Indmedica - India's Premier Medical Portal - Cyber Lectures

 

Cataract Surgery and IOL Implantation in Children

Dr.P.Mishra

Page 4

Topics

Discussion

The main objective of this study was to find out

  1. Which procedure is the safest and gives best long term visual outcome.
  2. The frequency of operative, early and late post operative complications.

It is a fact that the conventional aphakic spectacles are useful in optical rehabilitation after bilateral congenital or developmental cataract surgery but not satisfactory for rehabilitation after unilateral or traumatic cataracts because of the problem of aniseikonia. Therefore it is a greatest barrier to good visual out come and cosmetically unappealing also. Unilateral or bilateral contact lens rehabilitation has the advantage of providing accurate and changeable optical correction. How ever, contact lens use in children requires significant co operation among parents, child and practioner. During last few years, the recent development of capsulorhexis and placement IOL in the bag has led to renewed interest for IOL implantation in children, but controversy still surrounds the question of how much hyperopia children should remain. Some ophthalmologists believe the child should made emmetropic or even myopic without concern for later myopic, they advocate curing the amblyopia and handling the myopia later. Some argue the opposite view points. What ever the fact, it is not always easy to calculate the IOL power in children. In that case one could implant standard +20.50D lenses.

The visual outcome of childhood cataract is dependent on many factors such as type of cataract, age of onset, age at surgery, duration of opacity and compliance with optical rehabilitation and occlusion. This trial was designed to determine the best and most suitable surgical treatment for childhood cataract at present time. Overall in 90% of eyes the visual acuity was achieved 6/60 or better. Although there is no much variation in the final visual out come in three different groups the complications are less encountered with scleral tunnel surgeries. In no time eye collapses, anterior chamber becomes flat or there is iris prolapse during this procedure. It is much easier, surgeon is comfortable through out the procedure. How ever, tunnel dissection is little difficult in children, as the sclera is little thin. One should avoid muscle relaxants during general anaesthesia and could master the technique in no time. Similarly rhexis is more difficult in children as it is not easy to tear anterior capsule, with experience it is not a problem at all. The key to it’s success is to start the rhexis more centrally ie.the capsule should be opened with a 26 G bent needle, the starting position should be more central to create a small capsular flap, then the flap is grasped with Masket capsulorhexis forceps and the capsule is torn in a continuous curvilinear manner avoiding radial extension.

Retinal detachment is well recognized and usually a late complication of cataract surgery in children. In this series there were two retinal detachments encountered, one in lensectomy group and other which was pre existing in the scleral tunnel group, which was due to high myopia. Conclusion. Management of childhood cataract poses many challenges to the ophthalmologists in the developing countries. Over the years there has constantly been search for a new technique, that more effectively manage paediatric cataract. Prior to CCC most IOLs were almost left partly or fully supported by ciliary sulcus. Since uveal tissue in a child is highly reactive, placement of IOL in the bag has been viewed, as highly desirable by most of the paediatric cataract surgeons. We recommend scleral tunnel cataract surgery, that is self sealing, sutureless and phacoless is the surgery of choice at present, for paediatric cataracts because of following reasons.

  1. Anterior chamber never collapses during this procedure.
  2. No nucleus present in childhood cataract, the problem of nucleus management which is most difficult in adults cataract surgery is very easy here.
  3. Intra-operative complications are negligible, virtually there is no chance of expulsive haemorrhage.
  4. Proper placement of IOL in the bag is easy (Fig 2).
  5. The wound is more stable and secured, no side port entry is required.
  6. It is relatively easy and repeatable without long and risky learning curve.
  7. One can achieve faster and satisfactory visual rehabilitation, early ambulation possible (Fig 3).
  8. It is inexpensive, very cost effective which is one of the criteria in all developing countries where most of the surgeons are unable to afford high tech equipments.

No doubt the paediatric surgeons now stand at the threshold of a new era filled with excitement, which greeted modern cataract surgeons few years back as they entered to sutureless cataract surgery with IOL implantation. Should we say now, good bye to ECCE and Lensectomy?

References

  1. Kathryn M. Brady, C. Scott Atkinson, Laurra A Kitty, David A Hiles. Cataract surgery and lens implantation in children: Am J Ophthalmology 1995;120:1-9
  2. Michael Eckstein, P Vijaylaxmi, Clare Gilbert, Allen Foster. Randomized clinical trial of lensectomy versus Lens aspiration and primary capsulotomy for children in bilateral cataract in south India: Br J Ophthalmology 1999;83:524-529
  3. Surendra Basti,Mark J. Greenwald. Principle and paradigms of paediatric cataract management; Indian J Ophthalmology 1995;43:159-176
  4. Michael Eckstein, P. Vijaylaxmi, Millind Killeder, Clare Gilbert, Allen Foster.Use of Intraocular lenses in children with Traumatic cataract in South India: Br J Ophthalmol 1998;82:911-915
  5. Benjamin F Boyd. New Development in small Incision Manual Phacoframentation; Highlights of Ophthalmology 1999;6:5-12

For correspondence write to

Dr.P.Mishra ,
Professor of Ophthalmology,
R.M.M.CH.,Annamalai University-608002 India.
e-mail: [email protected]

!http://www.indmedica.com/pictures/pic1.jpg (Figure 1)!

Figure 1

!http://www.indmedica.com/pictures/pic2.jpg (Figure 2)!

Figure 2

!http://www.indmedica.com/pictures/pic3.jpg (Figure 3)!

Figure 3


*Dr.P.Mishra* ,
Professor of Ophthalmology,
R.M.M.CH.,Annamalai University-608002 India.
e-mail: [email protected]

1 2 3 4 Previous page Back