller eye
§Watch for smaller optic nerves
§Poorer visual prognosis

§Intraocular bleeding risk high
§Postoperative risk of phthisis high

§Reversibility following control of
metabolic problems reported
§ Butler PA. Reversible Cataracts in Diabetes Mellitus.J Am
Optom Assoc. 1994 Aug;65(8):559-63.
§ JinYY et al. Reversible Cataract as the Presenting Sign of
Diabetes Mellitus: Report of Two Cases and Literature Review.
Iran J Pediatr. 2012 Mar; 22(1): 125–128
§ Trindande R. Transient cataracts and hypermetropization in
diabetes mellitus: case report.Arq. Bras.
Oftalmol. vol.70 no.6 São Paulo Nov./Dec. 2007.
http://dx.doi.org/10.1590/S0004-
27492007000600030 version=html
Focus on Diabetes

§Usually good visual acuity despite central location
Taylor & Hoyt’s Pediatric Ophthalmology 2005

§VA can be as good as 6/7.5
§Consider waiting post amblyopia
age
§Glare and contrast sensitivity
problems

§Very minimimal effect on
vision
§Remember amblyopia
treatment in monocular cases

§ Amblyopia
§ Reopacification of ocular
media
§ Anisometropia
§ Aneisokonia
§ Propensity for inflammation
§ Different anatomy
§ Growing eyeball
§ Changing refraction
§ Will patient wear glasses?

http://www.taroticallyspeaking.com

§Deprivation amblyopia
§Persistent fetal vasculature
until proven otherwise
§Commit to aggressive
postop rehabilitation
§Before 6 weeks
Birch EE, Plager D. The critical period for
surgical treatment of dense congenital
unilateral cataract. Invest OphthalmolVis Sci.
1996 Jul;37(8):1532-8.

Onset during amblyogenic
age
§ Operate
§ Before nystagmus
§ Before deprivation amblyopia
§ Doing one vs both eyes
§ Typically before 8 weeks
Onset after 7 years of age
§ Amblyopia less of an issue
§ May do one eye at a time,
leisurely pace as in adult
©APSantiago 2018 #pediatriccataractsurgery June 5, 2018xs

PRIMARY IOL
§ VA </= 20/200 in 50%
§ VA > 20/32 in 6
§ At least 1 adverse event in 86%
§ Lens reproliferation
§ Pupillary membranes
§ Corectopia
§ At least 1 additional surgery in 72%
§ Glaucoma/suspect in 28%
APHAKIC with CONTACT LENS
§ VA </= 20/200 in 50%
§ VA > 20/32 in 13
§ At least 1 adverse event in 56%
(p=0.016)
§ At least 1 additional surgery in 21%
(p=<0.001)
§ Glaucoma/suspect in 35% (p=0.55)
Infant aphakia treatment study group. A Randomized Clinical Trial Comparing Contact Lens to Intraocular Lens Correction of Monocular Aphakia during Infancy: HOTV Optotype Acuity at Age 4.5
Years and Clinical Findings at Age 5 years. JAMA Ophthalmol. 2014 Jun; 132(6): 676–682. doi: 10.1001/jamaophthalmol.2014.531
Infant aphakia treatment study group. A Randomized Clinical Trial Comparing Contact Lens to Intraocular Lens Correction of Monocular Aphakia During Infancy: Grating Acuity and Adverse Events at
Age 1 Year
Arch Ophthalmol. 2010 Jul; 128(7): 810–818. doi: 10.1001/archophthalmol.2010.101

§IOL implantation be limited to infants at risk of
experiencing “significant periods of uncorrected
aphakia” if an IOL was not implanted.
§the cost and handling of a contact lens will be so
burdensome as to result in significant periods of
uncorrected aphakia
Age 1 Year

§All pseudophakic eyes had a targeted
postoperative refraction of +6 or +8 D at the time of
IOL implantation.
§Average refraction at end of study -2.25
(range of -19.00 to +5.00)
§3 required IOL exchange
Age 1 Year

7
5
2
1

§ “General consensus IOL for most older children.”
§ IOL implantation during the first year of life still
questioned
§ 6 mos or younger: CAUTION
Wilson 1996
Trivedi et al 2004
Infant Aphakia Treatment Study Group 2010

§Less uveal biocompatibility:
§Postoperative iridocyclitis
§Secondary glaucoma
§Rigid if > 12mm
§Lessened with heparinized PMMA lens
Wilson ME et al. Cataract Surgery in
Children,Trends and Controversies.
http://www.aapos.org/client_data/fil
es/2012/479_wilsonhandout.pdf
Accessed August 23, 2015

§3-piece MA series
§Less postop iridocyclitis
§Do well in bag and sulcus
§Less PC Opacity
§May not need to create an
opening in PC
https://www.alcon-
pharma.de/produkte/ophthalmochirurgie/intraokularlinsen-
u.-zubehor/acrysofae-multi-piece-acryllinsen/mn60ma-
natural-ma60ma/acrysofae-natural-mn60ma/intraok-acrysof-
natural-mn60ma.jpg/@@images/0e4a3521-e8f4-4140-ad67-
16e4700ca12b.jpeg

§ Single piece SA (and SN) series ideal for
children
§ Flexible haptics:
§ implant even in small eyes
§ Less ovaling of bag; less capsule stretch
§ excellent memory
§ Haptics unfold slowly
§ Resist equatorial lens capsular fibrosis
§ May not need to create an opening in PC https://www.reviewofophthalmology.com/CMSImagesC
ontent/2005/6/1_742_2.jpg

§SN/SA series
§square edge / sharp edge
§ Reduced PC opacity
§Adhesive biomaterial (AcrySof):
§ Hydrophobic material has higher
binding capacity to fibronectin
§ Fibronectin mediates adherence to
lens capsule, impeding lens epithelial
cell migration
https://www.reviewofophthalmology.com/CMSImagesC
ontent/2005/6/1_742_2.jpg

§SN/SA series
§Thinner (than PMMA): piggyback
§SN UV filter approximating a 20
yr old
§ Improved contrast sensitivity
§ Reduced central glare
§ Restoration of color vision (at least in
adults tested)

§ In-the-bag (e.g. ALCON SN60 IQ, Rayner
Cflex IOL)
§ Sulcus placement
§ PMMA avoids decentration (e.g. ALCON MC 60-BM)
§ Rayner Cflex IOL
§ 3 pc foldable acrylic (e.g.) Acrysof MA 60
§ Attempt optic capture through AC +/- PC
§ Haptic in Sulcus, IOL Optic Capture thru PCC
ME Wilson et al 2012, Faramarzi et al 2009, http://www.eye.uci.edu/pix/cataractsur
gery.jpg

Authors Year Age of
Patients
N Follow-up Conclusion
Pavlovic etal 1998 8 m– 15 y
(Mean 5.1 y)
8 18 – 46mo
(Mean: 29.6 m)
Safe, stable short term
Pavlovic S, Jacobi FK, Graef M et al. Silicone intraocular lens implantation in children, preliminary results. J
Cataract Refract Surg. 2000 Jan;26(1):88-95

§Axial Length Variability
§Newborn: 17mm
§Adult: 23-24mm
§Pediatric Eyes with
cataract: wide range!

Prado et al.Congenital and developmental cataract:
axial length and keratometry study in Brazilian
children. Arq. Bras. Oftalmol. vol.79 no.1 São
Paulo Jan./Feb.2016 http://dx.doi.org/10.5935/0004-
2749.20160007
Lin et al. Distribution of Axial Length
before Cataract Surgery in Chinese
Pediatric Patients.
https://www.nature.com/articles/srep2
3862

Bluestein EC,Wilson ME,Wang XH et al.
Dimensions of the Pediatric Crystalline Lens:
Implications for Intraocular Lenses in
Children. JPOS 1996; 33(1): 18-20. DOI:
10.3928/0191-3913-19960101-06

§1 pc hydrophobic acrylic:
§Acrysof SA/SN 60 series
§6.0 mm optic, 13.0 overall diameter
§Acrysof SA30AL
§5.5 mm optic, 12.5 mm overall
diameter
§3 pc acrylic optic-PMMA haptic
§Acrysof MA60BM
§6.0 mm optic, 13 mm overall diameter
1.ME Wilson et al. Cataract Surgery
in Children,Trends and
Controversies.
http://www.aapos.org/client_data/fil
es/2012/479_wilsonhandout.pdf
Accessed August 23, 2015.

ALCON Acrysof PMMA
1.ME Wilson et al. Cataract Surgery in Children,Trends and Controversies.
http://www.aapos.org/client_data/files/2012/479_wilsonhandout.pdf Accessed August 23, 2015.
• Proliferative
• Progress more slowly
• Less visually significant
• 2nd surgery less likely
• If Nd:YAG single sessions
• Fibrous
• Progress faster
• More visually significant
• 2nd surgery likely
• Reopacification =
repeated Nd:YAG

§ Not recommended when a primary posterior capsulotomy and
vitrectomy done
§ 2 or more images formed at the retina: immature visual system
will choose 1; alternating vision between near image or distant
image
§ Loss of contrast sensitivity
§ Eye growth and amblyopia
§ Myopia with eye growth
§ Deserves further study at this time
MEWilson et al. Cataract Surgery in Children,Trends and Controversies.http://www.aapos.org/client_data/files/2012/479_wilsonhandout.pdf Accessed August
23, 2015.

Majority of patients with Primary Posterior Capsulotomy and anterior
vitrectomy
§ In the bag PCIOL: reopen bag, viscodissection
§ Sulcus PCIOL: PMMA vs 3-pc acrylic
§ ACIOL
§ 3 pc acrylic transpupillary capture of IOL, haptics in sulcus
§ Artisan lens
§ Retropupillary fixation of Iris Fixated IOL (Mohr)
§ Transcleral?? As a last resort???
Wilson et al 2012,Wilson et al 2009,Trivedi et al 2005,Wilson et al 2011, Buckley 2007

§Age dependent myopic shift
§3/33 subluxed IOL
§10-0 prolene suture spontaneous breakage
§ 3.5, 8, 9 years
§Survey of 10 pediatric ophthalmologist:
§ 10 cases at average 5 years
Buckley EG. Hanging by a thread: the long-term efficacy and safety of transcleral sutured IOL in children (an AOS thesis).Trans AOS. 2007;105:294-311

Buckley EG. Hanging by a thread: the long-term efficacy and safety of transcleral sutured IOL in children (an AOS thesis).Trans AOS. 2007;105:294-311
Conclusion
Despite the 3/33 subluxed IOL
• appears to be a safe and effective
procedure
• provided that the suture material
used is stable enough to resist
significant degradation over time.
• caution with 10-0 polypropylene
suture
• an alternative material or size
should be considered.http://vignette3.wikia.nocookie.net

§ Get a good keratometry reading
§ Get a good axial length
determination
§ Get a good ultrasound
§ Get a good biometry
§ Even if you have to put the
patient under general
anesthesia!
http://www.aitindustries.com

IOL
Power
SRKII
SRK-T Holladay
HofferQ
ACCURACY?

§4 formulas studied: SRK II, SRK-T, Holladay, HofferQ
§No significant difference in accuracy
§Average postop error 1.2-1.4D in all formulas
§high degree of variability
§ SRK II being the least variable
§ Hoffer Q being the most variable,
§ particularly among the youngest group of children with the axial lengths
less than 19 mm
NeelyDE, PlagerDA, BorgerSM, GolubRL.Accuracy of intraocular lens calculations in infants and children undergoing cataract surgery. J AAPOS. 2005;9(2)160–165.
Andreo LK,Wilson ME, Saunders RA. Predictive value of regression and theoretical IOL formula in pediatric intraouclar lens implantation. J Pediatr Ophthalmol
Strabismus 1997; 34: 240-243..

Prediction Error vs. Desired Refraction
Age at Surgery
Axial Length
NeelyDE, PlagerDA, BorgerSM, GolubRL.Accuracy of intraocular lens calculations in infants and children undergoing cataract surgery. J AAPOS. 2005;9(2)160–165.

§Holladay 1 and SRK/T
§at 5 years, they found refractive errors ranging from +5.00
to -19.00 D,
§inability to predict axial elongation in infantile eyes
Vanderveen DK,Trivedi RH, Nizam A, Lynn MJ, Lambert SR. Pre- dictability of intraocular lens power calculation formulae in infantile eyes with
unilateral congenital cataract: results from the Infant Aphakia Treatment Study.Am J Ophthalmol. 2013;156(6):1252–1260.e2.

https://www.apacrs.org/barrett_universal2/

IOL Choice Advantage Dis
advantage
Adult Refraction
Initial
hyperopia
Hyperopia
improves as eye
grows
Less myopic shift
Initial specs or
contact lens
correction required
Low myopia or
emmetropia,
possibly hyperopia

IOL Choice Advantage Dis
advantage
Adult Refraction
Initial
emmetropia
No spectacle or
contact lens initially
Large myopic shift
with eye growth
Myopia, moderate
to high
Initial myopia Initially may not
require contact
lens or spectacle
correction to
prevent amblyopia
Large myopic shift
with eye growth
Myopia possibly
very high

• Emmetropia in early childhood
– Myopic shift
– Less anisometropia
• Hyperopia
– Mild to Moderate for ages 2-8 years
– Potential for amblyopia
– Less problems with myopic shift
MEWilson et al. Cataract Surgery in Children,Trends and Controversies.http://www.aapos.org/client_data/files/2012/479_wilsonhandout.pdf

AGE (Years) Target
Refraction
7 0 to +0.50
6 +1.00
5 +2.00
4 +3.00
3 +4.00
2 +5.00
Weigh:
• Refraction of other eye
• Risk of amblyopia
• Management of
induced anisometropia
• Rule of 7
ME Wilson et al 2012, Faramarzi et al 2009,

§ The power of IOL intended for capsular bag placement should be decreased by
1 D to 2 D when placed in the sulcus
§ depending on the IOL power:
§ the higher the power, the greater the reduction), when placed in the ciliary sulcus.
Trivedi RH,Wilson M. Selecting intraocular lens power in children. https://www.aao.org/eyenet/article/selecting-intraocular-lens-power-in-
children. Accessed May 10, 2018.

• Emmetropia in early childhood
– Myopic shift
– Less anisometropia
• Hyperopia
– Mild to Moderate for ages 2-8 years
– Potential for amblyopia
– Less problems with myopic shift
MEWilson et al. Cataract Surgery in Children,Trends and Controversies.

§http://toomacophthalmic.co.nz/diagnostic-
equipment/ab-scan-ultrasounds/eyecubed-ab-
scan-ultrasound

§In adults, 1mm of error = 2.5D error
§In axial length </= 20mm = 3.75D error
§ Trivedi RH,Wilson M. Selecting intraocular lens power in children.
https://www.aao.org/eyenet/article/selecting-intraocular-lens-power-
in-children. Accessed May 10, 2018.

§ Capozzi P, et al. Corneal curvature and axial length values in
children with congenital infantile cataract in the first 42 months of
life. Investigative Ophthalmol Vis Sci 2008; 49: 11. 4774-4778.
§ Trivedi RH,Wilson M. Keratometry in Pediatric Eyes With Cataract.
Arch Ophthalmol. 2008;126(1):38-42.
doi:10.1001/archophthalmol.2007.22.
§ Gordon RA, Donzis PB. Refractive development of the human eye.
Arch Ophthalmol 1985;103:785-789

Date of download: 8/23/2015 The Association for Research in Vision and Ophthalmology Copyright © 2015. All rights reserved.
From: Capozzi P et al. Corneal Curvature and Axial LengthValues in Children with Congenital/Infantile Cataract in the First 42 Months of Life Invest. Ophthalmol.Vis.
Sci.. 2008;49(11):4774-4778. doi:10.1167/iovs.07-1564
Figure Legend:
Scatterplot of K m by AL for unilateral and randomly selected single eyes of patients with bilateral cataract.

§ Pupil
§ Cornea with reduced rigidity
§ Thin sclera with reduced rigidity
§ Anterior capsule elastic
§ No hard nucleus
§ Increased vitreous pressure

§ Newborn to first year of life miotic
§ Dilates poorly
§ Too much dilating drops in leaky blood
ocular barrier = corneal haze
§ Poorly developed dilator muscle
§ Superviscous and viscous cohesive
viscoelastic adjunct to mydriasis.

§ Corneal tunnel
§ Conjunctiva undisturbed
§ Near the limbus for maximum healing
§ Sutured with 10-0 synthetic absorbable
§ Scleral tunnel
§ 2-2.5mm from the limbus into clear cornea
§ Preferred for rigid IOL
§ Enlarged for IOL
§ Sutured with 9-0 synthetic absorbable
http://www.reviewofophthalmology.com/
http://www.feather.co.jp

§Do not self seal in children!
§ Children less than 11, not water tight
§ Especially if combined with anterior vitrectomy
§ Low corneoscleral rigidity
Basti S,Krishnamachary M,Gupta S.Results of sutureless wound construction in children undergoing cataract
extraction.J POS 1996;l33:52-54
http://www.eyeworld.org

§ Superior incision
§ Wound protected by upper lid and Bell’s
§ Deep set orbits and overhanging brows not factors
§ Flat nose bridge makes it easier
§ Temporal incision
§ More space (just like adults)
§ But easily traumatized in children
§ Patients with against the rule astigmatism ?
§ Achieve preoperative astigmatism in 1 month
regardless

§Pediatric Speculums!
§Very small field and
limited space

§Anterior chamber collapse
§ Create snug fit for instruments
§ Bimanual anterior chamber former and separate aspiration
if available
§ appropriate gauge MVR blade
§ High irrigation setting
MEWilson et al. Cataract Surgery in Children,Trends and Controversies.http://www.aapos.org/client_data/files/2012/479_wilsonhandout.pdf

§Highly elastic Anterior Capsule
§Staining the AC: ICG,Trypan Blue
§High viscosity of viscoelastic
§Flatten the anterior capsule
§Leading with a cystotome
§CCC: continuous circular
capsulorrhexis
http://i.ytimg.com

§ Nischal’s Push-pull technique
§ Vitrectorrhexis
§ Use of radiofrequency
§ Cut edge in very young children
remains smooth because of capsule
elasticity
§ In slightly older children, the
vitrector creates a slightly
scalloped edge
§ dissecting microscope and
scanning electron microscope have
shown that the scallops roll outward
to leave a smooth edge.
23, 2015.
http://www.medicalmedia.co.il

§ Venturi pump preferred over
peristaltic pump
§ Separate infusion port
§ Snug fit of instruments
§ MVRs
§ AC maintainer
§ No need for cystotome
§ Cut rate 150-300/min
§ Size smaller than optic
1. MEWilson et al. Cataract Surgery in Children,Trends and Controversies.http://www.aapos.org/client_data/files/2012/479_wilsonhandout.pdf Accessed August 23, 2015.
2. Mihir K, Florence M, Najeeha S, Shalaka P. LARV: Limbal approach retropseudophakic vitrectorrhexis and vitrectomy—an innovative technique for the management of
pediatric cataracts. J Clin Exp Ophthalmol 2011: 2: 8. https://www.omicsonline.org/innovative-technique-for-the-management-of-pediatric-cataract-2155-9570.1000180.pdf.
Accessed May 10, 2-18.
©APSantiago 2018 #pediatri ccataractsurgery June 5, 2018

§CCC (preferred > 4 years)
§ Heavier viscoelastics
§ Runaway rhexis common
§ Done well: most resistant to tear
§Vitrectorrhexis (< 4 years)
§ Easier to perform
§ Next best in terms of resistance
§ Runaway less common
§Radiofrequency (any age)
§ Similar to vitrectorrhexis in advantage MEWilson et al 2012

§Beer can
§ “tight”
§Blue dye makes the
capsule more brittle?
§ less equatorial tears?

§ Advantages
§ Overall reduction in operative time
§ Less irrigating solution used
§ Facilitation of lens removal
§ Vasavada AR,Trivedi RH,Apple DJ,et al.Randomized,clinical trial
of multiquadrant hydrodissection in pediatric cataract surgery.
AJO.2003;135:84-88
§ Disadvantages
§ Extension of tears if not CCC
§ PC rupture in posterior lenticonus and
posterior polar cataracts

HYDRODISSECTION ISSUES
§Anterior capsule tear
§(Cohesive) Viscoelastic escape
§Iris Prolapse
§Nucleus Prolapse in AC
§PC rupture: absolute contraindication
in suspected preexisting PC defect
https://i.ytimg.com/vi/ydp5d5tlF1M/maxresdefault.jpg

§ Forego!
§ Use only with successful CCC
§ Do multiquadrant
hydrodissection gently
§ Release of nucleus not
necessary
§ Risk of equatorial and
posterior capsule tears

§ Soft nucleus/cortex but gummy
§ Aspiration for most
§ Occasional bursts for ‘gummy” lens
material

§In the bag preferred
§Sulcus if and only if
difficulty encountered
with in-the-bag fixation

§Create a nick at the
posterior capsule
§Push vitreous with
heavy viscoelastic
§Complete the posterior
capsulorrhexis
§Respect the vitreous
https://www.healio.com

§Nick the posterior capsule with a needle cystotome
§Push vitreous with heavy viscoelastic
§Proceed with posterior circular capsulorrhexis or
vitrectorrhexis
§Leave vitreous intact
§May or may not aspirate viscoelastic

ALCON Acrysof
§ Proliferative
§ Progress more slowly
§ Less visually significant
§ 2nd surgery less likely
§ If Nd:YAG single sessions
PMMA
§ Fibrous
§ Progress faster
§ More visually significant
§ 2nd surgery likely
§ Reopacification = repeated Nd:YAG

§Victrector-rhexis
§Posterior CCC
§Size smaller than optic

§ Primary posterior capsulotomy & small
anterior vitrectomy
§ Reduce need for 2nd surgery
§ Visual axis clearer, longer
§ Nd:Yag difficult in pediatric age group
§ Disadvantages
§ Vitreous violated
§ More surgery, more inflammation
§ Does not guarantee prevention of reopacification
§ Risk of retinal detachment, cystoid macular edema
http://www.aapos.org/client_data/files/2012/479_wilsonhandout.pdf Accessed August 23,
2015.
Mousa HG. Slideshare.net

§ Anterior vitreous reticular response
with acrylic intraocular lens usually
not visually significant
§ Optic capture?
§ Anterior vitrectomy depending on
patient’s age
Mihir K, Florence M, Najeeha S, Shalaka P. LARV: Limbal approach
retropseudophakic vitrectorrhexis and vitrectomy—an innovative technique for the
management of pediatric cataracts. J Clin Exp Ophthalmol 2011: 2: 8.
https://www.omicsonline.org/innovative-technique-for-the-management-of-
pediatric-cataract-2155-9570.1000180.pdf.Accessed May 10, 2-18.

<5
••Primary posterior capsulotomy
••Vitrectomy
5-8
••Primary posterior capsulotomy
••With or without vitrectomy
>8
••Intact posterior capsule
23, 2015.

§Anterior Chamber
§Tilts the IOL
§Pars plana/plicata
§Preserves IOL position
§Pars plana varies
§Risk of dialysis and retinal detachment
Mihir K, Florence M, Najeeha S, Shalaka
P. LARV: Limbal approach
retropseudophakic vitrectorrhexis and
vitrectomy—an innovative technique for
the management of pediatric cataracts. J
Clin Exp Ophthalmol 2011: 2: 8.
https://www.omicsonline.org/innovative
-technique-for-the-management-of-
pediatric-cataract-2155-
9570.1000180.pdf.Accessed May 10, 2-
18.

PREMATURE INFANT VS ADULT GLOBE
From Isenberg SJ,The Eye in Infancy 1994

Age Nasal Temporal
< 6 mos 2.2 mm 2.5 mm
6-12 mos 2.7 3.0
1-2 yrs 3.0 3.1
2-6 yrs 3.2 3.8
• Temporal ciliary body longer than nasal
Aiello AL,TranVT,Rao NA, 1992

Pediatric Pars PlanaAge Nasal Temporal
< 6 mos 2.2 mm 2.5 mm
6-12 mos 2.7 3.0
1-2 yrs 3.0 3.1
2-6 yrs 3.2 3.8
Sclerotomy Site
Aiello AL,TranVT,Rao NA, 1992
Age Trivedi &
Wilson
< 1 yr </= 2mm
1-4 y 2.5
>4 y 3.0
2-6 yrs 3.2
Trivedi andWilson 2005, inWilson et
al Pediatric Cataract Surgery

•• Most
rapid
growth
26-35
wks
••1.87mm
••(0.9-
2.8mm)
40
wks
> 3 mm
62
wks
PPV safe only after
62 wks post conception?
Trivedi andWilson 2005, inWilson et al Pediatric Cataract Surgery

§ Logarithmic curve up to age 20 years
§ Axial length: 16.8 mm to 23.6 mm
§ K power: 51.2D to 43.5D
§ Aphakic child’s shift in refraction: 10D
§ Normal child’s shift in refraction: -0.9D
Bluestein EC,Wilson ME,Wang XH et al. Dimensions
of the Pediatric Crystalline Lens: Implications for
Intraocular Lenses in Children. JPOS 1996; 33(1): 18-
20. DOI: 10.3928/0191-3913-19960101-06

• Reopacification rate high
• Especially if unable to
treat anterior vitreous
face
• Cost
• Availability ofYAG laser
mounted on operative
microscope
• Need for general
anesthesia
Trivedi andWilson 2005, inWilson et al Pediatric Cataract Surgery
Photo fr. Wilson ME

§Synechial closure prevented
§Prevents glaucoma
§Incites more iritis
§Risk of bleeding
§May not be necessary if in-the-
bag IOL placement
https://www.willseye.org/sites/default/files/i
magecache/health-library-gallery-
full/laser_iridotomy.017.jpg

§Leave sutureless?
§Tissue glue?
§Vicryl 10-0 (8-0)
§Nylon 10-0
http://www.resuresealant.com/wp-
content/uploads/2013/10/resure_website_resure_page_ad_02.jpg
©APSantiago 2018
#pediatriccataractsurgery
June 5, 2018

Subconjunctival steroids:
§ Injection of 1.2 mg triamcinolone acetonide at the end
of congenital cataract surgery in children <2 years of
age did not significantly affect IOP or central corneal
thickness in the first year after surgery.
§ Ventura et al,Congenital cataract surgery with intracameral triamcinolone: pre-
and postoperative central corneal thickness and intraocular pressure. J AAPOS.
2012 Oct;16(5):441-4.doi: 10.1016/j.jaapos.2012.06.005
§ IATS protocol: subconjunctival dexamethasone
§ Pupillary membranes still developed
§ 2 of 15 (13%) eyes that did not receive subconjunctival
steroids
§ 16 of 99 (16%) of eyes that received subconjunctival steroids
(p=0.99).
§ Lambert SR, Buckley EG, Drews-Botsch C, et al.The infant aphakia treatment study: design and
clinical measures at enrollment.Arch Ophthalmol. 2010;128:21–27.

§ Incision corneal, near limbus
§ Anterior capsulotomy CCC or vitrectorrhexis
§ Lens removal no hydrodissection, no hydrodelineation
§ Posterior capsule
§ primary capsulotomy if no IOL
§ Preserve capsule if with IOL
§ Vitreous preserve whenever possible
Patient
Surgery
Visual
Rehab

§Iritis
§Endophthalmitis
§IOL decentration
§CME: less than adults
§Retinal Detachment
§Ocular Hypertension &
Glaucoma
Taylor & Hoyt’s Pediatric Ophthalmology 2005©APSantiago 2018 #pediatriccataractsurgery June 5, 2018

§ IATS protocol
§ administration of topical prednisolone acetate 1%
at least 4 times a day for at least 1 month.
§ most common dosage of topical corticosteroids
prescribed for both treatment groups was
prednisolone acetate 6 times a day for 4 weeks;
§ 54/57 (95%) of patients in the IOL group
§ 38/57 (67%) of patients in the contact lens group were
prescribed topical corticosteroids >4 times a day
during the early postoperative period.
§ difficult to ascertain whether administration
of topical corticosteroids on a more frequent
basis would have further reduced the
incidence of inflammatory postoperative
adverse events such as pupillary
membranes.
Lambert SR, Buckley EG, Drews-
Botsch C, et al.The infant aphakia
treatment study: design and clinical
measures at enrollment. Arch
Ophthalmol. 2010;128:21–27. [PMC
free article]

§Steroids: more frequent
§ prednisolone 1%
§ Loteprednol
§Antibiotic: Moxifloxacin or levofloxacin
§Cycloplegia:
§ Tropicamide 0.5%
§ Tropicamide-phenylephrine (Sanmyd-P)
§ Atropine 1%
§Watch out for steroid-induced elevation of IOP

§Preop: waiting for clearance and
schedule
§ dilation with phenylephrine if with
red reflex
§ Not cycloplegic agents
§ Patch better eye
§Resume amblyopia management
ASAP after surgery
§Early spectacle correction (1-2
weeks postop)

§If one eye done at a time,
patch both until surgery
done on both eyes
§Bilateral patch to prevent
amblyopia in the 2nd eye

§Bilateral cataracts do well
with aphakic correction
§When to give adds?

§Still the treatment
of choice among
conservatives?

§ Amblyopia Treatment
§ Frequent refraction checks
§ Giving adds
§ Iritis and Glaucoma
§ Retinal detachment
§ May need exam under anesthesia in ages 2-5 years or uncooperative child
§ Lifetime of commitment

1. Aiello AL,Tran VT, Rao NA. Postnatal development of the ciliary body and pars plana. A morphometric study in
childhood. Arch Ophthalmol 1992; 110: 802-805.
2. Andreo LK,Wilson ME, Saunders RA. Predictive value of regression and theoretical IOL formula in pediatric intraouclar lens
implantation. J Pediatr Ophthalmol Strabismus 1997; 34: 240-243..
3. Basti S, Krishnamachary M, Gupta S. Results of sutureless wound construction in children undergoing cataract extraction.
J POS 1996;l33:52-54 Jaf HBQ, Diseases of the crystalline lens.
https://www.slideshare.net/AbbasTelakoe/ophthalmologydiseases-of-the-lensdrbaxtyar. Accessed April 4, 2017
4. Birch EE, Plager D. The critical period for surgical treatment of dense congenital unilateral cataract. Invest
OphthalmolVis Sci. 1996 Jul;37(8):1532-8.
5. BuckleyEG .Hangingbyathread:thelong-term efficacy and safety of transcleral sutured IOL in children (an AOS thesis).
Trans AOS. 2007;105:294-311
6. Butler PA. Reversible Cataracts in Diabetes Mellitus.J Am Optom Assoc. 1994 Aug;65(8):559-63.
7. Donahue S,Arnold RW, Ruben JB,AAPOSVision Screening Committee. Preschool vision screening: what should we be
detecting and how should we report it? Uniform guidelines for reporting results of preschool vision screening
studies. J AAPOS.2003 Oct;7(5):314-6. PMID: 14566312 DOI: 10.1016/S1091853103001824
8. Faramarzi A, Javadi MA. Comparison of 2 techniques of intraocular lens implantation in pediatric cataract surgery. J
Cataract Refract Surg. 2009;35:1040-5.WilsonMEJr,EnglertJA,GreenwaldMJ.In-the-bagsec- ondary intraocular lens
implantation in children. J AAPOS. 1999;3:350-5

9. Infant aphakia treatment study group. A Randomized Clinical Trial Comparing Contact Lens to Intraocular Lens Correction of Monocular
Aphakia During Infancy: Grating Acuity and Adverse Events at Age 1Year.Arch Ophthalmol.2010 Jul; 128(7): 810–818.
doi: 10.1001/archophthalmol.2010.101
10. Infant aphakia treatment study group.A Randomized Clinical Trial Comparing Contact Lens to Intraocular Lens Correction of Monocular
Aphakia during Infancy: HOTV Optotype Acuity at Age 4.5Years and Clinical Findings at Age 5 years. JAMA Ophthalmol.2014 Jun; 132(6):
676–682. doi: 10.1001/jamaophthalmol.2014.531
11. Jaf HBQ, Diseases of the crystalline lens. https://www.slideshare.net/AbbasTelakoe/ophthalmologydiseases-of-the-lensdrbaxtyar.
Accessed April 4, 2017
12. JinYY et al.Reversible Cataract as the Presenting Sign of Diabetes Mellitus: Report of Two Cases and Literature Review.Iran J Pediatr.2012
Mar; 22(1): 125–128.
13. Lambert SR, Buckley EG, Drews-Botsch C, et al.The infant aphakia treatment study: design and clinical measures at
enrollment. Arch Ophthalmol. 2010;128:21–27. [PMC free article]
14. Lambert SR,Plager DA, Buckley EG, et al.The Infant Aphakia Treatment Study: Further on intra- and postoperative complications in the intraocular lens
group. Journal of AAPOS : the official publication of the American Association for Pediatric Ophthalmology and Strabismus / American Association for
Pediatric Ophthalmology and Strabismus. 2015;19(2):101-103. doi:10.1016/j.jaapos.2015.01.012.
15. Moore DB, Zion IB, Neely et al. Accuracy of biometry in pediatric cataract extraction with primary intraocular lens implantation. J Cat
Refract Surg 2008; 34 (11): 1940-1947.
16. NeelyDE, PlagerDA, BorgerSM, GolubRL. Accuracy of intraocular lens calculations in infants and children undergoing cataract surgery. J
AAPOS. 2005;9(2)160–165.

17. Trindande R. Transient cataracts and hypermetropization in diabetes mellitus: case report.Arq.Bras.Oftalmol.vol.70 no.6 São
Paulo Nov./Dec.2007.http://dx.doi.org/10.1590/S0004-27492007000600030 version=h
18. Trivedi RH,Wilson M. Selecting intraocular lens power in children. https://www.aao.org/eyenet/article/selecting-intraocular-
lens-power-in-children. Accessed May 10, 2018.
19. TrivediRH,WilsonME,FaccianiJ.Secondaryintraocular lens implantation for pediatric aphakia. J AAPOS 2005;9:346-52
20. Wilson ME et al. Cataract Surgery in Children,Trends and Controversies.
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Wilkins, 2005.
21. WilsonME, HafezGA,TrivediRH. Secondary in-the-bag IOL implantation in children who have been aphakic since early infancy. J
AAPOS 2011;15:162-6
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2013;156(6):1252–1260.e2.
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2003;135:84-88

One hundred years from now,
It doesn’t matter what kind of house I lived in,
How much money I had,
What positions I held,
Or what my clothes were like.
But the world may be a little better,
Because I was important in the life of a child.
-Anonymous

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