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Considering the high risk of secondary glaucoma after pediatric cataract surgery, do you adopt surgical or medical preventive measures?
Many options possible
 Laurence Lesueur |
Ocular hypertension is a common complication after pediatric cataract surgery, occurring in approximately 5% of cases. Effective management of this complication depends on the understanding of its nature and causes.
First of all, it is important to realize that there are different forms of hypertension, just as there are different types of cataracts: from those associated to a pathologically abnormal development of the anterior segment, such as Peter’s anomaly or Axenfeld-Rieger syndrome, to those of infectious and inflammatory origin, caused by toxoplasmosis, cytomegalovirus or rubeola; from those originating from developmental anomalies, such as persistent hyperplastic primary vitreous or ectopia lentis, to those of idiopathic or familial origin.
The risk of hypertension is higher in cases of anterior segment anomalies and inflammation.
As far as intraocular implants are concerned, several studies have demonstrated that hypertension is not more common in IOL-implanted eyes than in aphakic eyes.
How do we prevent this complication? First of all, by close monitoring of IOP with repeated measurements and prophylactic administration of topical hypotensive medications.
Another way is by routinely performing peripheral iridectomy at the time of lens removal, with or without IOL implantation and anterior vitrectomy.
Finally, pressure-lowering procedures may be associated, such as 360° iridectomy, trabeculectomy or nonpenetrating deep sclerectomy.
Currently, there are no rules, but case-to-case decisions based on surgeons’ preferences. Long-term studies will hopefully provide us with information on the incidence and best management of hypertension after pediatric cataract surgery.
Laurence Lesueur, MD, is an ophthalmologist at Centre d’Ophtalmologie Jeanne d’Arc, Toulouse, France. Disclosure: Dr. Lesueur has no relevant financial disclosures.
One option effectively reduces risk
 Marie-José Tassignon |
While cataract surgery reduces IOP in adult eyes, it is known from the literature that secondary glaucoma is more frequent in infants and children after cataract surgery. A mean reduction of 4 mm Hg is to be expected in adults, but the same reduction is not observed in children or infants.
Surgical management of cataract in children is different from the techniques used in adult eyes. Surgeons often perform a primary posterior capsulorrhexis in combination with anterior vitrectomy. My surgical approach is different. I perform an anterior and posterior capsulorrhexis of equal sizes and implant an IOL that captures the remaining peripheral part of the capsule into the lens groove surrounding the optical part of the lens. This technique is named bag-in-the-lens and presents the major advantage of not needing a standard anterior vitrectomy. I am confident that this approach induces less secondary glaucoma.
However, one has to be cautious concerning postoperative pressure rise in infants and children because their cataract may be combined with developmental anomalies of the trabecular meshwork, leading to glaucoma anyway. My experience with the bag-in-the-lens in infants and children is currently of about 100 eyes. We observed postoperative pressure rise occasionally, but not in many cases. Anterior vitrectomy, when using bag-in-the-lens technique in pediatric cataract, is no longer necessary, and based on my experience, I strongly advise not to perform this maneuver.
Marie-José Tassignon, MD, PhD, is professor and head of ophthalmology, University Hospital, Antwerp, Belgium. Disclosure: Dr. Tassignon has an intellectual property licensed to Morcher for the bag-in-the-lens technology.