Download Primary capsulectomy, anterior vitrectomy, lensectomy, and

Primary capsulectomy, anterior
vitrectomy, lensectomy, and posterior
chamber lens implantation in children:
Limbal versus pars plana
Hamid Ahmadieh, MD, Mohammad Ali Javadi, MD,
Mandana Ahmady, MD, Farid Karimian, MD, Bahram Einollahi, MD,
Mohammad Zare, MD, Mohammad Hosein Dehghan, MD,
Arman Mashyekhi, MD, Naser Valaei, MS, Masoud Soheilian, MD,
Hamid Sajjadi, MD
ABSTRACT
Purpose: To compare the results of a limbal versus a pars plana approach for primary
posterior capsulectomy and anterior vitrectomy in the management of childhood
cataract.
Setting: Department of Ophthalmology, Labbafinejad Medical Center, Tehran, Iran.
Methods: A randomized, controlled, double-masked clinical trial of 45 eyes was
conducted. After being matched, 38 eyes were included in the study and were
divided into 2 equal groups for data analysis. All eyes had lensectomy and posterior
chamber intraocular lens (PC IOL) implantation. Primary posterior capsulectomy
and anterior vitrectomy were performed through the limbus in half of the eyes and
the pars plana in the other half. Main outcome measures included visual acuity,
estimated red reflex, postsurgical inflammatory reaction, corneal clarity, posterior
synechias, iris capture, IOL position, capsulectomy size, glaucoma, cystoid macular
edema, retinal tear, and postoperative refraction.
Results: No statistically significant differences were found between the 2 approaches
in the outcome measures.
Conclusion: The anatomic and visual results were encouraging when posterior capsulectomy and anterior vitrectomy, using a limbal or pars plana approach, were
combined with lensectomy and PC IOL implantation in children. The application of
these techniques depends on surgeon experience and skill. J Cataract Refract Surg
1999; 25:768 –775 © 1999 ASCRS and ESCRS
A
mblyopia is the most common cause of impaired
vision in children, and childhood cataract is a significant cause of it. Correction of aphakia and visual
rehabilitation are important steps in the management of
childhood cataract.
© 1999 ASCRS and ESCRS
Published by Elsevier Science Inc.
Many surgeons implant a posterior chamber intraocular lens (PC IOL) to correct aphakia in children.1– 8 This method is especially useful in unilateral
cases. Posterior capsule opacification (PCO), if the capsule remains intact, occurs in 51% to 100% of cases in
0886-3350/99/$–see front matter
PII S0886-3350(99)00040-1
PRIMARY POSTERIOR CAPSULECTOMY IN CHILDHOOD CATARACT
pediatric cataract surgery and prevents visual rehabilitation.3–5,9 –11 A neodymium:YAG (Nd:YAG) capsulotomy does not provide a long-lasting clear visual axis
because the anterior hyaloid face acts as a scaffold for the
growth of lens epithelial cells (LECs).12,13 The transformation of residual LECs results in dense membranes on
the anterior hyaloid surface, visual axis reocclusion, haptic displacement, and iris capture.12–14 To provide better conditions for visual rehabilitation, primary
posterior capsulotomy and anterior vitrectomy have
been recommended.3,5,7,15,16
There are 2 approaches to primary posterior capsulectomy and anterior vitrectomy: through the limbus3,7
and through the pars plana.5 We conducted a clinical
trial to compare the results of these 2 approaches.
Patients and Methods
A sequential, matched, randomized, doublemasked clinical trial was performed. The indications for
cataract surgery in children were defined as any lens
opacity that caused decreased visual acuity (20/60 or
worse), stereopsis disturbance, deviation of the eyes, or
all 3. The eyes were randomly assigned to be operated on
using Technique A (limbal approach) or Technique B
(pars plana approach).
Cases of developmental cataract were subdivided
into 2 groups: (1) zonular cataract; (2) other variations
of developmental cataract. Cases of traumatic cataract
were also subdivided into 2 groups: (1) associated with
corneal laceration; (2) unassociated with corneal
damage.
In cases of bilateral developmental cataract, each eye
was the control of the fellow eye. The randomization
schedule determined which technique was to be used in
the first eye having surgery. In unilateral cases, a randomization schedule also determined the approach.
Accepted for publication January 26, 1999.
From Labbafinejad Medical Center, Shaheed Beheshti University of
Medical Sciences, Tehran, Iran.
Presented in part at the annual meeting of the American Academy of
Ophthalmology, Chicago, Illinois, USA, October 1996.
None of the authors has a proprietary interest in any material used.
Reprint requests to Hamid Ahmadieh, MD, Labbafinejad Medical Center, Pasdaran Avenue, Boostan 9 Street, Tehran 16666, Iran.
Four statistical frames were prepared: (1) traumatic
cataract without corneal damage; (2) traumatic cataract
with corneal damage; (3) developmental cataract of
zonular type; (4) developmental cataract of other types.
The eligible cases were entered sequentially in related
frames according to the type of cataract and the results of
randomization.
Cases of bilateral or unilateral developmental cataract or traumatic cataract were sequentially included in
the study. The indication for cataract surgery was approved by at least 2 physicians independently. The minimum age was 3 years in unilateral cases and 5 years in
bilateral cases. The maximum age was 10 years in both
unilateral and bilateral cases. Traumatic cases with a
history of surgery other than primary repair and cases
with ocular hypotony were excluded. Eyes with scleral
laceration, vitreous prolapse into the anterior chamber,
signs of endophthalmitis and intraocular foreign bodies,
or cataract associated with ocular or systemic disease
were excluded. The presence of posterior synechias did
not result in exclusion.
An A-scan was used for PC IOL power calculation
to achieve emmetropia postoperatively. The refraction
in the fellow eye was considered, and anisometropia of
more than 3.0 diopters (D) was avoided. The PC IOL
type was identical in all cases: single-piece poly(methyl
methacrylate).
Surgical Technique
All cases were operated on using general anesthesia
and were performed by 1 of 3 surgeons (M.A.J., B.E.,
F.K.). Mydriatic drops, instilled before surgery, included tropicamide 1% (3 times) and phenylephrine
2.5% to 5% (1 time). A fornix-based peritomy was done
and a 100 degree midlimbal groove made. Two stab
incisions were created 120 to 150 degrees apart. An anterior capsulotomy was made with a needle and enlarged
to 6.0 mm with a vitrectomy probe. Lens material was
aspirated. This part of the procedure was similar in all
cases, but the surgery then continued differently based
on the technique used.
Technique A. Posterior capsulotomy was done with
a 23 gauge needle and then enlarged to 3.0 to 4.0 mm
with a vitrectomy probe. An anterior vitrectomy was
done through the posterior capsulotomy site. It was confirmed that no vitreous was present at the level of the
pupillary area. Then, a limbal groove was opened into
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the anterior chamber with corneal scissors. After injection of a viscoelastic material, the IOL was implanted
in the capsular bag. Peripheral iridectomy was done,
and the wound was closed with interrupted 10-0
nylon sutures.
Technique B. The limbal groove was opened into
the anterior chamber with corneal scissors. After injection of a viscoelastic material, the IOL was implanted in
the capsular bag. The wound was temporarily closed
with 3 separate 8-0 silk X-sutures. A sclerotomy was
made 2.5 mm from the limbus in 1 superior quadrant.
The infusion cannula was placed in the anterior chamber and the vitrectomy probe in the anterior vitreous
cavity. A 3.0 to 4.0 mm posterior capsulectomy was
made and an anterior vitrectomy performed, after which
the sclerotomy site was repaired with a 7-0 polyglactin
(Vicrylt) X-suture. The temporary X-sutures of the cataract wound were removed, a peripheral iridectomy was
done, and the wound was closed with interrupted 10-0
nylon sutures.
In all cases, a subconjunctival injection of 20 mg of
gentamicin and 4 mg of betamethasone and a sub-Tenon’s injection of methylprednisolone acetate 20 mg were
given.
Follow-up, which was 1 year, was done by 1 physician who was masked to the surgical technique used.
Written consent was obtained from all patients before
enrollment, but they too were masked concerning technique. Follow-up forms were completed 1 and 3 days, 1,
3, and 6 weeks, 3 and 6 months, and 1 year after surgery.
The type and dosage of postoperative medications,
especially the frequency of topical steroids and necessity
for systemic steroids, depended on the degree of inflammatory reaction in each eye. Medications on the first
postoperative day were a betamethasone drop every 1 to
4 hours according to the severity of inflammation, sulfacetamide 10% every 6 hours, short-acting mydriatics if
needed, and oral prednisolone if needed (1 mg/kg a day).
In all cases, fluorescein angioscopy was performed
using general anesthesia 4 to 6 weeks after surgery by
2 physicians (M.H.D., A.M.) masked as to surgical technique. An intravenous injection of 5 cc fluorescein sodium 10% was given. Indirect ophthalmoscopy was
performed with a blue filter and a 20.0 D lens. Fundoscopy and refraction were done during the same session.
Suture removal was performed according to the results
of refraction and keratometry.
770
Eyes were classified according to the visual acuity:
(1) light perception (LP)/hand movement (HM); (2)
finger counting (CF); (3) 20/200 to 20/120; (4) 20/80
to 20/40; (5) 20/30 or better. Changes in visual acuity
were evaluated by comparing preoperative and postoperative visual acuities, with the difference determined by
the degree of visual acuity improvement postoperatively,
which was shown by a plus (1) sign. For example, a
preoperative visual acuity of HM changing to postoperative acuity of CF was a 11 improvement and preoperative visual acuity of HM changing to postoperative
acuity of 20/120 was a 12 improvement. Thus, the
range of improvement was 11 to 14.
Eyes were also classified according to the estimated
red reflex: (1) LP or HM; (2) CF; (3) 20/200 to 20/50;
(4) 20/40 to 20/25; (5) 20/25 or better. The estimated
postoperative red reflex was compared with the estimated preoperative red reflex, and the difference determined the degree of improvement. Improvement in
postoperative red reflex was shown as a plus sign in the
same manner as the visual acuity evaluation.
Amblyopia Therapy
Occlusion therapy was used to treat amblyopia.
Therapy began before the surgery if possible. If not, it
started within 1 week after surgery. Therapy comprised
1 week per 1 year of age of full-time patching followed
by maintenance therapy. Every 3 months, full-time
patching was repeated on the same schedule according
to patient response.
Results
The study included 45 eyes of 31 patients, 14 of
whom had bilateral surgery. In the other 17 patients, the
cataract was unilateral, or if bilateral, surgery was indicated in 1 eye only. Mean patient age was 6.3 years 6 2
(SD).
A t test showed no statistically significant difference
between the 2 groups in age. Nineteen patients were
girls. Chi-square analysis showed no significant difference between the 2 groups in sex.
Of the 45 eyes, 39 eyes of 25 patients had developmental cataract and 6 patients had unilateral traumatic
cataracts. Of 39 eyes with developmental cataract, 20
had zonular cataract. All traumatic cataracts were associated with corneal damage. Repair of corneal laceration
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PRIMARY POSTERIOR CAPSULECTOMY IN CHILDHOOD CATARACT
was not required in 2 eyes because the small laceration
self-sealed. The interval between primary repair of
corneal laceration and lensectomy was 3 to 6 weeks
except in 1 case with an intumescent lens, in which
cataract surgery was done 10 days after corneal laceration repair.
Of 45 eyes, 2 (1 each in Techniques A and B)
were excluded because of postoperative trauma necessitating deep vitrectomy and IOL removal. Five patients were excluded for inadequate follow-up.
Distribution of the remaining 38 cases was as follows:
20 eyes with developmental cataract of zonular type,
14 with developmental cataract of other types, and 4
with traumatic cataract associated with corneal laceration (Table 1).
The 38 matched cases were compared according to
visual acuity and estimated red reflex before and after
surgery, postoperative intraocular inflammation (fibrin
formation in the anterior chamber), posterior synechias,
IOL position, corneal status, glaucoma, cystoid macular
edema (CME), anterior vitrectomy and posterior capsu-
Table 1. Distribution of matched cases by technique, number (%).
Type of Cataract
Developmental
Traumatic
Technique
Zonular
Nonzonular With Corneal Damage
Limbal
10 (52.7)
7 (36.8)
2 (10.5)
Pars plana
10 (52.7)
7 (36.8)
2 (10.5)
Table 2. Effect of technique on postoperative visual acuity,
number (%).
Improvement in Visual Acuity
11
12
13
14
Limbal
1 (9.1)
3 (27.3)
6 (54.5)
1 (9.1)
Pars plana
0
6 (54.5)
4 (36.4)
1 (9.1)
Technique
Table 3. Effect of technique on postoperative red reflex,
number (%).
Improvement in Red Reflex
Technique
11
12
13
14
Limbal
0
4 (21.0)
9 (47.4)
6 (31.6)
Pars plana
1 (5.3)
3 (15.8)
10 (52.6)
5 (26.3)
lectomy quality, status of retinal periphery, and postoperative refraction.
The postoperative increase in visual acuity was significant in both groups. Of the 27 eyes of 19 patients
who could cooperate in visual acuity determination with
an E-chart before and after surgery (16 and 11 eyes in
Techniques A and B, respectively), 24 had a visual acuity
worse than 20/200 before surgery, whereas 1 eye had this
acuity after surgery. The cause of decreased visual acuity
in this case was deep amblyopia unresponsive to proper
occlusion therapy. Table 2 shows visual acuity according
to the 2 techniques used. There were no statistically
significant differences between the 2 techniques in visual
acuity improvement.
The improvement in estimated red reflex was also
significant. Red reflex was evaluated in 45 eyes. Red
reflex worse than 20/200 was present in 41 eyes before
surgery. After surgery, red reflex was better than
20/40 in all eyes. Table 3 shows the effect on red
reflex based on technique. There was no statistically
significant difference between the techniques in
improvement.
In no case did complications such as CME, glaucoma, retinal tear, IOL dislocation, corneal edema, or an
increased cup-to-disc ratio occur. Iris capture occurred
in 1 case (zonular cataract, Technique B). One eye in
each group developed posterior synechias of less than
2 clock hours. Although fibrin formation was more
common with Technique B than A, chi-square analysis
showed that the difference was not statistically significant (Table 4).
Posterior capsulectomy smaller than 3.0 mm was
considered inadequate. In the Technique A group, the
visual axis was occluded in 1 eye. In other cases with
small capsulectomy size, refraction was difficult but did
not interfere with vision. The case with the occluded
visual axis had an Nd:YAG capsulotomy 3 months after
surgery. Inadequate capsulectomy was 3 times more
common with Technique A than Technique B; however, the Fisher exact test showed the difference was not
statistically significant (Table 5).
Refraction was performed at the last examination.
In all cases, mean astigmatism after surgery was 1.75
D, with the type being with the rule. Postoperative
mean spherical equivalent with Technique A was
– 0.64 6 1.02 D and Technique B, – 0.76 6 1.59 D.
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Table 4. Effect of technique on fibrin formation in the anterior
chamber, number (%).
Fibrin Formation in Anterior
Chamber
Technique
Yes
No
Limbal
4 (21.0)
15 (79.0)
Pars plana
5 (26.3)
14 (73.7)
Table 5. Effect of technique on posterior capsulotomy size,
number (%).
Capsulectomy Size
Technique
Inadequate
Adequate
Limbal
3 (15.8)
16 (84.2)
Pars plana
1 (5.3)
18 (94.7)
A t test analysis showed the difference was not statistically significant.
Discussion
The most important goal in pediatric cataract surgery is to provide ideal visual rehabilitation. There is an
increasing tendency toward IOL implantation in children to correct aphakia. The success rate of such implantation is improving and the complication rate decreasing
because of new surgical techniques and improved IOL
quality.
Even though more recent studies have shown encouraging results of pediatric IOL implantation, caution
in selecting patients for this procedure is crucial, especially in very young children. Visual rehabilitation of
unilateral aphakic children is more challenging than bilateral cases. Thus, the minimum age for which IOL
implantation should be considered in unilateral cases of
pediatric cataract is lower than that for bilateral cases.2,9,12,17 In a survey, the mean age for IOL implantation in children was 3 years in unilateral cases and 5 years
in bilateral cases.17 The minimum ages in our series were
the same. The maximum age was 10 years in both unilateral and bilateral cases.
In calculating IOL power, we aimed for emmetropia and minimizing anisometropia. This is an important factor in visual rehabilitation in children. The
correct IOL power leads to more successful amblyopia
treatment and increases the chance of binocularity in
772
this critical age period. In other series, however, different approaches have been considered in IOL power
calculation. In 1 study, 5 undercorrection was the goal
in patients younger than 9 years. In another,7 undercorrection was considered only in children 4 years or
younger. The undercorrection was an attempt to neutralize the myopic shift that can occur in growing
children.
Other authors believe that achievement of emmetropia is vital in patients with a pliable visual system
and that its benefits outweigh the consequence of subsequent myopia.3,4 The growth of the globe is almost
complete at 2 years of age.18 Thus, the myopic shift in
children 3 years and older would be expected to be less.
In our series, postoperative refraction was within the
range of emmetropia, as planned, and there was no statistically significant difference between the 2 techniques
in postoperative refraction.
To provide a clear media for visual rehabilitation,
primary posterior capsulectomy has been recently recommended. Several approaches to prevent or delay
PCO have been studied. Primary posterior capsulotomy
with a needle or a vitrectomy cutting device, a limbal or
pars plana approach anterior vitrectomy, and primary
posterior continuous curvilinear capsulorhexis (PCCC)
are some techniques that have been evaluated.5,7,15,16,19,20 The capsulotomy edge produced by
continuous curvilinear capsulorhexis is smooth.21 Nevertheless, performing PCCC is technically difficult.16
Capsulorhexis of the anterior capsule in young patients
is even more difficult than PCCC.16 We used a vitrector
to perform capsulectomies in both capsules, followed by
anterior vitrectomy. We found this technique easy and
reproducible.
There is no agreement whether the IOL should be
implanted before or after the primary posterior capsulectomy and anterior vitrectomy. Some advocate removing the posterior capsule and anterior vitreous before
IOL implantation.3,7 This can be performed by an anterior segment surgeon or a pediatric ophthalmologist.
The anterior vitrectomy can be done in a well-controlled
manner under good visibility.15 When the anterior vitrectomy is done, in-the-bag IOL implantation is easily
achieved. Dahan and Salmenson3 found no serious
complications using this technique in 80 children.
Other surgeons prefer to have the IOL in place before removing the posterior capsule5 to allow for an ad-
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equate posterior capsulectomy and a better anterior
vitrectomy. The advantage of implanting the IOL before the posterior capsulectomy is that the IOL can be
safely fixated in the desired plane. The risk of the IOL
being pushed out of the capsular bag may be minimized
by keeping the infusion in the anterior chamber. Buckley et al.,5 in a prospective study, used a technique that
involved endocapsular cataract extraction and PC IOL
implantation. However, the posterior capsulotomy and
anterior vitrectomy were performed through the pars
plana in the 20 patients, all with unilateral cataract. Visual axis clarity was rapidly restored in all patients without further intervention. The authors concluded that
there was a considerable advantage to having the lens in
place before removing the posterior capsule.
In an attempt to determine whether the IOL should
be implanted before or after posterior capsulectomy and
anterior vitrectomy, an experimental study was done
using pediatric autopsy eyes.22 This study found that
both techniques were feasible in a clinical setting. We
compared the limbal and pars plana approaches in a
clinical trial. In our study, the visual results were encouraging, and there was no significant difference between
the 2 techniques in postoperative improvement in visual
acuity. As well as providing a clear media and optical
correction, the aggressive amblyopia therapy was an important factor in achieving such results in our patients.
Estimation of the red reflex is a valuable method of
evaluating media clarity. There was considerable improvement in red reflex after the surgery and no difference between the 2 techniques in improvement in
postoperative estimated red reflex.
There is usually a considerable amount of inflammatory reaction after cataract surgery and IOL implantation in children.2,7,15 To reduce postoperative
inflammation, we gave a sub-Tenon’s injection of methylprednisolone acetate at the end of surgery in all cases.
Nevertheless, fibrin formed in 9 eyes in the early postoperative days. The inflammatory reaction was controlled with frequent instillation of topical steroids and
oral prednisolone. The technique used had no significant influence on the amount of postoperative
inflammation.
Iris capture, adhesion of the iris to the IOL, and
posterior synechias have been reported frequently after
pediatric cataract surgery and PC IOL implantation
when the procedure is not associated with primary pos-
terior capsulectomy and anterior vitrectomy.2,8,23
Anterior vitrectomy reduces the rate of such complications,5,7 which were uncommon in our series. There was
no significant difference between the 2 techniques in the
occurrence of such complications.
One objective of primary posterior capsulectomy
and anterior vitrectomy is providing long-term clarity of
the visual axis. We considered the primary posterior capsulectomy inadequate if it was smaller than 3.0 mm in
diameter. This was observed in 4 cases, but only 1 eye
required an Nd:YAG capsulotomy. This complication
was more common in the limbal approach group, but
the difference between techniques was not statistically
significant.
The advent of the vitrectomy machine reduced the
rate of retinal detachment as a late complication of pediatric cataract surgery. Keech and coauthors24 reported
1 case of retinal detachment 6 years after translimbal
lensectomy and anterior vitrectomy. No retinal detachment was observed in our series. To properly evaluate
the effect of technique on the occurrence of retinal detachment, long-term follow-up is needed.
Cystoid macular edema has an effect on visual rehabilitation of children who have lensectomy and IOL
implantation. Hoyt and Nickel25 observed CME in 10
of 27 cases of developmental cataract after lensectomy
and vitrectomy. Poer and coauthors26 observed no
CME in a study of 25 eyes of 18 patients after surgery for
management of infantile cataract. Gilbard and coauthors27 reported no CME in 25 eyes of 17 children who
had pars plicata lensectomy and vitrectomy. In a study
by Pinchoff and coauthors,28 fluorescein angiography
performed 4 to 16 weeks after translimbal lensectomy
and vitrectomy revealed no CME. Morgan and Franklin29 performed oral fluorescein angiography 3, 6, and
24 weeks after the surgery in patients from 2 months to
7 years and observed no macular leakage. In our series,
fluorescein angioscopy was performed 4 to 6 weeks after
the surgery, with no CME observed.
Different mechanisms for glaucoma in children after cataract surgery have been proposed. Performing
lensectomy and vitrectomy permits complete removal of
lens material and minimizes postoperative inflammation
and consequent pupillary block. In a study with shortterm follow-up, no case of glaucoma was observed in
children having lensectomy with a vitrectomy machine.
When the follow-up was continued, it became obvious
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PRIMARY POSTERIOR CAPSULECTOMY IN CHILDHOOD CATARACT
that glaucoma may threaten the vision of children who
have lensectomy and vitrectomy years after the surgery.30,31 Recent studies show that the incidence of
glaucoma after surgical management of infantile and
developmental cataract depends on the duration of follow-up.30,32 In our study, there was no difference between the 2 techniques in the occurrence of glaucoma.
Nevertheless, long-term follow-up is needed to make a
judgment about the possible effect of technique on the
occurrence of glaucoma.
In conclusion, when the intervening and background variables were matched there were no statistically significant differences between the limbal and pars
plana approaches and the visual and anatomic results
were encouraging in both groups. In addition, the rate of
complications was minimal and did not differ significantly between techniques.
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