Planning Pediatric Cataract Surgery: Diverse Issues



Planning Pediatric Cataract Surgery: Diverse Issues


Rupal H. Trivedi

M. Edward Wilson



Children are not miniature adults; they have unique anatomy, physiology, psychology, and social status. Not only are children’s eyes smaller than adults’, but also their tissues are much softer. A cataract in an adult reduces visual acuity, while in a child it may also interfere with normal visual (brain) development. In a young child, a cataract blurs the image received by the retina and disrupts the development of the visual pathways in the central nervous system. The timing of surgery, the surgical technique, the choice of aphakic correction, and the amblyopia management are of utmost importance in achieving good and long-lasting results in children.

The management of pediatric cataracts is far more complex than the management of cataracts in adults. Differences and difficulties encountered during the preoperative, intraoperative, and postoperative periods are listed in Table 8.1.

In this chapter, we cover some of the diverse issues that are not covered as individual chapters in the book.


WHO SHOULD PERFORM PEDIATRIC CATARACT SURGERY: PEDIATRIC OPHTHALMOLOGISTS OR ADULT CATARACT SURGEONS?

The incidence of pediatric cataracts is not high enough to allow many surgeons to devote their entire careers to pediatric cataract surgery. The result of our worldwide survey revealed that more than 71.5% of American Society of Cataract and Refractive Surgeon respondees performed <10 pediatric cataract surgeries per year, while the majority of American Association of Pediatric Ophthalmologist and Strabismus (AAPOS) respondees (85%) indicated <20 pediatric cataract surgeries performed per year.1 In most cases, either pediatric ophthalmologists or cataract surgeons (primarily performing adult cataract surgery) cultivate the interest in pediatric cataract surgery. In 2000, Wood and Ogawa2 wrote, “Given the overall paucity of clinical experience in pediatric patients and its hazardous nature, who should be performing pediatric cataract surgery in the first place? Is this the realm of the pediatric ophthalmologist, the adult cataract surgeon, or perhaps both?”

The question of who is best suited to perform pediatric cataract surgery is not easily answered. Is it best performed by pediatric ophthalmologists, who deal with children exclusively, or cataract surgeons, who frequently perform adult cataract surgery?3 We raised this question in our survey and found that 77.4% of ophthalmologists not performing pediatric cataract surgery referred patients to a pediatric ophthalmologist.1 Among ophthalmologists performing pediatric cataract surgery, more than half (52.6%) stated that either a pediatric ophthalmologist or an adult cataract surgeon should perform this procedure.1

This issue may depend on “local” situations and there is no “must” here. The ophthalmic surgeon with the most experience and interest in pediatric cataract surgery should be sent the surgical cases from the locale.4 Co-management among ophthalmologists works well in this setting. In the United States, pediatric ophthalmologists are more likely to be the most experienced, however, outside the United States, adult cataract surgeons generally lead the field. Pediatric ophthalmologists are much more aware of the anatomy and functional parameters of pediatric eyes. They have much to teach adult cataract surgeons about operating on the infant eye and various functional issues in postoperative management. Conversely, cataract surgeons (primarily performing adult cataract surgery) are much more experienced in surgical technique such as capsulorhexis and innovations in intraocular lens (IOL)-related technology, and they also have much to teach pediatric ophthalmologists about adult surgical advances that should be applied to children.4

In our opinion, the surgeon must have enough experience to feel comfortable with the specific difficulties of the pediatric eye. Children with cataracts often have other associated health problems that increase anesthesia risks.









Table 8.1 HOW DOES PEDIATRIC CATARACT SURGERY DIFFER FROM ADULT CATARACT SURGERY?









Preoperative Period




  1. Difficult and often delayed diagnosis



  2. Timing of surgery: In sharp contrast to the treatment of adult cataracts, the timing of cataract surgery in children is of paramount importance. It affects the visual result to a much greater extent than does the surgical technique or method of postoperative optical correction used by the surgeon.



  3. High incidence of associated ocular and systemic anomalies and prematurity



  4. Setup for pediatric general anesthesia a prerequisite



  5. Apprehension about general anesthesia



  6. Examination under anesthesia: necessary sometimes even to diagnose cataract and for preoperative assessment



  7. Need for automated keratometer and A-scan in operating room



  8. Difficulty in calculating IOL power



  9. Psychologic issues and preoperative counseling of parents


Intraoperative Period




  1. Risks of general anesthesia



  2. Smaller size of the eye



  3. Poor dilation of pupil more often associated with pediatric eyes



  4. Low scleral rigidity



  5. Relative size of the pars plana: The pars plana region in the infant eye is incompletely developed, so the anterior retina lies just behind the pars plicata.



  6. Incision and suturing: As opposed to adult eyes, a superior tunnel is preferable in pediatric eyes (as it provides better protection and, in general, children do not have deep-seated eyes, which would require temporal incision). It is preferable to suture even a “self-seal” tunnel incision in children as opposed to adults.



  7. Need for high-viscosity viscoelastic for capsular management



  8. Difficulty in performing an anterior capsulorhexis associated with a highly elastic anterior capsule and increased intralenticular and intravit-real pressure



  9. Densely formed vitreous and scleral collapse contributing to vitreous upthrust giving rise to raised intravitreal and lenticular pressure, making anterior and posterior capsular management difficult



  10. Removal of lens substance rarely requires phacoemulsification, but the cortex is stickier and gummier than in adults



  11. Posterior capsule plaques are common and may require intraocular scissors in addition to the vitrector



  12. Need for primary posterior capsule management to prevent dense and thick PCO in those too young to apply an awake YAG laser



  13. Need for vitrectomy instrumentation—preference for Venturi pump, which requires a nitrogen tank or wall hook up



  14. Difficult IOL implantation


Postoperative Period




  1. Higher risk for opacification of the visual axis



  2. Propensity for increased postoperative inflammation



  3. Compliance with the use of topical postoperative medications difficult



  4. Requirement for frequent correction of residual refractive error, as it is constantly changing due to growth of the eye



  5. Difficulty in documenting anatomic, refractive, and visual acuity changes due to poor compliance—also, young children do not know their letters, so alternative testing methods may be needed



  6. Examination possibly requiring repeated brief anesthesia due to lack of cooperation with office exam



  7. Tendency to develop amblyopia and need for patching



  8. Long-term follow-up important but not always easily achieved


They require close monitoring pre- and postoperatively by staff with expertise in pediatric anesthesia and recovery. It is mandatory to have appropriate backup in case of intraoperative or postoperative anesthetic complications, especially since childhood cataracts can be associated with a wide range of systemic and metabolic abnormalities. These cases are best handled at a pediatric care center or an operating room facility offering experienced pediatric anesthesiologists. Whoever performs pediatric cataract surgery must understand the importance of teamwork. A pediatric ophthalmologist should generally be following these eyes during the postoperative course for strabismus, amblyopia, and other functionally related issues. However, for each region a solution has to be individually tailored based on the resources available and the willingness of pediatric and adult cataract surgeons to continue to learn from each other and to work together to provide good care.


DOES CONSERVATIVE MANAGEMENT HAVE A PLACE IN PEDIATRIC CATARACT SURGERY?

Poor anatomical and functional outcomes of cataract surgery in children have prompted many surgeons to try conservative treatment such as the use of mydriatic drops.5,6,7,8
Chandler5

Only gold members can continue reading. Log In or Register to continue

Related posts:

  1. Etiology and Morphology of Pediatric Cataracts
  2. Anesthetic Management of the Pediatric Patient with Cataracts
  3. Role of Intraocular Lens Optic Capture in Pediatric Cataract Surgery
  4. Visual Outcome after Pediatric Cataract Surgery

Stay updated, free articles. Join our Telegram channel
Tags: , ,
May 24, 2016 | Posted by in OPHTHALMOLOGY | Comments Off on Planning Pediatric Cataract Surgery: Diverse Issues

Full access? Get Clinical Tree
Get Clinical Tree app for offline access