Publication Exclusive: Updates on surgical techniques for pediatric cataract surgery

Globally, congenital cataracts account for 5% to 20% of blindness in children, and these numbers differ in various countries. In the U.S., the prevalence of visually significant infantile cataract was estimated to be three or four per 10,000 live births. Congenital cataracts may involve one or both eyes and can span a wide spectrum of lens opacities, from a visually insignificant, small, focal opacity not involving the visual axis to total lens opacification. Hence, treatment strategies will vary depending on the type of lens opacity. The overall focus is to clear the visual axis in a timely fashion to prevent potential lifelong amblyopia.

Extent and location of the congenital cataract, combined with presenting age, are important factors that determine whether or not surgical intervention is indicated. If surgery can safely be delayed until eye growth stabilization has been attained and IOL implantation is appropriate, temporary nonsurgical avenues may be pursued, including pupillary dilation with tropicamide or phenylephrine; also, avoiding amblyogenic atropine may be appropriate. In selected cases, part-time occlusion may be required to prevent amblyopia. When surgical intervention is necessary, the type of procedure would be influenced by presenting age, and the surgeon should be familiar with the various complexities in the overall management of pediatric cataracts. A pediatric ophthalmologist should be an integral part of the overall team approach, along with family support, for an optimal outcome.

In this column, Drs. Vasavada, Shah and Vasavada provide a comprehensive view and a practical surgical approach in the management of pediatric cataracts.

Thomas “TJ” John, MD, OSN Surgical Maneuvers Column

Pediatric cataract surgery is a complex issue best left to surgeons who are familiar with its long-term complications and lengthy follow-up. Cataract surgery in children is the first steppingstone in the long road to visual rehabilitation. Treatment is often tedious and difficult, requiring a dedicated team effort with the most important members of the team being the parents. Maintaining a clear visual axis while correcting the eye for a changing residual refractive error requires careful observation, sound judgment and diligent follow-up.

Surgical technique

Pediatric cataract needs a special surgical strategy because these eyes have greater elasticity of the capsule, lower scleral rigidity, higher incidence of inflammation and posterior capsule opacification, a thick vitreous gel and a small, growing eye. The surgeon should strictly adhere to the principles of the closed chamber technique, such as valvular incision, injection of ophthalmic viscosurgical devices before removing any instrument from the eye, and bimanual irrigation and aspiration.

Anterior capsule management

The anterior capsule in children is very elastic, and therefore it may be difficult to perform a controlled manual continuous curvilinear capsulorrhexis (CCC). However, a manual CCC is the gold standard in terms of maintaining the integrity of the capsular edge. The shape, size and edge integrity of the anterior capsulotomy are important for long-term centration of the IOL. Capsulorrhexis is usually performed with microrhexis forceps (Figure 1). Alternative techniques to manual CCC include vitrectorhexis, radiofrequency diathermy with a Fugo plasma blade, the two-incision push-pull technique and the four-incision technique.

Click here to read the full publication exclusive, Surgical Maneuvers, published in Ocular Surgery News U.S. Edition, September 25, 2015.