PAEDIATRIC CATARACT CASES

In paediatric cataract cases, management of the posterior capsule is crucial, Abhay R Vasavada MD emphasised at the Combined Symposium of Cataract & Refractive Societies on “Cataract Surgery in Difficult Eyes” at the annual meeting of the ESCRS in London in September.

“Management of the posterior capsule significantly affects the outcome of paediatric cataract surgery,” stressed Dr Vasavada, Iladevi Cataract & IOL Research Centre, Raghudeep Eye Hospital, Ahmedabad, India. 

This is primarily because visual axis obscuration (VAO) is rapid and virtually inevitable in very young children when the posterior capsule is left intact. In paediatric cataract, primary posterior capsulotomy and vitrectomy are considered routine surgical steps, although there are many variations
in technique.

Dr Vasavada described his preferred method of posterior capsulorhexis, which he performs after insertion of the intraocular lens (IOL) into the capsular bag. “I find this technique to be easier, particularly in very small infant eyes, since the IOL maintains a certain capsular stability, far more so than when the bag is empty,” said Dr Vasavada.

Anterior approach

Of course, this isn’t possible via an anterior approach, so Dr Vasavada explained how he does it via the pars plicata. “This technique can be used to create a posterior capsulectomy of the desired size in a controlled manner, in order to avoid later destabilisation of the IOL,” he said, referring to a study he and his team published in the Journal of Cataract & Refractive Surgery.

This procedure should be followed by an anterior vitrectomy with the use of triamcinolone, he added. The posterior approach to procedure can also be used for lentiglobus (previously referred to as lenticonus), with the creation of a posterior capsulorhexis via a pars plana approach.

Dr Vasavada and his team have published a prospective study in which intracameral injection of preservative-free triamcinolone acetonide was shown to improve visualisation of the vitreous during paediatric cataract surgery. Triamcinolone was injected three times: once after the capsulorhexis, once after anterior vitrectomy and for a third time after IOL implantation. This is useful to detect any residual vitreous strands left behind following anterior vitrectomy through the limbal or pars
plicata approach.

Dr Vasavada also has experience with femtosecond capsulorhexis in paediatric cases. “This is quite effective, but it requires two docking sessions, one for the anterior capsule and one for the posterior capsule. This makes it expensive to use, and it also raises concerns about infection, since the incisions have been made prior to the second docking session and the pressure suction can cause potential influx of ocular surface contamination.”

The delegates and panel members asked several questions. Asked what his opinion was of one-piece IOLs in paediatric cases, Dr Vasavada responded: “My routine choice is a one-piece hydrophobic acrylic IOL, specifically Acrysof. However, if the bag is damaged I’m reluctant to use a one-piece, because if one haptic escapes it’s a disaster. It’s also very difficult and dangerous to implant both haptics of a one-piece lens in the sulcus.”

Abhay R Vasavada:

icirc@abhayvasavada.com