Paediatric cataract
Tony Quinn
Consultant Ophthalmologist
West of England Eye Unit
Royal Devon & Exeter Hospital
SWONS Exeter 2005
Outline
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What sort of cataract?
Why do children get cataracts?
What else could it be?
What else occurs in association?
Should we operate? What options are there?
How soon should we treat?
Complications?
Controversies? IOL Implants?
Outcomes?
Our local results?
SWONS Exeter 2005
What sort of cataract?
Nuclear, lamellar,
powdery, subcapsular,
sutural, total
• Can start off mild and
become more dense
• Obscures retinal image
• May cause amblyopia
SWONS Exeter 2005
Why do children get cataracts?
• Gene mistake
• Inherited
• Associated with other
genetic conditions
(Paediatrician workup)
• Trauma
• Uveitis
• Intrauterine infections
SWONS Exeter 2005
What else could it be?
• “white pupil”
differential diagnosis
• Retinoblastoma
• Retinopathy of
prematurity
• Coat’s disease
• Persistent fetal
circulation
SWONS Exeter 2005
What else occurs in association?
• Main problem is
amblyopia
• Eye growth
• Strabismus
SWONS Exeter 2005
Should we operate? What options
are there?
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Unilateral cataract: ? treatment
Bilateral cataract: Treat if visually significant:
Can you see in?
Is opacity >=3mm?
anterior or posterior
? Amblyopia, abnormal eye growth
SWONS Exeter 2005
How soon should we treat?
• <4 weeks may cause more glaucoma
• More than 10 weeks may cause irreversible
amblyopia, nystagmus
• Unilateral about 6 weeks
• Depends on how dense
SWONS Exeter 2005
Surgery
SWONS Exeter 2005
Complications?
• Infection, bleeding, GA
risk, loss of eye…
• Big risks: Re-op
• Glaucoma
• Retinal detachment
• Amblyopia
• Strabismus
• Glasses(bifocals) or
Contact lens for sure
SWONS Exeter 2005
What do we tell the parents?
• Lifetime journey
• Very hard work
• Lots of drops early, then glasses and
patching for years
• May not work well (unilateral)
• Long term risks
• Risk to other eye (sympathetic)
SWONS Exeter 2005
Controversies? IOL Implants?
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IOL implants: when to use?
Minimum age
Minimum corneal diameter
How long will they last?
Rigid (?Heparin coated) or foldable?
Where to place the lens?
Dealing with posterior capsule
SWONS Exeter 2005
Outcomes?
• Excellent results possible
• IOLs may be better overall than contact
lenses. Not much in it
• Refract, Refract, Refract!!!
• May need EUA
• Tonopen for awake IOP
SWONS Exeter 2005
Our local results? Methods
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Consecutive infant cataract surgery 00 - 03
9 infants, 15 eyes
Mean age at surgery 21 weeks (4-42w)
All posterior chamber, 13 in bag, 2 in sulcus
1 lost to follow up after 6 weeks
SWONS Exeter 2005
Methods
• primary pars plana Vx
• IOL: Heparin PMMA in 5, Acrysof MA 60
BM in 10 (both 6 mm optic)
• Healon 5 in 14, Healon GV in 1
• CCC in 14, MVR = 1
• 1 patient corneal diam 9.5
• 2 patients (4 eyes) nystagmus and
strabismus pre-op
SWONS Exeter 2005
Refractive target
• +4 to +8D, (SRK-T) but max +30D IOL
• Unilat Down +1.8D
SWONS Exeter 2005
Refractive outcomes: mean
followup 26.5 mo
Infant Cataract Pseudophakic Refraction Changes
Infant Cataract Pseudophakic Refractive Changes
Average Sphere (Dioptres)
10
Average Sphere (Dioptres)
12
D Right
A Right
D Left
A Left
E Right
B Right
10
E Left
B Left
5
F Right
C Right
8
F Left
G Left
H Right
6
H Left
0
4
2
-5
0
10
20
30
40
50
Time Post-Op (Months)
SWONS Exeter 2005
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10
20
30
Time Post-Op (Months)
Vision outcomes mean 26.5 mo
Comparison of Pre-op and 'Final' Visual Acuities
100
90
80
70
60
Percent of eyes (%)
50
PRE-OP
FINAL
40
30
20
10
0
6/6-6-12
SWONS Exeter 2005
<6/12-6/60
<6/60-6/120
Range of Visual Acuity
<6/120
Complications of surgery
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Strabismus in 6 of 8 (1 lost to follow-up)
Iris capture 1/14
Repeat posterior capsulectomy 6/14
Anterior capsule phimosis 1/14
Glaucoma nil mean 33 mo f/u. Mean IOP =14, range 1017mmHg
• Retinal detachment nil
• IOL decentred nil
SWONS Exeter 2005
Conclusions
• IOL implants in infants are possible with good
visual and refractive outcomes
• Myopic shift with time in most: ?emmetropisation
• Mildly microphthalmic child showed almost no
reduction in initial hypermetropia with time
• High rate of strabismus
• Nearly half re-op for “PCO”
SWONS Exeter 2005