Intraocular Lens Implantation as a Secondary Procedure in Neonatal Cataract

1
Intraocular Lens Implantation as a Secondary
Procedure in Neonatal Cataract
We have no financial interest in this presentation

• Dr. Ashok P. Shroff, MD
• Dr. Hardik A. Shroff, MD
• Dr. Dishita H. Shroff. MD
• Shroff Eye Hospital
• Navsari India.
• Email sehnavsari_at_yahoo.co.in

Courtesy Techniques of Cataract Surgery, Dr.
Mahipal Sachdev
2
Introduction

• Management of cataract is surgical but when the
  patient is infant then it requires special
  consideration because anatomy of infants eye is
  very much different from adults. Moreover their
  growth is also very fast in first two years of
  life. (Ref. 1 2)

• AP length
• At birth 16.8 mm
• First two years 22 mm
• At 16 years 23 mm
• Adult 23.6 mm
• Corneal curvature
• At birth 47 to 51 D

• Lens
• Horizontal diameter
• Infant 6 mm
• 21 months 8.4 mm
• 16 years 9.3 mm
• Lens capsule elastic, on puncture ? radially
  oriented tears

• Sclera very elastic
• Vitreous more viscous and formed
• Visual system
• Up to 8 years development continues

Therefore while considering surgery in
paediatric cataract, consider following points

• Age of the child
• Time of surgery
• Laterality
• Anaesthesia

• IOL (Newer designs ref. 3)
• Power calculation
• Type of IOL
• Possible complications

3
Purpose

• With the advent of newer technique and designs of
  IOLs, primary IOL implantation at / after 2 years
  is safe and gives excellent results.
• But if the child is under one year then all the
  surgeons do not agree for primary implantation.
  Hence we have done it in two stages.
• In this series, we have tried to evaluate
  secondary IOL implantation in neonates / infants
  with reference to long term results.

4
Demography

• No of patients 6
• No of eyes 12
• Previous surgical history
• Cataract removal by bimanual technique with
  primary posterior capsulotomy by vitreous cutter
• Time lapsed between previous surgery and present
  procedure 10 to 14 months

5
Method

• All the children were examined under GA for
• Anterior segment
• Peripheral capsular support
• IOPr
• Posterior segment evaluation
• Keratometry
• A-scan biometry

6
Method (Contd.)

• Procedure
• Lids were separated by using appropriate speculum
• Corneoscleral tunnel was made in upper part of
  limbus at convenient area
• Two stab incisions at limbus were made at 10 and
  2 oclock position
• Anterior chamber was entered with triangular
  pointed knife
• AC was filled with viscoelastic

7
Method (Contd.)

• Adhesion between iris and capsule was gently
  separated using iris repositor from both stab
  wounds
• Corneoscleral wound was enlarged up to 6 mm in
  width
• Appropriate PMMA IOL was introduced and was
  gently dialed to place in the sulcus
• Visco was removed using bimanual irrigation
  aspiration
• Anterior chamber was formed with air / BSS
• Conjunctiva was closed with wet field cautery

8
Results

• IOL was well placed in sulcus in all the cases
• Pupillary area remained clear in all cases
• Retina was found to be ok till last examination (
  even after 2 years)
• All the children behave well visually as their
  routine activities found to be normal by their
  parents

9
Discussion

• As mentioned earlier, congenital cataracts in
  both eyes need immediate surgical intervention at
  any age.
• Primary posterior capsulotomy by vitrectomy
  cutter is MUST to have clear visual axis
• Though many surgeons do primary IOL implantation
  (Ref. 4), we have resorted to do it at a later
  date for obvious reasons mentioned earlier
• Till then visual rehabilitation may be maintained
  by glasses or contact lenses (Status of clear
  visual axis is better even without correction is
  much better than obscured by cataract).
• IOL implantation at about 2 years age would be
  more appropriate because of proper anatomical
  growth.
• Due to opening in posterior capsule and adhesions
  of capsular bag, IOL implantation may but be easy
  in the bag.
• However, good quality and appropriate size of IOL
  can be placed in the sulcus after removing the
  adhesion between iris and capsular bag.
• As manipulation is minimum and vitreous
  disturbance is almost nil, retina remained ok
  even after 2 years

10
Conclusion

• 12 eyes of 6 children between 5 to 11 months were
  operated previously for cataract with posterior
  capsulotomy by vitreous cutter
• At appropriate age (i.e. between 1.5 to 2 years)
  they were taken up for secondary IOL implantation
• IOL power was calculated using Vasavada formula
• IOL implantation in the sulcus was easy after
  separating the adhesion between iris and capsules
• Visual outcome was good.

• References
• Gardan RA, Danzis PB Refractive development of
  the human eye Archives of ophthalmology,
  1985103785-789
• Inagaki Y The rapid change of corneal curvature
  in the neonatal period and infancy Archives of
  ophthalmology, 19861041026-1027
• Suresh k pandey M Edward Wilson at al
  Paediatric cataract surgery and IOL implantation
  Techniques of cataract surgery2007371-377
• Vasavada A, Chouhan H Intraocular lens
  implantation in infants with congenital
  cataracts journal of cataract and refractive
  surgery194420592-7