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Primary Versus Secondary Implantation of
Intraocular Lenses in Children - A Short Term
Study
Abdalla F. El Sawy, Mostafa A Haikal, M. Hany A. Salem,and Ayman A. Hamed
Purpose : To compare the results obtained after primary intraocular lens (I.O.L.)
implantation with posterior capsulotomy and anterior vitrectomy versus the results
obtained with the same technique done secondarily in aphakic eyes of children (2 mon15 y).
Methods : In the 1st. group (100 eyes) a routine extracapsular cataract extraction,
peripheral iridectomy, posterior chamber (P.C.) 1.0.L., pars plana (or pars plicta)
posterior capsulotomy (central 5-6 mm) and anterior vitrectomy were done . In the
second group (20 eyes) a pars plana /plicata lensectomy and anterior vitrectomy were
done, 1-2 month later a secondary I.O.L. implantation were done .
Results : The difficulties, the complications and the corrected visual outcome were
discussed. The overall results ensured a clear papillary area, minimal postoperative
complications and a favourable visual outcome in all cases . The difficulties were more
considerable in secondary implanted cases thanthose with primary implantation . The
postoperative reaction in primary implanted cases was a little more than those with
secondary implantation .
Conclusion: primary posterior chamber lens implantation with primary posterior
capsulotomy and anterior vitrectomy is the preferred technique in children; however, it
needs more follow up.
Key words: Cataract in children, Secondary I.O. L, Pars plana Posterior
capsulotomy.
BULL. OPHTHALMOL. SOC. EGYPT, 1997; VOL. 90, NUMBER 2, 259-263
Visual rehabilitation of unilaterally aphakic
children remains therapeutically challenging. The
options available are contact lenses, epikeratophakia
and intraocular lenses . Each of these methods has
associated problems that make them less than
ideal. (9) Of the four options, intraocular lenses have
the greatest potential for restoring normal vision.
In the last twenty years the intraocular lenses
(pseudophakia) have been used for the correction of
aphakia. They have many practical advantages over
contact lenses and there is no doubt that their optical
effect is superior. A well fixed and a well centered
lens implant produces a stable retinal image with
stable space localization. Pseudophakia, also can be
so made as to give the unilateral aphakic patient a
fair chance of iseikonia or at least of a minimui.n
and tolerable aniseikonia. Implants thus offers the
best chance of re-establishment of binocularity in
cases of unilateral aphakia. In children in whom
binocularity is so readily lost and so hard to
restore, there is strong indication for the. use of
implants (4) .
Secondary intraocular lens implantation in
children after contact lens failure may provide some
indications for the implantation (14)
Secondary intraocular lens implantation in a
child after a preliminary cataract extraction can be
an advantageous technique . The complications of
cataract extraction can be dealt with separately if
they occur, and the I.O.L. is not implanted except
when the eye is free of any complications.The power
of the I.O.L. is more easily determind by simple
refraction provided that the pupillary area is clear (8).
Patients and Methods
One-hundred and Twenty eyes of ninty five
children aged from two months to fifteen years were
Department of Ophthalmology, Benha Faculty of Medicine,
259
Primary versus secondary implantation of intraocular lenses in children - A-short term study
Abdalla F. El Sawy, and et.al
operated upon. An extracapsular cataract extraction
followed by an intraocular lens implantation
(primary implantation), posterior capsulotomy and
anterior vitrectomy via a pars plana or pars plicata
approach was done in 100 eyes of 80 children (60
eyes were congenital and 40 eyes were traumatic) .
Secondary intraocular lens implantation was
done in 20 aphakic eyes of 15 children (12 eyes were
operated upon for congenital cataract and 8 eyes for
trawnatic cataract) .
The intraocular lens (I.O.L.) implanted was
made of polymethylmethacrylate (P.M.M.A.), a
piano-convex surface, optic part was 6mm, three
pieces and the overall size was 14 mm. The I.O.L.
power was selected according to biometry or
according to the refraction of the other eye .
All
patients
were
subjected
to full
ophthalmological examination including, relative
and absolute visual acuity of the affected eyes if
possible, intraocular pressure measurement by
applanation or by Schiotz tonometer (under
general anaesthesia in very young patient),
biomicroscopic examination using slit lamp, fundus
examination and ultrasonography to examine the
inside of the eye in case of dense cataract and to
determine the needed power of the implant .
fixed over the capsular remenants. 10/0 prolene
sutures was used for scleral fixation technique
under a lamellar scleral flap fashioned at 10 and 4
o'clock meredians
Post operative regular examinations for any
complications, residual error of refraction and visual
acuity was measured by snellen's test, by acuity card
procedure or by observing ocular motor fixation
pattern in very young patients .
Follow-up was done weekly for one month, then
monthly for at least three months. Earlier cases was
followed for one year
Results
In primary implanted cases there were no
operative difficulties except the occuralice of sever
hypotony during vitrectomy, this was rapidly
compensated and the intraocular pressure was
restored by increasing the rate of fluid infusion.
There was no operative complications .
In secondary implanted cases there were many
operative difficulties . Five cases were presented
with posterior synechie and synecholysis using
either cystitome or iris spatula was done in these
cases .
Post-operative Complications
In primary implanted cases the method used was
a routine extracapsular cataract extraction . A 7 mm.
sclerocorneal groove incision (1mm. larger than the
optic of the implant), anterior capsulotomy was
done, then peripheral iridectomy was fashioned,
aspiration of the lens matter with a double -way
aspiration irrigation canula„ then the posterior
chamber I.O.L. was implanted after the injection of
0.25 ml of 2% methyl cellulose within the capsular
bag and in the anterior chamber. The viscoelastic
material was washed out, the wound was closed with
interrupted 10/0 nylon sutures and then the anterior
chamber was reformed with B. S. S .
Using a microvitreoretinal (M.V.R.) blade a
sclerotomy was done in the pars plana / plicata,the
M.V.R.blade was pushed toward the implant
centrally to do an incision 4-5 mm. in the posterior
capsule, an anterior vitrectomy was done. During
vitrectomy an infusion fluid was introduced through
a sclerotomy puncture by a 27 gauge needle .
Secondary I.O.L. implantation was used in cases
for which a pars plana/plicata lensectomy and
vitrectomy were done (after an interval of 1 -2
month) the implant was inserted over the capsular
remenants in five cases . Two haptic scleral fixation
were done in fourteen cases . Single haptic scleral
fixation was done in one case, the other haptic was
Complication
Primary Cases
Secondary cases
No.
No
%
°A
Iritis
. Mild
. Moderate
72%
21%
14
4
70%
20%
7
7%
2
- Posterior synachiae 42
42%
7
10%
35%
- Pupillary distorion
39%
5
25%
.
Sever
72
21
39
- I.O.L. capture
3
3%
1
5%
- Decentration
28
28%
4
20%
- Lens precipitates
- Retro-pseudophakic
71
5
71%
5%
14
2
70%
10%
1
1%
0
0%
opacification or
membrane .
- 2ry. glaucoma
All secondary cases were presented with collapse
of the capsular bag. However, sufficient capsular
remenants enabled us to insert the implaiit over it in
twelve cases. A scleral fixation tecluiique was
adopted in seven cases. Both tecluliques were used
for implantation in one case (one haptic was fixed
over the capsular remena.nts and the other haptic
was fixed by a scleral suture).
260
BULL. OPHTHALMOL. SOC. EGYPT, 1997; VOL. 90, NUMBER 2.
The most frequently early post operative
complication was a fibrinous uvitis . It was severe in
seven cases (7%) of primary implantation group and
in two cases (10%) of secondary implantation group,
it was moderate in (21 %)of primary implanted cases
and in (20%) of secondary implanted cases, it was
mild in (72%) of primary implanted cases and in
(70%) of secondary implanted cases. However, the
iritis was easy to control with medications during
the first ten days postoperatively.
were observed in those patients denoting a visual
improvemment .
Discussion
The technique of management of cataract in
children can be divided into three main categories .
The first is lensectomy, anterior vitrectomy followed
by intraocular lens implantation at a later date
(secondary implantation), the second is
extracapsular cataract extraction with intraocular
lens implantation (primary implantation), the third
is extracapsular cataract extraction, primary
posterior capsulotomy, anterior vitrectomy with
intraocular lens implantation (primar y
impl antation)(3)
Posterior synechiae were developed in (42%) of
primary implanted cases and in (35%) of secondary
implanted cases. Pupillary distorsion was occured
in (39%) of primary implanted cases and in (25%)
of secondary implanted cases .
In o ur s t ud y we ad o p t t he te c h niq ue o f
extracapsular cataract extraction, I.O.L.
implantation, primary posterior capsulotomy and
anterior vitrectomy. In this technique there is an
advantage of having the lens in place before the
posterior capsule is removed. This is the technique
also prefered by Buckly et. al, (1993).
Pupillary distorsion was found in (39%) of cases
of the primary implantation group and in (25%) of
cases of the secondary implantation group .
Only one case in the primary implantation group
was developed a rise of intraocular pressure for
which antiglaucoma medications were described and
the I.O.P. was controlled.
The main drawback to the primary I.O.L.
implantation in children is the changing diapoteric
power of an infant's eye from birth to the first few
years of life . The corneal curvature was found to
assume its adult dimensions by eight years of age,
the axial length of the infant eye is getting almost
the adult length by the second year of life, (10). In our
study we assumed to do emm-etropization by giving
the exact power needed considering the refraction of
the other eye.
Decentration of the implant was occured in
(28%) of primary implanted cases and in (20%) of
secondary implanted cases. Intraocular lens
precipitates of mild to moderate degrees were found
in (71%) of primary implanted cases and in (70%)
of secondary implanted cases. Intraocular lens
captures were found in three cases (3%) of the
primary implantation group and in one case (5%) of
the secondary implantation group.
Most cases of primary and secondary
implantation showed a clear pupillary area. Only
five (5%) of primary implanted cases and two (10%)
o f seco nd ary i mp lanted cases d evelop ed a
retropseudophakic membrane formation which
necessitated another secondary surgical interference
for further vitrectomy.
Van Ballen (1988), compared the axial length of
twenty seven pseudophakic eyes in children to their
contralateral normal eye at the time of intraocular
lens implantation and then ten years later. No
marked difference was found and the pseudophakic
eye seemed to have a normal course of
emmetropization, provided the eye attained
sufficient visual acuity .
All cases have achieved an improvement of
visual acuity especially those wit h traumatic
cataract. In the primary implantation group, five
cases have achieved a corrected visual acuity of 6/9,
three cases have achieved a visual acuity of 6/12,
twelve cases have achieved a visual acuity of 6/18,
and sixteen cases have achieved a visual acuity of
6/24. In the secondary implantation group the best
corrected visual acuity achieved was 6/12 in three
cases. Two cases has achieved a visual acuity of
6/18 and another two cases has achieved a visual
acuity of 6/24 . In the younger age patients the
improvement of visual acuity is difficult to assess,
however, an improvement of the fixation pattern
EI-Sada, (1987) reported that secondary I.O.L.
implantation in a child after a preliminary cataract
extraction can be advantageous technique. The
complications of cataract extraction can be dealt
with separately if they occur, and the I.O.L. is not
implanted except when the eye is free of any
complications . He added that, the power of the
I.O.L. is more easily determined by simple
refraction provided that the pupillary area is clear .
This technique is also adopted by Aron and Aron
Rosa, (1983), they mentioned that,implantation in a
quit, healed, aphakic eye offers the best chance for
functional succes .
261
Primary versus secondary implantation of intraocular lenses in children - A-short term study
Abdalla F. El Sawy, and et.al
visual acuity of 20/40 or better in 85.3% (29 of 34
One of the most frequent postoperative
eyes) of traumatic cataract and in 80% (8 of 10 eyes)
complications encountered in this study was iritis, it
of congenital cataract
was found by a variable degrees in both primary and
secondary implantation groups. However, it was
Conclusion
little more in prima ry than in secondary
Secondary implantation after an initial cataract
implantation group.
surgery is seemed to be techniqually difficult
This is agreed with the findings of Aron and
becouse of synechiae and adhesions between the
Aron Rosa, (1983) who encounter more infim
remenants of anterior and posterior capsules. The
matory reaction with extracapsular cataract
postoperative reaction is nearly the same in primary
extraction and primary I.O.L. implantation.
implantation and in secondary implantation,
however it is little more in primary than in
El-Sada, (1987) reported that the fibroblastic
secondary implanted cases. The visual results is
reaction characteristic of children's eye were found
nearly the same in both groups . However, it is little
to be less severe among his secondary implanted
better in primary than in secondary implanted
cases . He attributed this to the short operative
cases . The overall results make us to conclude
procedure required and to the relatively fewer
that primary implantation technique with
manipulations inside the eye once cataract
posterior capsulotomy and anterior vitrectomy is the
extraction was already done .
preffered technique than the secondary
implantation technique.
The high incidence of iritis may be due to
irritation by the residual lens matter,or performing
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