Disclosures: Vasavada and Agrawal report relevant financial disclosures for Alcon Laboratories. John reports no relevant financial disclosures.
March 04, 2021
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Surgeons face choice of whether to implant IOL in pediatric cataract surgery

Disclosures: Vasavada and Agrawal report relevant financial disclosures for Alcon Laboratories. John reports no relevant financial disclosures.
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Pediatric cataract continues to be a leading cause of childhood blindness.

Early detection of pediatric cataracts, appropriate surgical intervention, along with family members’ education and their participation in the child’s ophthalmic care are important even in the early stages when the initial diagnosis is made. Optimal visual recovery and amblyopia avoidance are areas of focus in these children. Further, appropriate management with a multispecialty approach, namely the ophthalmic surgeon, anesthesiologist, pediatric ophthalmologist, pediatrician and optometrist, is essential for an overall successful outcome when dealing with pediatric cataracts.

Thomas "TJ" John
Thomas "TJ" John

Pediatric cataract may be unilateral or bilateral, congenital or acquired, with focal or diffuse involvement of the lens. It may be an isolated occurrence in an otherwise healthy child, associated with genetic or metabolic disorders, or secondary to ocular trauma. The pathway to visual rehabilitation often encompasses a combination of IOLs, contact lenses and glasses. Patching may be necessary to avoid amblyopia in these children. There are several surgical challenges intraoperatively, including the decision to use an IOL or not, and postoperatively, including managing an eye with changing axial length and refraction.

In this column, Drs. Vasavada and Agrawal provide insight into the overall management of pediatric cataract in various age groups.

Thomas “TJ” John, MD
OSN Surgical Maneuvers Editor

Abhay R. Vasavada
Abhay R. Vasavada

Cataract surgery in children poses technical challenges to the surgeon due to the small size of the eye, increased compliance of the eye and exaggerated postoperative inflammatory response. These challenges are constantly being overcome by using high-viscosity viscoelastics, microincision instruments and closed chamber bimanual techniques. Femtosecond laser-assisted cataract surgery helps achieve precise and predictable anterior and posterior capsulorrhexes. The next major challenge faced by pediatric ophthalmic surgeons is whether or not to implant an IOL.

Children younger than 2 years

Primary IOL implantation is still controversial in children younger than 2 years, more so in children younger than 6 months of age. There is a higher risk for exaggerated postoperative inflammation, visual axis opacification and glaucoma.

IOL in the bag
Figure 1. Anterior continuous curvilinear capsulorrhexis, posterior continuous curvilinear capsulorrhexis, IOL in the bag.

Source: Abhay R. Vasavada, MS, FRCS, and Deepa Agrawal, MS

In children younger than 2 years, the decision to implant an IOL should be taken more cautiously by the surgeon, depending on their experience in pediatric cataract surgery. In this age group, implantation of a single-piece or multi-piece hydrophobic IOL in the bag, along with a posterior continuous curvilinear capsulorrhexis (PCCC) and anterior vitrectomy, gives good outcomes (Figure 1). Alternatively, pars plana posterior capsulectomy along with anterior vitrectomy can be safely performed after implanting the IOL in the bag (Figure 2).

Pars plana posterior capsulectomy
Figure 2. Pars plana posterior capsulectomy.

In bilateral cases, it is safe to opt for primary aphakia. We published a randomized study comparing aphakia vs. pseudophakia with a 5-year follow-up in children younger than 2 years with bilateral cataracts. Visual acuity in both groups was comparable at 5 years. However, visual rehabilitation was faster in the pseudophakic group. The complication rate between the groups was comparable at 5 years. In unilateral cases, primary IOL implantation is desirable, but if left aphakic, the child can be best managed with extended-wear contact lenses.

Ultrasound biomicroscopy
Figure 3. Ultrasound biomicroscopy showing good space in sulcus (a) and intact capsular support (b).

In both unilateral and bilateral aphakia, secondary IOL implantation can be considered after 5 years of age. A thorough examination under anesthesia should be performed before considering secondary IOL implantation. Ocular biometry, assessment of glaucoma, ultrasound biomicroscopy (UBM) and peripheral retinal examination should be done. Microphthalmos and glaucoma are contraindications for secondary IOL implantation. UBM is an important tool to assess capsular support (Figure 3) and the presence and extent of posterior peripheral synechiae (Figure 4). This helps in formulating a surgical strategy for secondary IOL implantation. Sometimes, in-the-bag IOL implantation can be achieved when UBM shows the presence of Soemmering’s ring. The anterior and posterior capsule can be separated, and the IOL can be implanted in the bag after aspiration of lens material (Figure 5).

Ultrasound biomicroscopy showing Soemmering’s ring
Figure 4. Ultrasound biomicroscopy showing Soemmering’s ring and posterior synechiae.
Soemmering’s ring with intact support
Figure 5. Soemmering’s ring with intact support (a). Opening of the bag space and irrigation/aspiration of lens material (b and c). IOL in the bag (d).

In cases in which UBM shows meridional posterior synechia, a three-piece IOL can be placed in the ciliary sulcus in the appropriate meridian.

In the absence of any capsular support or the presence of extensive posterior synechiae, transscleral fixation of an IOL using Gore-Tex suture, although off label, is an option. Intrascleral fixation of the haptics, glued IOL, the Yamane technique and retroiridial fixation of an iris-claw lens are also valid options.

Children older than 2 years

There is a consensus among pediatric cataract surgeons regarding the feasibility and safety of primary IOL implantation in children older than 2 years of age. IOL implantation can be safely and predictably performed using the same technique as in children younger than 2 years. However, in our experience, placing the haptics of a three-piece IOL in the bag and capturing the optic of the IOL through a PCCC gives a good outcome (Figure 6). In addition, with this technique of optic capture, anterior vitrectomy can be avoided in most cases.

Optic capture
Figure 6. Optic capture through posterior continuous curvilinear capsulorrhexis.

In a randomized clinical trial, we included children up to 4 years of age, and at 3 years’ follow-up, we found that visual axis opacification and complications such as glaucoma and inflammation were comparable in eyes that underwent in-the-bag IOL implantation of a three-piece hydrophobic acrylic IOL along with anterior vitrectomy vs. posterior optic capture without anterior vitrectomy. This technique of posterior optic capture is also useful in pediatric traumatic cataract surgery. In eyes with anterior capsule tear, PCCC can be performed and optic capture of the IOL is done. In our practice, capturing the optic through anterior continuous curvilinear capsulorrhexis (ACCC) or PCCC allows us to achieve stable IOL fixation and reduced opacification of the posterior capsule.

Children older than 5 years

A significant number of children have corneal astigmatism contributing to amblyopia. In our published study, we implanted toric IOLs in 76 eyes (Figure 7). We found that toric IOL implantation reduces postoperative refractive astigmatism and gives good uncorrected distance visual acuity.

toric IOL in the bag
Figure 7. Verion (Alcon)-guided toric IOL in the bag.

Multifocal IOLs may be considered in children older than 14 years of age. Periodic correction of ametropia plays a crucial role in multifocal IOLs.

Meticulous care during surgery, regular long-term follow-up and vision therapy are pivotal in achieving good outcomes.