This article is more than 5 years old. Information may no longer be current.
Early surgery leads to higher rates of glaucoma in certain children
Click Here to Manage Email Alerts
Cataract surgery in infants is associated with a high risk of secondary glaucoma, especially in eyes with associated microphthalmia, microcornea or persistent fetal vasculature, according to a study.
At the Moorfields Eye Hospital, London, the surgical notes and digital records of children who underwent cataract surgery between 1995 and 2016 were analyzed with the aim of assessing visual outcomes, the risk of glaucoma and, secondarily, the presence of strabismus or nystagmus, as well as the number of secondary interventions. Two subsets of children were included, the first with isolated cataract and the second with concomitant microphthalmia, microcornea or persistent fetal vasculature (MMP). Further subgroup analysis was done according to age at time of surgery, with an early intervention group including infants aged 48 days or younger and a late intervention group of those older than 48 days. A total of 111 children eligible for the study were selected, 86 with isolated cataract and 25 with cataract associated with MMP.
Early intervention did not result in better visual outcomes in either of the subgroups. In children with bilateral cataract associated with MMP, the proportion of eyes with final BCVA worse than 0.3 logMAR was similar regardless of age at surgery. In the isolated cataract group, more children with bilateral cataract had BCVA worse than 0.3 logMAR after early intervention (56%) than after later intervention (33%).
Glaucoma occurred frequently in eyes with associated MMP (28%) and significantly more often after early (75%) than after late (6%) intervention (P = .001). In the group with isolated cataract, 15% of eyes developed glaucoma, with again a higher prevalence (42%) after early than late intervention (11%). Strabismus or nystagmus were present in a very high percentage of children in both groups and, similarly, the rate of posterior capsule opacification was high.
“Our main findings were the high risk of glaucoma in infants with cataract associated with MMP undergoing lensectomy before the age of 48 days and the absence of better visual outcomes with early surgery,” the authors wrote. “Our finding that 75% of children in the early intervention group were diagnosed as having glaucoma clearly militates against early surgery in children with cataract associated with MMP.”
The lower prevalence of glaucoma and comparable visual outcomes make later surgery a better option, according to the authors. – by Michela Cimberle
Disclosure: The authors report no relevant financial disclosures.
Perspective
Back to Top
M. Edward Wilson, MD
In this series, very early surgery (before 6 weeks of age) on microphthalmic eyes with congenital cataract was associated with a high risk of glaucoma, while slightly later surgery seemed to reduce the risk without lowering the visual prognosis.
Current best practices are to avoid congenital cataract surgery in the first 30 days of life but to operate dense, visually significant unilateral cataracts by the end of the sixth week and bilateral cataracts by the end of the eighth week. This study may convince surgeons to delay surgery a few weeks to reduce the risk of glaucoma but not so long that visual prognosis worsens. We already delay until after 30 days. In these very small and immature eyes with persistent fetal vasculature, 2 or 3 additional weeks of delay may be seen as beneficial by some surgeons. We all recognize that microcornea and persistent fetal vasculature are markers for an immaturely developed trabecular meshwork, predisposing these eyes to what had been called “aphakia glaucoma” but is now referred to as “glaucoma after cataract surgery.”
In this study, the number of at-risk microphthalmic eyes was small. We need further studies to continue exploring the optimal timing of surgery for these complex and incompletely developed eyes. The goal is to minimize amblyopia while also minimizing the risk of glaucoma.
Click Here to Manage Email Alerts