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

After the discussion on the etiology of pediatric cataracts, and about when and how to operate we go further to know about choosing the IOL formulae, IOL material and power of IOL to be implanted in children. Also, an insight into the post-operative rehabilitation with follow up

eOphtha: Considering the varied opinions in choosing the IOL formulae for pediatric cataracts , what’s the formulae used in your practice ? Do you use different formulae in microphthalmic eyes?

Dr. Bharti Gangwani : I use Holladay 1 for young children and small eyes with AL < 22 mm and SRK/T for older children with AL > 22 mm.

No I do not use different formula in microphthalmic eyes though many of these eyes are left aphakic if the eye is really small.

Dr Kalpana Narendran : SRK - T formula is used. If Axial length <22 mm – Hoffer Q; axial length > 22 – SRK T.

Dr. Sudarshan Khokhar: We use modified SRK 2 or SRK/T formula for IOL power correction for all eyes. We do not implant IOL in AL<17mm.

Dr Sujatha Guha : I use the SRK/II formula for IOL power calculation in children. I usually do not implant any IOL in microphthalmic eyes or if the corneal diameter is less than 9 mm. In other cases with a small axial length in non mi rophthalmic eyes I use the Hoffer-Q formula along with SRK/II to decide the IOL power.

Dr Sumita Agarkar : I have used SRK 2 and SRK T without any major surprises . Surprises have always been in shorter eyes and smaller corneas where no formula has proved itself . Off late I am using Baretts formula .

Dr. Vaishali Vasavada : Our choice in these eyes is the SRK/T formula. For older children, where an optical biometry can be obtained, we prefer to use the Barrett Universal formula. As for microphthalmic eyes, if the child cannot co-operate for optical biometry, we would use the SRK/T or the Holladay II formula, and the Barrett Universal formula if the child can co-operate for an optical biometry.

eOphtha: How much of under-correction is preferred? Have you changed these norms according to your experience in the past?

Dr. Bharti Gangwani I leave the children with hyperopia of

6-8 D - Age 6 months-1 year

5 D - Age 1-2 years,

4 D - Age 2-3 years

3 D - Age 3-4 years

2 D - Age 4-5 years

1 D - Age 5-6 years

No undercorrection- > 6 years of age

Dr Kalpana Narendran: We follow the Wilson and Trivedi et al formula. Yes, we have changed our norms a little bit with past experience. An attachment of the formula is enclosed.

Dr. Sudarshan Khokhar: We have observed a difference in growth of Indian eyes as compared to western data. Based on our data, we have recently published under correction

20% for 3months - 6months

10% for 1 year,

5 % for 2 years

2% for 5 years of age.

Dr Sujatha Guha : I usually follow the Enyedi rule of seven and also take into consideration the refractive status of the other eye. If the other eye is phakic with minimal hyperopia I follow the appropriate undercorrection so as to reduce any anisometropia later. If the other eye is myopic, I would consider undercorrecting a little less so as to match the other eye.

Dr Sumita Agarkar : No not much I don’t do as much under correction in shorter eyes as I used to do earlier and I still end up with more hyperopia than I planned .

Dr. Vaishali Vasavada : In our practice, IOL power undercorrection is based on child’s age at surgery and a family history of refractive error / myopia in the fellow eye. Generally, younger the age, more the undercorrection – we use our own personalized nomogram, which is as follows :

<3 months – 35% undercorrection

3 to 6 months – 30% undercorrection

6 to 12 months – 25% undercorrection

12 to 24 months – 20% undercorrection

2-3 years – 15% undercorrection

3-5 years – 10% undercorrection

Over the years, although the general strategy remains the same, in children whom we feel will not be able to co-operate with glasses / contact lenses, especially in unilateral cataracts, we would perform lesser amount of undercorrection.

To summarise , Undercorrection is the rule in choosing the IOL power in children . Various nomograms are used as recommended by Enyedi et al., Trivedi et al.,or personalized ones from the centres

eOphtha: What is your preferred IOL material of choice and why ? Any experience with rigid PMMA IOL’s?

Dr. Bharti Gangwani My preferred IOL is single piece acrylic IOL (Acrysof^TM ) for in-the-bag fixation and 3 piece acrylic IOL for sulcus fixation. No I have not used PMMA IOL in pediatric eyes.

Dr Kalpana Narendran: Our preferred IOL material is foldable hydrophobic acrylic- 3 piece lens. We also use rigid PMMA lenses in older children and for secondary IOL, with good results

Dr. Sudarshan Khokhar: We prefer foldable hydrophobic acrylic IOL (white color) as they have less VAO formation, minimal glistening over time and can be placed via small incisions. We have used rigid PMMA IOLs and results are good in terms of media clarity but bigger wound is required for their insertion.

Dr Sujatha Guha : I prefer foldable acrylic IOLs. Although in my experience PMMA lenses have also had good long term outcomes. The only disadvantage is the larger size of the incision needed and a slightly higher risk of immediate post operative inflammation

Dr Sumita Agarkar : I am ancient I started with PMMA. large incision size and difficulties of putting iol in bag after vitrectomy in a soft eye are definite challenges with a learning curve but no complaints with lens per se . For past 15 years I have used only hydrophobic acrylic foldable lenses . I MUST SAY IF A SINGLE thing that has changed post op outcomes in childhood cataract it’s the availability of foldable lens . And every child irrespective of the paying capacity of the family must receive this lens .

Dr. Vaishali Vasavada : Our preferred IOL material of choice in pediatric eyes is hydrophobic acrylic (single or 3 piece IOLs). This is because of its excellent uveal biocompatibility as well as capsular biocompatibility. PCO is delayed, even in very young eyes when using hydrophobic acrylic IOLs. PMMA material is very friendly to the eye in terms of uveal response. However, PMMA IOLs lead to very early onset of PCO in children. Also, the rigid nature of the IOLs necessitates a large incision. Therefore, PMMA IOLs are no longer a material of choice for us.

eOphtha: How do you choose IOL power in unilateral cataracts ? I have seen a child post VR surgery and high myopia with unilateral congenital cataract , any inputs on how to choose IOL power?

Dr. Bharti Gangwani : I aim for the same undercorrection even in unilateral cataracts. I do not leave them with high hyperopia even if there is chance of higher myopic shift in unilateral cataract. The high hyperopia is more amblyogenic than the myopia which can be tackled in the future with contact lenses or refractive surgeries if need be. It is important to correct residual refractive error and do amblyopia treatment in these eyes.

Dr Kalpana Narendran: We use the formula by Trivedi and Wilson,

A post-operative anisometropia is inevitable in such a case. I would aim for a post-operative low hyperopia and manage myopic shift later in life. Sometimes, child can be left aphakic in case of low IOL power.

Dr. Sudarshan Khokhar: Unilateral cataracts are more complicated than bilateral cataracts in terms of choosing correct IOL power. Various studies in unilateral cataracts have shown abnormal growth as compared to fellow eye which may be too much or too little. In addition, too much undercorrection at the time of surgery will lead to anisometropia and hence, aniseikonia postoperatively. We choose IOL power with slightly less undercorrection compared to the formula mentioned above. But in these eyes, surgeons and parents need to be cautious regarding unexpected eye growth.

Post VR surgery without oil fill, similar formula can be used. With oil filled eye correction factor 0.732 to axial length can be used or an optical method may be used. Pertaining to this situation, high myopic eyes are likely to grow more so greater under-correction can be performed.

Dr Sujatha Guha : IOL power calculation in such eyes can be challenging, especially in silicone oil filled eyes. In such cases I prefer to perform the IOL surgery after the oil removal when possible so that accurate IOL power calculations can be done. I prefer doing an age appropriate undercorrection in unilateral cataracts so as to minimize anisometropia later. The amblyopia has to be managed aggressively with optical correction and occlusion therapy.

Dr Sumita Agarkar : I would match it with the other eye with little more hyperopia but if other eye is highly myopic I aim for emmetropia .

Dr. Vaishali Vasavada : Unilateral cataracts are a very unique situation. On one hand, the first priority is to combat amblyopia; on the other hand, is the desire to avoid high myopic shift in the future. For unilateral cataracts, we would choose an IOL power with some degree of undercorrection, however, it would be lesser than what is normally performed for bilateral cataracts. If the other eye is myopic, then we would not undercorrect the IOL power.

In the myopic, post-VR surgery child you have mentioned, I would try to keep a target refraction of about +1.5 diopters, since we already know the child is myopic and may turn more myopic with axial growth.

Yet, unilateral cataracts are a challenge for surgeons in deciding IOL power and nobody has the perfect answers. Patient awareness and compliance with glasses / vision therapy is also a deciding factor in choosing the IOL power.

eOphtha: Suturing the incisions is the norm in pediatric cataract. Do you prefer absorbable or nonabsorbable sutures and why ?

Dr. Bharti Gangwani: I prefer absorbable sutures and use 10-0 Biosorb for suturing all incisions in pediatric eyes. I would like to avoid putting them through general anesthesia for suture removal .

Dr Kalpana Narendran: We prefer absorbable sutures- 10-0 vicryl sutures. This is mainly done to avoid exposure to anaesthesia again for suture removal.

Dr. Sudarshan Khokhar: We have used both 10-0 nylon monofilament and 10-0 vicryl (polygalactin). Both works well and have their own advantages. Vicryl being absorbable need no removal while occasionally there may be a suture granuloma which does not happen with nylon

Dr Sujatha Guha : I suture all wounds in pediatric cataracts although sometimes I leave 23G self sealing wound unsutured. I use absorbable sutures. However, these suture materials commonly accumulate mucus and other debris which can act as a nidus for corneal infiltrates and infection. Hence with these materials we must closely watch the suture sites for any infiltrates or vascularization on follow up.

Dr Sumita Agarkar : I used to use nylon earlier but with a shift to clear corneal incision I use 10 vicryl now to avoid a second GA to remove sutures. Its perfectly ok to use nylon in scleral tunnels where you don’t need to remove suture in majority of cases .

Dr. Vaishali Vasavada : I prefer nonabsorbable sutures for pediatric eyes, since the degradation of vicryl sutures often causes more irritation, leading to rubbing of eyes. On the other hand, 10-0 nylon, which is my choice of material, tends to be more inert and does not cause redness or irritation unless the suture is very loose.

eOphtha: Is there any role of customized sizing of IOL in microphthalmos or buphthalmos ?

Dr. Bharti Gangwani: We do not have option to customize IOL in USA. Only standard adult size IOLs are available.

Dr Kalpana Narendran: No, I have no experience on this

Dr. Sudarshan Khokhar : No .We do not use any customized size IOLs. Microphthalmic eyes inherently have problems in addition to small size such as predisposition for glaucoma. Since there is no published data on these IOLs, we would not recommend them for such eyes.

Buphthalmic eyes in our experience do well with multipiece IOL in sulcus with optic capture with both anterior and posterior capsule for better stability.

Dr Sujatha Guha : I have never used customized IOLs in these eyes. I do not implant IOL in very small micophthalmic eyes . In buphthalmic eyes mostly a 6.5mm optic IOL with a diameter of 13mm fits in and I do a optic capture to stabilise the IOL if I note decentralisation on table.

Dr Sumita Agarkar : No personal experience

Dr. Vaishali Vasavada : Both situations need a customized IOL size – smaller IOLs for microphthalmos and larger for buphthalmic eyes. In fact, all young pediatric eyes need a customized, smaller IOL. The unfortunate part is that currently, no such IOLs are available.

To summarise , IOL implantation is not a recommendation in microphthalmic eyes . In buphthalmic eyes where decentration of IOL can be an issue, optic capture through anterior and posterior rhexis provides better stability

eOphtha: What is the post operative care regime you recommend ? Is there a role for oral steroids ?

Dr. Bharti Gangwani My post operative regime includes Predforte eye drops 4-6 times a day with 1 week taper, Moxifloxacin eyedrops (Vigamox) QID for 1 week, Cyclopentolate eye drops QHS for 1 week.

If the inflammation is high on day 1, then I may put them on Predforte every 2 hours until the inflammation is controlled.

I typically do not prescribe oral steroids after congenital cataract surgery.

Dr Kalpana Narendran: We usually treat them with topical steroid antibiotic combination of eye drops and Homatropine. An ointment formulation is preferred in infants and aphakia. We do not use oral steroids.

Dr. Sudarshan Khokhar: We limit use of oral or iv steroids for special conditions where significant postoperative inflammation is expected such as uveitis especially juvenile idiopathic arthritis. In routine cases, we start topical antibiotics for 2 weeks, topical steroids prednisolone 6 to 8t/d which is taped slowly over 8 weeks along with long acting cycloplegics such as atropine or homatropine for the same duration which helps in preventing pupillary membrane formation

Dr Sujatha Guha : I routinely prescribe a weekly tapering course of topical steroids beginning from hourly instillation in the first week. Along with this I prescribe a cycloplegic like homatropine in lens aspirations with IOLs and atropine in lensectomies. I do not prescribe antibiotics in all cases. I have seen many parents compromising on the topical steroids due to the antibiotic eye drops prescribed simultaneously. I do not routinely prescribe oral steroids. I give oral steroids if there was inadvertent intraoperative handling if uveal tissue, if there is a heightened post-op reaction or membrane formation or if there was a severe inflammation in the fellow eye. I have seen that the second eye frequently throws up a more severe inflammatory response than the first eye if done at a close interval.

Dr Sumita Agarkar : No oral steroids except in uveitic eyes. Sometimes fresh trauma can also induce severe inflammation in such situation there is a role for systemic steroids but carefully watch for infections all the more if trauma is penetrating in nature . Topical steroids- I give for 6-8 weeks in tapering fashion staring from 8-10 times a day .

Dr. Vaishali Vasavada : Our standard postoperative regime includes topical prednisolone acetate 1% eyedrops 6 times a day for the first 2 weeks which are tapered over 3 months, topical antibiotic for the first 4 weeks, topical cycloplegics (atropine under 2 years and cyclopentolate above 2 years) for 2 weeks and topical IOP lowering medications for 2 weeks. Although there is no published evidence for the same, we do give oral steroids in children who have undergone anterior vitrectomy.

To summarise , Topical steroids starting from 6-8 times daily with weekly taper over 4 to 6 weeks is used . Additional topical antibiotics and cycloplegics for 2 weeks is suggested . Oral or IV steroids are used in select cases

eOphtha: How do you manage amblyopia post surgery especially in bilateral congenital cataract ?

Dr. Bharti Gangwani : I perform cataract surgery in the amblyopic eye first and try to do the second eye surgery within a week. If there is significant amblyopia post surgery, then I treat the child with patching treatment starting within first week after surgery. I ensure that they are wearing residual refractive error. If the patching is a challenge, then I try atropine penalization or occluder contact lenses.

Dr Kalpana Narendran: Correct the refractive error (residual refraction) with glasses and regular follow up. If needed, occlusion therapy for the eye which has a decreased vision. We plan for other eye surgery within 2 weeks.

Dr. Sudarshan Khokhar: Appropriate refractive correction with near add has to be provided to the child immediately following surgery. We perform bedside retinoscopy at day 1 of surgery and spectacles are prescribed. Serial EUAs are performed at 1 month, 3 months and every 6 months; depending on the age of the child with regular OPD visits in between. Spectacles are changed as there is change in refractive error. Parents have to be counselled about need for spectacles before surgery.

For unilateral cataracts, in addition to refractive correction by spectacles or contact lens; occlusion therapy is given as per standard regimen

Dr Sujatha Guha : Amblyopia therapy involves prescribing glasses or contact lenses. I usually prescribe glasses 3 or 4 days after surgery. I then follow them up and if they develop amblyopia then advise them occlusion therapy. In unilateral cataracts I stress on the role of contact lenses and follow a more aggressive patching schedule.

Dr Sumita Agarkar : Give glasses as early as possible and insist on wearing glasses . Do give a near add EVEN IF CHILD IS 2 YEARS OLD.

Dr. Vaishali Vasavada : For amblyopia management, we start with giving ready made glasses of +5.0D on the first postoperative day following bilateral congenital cataract surgery. Occlusion therapy is initiated early on if there is squint, and if not, alternate day occlusion is started after giving final refraction, which is about 6 weeks from surgery. 6 to 8 weeks from surgery, a final refraction assessment is performed, if needed under EUA, and the glasses are changed.

To summarise , Post operative refractive correction with patching is suggested as early as possible

eOphtha: what are your key points with reference to pediatric cataract management ?

Dr. Bharti Gangwani : Preoperative counseling is the key component in management of congenital cataract. I explain to the parents that the main treatment starts after the cataract surgery. They need to adhere to full time glasses/contact lens correction, amblyopia treatment and frequent followup schedule. The child might need additional surgeries for secondary IOL implantation, visual axis obscuration, and strabismus surgery.

The outcomes of bilateral congenital cataract surgery are good with early intervention. The prevalence of amblyopia is high in unilateral congenital cataract owing to deprivation amblyopia and competition from healthy contralateral eye.

Dr Kalpana Narendran: With the advancements in technology, the paediatric cataract management has become easy but one should have a conservative approach while treating children, thinking about their longer living years

Dr. Sudarshan Khokhar: Parents have to be explained again and again and made aware that Pediatric cataracts are not rare and that these kids can do fairly well if the surgeries are done at appropriate time followed by the amblyopia treatment .Bilateral cases needs glasses to be worn regularly with frequent changes depending on refraction in follow up period .The occlusion treatment is mandatory for unilateral cases and actually is the corner stone of success

“A stitch in time saves nine” can’t be more appropriate for Pediatric cataracts

In post-operative phase after successful surgery and glasses prescription, the role of parents and the teachers becomes important to ensure compliance in wearing glasses or occlusion patches whichever in being used for the particular kid .Regular follow ups consultations to pick up any flaws at the earliest according to me is the most important step in management of Pediatric cataracts.

Dr Sujatha Guha : It is not always important to implant a lens in a pediatric eye. I feel a well done aphakia can give better outcomes than a poorly done pseudophakia. Cases such as complicated uveitic cataracts, some traumatic cataracts, microphthalmos are best left aphakic and they do well with appropriate optical correction

Dr Sumita Agarkar : Please do check IOP , refraction and fundus evaluation for every kid with a history of cataract surgery even if you haven’t done the surgery .

Dr. Vaishali Vasavada : All in all ,pediatric cataract management is a labour of love .The right combination of science , teamwork involving the optometrists , counsellors , parents , anaesthesiologist and ophthalmologist and lifelong follow up for managing visual rehabilitation as well as potential complications will yield good anatomical and functional outcomes .It would be wise for beginner surgeons to start off with older children and then slowly work their way with smaller babies , especially when considering primary IOL implantation .

To summarise , Cataract surgery in a child is the first step in visual rehabilitation. Refraction, assessment of Visual acuity, IOP measurements, ocular alignment , fundus examination to be done at every follow up post surgery .Post op refractive correction is as important as clearing off visual axis by surgery and long term follow up is warranted .