Transcript Management of IOLs in Pediatric Cataracts

Management of IOLs in
Pediatric Cataracts:
When, How, Where, and
Which type of IOL.
José A. Cristóbal, María A. del Buey, León Remón,
Francisco J. Ascaso.
Department of Ophthalmology “Lozano Blesa” Clinical University
Hospital, Zaragoza, SPAIN
No author has a financial or proprietary interest in any material or method
mentioned.
1
Purpose
To describe the different possibilities of treatment in
pediatric cataract with IOL implantation; analyzing the type
of IOL, the position of the haptics (sulcus or in the bag), the
position of the optic (in the bag or into the vitreous), the
posterior capsulorrhexis and anterior vitrectomy (depending
on the age and cooperation of the patient) and the use of
multifocal IOLs in special cases.
2
When to perform surgery?
WE RECOMMEND EARLY SURGERY
In case of great risk of
deep amblyopia: congenital,
central, dense, wide, total,…
(with significant visual
impairment).
Technique:
Lens
phacoaspiration
CARACTERISTICS OF PEDIATRIC CATARACT SURGERY
Small eye, elastic capsule, quick capsular opacification, difficulty in IOL power
calculation, postoperative treatment of amblyopia very hard.
Cataract surgery in children needs special considerations in the use of IOLs
and also in lens power calculation.
It is necessary to do a very careful surgery, having always in mind the necessity
of transparency in the visual axis and a good state of eyeball in case of the
possibility of future surgery.
3
How to perform surgery?
MANEUVERS TO AVOID POSTOPERATIVE OPACIFICATION OF
VISUAL AXIS.
They are necessary in non-cooperative children (usually under five
years of age), when there is no possibility of doing a Nd YAG laser
posterior capsulotomy in the slit lamp.
MANEUVERS
Anterior
Capsulorrhexis
Posterior
Capsulorrhexis
Anterior
Vitrectomy
Causes of opacification:
•Epitelial cells proliferation and migration in posterior capsule
•Inflamatory membranes
•Anterior vitreous opacification
4
Luxation of
the optic
CONGENITAL PEDIATRIC CATARACT ASSOCIATED WHITH
OTHER ABNORMALITIES.
A six-month-old baby with bilateral cataract,
microphthalmos and iris abnormalities.
TREATMENT: BILATERAL CATARACT EXTRACTION WITHOUT IOL
Aphakic Spectacles
Removal of fibrosis over the lens surface, anterior
capsulorrhexis, manualaspiration of lens material,
posterior capsulorrhexis and central anterior
mechanical vitrectomy.
5
Silicone contact lenses
correction
CONGENITAL PEDIATRIC CATARACT ASSOCIATED WHITH
OTHER ABNORMALITIES.
A two-year-old child with total
monolateral pediatric cataract. The
Echography shows persistent fetal
vessels.
TREATMENT: CATARACT EXTRACTION WITH MONOFOCAL IOL IN
“SULCUS” AND POSTERIOR OPTICAL LUXATION
Anterior capsulorrhexis, phacoaspiration of lens, incomplete posterior
capsulorrexis preserving the central vessel, anterior vitrectomy, IOL in
“sulcus” with the optic into the vitreous displacing the vessel.
6
Which type of IOLs?
WE RECOMMEND INTRAOCULAR LENS IMPLANTATION
ALWAYS IF POSSIBLE
DESIGN
CHILDREN UNDER 2 YEARS OF AGE
MONOFOCAL “3 PIECES” IOL WITH HAPTICS IN SULCUS AND
THE OPTIC IN THE BAG OR LUXATED INTO THE VITREUS
POWER
UNDERCORRECTION 20%
CHILDREN BETWEEN 2 AND 4 YEARS OF AGE
DESIGN
MONOFOCAL “3 PIECES” IOL IN THE BAG OR WITH THE OPTIC
LUXATED INTO THE VITREUS
POWER
EMMETROPIA – UNDERCORRECTION 10%
Luxation of
the optic
7
MULTIFOCAL DIFRACTIVE IOLS IN
CHILDREN
¿WHEN?
Good visual prognosis
Ideal capsular support
Posibility of good biometric calculation
Enough ocular development
MF IOL
Clear visual axis in a child
two years after surgery.
Cristóbal
Surgery in a polar evolutive central cataract. Anterior and posterior
capsulorrhexis removing polar opacification. Multifocal IOL in the capsular bag.
Since 2004, we have had a good experience in children with monocular cataract
(developmental, evolutive, traumatic…) and emmetropic contralateral eye. It is
our choice to improve binocularity and even stereopsis for distance and near
vision.
8
Conclusion
•
In our experience, the best option to manage with pediatric
cataract is to implant an IOL after cataract extraction, unless the
presence of associated ocular abnormalities make it inadvisable .
•
Visual recovery will be faster than in pediatric aphakic eyes and less
"hard". Controversy still persists about the appropriate power of
the IOL and how to calculate it.
José A. Cristóbal MD, PhD, FEBO.
Clinical University Hospital
Zaragoza, SPAIN
<[email protected]>
9