Accepted Manuscript

The timing of surgery for congenital cataracts

Nihal Mohammad El Shakankiri, MD, Nader Hussein Lotfy Bayoumi, MD

PII: S1091-8531(16)30068-4
DOI: 10.1016/j.jaapos.2016.04.002
Reference: YMPA 2411

To appear in: Journal of AAPOS

Received Date: 28 March 2016

Accepted Date: 11 April 2016

Please cite this article as: El Shakankiri NM, Bayoumi NHL, The timing of surgery for congenital
cataracts, Journal of AAPOS (2016), doi: 10.1016/j.jaapos.2016.04.002.

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 ACCEPTED MANUSCRIPT

<banner>Points of View

Does delayed surgery for congenital cataracts prevent aphakic glaucoma?

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<banner>Points of View

<title>The timing of surgery for congenital cataracts

<subtitle>Delayed surgery for best surgical outcomes

Nihal Mohammad El Shakankiri, MD, and Nader Hussein Lotfy Bayoumi, MD

Author affiliations: Ophthalmology Department, Faculty of Medicine, Alexandria University,

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Egypt

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Congenital cataract surgery in children is a major technical challenge and a demanding

surgical skill. Among the long list of complications associated with the procedure, glaucoma

stands out as a major threat and a potentially blinding condition. After all, complications such

as amblyopia, late refractive surprises, nystagmus, and the like are potentially treatable, at

least partially, and their worst-case scenarios leave an eye with visual acuity that is at least

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better than light perception—a privilege obviously denied in the case of glaucoma. The

reported incidence of glaucoma after congenital cataract surgery1-3 is in the range of 5% to

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41%. This figure increases with coexisting ocular anomalies such as microphthalmia, in

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which a recent report4 denotes a 30% incidence, and congenital rubella syndrome5 in which

an incidence of 43% is reported. The exact etiology (or etiologies) of glaucoma after

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congenital cataract surgery is not exactly known. However, implicated factors include
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abnormal biometric characteristics (eg, microcornea/microphthalmia), poor surgical
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technique, and excessive postoperative inflammation, among others.

Two major distinctions have to be made: disease conditions encompassing both

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congenital cataract and glaucoma on presentation (eg, Lowe syndrome) and in which the
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occurrence of glaucoma is independent from the surgery from cataract, and glaucoma that

develops de novo after an operation for congenital cataract. This latter group deserves a word
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of caution: the surgical technique for congenital cataract is highly variable in different parts
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of the world and among different surgeons. Studies are thus not quite comparable across
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different institutions and study groups. The newborn child’s eye is markedly different from

an adult eye and undergoes considerable changes in the first few months of life. Scleral

rigidity is remarkably low in the newborn and increases tremendously with growth, a factor

significantly affecting vitreous pressure in any intraocular procedure. The lens capsule

elasticity undergoes immense changes in the first few months of life relating almost

exponentially to the ease of its manipulation. The development of the pupil sphincter has
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serious implications on pupil dilatation, a major obstacle to lens surgery at all ages.

The current practice guidelines in Alexandria University include an exhaustive list of

considerations, all of which are related almost linearly to a child’s age. To start with, deep

anaesthesia by a skilled pediatric anesthesiologist is mandatory for a low vitreous pressure,

which is a basic requirement for anterior vitrectomy after a posterior continuous curvilinear

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capsulorrhexis (PCCC) during congenital cataract surgery and a mandatory step in the current

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Alexandria congenital cataract surgery protocol. The older the child, the easier and more

controllable is the depth of anesthesia. Adequate pupil dilatation—another age related issue—

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cannot be overemphasized. Noteworthy with regard to this issue is the fact that although

mechanical means of pupil dilatation are available, the greater the intraoperative

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manipulations, the greater the postoperative inflammation and hence the greater the
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likelihood of glaucoma. A manual, controlled, adequately sized, anterior continuous
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curvilinear capsulorrhexis (ACCC) and PCCC is mandatory in our practice, because this

facilitates in-the-bag placement of the intraocular lens (IOL), the IOL location anatomically
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associated with the least contact with uveal tissue (iris chaffing) and hence with the least
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postoperative inflammation and pigment dispersion, and, consequently, glaucoma. Having

touched on the topic of intraoperative manipulations, it is of utmost importance to stress the

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least possible manipulations. This entails the least anterior chamber (AC) fluctuation, ensured
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by adequate, controlled deep anesthesia in addition to the use of high viscosity viscoelastics
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and small corneal wounds.

Aphakic glaucoma remains a lifelong risk after surgery for congenital cataract.

Delayed surgery, roughly to beyond the third month of life, decreases the likelihood of

aphakic glaucoma, although the exact cut-off age limit for safety remains speculative and a

matter of considerable debate.

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References

1. Mills MD, Robb RM. Glaucoma following childhood cataract surgery. J Pediatr

Ophthalmol Strabismus 1994;31:355-60.

2. Sahin A, Caça I, Cingü AK, et al. Secondary glaucoma after pediatric cataract

surgery. Int J Ophthalmol 2013;6:216-20.

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3. Nagamoto T, Oshika T, Fujikado T, et al. Surgical outcomes of congenital and

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developmental cataracts in Japan. Jpn J Ophthalmol 2016;60:127-34.

4. Praveen MR, Vasavada AR, Shah SK, Khamar MB, Trivedi RH. Long-term

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postoperative outcomes after bilateral congenital cataract surgery in eyes with

microphthalmos. J Cataract Refract Surg 2015;41:1910-18.

5.
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Shah SK, Praveen MR, Vasavada AR, et al. Long-term longitudinal assessment of
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postoperative outcomes after congenital cataract surgery in children with
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congenital rubella syndrome. J Cataract Refract Surg 2014;40:2091-8.

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