Journal of the Formosan Medical Association (2017) 116, 940e945

Available online at www.sciencedirect.com

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ORIGINAL ARTICLE

Outcomes of pediatric cataract surgery with

triamcinolone-assisted vitrectomy
Tzu-Hsun Tsai a,b, Chia-Ying Tsai a, Jehn-Yu Huang a,c,
Fung-Rong Hu a,c,*

a
Department of Ophthalmology, National Taiwan University Hospital, Taipei, Taiwan, Republic of
China
b
Graduate Institute of Clinical Medicine, College of Medicine, National Taiwan University, Taipei,
Taiwan, Republic of China
c
Department of Ophthalmology, National Taiwan University College of Medicine, Taipei, Taiwan,
Republic of China

Received 24 November 2016; received in revised form 12 January 2017; accepted 17 January 2017

KEYWORDS Background/Purpose: To evaluate outcomes in pediatric patients undergoing lensectomy, pos-

anterior vitrectomy; terior capsulotomy, and triamcinolone-assisted vitrectomy for congenital cataract.
pediatric cataract; Methods: This retrospective study included 34 patients younger than 72 months who under-
triamcinolone went lensectomy, posterior capsulotomy, and triamcinolone-assisted vitrectomy with or
acetonide without intraocular lens (IOL) implantation for cataract at the National Taiwan University Hos-
pital from July 2006 to December 2012.
Results: Fifty-one eyes from 34 patients with cataract (unilateral in 17 patients, bilateral in 17
patients) were included. The mean age at surgery was 26.74 months (range: 2e72 months).
The mean postoperative follow-up was 27.8 months (range: 6e72 months). Primary IOL implan-
tation was performed in 25 eyes, 21 of which had the IOL implanted in the capsular bag. Fifty
eyes had a central round pupil. The median logarithm of the minimum angle of resolution vi-
sual acuity was 0.3 in patients with unilateral cataract and 0.1 in those with bilateral cataract.
Three eyes (5.9%) developed visual axis opacification (VAO) and required further surgery. Uni-
variate analysis using Fisher’s exact test indicated that surgery in the first 12 months of life was
significantly associated with development of VAO (p Z 0.047). The incidence of postoperative
VAO was approximately 15.8% in this age group.
Conclusion: Triamcinolone-assisted vitrectomy can be used in pediatric cataract surgery
without serious long-term adverse effects. While the incidence of VAO is low, it appears un-
avoidable in approximately one-sixth of patients who undergo surgery before 12 months of age.
Copyright ª 2017, Formosan Medical Association. Published by Elsevier Taiwan LLC. This is an open
access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

Conflicts of interest: No author has a financial or proprietary interest in any material or method mentioned.
* Corresponding author. Department of Ophthalmology, National Taiwan University Hospital, 12F, No. 7, Zhongshan South Road, Taipei
City, 100, Taiwan, Republic of China.
E-mail address: fungronghu@ntu.edu.tw (F.-R. Hu).

http://dx.doi.org/10.1016/j.jfma.2017.01.009
0929-6646/Copyright ª 2017, Formosan Medical Association. Published by Elsevier Taiwan LLC. This is an open access article under the
CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
Triamcinolone-assisted vitrectomy in children
Introduction
Childhood cataract is one of the leading causes of blindness
and severe visual impairment in children, and is problem-
atic in developing countries in terms of morbidity, eco-
nomic loss, and social burden.1 The prevalence of childhood
cataract is estimated to be 1.03 per 10,000 children, and
approximately 314,000 new cases are reported each year.2
Although surgically treatable, management of cataract in
children is challenging because of the increased elasticity
of the ocular tissues, robust inflammatory reactions, and a
more reactive vitreous face.3,4 The rate of posterior
capsular opacification following simple cataract extraction
is high,5 so combined lens extraction, posterior capsu-
lotomy, and anterior vitrectomy are routinely performed in
younger patients.6,7 Complications, including pupil syn-
echia, intraocular lens (IOL) decentration, and visual axis
opacification (VAO), still occur despite modern surgical
techniques. Appropriate vitreous management during sur-
gery is crucial for successful pediatric cataract surgery.
Triamcinolone acetonide (TA) is a water-insoluble steroid
molecule, granules of which become trapped in the gel-like
structure of the vitreous upon intraocular injection and
enhance visualization of the vitreous.8 TA has been used in
vitreoretinal surgery to stain the transparent vitreous,
which assists surgeons in separating the posterior vitreous
from the retina.9,10 In cataract surgeries complicated by
rupture of the posterior chamber, TA can be applied in the
anterior chamber to render the prolapsed vitreous more
visible.11 Triamcinolone-assisted vitrectomy in pediatric
cataract surgery was first described in 2009 by Shah et al.12
In a subsequent 1-year retrospective study, use of intra-
cameral triamcinolone in pediatric cataract surgery was
associated with less inflammation of the anterior chamber,
and no patients developed VAO postoperatively.13
In this study, we evaluated the visual outcomes of pe-
diatric cataract surgery with triamcinolone-assisted vit-
rectomy and analyzed the incidence of and risk factors for
complications following this technique.
Methods
Data were collected retrospectively from 34 patients with
congenital cataract who underwent lensectomy, posterior
capsulotomy, and triamcinolone-assisted anterior vitrec-
tomy between July 2006 and December 2012. All patients
were younger than 72 months at the time of treatment. All
surgeries were performed by the same surgeon (THT) at the
National Taiwan University Hospital, Taipei, Taiwan. The
Ethics Review Committee at the National Taiwan University
Hospital approved the study. Written informed consent was
obtained from all guardians/caregivers. All patients un-
derwent surgery soon after a diagnosis of cataract was
confirmed. We excluded patients with a concurrent retinal
or corneal abnormality and those with a systemic metabolic
disorder. All patients were followed up for more than 6
months postoperatively.
The surgical technique began with a clear corneal
incision at 10 o’clock. Using the two-handed-technique, a
second clear corneal stab incision was then made using a
microvitreoretinal blade at 2 o’clock for accommodation
941
of a handheld irrigation instrument. After injection of 1.4%
sodium hyaluronate (Healon GV; Advanced Medical Optics,
Santa Ana, CA, USA), an anterior capsulotomy was per-
formed manually using a bent 27-gauge needle and a
microcapsule forceps. Hydrodissection was performed via
injection of a balanced salt solution into the peripheral
cortex through a 30-gauge cannula. A 20-gauge vitrector
handpiece was used to remove lens material and perform
the posterior capsulotomy and anterior vitrectomy. The TA
was prepared as follows: 0.3 mL of TA suspension (40 mg/
mL, Kenalog-40 injection; Bristol-Myers Squibb Company,
Princeton, NJ, USA) was drawn into a sterile 1 mL syringe
attached to a 27-gauge needle after shaking the ampoule
to disperse the TA particles evenly. Next, the syringe was
positioned upside down, which allowed the TA crystals to
precipitate against the plunger in the lower portion of the
syringe. The supernatant was then discarded from the
syringe by slowly advancing the plunger to the 0.05 mL
mark. Finally, the needle was discarded and sterile
balanced saline solution was drawn into the syringe to the
1 mL mark. Approximately 0.1e0.2 mL of TA was injected
through a clear corneal incision to stain the anterior vit-
reous for improved visualization prior to vitrectomy; a
further injection was administered to confirm the absence
of residual vitreous strands. A foldable three-piece or one-
piece AcrySof IOL (MA60AC or SA60AT, respectively; Alcon,
Fort Worth, TX, USA) was implanted in the capsular
bag after injection of the viscoelastic material, mainly in
the patients aged 2 years and older. The corneal wounds
were sutured using 10-0 nylon (Alcon, Fort Worth, TX,
USA).
Postoperatively, a 1% prednisolone acetate ophthalmic
suspension (1%, Pred Forte; Allergan, Westport, County
Mayo, Ireland) was applied hourly for 3 days, and thereafter
four times daily for the following week. This was then
substituted with a 0.1% betamethasone disodium phosphate
ophthalmic solution (0.1%, Rinderon; Taiwan Shionoqi & Co.,
Ltd., Taipei, Taiwan) for 1 month. A 0.3% gentamicin
ophthalmic solution (0.3%, Garamycin; Schering-Plough,
Brussels, Belgium) was applied four times a day for 1 month,
and an ophthalmic ointment combining a steroid and anti-
biotic (neomycin and polymyxin B sulfates, and dexameth-
asone; Maxitrol; Alcon, Fort Worth, TX, USA) was used once
a day at bedtime for 1 week.
Cycloplegic refraction was performed during follow-up
visits at 1 day, 1 week, 1 month, and every 3 months
thereafter postoperatively, and spectacles were prescribed
if necessary. Intraocular pressure (IOP) was measured using
a Tono-Pen (Reichert Ophthalmic Instruments, Depew, NY,
USA). VAO was evaluated under a slit lamp, and a red reflex
examination was performed using a retinoscope. VAO was
defined as a fibrous or proliferative cell growth that was
either observed under retroillumination or led to a dull
retinoscopic reflex. Examination under anesthesia was
performed in patients who could not tolerate examination
in the outpatient clinic.
For further analysis of the incidence and risk factors
leading to complications, patients were divided into two
groups based on their age at surgery, i.e.,
or > 12
months. Data were collected on position of IOL implanta-
tion, pupil centration, visual acuity (if measurable) during
follow-up visits, presence of increased IOP, and VAO.
942 T.-H. Tsai et al.

The statistical analysis was performed using SPSS version

Table 2 Risk factor analysis for visual axis opacification
17.0 software for Windows (SPSS Inc., Chicago, IL, USA).
(VAO).
The categorical data were tested for statistically significant
differences using the Chi-square test or Fisher’s exact test. VAO (þ) VAO (e) p
Continuous data were analyzed using the Mann-Whitney U (3 eyes) (48 eyes) (two-sided)
test because the data were found not to be normally Male/Female 1/2 28/20 0.571a
distributed. Statistical significance was set at p < 0.05. OD/OS 1/2 24/24 > 0.99a
Age at OP (months)b 9.3  4.6 28.4  22.2 0.186c
Results
/> 12 months 3/0 16/32 0.047*a
First IOL
No/Bag/Sulcus 3/0/0 23/22/3 0.216d
We evaluated 51 eyes of the 34 patients recruited for this
Post-OP high IOP
study. Table 1 summarizes the patient demographic data
No/Yes 2/1 45/3 0.221a
grouped according to age at time of surgery. Follow-up ex-
aminations were performed, on average, 27.8 months (range IOL Z intraocular lens; IOP Z intraocular pressure; OD Z right
6e72) following surgery. Primary IOL implantation was per- eye; OP Z operation; OS Z left eye.
formed in 25 eyes, and 21 (84%) had the IOL implanted in the * Indicates statistical significance.
a
By Chi-square test.
bag. Postoperatively, 50 eyes (98%) had a central round b
Data presented as mean  standard deviation.
pupil. Only three eyes (5.9%) developed VAO that required c
By Mann-Whitney U test.
further surgery. The subgroup analysis included 19 eyes of 12 d
By Fisher’s exact test.
patients who had undergone surgery at 12 months or
younger and 32 eyes of 22 patients who had undergone
surgery at older than 12 months. There was no statistically
significant difference in sex or laterality between the two patients with unilateral cataract and 0.1 in those with
subgroups. The VAO rate was 15.8% in patients younger than bilateral cataract (Table 3, Table 4; Figure 1A,B). Eight
12 months at the time of surgery. The mean time until patients had strabismus prior to cataract surgery. At the
detection of postoperative VAO was 1 month. No patient end of follow-up, 12 patients were observed to have
aged over 12 months at the time of surgery, either with or strabismus.
without IOL implantation, required further surgery for
management of VAO during follow-up. Patients under 12
months of age were found to have a significantly higher risk Discussion
of developing VAO postoperatively (p Z 0.047; Table 2).
Increased IOP was observed in three patients after sur- This retrospective study evaluated the outcomes of cata-
gery. One patient showed a transient increase in IOP for ract surgery with triamcinolone-assisted vitrectomy in
1 day postoperatively because of residual viscoelastic sub- patients younger than 72 months of age. Satisfactory out-
stance. Another patient developed glaucoma at 4 years old comes were achieved, including improved postoperative
(3 years and 8 months after surgery). The third patient had visual acuity, a low complication rate with a high propor-
congenital glaucoma and underwent trabeculectomy after tion of in-the-bag IOL (84%), and intact pupillary configu-
cataract surgery. No patients developed endophthalmitis or ration (98%). The only significant risk factor for VAO was a
retinal detachment during the study period. younger age at surgery; undergoing surgery before 12
Best corrected visual acuity (BCVA) was measurable in 30 months of age was associated with a higher incidence of
eyes postoperatively. More than half (70%) of the eyes had a VAO.
BCVA better than 0.3 logMAR (logarithm of the minimum VAO or posterior capsular opacification is the most
angle of resolution) and 43.3% had a BCVA better than 0.1. frequent complication following cataract surgery in
logMAR. The median logMAR visual acuity was 0.3 in children.5,14 In addition to the intense postoperative

Table 1 Patient demographic data.

Age (months)
12 > 12 Total p
Patients (n) 12 22 34
Unilateral/Bilateral 5/7 12/10 0.473a
Female/Male 6/6 10/12 0.800a
Age at surgery (months)b 5.7  3.2 42.0  17.9 29.2  22.7 < 0.001*c
Eyes (n) 19 32 51
OD/OS 9/10 16/16 0.856a
VAO 3 0 0.047*d
OD Z right eye; OS Z left eye; VAO Z visual axis opacification.
* Indicates statistical significance.
a
By Chi-square test.
b
Data are presented as mean  standard deviation.
c
By Mann-Whitney U test; dBy Fisher’s exact test.
Triamcinolone-assisted vitrectomy in children 943

Table 3 Postoperative visual acuity in patients with unilateral cataract according to age at examination.
VA/age (months) 36e47.9, n (%) 48e59.9, n (%) 60e71.9, n (%) >72, n (%) Total, n (%)
<20/100 (logMAR 0.7) 2 (40) 0 0 0 2 (16.7)
20/100e20/40 (logMAR 0.7e0.3) 0 0 2 (100) 1 (25) 3 (25)
20/40e20/25 (logMAR 0.3e0.1) 3 (60) 0 0 1 (25) 4 (33.3)
>20/25 (logMAR 0.1) 0 1 (100) 0 2 (50) 3 (25)
logMAR Z logarithm of the minimum angle of resolution; VA Z visual acuity.

Table 4 Postoperative visual acuity in patients with bilateral cataract according to age at examination.
VA/age (months) 36e47.9, n (%) 48e59.9, n (%) 60e71.9, n (%) >72, n (%) Total, n (%)
<20/100 (logMAR 0.7) 0 1 (16.7) 0 0 1 (5.6)
20/100e20/40 (logMAR 0.7e0.3) 2 (100) 1 (16.7) 0 0 3 (16.7)
20/40e20/25 (logMAR 0.3e0.1) 0 2 (33.3) 2 (50) 0 4 (22.2)
>20/25 (logMAR 0.1) 0 2 (33.3) 2 (50) 6 (100) 10 (55.6)
logMAR Z logarithm of the minimum angle of resolution; VA Z visual acuity.

been routinely performed during recent decades in children

Figure 1 Visual acuity in patients following surgery accord-
ing to age. (A) Patients with unilateral cataract. (B) Patients
with bilateral cataract.
inflammatory response in young children, the reactivity of
epithelial cells in the lens is high, and both lead to the
proliferation of a fibrous membrane on the anterior surface
of the vitreous and development of VAO.14,15 Preventing
VAO in young children is critical because VAO impedes vi-
sual rehabilitation. Secondary membranectomy or Nd:YAG
laser capsulotomy under general anesthesia is required if
VAO is severe enough to hinder visual rehabilitation.5 Pri-
mary posterior capsulotomy and anterior vitrectomy have
younger than 6 years receiving cataract surgery, and have
decreased the incidence of VAO.6,7,16,17 The reported inci-
dence of VAO following these techniques varies from 9.2%
to 37.9%,7,15,18e21 depending on the patient inclusion
criteria used, choice of IOL implant, and duration of follow-
up. Instead of performing manual posterior continuous
curvilinear capsulorhexis, we used a vitrector to perform
the posterior capsulotomy because we considered vitrec-
torhexis to be an easier and more predictable method
that can be performed without needing to fill extra
ophthalmic viscosurgical devices. Moreover, using vitrec-
torhexis, anterior vitrectomy can be performed with the
same vitrector following completion of capsulotomy,
thereby preventing fluctuation of the anterior chamber
pressure during change of instruments.
Identification of the vitreous during anterior vitrectomy
is difficult because of its transparent appearance; thus, it is
also difficult to know if this step of the procedure has been
appropriately completed. Vitrectomy using triamcinolone
staining was first developed by Burk et al.22 in 2003, and has
proven useful for direct observation of vitreous behavior.
Shah et al.12 introduced this technique into pediatric
cataract surgery in 2009, and it was found to be safe and
effective in subsequent studies.13,23 We also found a low
incidence of VAO using this technique; however, the risk
was not entirely eliminated. Our findings indicated that
undergoing cataract surgery in the first year of life was
associated with an increased postoperative risk of devel-
oping VAO (p Z 0.047). Other variables, including gender,
laterality, whether the IOL implant was primary or sec-
ondary, and increased IOP after surgery were not significant
risk factors for development of VAO. IOL implantation is
widely considered to be a risk factor for VAO.24e27 The in-
flammatory reaction is higher in young children after im-
plantation of an IOL and the biocompatibility of the
material used in the IOL affects the appearance of VAO.26
However, in this study, no patient older than 12 months,
regardless of whether or not an IOL was implanted, devel-
oped VAO after surgery. Children younger than 12 months of
944
age have robust postoperative inflammatory responses and
highly active lens epithelial cells that proliferate rapidly
and migrate across the central visual axis to form VAO.
Moreover, in the smaller eyes, it was more difficult to judge
the appropriate size of the posterior capsulotomy, so the
need for a sufficiently clear visual axis had to be weighed
against that of adequate capsular support for future IOL
implantation. In the group of patients who underwent sur-
gery when aged younger than 12 months, we did not find
any common characteristics in the 3 eyes that developed
VAO when compared with the 16 other eyes. However, all 3
eyes were found to have VAO within 1 month post-
operatively, which might be related to an inadequately
sized posterior capsulotomy.
Steroids were shown to decrease vascular permeability
and stabilize damage at the blood-retinal barrier by sup-
pressing vascular endothelial growth factor and prostaglan-
dins.28 Intraocular triamcinolone injections are widely used
for macular edema caused by retinal vascular disease or
uveitis to reduce the inflammatory reaction.29e31 Use of
intracameral triamcinolone is reported to decrease inflam-
mation of the anterior segment postoperatively in children
who have undergone surgery for traumatic cataract32 and is
associated with a lower rate of cystoid macular edema and
residual vitreous strands in the anterior chamber in adult
patients with cataract and a posterior capsule rupture.11
There has been a report of preservatives such as benzyl
alcohol in TA suspensions leading to the necrosis of cells in the
retinal pigment epithelium and triggering mitochondrial
apoptosis.33 To reduce the risk of cytotoxic effects on intra-
ocular tissue, we removed the vehicles prior to diluting the TA
and injected only 1e3 mg, which is within the safe dose range
stated in the animal study.34 Further, Spitzer et al.35 reported
that TA only has cytotoxic effects in the retina when there is
close contact between the TA crystals and the cell mem-
brane. Most of the TA granules were removed along with the
vitreous during the vitrectomy, thus decreasing the chance of
direct contact between TA and retinal cells.
Three of our patients had increased IOP following sur-
gery. Aside from one patient with congenital glaucoma and
another with residual viscoelastic substance, one patient
developed aphakic glaucoma 3 years and 8 months post-
operatively. The timing of onset of glaucoma in this patient
suggests that an association with TA is unlikely. Ventura
et al.36 also found that injection of TA at the end of surgery
for congenital cataract in children younger than 2 years did
not significantly affect IOP or central corneal thickness in
the year following surgery. However, Wilson et al.37 re-
ported a case of bilateral cataracts with glaucoma in one
eye, which had retained TA. Removing all of the TA granules
at the end of vitrectomy is important, not only to reduce
the cytotoxicity of TA but also to reduce the risk of
elevated IOP.
The main limitations of our study are its retrospective
nature and the lack of a control group. However, this study
does provide long-term follow-up information for thorough
evaluation of this surgical technique and can serve as a
reference in clinical practice. Further prospective, ran-
domized, larger-scale studies are necessary for better
assessment of this surgical technique.
In conclusion, staining with TA facilitates identification of
vitreous strands in pediatric cataract surgery without serious
T.-H. Tsai et al.
long-term adverse effects. The antiinflammatory effect of
TA might play a role in the prevention of postoperative VAO.
Age at the time of surgery is related to the incidence of VAO.
Although the incidence of visual obscuration is low, it re-
mains unavoidable in approximately one-sixth of patients
who undergo surgery before 12 months of age.
Acknowledgments
This work was supported by the Ministry of Science and
Technology, R.O.C. (NSC 102-2420-H-002-016-MY2).
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