Perioperative Care of the Child with Congenital Cataract-Intraoperative and Post-operative Medication

Intraoperative medication

Intracameral heparin

Intracameral antibiotic

Subconjunctival corticosteroid (Orbital floor corticosteroid)

Topical anaesthetic

Postoperative medication

Topical antibiotic for 2 weeks

Topical corticosteroid, tapered over 4–6 weeks

Topical cycloplegics

13.1.2 Intracameral Tissue Plasminogen Activator

A prospective, double-masked, randomised trial in 26 patients (34 eyes) having cataract surgery at age 3–14 years compared the outcomes of 20 ug of intracameral recombinant tissue plasminogen activator (r-TPA) injected intracamerally at the end of surgery with eyes having BSS alone; the r-TPA group showed significantly less intraocular fibrin formation up to days 14 but no difference at day 30 and 90. The incidence of pigmented IOL deposits was significantly lower in the r-TPA group [6].

Intracameral r-TPA can also be used postoperatively to treat severe fibrinous membranes following paediatric cataract surgery [7].

13.1.3 Peroperative Corticosteroids

There are many potential methods of administration of corticosteroids at the time of surgery, in order to reduce inflammation and postoperative complications. The methods selected depend on surgeon preference and experience, pre-existing systemic and ocular conditions of the patient, and surgical technique and complications. Intracameral Corticosteroids

Some surgeons advocate the use of preservative-free intracameral corticosteroids in congenital cataract surgery in order to reduce the risk of postoperative anterior membranes. Several studies have shown that intracameral triamcinolone used at the time of childhood cataract surgery reduces the incidence of anterior chamber inflammation, posterior synaechae, deposits on the IOL and visual axis re-opacification [8,9]. A prospective randomised study of children having cataract surgery at age less than 2 years compared an intracameral injection of 1.2 mg/0.03 ml of triamcinolone acetonide (31 eyes) or 1 mg/kg per day of oral prednisolone for 15 days postoperatively (29 eyes) and found no difference in the incidence of cell deposits and posterior synaechae [10], suggesting that intracameral corticosteroids are as effective as oral in controlling post-operative inflammation.

Intracameral triamcinolone may also be used to allow visualisation of the anterior vitreous, to ensure adequate vitreous removal from the anterior chamber [11].

Children are at significant risk of ocular hypertension and glaucoma related to corticosteroid use. However, in a case series of 24 eyes in which intracameral dexamethasone was used at the time of infantile cataract surgery, no cases of glaucoma were reported at follow-up ranging from 20 to 48 months [12]. Intravitreal Corticosteroids

Intraoperative intravitreal steroids may be used in paediatric cataract surgery in selected cases (for example children with uveitis and refractory macular oedema). However caution needs to be made with regard to the risk of postoperative ocular hypertension and secondary glaucoma. Subconjunctival Corticosteroids

Sub-conjunctival corticosteroids may reduce postoperative inflammation. A half dose of subconjunctival short-acting dexamethasone may be used in infants, increased to full adult dose in older children. Subconjunctival use of long acting corticosteroids such as triamcinolone and depomedrone may precipitate a corticosteroid-related IOP rise, which occasionally necessitates removal of the corticosteroid deposit. Conjunctival necrosis has also been reported following subconjunctival corticosteroid injection in a child [13]. Orbital Floor Corticosteroids

Long acting corticosteroids (triamcinolone or depomedrone) can be given as an orbital floor injection at the end of surgery [14]. This is particularly helpful when there is a high risk of severe post-operative inflammation such as in infantile cataract surgery requiring iris hooks or in eyes with uveitis, or in situations when instillation of post-operative drops may be difficult (due to cooperation of the child, or parental compliance issues). There is a risk however of post-operative IOP rise.

13.1.4 Postoperative Corticosteroids Topical Corticosteroids

Topical corticosteroids are routinely used following childhood and adult cataract surgery to reduce postoperative inflammation. There is evidence however that systemic absorption of topical corticosteroids may cause growth suppression [15] and suppression of endogenous adrenal function [16]. Synacthen testing of 26 children who had cataract surgery at less than 5 years of age followed by topical dexamethasone treatment found that seven children (27 %) had adrenal insufficiency, which was severe in five children [17]. Cushing syndrome may be manifest as facial fullness, growth suppression, thin skin with bruising, and striae. Adrenal insufficiency reduces the physiological response to fever, infection, trauma and general anaesthesia; although the effects are reversible, hydrocortisone supplementation may be necessary during intercurrent infection or during further anaesthesia.

A significant number of children using topical corticosteroids have an ocular hypertensive response, and secondary glaucoma due to topical corticosteroids may occur even in infancy after a short course of topical corticosteroids [18].

High strength hourly topical corticosteroids can be used when the risk of severe inflammation is high (such as infantile cataract surgery with iris hooks, in cases with pre-operative uveitis) but risks systemic side effects in an infant. Topical corticosteroids are frequently used in a combined drop with antibiotics; six times a day maxitrol (dexamethasone, neomycin sulphate and polymixin B; Alcon UK) is usually sufficient following routine surgery, tapered over a 4–6 week period (combined with maxitrol ointment at night for the first few weeks) [19]. Systemic Corticosteroids

Oral corticosteroids have been advocated by some surgeons [10] in the postoperative period. Intracameral triamcinolone has been shown to be as effective as oral corticosteroids in children having cataract surgery at less than 2 years of age in prevention of IOL deposits and posterior synechiae [10]. However, the use of careful operative technique, periocular corticosteroid and postoperative corticosteroid drops has meant that oral corticosteroids and their associated side effects can be avoided in most cases. Intravenous corticosteroids are reserved for children with active uveitis prior to the cataract surgery. Topical Cycloplegics

Topical cycloplegics are usually given for 2 weeks following uncomplicated paediatric cataract surgery (for example cyclopentolate 0.5 or 1 % three times a day, topical phenylephrine 2.5 % two times a day).

13.2 Reduction of Risk of Infection

Endophthalmitis, although rare, has potentially devastating consequences following childhood cataract surgery, as in adults. The risk of endophthalmitis in paediatric cataract surgery is similar to that in adults; approximately 7 per 10,000 cases for paediatric anterior segment surgery [20]. Options for reducing the risk of endophthalmitis include use of pre-operative skin preparation, subconjunctival or intracameral peri-operative antibiotics, and topical post-operative antibiotics (as a sole drop or as a combination with a steroid). Systemic antibiotics are not usually necessary.

13.2.1 Pre-operative Skin and Conjunctival Disinfection

Pre-operative periocular skin disinfection (with 10 % povidone-iodine or polyvinyl alcohol-iodine) or conjunctival disinfection (with 5 % PI) significantly reduces the risk of endophthalmitis [21].

13.2.2 Peri-operative Antibiotics Subconjunctival Antibiotics

Half adult dose of subconjunctival antibiotics can be used at the end of the surgery (cefuroxime, vancomycin). Intracameral Antibiotics

The use of intracameral antibiotics at the end of the surgery has significantly reduced the incidence of endophthalmitis in adult cataract surgery [2225] and so has been widely adopted in paediatric cataract surgery also. The relative risk of endophthalmitis is 0.12 when intracameral antibiotics are used [25]. The standard adult dose of antibiotic (1 mg cefuroxime, cefazolin, moxifloxacin) can be instilled into the anterior chamber following placement and tying of the sutures. Any excess in the syringe can be washed onto the surface of the eye. Intracameral cefuroxime is safe to use in the presence of non-severe (non-IgE mediated anaphylaxis) penicillin allergy. Caution would be advised in cases of IgE mediated anaphylaxis to penicillin and an alternative agent such as intracameral vancomycin may be substituted.

13.2.3 Post-operative Antibiotics Topical Antibiotics

It is standard practice to use topical antibiotics following cataract surgery in adults and children, usually in a combination drop with a steroid (dexamethasone, neomycin sulphate and polymixin B; prednisolone and gentamicin; prednisolone and sulfacetamide or tobramycin). These are usually used four times daily for 2 weeks postoperatively, although there is no evidence that post-operative antibiotics alone are effective in reduction of endophthalmitis [25].

13.3 Reduction in Post-operative Pain

Topical anaesthetics are commonly given at the end of the cataract procedure in infants and children. Administration of a subtenon’s block following induction of anaesthesia has been shown to improve postoperative analgesia compared to intravenous fentanyl during cataract surgery in infants [26]. Postoperative analgesia can be given as necessary; paracetamol or non-steroidal anti-inflammatory medications are usually sufficient.

13.4 Miscellaneous Adjuncts to Cataract Surgery

13.4.1 Intra-cameral Mydriatics

Cataract surgery is facilitated by optimal pupillary dilation. Pre-operative preparation of the patient involves the use of topical mydriatics, but some infants and children may be sub-optimally dilated, or whilst undertaking surgery, the pupil may become constricted, making surgery more hazardous. The use of intracameral mydriatics (phenylephrine 0.5 %, epinephrine 0.5 cc/500 cc BSS, has been adopted for adult cataract surgery, particularly in the context of intra-operative floppy iris syndrome (IFIS). Concerns regarding the safety of intracameral phenylephrine in adult cataract surgery, particularly to the corneal endothelium, toxic anterior segment syndrome, and endophthalmitis, have been allayed by 6 year follow up demonstrating no significant difference in endothelial cell loss, IOP control, and PCO rates compared with controls only receiving topical mydriatics [27]. Systemic adverse effects are rare, although a small rise in mean arterial pressure has been described in adults [28]. A combination of intracameral phenylephrine and ketorolac (Omeros) has been shown to maintain mydriasis and reduce post-operative pain in adult cataract surgery [29]; a randomised controlled trial is underway to study its use in paediatric cataract surgery. Until data is available on the safety and efficacy of intracameral mydriatics in the paediatric population, they should be used with caution.

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Nov 21, 2017 | Posted by in OPHTHALMOLOGY | Comments Off on Perioperative Care of the Child with Congenital Cataract-Intraoperative and Post-operative Medication

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