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Child’s age dictates approach to treating cataracts
Variables include unilateral vs. bilateral approach, technique, timing, suture and IOL implantation.
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Welcome to another edition of CEDARS/ASPENS Debates. CEDARS/ASPENS is a joint society of cornea, cataract and refractive surgery specialists, here to discuss some of the latest hot topics in ophthalmology.
Managing the pediatric cataract and rehabilitating vision is always a challenge. These patients are at high risk for amblyopia, and the surgery itself is quite different from adult cataract surgery.
This month, Ehsan Sadri, MD, FACS, and Marjan Farid, MD, discuss their approaches to pediatric cataract surgery. We hope you enjoy the discussion.
Kenneth A. Beckman, MD, FACS
OSN CEDARS/ASPENS Debates Editor
Initial refraction crucial to establish residual target
Whether cataracts in children are congenital, unilateral or bilateral, early detection and treatment are important to reduce the distortion that can lead to amblyopia. The first thing to do is the systemic and metabolic workup to rule out diabetes and trauma.
The next priority is to get the best possible cycloplegic refraction. Targets for residual refraction depend on age. If the patient is 6 months old or younger, we aim for a residual refraction of 6 D to 10 D of hyperopia. If they are 6 to 12 months old, it is 4 D to 6 D; if they are between 1 and 3 years old, it is 4 D; if they are 3 to 4 years old, it is 3 D; and if they are 4 to 6 years old, it is 2 D. Beyond 8 years old, it is 1 D or 0. In theory, the patient’s eye is growing, and they will be myopic later on, and you need to account for that.
The timing of the surgery is also important. The literature indicates a critical period of visual development that extends to 9 years old.
Next I consider whether the cataract is unilateral or bilateral. If it is bilateral, we remove it as early as 2 months of age for best corrected visual acuity, and the literature supports this. If it is unilateral, the surgery could be done as young as 6 weeks of age. The surgeon needs to discuss the pros and cons of cataract surgery with the family and obtain informed consent, as the FDA does not approve implantation of IOLs in children.
The operation is straightforward, with general anesthesia.
For young children, we do a primary posterior capsulotomy with an absorbable 10-0 suture because Nd:YAG is difficult in small children. We comanage postoperatively with our pediatric specialist, and the follow-ups, with cycloplegic refraction using homatropine, occur at 1 day, 1 week, 1 month, 3 months and 6 months, depending on the patient. You want to be sure the refractive correction is good and that amblyopia was avoided. Spectacles can be used in young patients or contact lenses in those near adolescence.
Lastly, manage visual axis, opacification, glaucoma, inflammatory complications or myopic shifts in the postoperative period.
- For more information:
- Ehsan Sadri, MD, FACS, can be reached at Atlantis Eye Care, 361 Hospital Road, Suite 425, Newport Beach, CA 92663; email: esadrii@gmail.com.
Disclosure: Sadri reports he consults for a number of IOL manufacturers, including Johnson & Johnson Vision, Bausch + Lomb and Alcon.
Pediatric capsule, cornea behave differently from adult
The four primary considerations for pediatric cataract surgery are capsulorrhexis formation, posterior capsulotomy/anterior vitrectomy, wound closure and IOL implantation.
Regarding capsulorrhexis, the pediatric capsule behaves very differently from an adult capsule; it is thicker and more elastic. The maneuver in a child is more of a shearing vs. a tearing of the rhexis. I recommend starting with a smaller capsulotomy because it tends to enlarge naturally due to the elasticity. The use of Trypan blue will make the anterior capsule more brittle and easier to tear.
Posterior capsulotomy/anterior vitrectomy depends on the age of the patient. If the patient is 3 or 4 years old, cooperative and can sit for an Nd:YAG, there is no need to do a posterior capsular opening primarily during the surgery. If the patient is younger or an infant, and you will not be able to laser the capsule in clinic at a later time, you must do a primary posterior capsulotomy, which may include an anterior vitrectomy as well. You can either break through the posterior capsule with an anterior vitrector or you can do a primary posterior capsulorrhexis, but the key is to keep the posterior capsule opening small in order to place the IOL into the capsular bag vs. the sulcus.
A suture is usually required in pediatric corneas because they do not seal as well as an adult cornea. To avoid the need to remove it at the slit lamp, one option is a dissolvable 10-0 Vicryl suture. Another option for a toddler, because they tend to rub their eyes and are more difficult to control, is to make a scleral tunnel instead of a clear corneal incision so the wound is further back and has a tighter seal.
The decision to use an IOL in a child depends on their age. I usually collaborate with my pediatric ophthalmologist to determine the visual needs. If the parents are unable to use a contact lens, I recommend implanting an IOL because at least you know that when the baby wakes up, his or her vision is closer to emmetropia, and the risk of amblyopia development is lower. I definitely use an IOL in a child that is 2 or 3 years or older. The eye does not grow much after this. I would even consider toric or extended depth of focus lenses. Even though they are off label, children can neuroadapt to the optics. An extended depth of focus lens would reduce the patient’s need for bifocals significantly.
- For more information:
- Marjan Farid, MD, can be reached at Gavin Herbert Eye Institute at the University of California, Irvine, 850 Health Sciences Road, Irvine, CA 92697; email: mfarid@uci.edu.
Disclosure: Farid reports she is a consultant for Johnson & Johnson, Allergan, Shire Pharmaceuticals, EyePoint Pharmaceuticals, Kala Pharmaceuticals, CorneaGen and Bio-Tissue.