Taking a non-adult approach to pediatric cataract surgery

Listen to Jonathan C. Song, MD, discuss how a non-adult approach should be taken toward pediatric cataract surgery during the annual Current Concepts in Ophthalmology meeting at the Wilmer Eye Institute/Johns Hopkins University.

Take-home

Early treatment of pediatric cataracts is crucial, with proper consideration being given to age and the type of postoperative correction to be used.

By Liz Meszaros

Baltimore-Correcting cataracts in children differs greatly from cataract correction in adults, according to Jonathan C. Song, MD. Pediatric cataracts must be corrected quickly, with proper consideration being given to age and the type of postoperative correction to be used.

“In children, there are actually significant things we must think about before approaching cataracts,” said Dr. Song, assistant professor of ophthalmology, division of pediatric ophthalmology and adult strabismus, Wilmer Eye Institute, Johns Hopkins University School of Medicine, Baltimore. “The cataract itself can cause irreversible vision loss, and postoperative therapy, including patching, is much more important in children than the surgery itself.”

Pediatric cataracts must be treated early, Dr. Song continued. Once the child reaches age 7 (but perhaps even up to age 12), the visual loss can become irreversible, he cautioned.

“When you do see these cataracts, you have to act very quickly,” he said. “In monolateral cases, we do the cataracts very early-as soon as we see them. In unilateral cases, we will wait about 1 month.”

Pros and cons of correction

Postoperative vision correction in these children can be accomplished with spectacles, contact lenses, or lens implants. Dr. Song reviewed the advantages and disadvantages of these options.

Spectacle correction is low risk, readily available, the power is changeable, and the lens material is quite durable, he said. Among the disadvantages of spectacles are the lenses can be very thick and heavy, distortion, and high expense.

“Cosmetically, therefore, some parents push you to do lens implants in their children,” Dr. Song said. “We try to hold off on them.”

In unilateral cataracts, spectacle correction cannot be used alone. Rather, it must be used in tandem with contact lenses for optimal correction.

Contact lenses cause no distortion, are easily applicable in children less than 4 or 5 years old, and can be used in both monocular and binocular conditions. Risk of infection is lower with the new lenses, but they can be difficult to remove.

Lens implants can be used in children, and result in continuous correction and high patient satisfaction. Disadvantages are that once the lens is put in, it cannot be changed. In addition, the long-term effects are still unknown.

“One thing to remember is that the growth of the eye does change, and the power of correction does change to a certain age,” he added, citing the specifics of eye growth.

By age 1, the growth of the eye is to about 70% of the adult eye; by age 2, this increases to 80%. The biggest shift, therefore, occurs in the first year of life, and from ages 1 to 2 years, this shift is about 10 D. From age 2 to age 18, it decreases to about 4 D.

“This is where most people will talk about implants, from age 1 to age 2, mainly because the shift has happened already,” Dr. Song said. “If you do implants earlier, shoot for a correction of +6 to +7 D.

“There is no lens approved for children, and although implants are standard of care, they are being used off-label,” he added. “There’s no question that we can put lens implants in children, but the long-term effects are still unknown.”

Consider opacification rate

Ophthalmologists must also be aware of and watch for several complications with lens implants in children including dislocation, glaucoma, prolonged inflammation, and posterior opacification, which is the main problem, according to Dr. Song.

“In children, the opacification rate is about 50% higher, so you have to consider posterior capsulotomy at the same time you remove these, especially if they are not going to sit still for a YAG capsulotomy,” he said.

“Our recommendation is that you try contact lenses in children before the age of 1 until the Early Infantile Phakic study results finally do come out,” Dr. Song said. “If you are going to do a primary IOL implant, think about the posterior capsule. Consider glasses, contact lenses, and refractive surgery for the future. The goal is to clear the visual axis in these children.”

Jonathan C. Song, MD

P: 240/482-1100 or 410/893-0480

E: jsong41@jhmi.edu

Dr. Song did not indicate any proprietary interest in the subject matter.