Learn from the Masters: Tips & Tricks in the Management of Pediatric Cataract 1

Dr Sowmya R
Published Online: April 1st, 2021 | Read Time: 46 minutes, 21 seconds

Cataracts in children are one of the most common cause of avoidable blindness. The incidence is in the range of 1.8 to 3.6/10,000 per year and the prevalence is about 1.03 per 10,000 children (0.32– 22.9/10,000). Management at the right time and the right way goes a long way in rehabilitating them . To understand the current practices in management of pediatric cataract Dr. Sowmya R. spoke to a few experts across India.

Dr. Bharti Gangwani (Bharti Nihalani) is a practicing Pediatric Ophthalmologist, Assistant Professor of Ophthalmology and also the Director of Clinical Research for the department of Ophthalmology at Boston Children’s Hospital, Harvard medical school. She is actively involved in teaching Pediatric Ophthalmology to the residents and fellows. She has about 50 publications in peer and non-peer reviewed journals, books and review articles. She is a co-editor of a renowned book in strabismus management called “Learning strabismus surgery-A case-based approach”. She has focused her clinical expertise and research in pediatric cataract and pediatric uveitis.

Dr. Kalpana Narendran heads the Department of Cataract and Paediatric Ophthalmology and strabismus in Aravind Eye Hospital, Coimbatore since 1997 and has experience in performing more than 2000 pediatric cataract surgery and around 3000 squint surgeries. She has done observership at Johns Hopkins – Wilmer, Wills Eye Hospital, Philadelphia and Julies Stein Eye Institute, LA. She has presented in national and international conferences and has numerous publications to her credit. She has trained numerous residents and fellows in pediatric ophthalmology and strabismus over the years

Dr. Sudarshan Kumar Khokhar is currently working as Professor and Head of unit at Rajendra Prasad Centre, All India Institute of Medical Sciences New Delhi, India. He has expertise in Pediatric cataracts and complicated adult cataracts with over 100 indexed publications in peer-reviewed journals and has six chapters in Textbooks. He has been conducting instruction course on Pediatric cataracts in different national and international conferences. He is the designer of “Khokhar’s capsular painting cannulaand pioneer in using aPlasma blade in PFV eyes. He has more than 20 years of clinical teaching and Research experience at AIIMS

Dr. Sujata Guha is consultant in dept of pediatric ophthalmology and strabismus and heads the Kolkata branch of Sankara Nethralaya .Being an enthusiastic teacher, she introduced residency and fellowship programmes in SN Kolkata and has trained many ophthalmologists from all over the country. Her special interest is a pediatric cataract and complex strabismus. She is one of the most prolific pediatric cataract surgeons in Sankara Nethralaya.She has published various papers in national and international journals and has delivered various talks in national as well as international conferences.

Dr. Sumita Agarkar is consultant and deputy director of the department of pediatric ophthalmology and strabismus in sankara Nethraya , Chennai. She was trained in pediatric ophthalmology at Aravind eye hospital, post which she joined Sankara nethralaya. She is prolific teacher and trained numerous fellows in pediatric ophthalmology and strabismus. She has around 35 publications in peer-reviewed journal and contributed 6 chapters in various textbooks .

Dr. Vaishali Vasavada is currently working as a consultant ophthalmologist at Raghudeep Eye Hospital, Jaipur and Ahmedabad. Her area of expertise is in the management of complex cases of adult and pediatric cataracts. She has more than 20 peer reviewed publications in national and international journals. She is a reviewer for peer reviewed journals, including the Journal of Cataract & Refractive Surgery and Eye.

eOphtha: What are the common causes of cataract in pediatric age group in your institute?

Dr. Bharti Gangwani: We recently analyzed the causes of cataract in patients <18 years of age at our tertiary care center.In bilateral cataracts, 34% were idiopathic, 22% hereditary, 24% had systemic/metabolic/genetic causes, 15% had treatment of cancer/conditions requiring steroids and 5% has ocular dysmorphology. In contrast in patients with unilateral cataracts, 45% were idiopathic, 50% had ocular dysmorphology (including trauma) and only 5% had systemic causes.

Dr Kalpana Narendran : The common cause would be congenital (familial, idiopathic), developmental, rubella and trauma

Dr. Sudarshan Khokhar: In bilateral cases, familial cataract and TORCH infection are fairly common identified cause. Unilateral congenital cataracts which we get, almost one third to one half are persistent fetal vasculature (PFV) related. Traumatic cataracts are the commonest acquired unilateral cataracts in children.

Dr Sujatha Guha :The most common cause of cataract we see is idiopathic. This is followed by Rubella and other TORCH infections followed by hereditary and metabolic cataracts. Traumatic cataracts are also commoniy seen. However idiopathic cataracts are the most common type we encounter.

Dr Sumita Agarkar : Ours is a tertiary care institute so we do see a fair number of cataracts most are idiopathic or in other words we don’t do enough investigations to find out the cause as cost of testing is often prohibitive. We do see lots of infants with cataracts resulting due to intrauterine infections Third most important cause is familial or autosomal dominant cataract

Dr. Vaishali Vasavada: The commonest cause of cataract in our practice appears to be idiopathic. Most times we do are unable to isolate a cause for the cataract. However, following this, rubella (TORCH) infections, malnutrition appear to be the next common causes, followed by familial patterns of cataracts in young age

To summarise, Common causes of bilateral cataract in children are idiopathic, TORCH infections, AD inheritance and inborn errors of metabolism. Trauma and PFV constitute for majority of unilateral cataracts in children

eOphtha: What is your approach to a 1 month old child presenting with bilateral congenital cataract in terms of clinical assessment and investigations?

Dr. Bharti Gangwani: I inquire about birth history, family history of congenital cataract and medical history when I see the child first time in the clinic. All babies in Massachusetts undergo newborn screening for 32 disorders including galactosemia, metabolic disorders, hemoglobinopathies, cystic fibrosis etc. If the child has any systemic associations or unusual morphologic features, I advise genetic evaluation and additional testing is performed by the geneticist.

The visual acuity assessment is limited to blink to light at this age. I perform anterior segment exam with handheld slit lamp, measure intraocular pressure (IOP) and note the presence of strabismus and nystagmus. I dilate the baby to attempt refraction and perform posterior segment exam. B scan ultrasonography is done if there is poor view to the posterior segment.

I perform examination under anesthesia (EUA) on the day of surgery, that includes measurement of corneal diameter to rule out microcornea, intraocular pressure (IOP), posterior segment evaluation with fully dilated pupils to look for preexisting posterior capsule defect (PCD), keratometry (K) and axial length (AL) measurement in both eyes.

Dr Kalpana Narendran: The clinical assessment would be to check the anterior segment with detailing on corneal diameter, anterior segment dysgenesis, retinal evaluation, USG B scan, other abnormalities, systemic associations, investigations like torch titers, parent and sibling screening for cataract

Dr. Sudarshan Khokhar: A detailed history should be elicited including the symptoms noticed such as white reflex, abnormal eye movements and difficulty in following objects. Systemic history and gestational history should be taken; which may suggest metabolic or infective etiology. Family history is must and we also assess the parents after dilating their pupil for lenticular abnormalities and refractive errors. We have picked up few cases of Nance Horan syndrome as mothers had asymptomatic sutural cataracts

Clinical examination can be performed in outpatient department using torch light or distant direct ophthalmoscopy. My personal preference is distant direct examination which allows to visualize the red glow (Bruckner’s reflex), cataract, its location, size, glow around the cataract and any abnormal size of cornea or anterior chamber dysgenesis etc.

Vision can be assessed using Cardiff or Teller acuity testing. Morphology of cataract may provide clues to diagnosis such as oil droplet cataract in galactosemia, Total cataract in traumatic and partially absorbed with synechia in infective etiologies. Associated ocular abnormality such microphthalmos, non-dilating pupil, retinopathy may suggest infective etiology. Density and location are helpful in determining need for surgery. Abnormal ocular movements should be noted for prognostication. Systemic examination to look for cardiac, neurological or developmental abnormalities is to be performed. Systemic investigations should be tailor made according to the suspicion.

Sleeping IOP should be performed with a tonopen. USG should be performed to rule out retinal pathology including retinal detachment and retinoblastoma. Examination under anesthesia should be performed for Axial length, keratometry, corneal diameter (white to white) and UBM (ultrasound bio microscopy) if surgery is warranted. This can be done in the same sitting, meaning that you plan and examination and follow by surgery. Thus, consent has to be taken before hand itself

The clinical assessment would be to check the anterior segment with detailing on corneal diameter, anterior segment dysgenesis, retinal evaluation, USG B scan, other abnormalities, systemic associations, investigations like torch titers, parent and sibling screening for cataract.

Dr Sujatha Guha : When an infant presents with bilateral cataract we first assess the visual response of the child in terms of CSM. We try to asses if the child follows light with each eye and how briskly the child does so. Although this may not be possible always in 1 month old child. The next most important clinical sign is presence of nystagmus and strabismus. We then assess the morphology of the cataract. Assessment of the red glow using a distant direct ophthalmoscope with an undilated pupil is a simple and useful test to determine if the cataract is visually significant. This is followed by a dilated examination and fundus examination if the cataract is not dense.

We investigate the cases which are bilateral and non-familial. TORCH titers and urine for reducing sugars and amino acids are investigations we perform initially. We then advise a chromatography and other specific tests in case these screening tests suggest an abnormality. We also advise an echocardiography and consultation with a cardiologist. This is also needed as a part of anesthesia clearance. This is apart from the routine tests needed from anesthesia point of view

Dr Sumita Agarkar : I would take a thorough history in terms of antenatal infection, family history of cataract, examine the parents and siblings if possible . A good pediatric evaluation helps. Investigations are mainly TORCH titres testing and investigations directed to rule out inborn errors of metabolism apart from routine testing .

Dr. Vaishali Vasavada : For a bilateral cataract presenting at 4 weeks of age, I would first get a dilated ocular evaluation without anaesthesia. The child is advised evaluation with a pediatrician to rule out systemic diseases, and in particular, complete blood counts, TORCH IgG/IgM profiles, screening for galactosemia is done. A 2D echocardiography is advised for GA fitness along with a consult with the anaesthesiologist. Once a GA fitness is obtained, an examination under anaesthesia (EUA) is planned at the earliest. Our preference would be to perform an EUA and at the same sitting operate one eye, if the parents give a consent for the same. Typically, we would like to get the first eye surgery done by the age of 6 to 8 weeks.

To summarise, careful clinical examination to assess vision ( follow light), look for the presence of nystagmus or strabismus if any, detailed anterior and fundus evaluation forms the first step in assessing an infant with cataract. Examination of parents and siblings (post-dilation) helps in ruling out heredity as the cause for congenital cataracts. Laboratory investigations are a must in bilateral cataract which includes TORCH titers, urine for metabolic errors and specific investigation according to the syndromic features if any

eOphtha: Is there any difference in the investigation protocol you follow for unilateral congenital cataract?

Dr. Bharti Gangwani: No systemic workup is required for unilateral cataracts. A thorough ocular exam as described above is performed for both eyes .

Dr Kalpana Narendran :Unilateral cataracts usually have ocular cause. Hence extensive systemic evaluation is not done. The investigations are usually same, but for unilateral congenital cataract, a retinal evaluation is a must to rule out PHPV or other retinal pathology

Dr. Sudarshan Khokhar :Unilateral cases have associated ocular abnormalities and evaluating the involved eye helps in reaching a diagnosis.

Corneal size (white to White ) measurement and comparison with other eye for micro cornea and microphthalmos. Anterior Chamber assessment for PPM, depth is must. USG should be performed with extra caution. It can be repeated in high gain and dynamic USG should be performed. Still the sensitivity is around 80%, MRI and/or color doppler should be performed based on the available resources. If not available, keep a high suspicion of PFV at the time of surgery and prepare accordingly.

Dr Sujatha Guha :In patients with unilateral cataracts we do not do the routine tests like TORCH and urine tests. Only the tests needed for anesthesia point of view are done.

We however try actively to exclude persistent fetal vasculature with an ultrasound B Scan.

Dr Sumita Agarkar: I am less likely to ask for investigations if cause of cataract is obvious like PHPV or PFV, having said that if patient is an infant it makes sense to rule out intrauterine infections as they may lead to unilateral cataracts . It is imperative that we dilate and examine other eye to make sure that it is indeed an unilateral cataract and not bilateral and asymmetrical .

Dr. Vaishali Vasavada :My investigation protocol would remain the same in unilateral cataract. However, in these cases, ruling out PFV becomes important.

To summarise , unilateral cataract does not warrant systemic investigations. Detailed ocular examination including B scan to rule out PFV is important .

eOphtha: Is there any role for conservative management in congenital cataracts? ( criteria for visually significant cataract )

Dr. Bharti Gangwani : If the cataract is small and not visually significant such that it allows refraction and view to the posterior segment around the cataract with undilated pupils, it can be monitored conservatively. The conservative treatment can include patching treatment or atropine to keep the pupil dilated in the affected eye to promote visual development.

Dr. Kalpana Narendran :There is no conservative management in visually significant congenital cataracts. The criteria are: 1. Cataract more than 3 mm in size, 2. located closer to nodal point, 3. reduction in near vision, 4. Unable to view disc and macula with Direct Ophthalmoscopy in undilated pupil.

Dr. Sudarshan Khokhar :Definitely. Many morphologies are generally not visual significant such as sutural cataract, cataracta pulverulenta, blue dot cataract and early zonular cataracts. These needs evaluation and follow up .Compare vision and eye movements on follow ups and decide accordingly. Visually significant cataract will include cataract >3mm obscuring the visual axis or causing abnormal ocular movements ( Nystagmus or Nystagmoid) , strabismus and significant symptoms such as glare disability (squeezing eye in bright light), etc.

Dr Sujatha Guha : As explained earlier, a quick assessment with a DDO is useful. Initially undilated and then dilated. In case of focal lenticular opacities if there is some part of the clear lens within the pupillary axis then we might consider a trial of prescribing a mydriatic like tropicamide or homatropine along with part time occlusion of the other eye. This is done only in selective cases keeping a careful eye on the development of amblyopia.

Dr Sumita Agarkar: Yes I do use dilating drops if I feel cataract is visually insignificant like ant polar cataract or small central nuclear cataract less than 3 mm in size . Cataract surgery takes away accommodation in young children which is problematic so decision is fraught with doubts especially in preverbal children with unreliable vision test . Generally if you can refract the child, there is no nystagmus or strabismus we can watch nuclear cataracts closely till we have a reliable vision.

Dr. Vaishali Vasavada: If a child presents with a congenital cataract, typically surgery is the only answer and there is no role of conservative management. However, there may be exceptions where the child may have a unilateral or asymmetric bilateral cataract with one eye having a very small, limited lenticular opacity. If the opacity is not dense, larger than about 2mm in diameter and not obscuring the central visual axis, I may consider waiting. Yet, these are exceptions, but generally congenital cataracts will need surgery as early as possible.

To summarise, cataract is visually significant if the following are present: size >3 mm, location at post pole/post subcapsular area, obscuration of glow with DDO in undilated state, and presence of nystagmus or strabismus . Conservative management has a role only in the subset with visually insignificant cataracts. Dilating drops and patching with careful observation to note the development of amblyopia is suggested.

eOphtha: What is your take on the timing of surgery in congenital cataracts ( bilateral and unilateral )?

Dr. Bharti Gangwani : I typically schedule congenital cataract surgery between 4-6 weeks of age. If the surgery is performed before 3-4 weeks of age, there is higher risk of glaucoma and need for multiple surgeries owing to visual axis obscuration. If the surgery is delayed after 6 weeks then there is higher chance of poor visual outcomes, strabismus and nystagmus.

In bilateral cases, I schedule the first eye surgery at 4 weeks and the second eye surgery is performed within a week after ensuring the first eye is doing well.

In unilateral congenital cataract, the critical period is considered to be shorter owing to competition from healthy contralateral eye. I aim to perform surgery at 4 weeks of age.

Dr Kalpana Narendran :Unilateral cataracts- as early as possible, even after 2 weeks after birth. Bilateral cataracts are usually done after a month .

Dr. Sudarshan Khokhar : 4-6 weeks for unilateral cataracts and 6-8 weeks for bilateral cataract considering both the risk of amblyopia and anesthesia concerns. Less than 3 months have high risk for anesthesia.

Dr Sujatha Guha :Unilateral cataracts need surgery as early as possible after diagnosis. Surgery by 4-6 weeks or even earlier is advisable. The time of surgery in such cases is as soon as the child is fit for anesthesia. In bilateral cataracts we have a little longer window. They can be operated by 6-8 weeks of age. In bilateral cataracts, the interval between the two eyes should be kept minimum and we plan the second surgery one week after the first. Parents must be counselled about the same earlier.

Dr Sumita Agarkar : Unilateral needs early surgery, bilateral depends on vision and morphology of cataract for eg posterior cataracts need early surgery Cataracts associated with nystagmus and strabismus also need early intervention . Significant media opacity also needs intervention .

Dr. Vaishali Vasavada : For a unilateral congenital cataract, surgery as early as possible is my choice. However, if a child presents before 4 weeks or age, I would like to wait until the child is 4 to 6 weeks of age. The reasons for this is that the child may become a little more suitable for anaesthesia at that age. For bilateral cataracts, however, I would wait for 6-8 weeks from birth to perform the first eye surgery so that both the body and the eye attain a little more maturity, and the technical difficulties of general anaesthesia and surgery, particularly IOL placement maybe lesser. The second eye surgery is then performed 2 weeks after the first eye. This gap is given considering that repeated frequent anaesthesia may have a deleterious effect on the developing neurological system in the child.

To summarise, Hubel and Wiesel introduced the concept of a “latent period” and a “critical period” for visual development. During the latent period, visual deprivation has no lasting effect on vision in the deprived eye. After the latent period, there is a critical period during which visual deprivation results in irreversible vision loss in the deprived eye. Thus the importance of timing of surgery in pediatric cataract

The critical period for unilateral cataracts is between 4 to 6 weeks. Surgery at the earliest or at least by critical period is suggested

For bilateral cataracts, surgery is suggested by 6 to 8 weeks. Also important to plan other eye surgery in a weeks interval

eOphtha: What’s your preferred section for congenital cataract surgery and why? Do you alter the section preference in any clinical scenarios like connective tissue disorders or aniridia or associated congenital glaucoma?

Dr. Bharti Gangwani: I prefer a superior clear corneal incision in most pediatric eyes since the incision is hidden by the upper lid margin. I rarely perform a temporal incision if there is a bleb superiorly.

Dr. Kalpana Narendran:A scleral tunnel is my preference in infants and also up till 5 years of age. For congenital glaucoma, temporal section is preferred; for aniridia, clear corneal incisions are preferred. The incision will vary depending on the clinical scenarios.

Dr. Sudarshan Khokhar: All surgeries are done by limbal incisions, only if we operate on PCO the incision is pars plana for 23 G trocar

Dr. Sujatha Guha: In lensectomies, I make two 23 gauge ports at 11 and 2 “o” clock limbus. My preferred section is a superior clear corneal 2.8 to 3 mm section for lens aspirations just before inserting the IOL. I sometimes also enlarge the temporal side port to insert the IOL so that there is only one paracentesis to be sutured. In some cases I change my incision if there is any pathology like a corneal opacity. As I prefer a clear corneal section I don’t need to alter the position in a case of buphthalmos

Dr. Sumita Agarkar: I have done clear corneal incision for the past 10 years for all cases except cataract in which PK has been done where I have used scleral tunnel . I always suture all wounds up to 12 years of age.

Dr. Vaishali Vasavada: My preferred incision for congenital cataract surgery is a temporal, posterior limbal incision if IOL is placed along with superior and inferior posterior limbal paracenteses. The site and location of the incision is typically not altered whether or not there is an ocular comorbidity present.

To summarise, the section employed usually is a superior clear corneal or scleral ( more towards limbus ) section. Unlike adults, sections are not altered to correct astigmatism. Superior incisions give the advantage of being covered by lids and thus being safer in children

eOphtha: How do you manage anterior capsulotomy in these children?

Dr. Bharti Gangwani : Ours is a teaching institute so I feel it is safe to perform vitrectorhexis in all children younger than 2 years and the fellows are allowed to attempt manual capsulorhexis in children older than 2 years at the time of surgery.

Dr Kalpana Narendran : Anterior capsulorrhexis is the most important step to place the IOL in the bag. Usually, attempted with making a small flap with the cystitome and completed in a centripetal direction with the capsule forceps. High viscosity OVD, capsular staining dye- Trypan Blue is used. Extended rhexis can be rescued using ‘pull back technique’.

Dr. Sudarshan Khokhar : Tight non leaky incisions, heavy visco cohesive OVD should be used since the capsule in children is highly elastic and the rhexis tends to run off if the chamber is not fully formed. A microincision forceps can be used instead of capsulotomy. Frequent grasping as compared to adult capsule is recommended. Go slow and can use corneal marking to guide 5 mm rhexis. My microscope has Rhexis assist feature that projects 5mm ring onto cornea for accurate sizing

Dr Sujatha Guha: In cases of lensectomy where I do not plan to insert an IOL, I do the anterior capsulotomy using the vitrector with a low cut rate. In cases of lens aspiration, I initiate the rhexis with a cystitome and complete it using a 23G microrhexis forceps

Dr Sumita Agarkar : I use utrata forceps or in young children microcapsular forceps .

Dr. Vaishali Vasavada : My preferred technique is manual anterior capsulorhexis (ACCC). I always stain the capsule with trypan blue, irrespective of presence of red glow as I feel it makes visualization easier. I use microincision capsulorhexis forceps and perform ACCC through 1.2mm paracenteses incisions.

To summarise , Anterior capsule in children is highly elastic and capsulorhexis is facilitated by use of cohesive viscoelastics and capsular staining with trypan blue. Manual capsulorhexis using Microrhexis forceps or utrata seems to be the choice .Vitrectorhexis is the choice in infants .

eOphtha: What method of pupil dilatation do you use in cases of small pupil with cataract ?

Dr. Bharti Gangwani: I usually use iris hooks in case of small pupil with cataract

Dr Kalpana Narendran :Dilating drops, Intra cameral adrenaline and iris hooks

Dr. Sudarshan Khokhar: In pediatric cataracts, generally visco-dilatation is enough for performing surgery. If synechiae are present, they should be removed with blunt canula . If required, iris hooks may be used.

Dr Sujatha Guha : Pre-operative dilatation with tropicamide is generally done in our practice since the use of phenylephrine is not permitted in the OTs due to anesthetia concerns. I inject intracameral adrenaline for mydriasis. If the pupil is still non dilating, I use iris hooks to facilitate the surgery.

Dr Sumita Agarkar: I use Grieshaber hooks

Dr. Vaishali Vasavada : We prefer to start atropine eye ointment 1 day prior to planned surgery in cases with small pupils. On the day of surgery, a combination of tropicamide 1% and phenylephrine 10% is instilled twice at 15 minutes intervals. If the pupil is not dilated adequately despite this, we instill 0.1ml of intracameral adrenaline before instilling viscoelastic in the eye. If the pupil does not dilate even with this, then iris retractors (Grieshaber) are our choice.

To summarise, small pupils in small eyes can be a surgical challenge. Apart from preoperative mydriatic-cycloplegics , use of adrenaline intraoperatively and iris hooks seems to be the preferred way to dilate small pupils .

eOphtha: What’s your age limit cut offs for primary posterior capsulorhexis and anterior vitrectomy? Do you prefer limbal or pars plana approach ? And what stage do you do PPC and vitrectomy viz., before or after IOL implantation?

Dr. Bharti Gangwani: I perform primary posterior capsulorhexis (PCCC) and anterior vitrectomy in all children younger than 6 years of age. I sometimes do it in older children 7-8 years of age if they have severe developmental delays, would not be cooperative for YAG capsulotomy or if the family is coming from long distance and would be not be available for regular followups.

I prefer pars plana vitrectomy and perform it after IOL implantation. I feel it is a safe approach in a teaching institute.

Dr Kalpana Narendran : My cut off for PPC and anterior vitrectomy is usually 8 years. But, in some cases I prefer to do a PPC even upto the age of 10-12 years, with or without anterior vitrectomy (children with nystagmus, Down’s syndrome, children who probably will not cooperate for a YAG capsulotomy).

I prefer a limbal approach. PPC and anterior vitrectomy is usually done after an IOL implantation.

Dr. Sudarshan Khokhar :

We recommend PCCC with AV till 5-6 years and PCCC till 8 years. This significantly reduces VAO( visual axis opacification ) formation. If child has neurological problems like head nodding or significant nystagmus, PCCC can be performed after 8 years as well. In cases of Down’s syndrome having mental retardation PCCC is done for all ages.

At RPCentre AIIMS we perform PCCC before implanting IOL in all cases via limbal incision

Dr Sujatha Guha : I perform a PPC in all children below 8 years. I also perform a PPC in some children who may not co-operate for YAG capsulotomy like mentally challenged children. I prefer a limbal approach in my cases. I perform the PPC and anterior vitrectomy before implantation of the IOL. I always perform a large PPC in aphakic children of about 7-8mm, or as large as the pupil allows me. Also in these children I perform a thorough anterior vitrectomy especially under the edges of the PPC to remove any vitreous which can act as a scaffold for membrane formation.

Dr Sumita Agarkar : I do PPC with vitrectomy up to 8 years of age and ppc without vitrectomy in older children up to 12 years . I prefer limbal approach and I almost always do it before iol implantation

Dr. Vaishali Vasavada : I perform a PCCC and anterior vitrectomy for all children upto the age of 5 years, if an IOL is being placed in the capsular bag. However, if a posterior optic capture is performed (IOL haptics in the bag, optic pushed behind the PCCC margin), which I am performing more and more, then I would not perform an anterior vitrectomy even in younger children. Between 5 to 7 years of age, I would perform a PCCC for all eyes, but anterior vitrectomy only if the child is found unco-operative for a laser capsulotomy, or there is an iatrogenic vitreous face disruption during surgery. Beyond 7 years of age, a PCCC with / without anterior vitrectomy is generally not performed, unless the child is found to be unsuitable for a laser capsulotomy in the future. My preferred approach for anterior vitrectomy is a pars plana vitrectomy, which I usually perform following IOL implantation.

To summarise, Primary posterior capsulorhexis and anterior vitrectomy are additional steps in pediatric cataract surgery done to prevent the visual axis opacification.

PPC with anterior vitrectomy is preferred till 6 -8 years of age and only PPC is done till 10 -12 years. Though with optic capture of IOL through PPC ( Gimbel’s technique ) the age limits can be lower. The opinions seem equally divided for performing PPC through pars plana or limbal approaches and the timing before or after IOL implantation.

eOphtha: I have seen capsular phimosis in few cases of microphthalmos with cataract post lensectomy? Any comments?

Dr. Bharti Gangwani: I notice capsular phimosis if the capsulorhexis is small, and/or if the vitrectomy is inadequate. It is helpful to use iris hooks for pupil dilation to ensure sufficient size capsulorhexis and to perform an adequate anterior vitrectomy.

Dr Kalpana Narendran : An adequately sized capsulorrhexis is ideal. But, children do develop phimosis and this usually should be cleared with a repeat membranectomy.

Dr. Sudarshan Khokhar : Size of opening may be an issue in microphthalmos cases as eyes are extremely small. A central 5mm opening should be adequate and to ensure this calipers or microscope assist such as callisto may be used. If pupillary opening is too small, pupilloplasty should be performed. The rhexis tends to contract over a period thus avoid ACCC smaller than 5 mm and if small ,can be extended after IOL insertion using micro scissors and forceps to desired size.

Dr Sujatha Guha : Yes. I always prefer an anterior capsulorhexis of 5-6mm to minimize the chances of phimosis in all pediatric eyes.

Dr Sumita Agarkar: Yes happens in cases of micropthalmos and in colobomas . Its good to counsel parents about need for a second surgery and to make larger capsular opening while operating

Dr. Vaishali Vasavada: In young eyes, particularly those with comorbidities, such as microphthalmos, the capsular response tends to be very aggressive and rapid. Therefore, both anterior capsular phimosis and visual axis obscuration tend to be a problem. While performing lensectomy in these eyes, it should be kept in mind that the anterior capsulotomy should be made reasonably large in size keeping this possibility in mind.

To summarise, Microphthalmic eyes can pose a challenge with the sizing of rhexis and subsequent capsular phimosis so caution needs to be exercised

eOphtha: What’s your take on IOL implantation in children less than 7 months ? what is the youngest age at which you have implanted an IOL?

Dr. Bharti Gangwani : I do not perform IOL implantation in children less than 7 months of age. I offer IOL implantation in children between 7 months to 1 year of age and discuss the risks and benefits with the parents and leave the decision of IOL implantation to them. The youngest age that I have implanted IOL is 8 months of age in the US.

Dr Kalpana Narendran: In unilateral cataracts, we have implanted an IOL as early as 4 weeks and in bilateral cataracts, if the corneal diameters are normal, no other abnormalities, IOL can be implanted even in children less than 7 months.

Dr. Sudarshan Khokhar: The criteria for IOL implantation should be WTW> 10mm and AL>17mm. Age should be considered for under-correction. The youngest child we have implanted was a unilateral cataract at 24 days of life.

Dr Sujatha Guha: I do not implant IOL in children below 7 months and that is the youngest age I have implanted an IOL

Dr Sumita Agarkar: Youngest I have implanted is 5 months old . I will implant IOL if child dilates well, no ocular comorbidities and fulfills anatomical parameters of corneal diameter of 10.5 mm and axial length of 18mm . And yes parents must be willing to come for follow up .

Dr. Vaishali Vasavada : As far as IOL implantation in infants goes, I do not have a “hard” cut off age below which primary IOL implantation is not performed. My criteria for choosing primary IOL implantation are that the horizontal corneal diameter should be more than 9.5mm and the axial length should be normal for the age. Provided I am comfortable implanting an IOL in the bag, I do go ahead with IOL implantation. I do not perform ciliary sulcus IOL in these eyes below 6 months. Therefore, if during surgery I cannot place the IOL in the bag for any reason, I would leave the child aphakic. However, the youngest age at which I have implanted an IOL is about 8 weeks

To summarise,IOL implantation in an infant eye is always a challenge both in terms of decision making ( to implant or not to) and also surgically .Two important parameters ,corneal diameter > 10-10.5 mm and axial length >17-18 mm are required before making a decision . Though they agree on cut off age as 7 months, experienced surgeons implanted the IOL in younger infants when the corneal diameter and axial length were normal .So, except in experienced hands IOL implantation in less than 7 months is not suggested

Dr Sowmya R
Consultant, Department Pediatric Ophthalmology, Sankara Eye Hospital, Bangalore,
Dr Sowmya R , works as a senior consultant in Dept of Pediatric ophthalmology and Strabismus at Sankara eye hospital, Bengaluru. She has been given best student award every year in her school days. She grauated from Vijayanagara institute of medical sciences Bellary as the Best outgoing student of her batch . Finished her postgraduation from mysore medical college and stood second for the university. Being passionate about strabismus, did her fellowship from sankara nethralaya Chennai in 2010 . Post fellowship she joined sankara eye hospital. Actively involved in teaching and mentoring DNB students , fellows in pediatric ophthalmology and strabismus in the institute. She has been chief instructor for IC at state conferences every year and co- instructor at all India conferences. Been invited for talks at various conferences and CMEs . She has been instrumental in organising the annual post graduate update programme 3rd eye PG UPDATE at her institute since last 8 years .She has won best video award at SPOSI 2016 and best paper in optics session at Karnataka state conference 2018 . She is very passionate about teaching and making the subject simple and interesting . She has nearly 12 publications in various indexed journals. Modified Nishida s procedure (newer transposition procedure) for MED published in Jaapos was the first report ever of this procedure for MED. Apart from teaching and surgeries , she enjoys photography ,writing and travelling
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