Partnering with the Pediatric Ophthalmology Service: Special Considerations for Cataract Surgery in Children

Alvina Pauline D. Santiago, MD
April 29, 2017
1:00 -1:15 PM

No proprietary interest with any of the products
mentioned.

 Is the cataract visually significant?
 Can vision be improved with surgery?
 When do I operate?
 Will I put in an IOL?
 What formula do I use?
 What is my target postop refraction?
 How different is the procedure
compared to adult cataract surgery?
 What are my postop medications?
 How do I rehabilitate the eye?
http://www.taroticallyspeaking.com

Donahue S, Arnold RW, Ruben JB,
AAPOS Vision Screening
Committee. Preschool vision
screening: what should we be
detecting and how should we report
it? Uniform guidelines for reporting
results of preschool vision screening
studies. J AAPOS. 2003
Oct;7(5):314-6. PMID: 14566312
DOI: 10.1016/S1091853103001824
 Anisometropia (sph or cyl) >1.5D
 Any manifest strabismus
 Hyperopia >3.5D in any meridian
 Myopia > 3.0D in any meridian
 Any media opacity >1mm size
 Astigmatism
 >1.5D at 90, 180
- >1.0 D at oblique axis (>10deg of 90, 180)
 Ptosis </= 1 mm MRD
 VA per age appropriate standards

 In central visual axis, bigger than 3 mm
 Posterior cataract
 No clear zones in between
 Retinal details not visible with direct
ophthalmoscope
 Nystagmus or strabismus present
 Poor central fixation after 8 weeks
 Jaf HBQ, Diseases of the crystalline lens.
https://www.slideshare.net/AbbasTelakoe/ophthalmologydiseases-of-the-
lensdrbaxtyar. Accessed April 4, 2017

Check red orange reflex
with the retinoscope to
assess “size” of the
cataract.
If one can penetrate using
ophthalmoscope or
indirect ophthalmoscope,
reconsider doing the
surgery

Taylor & Hoyt’s Pediatric Ophthalmology 2005
Usually a smaller eye
Watch for smaller optic nerves
Poorer visual prognosis

Intraocular bleeding risk high
Postoperative risk of phthisis high

Reversibility following control of
metabolic problems reported
 Butler PA. Reversible Cataracts in Diabetes Mellitus. J
Am Optom Assoc. 1994 Aug;65(8):559-63.
 Jin YY et al. Reversible Cataract as the Presenting Sign of
Diabetes Mellitus: Report of Two Cases and Literature
Review. Iran J Pediatr. 2012 Mar; 22(1): 125–128
 Trindande R. Transient cataracts and hypermetropization
in diabetes mellitus: case report. Arq. Bras.
Oftalmol. vol.70 no.6 São Paulo Nov./Dec. 2007.
http://dx.doi.org/10.1590/S0004-
27492007000600030 version=html
Focus on Diabetes

Usually good visual acuity
despite central location

VA can be as good as 6/7.5
Consider waiting post amblyopia
age
Glare and contrast sensitivity
problems

Very minimimal effect on
vision
Remember amblyopia
treatment in monocular cases

 Amblyopia
 Reopacification of ocular
media
 Anisometropia
 Aneisokonia
 Propensity for inflammation
 Different anatomy
 Growing eyeball
 Changing refraction
 Will patient wear glasses?

http://www.taroticallyspeaking.com

Deprivation amblyopia
PFV until proven
otherwise
Commit to aggressive
postop rehabilitation
Before 6 weeks
 Birch EE, Plager D. The critical period for
surgical treatment of dense congenital
unilateral cataract. Invest Ophthalmol Vis
Sci. 1996 Jul;37(8):1532-8.

Onset during amblyogenic age
 Operate
 Before nystagmus
 Before deprivation amblyopia
 Doing one vs both eyes
 Typically before 8 weeks
Onset after 7 years of age
 Amblyopia less of an issue
 May do one eye at a time,
leisurely pace as in adult

PRIMARY IOL
 VA </= 20/200 in 50%
 VA > 20/32 in 6
 At least 1 adverse event in 86%
 Lens reproliferation
 Pupillary membranes
 Corectopia
 At least 1 additional surgery in 72%
 Glaucoma/suspect in 28%
APHAKIC with CONTACT LENS
 VA </= 20/200 in 50%
 VA > 20/32 in 13
 At least 1 adverse event in 56%
(p=0.016)
 At least 1 additional surgery in 21%
(p=<0.001)
 Glaucoma/suspect in 35% (p=0.55)
Infant aphakia treatment study group. A Randomized Clinical Trial Comparing Contact Lens to Intraocular Lens Correction of Monocular Aphakia during Infancy: HOTV Optotype Acuity at
Age 4.5 Years and Clinical Findings at Age 5 years. JAMA Ophthalmol. 2014 Jun; 132(6): 676–682. doi: 10.1001/jamaophthalmol.2014.531
Infant aphakia treatment study group. A Randomized Clinical Trial Comparing Contact Lens to Intraocular Lens Correction of Monocular Aphakia During Infancy: Grating Acuity and
Adverse Events at Age 1 Year
Arch Ophthalmol. 2010 Jul; 128(7): 810–818. doi: 10.1001/archophthalmol.2010.101

IOL implantation be limited to infants at risk of
experiencing “significant periods of uncorrected
aphakia” if an IOL was not implanted.
the cost and handling of a contact lens will be so
burdensome as to result in significant periods of
uncorrected aphakia

All pseudophakic eyes had a targeted postoperative
refraction of +6 or +8 D at the time of IOL
implantation.
Average refraction at end of study -2.25
(range of -19.00 to +5.00)
3 required IOL exchange

 “General consensus IOL for most older children
 IOL implantation during the first year of life still
questioned
 6 mos or younger: CAUTION
Wilson 1996
Trivedi et al 2004
Infant Aphakia Treatment Study Group
2010

Less uveal biocompatibility:
Postoperative iridocyclitis
Secondary glaucoma
Rigid if > 12mm
Lessened with heparinized PMMA
lens
Wilson ME et al. Cataract Surgery
in Children, Trends and
Controversies.
http://www.aapos.org/client_data/file
s/2012/479_wilsonhandout.pdf
Accessed August 23, 2015

3-piece MA series
Less postop iridocyclitis
Do well in bag and sulcus
Less PC Opacity
May not need to create an
opening in PC https://www.alcon-
pharma.de/produkte/ophthalmochirurgie/intraokularlinsen-
u.-zubehor/acrysofae-multi-piece-acryllinsen/mn60ma-
natural-ma60ma/acrysofae-natural-mn60ma/intraok-
acrysof-natural-mn60ma.jpg/@@images/0e4a3521-e8f4-4140-
ad67-16e4700ca12b.jpeg

 Single piece SA (and SN) series ideal for
children
 Flexible haptics:
 implant even in small eyes
 Less ovaling of bag; less capsule stretch
 excellent memory
 Haptics unfold slowly
 Resist equatorial lens capsular fibrosis
 May not need to create an opening in PC
https://www.reviewofophthalmology.com/CMSImagesCo
ntent/2005/6/1_742_2.jpg

SN/SA series
square edge / sharp edge
 Reduced PC opacity
Adhesive biomaterial (AcrySof):
 Hydrophobic material has higher
binding capacity to fibronectin
 Fibronectin mediates adherence to
lens capsule, impeding lens epithelial
cell migration
https://www.reviewofophthalmology.com/CMSImagesCo
ntent/2005/6/1_742_2.jpg

SN/SA series
Thinner (than PMMA):
piggyback
SN UV filter approximating a 20
yr old
 Improved contrast sensitivity
 Reduced central glare
 Restoration of color vision (at least in
adults tested)

https://www.mylifestylelens.com/wp-
content/uploads/sources/alcon/acrysof-
multipiece-EN.pdf

 In-the-bag (e.g. ALCON SN60 IQ, Rayner
Cflex IOL)
 Sulcus placement
 PMMA avoids decentration (e.g. ALCON MC 60-
BM)
 Rayner Cflex IOL
 3 pc foldable acrylic (e.g.) Acrysof MA 60
 Attempt optic capture through AC +/- PC
 Haptic in Sulcus, IOL Optic Capture thru
PCC
ME Wilson et al 2012, Faramarzi et al 2009, http://www.eye.uci.edu/pix/cataractsu
rgery.jpg

 multi-center meta-analysis
 a lower incidence of glaucoma in infantile eyes that underwent IOL implantation
at the time of cataract surgery compared to eyes that were left aphakic.
 Mataftsi A, Haidich AB, Kokkali S, et al. Postoperative glaucoma following infantile cataract surgery: an individual patient data
meta-analysis. JAMA Ophthalmol. 2014;132:1059–1067.
 Not RCT
 Varying definitions of glaucoma of different centers
 Lambert SR, Plager DA, Buckley EG, et al. The Infant Aphakia Treatment Study: Further on intra- and postoperative complications
in the intraocular lens group. Journal of AAPOS : the official publication of the American Association for Pediatric Ophthalmology
and Strabismus / American Association for Pediatric Ophthalmology and Strabismus. 2015;19(2):101-103.
doi:10.1016/j.jaapos.2015.01.012.

Axial Length Variability
Newborn: 17mm
Adult: 23-24mm
Pediatric Eyes with
cataract: wide range!

Prado et al. Congenital and developmental
cataract: axial length and keratometry study in
Brazilian children. Arq. Bras.
Oftalmol. vol.79 no.1 São Paulo Jan./Feb. 2016
http://dx.doi.org/10.5935/0004-2749.20160007
Lin et al. Distribution of Axial Length
before Cataract Surgery in Chinese
Pediatric Patients.
https://www.nature.com/articles/srep2
3862

Bluestein EC, Wilson ME, Wang XH et al.
Dimensions of the Pediatric Crystalline
Lens: Implications for Intraocular Lenses
in Children. JPOS 1996; 33(1): 18-20.
DOI: 10.3928/0191-3913-19960101-06

1 pc hydrophobic acrylic:
Acrysof SA/SN 60 series
6.0 mm optic, 13.0 overall diameter
Acrysof SA30AL
5.5 mm optic, 12.5 mm overall
diameter
3 pc acrylic optic-PMMA haptic
Acrysof MA60BM
6.0 mm optic, 13 mm overall
diameter
1.ME Wilson et al. Cataract
Surgery in Children, Trends and
Controversies.
http://www.aapos.org/client_data/file
s/2012/479_wilsonhandout.pdf
Accessed August 23, 2015.

ALCON Acrysof PMMA
1.ME Wilson et al. Cataract Surgery in Children, Trends and Controversies.
http://www.aapos.org/client_data/files/2012/479_wilsonhandout.pdf Accessed August 23, 2015.
• Proliferative
• Progress more slowly
• Less visually significant
• 2nd surgery less likely
• If Nd:YAG single sessions
• Fibrous
• Progress faster
• More visually significant
• 2nd surgery likely
• Reopacification =
repeated Nd:YAG

 Not recommended when a primary posterior capsulotomy and
vitrectomy done
 2 or more images formed at the retina: immature visual system
will choose 1; alternating vision between near image or distant
image
 Loss of contrast sensitivity
 Eye growth and amblyopia
 Myopia with eye growth
 Deserves further study at this time
ME Wilson et al. Cataract Surgery in Children, Trends and Controversies. http://www.aapos.org/client_data/files/2012/479_wilsonhandout.pdf Accessed
August 23, 2015.

Majority of patients with Primary Posterior Capsulotomy and anterior
vitrectomy
 In the bag PCIOL: reopen bag, viscodissection
 Sulcus PCIOL: PMMA vs 3-pc acrylic
 ACIOL
 3 pc acrylic transpupillary capture of IOL, haptics in sulcus
 Artisan lens
 Retropupillary fixation of Iris Fixated IOL (Mohr)
 Transcleral?? As a last resort???
Wilson et al 2012, Wilson et al 2009, Trivedi et al 2005, Wilson et al 2011, Buckley
2007

Age dependent myopic shift
3/33 subluxed IOL
10-0 prolene suture spontaneous breakage
 3.5, 8, 9 years
Survey of 10 pediatric ophthalmologist:
 10 cases at average 5 years
Buckley EG. Hanging by a thread: the long-term efficacy and safety of transcleral sutured IOL in children (an AOS thesis). Trans AOS. 2007;105:294-311

Buckley EG. Hanging by a thread: the long-term efficacy and safety of transcleral sutured IOL in children (an AOS thesis). Trans AOS.
Conclusion
Despite the 3/33 subluxed IOL
• appears to be a safe and effective
procedure
• provided that the suture material
used is stable enough to resist
significant degradation over time.
• caution with 10-0 polypropylene
suture
• an alternative material or size
should be considered.http://vignette3.wikia.nocookie.net

 Get a good keratometry reading
 Get a good axial length
determination
 Get a good ultrasound
 Get a good biometry
 Even if you have to put the
patient under general anesthesia!
http://www.aitindustries.com

IOL
Power
SRKII
SRK-T Holladay
HofferQ
ACCURACY?

4 formulas studied: SRK II, SRK-T, Holladay, HofferQ
No significant difference in accuracy
Average postop error 1.2-1.4D in all formulas
high degree of variability
 SRK II being the least variable
 Hoffer Q being the most variable,
 particularly among the youngest group of children with the axial lengths
less than 19 mm
NeelyDE, PlagerDA, BorgerSM, GolubRL. Accuracy of intraocular lens calculations in infants and children undergoing cataract surgery. J AAPOS.
Andreo LK, Wilson ME, Saunders RA. Predictive value of regression and theoretical IOL formula in pediatric intraouclar lens implantation. J Pediatr
Ophthalmol Strabismus 1997; 34: 240-243..

Prediction Error vs. Desired Refraction
Age at Surgery
Axial Length
NeelyDE, PlagerDA, BorgerSM, GolubRL. Accuracy of intraocular lens calculations in infants and children undergoing cataract surgery. J AAPOS.
2005;9(2)160–165.

IOL Choice Advantage Dis
advantage
Adult Refraction
Initial
hyperopia
Hyperopia
improves as eye
grows
Less myopic shift
Initial specs or
contact lens
correction required
Low myopia or
emmetropia,
possibly hyperopia

IOL Choice Advantage Dis
advantage
Adult Refraction
Initial
emmetropia
No spectacle or
contact lens initially
Large myopic shift
with eye growth
Myopia, moderate
to high
Initial myopia Initially may not
require contact
lens or spectacle
correction to
prevent amblyopia
Large myopic shift
with eye growth
Myopia possibly
very high

• Emmetropia in early childhood
– Myopic shift
– Less anisometropia
• Hyperopia
– Mild to Moderate for ages 2-8 years
– Potential for amblyopia
– Less problems with myopic shift
ME Wilson et al. Cataract Surgery in Children, Trends and Controversies.

AGE (Years) Target Refraction
7 0 to +0.50
6 +1.00
5 +2.00
4 +3.00
3 +4.00
2 +5.00
Weigh:
• Refraction of other
eye
• Risk of amblyopia
• Management of
induced
anisometropia
ME Wilson et al 2012, Faramarzi et al 2009,

AGE (Years) Target Refraction
7 0 to +0.50
6 +1.00
5 +2.00
4 +3.00
3 +4.00
2 +5.00
Weigh:
• Refraction of other eye
• Risk of amblyopia
• Ease of management of
induced anisometropia
ME Wilson et al 2012, Faramarzi et al 2009,

 Capozzi P, et al. Corneal curvature and axial length values in children with
congenital infantile cataract in the first 42 months of life. Investigative
Ophthalmol Vis Sci 2008; 49: 11. 4774-4778.
 Trivedi RH, Wilson M. Keratometry in Pediatric Eyes With Cataract. Arch
Ophthalmol. 2008;126(1):38-42. doi:10.1001/archophthalmol.2007.22.
 Gordon RA, Donzis PB. Refractive development of the human eye. Arch
Ophthalmol 1985;103:785-789

Date of download: 8/23/2015 The Association for Research in Vision and Ophthalmology Copyright © 2015. All rights reserved.
From: Capozzi P et al. Corneal Curvature and Axial Length Values in Children with Congenital/Infantile Cataract in the First 42 Months of Life Invest.
Ophthalmol. Vis. Sci.. 2008;49(11):4774-4778. doi:10.1167/iovs.07-1564
Figure Legend:
Scatterplot of K m by AL for unilateral and randomly selected single eyes of patients with bilateral cataract.

 Pupil
 Cornea with reduced rigidity
 Thin sclera with reduced rigidity
 Anterior capsule elastic
 No hard nucleus
 Increased vitreous pressure

 Newborn to first year of life miotic
 Dilates poorly
 Too much dilating drops in leaky blood
ocular barrier = corneal haze
 Poorly developed dilator muscle
 Superviscous and viscous cohesive OVD
adjunct to mydriasis.

 Corneal tunnel
 Conjunctiva undisturbed
 Near the limbus for maximum healing
 Sutured with 10-0 synthetic absorbable
 Scleral tunnel
 2-2.5mm from the limbus into clear cornea
 Preferred for rigid IOL
 Enlarged for IOL
 Sutured with 9-0 synthetic absorbable
http://www.reviewofophthalmology.com/
http://www.feather.co.jp

Do not self seal in children!
 Children less than 11, not water tight
 Especially if combined with anterior vitrectomy
 Low corneoscleral rigidity
Basti S, Krishnamachary M, Gupta S. Results of sutureless wound construction in children
undergoing cataract extraction. J POS 1996;l33:52-54
http://www.eyeworld.org

 Superior incision
 Wound protected by upper lid and Bell’s
 Deep set orbits and overhanging brows not factors
 Flat nose bridge makes it easier
 Temporal incision
 More space (just like adults)
 But easily traumatized in children
 Patients with against the rule astigmatism ?
 Achieve preoperative astigmatism in 1 month
regardless

Pediatric Speculums!
Important
Very small field and
limited space

Anterior chamber collapse
 Create snug fit for instruments
 Bimanual anterior chamber former and separate
aspiration if available
 appropriate gauge MVR blade
 High irrigation setting

Highly elastic Anterior Capsule
Staining the AC: ICG, Trypan
Blue
High viscosity of OVD
Flatten the anterior capsule
Leading with a cystotome
Capsulorrhexis: CCC
http://i.ytimg.com

 Nischal’s Push-pull technique
 Vitrectorrhexis
 Use of radiofrequency
 Cut edge in very young children
remains smooth because of capsule
elasticity
 In slightly older children, the
vitrector creates a slightly
scalloped edge
 dissecting microscope and scanning
electron microscope have shown
that the scallops roll outward to
leave a smooth edge.
August 23, 2015.
http://www.medicalmedia.co.il

 Venturi pump preferred over peristaltic pump
 Separate infusion port
 Snug fit of instruments
 MVRs
 AC maintainer
 No need for cystotome
 Cut rate 150-300/min
 Size smaller than optic
August 23, 2015.

CCC (preferred > 4 years)
 Heavier viscoelastics
 Runaway rhexis common
 Done well: most resistant to tear
Vitrectorrhexis (< 4 years)
 Easier to perform
 Next best in terms of resistance
 Runaway less common
Radiofrequency (any age)
 Similar to vitrectorrhexis in advantage
ME Wilson et al 2012

Beer can
Blue dye makes the
capsule more brittle? (less
equatorial tears)

 Advantages
 Overall reduction in operative time
 Less irrigating solution used
 Facilitation of lens removal
 Vasavada AR, Trivedi RH, Apple DJ, et al. Randomized, clinical
trial of multiquadrant hydrodissection in pediatric cataract
surgery. AJO. 2003;135:84-88
 Disadvantages
 Extension of tears if not CCC
 PC rupture in posterior lenticonus and
posterior polar cataracts

HYDRODISSECTION
ISSUES
Anterior capsule tear
(Cohesive) Viscoelastic escape
Iris Prolapse
Nucleus Prolapse in AC
PC rupture: absolute contraindication
in suspected preexisting PC defect
https://i.ytimg.com/vi/ydp5d5tlF1M/maxresdefault.jpg

 Forego!
 Use only with successful CCC
 Do multiquadrant
hydrodissection gently
 Release of nucleus not
necessary
 Risk of equatorial and
posterior capsule tearsTaylor & Hoyt’s Pediatric Ophthalmology 2005

 Soft nucleus/cortex but gummy
 Aspiration for most
 Occasional bursts for ‘gummy” lens material

Mostly I & A only
Phacoburst
Very minimal
ultrasound power /
phacoemulsification
required RARELY

In the bag preferred
Sulcus if and only if
difficulty encountered
with in-the-bag fixation

Create a nick at the posterior capsule
Push vitreous with heavy viscoelastic
Complete the posterior capsulorrhexis
Respect the vitreous

ALCON Acrysof
Proliferative
Progress more slowly
Less visually significant
2nd surgery less likely
If Nd:YAG single sessions
PMMA
Fibrous
Progress faster
More visually significant
2nd surgery likely
Reopacification = repeated
Nd:YAG

 Primary posterior capsulotomy & small
anterior vitrectomy
 Reduce need for 2nd surgery
 Visual axis clearer, longer
 Nd:Yag difficult in pediatric age group
 Disadvantages
 Vitreous violated
 More surgery, more inflammation
 Does not guarantee prevention of reopacification
 Risk of retinal detachment, cystoid macular
edema
http://www.aapos.org/client_data/files/2012/479_wilsonhandout.pdf Accessed August 23,
2015.
Mousa HG. Slideshare.net

 Anterior vitreous reticular response with acrylic intraocular lens usually not
visually significant
 Optic capture
 Anterior vitrectomy depending on patient’s age

Victrector-rhexis
Posterior CCC
Size smaller than optic

<5
• Primary posterior capsulotomy
• Vitrectomy
5-8
• Primary posterior capsulotomy
• With or without vitrectomy
>8
• Intact posterior capsule
August 23, 2015.

Anterior Chamber
Tilts the IOL
Pars plana/plicata
Preserves IOL position
Pars plana varies
Risk of dialysis and retinal detachment

PREMATURE INFANT VS ADULT GLOBE
From Isenberg SJ, The Eye in Infancy 1994

Age Nasal Temporal
< 6 mos 2.2 mm 2.5 mm
6-12 mos 2.7 3.0
1-2 yrs 3.0 3.1
2-6 yrs 3.2 3.8
• Temporal ciliary body longer than nasal
Aiello AL, Tran VT, Rao NA, 1992

Pediatric Pars PlanaAge Nasal Temporal
< 6 mos 2.2 mm 2.5 mm
6-12 mos 2.7 3.0
1-2 yrs 3.0 3.1
2-6 yrs 3.2 3.8
Sclerotomy Site
Aiello AL, Tran VT, Rao NA, 1992
Age Trivedi &
Wilson
< 1 yr </= 2mm
1-4 y 2.5
>4 y 3.0
2-6 yrs 3.2
Trivedi and Wilson 2005, in Wilson
et al Pediatric Cataract Surgery

•Most
rapid
growth
26-35
wks
• 1.87mm
• (0.9-
2.8mm)
40
wks
> 3 mm
62
wks
PPV safe only after
62 wks post conception?
Trivedi and Wilson 2005, in Wilson et al Pediatric Cataract Surgery

 Logarithmic curve up to age 20 years
 Axial length: 16.8 mm to 23.6 mm
 K power: 51.2D to 43.5D
 Aphakic child’s shift in refraction: 10D
 Normal child’s shift in refraction: -
0.9D
Bluestein EC, Wilson ME, Wang XH et al.
Dimensions of the Pediatric Crystalline Lens:
Implications for Intraocular Lenses in Children.
JPOS 1996; 33(1): 18-20. DOI: 10.3928/0191-3913-
19960101-06

• Reopacification rate high
• Especially if unable to
treat anterior vitreous
face
• Cost
• Availability of YAG laser
mounted on operative
microscope
• Need for general
anesthesia
Trivedi and Wilson 2005, in Wilson et al Pediatric Cataract
Surgery
Photo fr. Wilson ME

Nick the posterior capsule with a needle cystotome
Push vitreous with heavy viscoelastic
Proceed with posterior circular capsulorrhexis or
vitrectorrhexis
Leave vitreous intact
May or may not aspirate OVD

Synechial closure prevented
Prevents glaucoma
Incites more iritis
Risk of bleeding
May not be necessary if in-the-
bag IOL placement
https://www.willseye.org/sites/default/files/i
magecache/health-library-gallery-
full/laser_iridotomy.017.jpg

 Leave sutureless?
 Vicryl 10-0 (8-0)
 Nylon 10-0
http://www.resuresealant.com/wp-
content/uploads/2013/10/resure_website_resure_page_ad_02.jpg

Subconjunctival steroids:
 Injection of 1.2 mg triamcinolone acetonide at the end
of congenital cataract surgery in children <2 years of
age did not significantly affect IOP or central corneal
thickness in the first year after surgery.
 Ventura et al, Congenital cataract surgery with intracameral triamcinolone: pre-
and postoperative central corneal thickness and intraocular pressure. J AAPOS.
2012 Oct;16(5):441-4. doi: 10.1016/j.jaapos.2012.06.005
 IATS protocol: subconjunctival dexamethasone
 Pupillary membranes still developed
 2 of 15 (13%) eyes that did not receive subconjunctival
steroids
 16 of 99 (16%) of eyes that received subconjunctival steroids
(p=0.99).
 Lambert SR, Buckley EG, Drews-Botsch C, et al. The infant aphakia treatment study:
design and clinical measures at enrollment. Arch Ophthalmol. 2010;128:21–27.

 Incision corneal, near limbus
 Anterior capsulotomy CCC or vitrectorrhexis
 Lens removal no hydrodissection, no hydrodelineation
 Posterior capsule
 primary capsulotomy if no IOL
 Preserve capsule if with IOL
 Vitreous preserve whenever possible
Patient
Surgery
Visual
Rehab

Iritis
Endophthalmitis
IOL decentration
CME: less than adults
Retinal Detachment
Ocular Hypertension &
Glaucoma

 IATS protocol mandated the administration of topical
prednisolone acetate 1% at least 4 times a day for at
least 1 month.
 most common dosage of topical corticosteroids
prescribed for both treatment groups was
prednisolone acetate 6 times a day for 4 weeks; 54/57
(95%) of patients in the IOL group and 38/57 (67%) of
patients in the contact lens group were prescribed
topical corticosteroids >4 times a day during the early
postoperative period.
 difficult to ascertain whether prescribing the
administration of topical corticosteroids on a more
frequent basis would have further reduced the
incidence of inflammatory postoperative adverse
events such as pupillary membranes.
Lambert SR, Buckley EG, Drews-
Botsch C, et al. The infant aphakia
treatment study: design and clinical
measures at enrollment. Arch
Ophthalmol. 2010;128:21–27. [PMC
free article]

Steroids more frequent
Cycloplegia: tropicamide, atropine, cyclopentolate,
combination
Eyeglass correction
Amblyopia management
 Patch both eyes in binocular cataracts
When to give adds

Steroids:
 prednisolone 1%
 Loteprednol
Antibiotic: Moxifloxacin or levofloxacin
Cycloplegic:
 Tropicamide 0.5%
 Tropicamide-phenylephrine (Sanmyd-P)
 Atropine 1%
Watch out for steroid-induced elevation of
IOP

Preop: waiting for clearance and
schedule
 dilation with phenylephrine if with
red reflex
 Not cycloplegic agents
 Patch better eye
Resume ASAP postop
Early spectacle correction (1-2
weeks postop)

If one eye done at a time,
patch both until surgery
done on both eyes
Bilateral patch to prevent
amblyopia in the 2nd eye

Bilateral cataracts do well
with aphakic correction

Still the treatment
of choice among
conservatives?

 Amblyopia Treatment
 Frequent refraction checks
 Giving adds
 Iritis and Glaucoma
 Retinal detachment
 May need exam under anesthesia in ages 2-5 years or uncooperative child
 Lifetime of commitment

2:00 – 2:25
2:25 - 2:50
Approach to Pediatric Cataract
Not like “the usual” adult case
 Do I operate now?
 How do I get the biometry?
 IOL of choice…. or none?
 My surgical approach?
 Surgery done. Now what?
Dr. Pamela Astudillo and
Dr. Melissa Santos-
Gonzales

Alvina Pauline D. Santiago, MD
August 29, 2015
http://www.slideshare.net/AlvinaPaulineSantiag/little-folks-
different-strokes-pediatric-cataracts-anesthesia-anatomy-surgery

1. Aiello AL, Tran VT, Rao NA. Postnatal development of the ciliary body and pars plana. A morphometric study in
childhood. Arch Ophthalmol 1992; 110: 802-805.
2. Andreo LK, Wilson ME, Saunders RA. Predictive value of regression and theoretical IOL formula in pediatric
intraouclar lens implantation. J Pediatr Ophthalmol Strabismus 1997; 34: 240-243..
3. Basti S, Krishnamachary M, Gupta S. Results of sutureless wound construction in children undergoing cataract
extraction. J POS 1996;l33:52-54 Jaf HBQ, Diseases of the crystalline lens.
https://www.slideshare.net/AbbasTelakoe/ophthalmologydiseases-of-the-lensdrbaxtyar. Accessed April 4, 2017
4. Birch EE, Plager D. The critical period for surgical treatment of dense congenital unilateral cataract. Invest
Ophthalmol Vis Sci. 1996 Jul;37(8):1532-8.
5. BuckleyEG .Hangingbyathread:thelong-term efficacy and safety of transcleral sutured IOL in children (an AOS
thesis). Trans AOS. 2007;105:294-311
6. Butler PA. Reversible Cataracts in Diabetes Mellitus. J Am Optom Assoc. 1994 Aug;65(8):559-63.
7. Donahue S, Arnold RW, Ruben JB, AAPOS Vision Screening Committee. Preschool vision screening: what should we
be detecting and how should we report it? Uniform guidelines for reporting results of preschool vision screening
studies. J AAPOS. 2003 Oct;7(5):314-6. PMID: 14566312 DOI: 10.1016/S1091853103001824
8. Faramarzi A, Javadi MA. Comparison of 2 techniques of intraocular lens implantation in pediatric cataract surgery.
J Cataract Refract Surg. 2009;35:1040-5. WilsonMEJr,EnglertJA,GreenwaldMJ.In-the-bagsec- ondary intraocular
lens implantation in children. J AAPOS. 1999;3:350-5

9. Infant aphakia treatment study group. A Randomized Clinical Trial Comparing Contact Lens to Intraocular Lens Correction of
Monocular Aphakia During Infancy: Grating Acuity and Adverse Events at Age 1 Year. Arch Ophthalmol. 2010 Jul; 128(7): 810–818.
doi: 10.1001/archophthalmol.2010.101
10. Infant aphakia treatment study group. A Randomized Clinical Trial Comparing Contact Lens to Intraocular Lens Correction of
Monocular Aphakia during Infancy: HOTV Optotype Acuity at Age 4.5 Years and Clinical Findings at Age 5 years. JAMA
Ophthalmol. 2014 Jun; 132(6): 676–682. doi: 10.1001/jamaophthalmol.2014.531
11. Jaf HBQ, Diseases of the crystalline lens. https://www.slideshare.net/AbbasTelakoe/ophthalmologydiseases-of-the-lensdrbaxtyar.
Accessed April 4, 2017
12. Jin YY et al. Reversible Cataract as the Presenting Sign of Diabetes Mellitus: Report of Two Cases and Literature Review. Iran J
Pediatr. 2012 Mar; 22(1): 125–128.
13. Lambert SR, Buckley EG, Drews-Botsch C, et al. The infant aphakia treatment study: design and clinical measures at
enrollment. Arch Ophthalmol. 2010;128:21–27. [PMC free article]
14. Lambert SR, Plager DA, Buckley EG, et al. The Infant Aphakia Treatment Study: Further on intra- and postoperative complications in the
intraocular lens group. Journal of AAPOS : the official publication of the American Association for Pediatric Ophthalmology and Strabismus /
American Association for Pediatric Ophthalmology and Strabismus. 2015;19(2):101-103. doi:10.1016/j.jaapos.2015.01.012.
15. Moore DB, Zion IB, Neely et al. Accuracy of biometry in pediatric cataract extraction with primary intraocular lens implantation. J
Cat Refract Surg 2008; 34 (11): 1940-1947.
16. NeelyDE, PlagerDA, BorgerSM, GolubRL. Accuracy of intraocular lens calculations in infants and children undergoing cataract
surgery. J AAPOS. 2005;9(2)160–165.

17. Trindande R. Transient cataracts and hypermetropization in diabetes mellitus: case report. Arq. Bras. Oftalmol. vol.70 no.6 São
Paulo Nov./Dec. 2007. http://dx.doi.org/10.1590/S0004-27492007000600030 version=h
18. TrivediRH,WilsonME,FaccianiJ.Secondaryintraocular lens implantation for pediatric aphakia. J AAPOS 2005;9:346-52
19. Wilson ME et al. Cataract Surgery in Children, Trends and Controversies.
20. Wilson ME, Trivedi RH, Pandey SK. Pediatric Cataract Surgery, Techniques, Complications and Management. PA, Lippincott
Williams & Wilkins, 2005.
21. WilsonME, HafezGA, TrivediRH. Secondary in-the-bag IOL implantation in children who have been aphakic since early infancy. J
AAPOS 2011;15:162-6
22. Vasavada AR, Trivedi RH, Apple DJ, et al. Randomized, clinical trial of multiquadrant hydrodissection in pediatric cataract surgery.
AJO. 2003;135:84-88

One hundred years from now,
It doesn’t matter what kind of house I lived in,
How much money I had,
What positions I held,
Or what my clothes were like.
But the world may be a little better,
Because I was important in the life of a child.
-Anonymous

Partnering with the Pediatric Ophthalmology Service: Special Considerations for Cataract Surgery in Children

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Partnering with the Pediatric Ophthalmology Service: Special Considerations for Cataract Surgery in Children