Study evaluates visual outcomes, complications of lensectomy in children
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A cohort study of lensectomy in children found a high cumulative incidence of glaucoma-related adverse events at 5 years, higher in aphakic eyes, and a modest myopic shift after placement of an IOL.
The study was based on the data registry of the Pediatric Eye Disease Investigator Group and included 1,268 eyes of 994 children aged between 2 weeks and 13 years who underwent bilateral or unilateral lensectomy. Bilateral surgery was performed in 428 participants, and an IOL was implanted in 750 eyes. A further 120 IOLs were implanted during the 5 years of follow-up.
At 5 years after surgery, visual acuity data were available for 701 eyes. Although some of the children achieved good visual acuity outcomes, age-normal visual acuity was uncommon, ranging from 12% in the unilateral aphakic group to 42% in the bilateral pseudophakic group. In bilateral cases, no difference was found in relation to the timing of surgery, while better visual outcomes were achieved in unilateral cases when surgery was performed before 3 months of age.
The cumulative incidence of glaucoma or glaucoma suspect at 5 years was 46% among children with bilateral aphakia and 25% among children with unilateral aphakia. It was lower in pseudophakic children, reaching 7% in the bilateral lensectomy group and 17% in the unilateral lensectomy group.
Secondary optical axis opacification was the most common cause for secondary interventions, including anterior vitrectomy and Nd:YAG capsulotomy.
The median change in spherical equivalent at 5 years was significantly lower after IOL implantation. It was –8.38 D in bilateral aphakic eyes as compared with –1.63 D in bilateral pseudophakic eyes and –10.75 D in unilateral aphakic eyes as compared with –1.94 D in unilateral pseudophakic eyes.
“These results support frequent monitoring after pediatric cataract surgery to detect glaucoma and visual axis obscuration causing reduced vision and for management of refractive error,” the authors wrote.
Perspective
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This cohort study delivers four key messages. The first is that cataract surgery performed on children younger than 13 years of age results in age-normal visual acuity 5 years after surgery in only 12% of unilateral aphakic eyes, 18% of unilateral pseudophakic eyes, 20% of bilateral aphakic eyes and 42% of bilateral pseudophakic eyes. Eyes left aphakic were mostly those operated younger than age 2 years, while most pseudophakic eyes were operated older than 2 years of age at surgery.
The second key message was that the risk for glaucoma-related adverse events, the most important long-term complication of childhood lensectomy, is high. Glaucoma or glaucoma suspect was diagnosed in 46% of bilaterally aphakic eyes operated at ages 0 to 2 years and continued to increase each year.
Third, the incidence of additional surgery to clear the visual axis in pseudophakic eyes was significantly reduced when an anterior vitrectomy was performed at the time of cataract surgery.
Finally, serious adverse events such as endophthalmitis and retinal detachment were rare.
This study confirms the critical role of frequent monitoring after pediatric cataract surgery. For children operated early in life, long-term follow-up is mandatory, and IOP needs to be monitored long term because glaucoma may develop many years after surgery. The lost to follow-up rate in this registry was high with only 66% of the patients reaching their 5-year visit after cataract surgery. More prospective studies are needed with better retention. Also, children operated from age 0 to 13 years were lumped together. More age-stratified cohorts need to be studied because results vary based on the age of cataract onset and the age of initial cataract surgery.
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