swons exeter 2005 paediatric cataract tony quinn consultant ophthalmologist west of england eye unit...

SWONS Exeter 2005

Paediatric cataract

Tony Quinn

Consultant Ophthalmologist

West of England Eye Unit

Royal Devon & Exeter Hospital

SWONS Exeter 2005

Outline• What sort of cataract?• Why do children get cataracts?• What else could it be?• What else occurs in association?• Should we operate? What options are there?• How soon should we treat?• Complications?• Controversies? IOL Implants?• Outcomes?• Our local results?

SWONS Exeter 2005

What sort of cataract?

Nuclear, lamellar, powdery, subcapsular, sutural, total

• Can start off mild and become more dense

• Obscures retinal image• May cause amblyopia

SWONS Exeter 2005

Why do children get cataracts?

• Gene mistake

• Inherited

• Associated with other genetic conditions

(Paediatrician workup)

• Trauma

• Uveitis

• Intrauterine infections

SWONS Exeter 2005

What else could it be?

• “white pupil” differential diagnosis

• Retinoblastoma• Retinopathy of

prematurity• Coat’s disease• Persistent fetal

circulation

SWONS Exeter 2005

What else occurs in association?

• Main problem is amblyopia

• Eye growth • Strabismus

SWONS Exeter 2005

Should we operate? What options are there?

• Unilateral cataract: ? treatment• Bilateral cataract: Treat if visually significant: • Can you see in? • Is opacity >=3mm?• anterior or posterior• ? Amblyopia, abnormal eye growth

SWONS Exeter 2005

How soon should we treat?

• <4 weeks may cause more glaucoma

• More than 10 weeks may cause irreversible amblyopia, nystagmus

• Unilateral about 6 weeks

• Depends on how dense

SWONS Exeter 2005

Surgery

SWONS Exeter 2005

Complications?

• Infection, bleeding, GA risk, loss of eye…

• Big risks: Re-op• Glaucoma• Retinal detachment• Amblyopia• Strabismus• Glasses(bifocals) or

Contact lens for sure

SWONS Exeter 2005

What do we tell the parents?

• Lifetime journey

• Very hard work

• Lots of drops early, then glasses and patching for years

• May not work well (unilateral)

• Long term risks

• Risk to other eye (sympathetic)

SWONS Exeter 2005

Controversies? IOL Implants?

• IOL implants: when to use?

• Minimum age

• Minimum corneal diameter

• How long will they last?

• Rigid (?Heparin coated) or foldable?

• Where to place the lens?

• Dealing with posterior capsule

SWONS Exeter 2005

Outcomes?

• Excellent results possible

• IOLs may be better overall than contact lenses. Not much in it

• Refract, Refract, Refract!!!

• May need EUA

• Tonopen for awake IOP

SWONS Exeter 2005

Our local results? Methods

• Consecutive infant cataract surgery 00 - 03

• 9 infants, 15 eyes

• Mean age at surgery 21 weeks (4-42w)

• All posterior chamber, 13 in bag, 2 in sulcus

• 1 lost to follow up after 6 weeks

SWONS Exeter 2005

Methods

• primary pars plana Vx• IOL: Heparin PMMA in 5, Acrysof MA 60

BM in 10 (both 6 mm optic)• Healon 5 in 14, Healon GV in 1• CCC in 14, MVR = 1• 1 patient corneal diam 9.5• 2 patients (4 eyes) nystagmus and

strabismus pre-op

SWONS Exeter 2005

Refractive target

• +4 to +8D, (SRK-T) but max +30D IOL

• Unilat Down +1.8D

SWONS Exeter 2005

Refractive outcomes: mean followup 26.5 mo

Infant Cataract Pseudophakic Refraction Changes

0 10 20 30 40 50-5

0

5

10

Average Sphere (Dioptres)

Time Post-Op (Months)

D Right

D Left

E Right

E Left

F Right

F Left

G Left

H Right

H Left

Infant Cataract Pseudophakic Refractive Changes

0 10 20 302

4

6

8

10

12

Average Sphere (Dioptres)

Time Post-Op (Months)

A Right

A Left

B Right

B Left

C Right

SWONS Exeter 2005

Vision outcomes mean 26.5 mo

0

10

20

30

40

50

60

70

80

90

100

Percent of eyes (%)

6/6-6-12 <6/12-6/60 <6/60-6/120 <6/120

Range of Visual Acuity

Comparison of Pre-op and 'Final' Visual Acuities

PRE-OP

FINAL

SWONS Exeter 2005

Complications of surgery

• Strabismus in 6 of 8 (1 lost to follow-up)

• Iris capture 1/14

• Repeat posterior capsulectomy 6/14

• Anterior capsule phimosis 1/14

• Glaucoma nil mean 33 mo f/u. Mean IOP =14, range 10-17mmHg

• Retinal detachment nil

• IOL decentred nil

SWONS Exeter 2005

Conclusions

• IOL implants in infants are possible with good visual and refractive outcomes

• Myopic shift with time in most: ?emmetropisation• Mildly microphthalmic child showed almost no

reduction in initial hypermetropia with time• High rate of strabismus• Nearly half re-op for “PCO”