You are on page 1of 3

International Journal of Current Medical And Applied Sciences, vol.5. Issue 1, December: 2014. PP: 11-13.

Management of Pediatric Cataract:


A Challenge
Jyoti Bhuyan*
* Professor, Department of Ophthalmology, RIO, Gauhati Medical College, Guwahati, Asam
INDIA.
Corresponding E-mail ID: bishnujyotidas@gmail.com
Subject: Ophthalmology
Review Article
--------------------------------------------------------------------------------------------------
pediatric cataract has become technically more
Abstract: sound and the results more predictable [3].

Pediatric cataract is an important cause Current Surgical Techniques:


of visual morbidity in early childhood and ranks
as third major cause of childhood blindness. The aim of the surgical technique is to
Management of pediatric cataract is still a provide a long term clear visual axis by
challenge because facilities for management of preventing PCO or secondary membrane. The
pediatric cataract are inadequate in India. The best current technique is “Phacoaspiration with
aim of surgery is to provide long term visual axis primary posterior capsulotomy with or without
by preventing Posterior capsular opacification anterior vitrectomy and capsular bag
(PCO). Surgery for pediatric cataract is implantation/optic capture of intraocular
aspiration by using two way irrigation- lens”[4].
aspiration (IA) canula or automated IA.
Membranous cataract needs Preoperative Evaluation:
phacoemulsification. IOL implantation is A thorough history is useful to diagnose
recommended after 2 years of age. Primary whether the cataract is congenital,
posterior capsulotomy with or without anterior developmental or traumatic in origin.
vitractomy is considered to prevent PCO. Leucocoria is usually noticed in congenital
Key words: cataract, Irrigation Aspiration [ IA], cataract, so other causes of leucocoria should be
IOL, posterior capsulotomy, visual excluded. Maternal history of drug use, infection
rehabilitation. or exposure must be ascertained. Family history
-------------------------------------------------------------- of cataract and families with inherited cataracts
should receive genetic counselling. Each child
Introduction: should be examined by a paediatrician for
Pediatric cataract is one of the major thorough systemic work up to rule out systemic
causes of childhood blindness and it ranks third associations, anomalies or congenital rubella.
after refractive errors and amblyopia. Assessment of visual function: it
Prevalence of childhood cataract has been includes History of behavioural change like
reported as 1 to 15 cases 10,000 children. It is bringing objects close to eye, frequent fall or
estimated that globally, there are 200,000 hitting the wall etc. Ruling out
children blind from bilateral cataract [1]. It is nystagmus/nystagmoid movements, squint and
said that ‘treating childhood blindness is like noting for central, steady and maintained
treating 10 blind adults.’ There are still fixation.Slit lamp examination to evaluate
inadequate facilities for management of various types of cataract. Congenital cataracts
pediatric cataract in India [2]. With the advances are more amblyogenic than developmental
in surgical techniques like maintaining closed cataracts.
chamber during surgery, viscoelastic agents, Evaluation of fundus and B-Scan
vitrectomy techniques, methods of calculating ultrasound whenever required. Examination to
IOL calculation and type of IOLs, management of rule out congenital abnormalities like
microphthalmos, coloboma and persistent
hyperplastic primary vitreous.
.

Copyright @ 2014 Logic Publications, IJCMAAS,E-ISSN:2321-9335,P-ISSN:2321-9327, Page I 11


Jyoti Bhuyan

Figure 1: Ant. Polar cataract Figure 2: Sutural cataract

Figure 3: Lamellar cataract Figure 4: Nuclear cataract

Preoperative Investigations: early surgery and in bilateral cataract, after


operating first eye, second eye may be operated
Serology for intrauterine infections (TORCH within a week or two to prevent amblyopia. In
infection): Urine analysis for- reducing general optimum age for surgery for unilateral
substance after milk feeding for Galactosemia, cataract is 6 weeks and bilateral cataract is 8
amino acids for Lowe syndrome, copper for weeks.
Wilson’s disease, protein for All port
syndrome.Blood glucose level for diabetes Preoperative Counselling:
mellitus.VDRL for syphilis.Serum calcium for Preoperative counselling is most
Hyper or Hypothyroidism. important. Parents must understand that surgery
is the first step of management. The following
IOL Power Calculation: points to be stressed. Follow up for a long period
for repeated correction and occlusion therapy.
The type of biometric formula for IOL Possibility of postoperative complications and
power calculation is not defined and different need of secondary intervention must be
theories have been proposed by different emphasized.
surgeons. Most reports have recommended
under-correction anticipating the myopic shift Anaesthesia:
following IOL implantation. The axial length and Surgery is performed under general anaesthesia.
keratometry readings should be measured for
power calculation. The most preferred approach Cataract Removal In < 18 Months:
is the one put forwarded by Dahan et al. [5] thus; Two side ports are created at the limbus
children between 2-3 years are under corrected and with a guillotine type vitrectomy probe an
by 30%, 3-5 years by 20% and 5-8 years by 10%. opening is made in the anterior capsule. Lens
After 8 years, the IOL power is targeted for material is aspirated and a posterior continuous
emmetropia. curvilinear capsulorhexis ( PCCC) and anterior
vitrectomy is done. For secondary IOL after 2
Indications For Pediatric Cataract Surgery: years of age, a capsular rim is left. The small side
Cataract which occupy visual axis and occupy port entry may have to be sutured if required.
3mm or more of the pupil.Unilateral partial or Nowadays this surgery can be done with 25
complete cataract to prevent amblyopia. Cataract gauge vitrectomy instruments also [6].
with squint,nystagmus / unsteady fixation.Poor
retinoscopy reflex: if during retinoscopy reflix is Pediatric Cataract Surgery with IOL
poor due to cataract. Implantation:
Timing of Surgery: A scleral tunnel incision is preferred due
Once indicated child may be operated as to better wound apposition [7]. But with the
early as 2 weeks of age. Unilateral cataract needs availability of soft foldable lens which require

Copyright @ 2014 Logic Publications, IJCMAAS,E-ISSN:2321-9335,P-ISSN:2321-9327, Page I 12.


Logic Publications @2014, IJCMAAS, E-ISSN: 2321-9335,P-ISSN:2321-9327.

incision of 3 mm or less some surgeons are therapy for unilateral cataract after surgery
shifting to clear corneal incision with good should be instituted early as these children are at
results. Two paracentesis incisions are made in a higher risk of developing amblyopia. Children
the clear cornea. after cataract surgery need to undergo refraction
A Continuous curvilinear capsulotomy routinely due to the frequent refractive changes.
(CCC) is challenging as the anterior capsule is
more elastic. Rhexis should be aimed as small as Conclusion:
possible. The desirable size is 5.0 to 5.5 mm in Management of paediatric cataract is
diameter. It is preferable to use a cohesive challenging, if not treated early, may be
vicoelastic agent. Maximum removal of cortex associated with dismal results. However early
and lens epithelial cells from the equatorial surgery combined with appropriate refractive
region is essential. Cortical material is aspirated correction and aggressive amblyopic therapy
using two port irrigation-aspiration (IA). usually provide encouraging results. The role of
As Posterior capsular opacification parents is as important as the paediatric
(PCO) is the most frequent complication after a ophthalmologist for optimum visual outcome.
successful surgery in children, primary posterior
capsulotomy with anterior vitractomy needs to
be done [8,9].
References:
1. Jagat Ram, Crrent Surgical Techniques for Pediatric
An ideal PCCC should be around 3-4 mm Cataract Surgery, Ready Reckoner in
circular ring and should be performed under the Ophthalmology 2010, p 179-182.
age of 6 years. Most surgeons prefer doing 2 . GVS Murthy, N Jhon, SK Gupta, P Vashist, GV Rao;
anterior vitrectomy to decrease the PCO, stabilise Status of pediatric Eye care in India; Indian Journal
the IOL and vitreous prolapsed in the anterior of Ophthalmology 2008: Vol 56, Issue 6 ,pp 481-88
chamber. The vitrectomy may be performed 3. Rishikesh Mayee , Pediatric Cataract- Management
using limbal or pars plana route. Options, DOS Times- Vol. 15, No. 8, February 2010.
Capsular bag implantation is the best 4 . Ram J, Brar GS. Textbook of Pediatric Cataract
Surgery , Jaypee Brothers, New Delhi, 2006.
choice. Hydrophobic acrylic, foldable lens are
5. Dahan E. Intraocular Lens implantation in children.
preferred now a days [10,11]. Some surgeons Curr Opin Ophthalmol. 2000 Feb; 11(1): 51-5.
prefer optic capture, whereby haptics are placed 6. Chee KY, Lam GC. Management of congenital cataract
in the bag and optic is pushed through the PCCC. in children younger than 1 year using a 25-gauge
The principle behind the optic capture is to avoid vitractomy system. J Cataract Refract surg. 2009
the need for vitrectomy and better IOL Apr;35(4):720-4.
centration. 7. Bayramlar H, Colak A. Advantages of the sclera
All incisions should be closed with a incisions in pediatric cataract surgery. J Cataract
suture because of lower scleral rigidity with Refract Surg. 2005 Nov;31(11):2039.
8. Dholakia SA, Praveen MR, Vasavada AR, Nihalani B.
higher risk of fish mouthing of the incision.
Completion rate of primary posterior continuous
For secondary IOL in paediatric aphakia, curvilinear capsulorhexis and vitreous disturbance
the IOL is can be implanted in the sulcus, and during congenital cataract surgery. J AAPOS. 2006
very rarely into the capsular bag. PMMA lenses Aug;10(4):351-6.
are preferred over acrylic IOLs for lesser chances 9. Hardwig PW, Erie JC, Buettner H. Preventing
of decentration [12]. recurrent opacification of the visual pathway after
Post-Operative Management: pediatric cataract surgery. J AAPOS.2004
Pediatric eye tends to show more tissue De;8(6):560-5.
reaction and chances of fibrinous reactions are 10. Nihalani BR, Vasvada AR. Single-piece AcrySof
intraocular lens implantation in children with
significantly high. Hence post-operative
congenital and developmental cataract. J Cataract
management include frequent instillation of high Refract Surg. 2006 Sep; 32(9):1527-34.
potent topical steroid like prednisolone acetate 11. Aasuri MK, Fernandes M, Pathan PP. Comparison of
and a cycloplegic agent. If required systemic acrylic and polymethyl methacrylate lenes in a
steroid have to be administered. pediatric population. Indian J Ophthalmol. 2006
Visual Rehabilitation: Jun; 54(2): 105-9.
Visual rehabilitation is as important as 12. Trivedi RH, Wilson ME Jr, Facciani J. Secondary
surgery itself. Amblyopic therapy should be intraocular lens implantation for pediatric
instituted meticulously. Children <2 years aphakia. J AAPOS. 2005 Aug;9(4): 346-52.
retinoscopy is done on the table after surgery -------------------------------------------------
and prescribe glass immediately. Occlusion

International Journal of Current Medical And Applied Sciences [IJCMAAS] volume 5, Issue 1.