Primary posterior capsulotomy urged for pediatric cataracts at ages 1 to 6

Retrospective chart review finds high PCO rate in this age group. Capsule can be preserved in older children.

ByBob Kronemyer

CHICAGO — Age appears to be the only risk factor that significantly influences the rate of posterior capsule opacification (PCO) formation, according to a retrospective chart review of 63 children (67 eyes) who underwent IOL surgery without a primary posterior capsulotomy and anterior vitrectomy.

“Therefore, we recommend that children ages 1 to 6 have a primary posterior capsulotomy, while for ages 6 to 13, the posterior capsule be maintained and opened later if indicated,” said Allison A. Jensen, MD, a chief resident in ophthalmology at Northwestern University here in Chicago.

Discussing the chart review, Dr. Jensen noted that management of the posterior capsule is one of the most challenging aspects of pediatric cataract surgery with IOLs.

“Traditionally, the practice at Children’s Memorial Hospital in Chicago has been to keep the posterior capsule intact,” she said.

The chart review excluded any patient who had a primary posterior capsulotomy, any unintended posterior capsule rent or any child over 13 years old. This left 30 eyes for analysis. “We looked for specific factors that may influence PCO, including postoperative fibrin clots in the anterior chamber, residual cortex left at the time of surgery, IOL placement (whether it was in the bag or in the sulcus) the type of cataract, the history (trauma that caused the cataract) and age,” Dr. Jensen said.

PCO rates

---Allison A. Jensen, MD

Criterion for PCO, and hence the need for a laser capsulotomy, was an inability to perform adequate retinoscopy. There was a 40% (12 of 30) incidence of significant PCO. The mean follow-up was 22 months in patients with PCO and 24 months in patients without PCO.

Children who were 1 to 6 years old had a PCO rate that was statistically higher than for those 6 to 13 (P=.03). Specifically, 64% (9 of 14) of children 1 to 6 had PCO, compared with only 19% (3 of 16) of children 6 to 13.

Repeated intervention was performed on 25% (3 out of 12) of the PCO patients.

“Although these cases did not deviate surgically from the others reviewed, one case involved a 6-year-old child with a traumatic cataract requiring a secondary membranectomy vitrectomy 13 months after the primary capsulotomy,” Dr. Jensen said. The second patient was a 4-year-old child with a congenital cataract requiring a secondary capsulotomy 7 months after the primary capsulotomy, and the third was a child, age 7, with a congenital cataract requiring a secondary membranectomy and vitrectomy 1 month after the primary capsulotomy.

Increased complication rate

Commenting on the chart review study, John D. Baker, MD, commended the authors on their solid work. However, he voiced concern over the recommendation that children under the age of 6 have a primary posterior capsulotomy. “There is an increase in the complication rate, both in pediatric and adult patients, when the posterior capsule — either primarily, purposely or inadvertently — is disrupted during cataract surgery,” he said. “Is this recommendation appropriate or are there other considerations?”

Dr. Baker believes that it is important to prepare young children for the laser delivery system. Performing a slit lamp examination at every possible visit “will train the child that this is not something to be afraid of.” In fact, by the time a YAG capsulotomy is needed, “it may become a type of laser computer game,” he said. In many instances, “this allows us the luxury of leaving an intact posterior capsule at the time of surgery, and having a better feel that the IOL is nicely in place at the end of the surgery.”

Still, there is a downside of a YAG capsulotomy in general, especially in this younger population. “The opening is often small,” Dr. Baker said. “Sometimes it is difficult to retinoscope through. In these younger patients, proper refractive correction is certainly a critical element of amblyopia therapy.”

Second procedure

If the capsule has to be opened primarily, “one might consider leaving it intact, optimally placing the IOL in the bag, and then almost planning for a second procedure if there are problems,” Dr. Baker said. For example, a vitreoretinal surgeon might perform a posterior segment procedure through the pars plana or pars plicata. “This will leave a good opening, provide good retinoscopy and perhaps an easier amblyogenic situation to treat,” he said. New acrylic lenses also may offer a smaller incidence of capsular opacification.

Another question Dr. Baker raised is if the complication rate is lower with a planned YAG opening of the posterior capsule. “By performing the procedure in the early postop period — as soon as any opacification is seen — you avoid the need for a large amount of YAG energy,” Dr. Baker said. “This would allow the IOL to be inserted comfortably in the bag with the intact capsule.” Such a strategy may result in a reduced incidence of problems associated with primarily opening the capsule.

Finally, “in trying to ferret out the value of the authors’ recommendation, it might be interesting to know what the incidence of secondary problems were in those patients that had their posterior capsules opened primarily, either as planned or inadvertent events,” Dr. Baker said.

For Your Information:

Allison A. Jensen, MD, can be reached at 2300 Children’s Plaza, Box 70, Chicago, IL 60614 U.S.A.; +(1) 773-880-4346; fax: +(1) 312- 503-8152; e-mail: aajeye@aol.com. Dr. Jensen has no direct financial interest in any of the products mentioned in this article, nor is she a paid consultant for any companies mentioned.

John D. Baker, MD, can be reached at 2355 Monroe, Dearborn, MI 48124 U.S.A.; +(1) 313-561-1777; fax: +(1) 313-561-8044; e-mail: jbaker4051@aol.com. Dr. Baker has no direct financial interest in any of the products mentioned in this article, nor is he a paid consultant for any companies mentioned.