Ординатура / Офтальмология / Английские материалы / Pediatric Ophthalmology Current Thought and A Practical Guide_Wilson, Saunders, Trivedi_2008

termined monocularly whenever possible (http:// one.aao.org/CE/PracticeGuidelines/PPP_Content. aspx?cid=761ac199-5cfe-42f4-b40b-33f9d5f0d364 – appendix). The fellow eye should be completely covered (with adhesive occluder to prevent peeking). The test should be performed at a distance of 15–20 feet with the eye chart calibrated to the exact measured distance from the examination chair to the chart.

Children should be tested using a linear display of letters if possible. Young children may be easier to test if isolated optotypes with crowding bars are used. We like the HOTV matching game since the letters can be called by name or identified by pointing to the matching letter on the lap card. The letters HOTV are chosen because they avoid right to left confusion by being mirror-image letters. In addition to VA, the testing distance, type of optotype, whether the optotype is presented a line at a time or isolated, and cooperation level of the child should be documented in the medical record.

Fusion and stereoacuity testing at distance as well as near may also be helpful when deciding how much visual dysfunction is present in a cataract patient. In children with posterior subcapsular cataracts who complain of intolerable glare, but have good Snellen VA, glare testing should be performed to evaluate the need for surgery.

22.3.2 Red Reflex Test

The red reflex test can be used to detect the density and extent of the opacity in the visual axis. The retinoscope is a very useful instrument for viewing the red reflex within the pupillary space to see how much of the reflex is blackened by the cataract. In addition, the direct ophthalmoscope can be used to perform the

Bruchner red reflex test where both eyes are viewed together and the red reflexes compared. When both eyes are viewed simultaneously, potentially amblyogenic conditions, such as anisometropia, strabismus, and asymmetric cataracts can be identified. The direct ophthalmoscope is focused on both eyes simultaneously at approximately 3 feet away.

22.3.3 Ocular Alignment and Motility

Detailsonstrabismusandnystagmusmainlyhelpwhen explaining prognosis to the parents and to prepare them for patching or further surgeries. Ocular alignment is assessed by using the corneal light reflection, the binocular red reflex test (see Sect. 22.3.2), and the cover test (http://one.aao.org/CE/PracticeGuidelines/

PPP_Content.aspx?cid=761ac199-5cfe-42f4-b40b- 33f9d5f0d364 – appendix). Cover/uncover and alternate cover tests are performed in primary gaze at distance and at near. Accommodative targets are utilized when feasible. These tests require the patient’s cooperation and interaction with the examiner in addition to sufficient vision to fixate on the target. Ear- lier-onset unilateral cataracts have the highest risk for strabismus and late-onset bilateral cataracts have the least risk. Also, as a general rule, patients with partial cataracts and relatively good preoperative VA have less strabismus. Strabismus at presentation is often an indication that the cataract is long-standing and that significant amblyopia is likely to be present. Infants with profound bilateral dense cataracts develop nystagmus at approximately 3 months of age because the fixation reflex normally develops by that time. Once nystagmus has developed, it is likely to persist even if the cataracts are subsequently removed. If manifest nystagmus does develop, the visual prognosis is worse. Visual acuity in eyes with nystagmus and infantile cataracts is rarely better than 20/100 after cataract surgery.

22.3.4External Examination and Anterior Segment Evaluation

External examination of the eye with a suspected cataract usually consists of a penlight evaluation of eyelids, eyelashes, conjunctiva, sclera, cornea, and iris. Evidence of blepharitis or any discharge or tearing should be evaluated and, if applicable, treatment should be advised prior to the proposed surgery date. For pupil, size, shape, symmetry, and reaction to light should be noted. Microphthalmia and poorly dilating pupils are indicators of arrested developed and in-

crease the risk of a poor anatomical and functional outcome after cataract surgery.

After dilation, a slit-lamp evaluation should be carried out if the child is old enough to be cooperative. The slit-lamp examination findings can help with the search for a cause of the cataract, help establish a prognosis, and help plan the surgical strategy. The morphology of the cataract may affect prognosis and give a clue to the etiology. Unilateral posterior subcapsular cataract (PSC) should prompt a careful search for evidence of trauma. Bilateral PSC may result from chronic uveitis, prolonged corticosteroid treatment for chronic disease, radiation treatment for malignancy, or non-accidental injury (child abuse). Children with juvenile idiopathic arthritis may have associated band-shaped keratopathy and posterior synechiae. Lens subluxation, iridodonesis, and aniridia should be looked for. Total cataract involving the whole lens can occur in Down syndrome, type 1 diabetes mellitus, in congenital rubella (where shaggy nuclear cataracts are more common), and posterior lentiglobus. In cases of unilateral cataract, examination of the fellow eye after pupil dilation is essential to rule out asymmetric bilateral findings.

Anterior lenticonus is most often associated with Alport’s syndrome and should be investigated accordingly. A sudden onset of total cataract may be an indication of unsuspected trauma, diabetic cataract, or preexisting ruptured anterior (reported in anterior lenticonus) or posterior capsule (reported in posterior lentiglobus).

For children approximately above 5–6 years of age, the ability of a child to cooperate for slit-lamp examination is also an indirect indicator that the child will cooperate for YAG-laser capsulotomy if needed. In children above 5–6 years of age with an intact posterior capsule and AcrySof intraocular lens (IOL) implantation, visually significant posterior capsule opacification (PCO) is known to develop

18–24 months after surgery. If a child in this age range seems to be cooperative for slit-lamp examination during preoperative evaluation, the surgeon may decide to leave behind an intact posterior capsule (assuming high odds of getting the child’s cooperation for YAG if needed).

Finally, a slit-lamp examination of both parents, if possible, helps to establish the presence of familial cataracts and cataract-associated conditions. These

findings can be subtle and the parents may not have been told that they have any pathology at all.

22.4 Important Decisions

22.4.1 Indication for Surgery

Indications for cataract surgery include cataracts obstructing the examiner’s view for fundus examination in the non-dilated pupil or a blackened retinoscopic reflex preventing refraction of the patient. Deciding when to remove a partial cataract can be difficult. Non-verbal children add more difficulties to this decision. Individual judgment needs to be made for partial cataract. The loss of accommodation after the cataract is removed may negatively affect visual functioning more than the partial cataract itself. Visual function evaluation was discussed earlier in this chapter (Sect. 22.3.1). For verbal children, cataract surgery is contemplated if Snellen VA is 20/50 or worse, or if the child is intolerant to glare or resistant to amblyopia therapy with gradually deteriorating visual function. Since a subjective VA cannot be obtained in infants with cataracts, greater reliance is placed on the morphology of the cataract, other associated ocular findings, and the visual behavior of the child in order to ascertain whether the cataract is visually significant or not. The degree of visual impairment induced by lens opacity differs markedly depending on the location of the opacity. Generally, a more posterior and more central location of the opacity is more amblyogenic. Generally speaking, a cataract that blackens the retinoscopic reflex for 3 mm or more in the center of the pupil is considered visually significant.

If a partial cataract is being treated conservatively, it is important to carefully follow these children. Conservative treatment using mydriatic drops necessitates the patient wearing glasses for reading if any cycloplegic effect is induced. This has not found widespread acceptance. Associated glare and loss of accommodation are the most common obstacles. Visual outcome has also been unimpressive. Despite these limitations, the use of mydriatic drops may be kept in reserve in eyes with slowly progressive cataracts or paracentral cataracts less than 3 mm and, es-

pecially, in patients for whom cataract surgery needs to be deferred for any reason, be it medical (high risk for anesthesia), social, or economic.

22.4.2 Timing of Surgery

Deciding on the appropriate timing of surgery is most critical during early infancy (Table 22.4). In the case of a unilateral dense cataract diagnosed at birth, the surgeon can wait until 4–6 weeks of age. Waiting until this age decreases anesthesia-related complications and facilitates the surgical procedure. Waiting beyond this time, however, adversely affects visual outcome

[1, 14]. In the case of a bilateral cataract diagnosed at birth, a good visual outcome can be achieved if the child is operated on before 10 weeks of age [6]. The first eye surgery can be offered at 4–6 weeks of age, and the second eye surgery after another 1–2 weeks. It is important to keep the time interval to a minimum between the two eye surgeries. Lloyd and colleagues note that they advise patching the first operated eye until the second has had surgery, to prevent amblyopia in the second operated eye [8]. This type of occlusion is not commonly done but undue delays between surgeries should be avoided. For older children, timing of surgery is not as crucial. In children beyond the amblyopic age, surgery can often be decided based on convenience and other logistic issues.

Sequential cataract surgery, more popularly known as simultaneous bilateral cataract surgery (SBCS), remains controversial. Almost every discussion on SBCS either starts or ends with a comment on the disagreement surrounding its use. The important question is not “can it be done?” but, more properly, “should it be done?” Even conservative surgeons, who vote against routine use of SBCS in children, are more likely to use this approach when anesthesia

poses more than average risks or the patient lives far away and a visit for surgery on the second eye would be difficult.

In eyes with penetrating trauma and cataract, primary repair of the corneal or scleral wound is usually preferred as the initial step. Cataract surgery with IOL implantation should be performed 1–4 weeks after a complete evaluation of damage to intraocular structures (e.g., posterior capsule rupture, vitreous hemorrhage, and retinal detachment) with ancillary methods such as B-scan ultrasonography.

22.4.3 Aphakic Rehabilitation

Intraocular lens implantation in children has the benefit of reducing dependency on compliance with other external optical devices (aphakic glasses and contact lenses) and providing at least a partial optical correction. These are important advantages to the visual development in amblyopia-prone eyes. However, concerns about primary IOL implantation are the technical difficulties of implanting an IOL in the eyes of children, selecting an appropriate IOL power, and the risk of visual axis opacification (VAO) after implantation. Despite performing primary posterior capsulectomy and vitrectomy, the rate of VAO is higher in pseudophakic infantile eyes as compared with aphakic infantile eyes [7]. On the other hand, although it is possible for an eye with a unilateral infantile cataract to achieve good visual outcome following contact lens correction, it has continued to be the exception rather than the rule. Both IOLs and aphakic contact lenses may support similar VA after surgery for unilateral cataract in the presence of good compliance with contact lens wear. However, IOLs support better VA when compliance with contact lens wear is moderate or poor [2]. For bilateral cataracts, aphakic

glasses (Fig. 22.4) and/or contact lens use may be a reasonable option. However, for unilateral cataracts in infancy, the issue of when to implant an IOL is unresolved. We await the results of ongoing multicenter clinical trial research to help guide us. For children beyond infancy, IOL implantation is less controversial.

22.5 Parental Counseling

In this electronic age, with many having access to internet information, families often arrive in the office with much more knowledge about their child’s condition than would have been true only a few years ago. Parents may come with list of questions (Table 22.5). Surgeons who perform pediatric cataract surgery should be prepared for sometimes a quite lengthy discussion with this new breed of parent/patient. A coordinated plan of action can best be developed when the parents understand the reasons for, goals of, and the advantages and potential complications of cataract surgery. When properly informed preoperatively, the parents and the physician become partners with the common goal of doing what is best for the child. Time spent establishing this partnership is not wasted, because a better-informed family is much more likely to comply with the frequent follow-ups, medications, patching, glasses wear, etc., that are so essential to the eventual visual outcome (Table 22.6). The parents/ caregivers play a critical role in the postoperative care of the eye and treatment of amblyopia. They must understand that a successful visual outcome depends on more than the surgical procedure; it also depends on their ability to maintain adequate aphakic correction and follow through with amblyopia therapy. The lion’s share of the discussion in regards to pediatric cataract surgery will be with issues related to the IOL. Before moving forward with IOL implantation, it is important to discuss the major pros and cons of the available options with the parents/legal guardian. In the USA, parents should be made aware that while IOL implantation has become the most common method used to correct aphakia in children overall, it is still considered “off label” by the Food and Drug Administration (FDA). This designation means that the IOLs implanted in children were tested as part of their FDA market approval process, but only in

Fig. 22.4  Aphakic glasses in a child with bilateral aphakia

Table 22.5  Parents’ questions

–What causes cataract in my child?

–How frequent is it?

–Is this cataract ready for removal?

–What will my child see after surgery?

–How often will my child need to visit the hospital after cataract surgery?

–Would you consider implanting an IOL for my child?

–Would you implant an IOL if this was your child?

Table 22.6  Parental counseling

–Reason for surgery

–Goal of surgery

–Advantages of surgery

–Explain visual prognosis

–Potential complications and consequences of surgery

–Prepared for frequent postoperative follow-up visits and serial EUA (if needed)

–FDA status (for surgery in USA)

–Importance of refractive error correction and amblyopia treatment postoperatively

adults. It does not mean that the FDA has disallowed their use in children. It only implies that the device is being used for a purpose or in a patient population that is different from the one in which it was tested as part of the market approval process [13].

Parents should be made aware that surgery is only one component of the treatment. A child operated on forcataractrequiresregularscheduledcareforthefirst

decade of life, and then every 1–2 years throughout life. However, to achieve the best visual outcome for the child, a long-term commitment from the parents is required. Visual prognosis can be explained to the parent based on preoperative evaluation (Table 22.7). The changing refraction will require frequent followup examinations. Glaucoma is known to develop even years after cataract surgery. Parents need to understand that their child may need serial examinations under anesthesia until the child is cooperative enough to be examined in the office. The parents should also be informed about treatment of VAO, strabismus, glaucoma, and rarely, decentered IOL, synechiolysis, or removal of a loose stitch. For eyes operated during early infancy, parents should be made aware that the first 6-month follow-up is crucial. Despite performing primary posterior capsulectomy and vitrectomy, many infant eyes develop VAO, and most eyes that develop VAO, develop it in the first six postoperative months. Earlier detection (and treatment if needed) can help to achieve a better visual outcome. For eyes operated on with an intact posterior capsule, parents should be made aware that the child would require a secondary procedure for PCO. Parents of children with lens implants are also made aware that glasses will likely still be needed postoperatively even when an IOL is implanted. In addition, glasses power may need to be changed frequently after surgery, because of changing refraction. Useful web resources for parents are http://www.pgcfa.org/cataract.htm and http:// www.ich.ucl.ac.uk/factsheets/families/F020023/ (information for families with cataract).

Table 22.7  Preoperative factors indicating poor prognosis following surgery

1.Longer duration between onset of cataract and surgery

2.Unilateral cataract

3.If bilateral: asymmetrical cataract

4.Any manifest strabismus

5.Presence of nystagmus

6.Severe preoperative visual impairment as per age appropriate standards (e.g., in an awake and alert child, poor fix and following noted binocularly after 3 months of age is an indicator of poor vision)

22.6 Next Steps

The surgeon may elect to prepare for surgery but delay the final decision on surgery until the time of the EUA. We routinely perform an EUA during the same session as the cataract surgery. However, to do an EUA as a separate session is also an acceptable approach. As preoperative preparation for surgery we prescribe topical medications: on check-in (approximately 1 h before surgery), the antibiotic drop (fourth-generation fluoroquinolone) is given every

5 min (4 times) and the dilating drops (peds combo, 2 mL 2% cyclopentolate, 0.5 mL 10% phenylephrine, 0.5 mL 1% tropicamide) are also given every 5 min (3 times). Dilating drops should be given for both eyes. We also advise for any laboratory investigation to detect the cause of cataract (see Sect. 22.7) and refer the child for preoperative anesthetic workup.

22.7Laboratory Investigations

to Detect the Cause of Cataract

As compared to unilateral cataract, laboratory investigation of bilateral cases is more rewarding. Exhaustive lists of possible laboratory investigations for a child with cataract can be found in several text books, however, in an otherwise healthy child, most physicians do not advise extensive laboratory and genetic investigations. After detailed evaluation, 86% of unilateral and 68% of bilateral cataract have no discernible cause [4]. Based on history and examination, customized laboratory investigations can be advised.

Deciding the list of laboratory investigations to detect the cause can be occasionally based on logistic issues, financial considerations, and parents’ enthusiasm and willingness to spend time and effort to do so. While recommending laboratory investigation, it is important to keep in mind that the common causes of cataract in children include intrauterine infections, metabolic disorders, and genetically transmitted syndromes. Since cataracts can be the presenting sign of diabetes, children with acquired cataracts of unknown etiology should be questioned about classic symptoms

associated with pars planitis, cataract associated with severe ocular anomalies or systemic problems

hypotonia, mental retardation, aminoaciduria, and an abnormal facial appearance with frontal bossing, and

chubby cheeks. The lens typically has a reduced an- terior-posterior diameter [11]. In addition, these eyes have frequent association with glaucoma. If Lowe syndrome is suspected, the urine should be screened for amino acids. If there is a history of maternal rash, fever, flu-like symptoms, or neonatal physical signs of intrauterine infection, then acute and convalescent TORCH titers should be obtained. Developmental pediatricians and clinical geneticist are experts in selective investigation based on the characteristics of the child. These specialists are invaluable and should be consulted when appropriate.

22.8 Examination Under Anesthesia

Intraocular pressure (IOP) should be checked as soon as possible after induction of anesthesia (Table 22.3). Although we routinely use the Tono-Pen, if in doubt, we recheck IOP using the Perkins tonometer. In addition to high IOP, a difference of IOP between the two eyes is alarming. Cataracts and glaucoma are associated with congenital rubella and Lowe syndrome.

The next step for us is to take keratometry measurements. We use the Nidek handheld keratometer (Fig. 22.5). However, many other centers uses an autorefractokeratometer for this purpose. The remaining examinations listed below can be performed in any chronology: examine the eye using the operating microscope, immersion A-scan ultrasound for globe axial length (Fig. 22.6), horizontal corneal diameter,

retinoscopy (if possible), and a retinal fundus examination. Some physicians use a slit-lamp attachment to the operating microscope for evaluating location of the cataract. Immersion A-scan performed by a skilled ultrasonographer helps to reduce the incidence of postoperative refractive surprises. A shorter or longer axial length in the eye with the cataract can be a sign of poor prognosis. When possible, at least the posterior pole of the fundus should be assessed by indirect ophthalmoscopy, looking particularly for underdevelopment or malformation of the disc or macula and the presence of abnormal pigmentation.

In the case of no view on fundus examination, we perform a B-scan ultrasound examination. Although it is often not possible to do a preoperative cycloplegic refraction of an eye with a dense cataract, an uninvolved or less involved fellow eye should be refracted. The presence of refractive error in the fellow eye may help when deciding on an IOL power. In case of congenital anterior lens opacity (CALO), anisometropia has been reported to be more amblyogenic than the size of lens opacity [3]. Patients with

CALOs who have anisometropia of 1 diopter D or more are 6.5 times more likely to develop amblyopia. At the end of the EUA and before the start of surgery, we visit with the parents to explain the findings of the EUA in brief. We explain what findings were expected and any that were not expected. We discuss any changes in the surgical plan that might be appropriate given the findings at EUA. This also gives the parents a good sense of how long the examination took and how long the surgery will take.

22.9Selection of Intraocular Lens Power

Implantation of a fixed-power IOL into an eye that is still growing makes it difficult to choose the IOL power to implant. IOL implantation at the calculated emmetropic power helps to fight amblyopia during childhood, but risks significant myopia at ocular maturity. Ideal IOL power should balance the best help to amblyopia management in childhood with the least possible refractive error in adulthood (Fig. 22.7). With a growing eye prone to develop a myopic shift of refraction after cataract removal, the surgeon faces the decision of what refraction should be the immediate postoperative aim [5, 9, 10, 12]. Several nomograms have been published in the literature. However, we do not recommend the use of any published table alone for deciding IOL power. These tables are only meant to help as a starting point toward appropriate IOL power selection, which is a multifactorial decision customized for each child based on many variables [age, laterality (one eye or both), amblyopia status (dense or mild), likely compliance with glasses, and family history of myopia]. Our recom-

Table 22.8 Expected postoperative residual refraction based on patient age at cataract surgerya

a We do not recommend the use of any published table alone for deciding IOL power. These tables are only meant to help as a starting point toward appropriate IOL power selection, which is a multifactorial decision customized for each child based on many variables [especially, age, laterality (one eye or both), amblyopia status (dense or mild), likely compliance with glasses, and family history of myopia]

Near “zero”

High “plus”

mendations to lessen long-term myopia are shown in Table 22.8. It is noteworthy that while analyzing

471 eyes in our database, we noted that we had selected less undercorrection than is typically advised to lessen late myopia (unpublished data). The median residual refractions we aimed for are also listed in Table 22.8. When implanting IOLs in children with bilateral cataracts and no amblyopia, leaving mild, moderate, or even a marked amount of hypermetropia is reasonable. However, in unilateral cataracts with dense amblyopia, less early dependence on glasses may help the amblyopia treatment. The late myopia, even if marked, may be an acceptable trade for better visual outcome from amblyopia treatment. Refractive surgery or IOLexchange may be needed in these eyes at ocular maturity.

Acknowledgements.  Supported in part by the Grady Lyman Fund of the MUSC Health Sciences Foundation, Charleston, S.C.

References

1.Birch EE, Stager DR (1996) The critical period for surgical treatment of dense congenital unilateral cataract. Invest Ophthalmol Vis Sci 37:1532–1538

2.Birch EE, Cheng C, Stager DR Jr, Felius J (2005) Visual acuity development after the implantation of unilateral intraocular lenses in infants and young children. J AAPOS 9:527–532

3.Ceyhan D, Schnall BM, Breckenridge A, Fontanarosa J, Lehman SS, Calhoun JC (2005) Risk factors for amblyopia in congenital anterior lens opacities. J AAPOS 9:537–541

Take Home Pearls

•A cataract that reduces the VA to worse than or equal to 20/50, or blackens the retinoscopic reflex for 3 mm or more in the center of the pupil is likely visually significant enough to consider surgery.

•Bilateral cataracts may be associated with metabolic conditions, congenital infections, or genetic syndromes.

Acustomized investigation is recommended based on the evaluation by experts in development pediatrics and clinical genetics.

•Athorough examination of an eye with a cataract, the fellow eye, and the eyes of the parents will help define the associated findings, the etiology, and the prognosis.

•For IOL power selection, several nomograms based on age at surgery have been published. However, we do not recommend the use of any published table alone for deciding IOL power. Selection of an optimum power of IOL is a multifactorial decision, customized to each child.

•Cataract surgery in children is but one step on the long road to visual

rehabilitation, not the end of the journey.

gical treatment of children with dense bilateral congenital cataracts? J AAPOS 10:30–36

7.Lambert SR, Lynn M, Drews-Botsch C, Loupe D, Plager DA, Medow NB, Wilson ME, Buckley EG, Drack AV, Fawcett SL (2001) A comparison of grating visual acuity, strabismus, and reoperation outcomes among children with aphakia and pseudophakia after unilateral cataract surgery during the first six months of life. J AAPOS

5:70–75

sell-Eggitt I, Taylor D (1992) Neonatal cataract: aetiology, pathogenesis and management. Eye 6:184–196

9.Plager DA, Kipfer H, Sprunger DT, Sondhi N, Neely DE (2002) Refractive change in pediatric pseudophakia: 6-year follow-up. J Cataract Refract Surg 28:810–815

10.Plager DA, Lipsky SN, Snyder SK, Sprunger DT, Ellis FD, Sondhi N (1997) Capsular management and refractive error in pediatric intraocular lenses. Ophthalmology 104:600–607

11.Tripathi RC, Cibis GW, Tripathi BJ (1986) Pathogenesis of cataracts in patients with Lowe’s syndrome. Ophthalmology 93:1046–1051

12.Trivedi RH, Wilson ME (eds) (2007) Intraocular lens power calculation for children. Jaypee Brothers Medical, New Delhi

13.Wilson ME (2000) Intraocular lenses for children in the year 2000: when is oversight by the institutional review board or Food and Drug Administration required? J AAPOS 4:325

14.Wilson ME Jr, Trivedi RH, Hoxie JP, Bartholomew LR

(2003) Treatment outcomes of congenital monocular cataracts: the effects of surgical timing and patching compliance. J Pediatr Ophthalmol Strabismus 40:323–329

Contents

23.3Surgical Steps  . . . . . . . . . . . .   328

23.3.1Incision  . . . . . . . . . . . . . .   328

23.3.2 Anterior Capsulotomy  . . . . . . . .   330

23.3.3Lens Substance Aspiration

(Phacoaspiration)  . . . . . . . . . .   332

23.4Postoperative Medications and Follow-up    336

23.5Special Considerations  . . . . . . . .   337

23.5.1Traumatic Cataract  . . . . . . . . . .   337

23.5.2Ectopia Lentis  . . . . . . . . . . . .   337

23.5.3 Secondary Intraocular Lens Implantation  .   337

23.6Postoperative Complications and Visual Outcome  . . . . . . . . . . . . . .   339

23.6.1VisualAxis Opacification  . . . . . . .   339

23.6.2 Deposits and Synechiae  . . . . . . . .   339

23.6.3Glaucoma  . . . . . . . . . . . . .   339

23.6.6Choroidal Effusion  . . . . . . . . . .   340

References  . . . . . . . . . . . . . . . . .   340

1The authors have no financial or proprietary interest in any product mentioned herein.

Core Messages

•Surgical management of cataracts in children is markedly different from adults. Children have reduced scleral and corneal rigidity, more inflammation after surgery, and a propensity to develop reopacification of the visual axis.

•For proper management of the anterior and posterior capsule in children, technique changes have been made that are unique to pediatric surgery. Vitrectomy instrumentation is used

extensively in childhood cataract surgery.

•The best surgical techniques for children will evolve most efficiently with optimal cooperation and collaboration between pediatric ophthalmologists and adult cataract surgeons. This way, new adulttested techniques can be selectively utilized for pediatric surgery.

•The approach chosen to correct aphakia plays an important role in the outcome of pediatric cataract surgery. Intraocular lens power selection is a complex decision based on eye growth projections and the management of amblyopia.

•When cataract surgery is required in the early years of life, complications such as glaucoma and visual axis opacification are frequent. These patients must be monitored and may need examinations under anesthesia during the higher risk years.