Evaluations continue in many areas of pediatric cataract surgery

Issue: April 10, 2011

ByRichard L. Lindstrom, MD

Richard L. Lindstrom

The ideal approach for the management of pediatric cataract is still under evaluation.

In the 1980s, my pediatric ophthalmologist partners at the University of Minnesota never implanted an IOL in patients younger than 3 years. In bilateral or unilateral visually significant cataracts, a lensectomy, including removal of the posterior capsule and anterior vitreous with a vitrector, was performed, in some cases with an incision through the pars plana. Surgery was usually performed at 2 to 3 months of age, and in some cases, a single anesthetic was used for the exam under anesthesia and removal of both cataracts to reduce the risk of multiple general anesthetics. This was my first introduction to bilateral sequential same-day cataract surgery, and the risk-benefit ratio seemed quite favorable to me.

I continue to do both eyes in uncooperative patients who require general anesthesia at all ages, as the results have been excellent. There are surgeons who advocate this approach in all patients, but for me, the requirement of a general anesthetic is the trigger to consider bilateral sequential same-day surgery.

In those early years, bilateral cataract patients were managed quite well with aphakic spectacles or contact lenses. Unilateral cases required contact lens wear and more aggressive amblyopia therapy, and these were the toughest cases. Once patients with unilateral cataracts reached age 2 to 3 years and refractions seemed stable, many were referred to me for a secondary IOL implant. I placed sulcus-fixated PMMA IOLs in many patients, and the outcomes were excellent. I still see some of these patients in their late 20s and early 30s, and while not all have 20/20 vision, many are 20/40 with straight eyes. The IOLs have been well-tolerated. Some of the patients with bilateral cataracts did well with glasses or contact lenses for more than a decade and underwent secondary implantation in their teens or later. These patients have done even better, and again, secondary lens implantation was fairly straightforward.

The young eye has a lower scleral rigidity, but with modern viscoelastics and foldable acrylic IOLs, this does not present much of a problem. I have not done scleral-fixated IOLs for young adults, and I am not confident any suture will last for 80 years or more, having seen many fail in my own practice after 10 to 15 years. Fortunately, most of these young patients have good capsular support remaining, and posterior optic capture in those who underwent posterior capsulectomy and anterior vitrectomy works extremely well.

A stronger topical steroid such as difluprednate and a topical NSAID for both the primary cataract surgery and secondary lens implant when indicated, used for a longer period of time, make sense, as the inflammatory response is greater. Having seen such good long-term results with this approach, I believe it remains the best choice for those who are not participating in clinical trials evaluating IOLs in patients in the first few months of life. IOLs in these very young patients are associated with more inflammation, synechiae, and membranes posterior and, in some cases, anterior to the IOL. Most of the time, these membranes are not manageable with a simple YAG laser procedure and require another general anesthetic. I will be surprised if the clinical trials confirm a major advantage for lens implantation in the first months of life.

In regard to IOL selection, a monofocal IOL, today aspheric, remains the standard. A multifocal IOL can work in the young adult with a monocular traumatic cataract, but there are issues that, for me, argue against it in very young children. We are learning that any residual refractive error, especially any astigmatism, degrades significantly the optical performance of a multifocal IOL. In the adult patients, enhancements with LASIK or PRK can generate outcomes with less than 0.5 D of defocus and astigmatism, but applying laser corneal refractive surgery to patients younger than 5 years is, to me, in itself an investigational procedure. Again, well-controlled clinical trials of multifocal IOLs as primary implants in the first few years of life are reasonable, but for most children, an aspheric monofocal IOL seems appropriate.

In the larger metropolitan areas, the majority of pediatric cataracts are managed by the pediatric ophthalmologist, but in some rural areas in the U.S., and certainly many parts of the world, patients just cannot or will not access a pediatric ophthalmologist. In these cases, removal of the cataract alone combined with posterior capsulectomy and anterior vitrectomy with secondary lens implantation once the eye matures and the refractive error stabilizes remains a strategy that is within the surgical skill set of the well-trained anterior segment or, for that matter, posterior segment surgeon. Of course, postoperative management, including aggressive amblyopia therapy, remains critical for a good outcome. As always, the challenge of making an early diagnosis with timely referral from the infant’s primary care physician remains a key challenge. Vigilant evaluation of all newborns for an asymmetric red reflex or evidence of strabismus remains an elusive global goal, but one well worth supporting.