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

2

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.

Purpose

3

CARACTERISTICS OF PEDIATRIC CATARACT SURGERYSmall eye, elastic capsule, quick capsular opacification, difficulty in IOL power calculation, postoperative treatment of amblyopia very hard.

WE RECOMMEND EARLY SURGERY

Technique: Lens

phacoaspiration

In case of great risk of deep amblyopia: congenital, central, dense, wide, total,… (with significant visual impairment).

When to perform surgery?

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.

4

Causes of opacification:•Epitelial cells proliferation and migration in posterior capsule •Inflamatory membranes •Anterior vitreous opacification

Anterior Capsulorrhexis

Posterior Capsulorrhexis

Anterior Vitrectomy

Luxation of the optic

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

How to perform surgery?

5

TREATMENT: BILATERAL CATARACT EXTRACTION WITHOUT IOL

Removal of fibrosis over the lens surface, anterior capsulorrhexis, manualaspiration of lens material, posterior capsulorrhexis and central anterior mechanical vitrectomy.

A six-month-old baby with bilateral cataract, microphthalmos and iris abnormalities.

Silicone contact lenses correction

Aphakic Spectacles

CONGENITAL PEDIATRIC CATARACT ASSOCIATED WHITH OTHER ABNORMALITIES.

6

A two-year-old child with total monolateral pediatric cataract. The Echography shows persistent fetal

vessels.

CONGENITAL PEDIATRIC CATARACT ASSOCIATED WHITH OTHER ABNORMALITIES.

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.

DESIGN MONOFOCAL MONOFOCAL “3 PIECES”“3 PIECES” IOL WITH IOL WITH HAPTICS IN SULCUSHAPTICS IN SULCUS AND AND THE OPTIC IN THE BAGTHE OPTIC IN THE BAG OR LUXATED INTO THE VITREUS OR LUXATED INTO THE VITREUSPOWERUNDERCORRECTION 20%UNDERCORRECTION 20%

7

CHILDREN UNDER 2 YEARS OF AGE

DESIGN MONOFOCAL MONOFOCAL “3 PIECES” IOL IN THE BAG“3 PIECES” IOL IN THE BAG OR WITH THE OR WITH THE OPTIC LUXATED INTO THE VITREUSOPTIC LUXATED INTO THE VITREUS POWER EMMETROPIA – UNDERCORRECTION 10%EMMETROPIA – UNDERCORRECTION 10%

WE RECOMMEND INTRAOCULAR LENS IMPLANTATION ALWAYS IF POSSIBLE

Which type of IOLs?

CHILDREN BETWEEN 2 AND 4 YEARS OF AGE

Luxation of the optic

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

Cristóbal

MULTIFOCAL DIFRACTIVE IOLS IN CHILDREN

Good visual prognosisIdeal capsular supportPosibility of good biometric calculationEnough ocular development

¿WHEN?

MF IOL

Surgery in a polar evolutive central cataract. Anterior and posterior capsulorrhexis removing polar opacification. Multifocal IOL in the capsular bag.

Clear visual axis in a child two years after

surgery.

9

<joseangelcristobal@yahoo.es>

• 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.

Conclusion

José A. Cristóbal MD, PhD, FEBO. Clinical University Hospital

Zaragoza, SPAIN