Safety favorable with pediatric primary IOL implantation

Charleston, SC-Pediatric cataract surgery with IOL implantation and primary posterior capsulectomy plus vitrectomy is associated with a satisfactory outcome, especially in children operated on after their first birthday, said Rupal H. Trivedi, MD, MSCR.

Dr. Trivedi, research assistant professor of ophthalmology, Storm Eye Institute, Medical University of South Carolina, Charleston, reported results from a retrospective chart review study examining postoperative complications after cataract surgery in patients <18 years of age and having a minimum follow-up of 1 year. Data were excluded from patients who had traumatic cataracts, uveitis, aniridia, a history of treatment for retinopathy of prematurity, or lens subluxation. When a child had bilateral surgery, the data were analyzed from one randomly selected eye.

Using those selection criteria, 131 of 553 eyes in the pediatric database were included in the analysis. The children had a mean age at surgery of 4.2 years (range, 0.02 to 16.3 years) and mean postoperative follow-up of 4.4 years (range, 1.0 to 11.8 years). Of the 131 cases, 33 (25.2%) were operated on prior to their first birthday. Primary posterior capsulectomy plus vitrectomy was performed in 107 (80.5%) eyes.

And, even with primary posterior capsulectomy and vitrectomy, the risk of requiring secondary surgery for visual axis opacification was increased fivefold in children operated on prior to their first birthday versus at an older age. Surgery prior to 1 year of age was also associated with a significantly increased risk of glaucoma, Dr. Trivedi reported.

"One early critic of Sir Harold Ridley asked whether he would implant an IOL in his own son. Although the answer more than 50 years ago would likely have been 'no,' as of 2006, many ophthalmologists are recommending IOL implantation in selected children undergoing cataract surgery," Dr. Trivedi said. "Currently, IOLs are approved by the FDA for implantation in adults. Accumulation of long-term follow-up of eyes operated on for cataract-IOL surgery will help the effort to expand the age limit so IOLs are approved for use in children."

Within the series of 131 eyes, 25 (19.1%) required treatment for visual axis opacification. Among the 24 eyes with an intact posterior capsule, 12 (50%) required Nd:YAG laser capsulotomy at a mean of 18 months postoperatively, and in two of those 12 eyes, a repeat procedure was necessary. However, in the much larger subgroup of eyes receiving primary posterior capsulectomy plus vitrectomy, visual axis opacification requiring treatment occurred in nine (27.3%) of 33 eyes operated on prior to 1 year of age and in four (5.4%) of the 74 eyes that had surgery after the child's first birthday.

"One of the latter four eyes was in a child age 5 years, but the other three cases of visual axis opacification occurred in eyes operated on in children who were just 13 to 14 months of age," Dr. Trivedi said.

There were five (3.8%) cases of glaucoma in the series, and all occurred in the children operated on before their first birthday, yielding a rate of glaucoma development in that subgroup of 15.2%.

"Although this study did not include a control group of eyes that did not have an IOL implanted, we have recently published a study showing there is a high risk of glaucoma irrespective of IOL implantation in eyes operated on before the patient reaches 1 year of age," Dr. Trivedi told Ophthalmology Times.

There were only three other complications encountered in the series, and they consisted of single cases each of dislocated IOL, synechiolysis, and a wound leak that required resuturing.

Lowering the age limit

Dr. Trivedi also presented data showing that the age cataract surgeons consider acceptable for IOL placement in pediatric eyes is gradually decreasing. According to the results of a survey conducted by Storm Eye Institute ophthalmologists of members of the American Society of Cataract and Refractive Surgery and the American Association for Pediatric Ophthalmology and Strabismus [J Cataract Refract Surg 2003;29:1811-1820], the average minimum recommended ages for unilateral and bilateral implantation were 6.9 years and 11.8 years, respectively, when surgeons were polled in 1993. However by 2001, those recommended ages had dropped to 2.1 and 3.3 years, respectively.