3 strategies for managing traumatic cataract in children

Take-Home:

There are several vital components surgeons need to take into consideration when treating children who have traumatic cataracts.

Dr. Buckley

Durham, NC-Managing traumatic cataracts in children requires attention to three issues when implanting an IOL: namely, the timing of the implantation, the type of lens,  and the IOL calculation, according to Edward G. Buckley MD.

However, there are several controversies regarding IOL implantation in children.

Whether to implant the IOL in the sulcus or capsule, if the surgery is primary or secondary, and how to deal with the lack of capsular support are some of the concerns, said Dr. Buckley, professor of ophthalmology and pediatrics and vice dean of medical education, Duke University School of Medicine, Durham, NC.

“All of the issues surrounding IOL implantation in children concern the anterior segment and what it looks like at the time of intervention,” he said.

Timing

The general rule, Dr. Buckley said, is “the later the better.”

If surgery in a patient’s inflamed eye can be avoided, the surgery will be:

• Easier.

• The cornea will be clearer.

• The tissue will be less reactive.

• The IOL calculations will be more accurate.

• There is a better chance of in-the-bag placement.

• There will be fewer postoperative issues, he pointed out.

The surgeon must determine to insert the IOL during the primary surgery or during a secondary procedure.

“The answer depends on the anterior chamber,” Dr. Buckley said. “If the chamber is not in good shape after the initial surgery, waiting is likely a better option to avoid a rocky postoperative course with further complications.

“The general rule is when in doubt, don’t do it,” he said.

Location

There is no long-term data that suggest a difference in children with traumatic cataract regarding capsular implantation or sulcus fixation.

“Exerting heroic efforts to put the IOL in the bag is probably not a good idea, especially in the presence of a poor anterior segment,” Dr. Buckley said.

IOL types

There are two IOL options for use in children.

 A single-piece polymethylmethacrylate (PMMA) IOL is the hallmark IOL for use in inflamed eyes, Dr. Buckley said. This IOL is implanted through a 7-mm incision and is more suitable in the sulcus.

The other lenses are the acrylic, single-piece AcrySof IOL (MA60AC Alcon) that is foldable and implantable through a 4-mm incision, and the SA60AT (Alcon) that is injectable through a 2.75-mmm incision.

The acrylic SA60AT IOL is by far the IOL of choice by 93.3% of pediatric ophthalmologists for in-the-bag fixation and not for implantation in the sulcus.

The MA60AC IOL should be considered for eyes with a great deal of inflammation. When sulcus fixation is desired, a 3-piece acrylic IOL or a 1-piece PMMA IOL is the best choice.

To determine if a PMMA IOL can be implanted in the sulcus, surgeons need to find the degree of optic support that is available, Dr. Buckley said.

If the capsule can support the optic, a MA60AC IOL is “perfectly satisfactory,” he said.

In the absence of optic support, a PMMA IOL may be a better choice because it is sufficiently rigid to achieve adequate support.

Inflammation is an important factor when choosing the appropriate lens in these cases.

The acrylic IOLs can develop a great deal of deposits and are not a good choice in an eye that may have severe inflammation.

The PMMA IOLs, however, are easier to clean than the acrylic IOLs.

In the absence of adequate capsular support, the surgeon is faced with the choice of an anterior chamber IOL or suturing an IOL in the posterior chamber.

“In children, the anterior chamber IOLs do not have a good track record because of pupil problems, persistent inflammation, hyphema, and glaucoma,” Dr. Buckley said.

A new lens-the Artisan Iris Clip Lens (Ophtec)-may be advantageous, but the long-term performance is unknown.

IOLs that are sutured in place are associated with complications during the initial surgery.

The long-term safety is a question that centers around the 10-0 Prolene suture material, which tends to break (average time to breakage, 6 years) in the long term in up to 33% of patients, Dr. Buckley said. This can be avoided by using 9-0 Prolene.

IOL calculations

There is a myopic shift in children over time that extends into the teen years.

“Surgeons need to consider the myopic shift ahead of time,” Dr. Buckley said. “The eye should be undercorrected early to avoid very high myopia later.”

The formula used to calculate IOL powers does not matter.

“Because timing is an issue, waiting until the eye is 'quiet' is best,” he said. “The IOL type depends on the implant location, which dictates the optimal lens material.

“The myopic shift must be considered when doing the IOL calculations,” Dr. Buckley said.

Edward G. Buckley, MD

E: Edward.buckley@duke.edu

Dr. Buckley has no financial interest in the subject matter.

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