swons exeter 2005 paediatric cataract tony quinn consultant ophthalmologist west of england eye unit...
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SWONS Exeter 2005
Paediatric cataract
Tony Quinn
Consultant Ophthalmologist
West of England Eye Unit
Royal Devon & Exeter Hospital
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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?
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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
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Why do children get cataracts?
• Gene mistake
• Inherited
• Associated with other genetic conditions
(Paediatrician workup)
• Trauma
• Uveitis
• Intrauterine infections
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SWONS Exeter 2005
What else could it be?
• “white pupil” differential diagnosis
• Retinoblastoma• Retinopathy of
prematurity• Coat’s disease• Persistent fetal
circulation
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SWONS Exeter 2005
What else occurs in association?
• Main problem is amblyopia
• Eye growth • Strabismus
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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
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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
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SWONS Exeter 2005
Surgery
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Complications?
• Infection, bleeding, GA risk, loss of eye…
• Big risks: Re-op• Glaucoma• Retinal detachment• Amblyopia• Strabismus• Glasses(bifocals) or
Contact lens for sure
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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)
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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
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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
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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
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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
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Refractive target
• +4 to +8D, (SRK-T) but max +30D IOL
• Unilat Down +1.8D
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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
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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
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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
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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”