Treatment of congenital cataract
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《英国眼科学杂志》
Correspondence to:
S R Lambert
Emory Eye Center, 1365-B, Clifton Road, NE, Atlanta, GA 30322, USA; slamber@emory.edu
Accepted for publication 26 February 2004
It may all come down to timing
Keywords: surgery; glaucoma
The visual prognosis for children with congenital cataracts has improved dramatically since it was first recognised that cataract surgery during infancy is critical for a good visual outcome1,2; however, the optimal time to perform cataract surgery in a child with a congenital cataract is still in question. Anecdotal reports have noted excellent visual outcomes in neonates undergoing cataract surgery during the first week of life1,3; however, a subsequent analysis of 45 children with dense unilateral cataracts, who underwent cataract surgery, found that the visual outcome was the same regardless of when the surgery was performed during the first 6 weeks of life.4 While the same analysis has not been performed on children with bilateral congenital cataracts, it has been proposed that the critical period for treating children with bilateral congenital cataracts may extend to 8 weeks of life.2,5,6 Paediatric ophthalmologists are now trying to determine the optimal time to perform cataract surgery to reduce the high incidence of complications that have been reported following cataract surgery during infancy.
One of the most serious complications that occurs following paediatric cataract surgery is glaucoma. It is usually open angle and has been reported to develop in up to one third of children after a lensectomy and vitrectomy.7–11 Known risk factors for aphakic glaucoma include microcornea, persistent fetal vasculature, and cataract surgery during infancy. Parks et al8 reported that 54% of the children in their series who developed aphakic glaucoma underwent cataract surgery when they were younger than 2 months of age. Rabiah11 reported that 37% of children undergoing cataract surgery when 9 months of age or younger developed glaucoma compared to only 6% of children undergoing surgery thereafter. Vishwanath et al reports in this issue of the BJO (p 905) that 50% of children undergoing bilateral lensectomies during the first month of life developed glaucoma in one or both eyes after a 5 year follow up compared to only 15% of children undergoing cataract surgery thereafter. Lundvall and Kugelberg5 also reported that 80% of the children in their series of children with bilateral congenital cataracts who developed glaucoma underwent cataract surgery during the first 4 weeks of life. Finally, Watts and coworkers12 reported that aphakic glaucoma was more prevalent in children undergoing surgery when 14–34 days of age. While it is possible that eyes with congenital cataracts requiring early surgery are more prone to develop glaucoma than eyes that acquire cataracts later in childhood, it is also likely that early surgery increases the risk of these eyes developing glaucoma. For this reason, Vishwanath and coworkers have proposed that cataract surgery should be deferred until after the first 4 weeks of life.
It would appear that the optimal time to remove a dense congenital cataract in an infant and to initiate optical treatment is when the child is 4–6 weeks of age
The pathophysiology of aphakic open angle glaucoma is poorly understood. Its aetiology has been attributed to damage to the trabecular meshwork by inflammation, the loss of mechanical support of the trabecular meshwork, or a toxic substance gaining access to the trabecular meshwork from the vitreous humour.13 It has been reported to occur after both limbal and a pars plicata based lensectomies, suggesting that the surgical approach is not the critical factor in determining its occurrence.14
Children are more commonly being optically corrected with intraocular lenses following cataract surgery.15 Asrani and coworkers13 have reported a decreased incidence of open angle glaucoma in older children undergoing primary IOL implantation following cataract surgery. Recent studies, however, have noted a high incidence of open angle glaucoma in children undergoing IOL implantation during the first 4 weeks of life.16–18
A final factor to consider is the safety of general anaesthesia during infancy. The immaturity of an infant’s cardiovascular, pulmonary, and gastrointestinal systems, as well as their liver, kidneys, and thermoregulation puts them at greater risk from general anaesthesia.19 The most life threatening risk to an infant is postoperative apnoea. The risk of postoperative apnoea has been shown to be higher in preterm infants less than 44 post-conception weeks of age.20 For this reason, it has been recommended that all non-essential surgery for preterm infants be delayed until they are older than 44 post-conception weeks of age.21 While an increased risk of postoperative apnoea in a full term infant following general anaesthesia has not been established, waiting until an infant is older to perform cataract surgery allows all of the different systems in an infant to mature to some degree and should be safer.
From the available data, it would appear that the optimal time to remove a dense congenital cataract in an infant and to initiate optical treatment is when the child is 4–6 weeks of age. To remove the cataract before 4 weeks of age appears to increase the risk of the eye developing aphakic glaucoma, whereas waiting beyond 6 weeks of age compromises the visual outcome.
REFERENCES
Beller R , Hoyt CS. Good visual function after neonatal surgery for congenital monocular cataracts. Am J Ophthalmol 1981;91:559–65.
Gelbart SS, Hoyt CS, Jastrebski G, et al. Long-term visual results in bilateral congenital cataracts. Am J Ophthalmol 1982;93:615–21.
Gregg FM, Parks MM. Stereopsis after congenital monocular cataract extraction. Am J Ophthalmol 1992;114:314–17.
Birch EE, Stager DR. The critical period for surgical treatment of dense congenital unilateral cataract. Invest Ophthalmol Vis Sci 1996;37:1532–8.
Lundvall A , Kugelberg U. Outcome after treatment of congenital bilateral cataract. Acta Ophthalmol Scand 2002;80:593–7.
Magnusson G , Abrahamsson M, Sj?strand J. Changes in visual acuity from 4 to 12 years of age in children operated for bilateral congenital cataracts. Br J Ophthalmol 2002;86:1385–9.
Simon JW, Mehta N, Simmons S, et al. Glaucoma after pediatric lensectomy/vitrectomy. Ophthalmology 1991;98:670–4.
Parks MM, Johnson DA, Reed GW. Long-term visual results and complications in children with aphakia. A function of cataract type. Ophthalmology 1993;100:826–41.
Egbert JE, Wright MM, Dahlhauser KF, et al. A prospective study of ocular hypertension and glaucoma after pediatric cataract surgery. Ophthalmology102:1098–101.
Johnson CP, Keech RV. Prevalence of glaucoma after surgery for PHPV and infantile cataracts. J Pediatr Ophthalmol Strabismus 1996;33:14–17.
Rabiah PK. Frequency and predictors of glaucoma after pediatric cataract surgery. Am J Ophthalmol 2004;137:30–7.
Watts P , Abdolell M, Levin AV. Complications in infants undergoing surgery for congenital cataract in the first 12 weeks of life: Is early surgery better? J AAPOS 2003;7:81–5.
Asrani S , Freedman S, Hasselblad V, et al. Does primary intraocular lens implantation prevent "aphakic" glaucoma in children? J AAPOS 1999;3:33–9.
Mu?oz M , Parrish RK, Murray TG. Open-angle glaucoma after pars plicata lensectomy and vitrectomy for congenital cataracts. Am J Ophthalmol 1995;119:103–4.
Lambert SR, Lynn M, Drews-Botsch C, et al. Intraocular lens implantation during infancy: Perceptions of parents and the American Association for Pediatric Ophthalmology and Strabismus members. J AAPOS 2003;7:400–5.
Lambert SR, Buckley EG, Plager DA, et al. Unilateral intraocular lens implantation during the first six months of life. J AAPOS 1999;3:344–9.
Wilson ME, Peterseim MW, Englert JA, et al. Pseudophakia and polypseudophakia in the first year of life. J AAPOS 2001;5:238–45.
Plager DA, Yang S, Neely D, et al. Complications in the first year following cataract surgery with and without IOL in infants and older children. J AAPOS 2002;6:9–14.
Miller RD. Developmental physiology of the infant. In: Anesthesia. 5th ed. Edinburgh: Churchill Livingstone, 2000:2089–92.
Wellborn LG, Ramirez N, Oh TH, et al. Postanesthetic apnea and periodic breathing in infants. Anesthesiology 1986;65:658.
Gregory GA, Steward DJ. Life-threatening perioperative apnea in the ex’"premie" (editorial). Anesthesiology 1983;59:495.(S R Lambert)
S R Lambert
Emory Eye Center, 1365-B, Clifton Road, NE, Atlanta, GA 30322, USA; slamber@emory.edu
Accepted for publication 26 February 2004
It may all come down to timing
Keywords: surgery; glaucoma
The visual prognosis for children with congenital cataracts has improved dramatically since it was first recognised that cataract surgery during infancy is critical for a good visual outcome1,2; however, the optimal time to perform cataract surgery in a child with a congenital cataract is still in question. Anecdotal reports have noted excellent visual outcomes in neonates undergoing cataract surgery during the first week of life1,3; however, a subsequent analysis of 45 children with dense unilateral cataracts, who underwent cataract surgery, found that the visual outcome was the same regardless of when the surgery was performed during the first 6 weeks of life.4 While the same analysis has not been performed on children with bilateral congenital cataracts, it has been proposed that the critical period for treating children with bilateral congenital cataracts may extend to 8 weeks of life.2,5,6 Paediatric ophthalmologists are now trying to determine the optimal time to perform cataract surgery to reduce the high incidence of complications that have been reported following cataract surgery during infancy.
One of the most serious complications that occurs following paediatric cataract surgery is glaucoma. It is usually open angle and has been reported to develop in up to one third of children after a lensectomy and vitrectomy.7–11 Known risk factors for aphakic glaucoma include microcornea, persistent fetal vasculature, and cataract surgery during infancy. Parks et al8 reported that 54% of the children in their series who developed aphakic glaucoma underwent cataract surgery when they were younger than 2 months of age. Rabiah11 reported that 37% of children undergoing cataract surgery when 9 months of age or younger developed glaucoma compared to only 6% of children undergoing surgery thereafter. Vishwanath et al reports in this issue of the BJO (p 905) that 50% of children undergoing bilateral lensectomies during the first month of life developed glaucoma in one or both eyes after a 5 year follow up compared to only 15% of children undergoing cataract surgery thereafter. Lundvall and Kugelberg5 also reported that 80% of the children in their series of children with bilateral congenital cataracts who developed glaucoma underwent cataract surgery during the first 4 weeks of life. Finally, Watts and coworkers12 reported that aphakic glaucoma was more prevalent in children undergoing surgery when 14–34 days of age. While it is possible that eyes with congenital cataracts requiring early surgery are more prone to develop glaucoma than eyes that acquire cataracts later in childhood, it is also likely that early surgery increases the risk of these eyes developing glaucoma. For this reason, Vishwanath and coworkers have proposed that cataract surgery should be deferred until after the first 4 weeks of life.
It would appear that the optimal time to remove a dense congenital cataract in an infant and to initiate optical treatment is when the child is 4–6 weeks of age
The pathophysiology of aphakic open angle glaucoma is poorly understood. Its aetiology has been attributed to damage to the trabecular meshwork by inflammation, the loss of mechanical support of the trabecular meshwork, or a toxic substance gaining access to the trabecular meshwork from the vitreous humour.13 It has been reported to occur after both limbal and a pars plicata based lensectomies, suggesting that the surgical approach is not the critical factor in determining its occurrence.14
Children are more commonly being optically corrected with intraocular lenses following cataract surgery.15 Asrani and coworkers13 have reported a decreased incidence of open angle glaucoma in older children undergoing primary IOL implantation following cataract surgery. Recent studies, however, have noted a high incidence of open angle glaucoma in children undergoing IOL implantation during the first 4 weeks of life.16–18
A final factor to consider is the safety of general anaesthesia during infancy. The immaturity of an infant’s cardiovascular, pulmonary, and gastrointestinal systems, as well as their liver, kidneys, and thermoregulation puts them at greater risk from general anaesthesia.19 The most life threatening risk to an infant is postoperative apnoea. The risk of postoperative apnoea has been shown to be higher in preterm infants less than 44 post-conception weeks of age.20 For this reason, it has been recommended that all non-essential surgery for preterm infants be delayed until they are older than 44 post-conception weeks of age.21 While an increased risk of postoperative apnoea in a full term infant following general anaesthesia has not been established, waiting until an infant is older to perform cataract surgery allows all of the different systems in an infant to mature to some degree and should be safer.
From the available data, it would appear that the optimal time to remove a dense congenital cataract in an infant and to initiate optical treatment is when the child is 4–6 weeks of age. To remove the cataract before 4 weeks of age appears to increase the risk of the eye developing aphakic glaucoma, whereas waiting beyond 6 weeks of age compromises the visual outcome.
REFERENCES
Beller R , Hoyt CS. Good visual function after neonatal surgery for congenital monocular cataracts. Am J Ophthalmol 1981;91:559–65.
Gelbart SS, Hoyt CS, Jastrebski G, et al. Long-term visual results in bilateral congenital cataracts. Am J Ophthalmol 1982;93:615–21.
Gregg FM, Parks MM. Stereopsis after congenital monocular cataract extraction. Am J Ophthalmol 1992;114:314–17.
Birch EE, Stager DR. The critical period for surgical treatment of dense congenital unilateral cataract. Invest Ophthalmol Vis Sci 1996;37:1532–8.
Lundvall A , Kugelberg U. Outcome after treatment of congenital bilateral cataract. Acta Ophthalmol Scand 2002;80:593–7.
Magnusson G , Abrahamsson M, Sj?strand J. Changes in visual acuity from 4 to 12 years of age in children operated for bilateral congenital cataracts. Br J Ophthalmol 2002;86:1385–9.
Simon JW, Mehta N, Simmons S, et al. Glaucoma after pediatric lensectomy/vitrectomy. Ophthalmology 1991;98:670–4.
Parks MM, Johnson DA, Reed GW. Long-term visual results and complications in children with aphakia. A function of cataract type. Ophthalmology 1993;100:826–41.
Egbert JE, Wright MM, Dahlhauser KF, et al. A prospective study of ocular hypertension and glaucoma after pediatric cataract surgery. Ophthalmology102:1098–101.
Johnson CP, Keech RV. Prevalence of glaucoma after surgery for PHPV and infantile cataracts. J Pediatr Ophthalmol Strabismus 1996;33:14–17.
Rabiah PK. Frequency and predictors of glaucoma after pediatric cataract surgery. Am J Ophthalmol 2004;137:30–7.
Watts P , Abdolell M, Levin AV. Complications in infants undergoing surgery for congenital cataract in the first 12 weeks of life: Is early surgery better? J AAPOS 2003;7:81–5.
Asrani S , Freedman S, Hasselblad V, et al. Does primary intraocular lens implantation prevent "aphakic" glaucoma in children? J AAPOS 1999;3:33–9.
Mu?oz M , Parrish RK, Murray TG. Open-angle glaucoma after pars plicata lensectomy and vitrectomy for congenital cataracts. Am J Ophthalmol 1995;119:103–4.
Lambert SR, Lynn M, Drews-Botsch C, et al. Intraocular lens implantation during infancy: Perceptions of parents and the American Association for Pediatric Ophthalmology and Strabismus members. J AAPOS 2003;7:400–5.
Lambert SR, Buckley EG, Plager DA, et al. Unilateral intraocular lens implantation during the first six months of life. J AAPOS 1999;3:344–9.
Wilson ME, Peterseim MW, Englert JA, et al. Pseudophakia and polypseudophakia in the first year of life. J AAPOS 2001;5:238–45.
Plager DA, Yang S, Neely D, et al. Complications in the first year following cataract surgery with and without IOL in infants and older children. J AAPOS 2002;6:9–14.
Miller RD. Developmental physiology of the infant. In: Anesthesia. 5th ed. Edinburgh: Churchill Livingstone, 2000:2089–92.
Wellborn LG, Ramirez N, Oh TH, et al. Postanesthetic apnea and periodic breathing in infants. Anesthesiology 1986;65:658.
Gregory GA, Steward DJ. Life-threatening perioperative apnea in the ex’"premie" (editorial). Anesthesiology 1983;59:495.(S R Lambert)