Glaucoma-associated adverse events common in pediatric eyes after lensectomy
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Key takeaways:
- Glaucoma-related adverse events are common in children after lensectomy.
- Aphakia and age younger than 3 months are associated with a higher risk.
Glaucoma-related adverse events are frequent after lensectomy in children, according to a study.
Aphakia and age younger than 3 months were associated with a higher risk, while the risk was lower in older children with pseudophakia.
The study used longitudinal registry data collected annually for 5 years by the Pediatric Eye Disease Investigator Group at 45 institutional sites and 16 community sites. A total of 1,049 eyes of 810 children were included; 443 eyes of 321 children were aphakic after lensectomy, and 606 eyes of 489 children were pseudophakic. Most aphakic eyes were in children younger than 6 months.
The cumulative incidence of glaucoma-related adverse events after 5 years was 29% in the group of aphakic eyes and 7% in the group of pseudophakic eyes. These events were more common among aphakic eyes when lens surgery was performed within the first 6 weeks of life (44%) and between 6 weeks and 3 months of age (35%).
Other studies have identified the first 3 months of life as the highest risk period for the development of glaucoma following lensectomy, the authors noted, recommending caution when considering cataract surgery at this early age.
Over the time span of 5 years, 33 aphakic eyes (7%) and three pseudophakic eyes (0.5%) required glaucoma surgery.
“The high incidence of glaucoma-related adverse events in aphakic and pseudophakic eyes found in this study suggests the need for close monitoring for glaucoma after lensectomy,” the authors said.
References:
- Bothun ED, et al. Ophthalmology. 2019;doi:10.1016/j.ophtha.2019.03.011.
- Bothun ED, et al. Ophthalmology. 2021;doi:10.1016/j.ophtha.2020.07.020.
- Freedman SF, et al. JAMA Ophthalmol. 2015;doi:10.1001/jamaophthalmol.2015.1329.
- Freedman SF, et al. JAMA Ophthalmol. 2021;doi:10.1001/jamaophthalmol.2020.5664.
- Nyström A, et al. Acta Ophthalmol. 2020;doi:10.1111/aos.14414.
- Solebo AL, et al. Br J Ophthalmol. 2020;doi:10.1136/bjophthalmol-2019-314804.
Perspective
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The take-home message from this large cohort study is that glaucoma-related adverse events (AEs) after pediatric cataract surgery occur more commonly in those children who need cataract surgery in the first 3 months of life. These eyes are often developmentally immature and microphthalmic. The glaucoma can present early after surgery, or it may develop many years later. With surgery later in childhood, glaucoma-related AEs are uncommon but still occur in a smaller percentage compared with infants. These older eyes are also less likely to have anterior segment developmental anomalies or microcornea, which are also important risk factors for the development of secondary glaucoma.
The authors urge caution when considering surgery at younger than 6 weeks of age because the incidence of glaucoma-related AEs was the highest in this group at 44%. However, the reader may worry that delaying surgery beyond 6 weeks of age in a dense unilateral congenital cataract may worsen amblyopia. Glaucoma-related AEs were still common (35%) when surgery was done between 6 weeks and 3 months of age. Many surgeons are now cautiously delaying surgery a few weeks longer than had been common practice before, especially in bilateral cases, in hopes of reducing the incidence of secondary developmental glaucoma (now referred to as glaucoma after cataract surgery) without worsening deprivation amblyopia.
This study also supports the recommendation that children operated for cataracts in infancy need glaucoma monitoring for many years after surgery. Children operated beyond infancy are at much lower risk for glaucoma, but monitoring is still recommended.
This was an important and robust study of 810 children (1,049 eyes) followed for 5 years. It helps to confirm the findings of other studies that have been previously published, such as the Infant Aphakia Treatment Study, the IoLunder2 cohort, the Swedish National Pediatric Cataract Register, and the Toddler Aphakia and Pseudophakia Study. It does not, however, allow any analysis of the effects, if any, of an IOL on the risk for glaucoma. In this study, very young infants were left aphakic, and older children were implanted with an IOL. In other words, the eyes at risk were left aphakic because they were very young and often had microcornea and anterior segment developmental anomalies. This study does not conclude that aphakia is an independent risk factor for glaucoma after cataract surgery.
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