Pediatric Cataract With Special Considerations
S. Grace Prakalapakorn, MD, MPH
UVEITIC CATARACT
The pre- and postoperative management of the patient with the uveitic cataract is critical to a good outcome
Preoperative Considerations
Co-management with a uveitis and/or rheumatology specialist is invaluable. Consider increasing immunomodulating agents prior to surgery.
On clinical examination:
Note other coexisting ocular pathology: band keratopathy, posterior synechiae, glaucoma, macular edema.
Note type of cataract (eg, anterior subcapsular, posterior subcapsular).
Check for macular edema prior to surgery (perform OCT imaging if possible).
Ensure the uveitis is under control before cataract surgery (at least 3 months).
Consider starting or increasing steroids (topical and/or oral) in the immediate preoperative period (especially if there is macular edema prior to surgery)1.
Surgical Considerations
Small pupils (see Small Pupil section below): try to minimize iris manipulation.
Consider performing a posterior capsulotomy and anterior vitrectomy at the time of cataract surgery if it is felt that the posterior capsule will soon opacify following surgery (see Chapter 6).
There are no standard guidelines for IOL implantation in pediatric uveitis.
Do not place an IOL in the setting of active inflammation.
If able to implant an IOL, try to place it in the capsular bag.
Consider an acrylic or heparin surface modified IOL to possibly induce less intraocular inflammation.
Consider administering IV steroids (communicate with anesthesia team) and also injecting 0.2 mL of 40 mg/mL triamcinolone (ie, Triesence) into the posterior
segment at the end of the case (either through the posterior capsular opening, if there is one, or via a pars plana injection) (see Chapter 3).
Postoperative Considerations
Taper topical steroids slowly (over many weeks) and maintain patient on a cycloplegic agent until inflammation resolves to prevent the formation of synechiae, posterior capsular opacification, and macular edema.
Monitor for macular edema (perform OCT imaging if possible).
Possible complications: recurrent uveitis, hypotony, glaucoma, synechiae, secondary membranes, cystoid macular edema, retinal detachment.
TRAUMATIC CATARACT (see Chapter 26)
Preoperative Considerations
On clinical examination:
Note other coexisting ocular pathology: corneal wound/scar, iris tear, iridodialysis, peaked pupil, posterior synechiae, angle recession, presence of vitreous in the anterior chamber, and vitreous hemorrhage.
Note type of cataract, appearance of anterior capsule (may appear fibrotic secondary to trauma), and anterior chamber depth.
Check for phacodonesis. If zonules are missing, estimate the missing clock hours and determine if there will be enough structural support to implant a lens.
Perform ultrasound prior to surgery to evaluate for possible retinal detachment. If retinal pathology present, consult a retinal specialist prior to proceeding with cataract surgery.
Surgical Considerations
May be performed through either a limbal or pars plana approach.
The pupil may not dilate well (see Small Pupil section below).
If there is a white cataract, consider trypan blue to stain the anterior capsule (see Chapter 3).
If there is vitreous in the anterior chamber, perform limited anterior vitrectomy before proceeding with the cataract extraction. Use of a cohesive viscoelastic can help tamponade the vitreous.
If the lens capsule is fibrotic:
Attempt to make an incision in the anterior capsule with a cystotome or MVR blade by starting at the edge of the thickened anterior capsule (in normal anterior capsule if possible and not too far peripherally). Make the incision big enough to allow the edge of the anterior capsule to be grasped if planning on performing a manual capsulorrhexis or to allow the vitrector to engage the capsule to start the vitrectorhexis.
Intraocular scissors can also be used to cut through the plaque. It is often helpful to cut the capsule into pie-shaped wedges that are easier to engage with the vitrector.
It is not necessary to remove the entire fibrotic capsule, just the portion in the visual axis.
If there is zonular dehiscence:
For mild cases (<4 clock hours) consider the following:
Placement of a 3-piece lens in the bag with the haptics oriented in the area of zonular weakness.
Placement of a capsular tension ring.
Placement of a 3-piece lens in the sulcus with the haptics oriented over the areas of good zonular support.
For moderate cases (4-6 clock hours): Consider using a capsular tension ring.
For severe cases (>6 clock hours): Consider leaving the child aphakic and using a contact lens (see Chapter 4). If planning lens implantation, may need to consider, iris-fixated or scleral-fixated IOL.
Stay updated, free articles. Join our Telegram channel
Full access? Get Clinical Tree
