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   Table of Contents      
Year : 2010  |  Volume : 58  |  Issue : 6  |  Page : 563-568

Management of congenital cataract: A review

R. P. Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, Ansari Nagar, New Delhi - 110 029, India

Date of Web Publication16-Oct-2010

Correspondence Address:
Rajesh Sinha
S-7, R. P. Centre, All India Institute of Medical Sciences, Ansari Nagar, New Delhi - 110 029
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Source of Support: None, Conflict of Interest: None

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How to cite this article:
Sinha R, Bali SJ, Sharma N, Titiyal JS. Management of congenital cataract: A review. Indian J Ophthalmol 2010;58:563-8

How to cite this URL:
Sinha R, Bali SJ, Sharma N, Titiyal JS. Management of congenital cataract: A review. Indian J Ophthalmol [serial online] 2010 [cited 2020 Jun 2];58:563-8. Available from: http://www.ijo.in/text.asp?2010/58/6/563/71706

Cataract surgery is the most commonly performed intraocular surgery in the pediatric population. The experiences with pediatric cataract surgery and intraocular lens (IOL) implantation are constantly evolving worldwide. The placement of an IOL in children and infants undergoing cataract surgery is gaining wider acceptance. This article discusses issues and advances related to the management of congenital cataract, including timing of the surgery, surgical techniques, IOL related controversies and complications of the pediatric cataract surgery.

  Preoperative Plan Top

When should the surgery be performed?

Bilateral cataracts

Jain et al. (JAAPOS 2010;14(1):31-34), in a retrospective review of dense bilateral congenital cataracts, found that visual acuity after surgery for bilateral congenital cataracts appears to decline exponentially with duration of visual deprivation.

Birch et al. (JAAPOS 2009;13(1):67-71) assessed the 5-year visual outcome in infants operated for dense bilateral congenital cataracts. They noted that during weeks 0-14, mean visual acuity decreased by 1 line with each 3 weeks' delay in surgery. From 14 to 31 weeks, visual acuity was independent of the subject's age at surgery, averaging 20/80. It was also noted that surgery after 4 weeks was associated with a greater prevalence of strabismus and nystagmus than surgery before 4 weeks, whereas surgery during the first 4 weeks was associated with a greater prevalence of secondary membrane formation and glaucoma.

Lambert et al. (JAAPOS 2006;10(1):30-6) performed a retrospective analysis of children with dense bilateral congenital cataract and noted that a best-corrected visual acuity (BCVA) of 20/100 or worse occurred only among eyes undergoing surgery when infants were older than 10 weeks. They also reported that absence of preoperative nystagmus was a better predictor of a good visual outcome than the age at surgery.

Watts et al. (JAAPOS 2003;7(2):81-5) suggested that the first 2 weeks of life comprise the most favorable time for decreasing postoperative complications resulting from surgical intervention for infants presenting with cataracts within the first 12 weeks of life.

Unilateral cataracts

Birch et al. (Invest Ophthalmol Vis Sci. 1993;34(13):3687-99) found that treatment initiated at 1-6 weeks of age in congenital unilateral cataract maximizes the opportunity for normal or near-normal visual development with little or no risk to the phakic fellow eye.

Birch et al. (Invest Ophthalmol Vis Sci. 1996;37(8):1532-8), in another study of dense congenital unilateral cataracts, reported that intervention before 6 weeks of age may minimize the effects of congenital unilateral deprivation on the developing visual system and visual rehabilitation.

Birch et al. (Invest Ophthalmol Vis Sci. 1998;39(9):1560-6), in a comparative study between unilateral and bilateral cataracts, observed that patients with a history of unilateral cataract showed greater deficits in contrast sensitivity when treatment was initiated later (i.e., at 12-30 weeks). It was hypothesized that only visual deprivation is active as an amblyogenic factor during the first weeks of life, but when unilateral deprivation is prolonged to 12-30 weeks, unequal competition also plays a role in amblyogenesis.

Simultaneous or sequential surgery?

Dave et al. (Arch Ophthalmol. 2010;128(8):1050-4) retrospectively compared sequential versus simultaneous bilateral cataract surgery for infants with congenital cataracts. It was noted that simultaneous bilateral cataract surgery for infants with congenital cataracts is associated with a 21.9% reduction in medical payments and no discernible difference in the incidence of adverse events or visual outcomes.

Nallasamy et al. (JAAPOS 2010;14(1):15-9) reviewed the records of children undergoing simultaneous bilateral intraocular surgery and reported that the surgery was performed safely in 48 cases during a 15-year period.

Magil et al. (Eur J Ophthalmol. 2009;19(1):24-7) retrospectively studied bilateral congenital cataract patients who had undergone cataract extraction from both eyes in a single surgical session. They concluded that simultaneous surgery in bilateral congenital cataract may be taken into consideration, especially in patients with a high anesthesiologic risk profile.

Yu et al. (Eye 2009;23(6):1451-5) described the management of bilateral uneven cataracts treated by sequential IOL implantation. In the same patient, the amblyopic eye with the denser cataract underwent primary IOL implantation, whereas the better eye was temporarily left aphakic as an alternative to patching. A secondary IOL implantation was performed in the aphakic eye when BCVA in the amblyopic eye attained its best potential. They concluded that optical penalization by temporary aphakia of the dominant eye is a convenient means for treating amblyopia in children with bilateral uneven cataracts.

Infants: Contact lenses or intraocular lens implantation?

Lambert et al. (Infant Aphakia Treatment Study Group) (Arch Ophthalmol. 2010;128(7):810-8) performed a randomized, multicenter (12 sites) clinical trial in infants with unilateral congenital cataract, assigned to undergo cataract surgery between 1 and 6 months of age, either with or without primary IOL implantation. Contact lenses (CLs) were used to correct aphakia in patients who did not receive IOLs. No statistically significant difference was found in grating visual acuity at age 1 year between IOL and CL groups; however, additional intraocular operations were performed more frequently in the IOL group.

Lu et al. (Graefes Arch Clin Exp Ophthalmol.2010;248(5):681-6) studied the visual results and complications of primary IOL implantation in infants aged 6-12 months and reported that it is safe and effective for infantile cataract surgery. Total or unilateral cataract, nystagmus, strabismus, and inadequate amblyopia therapy were predictors of poor BCVA.

Ram et al. (Indian J Ophthalmol.2007;55(3):185-9) reported that meticulously performed primary IOL implantation and primary posterior capsulorhexis with anterior vitrectomy in the first two years of life is a safe and effective method of aphakic correction.

Lundvall et al. (J Cataract Refract Surg.2006;32(10):1672-7) evaluated the complications and visual results in eyes undergoing cataract extraction with IOL implantation in the first year of life. They found that after-cataract with membrane formation was the main complication in infants with primary IOL implantation.

Birch et al. (JAAPOS 2005;9(6):527-32) reported that IOLs and aphakic CLs provide similar visual acuity development after surgery for a unilateral cataract. They suggested that IOLs may support better visual acuity development when compliance with CL wear is moderate to poor or when a cataract is extracted after 1 year of age.

Lambert et al. (Br J Ophthalmol. 2004;88(11):1387-90) compared optotype acuities and re-operation rates in children corrected with CL and with IOL following unilateral cataract extraction during infancy. They found that optotype acuities were similar in both the groups; however, children in the IOL group underwent more re-operations.

  Biometry Top

Eibschitz-Tsimhoni et al. (JAAPOS 2008;12(2):173-6) concluded that the sensitivity of IOL power calculation to an axial length (AL) measurement error is increased at 4-14 diopter (D)/mm error in AL in children compared with 3-4 D/mm error in AL in adults. The error in calculation is 0.8-1.3 D/D error in keratometry measurement for both children and adults.

Ben-Zion et al. (JAAPOS 2008;12(5):440-4) compared immersion and contact A-scan biometry in pediatric cataract eyes and did not find a significant difference in IOL prediction error between the two methods in pediatric IOL calculations.

Khan (Br J Ophthalmol. 2006;90(8):987-9), in a retrospective review of records of aphakic eyes operated for congenital cataract, found that the ultrasonic AL values and estimated AL values had an average difference of 0.05 mm and were not significantly different. They noted that estimation of AL from the aphakic refraction alone seems to be a useful technique in the average pediatric eye, especially if biometry is unavailable.

Hug et al. (J Pediatr Ophthalmol Strabismus2004;41(4):209-11) compared the use of aphakic refraction in IOL power calculation and measured AL for calculation of IOL power in children undergoing secondary IOL implantation. They concluded that the use of the aphakic refraction to calculate AL and a standard keratometry value provides an alternative in pediatric patients when ultrasonic or nonsedated ultrasonic AL measurements are not possible.

Mittelviefhaus et al. (Ophthalmologe 2000;97(3):186-8) evaluated errors in keratometry in infants and concluded that lack of fixation in children who have keratometry under general anesthesia leads to inaccurate readings. They suggested that deviation from the required postoperative refraction of up to 6.0 D is expected in individual cases if IOLs are implanted. They concluded that to improve the accuracy, multiple keratometric measurements should be taken.

  Intraoperative Decisions Top

Which technique?

Basti et al. (Ophthalmology1996;103(5):713-20) compared three methods of management of pediatric cataract: lensectomy anterior vitrectomy (LAV), extracapsular cataract extraction with IOL implantation (ECCE + IOL) and ECCE, primary posterior capsulotomy, anterior vitrectomy with IOL (ECCE + PPC + AV + IOL). They concluded that ECCE + PPC + AV+ IOL was conducive to at least short-term maintenance of a clear visual axis, provided optimum refractive correction, and was not associated with increased risk of short-term complications.

Eckstein et al. (Br J Ophthalmol. 1999; 83(5): 524-529) performed a randomized clinical trial of lensectomy versus lens aspiration and primary capsulotomy for children with bilateral cataract. They concluded that lens aspiration with PPC gives an acceptable visual outcome, provided there is good follow-up to manage capsule opacification. They added that if secondary intervention is not possible owing to poor compliance with follow-up, then lensectomy is likely to give better long-term visual rehabilitation.

Chee et al. (J Cataract Refract Surg. 2009;35(4):720-4) reported that the 25-G vitrectomy system appears safe and effective for the management of infantile cataract. Advantages include more precise manipulations with smaller instruments in infant eyes, a more stable anterior chamber, and less postoperative astigmatism.

Gessner et al. (Ophthalmologe2004;101(9):901-6) reported that visual function after lensectomy is better in eyes with bilateral cataracts compared to unilateral cataracts. Early surgery as well as adequate orthoptic therapy and compliance with wearing CL are necessary for good outcome.

Meier et al. (Graefes Arch Clin Exp Ophthalmol. 2001;239(9):649-55) also reported that pars plana or pars plicata lentectomy is a suitable and safe method for treating cataract in children.

Chen et al. (Ophthalmic Surg Lasers Imaging2005;36(1):6-13) reported that aphakic glaucoma (AG) was the most common postoperative complication (20.2%) of lensectomy in pediatric cataracts.

Incision and astigmatism

Bradfield et al. (J Cataract Refract Surg. 2004;30(9):1948-52), in a retrospective review, found that small-incision clear corneal cataract extraction with IOL implantation in children led to minimal postoperative astigmatism that remained stable over time. Less astigmatism was observed in children operated at an age of 36 months or less.

Bar-Sela et al. (Eur J Ophthalmol. 2009;19(3):376-9), in a retrospective review, found that congenital cataract surgery using a small, clear corneal incision with IOL implantation caused high early postoperative astigmatism, which spontaneously regressed thereafter. They also noted that younger patients had higher early postoperative astigmatism.

Spierer et al. (J Pediatr Ophthalmol Strabismus2004;41(1):35-8) evaluated changes in astigmatism after congenital cataract surgery and foldable IOL implantation and showed a significant spontaneous reduction in astigmatism postoperatively.

Management of anterior capsule

Guo et al. (J Pediatr Ophthalmol Strabismus. 2003;40(5):268-71) reported that staining the anterior capsule with indocyanine green is an excellent way to facilitate performance of an anterior capsulorhexis in pediatric dense white cataracts.

Wilson et al. (Trans Am Ophthalmol Soc. 2004;102:391-422) discussed the anterior capsule management in pediatric cataract surgery. They concluded that vitrectorhexis is well suited for use in infants and young children and manual continuous curvilinear capsulorhexis (CCC) is best used beyond infancy. They reported that in addition, Kloti diathermy unit, Fugo plasma blade, and "can-opener" technique, though used uncommonly, are recommendable for children.

Hazirolan et al. (J Pediatr Ophthalmol Strabismus 2009;46(2):104-7) suggested that both forceps capsulorhexis and vitrectorhexis are equally safe and effective for anterior and posterior capsulorhexis in congenital cataract.

Wilson et al. (JAAPOS2007;11(5):443-6) compared anterior vitrectorhexis and continuous curvilinear capsulorhexis in pediatric cataract surgery. They reported that vitrectorhexis is well suited for use in children less than 6 years of age due to their highly elastic anterior lens capsule, and for children aged 6 years and older, manual CCC is the best technique.

Wilson et al. (J Pediatr Ophthalmol Strabismus1996;33(4):237-40), in a prospective study, observed that mechanized anterior capsulectomy technique can produce a circular capsular opening that resists tearing during lens aspiration and IOL insertion. They noted that vitrector-cut capsulectomy performed well even in the youngest patients in whom manual capsulorhexis would have been difficult to control.

Comer et al. (J Cataract Refract Surg. 1997;23 Suppl 1:641-4) discussed the results of radiofrequency diathermy capsulorhexis of the anterior and posterior capsules in pediatric cataract surgery. Their results showed no epithelial regrowth or opacification of the posterior capsule following diathermy capsulorhexis with follow-up of 7-16 months.

Management of posterior capsule

Jensen et al. (Ophthalmology2002;109(2):324-7) reported that primary posterior capsulotomy is advisable for children less than 6 years old during cataract extraction with PC IOL implantation.

Raina et al. (J Cataract Refract Surg. 2004;30(5):1082-91) noted that the benefits of a foldable acrylic IOL in pediatric cataract surgery can be increased by combining it with PCCC, with or without anterior vitrectomy, or with optic capture of the IOL.

Hong et al. (Can J Ophthalmol. 2009;44(4):441-3) observed that posterior capsulectomy using a 25-G vitrectomy offers an option for preventing secondary visual axis opacification (VAO) after congenital cataract surgery.

Sharma et al. (BMC Ophthalmol. 2006;6:12), in a prospective, randomized, controlled study, reported that trypan blue facilitates posterior capsulorhexis with optic capture of AcrySof IOL in cases of pediatric cataracts.

Management of anterior vitreous

Parveen et al. (J AAPOS. 2010 Jul 14. [Epub ahead of print]), in a prospective case series, reported that preservative-free triamcinolone acetonide improved visualization of the vitreous during pediatric cataract surgery, thereby ensuring thorough and complete anterior vitrectomy. The intraocular pressure was not affected, and no adverse postoperative results were observed.

Huang et al. (Br J Ophthalmol. 2010;94(8):1024-7) used 25-G instruments to perform pars plana capsulotomy and anterior vitrectomy in pediatric cataract surgery and reported that the technique is safe and effective for the management of posterior lens capsule and anterior vitreous in surgery for pediatric cataract.

  Issues Related to Intraocular Lenses Top

Which intraocular lens should be implanted?

Aasuri et al. (Indian J Ophthalmol. 2006;54(2):105-9), in a comparative evaluation of acrylic and polymethyl methacrylate (PMMA) lenses in pediatric cases, reported that the incidence of posterior capsular opacification (PCO) and postoperative uveal inflammation is significantly less with acrylic lenses.

Rowe et al. (Br J Ophthalmol. 2004;88(4):481-5) reported that compared to acrylic, PMMA IOLs were significantly associated with perioperative complications. They noted that primary implantation of foldable soft acrylic IOLs in pediatric eyes allowed fewer perioperative complications than rigid PMMA IOLs.

Basti et al. (J Cataract Refract Surg. 1999;25(6):782-7) conducted a prospective, randomized, controlled clinical trial and reported a lower incidence of inflammatory cell deposit formation in eyes with heparin surface modified PMMA IOLs. They concluded that these IOLs have greater biocompatibility than unmodified IOLs in pediatric cataract surgery.

Koraszewska-Matuszewska et al. (Klin Oczna 2003;105(5):273-6) reported that heparin surface modified IOLs are more advantageous than PMMA lenses in young patients as they reduce postoperative inflammation and delay the incidence of PCO in children.

Brar et al. (Clin Experiment Ophthalmol. 2008;36(7):625-30), in a randomized controlled study, reported that square-edge PMMA IOLs offer a significant cost advantage over acrylic lenses at similar rates of PCO formation following pediatric cataract surgery.

Nihalani et al. (J Cataract Refract Surg. 2006;32(9):1527-34) reported that 1-piece AcrySof IOL provided satisfactory visual axis clarity, produced an acceptable inflammatory response, and maintained centration in pediatric eyes.

Beauchamp et al. (JAAPOS 2007;11(2):166-9) compared standard nontinted AcrySof foldable acrylic IOL and blue light filtering tinted IOL in children. They reported that transient inflammation is higher with implantation of tinted versus nontinted IOLs, but long-term inflammatory sequelae are roughly equal, as is the rate of PCO.

Grueterich et al. (J Cataract Refract Surg. 2008;34(4):591-5) reported that insertion of Acri. Smart (46S) IOL through sub-2.0 mm paracentesis minimizes manipulation in juvenile eye.

Intraocular lens power calculation: Which formula should be used?

Mezer et al. (J Cataract Refract Surg 2004;30:603-610) evaluated refractive outcomes in pediatric patients using five IOL calculation formulae (SRK, SRK II, SRK/T, Hoffer Q, and Holladay). They observed that all five IOL power calculation formulas were unsatisfactory in achieving the target refraction in pediatric patients. However, the SRK formula showed poor to moderate agreement between the predicted and the actual refraction, whereas the SRK II formula provided fair to good agreement.

Neely et al. (JAAPOS 2005;9(2):160-5) analyzed the lens calculation errors in children predicted by four formulas (SRK II, SRK/T, Holladay I, and Hoffer Q). They noted that newer theoretic IOL calculation formulae did not outperform older regression models. Each formula demonstrated a high degree of variability, with SRK II being the least variable and Hoffer Q being the most variable, particularly among the youngest group of children with AL less than 19 mm.

Eibschitz et al. (Ophthalmology2007;114(2):383-6) noted significant differences in IOL power prediction among the Hoffer Q, Holladay I, and SRK II formulae in pediatric range of AL and keratometry values. The Holladay I and Haigis formulae were found to be similar in their IOL power prediction. The SRK/T was comparable with Holladay I and Haigis formulae, but still differed in high keratometry values.

Kora et al. (Nippon Ganka Gakkai Zasshi 2002;106:273-280) evaluated the accuracy of prediction of refraction using four IOL power calculation formulae (SRK, SRK II, SRK/T, and Holladay) in pediatric patients. They concluded that all the formulae were less accurate in patients with AL of 22 mm or shorter. They also found that the SRK formula had the best preoperative prediction of refraction compared to SRK/T and Holladay formulae.

Tromans et al. (Br J Ophthalmol.2001;85(8):939-41) noted larger errors in IOL power calculation in eyes with AL less than 20 mm and in children less than 36 months of age.

Nihalani et al. (Ophthalmology2010;117(8):1493-1499) reported that Hoffer Q was predictable for the highest number of pediatric eyes. They also noted that most formulae gave an undercorrection, except for Hoffer Q.

Refractive goal

Dahan et al. (J Cataract Refract Surg. 1997;23 Suppl 1:618-23), in a retrospective study, advised to categorize the children as (1) children younger than 2 years of age or (2) children older than 2 years. For the first group, in whom AL and keratometry readings change rapidly, they advised to undercorrect by 20%. For the second group, in whom the changes are slower and more moderate, they advised to undercorrect by 10%.

Wilson et al. (J Cataract Refract Surg.2003;29(9):1811-20) surveyed ASCRS and JAAPOS members in 2001. They concluded that most surgeons aim for moderate hyperopia (?3 D and <7 D) in infants at 6 months of age and mild (<3 D) to moderate hyperopia in infants at 12 months.

Enyedi et al. (Am J Ophthalmol. 1998;126:772-81) recommended a postoperative goal of +6 D for a 1 year old, +5 D for a 2 year old, +4 D for a 3 year old, +3 D for a 4 year old, +2 D for a 5 year old, +1 D for a 6 year old, plano for a 7 year old and -1 to -2 D for an 8 year old or older children.

Crouch et al. (JAAPOS 2002;6(5):277-82) recommended that the refractive goal should be +4 D for less than 2 years, +2 to +3 D for 2-4 years of age, +1 to +2 D for 4-6 years of age and up to +1 D for 6-8 years of age.

Multifocal intraocular lenses in children

Lin et al. (Eye (Lond) 2010;24(6):1107) reported that multifocal IOL implantation was successful in treating the amblyopia and in reshaping the patient's personality.

Jacobi et al. (Ophthalmology2001;108(8):1375-80) studied pediatric patients aged 2-14 years with multifocal IOL implantation with more than 1 year of follow-up. They found that only 22% children reported permanent use of an additional near correction. The remaining children were either using distance correction only (44%) or no glasses at all (33%). It was concluded that multifocal IOL implantation is a viable alternative to monofocal pseudophakia in this age group.

Sutured intraocular lenses in children

Bardorf et al. (JAAPOS 2004;8(4):318-24) reported that trans-scleral sutured IOL implantation is safe and effective for correcting aphakia in pediatric eyes that lack adequate capsular support.

Asadi et al. (Ophthalmology 2002;109:2315-2324) described long-term results of scleral fixation of posterior chamber (PC) IOLs in children and reported a high rate of complications.

Ganesh et al. (Ophthalmic Surg Lasers Imaging 2009;40(4):354-60) noted that scleral-fixated PC IOLs are beneficial for children with aphakia without posterior capsular support, who are lacking other means of visual rehabilitation.

  Complications Top

Visual axis opacification: Methods of prevention

Ram et al. (J Cataract Refract Surg.2003;29(8):1579-84) reported that it is the management of the posterior capsule rather than IOL design and material that influences the incidence of PCO.

Dada et al. (Clin Experiment Ophthalmol. 2000;28(5):361-3) noted that lens aspiration using intracameral heparin, combined with primary posterior capsulorhexis and optic capture of a heparin-coated IOL, was a useful technique to prevent secondary VAO in pediatric cataracts.

Koch et al. (Trans Am Ophthalmol Soc. 1997;95:351-60) reported that posterior capsulorhexis with anterior vitrectomy was the only effective method of preventing or delaying secondary cataract formation in infants and children.

Dixit et al. (J Cataract Refract Surg. 2010;36(9):1494-1498) reported that pediatric eyes receiving intracameral triamcinolone intraoperatively had significantly less anterior segment inflammation and no visual axis obscuration after cataract surgery with IOL implantation.

Raina et al. (J Pediatr Ophthalmol Strabismus.2002;39(5):278-87) noted that PCCC with optic capture of PC IOL prevented secondary VAO even in the absence of vitrectomy.

Grieshaber et al. (J Cataract Refract Surg. 2005;31(5):886-94) reported that posterior capsulotomy with optic entrapment of IOL proved to be a safe and efficient surgical procedure for preventing PCO in children with congenital cataracts. They concluded that an intact anterior hyaloid does not induce capsule opacification in association with optic entrapment; therefore, a vitrectomy is not indicated even in infants and children under 5 years.

Chen et al. (Zhonghua Yan Ke Za Zhi. 2006;42(5):400-2) reported that optic capture of PC IOL is safe and effective in prevention of secondary opacification of the visual axis in children.

Tassignon et al. (J Cataract Refract Surg. 2007;33(4):611-7) concluded that bag-in-the-lens implantation technique in children is safe and keeps the visual axis clear after cataract surgery.

Onol et al. (Can J Ophthalmol.2008;43(6):673-7) reported that pars plana lensectomy with double-capsule-supported IOL implantation technique in children limits PCO in long term.

Management of visual axis opacification

Lam et al. (Clin Experiment Ophthalmol. 2005;33(5):495-8) reported that posterior capsulotomy using 25-G vitrectomy system is safe and effective in management of PCO in pseudophakic children. There is ease of manipulation with smaller instruments in these small eyes.

Xie et al. (J Pediatr Ophthalmol Strabismus2008;45(6):362-5) also noted that pars plana capsulectomy and vitrectomy is safe and effective in thick PCOs in pseudophakic children.

Stager et al. (JAAPOS 2006;10(2):159-63) reported that Nd:YAG laser capsulotomy is an acceptable option for the management of PCO after AcrySof IOL implantation in children and produces complications infrequently.

  Glaucoma Top

Vishwanath et al. (Br J Ophthalmol. 2004;88(7):905-10) reported that bilateral lensectomy during the first month of life is associated with a higher risk of subsequent glaucoma than surgery performed later. They suggested that it may be prudent, in bilateral cases, to consider delaying surgery until the infant is 4 weeks old.

Trivedi et al. (JAAPOS 2006;10(2):117-23) concluded that patients undergoing cataract surgery with or without IOL implantation at an early age are at high risk for development of glaucoma.

Swamy et al. (Br J Ophthalmol.2007;91(12):1627-30) reported secondary glaucoma as an important sequela following surgery for congenital cataracts. They concluded that these patients should have lifelong surveillance, as glaucoma can occur years after surgery.

Michaelides et al. (BMC Ophthalmol. 2007;7:13) also reported that early surgery in patients with bilateral cataracts is associated with a marked increase in risk of AG. They suggested that an intact posterior capsule may be associated with a lower rate of AG.

Khan et al. (JAAPOS 2009;13(2):166-9) noted that the lowest relative risk for later AG in their cohort was for surgery performed at 3-4 months of age.

Kirwan et al. (Acta Ophthalmol. 2010;88(1):53-9) noted that surgery for congenital cataract at an early age increases the risk of glaucoma development, regardless of whether the eye is aphakic or pseudophakic.

Tatham et al. (Eye 2010 Apr 23 [Epub ahead of print]), in a 20-year retrospective study, noted that factors other than age at surgery are important risk factors for glaucoma in these eyes.

  Congenital Cataracts Associated with Other Ocular Anomalies Top

Vasavada et al. (J Cataract Refract Surg. 2009;35(3):519-28) suggested that good visual outcome can be obtained in microphthalmic patients with bilateral congenital cataract after early surgical intervention, with an acceptable rate of serious postoperative complications; 10% eyes had an incomplete anterior capsulorhexis, 6.7% had iris trauma, and 6.7% had peripheral extension of the posterior capsulectomy edge. The complications noted in postoperative period were posterior synechias in 35.7%, glaucoma in 30.9%, and VAO in 16.7% eyes.

Yu et al. (Korean J Ophthalmol. 2006;20(3):151-5) recommended secondary PC IOL implantation in pediatric cataract with microcornea and/or microphthalmos as a means of improving vision in order to avoid possible complications.

Mullner-Eidenbock et al. (J Cataract Refract Surg. 2004;30(3):611-9) reported that in congenital cataract caused by persistent fetal vasculature or minimal fetal vascular remnants, cataract surgery must be performed in a guarded fashion because of high risk of preexisting posterior capsule breaks.

Kuhli-Hattenbach et al. (Am J Ophthalmol. 2008;146(1):1-7) noted that patients with preoperative predictors at presentation, such as persistent fetal vasculature (PFV), require extensive postoperative care after congenital cataract surgery.

Khan et al. (Eye Contact Lens. 2007;33(4):199-200) reported emmetropization in a case, caused by corneal steepening and axial elongation, after lensectomy and anterior vitrectomy for cataract with persistent hyperplastic primary vitreous.

Mullner-Eidenbock et al. (Ophthalmology2004;111(5):906-13) reported that abnormalities of the central part of the posterior capsule, such as a translucent opacity or a lenticonic area leading to occurrence of a hole during lens aspiration, may be caused by minimal remnants of PFV.


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