Experienced pediatric ophthalmologists need to manage children’s cataract surgeries
Click Here to Manage Email Alerts
Two to three of every 10,000 children born each year in the U.S. have a congenital cataract.
With 3.66 million births a year in the U.S., that equates to 732 to 1,098 new congenital cataracts per year. If we add in a small number of acquired and traumatic pediatric cataracts, there are at most 1,500 pediatric cataracts to remove every year in America. This is 0.04% of the 4 million cataracts that undergo surgery each year.
There are just more than 1,000 pediatric ophthalmologists in the U.S. and about 10,000 ophthalmologists who are active as cataract surgeons. If every cataract surgeon chose to operate on pediatric cataracts, the average would be one pediatric cataract surgery per cataract surgeon every 6 years. In my opinion, that is not enough to be expert in managing these complex cases. If all pediatric ophthalmologists performed cataract surgery on young children, they would also only perform one to two surgeries per year. For this reason, only about 40% of pediatric ophthalmologists perform cataract surgery, and the average for these surgeons would still be only four cases per year if they were divided equally.
The child with a cataract presents unique challenges for the surgeon during the procedure and in the postoperative period. In addition, the parents often present challenges that are unfamiliar to the adult cataract surgeon.
In the 1980s, as the busiest cataract surgeon on the faculty at the University of Minnesota Department of Ophthalmology, I operated on children with pediatric cataracts. I found inflammation was a significant challenge. I placed epinephrine and heparin in the balanced salt solution irrigating solution and treated aggressively with intraocular, subconjunctival and topical corticosteroids. Today I would add NSAID therapy. Now, at Minnesota Eye Consultants, these patients are all referred to a pediatric ophthalmologist skilled in the art.
A few thoughts on the special challenges inherent in managing pediatric cataracts. My favorite source of reliable information in pediatric ophthalmology is the Pediatric Eye Disease Investigator Group (PEDIG). Founded in 1997, PEDIG comprises 61 institutional and community-based practices that focus on the management of pediatric eye disease. All of them are fellowship-trained pediatric ophthalmologists and active in the American Association for Pediatric Ophthalmology and Strabismus. This group published a paper in JAMA Ophthalmology titled “Visual acuity and ophthalmic outcomes in the year after cataract surgery among children younger than 13 years.” There were 880 children in this cohort. Important findings included the need for amblyopia therapy to age 12 to 14 years in 51% of patients. Despite expert surgery and quality amblyopia management, the median visual acuities achieved were only 20/63 to 20/80. Forty-one percent of patients had bilateral cataract surgery and 59% unilateral. Sixty percent received an IOL. Vision was better in older children and when an IOL was implanted.
In another PEDIG study and paper, “Complications occurring through 5 years following primary intraocular lens implantation for pediatric cataract,” just published in JAMA Ophthalmology in 2023, the most common complications were visual axis opacification in 32% and glaucoma in 7%.
Most pediatric cataract surgeons today perform an intraoperative posterior capsulectomy and anterior vitrectomy and, when an IOL is implanted, utilize posterior optic capture. If the capsule is left intact at cataract surgery, most young children develop visually significant capsular opacity from fibrosis, and these dense membranes in children are difficult to impossible to treat with a YAG laser capsulotomy. Even with a primary posterior capsulectomy and anterior vitrectomy, secondary visual axis opacification occurs in 15% to 20% of patients, often requiring a second surgical intervention. Another review paper I read reported the incidence of retinal detachment at 2.5%, with male sex and axial myopia being risk factors.
The small number of pediatric patients who require cataract surgery each year, the fact that these young patients require general anesthesia usually in a hospital setting from anesthesia and recovery room providers familiar with managing children, the need for a routine posterior capsulectomy and anterior vitrectomy, the postoperative requirement of intense amblyopia therapy to age 12 to 14 years, the high incidence of difficult to manage pediatric glaucoma, and the expectation in a best-case scenario of a resultant visual acuity of 20/63 to 20/80 in the face of demanding and stressed parents lead me to recommend that these cases be managed by an experienced fellowship-trained pediatric ophthalmologist. We are fortunate to have an adequate number of them available in America to help manage these difficult and complex cases.
- References:
- Writing Committee for the Pediatric Eye Disease Investigator Group (PEDIG), et al. JAMA Ophthalmol. 2019;doi:10.1001/jamaophthalmol.2019.1220.
- Yen KG, et al. JAMA Ophthalmol. 2023;doi:10.1001/jamaophthalmol.2023.2335.
Collapse
Read more about
Click Here to Manage Email Alerts