Journal of Pediatric Ophthalmology and Strabismus

Original Article 

Bilateral Pediatric Cataract Surgery: Outcomes of 390 Children From Nepal and Northern India

Albrecht Hennig, MD; Bernd Schroeder, MD; Clare Gilbert, FRCOphth, MD

Abstract

Purpose:

To report the outcomes of bilateral pediatric cataract surgery from eastern Nepal and northern India.

Methods:

Preoperative, intraoperative, and postoperative data of 390 children who underwent surgery bilaterally between 2007 and 2009 were analyzed.

Results:

Forty-two (10.8%) children came from Nepal and 348 (89.2%) from India (mainly Bihar State). Intraocular lens (IOL) implantation with posterior capsule opening and anterior vitrectomy were achieved in 386 (99.0%) children bilaterally. Median age at surgery was 7 years and 69.2% were male. At first presentation, 243 (62.3%) of the children were blind (< 3/60 in the better eye). After more than 1 year, 53.5% had a normal visual status (range: 6/6 to 6/18), 5.6% of children were still blind, and mean refractive error spherical equivalent was +1.0 ± 2.4 diopters. Astigmatism changed from suture-induced with the rule at discharge to against the rule within 3 weeks of surgery. Mean long-term astigmatic error was 1.0 ± 0.9 diopters after 1 year. Glaucoma was rare.

Conclusions:

Even in a setting with limited resources, successful, cost-effective, high-volume surgery for pediatric cataract is possible. Despite late presentation and limited follow-up, more than half achieved good outcomes after more than 1 year. Only 5.6% remained blind due to amblyopia or eye anomalies. Bilateral surgery during one hospital stay, IOL implantation with undercorrection according to age, aggressive surgery to prevent secondary cataract, intensive anti-inflammatory therapy, and provision of durable, high-quality spectacles to take home all proved beneficial because many children cannot attend for regular follow-up.

[J Pediatr Ophthalmol Strabismus 2013;50(5):312–319.]

From Sagarmatha Choudhary Eye Hospital, Lahan, Nepal (AH); Asklepios Klinik Nord, Department of Ophthalmology, Hamburg, Germany (BS); and International Centre for Eye Health, Clinical Research Department, London, England (CG).

The authors have no financial or proprietary interest in the materials presented herein.

Correspondence: Albrecht Hennig, MD, Eastern Regional Eye Care Program, Sagarmatha Choudhary Eye Hospital, Lahan, Nepal. E-mail: akhennig@gmx.net

Received: September 14, 2012
Accepted: March 04, 2013
Posted Online: April 09, 2013

Abstract

Purpose:

To report the outcomes of bilateral pediatric cataract surgery from eastern Nepal and northern India.

Methods:

Preoperative, intraoperative, and postoperative data of 390 children who underwent surgery bilaterally between 2007 and 2009 were analyzed.

Results:

Forty-two (10.8%) children came from Nepal and 348 (89.2%) from India (mainly Bihar State). Intraocular lens (IOL) implantation with posterior capsule opening and anterior vitrectomy were achieved in 386 (99.0%) children bilaterally. Median age at surgery was 7 years and 69.2% were male. At first presentation, 243 (62.3%) of the children were blind (< 3/60 in the better eye). After more than 1 year, 53.5% had a normal visual status (range: 6/6 to 6/18), 5.6% of children were still blind, and mean refractive error spherical equivalent was +1.0 ± 2.4 diopters. Astigmatism changed from suture-induced with the rule at discharge to against the rule within 3 weeks of surgery. Mean long-term astigmatic error was 1.0 ± 0.9 diopters after 1 year. Glaucoma was rare.

Conclusions:

Even in a setting with limited resources, successful, cost-effective, high-volume surgery for pediatric cataract is possible. Despite late presentation and limited follow-up, more than half achieved good outcomes after more than 1 year. Only 5.6% remained blind due to amblyopia or eye anomalies. Bilateral surgery during one hospital stay, IOL implantation with undercorrection according to age, aggressive surgery to prevent secondary cataract, intensive anti-inflammatory therapy, and provision of durable, high-quality spectacles to take home all proved beneficial because many children cannot attend for regular follow-up.

[J Pediatr Ophthalmol Strabismus 2013;50(5):312–319.]

From Sagarmatha Choudhary Eye Hospital, Lahan, Nepal (AH); Asklepios Klinik Nord, Department of Ophthalmology, Hamburg, Germany (BS); and International Centre for Eye Health, Clinical Research Department, London, England (CG).

The authors have no financial or proprietary interest in the materials presented herein.

Correspondence: Albrecht Hennig, MD, Eastern Regional Eye Care Program, Sagarmatha Choudhary Eye Hospital, Lahan, Nepal. E-mail: akhennig@gmx.net

Received: September 14, 2012
Accepted: March 04, 2013
Posted Online: April 09, 2013

Introduction

Cataract is an important treatable cause of childhood blindness in low income communities, accounting for up to 39% of all childhood blindness. Most blind children with cataract live in developing countries, affecting approximately 200,000 children worldwide.1

Successful long-term outcome of treatment of pediatric cataract requires high-quality surgery that prevents secondary visual axis opacification and long-term follow-up to manage complications and best optical correction. Outcomes are also influenced by the degree of amblyopia at the time of surgery. Children with cataract in developing countries present late for various reasons.2

The Sagarmatha Choudhary Eye Hospital is located in South-East Nepal, close to the Indian State of Bihar, and provides affordable, high-volume, high-quality eye services to patients from eastern Nepal and northern India. Patients often travel for many days to receive treatment. A total of 1,786 pediatric cataract operations were performed between 2007 and 2009 (1.5% of all cataract operations). Because of the challenges of general anesthesia, surgery is not offered to children younger than 6 months of age.

Treatment protocols at Sagarmatha Choudhary Eye Hospital for childhood cataract have been modified over time. Changes include routine recording of ocular and systemic abnormalities, family history, biometry, and intraocular lens (IOL) power, postoperative refractive details, and intraocular pressure (IOP) at follow-up into an improved data management system. Detailed postal address and telephone numbers of parents and relatives are obtained to assist follow-up.

A retrospective analysis of 2,633 eyes operated on between 2003 and 2007 has already been published.3 The aim of this prospective study was to reevaluate the outcomes with revised protocols and better follow-up data.

Patients and Methods

Children aged 6 months to 15 years with bilateral cataract operated on between 2007 and 2009 at Sagarmatha Choudhary Eye Hospital were recruited prospectively. Excluded were children who had only their first eye operated on during the study period (n = 25), had the first eye operated on elsewhere (n = 7), and did not attend any follow-up (n = 66).

A total of 390 children (780 eyes) were included; 265 (67.9%) had surgery on both eyes during the same hospital admission, with a gap of 2 days. Parents were asked when they first noticed a problem with their child’s eyes and/or vision.

A standardized form was used to record basic demographics, contact information, preoperative and postoperative ocular findings, surgical details, and follow-up data into a spread sheet database (Microsoft Excel, Redmond, WA) and analyzed using Statistical Package for the Social Sciences (SPSS, Inc., Chicago, IL) statistical analysis software for Windows. The Wilcoxon Mann–Whitney test was used to compare patient subgroups.

Visual acuity (VA) was measured by two experienced pediatric ophthalmic assistants using age-appropriate tests including Cardiff preferential looking cards, Lea Symbols matching test, and Snellen chart. VA was categorized according to World Health Organization classification (not impaired: 6/18 or better, visual impairment: < 6/18 to 6/60, severe visual impairment: < 6/60 to 3/60, and blind: < 3/60). Children whose VA was too poor to be measured or who could not cooperate were classified as blind. Best corrected VA is reported by eye and by child. The latter used the VA in the better seeing eye and is termed the “visual status” of the child.

All children underwent preoperative B-scan ultrasound (Cinescan; Quantel Medical, Cournon d’Auvergne, France) and funduscopy whenever possible to rule out posterior segment pathology. Biometry was done on all children either awake or under general anesthesia using A-scan ultrasound (US-800; Nidek, Tokyo, Japan) and a hand-held automated keratometer (Retinomax K; Nikon, Tokyo, Japan). The SRK/T formula was used to calculate IOL power. To avoid high myopia, IOL power was chosen to give approximately 20% undercorrection in children younger than 2 years and 10% from 2 to 8 years of age. Older children were fully corrected.

When possible, surgery was done under local anesthesia by retrobulbar injection of xylocaine 2%, containing adrenalin 1:200.000 and hyaluronidase 75 IU/mL and manual ocular pressure for 5 to 10 minutes. When general anesthesia was needed, a combination of intravenous ketamine (2 to 4 mg/kg) plus a retrobulbar block and manual ocular pressure were used, with electrocardiography and pulse-oxymetry monitoring.

Bilateral surgery during one hospital stay was strongly encouraged because it was expected that many families would not return for a second eye surgery. In cases with strabismus or different density of cataract between both eyes, eyes with the presumed better prognosis were operated on first. Surgery was performed by two experienced surgeons (AH, RS).

The standard technique was a superior 3-mm sclerocorneal tunnel with a frown incision and two 1-mm corneal paracenteses at the 3- and 9-o’clock positions. The anterior capsule was always stained with trypan blue. After injection of hydroxymethyl-cellulose 2% into the anterior chamber, a continuous curvilinear capsulorhexis (CCC) with an attempted diameter of approximately 5 mm was created with an Utrata forceps. Lens nucleus and cortex were removed using a two-way Simcoe cannula and bimanual irrigation and aspiration. A posterior CCC, 1 to 2 mm smaller in diameter than the anterior CCC, was created with the Utrata forceps. This was followed by “dry” anterior vitrectomy without irrigation that continued until the eye was soft, using a phacovitrectomy machine and a 20-gauge vitrectomy cutter (OS3; Oertli Instruments, Berneck, Switzerland). In cases of dense capsular plaques, openings were created by bipolar, high-frequency capsulotomy (Kloeti capsulotomy probe; Oertli Instruments). A 5.5-mm optic single-piece polymethylmethacrylate (PMMA) IOL (Fred Hollows, Tilganga, Nepal) was inserted into the capsular bag after enlargement of the sclerocorneal tunnel incision.

To have a water-tight wound, two absorbable 8-0 sutures were placed to secure the sclerocorneal tunnel that was finally covered by the conjunctival flap. Corneal paracenteses were always left without sutures to prevent secondary suture-related complications. In case of leakage, paracenteses were hydrated with balanced salt solution and an air bubble was injected into the anterior chamber. At the end of the procedure, 1 mg cefuroxime was injected intracamerally and 2 mg dexamethasone and 10 mg gentamicin were injected subconjunctivally followed by a parabulbar injection of 5 mg triamcinolone into the upper conjunctival fornix.

A short video demonstrating this pediatric cataract surgery is available at http://www.erec-p.org under Surgical Videos, scroll down to Paediatric Cataract Surgery in Lahan, Nepal (10:40 minutes).

Postoperative medication included dexamethasone and antibiotic eye drops every 30 minutes and atropine eye drops once daily. Patients usually stayed 3 to 5 nights and were reviewed daily. Families were advised to taper eye medication over 6 weeks.

Streak retinoscopy was used to assess refraction and to evaluate the clearness of the optical axis after surgery and at follow-up. At discharge, only spherical glasses were prescribed because suture-induced astigmatism was significant but was expected to regress postoperatively. Children up to the age of 2 years received monofocal glasses with +1 diopter (D) overcorrection. Starting at the age of 3 years, children received bifocal spectacles with addition of +3 D for near. Whenever necessary, family members were advised about amblyopia treatment.

To improve return for follow-up visits after 1 month, 6 months, and 1 year, postcards were sent and attempts were made to contact families by telephone. Financial incentives for food, travel cost, free spectacles, and minimum waiting time at the hospital were also offered.

Follow-up assessment included standard clinical examination and refraction. Spectacles were changed when required. Attempts were made to measure IOP at each visit (Pulsair Tonometer, Keeler Ltd, Windsor, UK) and to assess optic discs for glaucomatous damage. Follow-up data were recorded until March 2011.

This study complied with all local laws and the principles of the Declaration of Helsinki. Ethical committee approval was not required because the study used routine data, which were collected in a standard manner on all cases. No additional interventions were used, nor was additional information sought from parents over and above that required for usual care.

Results

Three hundred ninety children (780 eyes) who had undergone bilateral surgery were analyzed; 265 (67.9%) received bilateral surgery during one hospital stay. Forty-two children (10.8%) were Nepali and 348 (89.2%) came from India. Two hundred seventy (69.2%) children were male. Mean age at first presentation was 7.4 ± 4.0 years (7.5 ± 4.0 years for boys and 7.2 ± 4.0 years for girls). The youngest child operated on was 6 months old and only 18 children presented before 12 months of age. A total of 101 children (25.9%) had nystagmus and 135 (34.6%) had manifest strabismus at presentation. Information on age at onset of reduced VA was not reliable and therefore not analyzed. Overall, 84% of the families paid 1,000 Nepalese rupees (equivalent to 13.70 USD) per eye for the operation and 16% had free or subsidized treatment.

Surgery was performed under local anesthesia in 219 (56.2%) children and under ketamine anesthesia in the remainder. The latter was well tolerated and no complications were observed.

IOL implantation and posterior capsule opening with anterior vitrectomy were possible in 386 (99.0%) operations bilaterally. Anterior and/or posterior capsule plaques were present in 174 (22.3%) eyes, 98 (13.6%) of which required bipolar capsulotomy. IOLs were placed in the ciliary sulcus in 16 (2.1%) eyes on account of tears in the anterior capsule and optic capture through the posterior capsule opening was done in 8 eyes. Iridectomies were not routinely performed. No IOL was inserted in 4 eyes due to severe uveitis (n = 2) or retinal detachment (n = 2) detected during surgery. The average duration of surgery was 13 ± 6 minutes.

Ocular structural anomalies were detected in 68 (8.7%) eyes. Forty-two eyes (5.4%) had microcornea (corneal diameter < 10 mm), 14 were highly myopic, 2 had retinochoroidal coloboma, and 2 had diffuse optic atrophy. Posterior synechiae after old uveitis were noted in 10 eyes (Table 1).

Demographic and Preoperative Ocular Characteristics

Table 1:

Demographic and Preoperative Ocular Characteristics

Transient ocular hypotony with shallowing of the anterior chamber from paracentesis wound leakage occurred in 10 (1.3%) eyes. This was always reversed without intervention. Transient corneal edema resolving prior to discharge occurred in 24 eyes.

Mild to moderate fibrin reaction, which resolved during the first postoperative days, occurred in 173 (22.2%) eyes. A total of 32 (4.1%) eyes developed more severe fibrinous anterior uveitis, which did not resolve completely during the first postoperative days. Posterior synechiae were noted during follow-up visits in 18 (2.3%) eyes. Optic capture or decentration of the IOL was observed in 12 (1.5%) eyes. However, IOLs remained in the optical axis in all cases. IOP measurements were possible on at least one occasion in 12 of the 18 children operated on before the age of 12 months, and no raised IOP was found. Glaucomatous cupping of the optic disc with elevated IOP was identified in 6 (< 1%) eyes in children aged 6 to 15 years. Three children (4 eyes) had raised IOP after prolonged use of steroid drops (1 to 3 months), which declined after stopping medication.

Clarity of the optical axis was assessed by retinoscopy and slit-lamp examination whenever possible during all follow-up visits. In 8 (1.0%) eyes, the optical axis was not clear at the last follow-up visit; 4 eyes had a fibrin membrane on the IOL surface and 4 eyes had corneal pathology. Secondary cataract impairing the optical axis was not observed.

First follow-up visits were 3 weeks to 3 months after surgery in 245 (63.1%) children. The last visit was more than 3 months postoperatively in 123 (31.5%) children and 71 (18.2%) children had at least 1 year of follow-up. Children with more than 1 year of follow-up did not differ significantly from those with shorter follow-up in relation to preoperative strabismus (P = .51), nystagmus (P = .17), and visual status (P = .13).

Preoperative visual status was similar in groups with shorter and longer follow-up. Before surgery, 147 of 390 (37.7%) were visually impaired or severely visually impaired and 243 of 390 (62.3%) were blind (Table 2). At the last postoperative follow-up visit (median = 40 days, range = 7 days to 3 years), 43.1% children were not visually impaired, 31.5% were visually impaired, 7.2% were severely visually impaired, and 18.2% were still blind. Visual status improved thereafter, especially during the first 3 postoperative months. Only 5.6% of children with more than 1 year of follow-up (n = 71) were still blind (Table 2).

Preoperative and Postoperative Visual Status Using Corrected Visual Acuity

Table 2:

Preoperative and Postoperative Visual Status Using Corrected Visual Acuity

At discharge, there was significant suture-induced with-the-rule astigmatism (mean power: 3.4 ± 2.4 D). This regressed over the first postoperative weeks, changing to against-the-rule astigmatism (mean power: 1.4 ± 1.1 D) and remaining relatively stable thereafter. After more than 1 year of follow-up, mean astigmatism was 1.3 ± 0.95 D (against-the-rule in 65.5%, with-the-rule in 21.0%, and oblique in 13.5%) (Table 3).

Changes in Spherical Equivalent Refraction and Astigmatism During Follow-up, by Eye

Table 3:

Changes in Spherical Equivalent Refraction and Astigmatism During Follow-up, by Eye

Due to the intended undercorrection of the IOL power, most eyes were hyperopic postoperatively. Mean spherical equivalent at discharge was +1.8 ± 2.4 D. During the first postoperative year, a mean myopic shift of 0.8 ± 0.9 D was noted. Spherical equivalent after more than 1 year of follow-up was +1.1 ± 2.4 D (Table 3).

Discussion

Most children in this study presented late for surgery (mean age: 7.4 years), including children from Nepal (mean age: 6.2 years). This was similar to our previous study and a study from Kathmandu, Nepal (mean: 6.3 years).3,4 Late presentation has also been reported from Dar-Es-Salaam, Tanzania (53% of children were < 6 years), and Chandigarh, India (mean age: 4.2 years).5,6 However, only 25.9% of children in our study had nystagmus, similar to the study from Tanzania, implying early onset of bilateral opacities and dense amblyopia at the time of surgery,5 and 75% of the children had no nystagmus, indicating that the cataracts either developed after the first few months of life or that lens opacities present from birth were not dense.

Reasons for late presentation are complex, including sociocultural factors, educational and economic issues, and poor infrastructure and distance.2 There is also a significant lack of knowledge among primary health workers, physicians, and traditional healers of the importance of early surgery. In Asia, decisions regarding health care are usually made by the male head of household, who often works away from home and is therefore not available to make the decision, plan the visit, raise the funds, and accompany the child to hospital. Poor roads and long distances may require 1 to 3 days of travel to reach the hospital, especially for those living in the hilly areas of Nepal or in northern India. Indeed, travel can constitute a high proportion of overall out-of-pocket expenditure.

Poor quality of the pediatric eye care services that are available may also be an issue because a lack of tertiary eye centers with trained pediatric cataract surgeons, adequate equipment, and availability of general anesthesia are also evident in northeastern India.7 Thus, children who had undergone surgery elsewhere often presented aphakic and uncorrected or had decentered IOLs and dense visual axis opacification. Continuous curvilinear anterior and posterior capsulorhexis with anterior vitrectomy are not routine clinical practice in this region. Poor outcome may therefore also contribute to poor acceptance of services.

Strikingly, only 120 (30.8%) of our cases were female, although no gender difference in the incidence of cataract would be expected. This gender difference has not improved since our earlier study and other reports from Nepal and Kenya.3,4,6,8 It appears that parents give preference to their sons for cultural, economic, social, and religious reasons. Similarly, girls were less likely to return for follow-up. Despite this, there was no difference in long-term visual outcome between boys and girls in our series. Factors that might encourage parents to bring their daughters for surgery need to be explored.

The management of cataract in children is specialized, demanding, and very different from that in adults. According to World Health Organization recommendations, it should be performed by a well-trained staff in adequately equipped tertiary eye centers that can provide comprehensive care.9 Because treatment with contact lenses is not advisable in developing countries, all children underwent IOL implantation. We used PMMA IOLs, which are good quality, low cost (2 USD), and available in Nepal with a wide range of optical powers. PMMA is also a tried and tested material not associated with some of the surface changes described in foldable IOLs.10,11 Foldable IOLs manufactured in Nepal and India are 10 times more expensive than PMMA IOLs and those from the European Union or the United States are 50 times more expensive, far beyond what most families could afford.

Placement of the haptics in the capsular bag may be easier with soft, single-piece foldable IOLs, especially in small eyes.12 However, because soft haptic lenses are not suitable for sulcus and optic capture fixation, IOLs with more rigid haptics should always be in stock in case sulcus fixation becomes necessary during surgery. Whether PMMA IOL implantation ultimately leads to more complications than foldable IOLs remains controversial and may also relate to surgical technique and the surgeon’s experience and preferences. Rowe et al.13 described more intraoperative complications with PMMA IOLs compared to foldable IOLs due to the larger incision, but Gupta et al.14 found no such difference.

Capsulorhexis can be demanding, especially in very young children where the capsule is elastic or where there are calcified plaques. High frequency bipolar capsulotomy proved helpful, giving controlled opening of the capsule.

Some surgeons prefer to leave the posterior capsule intact in older children, performing prophylactic Nd:YAG laser capsulotomy or surgery should visual axis opacification develop.2,4,6,15 We changed practice in 2007 in light of our retrospective series and unpublished observation that visual axis opacification developed despite Nd:YAG laser capsulotomy.3 Since 2007, all children undergo primary posterior CCC with aggressive, “dry” anterior vitrectomy, which has greatly reduced the need for secondary procedures; only one child required removal of membranes in front of the IOL in both eyes at 5 months. However, children in this study were relatively old and proliferative activity of lens epithelial cells was likely to be low. In other studies, the need for secondary procedures to remove visual axis opacification ranged from 0% to almost 100%, being more frequent if the posterior lens capsule was left intact and in children younger than 2 years.8,14,16–18

Bilateral surgery during one hospital stay, IOL implantation with undercorrection according to age, and the provision of durable, high-quality spectacles to take home all proved beneficial because many children cannot return for follow-up visits.

In our series, surgery was performed under local anesthesia on more than half of the children, some being as young as 5 years. A study from China also reported that surgery under local anesthesia is possible in carefully selected children aged 7 to 15 years.19 In children where cooperation was doubtful, general anesthesia using ketamine plus a retrobulbar block was well tolerated, safe, cost-effective, and efficient, especially because the surgical time was short. Ketamine is known for a wide margin of dosage safety, without the respiratory and cardiovascular depression seen with propofol, fentanyl, or midazolam.20 Indeed, laryngospasm severe enough to warrant intubation has been reported in only 2 of 11,589 patients receiving ketamine anesthesia.21

Significant improvement in visual status was observed after surgery and during follow-up, especially during the first 3 months, and only 5.6% remained “blind” after surgery. Our results were comparable to other reports from low-income countries, where 30% to 60% achieved a best corrected VA of 6/18 or better.4–6,8,21 Interestingly, preexisting nystagmus and strabismus improved after cataract surgery. Yorston et al. observed that only 5 of 21 patients with preoperative nystagmus still had nystagmus after a minimum follow-up of 6 months.8

Children need regular refraction and frequent change of spectacles postoperatively because their eyes are still growing and spectacles will be lost and damaged quickly. Unfortunately, local optical stores usually do not stock spectacle frames for young children and those that are available are often of poor quality. Thus, correction of refractive errors remains a challenge in young children.

After regression of the suture-induced astigmatism, mean power of astigmatism was 1.3 ± 0.95 D after 3 months and thereafter. Using a similar technique and posterior chamber IOL type, Bowman had similar findings.5 Foldable IOLs are reported to cause less astigmatism due to the smaller incision.6,12,13,15

Due to the intended undercorrection of the IOL power, eyes were hyperopic postoperatively and a mean myopic shift of 0.8 ± 0.9 D was noted during the first postoperative year. Spherical equivalent after more than 1 year was +1.1 ± 2.4 D. Longer follow-up would be needed to assess whether this is likely to change further over time.

In this study, transient mild to moderate fibrin formation was relatively common but severe fibrinous uveitis was uncommon and lower than in other case series, where rates of 12% to 81.8% have been reported.5,22 Our intensive postoperative steroid regimen and the older age at surgery may have helped to reduce this complication.

Transient wound leakage through the paracentesis was uncommon and never required revision. In our view, the advantage of avoiding suture-related problems (ie, keratitis and need for suture removal) far outweighs the risk of transient hypotony.

Postoperative glaucoma was rare, which almost certainly reflects the older age at surgery than is the case in industrialized countries. In a recent review, Solebo et al. identified age at surgery as the most important risk factor for pseudo or aphakic glaucoma in children in the United Kingdom, with the greatest risk among children younger than 3 months at surgery.23 In our study, no child was operated on before 3 months of age.

The guardians of all children in this study were strongly encouraged to return for follow-up. In other reports, similar incentives had similar results.2,24 Despite these efforts, the follow-up rate at our institution was still low but has improved over time; in our retrospective series, only 5.1% of children had follow-up longer than 6 months.3

References

  1. Gilbert C, Foster A. Childhood blindness in the context of VISION 2020—the right to sight. Bull World Health Organ. 2001;79:227–232.
  2. Kishiki E, Shirima S, Lewallen S, Courtright P. Improving postoperative follow-up of children receiving surgery for congenital or developmental cataracts in Africa. J AAPOS. 2009;13:280–282. doi:10.1016/j.jaapos.2008.12.002 [CrossRef]
  3. Wilson ME, Hennig A, Trivedi RH, Thomas BJ, Singh SK. Clinical characteristics and early postoperative outcomes of pediatric cataract surgery with IOL implantation from Lahan, Nepal. J Pediatr Ophthalmol Strabismus. 2011;48:286–291. doi:10.3928/01913913-20100920-03 [CrossRef]
  4. Thakur J, Reddy H, Wilson ME Jr, et al. Pediatric cataract surgery in Nepal. J Cataract Refract Surg. 2004;30:1629–1635. doi:10.1016/j.jcrs.2003.12.047 [CrossRef]
  5. Bowman RJ, Kabiru J, Negretti G, Wood ML. Outcomes of bilateral cataract surgery in Tanzanian children. Ophthalmology. 2007;114:2287–2292. doi:10.1016/j.ophtha.2007.01.030 [CrossRef]
  6. Ram J, Gupta N, Sukhija JS, et al. Outcome of cataract surgery with primary intraocular lens implantation in children. Br J Ophthalmol. 2011;95:1086–1090. doi:10.1136/bjo.2010.186072 [CrossRef]
  7. Murthy G, John N, Gupta SK, Vashist P, Rao GV. Status of pediatric eye care in India. Indian J Ophthalmol. 2008;56:481–488. doi:10.4103/0301-4738.42642 [CrossRef]
  8. Yorston D, Wood M, Foster A. Results of cataract surgery in young children in east Africa. Br J Ophthalmol. 2001;85:267–271. doi:10.1136/bjo.85.3.267 [CrossRef]
  9. World Health Organization. Preventing Blindness in Children: Report of a WHO/IAPB Scientific Meeting. Hyderabad, India: Author; 1999:6–33.
  10. Tognetto D, Toto L, Sanguinetti G, Ravalico G. Glistenings in fold-able intraocular lenses. J Cataract Refract Surg. 2002;28:1211–1216. doi:10.1016/S0886-3350(02)01353-6 [CrossRef]
  11. Werner L. Glistenings and surface light scattering in intraocular lenses. J Cataract Refract Surg. 2010;36:1398–1420. doi:10.1016/j.jcrs.2010.06.003 [CrossRef]
  12. Zetterström C, Kugelberg M. Pediatric cataract surgery. Acta Ophthalmol Scand. 2007;85:698–710. doi:10.1111/j.1600-0420.2007.01007.x [CrossRef]
  13. Rowe NA, Biswas S, Lloyd IC. Primary IOL implantation in children: a risk analysis of foldable acrylic v PMMA lenses. Br J Ophthalmol. 2004;88:481–485. doi:10.1136/bjo.2003.023275 [CrossRef]
  14. Gupta A, Kekunnaya R, Ramappa M, Vaddavalli PK. Safety profile of primary intraocular lens implantation in children below 2 years of age. Br J Ophthalmol. 2011;95:477–480. doi:10.1136/bjo.2010.184606 [CrossRef]
  15. Gupta A, Ramappa M, Kekunnaya R, et al. Comparing the astigmatic outcome after paediatric cataract surgery with different incisions. Br J Ophthalmol. 2012;96:386–389. doi:10.1136/bjo.2011.202622 [CrossRef]
  16. Taylor D. Choice of surgical technique in the management of congenital cataract. Trans Ophthalmol Soc U K. 1981;101:114–117.
  17. Vasavada A, Desai J. Primary posterior capsulorhexis with and without anterior vitrectomy in congenital cataracts. J Cataract Refract Surg. 1997;23(suppl 1):645–651. doi:10.1016/S0886-3350(97)80048-X [CrossRef]
  18. Kugelberg M, Kugelberg U, Bobrova N, Tronina S, Zetterström C. After-cataract in children having cataract surgery with or without anterior vitrectomy implanted with a single-piece AcrySof IOL. J Cataract Refract Surg. 2005;31:757–762. doi:10.1016/j.jcrs.2004.08.044 [CrossRef]
  19. Fan DS, Tang EW, Rao SK, Xiu-Qin Z, Lam DS. The use of peribulbar anesthesia in pediatric cataract surgery (age 7–15 years) in a mobile eye camp in China. Acta Ophthalmol Scand. 2006;84:384–387. doi:10.1111/j.1600-0420.2005.00599.x [CrossRef]
  20. Dolansky G, Shah A, Mosdossy G, Rieder MJ. What is the evidence for the safety and efficacy of using ketamine in children?Paediatr Child Health. 2008;13:307–308.
  21. Green SM, Johnson NE. Ketamine sedation for pediatric procedures: Part 2. Review and implications. Ann Emerg Med. 1990;19:1033–1046. doi:10.1016/S0196-0644(05)82569-7 [CrossRef]
  22. Javadi MA, Ahmadieh H. Opacification of the ocular media. In: Wilson ME Jr, Trivedi RH, Pandey SK, eds. Pediatric Cataract Surgery: Techniques, Complications, and Management. Philadelphia: Lippincott, Williams & Wilkins; 2005:240.
  23. Solebo AL, Rahi J, Grehn F. Aphakic and pseudophakic glaucoma following pediatric cataract surgery [article in German]. Ophthalmologe. 2012;109:83–92. doi:10.1007/s00347-011-2516-5 [CrossRef]
  24. Mwende J, Bronsard A, Mosha M, et al. Delay in presentation to hospital for surgery for congenital and developmental cataract in Tanzania. Br J Ophthalmol. 2005;89:1478–1482. doi:10.1136/bjo.2005.074146 [CrossRef]

Demographic and Preoperative Ocular Characteristics

CharacteristicsAll (N = 390)Male (n = 270)Female (n = 120)
Children
  Mean age ± SD (y)7.40 ± 4.07.47 ± 4.07.22 ± 4.0
  From Nepal10.8%11.5%8.3%
  From India89.2%88.5%91.7%
  Nystagmus25.9%25.6%26.6%
  Strabismus34.6%33.3%37.5%
Eyes
  Median keratometry (mm)   (min; 25%; 75%; max)7.73 (6.61; 7.46; 7.98; 9.38)7.77 (6.64; 7.53; 8.02; 9.38)7.60 (6.44; 7.36; 7.76; 8.61)
Median astigmatism (mm)   (min; 25%; 75%; max)0.19 (0; 0.12; 0.29; 1.1)0.19 (0; 0.11; 0.30; 1.1)0.20 (0; 0.13; 0.28; 0.83)
Median axial length (mm)   (min; 25%; 75%; max)21.7 (15.1; 20.7; 22.8; 27.8)21.8 (15.1; 20.7; 22.9; 27.8)21.6 (16.5; 20.3; 22.6; 25.8)
IOL power for emmetropia   (min; 25%; 75%; max)26 (10; 22; 29; 39)26 (10; 22; 29; 38)26 (12; 22; 30; 39)
  Ocular anomalies8.7%8.8%8.5%

Preoperative and Postoperative Visual Status Using Corrected Visual Acuity

Follow-upNot ImpairedVisual ImpairmentSevere Visual ImpairmentBlind
Last follow-upa (n = 390)
  Preoperative0%19.4%18.3%62.3%
  Better eye43.1%31.5%7.2%18.2%
  1st eye operated39.2%33.9%7.4%19.5%
  2nd eye operated32.3%32.3%10.3%25.1%
More than 3 weeks of follow-up (n = 245)
  Preoperative0%22.0%18.4%59.6%
  Better eye49.6%29.3%8.9%12.2%
  1st eye operated45.9%31.7%8.9%13.4%
  2nd eye operated39.8%30.5%10.6%17.9%
More than 3 months of follow-up (n = 123)
  Preoperative0%23.6%17.1%59.4%
  Better eye54.0%29.8%8.9%7.3%
  1st eye operated49.2%33.1%8.9%8.8%
  2nd eye operated43.6%29.0%14.5%12.9%
More than 1 year of follow-up (n = 71)
  Preoperative0%20.0%15.7%64.3%
  Better eye53.5%35.3%5.6%5.6%
  1st eye operated50.7%36.6%4.2%8.5%
  2nd eye operated45.1%29.6%15.4%9.9%

Changes in Spherical Equivalent Refraction and Astigmatism During Follow-up, by Eye

Follow-upSpherical Equivalent (D)Astigmatism (D)Axis (W, O, A)
Last follow-up (n = 390)
  Discharge - right1.5 ± 2.33.4 ± 2.564.5%, 11.7%, 23.8%
  Discharge - left1.3 ± 2.43.7 ± 2.477.0%, 6.8%, 16.2%
  Last follow-up - right1.2 ± 2.31.4 ± 1.117.1%, 12.3%, 70.6%
  Last follow-up - left1.1 ± 2.31.5 ± 1.116.3%, 10.9%, 72.8%
More than 3 weeks of follow-up (n = 245)
  Discharge - right1.8 ± 2.33.2 ± 2.465.7%, 12.0%, 22.3%
  Discharge - left1.5 ± 2.63.7 ± 2.679.3%, 5.8%, 14.9%
  > 3 weeks - right1.2 ± 2.31.4 ± 1.116.9% ,11.2%, 71.9%
  > 3 weeks - left1.1 ± 2.31.5 ± 1.115.2%, 11.1%, 73.7%
More than 3 months of follow-up (n = 123)
  Discharge - right2.1 ± 2.53.3 ± 2.567.5%, 11.7%, 20.8%
  Discharge - left1.9 ± 2.73.6 ± 2.678.3%, 5.0%, 16.7%
  > 3 months - right1.4 ± 2.41.2 ± 1.019.7%, 11.4%, 68.9%
  > 3 months - left1.2 ± 2.41.4 ± 1.017.0%, 16.2%, 66.8%
More than 1 year of follow-up (n = 71)
  Discharge - right2.0 ± 2.33.3 ± 2.467.6%, 14.7%, 17.7%
  Discharge - left1.7 ± 2.63.5 ± 2.975.0%, 4.5%, 20.5%
  > 1 year - right1.2 ± 2.41.2 ± 0.924.6%, 10.1%, 65.3%
  > 1 year - left1.0 ± 2.41.4 ± 1.018.6%, 15.7%, 65.7%

10.3928/01913913-20130402-01

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