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Dilated pupil makes capsule defects easier to detect in congenital cataract

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PARIS — Dilating the pupil allows surgeons to recognize diagnostic signs of posterior capsule defects in mature white congenital cataracts, according to an Indian surgeon speaking here.

The rare condition is typically hidden when a totally white cataract is observed through an undilated pupil, said Abhay Vasavada, MD, here at the European Society of Cataract and Refractive Surgeons meeting.

The diagnostic signs of pre-existing posterior capsule defects (PPCD) include demarcated, thickened margins on the posterior capsule, white dots on the posterior capsule and in the anterior vitreous, and a “fishtail sign,” he said.

“The fishtail sign on the anterior vitreous — it’s chalky white spots in a cluster or rough circle at the level of the posterior capsule,” he said.

Surgical strategy in cases with PPCD should include adhering to the principles of the closed chamber technique, he said, which means “no hydrodissection, performing bimanual irrigation and aspiration, and using a two-port anterior vitrectomy,” Dr. Vasavada said. He said he prefers Alcon’s AcrySof three-piece IOL for these patients.

Dr. Vasavada analyzed 400 consecutive eyes and found that 27 had PPCD, a 6.75% incident rate. Of the 27 eyes, 24 were implanted with the AcrySof, and 20 of those were in-the-bag implantations. IOL centration was achieved in 24 eyes (88%), he said.

The real genesis of pediatric cataract may be rapidly progressive posterior lenticonus, Dr. Vasavada suggested. “Evaluate the fellow eye for posterior lenticonus. Look for the oil sign,” he said.

During a question-and-answer period, members of the pediatric cataract surgery panel noted that the rate of PPCD is lower in Europe than in India. Dr. Vasavada said he believes ophthalmologists in Europe tend to see pediatric patients at an earlier age than those in India, which could explain the difference in incidence.

“We see patients around 1 year plus,” he said. “Early detection is the key and could explain why the rates are lower in Europe.”