Cataract surgery following penetrating keratoplasty in children

Background: Following penetrating keratoplasty, cataract surgery warrants certain modifications to ensure maximum survival of the graft. Purpose: To emphasize the intraoperative challenges and surgical manipulations to be followed. Synopsis: The surgeon makes a superior sclerocorneal tunnel avoiding the graft host junction. Dispersive viscoelastic is used. Continuous curvilinear capsulorhexis is done. Cataractous lens aspirated with a low flow rate. The intraocular lens is placed in the bag. Superior peripheral iridectomy and primary posterior capsulorhexis are done. The wound closed with two interrupted 10�nylon sutures. Graft host junction integrity is maintained. Highlights: Ensure 1. Good intraoperative corneal visibility, 2. Avoid graft host junction for main port incision 3. Generous dispersive viscoelastic use/soft shell technique to protect the corneal endothelium, 4. Avoid phaco energy in case of soft cataracts/low phaco energy and flow rates, 5. Phaco probe to be meticulously oriented away from corneal endothelium, 6. Primary posterior capsulorhexis to be done as in any pediatric cataract surgery, 7. Make sure of the graft host junction integrity at the end of the surgery, 8. Restrict to a single port whenever possible.

Comparison of topical steroids versus adjunctive intracameral triamcinolone versus posterior subtenon triamcinolone in pediatric cataract surgery

Purpose: Prolonged postoperative topical corticosteroids are commonly given after pediatric cataract surgery to control inflammation. This study was undertaken to compare the efficacy, safety, and compliance of postoperative topical steroids and adjunctive intracameral (I/C) triamcinolone acetonide (tricort) and posterior subtenon (PST) triamcinolone in modulating postoperative inflammation after surgery. Methods: Forty?eight eyes of children with pediatric cataract between the ages of 5 and 10 years were randomized into three equal groups (T, I, S) before surgery. Group T received postoperative topical 1% prednisolone tapered over 4 weeks; Group I received adjunctive intraoperative I/C 1.2 mg/0.03 ml tricort and topical 1% prednisolone for 2 weeks postoperatively, and Group S received a single 0.5 ml (40 mg/ ml) PST tricort without topical steroids. Signs of inflammation, intraocular pressure (IOP), and central corneal thickness were assessed at day 1, week 1, week 3, week 6, and week 12 postoperatively with optical coherence tomography (OCT) macula to rule out cystoid macular edema at the sixth and 12th weeks postoperatively. Results: Posterior synechiae were present in two eyes out of 16 in groups T and I, which resolved. Severe anterior chamber cells were present in four eyes out of 16 in group T, in two eyes in group I, and in one eye in group S, which resolved. All groups had comparable pre? and postoperative IOP. Conclusion: In pediatric cataracts, outcomes were better with PST tricort and the adjunctive I/C tricort compared to postoperative topical prednisolone, for modulating postoperative inflammation

Comparative analysis of non-absorbable 10-0 nylon sutures with absorbable 10-0 Vicryl sutures in pediatric cataract surgery

Purpose: The purpose of the study is to compare the efficiency as well as the rate and type of suture-related complications between 10-0 monofilament nylon (Aurolab Nylon Sutures, double arm, Aurolab) and 10-0 polyglactin 910 sutures (Vicryl, single arm, Aurolab) for pediatric cataract surgery. Methods: It is a prospective, comparative study performed in children who underwent surgery for congenital or developmental cataract from March 2013 to February 2016. Patients underwent suturing with either nylon or Vicryl in unilateral cases, but in most bilateral surgeries, one eye received Vicryl sutures while the other eye received nylon. The sutures were compared for their complications and the need for suture removal. Results: Forty-one children (72 eyes) were included in the study, of which 31 children (62 eyes) underwent bilateral surgery while 10 (10 eyes) underwent unilateral surgery. Sixty-four nylon sutures were placed in 32 children (34 eyes), of which 22 (34.4%) were removed due to suture-related complications, whereas 14 (19.7%) (P = 0.03) of the 71 Vicryl sutures placed in 32 children (38 eyes) needed suture removal at an average of 2.9 weeks with the earliest at 6 days postoperatively. The odds of Vicryl suture being removed was 0.42 times with respect to nylon. The most common reason encountered for suture removal in both the materials was sutures becoming loose (16.3%), followed by vascularization (14.1%), infiltration (1.5%), and opacification (4.4%). Conclusion: Absorbable suture such as 10-0 Vicryl is preferred over nonabsorbable suture 10-0 nylon for suturing incisions in pediatric cataract surgery, to avoid subjecting the child to repeated anesthesia.

Completion rates of anterior and posterior continuous curvilinear capsulorrhexis in pediatric cataract surgery for surgery performed by trainee surgeons with the use of a low-cost viscoelastic.

Context: Pediatric cataract surgery is traditionally done with the aid of high-molecular-weight viscoelastics which are expensive. It needs to be determined if low-cost substitutes are just as successful. Aims: The study aims to determine the success rates for anterior and posterior capsulorrhexis and intraocular lens (IOL) implantation in the bag for pediatric cataract surgery performed with the aid of a low-molecular-weight viscoelastic. Settings and Design: Nonrandomized observational study. Materials and Methods: Children less than 6 years of age who underwent cataract surgery with IOL implantation in the period May 2008–May 2009 were included. The surgeries were done by pediatric ophthalmology fellows. A standard procedure of anterior capsulorrhexis, lens aspiration with primary posterior capsulorrhexis, anterior vitrectomy, and IOL implantation was followed. Three parameters were studied: successful completion of anterior and posterior capsulorrhexis and IOL implantation in the bag. Results: 33 eyes of 28 children were studied. The success rate for completion was 66.7% and 88.2 % for anterior and posterior capsulorrhexis, respectively. IOL implantation in the bag was successful in 87.9%. Conclusions: 2% hydroxypropylmethylcellulose is a viable low-cost alternative to more expensive options similar to high-molecular-weight viscoelastics. This is of great relevance to hospitals in developing countries.

Postoperative follow up Challenge in Paediatric Cataract Surgery in Nepal.

Introduction: Paediatric ophthalmology is a branch of specialty care for the health of the eyes of children. It focuses on the removal of paediatric cataracts and management of refractive error, strabismus etc. Perioperative and post-operative challenges related to paediatric cataract are known to all ophthalmologists worldwide. However, in a developing country like Nepal the main challenge of these patients are the post-operative follow up. The aim of the study is to find out the ways to reduce the post-operative follow up challenges in paediatric cataract surgery. Hence the ophthalmic assistants in the community eye centers need to be trained to examine the eyes of children. Materials and Methods: This was a retrospective study. A review of patient records, operated from July 2006 to December 2007, at Tilganga Institute of Ophthalmology was done. One hundred eyes of 69 patients were operated during the study period. Results: Follow-up assessment of visual acuity was available for 19 eyes only at the end of six weeks. Conclusion: At the end of six postoperative weeks, refractive status is important. This helps to prescribe the glasses to children as per need. If the post-operative visual status is not known, it is as equal as not performing the surgery. Ophthalmic assistants at community eye centers need to be trained to evaluate and record postoperative visual status of the paediatric age group. For this regular training and refreshers course on the pediatric eye care service is being conducted at the tertiary level for the ophthalmic assistants. This is more practical in the developing countries like Nepal.

Factors Affecting Stereopsis After Pediatric Cataract Surgery

PURPOSE: To evaluate factors influencing stereoacuity outcomes after pediatric cataract surgery. METHODS: We retrospectively reviewed 38 eyes of 22 patients who had undergone irrigation and aspiration of cataracts and primary posterior chamber intraocular lens implantation from February 1992 to July 2006. In all patients, stereoacuity was assessed with the Titmus stereo test. Patients were divided into two groups according to stereoacuity: group 1 (n=9) had a stereoacuity less than 100 sec/arc; group 2 (n=13) had a stereoacuity more than 100 sec/arc. Nine variables associated with stereoacuity were evaluated in each group. RESULTS: Postoperative strabismus was the strongest factor influencing the stereoacuity level. Good postoperative mean visual acuity was related with good stereoacuity. Though mean visual acuity in two children with exodeviation over 30PD was 0.7 and 0.8, their stereoacuity was 400 sec/arc. Showing little difference in the spherical equivalent between the eyes was also related to good stereoacuity. CONCLUSIONS: Postoperative strabismus onset, postoperative mean visual acuity between the two eyes, and differences in the spherical equivalent were important factors influencing stereoacuity in patients after pediatric cataract surgery.

Surgical Results and Complications of Implanted Primary Intraocular Lenses in Pediatric Cataract

PURPOSE: To evaluate surgical results and complications of different intraocular lenses (IOL) implantation in pediatric cataract surgery. METHODS: We retrospectively reviewed 139 eyes of 80 patients who had undergone irrigation and aspiration of cataracts and primary posterior chamber intraocular lens implantation with posterior continuous curvilinear capsulorhexis and optic capture from July 1998 to December 2005. All the eyes were divided into three groups into the intraocular lenses implanated: group 1 (n=40), PMMA lens was implantated; group 2 (n=42), hydrophobic acrylic lens was implantated; group 3 (n=57), hydrophilic acrylic lens was implanated. The surgical results and complications was evaluated. RESULTS: Wound leakage, iris prolapse, shallow anterior chamber during operation were the most common in group 1. Peripheral anterior synechiae, conjuntival cyst, pigment deposition of IOL, exudative membrane, elevated intraocular pressure were also the most common in group 1 (P<0.05). There was no statistically significant defference in the prevalence of intraoperative and postoperative complications between group 2 and 3. Postoperative final visual acuity and astigmatism were not significantly different between the three groups. CONCLUSIONS: Implantation of hydrophilic acrylic IOLs, as well as hydrophobic acrylic IOLs decrease complications and have good surgical results compared to PMMA IOLs in pediatric cataract surgery.