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 Table of Contents  
Year : 2013  |  Volume : 3  |  Issue : 4  |  Page : 151-155

Long-term results of extraction of childhood cataracts and intraocular lens implantation

Department of Ophthalmology, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan

Date of Web Publication20-Nov-2013

Correspondence Address:
Mei-Ching Teng
123 Dapi Road, Niao Sung District, Kaohsiung City
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Source of Support: None, Conflict of Interest: None

DOI: 10.1016/j.tjo.2013.10.005

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Purpose: To study the long-term changes in refraction and visual outcome after extraction of congenital/ developmental cataracts and intraocular lens (IOL) implantation in children.
Methods: Cataract extraction and IOL implantation were performed in 33 eyes of 21 children aged 4–59 months. Refraction and best-corrected visual acuity (BCVA) were measured 4–5 years later. The cases were grouped by age at surgery: Group A: ≤1 year, Group B: 1–3 years, and Group C: >3 years. Results: The mean myopic change was significantly lower in bilateral (mean −3.88 ± 2.47 D) than in unilateral (mean −7.68 ± 5.04 D) cases (p = 0.003). The latest BCVA values were logMAR 0.76 ± 0.86 and logMAR 0.43 ± 0.32 in unilateral and bilateral cases, respectively (p = 0.055). The mean myopic change values were −5.17 ± 4.49 D, −6.34 ± 3.44 D, and −3.45 ± 2.50 D in Groups A, B, and C, respectively (p = 0.104). The latest BCVA values were logMAR 0.84 ± 0.46, logMAR 0.55 ± 0.64, and logMAR 0.14 ± 0.17 in Groups A, B, and C, respectively (p = 0.035).
Conclusion: Best-corrected Snellen visual acuity ≥0.2 was achieved in most patients. We found less myopic shift in patients with bilateral cataracts and better visual outcomes in patients who underwent cataract surgery at older ages, probably because the cataracts in older patients were less dense initially and thus less likely to cause deprivation amblyopia.

Keywords: childhood cataract, congenital cataract, intraocular lens implantation

How to cite this article:
Sun IT, Kuo HK, Chen YJ, Fang PC, Lin SA, Wu PC, Kuo MT, Teng MC. Long-term results of extraction of childhood cataracts and intraocular lens implantation. Taiwan J Ophthalmol 2013;3:151-5

How to cite this URL:
Sun IT, Kuo HK, Chen YJ, Fang PC, Lin SA, Wu PC, Kuo MT, Teng MC. Long-term results of extraction of childhood cataracts and intraocular lens implantation. Taiwan J Ophthalmol [serial online] 2013 [cited 2023 Mar 28];3:151-5. Available from: https://www.e-tjo.org/text.asp?2013/3/4/151/203912

  1. Introduction Top

Congenital/developmental cataracts produce deprivation amblyopia and can thus cause lifelong visual impairment. Successful outcome requires early diagnosis, referral for surgery when indicated, accurate optical rehabilitation, and regular postoperative supervision. Cataract surgery in children has improved dramatically in recent decades, and the combination of better understanding of the sensitive periods for the development and reversal of amblyopia with respect to the timing of cataract removal and improved surgical techniques has led to better visual outcomes after congenital/developmental cataract surgery.[1] Primary intraocular lens (IOL) implantation has been accepted in children older than 2 years, but IOL implantation in children younger than 2 years remains controversial because their eyes are more susceptible to intense posterior capsular opacification (PCO) and excessive uveal inflammation.[2],[3]

Some studies have reported good visual outcomes of surgery performed before the age of 2–3 months, and no serious complications have occurred.[4],[5],[6] The visual outcome following cataract surgery depends on the age at surgery, laterality, postoperative complications, and postoperative amblyopia treatment. There have been some studies of the long-term outcomes after surgical treatment of congenital/developmental cataracts. The aim of our study was to investigate the long-term clinical results of cataract removal and IOL implantation in patients with congenital/developmental cataracts.

  2. Methods Top

With institutional review board approval, the medical records of 29 Taiwanese children who underwent surgery for congenital/ developmental cataracts at Kaohsiung Chang-Gung Memorial Hospital between 1996 and 2005 were reviewed retrospectively. Children were eligible if they met the following criteria: unilateral or bilateral significantly dense cataracts, presumed congenital or developmental cataract origin, and follow-up for 4–5 years after IOL implantation with regular yearly measurement of refraction and visual acuity. Patients with congenital intraocular anomalies, cataracts of traumatic origin, or irregular or incomplete follow-up examinations were excluded. The excluded cases comprised two patients with persistent hyperplastic primary vitreous, two patients with retinopathy of prematurity, one patient with familial exudative vitreoretinopathy, one patient with microphthalmia, and two patients who were lost to follow-up at our hospital. Finally, 33 eyes of 21 patients, nine children with unilateral congenital/ developmental cataracts, and 12 children with bilateral congenital/ developmental cataracts were included in our study. We described the morphology of the cataracts as total, lamellar, nuclear, or posterior. Most of the cataracts were detected younger than one year old, whereas the diagnosis in older patients was almost always peripheral lamellar or nuclear cataracts.

Surgery was performed by six different surgeons after at least 5 months of age or as soon as possible following diagnosis of visually significant cataracts. Those who underwent surgery at older than 3 years old received a diagnosis of initially less dense congenital/ developmental cataracts before 3 years of age. All patients underwent preoperative examinations, including keratometry measurement, axial length measurement by A-scan ultrasound through an applanation technique, slit-lamp biomicroscopy, fundus examination, and B-scan ultrasonography. If the patients were too young to cooperate with the examinations, we performed thorough ocular examinations under general anesthesia in the operation room. Other information collected included age at IOL implantation, the choice of IOL, and targeted refraction immediately after IOL implantation. The SRK/T formula was used to calculate IOL power for all patients. The choice of IOL power was determined by the patient’s age. Because of the preferences of the individual surgeons there was some variation in the choice of target refraction. Generally, more hyperopic states immediately after surgery were chosen for younger patients, allowing for a myopic shift. The target refraction was approximately +2.5–3.5 D for patients 1 year old or younger, +1.5–2.5 D for those 1–2 years old, and +1.0–1.5 D for those 2–4 years old. Postoperative refraction (measured using an autorefractometer, Topcon RM-6000), refractive change (finally achieved versus initially targeted refraction), and best-corrected visual acuity (BCVA) at the last follow-up examination were also recorded. The demographic data of all patients are shown in [Table 1].
Table 1: Demographic data of 21 patients: Cases 1–9 had unilateral cataracts and Cases 10–21 had bilateral cataracts.

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The surgical technique used was similar in all cases, except a few in which IOL implantation was delayed and performed as a secondary operation because of the unavailable power of IOL suitable for too-short axial length and the risk of increased tissue reactivity if the IOL implants were placed when the patient is too young. Two unilateral cases (Cases 1, 4) and three bilateral cases (Cases 14, 15, and 17) underwent primary cataract extraction initially and secondary IOL implantation at an older age. All surgeries were performed by a superior approach technique using clear cornea or scleral tunnel incisions just large enough to accommodate the foldable IOL, based on each surgeon’s habitual techniques. A small paracentesis was placed approximately at the 2 o’clock or 3 o’clock position away from the site of an incision made for the phaco handpiece or handheld irrigation tip. After anterior continuous circular capsulorhexis and hydrodissection, the lens material was removed with an aspirator handpiece. Posterior capsulotomy and anterior vitrectomy were performed on some eyes [Table 1]. Most of the foldable IOLs were implanted into the bag, but some fit into the sulcus when a large posterior capsule defect with adequate anterior capsule support was present. All wounds were closed with 10-0 Ethilon nylon sutures. The patients who underwent extraction of cataracts and waited for secondary IOL implantation received occlusion therapy in the healthy eye. The patients who exhibited amblyopia during the regular follow-up visits after IOL implantation received occlusion therapy and wore spectacles if necessary. The major complication after the surgery was posterior capsular opacities. If posterior capsular opacities that hindered the vision of the red reflex at ocular fundus examination or impeded the autorefractometer measurement, YAG capsulotomy or revised posterior capsulotomy combined with anterior vitrectomy was performed. No patients developed glaucoma after the surgery.

Patients with unilateral or bilateral cataracts were divided into three groups based on their ages at IOL implantation: Group A: age 1 year old or younger, Group B: age 1–3 years, and Group C: older than 3 years. Multivariate analysis was used to evaluate the factors that might influence the final refraction, refraction change, and final BCVA. Nonparametric analysis by the Mann-Whitney U test and the Kruskal-Wallis test was used because of the limited number of cases. A p value <0.05 was considered statistically significant. When the result of Kruskal-Wallis test was significant (p < 0.05), the Mann-Whitney U test with the Bonferroni correction was used to evaluate which group’s coordinates were significantly different from each other.

  3. Results Top

From 1996 to 2005, congenital/development cataracts were diagnosed in 33 eyes of 21 patients age 1–59 months and treated with cataract extraction and posterior chamber IOL implantation after at least 5 months of age. The length of the follow-up period was 4–5 years. Nine children had unilateral cataracts and 12 bilateral cataracts. The age at surgery did not differ between children with unilateral (mean, 31.4 ± 15.9 months, range, 10–57 months) and bilateral (mean, 25.4 ± 20.4 months, range, 5–59 months) cataracts (p = 0.337). The IOL powers chosen (as calculated using the SRK/T formula) ranged from 18.5 to 30 D (mean 23.4 ± 3.1 D) in children with unilateral cataracts and from 18.0 to 30 D in those with bilateral cataracts (mean 23.8 ± 3.8 D); the power used was chosen based on the patient’s age at IOL implantation and the surgeon’s individual preferences. The target refraction immediately after IOL implantation did not differ between children with unilateral (mean 1.95 ± 1.29 D, range 0.56–3.88 D) and bilateral (mean 1.67 ± 0.96 D, range 0.43–3.72 D) cataracts (p = 0.252). The mean refraction errors at the last follow-up visit were significantly greater in the unilateral (mean −5.74 ± 4.61 D) than in the bilateral (mean −2.22 ± 2.32 D) cases (p = 0.003). A myopic shift occurred in all 33 eyes. The mean myopic change, which was the difference between the refraction at the last follow-up visit and the target refraction immediately after IOL implantation, was significantly smaller in bilateral (mean −3.88 ± 2.47 D) than in unilateral (mean −7.68 ± 5.04 D) cases (p = 0.003). Most of the eyes with significant myopic shift were total opacities of cataracts [Table 1]. The BCVA values at the last follow-up visit were logMAR 0.76 ± 0.86 and logMAR 0.43 ± 0.32 in unilateral and bilateral cases, respectively (p = 0.055) [Table 2]. There are seven eyes with BCVA worse than logMAR 1.0, including four total opacities and three nuclear cataracts [Table 1].
Table 2: Comparison between children with unilateral and bilateral cataracts.

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Twelve eyes (36.4%) underwent IOL implantation during the 1st year of life (Group A), 10 eyes (30.3%) between 1 and 3 years of age (Group B), and 11 eyes (33.3%) at greater than 3 years of age (Group C). The target refractions immediately after IOL implantation were 2.62 ± 1.11 D in Group A, 1.45 ± 0.71 D in Group B, and 1.05 ± 0.40 D in Group C (p = 0.006). The mean refraction errors at the last follow-up visit were −2.54 ± 4.00 D in Group A, −4.89 ± 3.27 D in Group B, and −2.30 ± 2.47 D in Group C (p = 0.188). The mean myopic changes were −5.17 ± 4.49 D in Group A, −6.34 ± 3.44 D in Group B, and −3.45 ± 2.50 D in Group C (p = 0.104). Neither the mean refraction at the last follow-up visit nor the myopic change differed significantly among the three age groups. However, the BCVA at the last visit was best in Group C (logMAR 0.14 ± 0.17), followed by Group B (logMAR 0.55 ± 0.64), and then Group A (logMAR 0.84 ± 0.46); this effect was significant (p = 0.035). Also, the BCVA at the last visit in Group C was significantly better than Group A (Mann-Whitney U test, p < 0.001) [Table 3].
Table 3: Comparison among children who underwent surgery at different ages.

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In unilateral cases, the BCVA at the last visit did not differ among the three age groups (p = 0.077). In bilateral cases, the BCVA at the last visit was best in Group C (logMAR 0.14 ± 0.16), followed by Group B (logMAR 0.37 ± 0.19), and then Group A (logMAR 0.69 ± 0.27); this effect was significant (p = 0.040).

Ten of 21 patients (47.6%) exhibited postoperative strabismus [Table 1]. Exotropia was more common than esotropia, with incidence rates of 33.3% and 14.3%, respectively. Six of 21 patients (28.6%) with existing nystagmus preoperatively had irreversible nystagmus postoperatively [Table 1].

  4. Discussion Top

Implantation of IOLs in children is becoming an accepted practice for many surgeons.[7],[8],[9],[10] Despite the demonstrated efficacy and safety of pediatric cataract surgery, some challenging questions remain, including the most appropriate age for surgery, primary versus secondary IOL implantation, the intended postoperative target refraction, and IOL calculations. The rapid growth of the eye in children, especially during the 1st year of life, as well as the increased tissue reactivity and decreased scleral rigidity, make pediatric cataract surgery particularly challenging.[11],[12],[13],[14],[15],[16],[17] One of the most difficult challenges has been how to choose an appropriate IOL power for growing children, especially those younger than 1 year.[17],[18] Previous studies have made recommendations on the extent to which to underpower IOLs in children of different ages in order to compensate for the myopic shift that occurs as children’s eyes grow.[15],[19],[20] In our study, we considered the possible future myopic shift when choosing the IOL power and intentionally made the postoperative target refractions slightly hyperopic. The magnitude of the hyperopic state depended on the age at IOL implantation and the surgeons’ individual preferences. The mean target refractions as calculated by the SRK/T formula were +2.62 ± 1.11 D for Group A, +1.45 ± 0.71 D for Group B, and 1.05 ± 0.40 D for Group C.

Astle et al showed a logarithmic change in myopic shift over time as the children in their study grew up, and found that less myopic shift occurred in children who were older at the time of implantation.[21] Crouch et al demonstrated that the refractive power of a child’s eye changes most rapidly between 1 and 3 years of age and follows a more linear course after the age of 3 years.[15] Yam et al showed that patients who were 0–2 years old at the time of surgery had a significantly larger myopic shift rate than patients who were older than 6 years.[22] Our results showed that the smallest mean myopic shift was observed in patients who underwent surgery at age 3 years or older, though the mean refractive change after age 4–5 years did not differ significantly among the different age groups (p = 0.104). However, the best final BCVA was observed in patients who underwent surgery at age 3 years or older, followed by those who underwent surgery at 1 –3 years of age, and at age 1 year or younger. This effect was statistically significant among three age groups (p = 0.035). Furthermore, the final BCVA in patients who underwent surgery at age 3 years or older was significantly better than those who underwent surgery at age 1 year or younger (Mann-Whitney U test, p < 0.001). Fan et al studied 34 eyes of 20 children who underwent cataract extraction and primary IOL implantation at the age of 3–12 months and found that myopic shift had occurred in all 34 eyes 3 years after surgery. The final mean refractive error was −2.49 ± 3.08 D and the mean myopic progression 7.11 ± 3.17 D.[23] In comparison, in our study, the 12 patients who underwent surgery at age 12 months or younger exhibited less myopic shift, with a mean refractive error of 2.54 ± 4.00 D and mean myopic progression of 5.17 ± 4.49 D. Our results differed from those of previous studies[5],[24],[25],[26] in that the final BCVA was better in the patients who underwent cataract surgery at older ages. The results suggested that the cataracts in the older patients may have been less dense initially and probably less likely to cause apparent deprivation amblyopia.

The visual outcome at the last follow-up visit was satisfactoryin both patients with unilateral cataracts and those with bilateral cataracts. The final refractive errors and refractive changes were significantly smaller in bilateral cases (p = 0.003). Because patients with unilateral congenital/developmental cataracts have two amblyogenic factors, pattern vision deprivation and anisometropia, patients with bilateral congenital/developmental cataracts are expected to achieve better binocular function and visual outcome.[27] In our study, the visual outcome was indeed better in bilateral cases, although the difference was not statistically significant (p = 0.055). It is difficult to compare our results with those of other studies due to differences in patient selection, postoperative follow-up, and presentation of visual outcome. Agervi et al[28] reported on 65 children who underwent cataract surgery at 3–15 years of age. The mean spherical equivalent 2 years after surgery was 0.23 D (−5D to +3.25 D) in the unilateral cases and 0.62 D (−3.1 D to +3.5 D) in the bilateral cases. Seven unilaterally affected patients (44%) and 36 eyes (90%) of bilaterally affected patients attained Snellen visual acuities (VAs) ≥ 0.2 with optical correction. Two eyes (12%) ofunilaterallyaffected patients and 16 eyes (40%) of bilaterally affected patients attained Snellen VAs ≥ 0.5 with optical correction.[28] In our study, five eyes (56%) of unilaterally affected patients, and 21 eyes (88%) of bilaterally affected patients attained Snellen VAs ≥0.2 with optical correction. Four eyes (44%) of unilaterally affected patients and seven eyes (29%) of bilaterally affected patients attained Snellen VAs ≥0.5 with optical correction. Our results revealed similar or better visual outcomes 4–5 years after surgery.

Ten of 21 patients (47.6%) in our study, four with unilateral cataracts and six with bilateral cataracts, exhibited postoperative strabismus. Exotropia was more common than esotropia, with incidence rates of 33.3% and 14.3%, respectively. This result was similar to those of several previous studies[24],[29],[30],[31] but different from those of Agervi et al[28] and Hiles and Sheridan,[32] who found that esotropia occurred more often. The incidence of strabismus was higher in our patients who had undergone surgery for congenital/developmental cataracts than in the general population (1.3–4.5%).[30] Despite the presence of strabismus, most of our patients achieved Snellen VAs ≥ 0.2 with optical correction after surgery. Dense congenital/developmental cataracts usually lead to irreversible sensory nystagmus, which is often obvious by 3 months of age.[24],[33] Some previous studies have suggested that preoperative sensory nystagmus predicts a poor visual outcome after cataract surgery, whereas others have reported that good VA can still be achieved in some cases.[24],[28],[33],[34],[35] In our study, four of six patients with postoperative nystagmus had achieved fair Snellen BCVAs (≥0.2) by the last follow-up visit. The good visual outcome and few cases of nystagmus in our study might indicate that the cataracts in these cases were not very dense initially.

In summary, best-corrected Snellen VA ≥ 0.2 was achieved in most of the patients with congenital/developmental cataracts in this 4–5-year follow-up study. We found less myopic shift in patients with bilateral cataracts and better visual outcome in patients who underwent cataract surgery at older ages. The major limitations of our study were the small sample size and retrospective review of medical records, which limited our ability to study the various factors that may have influenced the visual outcome. However, the sample was large enough to obtain statistically significant differences between the unilateral and bilateral groups and among the different age groups. Long-term follow-up was necessary for these patients in order to provide adequate amblyopia treatment if necessary.

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  [Table 1], [Table 2], [Table 3]

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