Long-term Risk of Glaucoma After Congenital Cataract Surgery

We read with great interest the article published by Lambert and associates. They have highlighted a very important complication after pediatric cataract surgery. There are certain issues that need to be addressed. The authors enrolled 62 eyes of 37 patients. Seventeen eyes underwent secondary intraocular (IOL) implantation and 6 primary IOL. We would like to know the procedure for the remaining patients. Also, 11 patients had unilateral cataract and 26 bilateral, which makes 63 eyes. In the description on cataract morphology the number of cataracts totals to 37.

It would be worthwhile to know why the adult cut-off of 21 mm Hg was chosen for intraocular pressure (IOP), as in children the pressure varies from 8-14 mm Hg. If the corneal thickness increased after surgery it would mean underestimating the IOP at 21 mm Hg. A lower cut-off should therefore have been taken. The frequency of corticosteroid use should be mentioned, as the age group included in this series has a predisposition to intense inflammation. A table showing synechiae formation or pupil irregularities or inflammatory deposits on IOL and sulcus or bag fixation of IOL would be informative, as these are risk factors for raised IOP. Gonioscopy in children could have helped in knowing peripheral anterior synechiae, especially in the ones who had high IOP. It would be interesting to compare the pattern of IOP in those with secondary IOL vs where a second IOL was implanted. Four of 16 suspects underwent secondary IOL implantation. What surgery did the remaining 12 have? What was the mean age at which secondary IOL implantation was performed? A graphical representation showing the trend of IOP from immediately postoperative until when diagnosed as ocular hypertensive would make one wiser in managing this subgroup, as the median age at diagnosis was 7.5 years. IOP trend over the follow-up period of all patients could highlight differences in IOP in this very young subgroup. Was there any difference in IOP in eyes where a single-piece IOL was implanted vs 3-piece IOL? Was there any family history of glaucoma in the ones who had glaucoma? One needs to check this pediatric population for steroid responders as well. Preoperative predictors of developing glaucoma at presentation such as young age at the time of surgery (<3 months), a family history of aphakic glaucoma, and nuclear cataract are indicators for a longer follow-up.

Recent study by Sahin and associates has shown significantly less incidence of glaucoma in children operated at less than 5 months where a primary IOL (Acrysof) was implanted as compared to those who were left aphakic. Ram and associates showed very low incidence of glaucoma (0.5%) in one of the largest series of congenital cataract surgery where primary endocapsular IOL implantation was done. It is a well-known fact that the incidence of aphakic glaucoma doubles if operated before 10 months age.

Studies quoted by the authors where primary IOL implantation was performed are those where either rigid IOLs were used or there was associated anterior segment dysgenesis. Until more prospective randomized studies comparing primary IOL (hydrophobic third-generation IOLs) implantation vs secondary are performed, it may not be correct to generalize the incidence of glaucoma based on this retrospective study. However, the present study is an eye opener for managing children with pediatric cataract with secondary IOL implantation.

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Jan 9, 2017 | Posted by in OPHTHALMOLOGY | Comments Off on Long-term Risk of Glaucoma After Congenital Cataract Surgery
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