July 01, 2001
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Capsular bag fixation preferred for IOL in pediatric traumatic cataracts

Lower incidence of uveitis and no cases of pupillary capture found with capsular bag fixation as opposed to ciliary sulcus fixation.

CHARLESTON, S.C. — Although visual results are comparable for either capsular bag or ciliary sulcus fixation of the posterior chamber IOL in children with traumatic cataracts, capsular bag fixation is associated with fewer postoperative complications, including fibrinous anterior uveitis and pupillary capture.

“Whenever possible, the surgeon should always attempt the implantation of an IOL within the capsular bag,” said Suresh K. Pandey, MD, a postdoctoral fellow at the Center for Research on Ocular Therapeutics and Biodevices, Storm Eye Institute.

Dr. Pandey was lead author of a study that evaluated 20 children (20 eyes) with traumatic cataracts that underwent extracapsular cataract extraction and posterior chamber IOL implantation. Capsular bag fixation was randomly performed in 10 children (10 eyes) and ciliary sulcus fixation in the other 10 children. All surgery was performed by the same surgeon (Jagat Ram, MD, of India).

Co-authors of the study were Dr. Ram, Liliana Werner, MD, PhD, and David J. Apple, MD.

Two-year follow-up

The study, which involved children 4 to 12 years old, had a mean follow-up of 24.6 months. The incidence of moderate-to-severe fibrinous anterior uveitis was 20% in patients with capsular bag fixation, compared to 70% with ciliary sulcus fixation.

“This is a significant difference,” Dr. Pandey said. Fortunately, treatment is often effective using topical steroids. “Children with severe uveitis, though, can also be placed on systemic steroids,” he said.

There was no incidence of pupillary capture of the IOL optic in the capsular bag group as opposed to 40% of eyes with pupillary capture in the ciliary sulcus group.

“Increased uveal contact of the IOL in the sulcus-fixated group leads to low-grade uveitis and predisposes to synechia formation between the lens optic and iris, causing pupillary capture. Pupillary capture can occur, despite angulated (10°) haptics,” he said. Successful treatment consists of dissecting the synechia and then repositioning the lens.

Posterior capsule opacification (PCO) was also less in the capsular bag group: 50% versus 70%.

“Although this difference was not statistically insignificant, PCO can lead to a decrease in visual acuity, so this is a concern,” he said. Dr. Pandey noted that in children undergoing cataract surgery and lens implantation, the rate of PCO is nearly 100% at 2 years. A Nd:YAG laser posterior capsulotomy was performed for management of PCO in all affected eyes.

VA results

Preoperative visual acuity ranged from 20/400 to hand movements in the capsular bag group and from 20/200 to hand movements in the ciliary sulcus group. The capsular bag group achieved best corrected visual acuity (BCVA) of 20/40 or better in nine eyes and 20/60 in one eye. This less successful eye was due to the development of amblyopia. BCVA was similar in the ciliary sulcus group, with eight eyes achieving 20/40 or better and the remaining two eyes 20/60 (corneal scar) and 20/80 (commotio retinae).

Since publication of the study in the Journal of Cataract and Refractive Surgery in 1999, Dr. Pandey continues to observe the same results overall.

“The two surgical techniques are also performed in about the same way,” he said. However, capsular bag fixation is slightly more difficult to execute.

“But with the increased use of capsulorrhexis that ensures secure and permanent fixation of both haptics of IOLs in the capsular bag, this is becoming easier. Experience is required to properly position both haptics into the capsular bag.”

Dr. Pandey said it is more important to position both haptics of the IOL in the ciliary sulcus; otherwise, “problems such as decentration or tilting can arise if you place one haptic in the capsular bag and the other haptic in the sulcus.” Tears in the anterior or posterior capsule during the surgical procedure prevent consistent placement of the IOL haptics in the capsular bag.

Ciliary sulcus fixation is recommended when there is no posterior capsular support. There have also been a few reports using anterior chamber IOLs and scleral-sutured IOLs in children.

“However, these two techniques are usually not recommended in children because of associated complications and uncertain long-term outcome,” Dr. Pandey said.

“The capsular bag is considered the best site for IOL implantation because it sequesters the IOL from uveal structures and reduces the chances of IOL decentration,” he said.


Slit lamp photograph of the anterior segment of a 6-year-old male child showing traumatic cataract after firecracker injury (blunt trauma). Note the formation of a posterior synechia at the 2:30 o’clock position. The visual acuity on presentation was 2/60.


The same eye 4 weeks postoperatively, showing the clear visual axis after phacoemulsification and capsular bag fixation of a posterior chamber IOL.


Slit lamp photograph of the anterior segment of a 7-year-old female after the repair of bow and arrow (penetrating) injury. Note the formation of a traumatic cataract associated with an irregular pupil. The implantation of a posterior chamber IOL was performed 6 weeks after the repair of the corneal laceration.


Slit lamp photograph of the anterior segment of a 7-year-old male child 10 weeks following the sulcus fixation of a posterior chamber IOL. Notice exudative membrane formation in the pupillary region following the severe fibrinous anterior uveitis.


Slit lamp photograph of the anterior segment of a 12-year-old female child 13 months after ciliary sulcus fixation of a posterior chamber IOL. Note the marked pupillary capture of the IOL optic, extending from 12 o’clock to 5 o’clock associated with pupillo-capsular synechia and marked posterior capsule opacification. BCVA was 20/80 in this eye due to PCO. It required Nd:YAG laser posterior capsulotomy.


Slit lamp photograph of the anterior segment of a 7-year-old male child 18 months following capsular bag fixation of a posterior chamber IOL. This patient required Nd:YAG laser posterior capsulotomy for PCO. There was also an opacification of the anterior capsule including the capsulorrhexis margin.


Slit lamp photograph of a 7-year-old female child 13 months after ciliary sulcus fixation of a posterior chamber IOL. The visual axis is clear following the Nd:YAG laser posterior capsulotomy for PCO.


A 4-year-old male child presented with history of injury to the left eye from a firecracker. Note the white reflex in the pupillary region associated with convergent strabismus signifying the development of traumatic cataract as well as amblyopia. Even if the surgery is successful, such eyes are often functionally doomed because of amblyopia.

For Your Information:
  • Suresh K. Pandey, MD, can be reached at the Storm Eye Institute, 167 Ashley Ave., PO Box 250676, Charleston, SC 29425; (843) 792-0777; fax: (843) 792-7920; e-mail: pandeys@musc.edu.
Reference:
  • Pandey SK, Ram J, et al. Visual results and postoperative complications of capsular bag and ciliary sulcus fixation of posterior chamber intraocular lenses in children with traumatic cataracts. J Cataract Refract Surg. 1999;25:1576-1584.