3.
Technique of surgery
A. Incision construction
The preferred incision type used now in pediatric cataract surgery is tunnel incision
adapted from the adult cataract surgical technique. This incision offer less postoperative
astigmatism, better wound adaptation, less frequent occurrence of iris synechias and
prolapse, better anterior chamber stability and less postoperative inflammation than limbal
incision. The tunnel incision constructed with equal length and width diameter (square
incision) offers the best wound stability. Most of the pediatric surgeons prefer superior
location (10) but superior temporal location is gaining popularity. Corneal tunnel incision
offers several advantages (no involvement of the conjunctiva, better wound cosmetics,
less hemorrhages, ease of intraoperative maneuvering, better outcome of future glaucoma
surgery) but is associated with higher rate of surgically induced astigmatism (especially in
small patiernts) and endothelial cells loss. Probably corneal incision is not associated with
higher risk of postoperative endophthalmitis because in children tunnels are usually
sutured. (10) Rule of thumb is that the smaller the child (infants) and the bigger the
incision the more posterior (scleral) it should be performed. Use of diamond knifes is
gaining popularity because of great cutting precision and ease of incision in soft children
and vitrectomized eye. One can also speculate that these more even incisions should
produce less astigmatism during healing. However, more attention is required during
cutting with diamond knifes.
We prefer to perform superior temporal, square tunnel starting in the limbus, of a 2,5 – 3,0
mm width, prepared with the use of diamond knife after coagulation of limbal vessels in
the area of future tunnel. Most of the tunnel is left unopened and only central opening of
0,9 mm is performed with diamond knife. With the use of modern surgical
instrumentation this incision width enables insertion of instruments endings but is tight
enough to avoid leakage of intraocular fluids. Side-port incision of a 0,9 mm is made
about 90º to the left of the tunnel in front of limbal vascular arcade with the use of
diamond knife.
B. Anterior capsule surgery
Surgery of the anterior capsule is one of most difficult stages of cataract surgery in
children because of extreme elasticity of the capsule, necessity to use more force to tear
the capsule, ease of extension of tearing out toward the lens equator, high vitreous
pressure, ease of anterior chamber collapse and frequent poor pupil dilatation.
The preparations for anterior capsule surgery include pupil dilatation with 1:10000
intracameral adrenaline injection (if there are no systemic contraindications) and filling
the anterior chamber with viscoelastic agents. Authors preference is high-viscosity
cohesive viscoelastics because of better space creation by these agents (which is important
in shallow, easily collapsing during surgical manipulations anterior chamber of small
children), better maintenance of pupil dilatation and anterior capsule flattening (easier,
more controlled capsulorhexis). The most popular techniques of anterior capsule surgery
nowadays include manual continuous curvilinear capsulorhexis (the most difficult to
perform), vitrectorhexis (performed with the use of a vitrector supported by a Venturi
pump) and radiofrequency diathermy capsulotomy. Less popular of techniques include
can-opener technique, Fugo plasma blade capsulotomy and two-incision push-pull
technique (36, 40, 42). Comparative studies have shown that manual continuous
curvilinear capsulorhexis produce more stronge, smooth, tear resistant, elastic capsular
edge than bipolar radiofrequency capsulotomy and vitrectorhexis although results the last
method were nearly comparable with the first one (37-40, 42). Therefore, although the
most difficult, manual continuous curvilinear capsulorhexis remains gold standard of
anterior capsular surgery in pediatric cataract. (Fig. 14) Indocyanine green staining of the
anterior capsule may facilitate performance of manual continuous curvilinear
capsulorhexis in children (40).
Authors preferred technique of anterior capsular surgery is manual continuous curvilinear
capsulorhexis performed after filling anterior chamber with high-viscosity cohesive
viscoelastic agent, with “frequent grasp/regrasp technique”, tearing force directed toward
the center of the pupil and capsulorhexis size of no more than 4,0 mm (size of opening
will enlarge during next step of operation because of capsule elasticity).
Fig. 14 Anterior capsule 2 years after manual capsulorhexis in 2,5-years-old child.
C. Multiquadrant, cortical-cleaving hydrodissection
Because of softness of children’s lens nucleus and cortex hydrodissection is not so
important step in pediatric cataract surgery than it is in adults. However, this technique
facilitates lens substance removal, decrease its time and lessens volume of used fluid. (41)
D. Aspiration of lens substance
The aim of aspiration is to remove thoroughly lens substance to clear visual axis and to
prevent future proliferation of mitotically active lens epithelial cells and visual axis
opacification. Because children’s lens nucleus and cortex are soft any method of
phacoemulsification or phacofragmentation are used and only simple irrigation and
aspiration of lens substance is performed. Two methods of irrigation and aspiration are
used: single-port and bimanual. Both methods can be manual and automated. Bimanual
approach is preferably used in pediatric cases because of more thorough removal of lens
substance (especially in subincisional space), better maintenance of anterior chamber and
less fluctuations of fluids in the anterior chamber. Standard irrigation/aspiration hand
pieces are used but lens material can be also aspirated using vitrector with
irrigation/aspiration working mode which shortens time of surgery and diminish anterior
chamber manipulations associated with repeated entries into the eye during changing of
hand pieces before posterior capsulectomy and anterior vitrectomy. Use of automated
irrigation/aspiration helps in maintaining of the anterior chamber because of better
balancing of aspiration and infusion.
E. Posterior capsule surgery and anterior vitrectomy
It is well known that posterior capsule opacification is very rapid in children. The younger
the child the more pronounced is opacification. It is caused by proliferation and migration
of residual lens epithelial cells and their transformation to myofibroblasts. (40) In children
vitreous is the dense structure and anterior vitreous face is in closed contact with posterior
capsule. Therefore it can act as a scaffold not only for lens epithelial cells, but also for
metaplastic pigment epithelial cells, exudates. (42) Visual axis opacification (VAO) is the
most common complication and one of the most important in pediatric cataract surgery
because it induces amblyopia and it stops development of binocular vision if it occurs
during the critical period of visual development in children. Therefore most surgeons
routinely perform posterior capsulotomy in children younger then 8-10 years. (40, 42)
However, primary posterior capsulotomy is not enough to prevent VAO if it is performed
without anterior vitrectomy (40, 42, 43). Also posterior optic capture without anterior
vitrectomy do not ensure clear visual axis. (35) Therefore primary posterior capsulotomy
and anterior vitrectomy is regarded nowadays as standard surgical procedure of pediatric
cataract surgery in children younger than 8-10 years. (40, 42, 43, 44)
Various options have been proposed how to perform posterior capsulotomy and anterior
vitrectomy. As with anterior capsulorhexis posterior capsulotomy can be made with
manual technique, vitrector or with radiofrequency diathermy. The last method is
nowadays the least popular because capsular margin after this procedure is the least tear
resistant. Posterior capsule is much thinner than anterior one (4-9μm) and performance
of manual capsulorhexis or vitrectorhexis is more complicated than anterior capsulorhexis
although achieved opening margin is smooth and strong. Many surgeons prefer to perform
posterior capsulotomy with vitrector if anterior vitrectomy is simultaneously planned.
Capsule opening margin after this procedure is strong enough to maintain position of IOL
in the capsular bag and both procedures are made with one instrument what shortens time
of surgery. Diameter of posterior capsulotomy should be 4,0 to 4,5 mm and anterior
vitrectomy should be 3 mm deep to prevent capsule opacification. (40, 45) (Fig. 15, 16)
Only central anterior vitreous should be removed. There are still controversies whether
they should be performed or after IOL implantation. It is easier to perform the procedures
first but then it is more difficult to implant IOL in the bag in a soft vitrectomized eye. IOL
is more easily implanted into the bag with the intact posterior capsule and IOL is already
in place before posterior capsule management but then is more difficult to remove capsule
and anterior vitreous. Performance of manual posterior capsulorhexis with IOL in the bag
may be troublesome because tilted IOL can produce uneven tensions of different parts of
posterior capsule. The more common practice now is to do posterior capsulotomy and
anterior vitrectomy before IOL implantation. (42) Posterior capsulotomy and anterior
vitrectomy can also be performed through pars plana, usually after IOL implantation. (42,
46) With this approach one can obtain larger capsule opening because IOL is already in
place and no vitreous strand will be attached to wound but this procedure extends the
time and scope of operation (most pediatric cataract surgeon are not routinely familiar
with pars plana approach), requires additional incision of sclera and pars plana and
scleral and conjunctival suturing. Therefore this technique is now not commonly used.
Primary posterior capsulotomy with optic capture was described by Gimbel and DeBroff.
(47) However, if optic capture if performed without anterior vitrectomy it do not ensure
clear visual axis. (45) Optic capture is rarely used because it is technically challenging,
associated with higher rate of IOL subluxation and future IOL exchange is more difficult.
(40) Nd-YAG laser capsulotomy is nowadays rarely used as a primary procedure because
of high reopacification rate (scaffold of the anterior vitreous face is not removed).
The author’s preferred approach is to perform both limbal posterior capsulotomy of 4,0 to
4,5 mm diameter and anterior vitrectomy with vitrector and side-port separate irrigation
before IOL implantation.
F. IOL implantation
Preferable method is implantation with the use of injectors because of more aseptic
condition of this maneuver and smaller incision. During implantation it is very important
to place lower haptic in the capsular bag which sometimes may be difficult in children’s
soft, vitrectomized eye because of movements of lower haptic during unfolding. It is
advisable to wait until lower haptic unfold completely in the center of anterior chamber
and guide it into the bag with the spatula or hook inserted through the side-port.
G. Bimanual aspiration/irrigation of viscoelastic agent
Postoperative IOP elevation is infrequent after cataract surgery in children because of
good outflow facility. However, it is advisable to remove viscoelastics from the anterior
chamber at the end of operation.
H. Wound suturing
Tunnel incision in children usually is not self sealing because of high elasticity of
pediatric cornea and sclera. More poor wound healing can be also attributed to frequent
eye rubbing in children, more frequent eye trauma, using of higher doses of steroids and
more vivid behavior of children after the surgery. Performance of detailed slit lamp
examination of the wound to diagnose leakage is often difficult or even impossible in
small children. Clinical observations of Basti and coworkers have shown that unsutured
wounds are usually not watertight in children after cataract surgery especially when
anterior vitrectomy was performed. (48). Therefore it is advisable to suture tunnel incision
after pediatric cataract surgery. (49) In USA only 2,8% of pediatric ophthalmologists
performing cataract surgery left incision unsutured. (6) Usually wound 2,5 – 3,0 mm is
closed with one single 10/0 nylon suture although 10/0 Vicryl adsorbable sutures are also
used. (49) It is important that needle entries should be equidistant from wound edges,
placed at the same depth of cornea or sclera, placed perpendicular to wound and knots
should be hidden inside wound. Suture tension should be corrected with Maloney
keratometer with the eye filled with Ringer solution injected through the side-port. These
precautions should diminish development of postoperative astigmatism in children.
Fig. 15 Implanted IOL three years after surgery in 5-year-old child. Note anterior
and posterior capsulorhexis and opacification of the anterior capsule.
TABLE IV
Technique of pediatric cataract surgery (authors preference)
1. Coagulation of limbal vessels in the area of future limbus tunnel
2. Preparation of unopened limbus, superior temporal, square tunnel of
a 2,5 – 3,0 mm width with the use of diamond knife
3. 0,9 mm anterior chamber opening in the center of tunnel incision
4. 0,9 mm sideport incision (diamond knife)
5. Pupil dilation with the use of intracameral injection of 1:10 000
adrenaline solution
6. Filling anterior chamber with high viscosity viscoelastic agent
7. Manual continuous curvilinear capsulorhexis (“frequent grasp/ regrasp
technique”, tearing force directed toward the center of the pupil,
capsulorhexis size no more than 4 mm)
8. Multiquadrant, cortical-cleaving hydrodissection
9. Automated bimanual irrigation and aspiration of lens substance
10. Limbal posterior capsulotomy (4,0 to 5,0 mm diameter) and anterior
vitrectomy with the use of vitrector and separate side-port irrigation
11. Enlargement of tunnel incision to 2,5 – 3,0 mm incision (according to
the type of IOL and injector) with diamond knife
12. Loading of foldable IOL to the injector
13. Injector implantation of IOL
14. Bimanual aspiration/irrigation of viscoelastic agent
15. Tunnel suturing with single 10/0 nylon
16. Suture tension adjustment with the use of Maloney keratometer
4-5
mm
4 mm
Fig, 16 Schematic presentation of the technique of pediatric cataract surgery with IOL
implantation
I.
SECONDARY IOL IMPLANTATION
1. Timing of surgery
There are two main indications for secondary IOL implantation in a child after cataract
surgery without IOL implantation: noncompliance to other forms of aphakic correction and
IOL implantation as final aphakia correction.
In first situation secondary implantation can be performed at any age even in a child younger
than 1 year. Main indication for the surgery is achievement of the best conditions for the
development of binocular vision. So, the decision of the age of surgery must be individually
considered according to a situation.
Up to now there are no recommendations concerning the age of IOL implantation for final
aphakic correction. From one side implantation should be performed as late as possible
because axial growth is increasing until age of 14 years. (Fig. 8) This ensures the smallest
residual refraction for the rest of the adult life. From the other side contact lenses or thick
aphakic eyeglasses are very inconvenient for the child and create both cosmetic (eyeglasses)
and maintenance problems (contact lenses). A lot of parents are asking for IOL implantation
because they afraid that with going to school for the most of the day they will loose control
over the child and changing of the life environment from home to school will create new
problems for the aphakic child. Primary school starts at different age in various
countries,
usually between 5 and 7 years of life. In Poland children go to school at age of 6 years but the
first year is so called preschool education. The changes of IOL power necessary for aphakia
correction are small after 7-8 years of life (Fig. 12). Therefore the author’s recommendation is
to perform secondary implantation before starting regular school activity i.e. at age of 7 years.
2. Technique of implantation
Generally the technique of secondary IOL implantation is similar to primary IOL
implantation. The main difference is that we are not removing opacified lens but we have to
create the support for IOL using different anatomical structures inside the eye. The methods
of IOL fixation includes: in-the bag fixation, ciliary sulcus fixation, optic capture, scleral
fixation, iris fixation and anterior chamber fixation.
A.
In-the bag-fixation
In-the-bag implantation creates the best position for IOL because it sequestrates acrylic IOL
material from the highly reactive uveal tissues and ensures its best centration. (50) Bag
reopening is possible if previous lensectomy was properly performed leaving peripheral parts
of both anterior and posterior capsules in place. If lensectomy is performed early (in infants)
intensive proliferation of lens epithelial cells creates cortical masses separating peripheral
parts of the anterior and posterior capsules. They can not to be absorbed because they are
trapped in the bag by the fusion of the incised edges of the anterior and posterior capsules. It
forms the space for the future secondary implantation. In older children lens epithelial cells
proliferation is much less intensive and both capsules fuse together far to the periphery.
Reopening of the bag is of course not always possible. Sometimes dissected posterior capsule
is not strong enough to support IOL. Wilson reported the technique of bag opening with the
use of vitrectomy probe. (51) In these operation fused capsular edges are cut with vitrector,
separated, capsular bag is cleaned of cortical masses with aspiration and irrigation, capsular
bag is opened with viscoelastic and IOL implantation is performed.
B.
Ciliary sulcus fixation
If capsules are inseparable and in-the-bag implantation is not possible ciliary sulcus fixation is
chosen. (Fig. 17) There are some reports that sulcus fixation is quite safe and effective in
children (52, 53, 54). Avad studied position of secondary sulcus implanted IOLs in children
and did not observed haptic erosion into the sclera, ciliary body or sulcus. (53) However,
pigment dispersion syndrome may sometimes develop in long-term in some children because
of the direct contact of IOL material with pigmented layer of the iris. If IOL diameter is not
properly chosen IOL may move or tilt inside the eye and papillary capture may develop.
Fig, 17 Schematic presentation of the technique of secondary IOL implantation with
sulcus fixation.
C.
Optic capture
Optic capture of the ciliary sulcus implanted IOL behind the fused anterior and posterior
capsules is sometimes used to achieve better centration of an IOL. (50) (Fig. 18) However,
children with optic capture are more prone to synechia formation and development cellular
deposits on an IOL optic. (55)
Fig, 18 Schematic presentation of the technique of secondary IOL implantation with
sulcus fixation and optic capture.
D.
Scleral fixation
Scleral suture IOL fixation is used if capsular support is absent. Several techniques of this
procedure both ab externo and ab interno have been described. (56) Their detailed description
is outside of scope of this chapter. The aim of the operation is to suture IOL to the sclera in
the ciliary sulcus with the use of 10/0 polypropylene suture with long (16 mm) straight
needle. (Fig. 19) Two partial-thickness scleral flaps are prepared at 2 (or 4) and 8 (or 10)
o’clock positions. They are used afterwards to cover the prolene suture knots and to prevent
endophthalmitis and conjunctiva erosion over the knot. It is advisable to avoid 3 and 9 o’clock
position because of the presence of long ciliary arteries and nerves. Scleral flaps are prepared
after incision of the conjunctiva or limbal incision is made and sclera is dissected backwards
without dissecting the conjunctiva. (57) The straight needle of 10/0 polypropylene suture is
then passed through the sclera under one of the scleral flaps (0,75 mm posterior to the
limbus), entering the posterior chamber and going out of the eye under the flap on the other
side of cornea. The suture is taken out of the posterior chamber cut and one end is tied to IOL
haptic pushed out of the injector nozzle. IOL is injected to the posterior chamber with the
second haptic left in the wound. Second end of polypropylene suture is then tied to this haptic
and IOL is placed in posterior chamber. The author preference is to use foldable, hydrophilic
IOLs with complex haptic (Super-flex, Rayner) because of better uveal biocompatibility of
acrylic hydrophilic material and closed, deformation-resistant haptic system. It is very
important to adequately fixate polypropylene suture to the sclera under the flap with 1 or 2
large bites and carefully close covering flaps with 10/0 nylon sutures.
IOL scleral fixation technique is usually safe and effective for secondary IOL implantation in
children but some serious complications have been reported in the literature. They include
polypropylene knots erosion through the conjunctiva, endophthalmitis (probably caused by
the exposed knots), suture rupture and IOL dislocation although these complications do not
occur so frequent in children. (56, 58, 59)
Fig, 19 Schematic presentation of the technique of secondary IOL implantation with
scleral fixation.
E.
Iris fixation
IOL can be fixated to the iris with the prolene suture or using iris-claw design. Much more
common is now iris-claw popularized by Jan Worst. Pediatric and foldable iris-claw IOL’s are
now produced. Iris-claw IOL is fixated to the iris in the anterior chamber using grasping
mechanism of “claws”. (Fig. 20) The technique of implantation is simple. The lens is
introduced into the anterior chamber and peripheral parts of the iris at 3 and 9 o’clock position
are enclavated inside the claws. (60) It is also possible to fixate IOL to the back of the iris in
posterior chamber. Peripheral iridectomy is performed to prevent papillary block. The
advantage of iris-claw IOLs is that it can be fixated to the internal structure of the eye (in
opposition to scleral fixated IOLs).
The lens can be easily removed and exchanged.
Postoperative complications include: papillary ovaling, iris root tear, glaucoma (closure of
peripheral iridectomy), lens dislocation and endothelial cell damage, although they occur
infrequently with the late generations of iris-claw IOLs. (60) Resistance of the iris tissue to
long-term grasping of “claws” and long-term effects of IOL in the anterior chamber on
corneal endothelium are yet to be determined.
Fig, 20 Schematic presentation of the technique of secondary IOL implantation with
iris-claw fixation.
Iris suturing of IOLs with polypropylene suture (Fig. 21) is not frequently performed in
pediatric cataract surgery. This technique is sometimes used for suturing one haptic of
dislocated sclerally fixed IOL because the surgery can be performed through two small
openings of the anterior chamber without necessity of preparing new scleral flap for fixation.
Fig, 21 Schematic presentation of the technique of secondary IOL implantation with iris
fixation.
F.
Anterior chamber fixation
Until recently anterior chamber IOLs (ACIOLs) were not used in pediatric cataract surgery
because of frequency of complications associated with the implantation of previous
generations of ACIOLs. May be the situation will change with introduction of modern,
flexible, open loop ACIOLs but the experience with these IOL designs is still limited.
3. Choice of IOL
IOls which are preferred by surgeon for cataract surgery are used for secondary in-the-bag
implantation. Special pediatric sized and for patient with microcornea iris-claw IOL’s are now
produced for iris fixation. Until now there are no recommendations about the use of IOL for
ciliary sulcus and scleral fixation in children. The author preference is Super-flex IOL
(Rayner, UK). This IOL is produced from hydrophilic acrylic material has
mm and overall length of 12.50 mm and has
optic diameter of 6.25
closed loop, complex haptic. Its hydrophilic material
ensures the best uveal biocompatibility when in touch with iris tissue (see above). This lens
fits better for ciliary sulcus diameter because of enlarged overall diameter comparing to
standard IOLs for in-the-bag implantation. Haptics with closed loop, not too elastic, complex
system provides good IOL stabilization, centration and adaptation in the cilary sulcus. Closed
loop haptic system is also more versatile in use for scleral fixation because polypropylene
suture can be tied or looped through the haptics without tying.
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Recommended reading
1. Wilson ME, Trivedi RH, Pandey SK (eds): Pediatric cataract surgery. Lippincott,
Wiliams &Wilkins, 2005.