Bernadette Lanigan

Visual outcomes and complications of posterior chamber intraocular lens implantation in the first year of life

Purpose: To document the visual outcome and postoperative complications in infants who had congenital cataract surgery with posterior chamber intraocular lens (PC IOL) implantation in the first year of life. Setting: The Childrens Hospital, Dublin, Ireland. Methods: Twenty‐seven eyes of 20 infants were reviewed. Seven infants (14 eyes) had bilateral congenital cataract and 13 (13 eyes), uniocular cataract. The mean age at surgery was 4 months (range 3 weeks to 11 months). A standard surgical technique involved anterior capsulorhexis, phacoemulsification with or without posterior capsulorhexis with in‐the‐bag PC IOL implantation, and no anterior vitrectomy. Surgery was performed by 1 surgeon. The mean follow‐up was 41 months (range 6 to 88 months). Results: The main complication was lens reproliferation into the visual axis. Of the 11 eyes that did not have a primary posterior capsulorhexis, 10 had 1 or more capsulotomies. Seven required a neodymium:YAG (Nd:YAG) laser capsulotomy a mean of 6 months postoperatively, and 2 had 2 Nd:YAG capsulotomies. Six eyes also had a surgical capsulotomy when the membrane was deemed too thick for further laser treatment. Fourteen of 25 eyes had a primary posterior capsulorhexis; 8 had no further intervention. Four eyes had persistent hyperplastic primary vitreous (PHPV), 3 required a surgical capsulotomy, 2 had an Nd:YAG laser capsulotomy, 2 had an anterior vitrectomy, and 1 developed open‐angle glaucoma. There was a mean refractive shift of 6.0 diopters after a mean follow‐up of 41 months, with most of the myopic shift occurring in the first 24 months. Conclusions: Visual axis reopacification was the main complication of IOL implantation in infants, with PHPV leading to more complications and repeat procedures. Anterior vitrectomy appeared to reduce the reoperation rate. Results indicate that primary posterior capsulorhexis is important and Nd:YAG capsulotomy is not satisfactory in infants. In addition, the reduction in glaucoma with IOL implantation, if borne out over the long term, is a significant advantage in cases of congenital cataract.

Intraocular lenses in children: changes in axial length, corneal curvature, and refraction

AIM To assess changes in axial length, corneal curvature, and refraction in paediatric pseudophakia. METHODS 35 eyes of 24 patients with congenital or developmental lens opacities underwent extracapsular cataract extraction and posterior chamber intraocular lens implantation. Serial measurements were made of axial length, corneal curvature, objective refraction, and visual acuity. RESULTS For patients with congenital cataracts (onset <1 year age) the mean age at surgery was 24 weeks. Over the mean follow up period of 2.7 years, the mean increase in axial length of 3.41 mm was not significantly different from the value of an expected mean growth of 3.44 mm (pairedt test, p=0.97) after correction for gestational age. In the developmental cataract group (onset >1 year of age) the mean age at surgery was 6.4 years with a mean follow up of 2.86 years. This group showed a mean growth in axial length of 0.36 mm that was not significantly different from an expected value of 0.47 mm (paired t test, p = 0.63). The mean preoperative keratometry was 47.78 D in the congenital group and 44.35 D in the developmental group. At final follow up the mean keratometry in the congenital group was 46.15 D and in the developmental group it was 43.63 D. In eyes followed for at least 2 years, there was an observed myopic shift by 24 months postoperatively of 3.26 D in the congenital cases (n=10) and 0.96 D in the developmental cases (n=18). CONCLUSION The pattern of axial elongation and corneal flattening was similar in the congenital and developmental groups to that observed in normal eyes. No significant retardation or acceleration of axial growth was found in the eyes implanted with IOLs compared with normal eyes. A myopic shift was seen particularly in eyes operated on at 4–8 weeks of age and it is recommended that these eyes are made 6 D hypermetropic initially with the residual refractive error being corrected with spectacles.

Long term follow up of primary trabeculectomy for infantile glaucoma

BACKGROUND--The treatment for infantile glaucoma is surgical. Treatment options include goniotomy, trabeculotomy, combined trabeculotomy-trabeculectomy, and trabeculectomy. METHODS--Patients who had a follow up of 5 years or longer after primary trabeculectomy were examined to determine the long term stability in infantile glaucoma. RESULTS--In eyes with primary infantile glaucoma 92.3% achieved control of their glaucoma with a single trabeculectomy; 100% achieved control with two trabeculectomies; 85.7% of eyes with secondary infantile glaucoma achieved control with a single trabeculectomy. There were no serious complications experienced in either group. CONCLUSION--Primary trabeculectomy is a safe and successful operation for infantile glaucoma.

Long term functional and structural outcomes of laser therapy for retinopathy of prematurity.

Aims: To assess the long term functional and structural outcomes of premature babies who received diode laser photocoagulation for threshold retinopathy of prematurity (ROP). Methods: 25 patients (43 eyes) treated with laser were recalled for assessment at a mean follow up of 11 years. A further seven patients (14 eyes) with subthreshold ROP, which had regressed spontaneously without laser treatment, were also examined. All children underwent distance acuity, near acuity, contrast sensitivity (CS), and colour vision assessments followed by a dilated fundal examination and cycloplegic autorefraction. Results: The laser treated eyes had a mean distance visual acuity of 0.37 logMAR, a mean near visual acuity of 0.39 logMAR, a mean contrast sensitivity of 1.49 log CS units, and a mean spherical equivalent of −2.10D. An unfavourable distance visual acuity outcome occurred in five eyes (13.5%). An unfavourable near visual acuity outcome was also noted in the five eyes (13.5%) with poor distance visual outcome. 7% had an unfavourable structural outcome. On comparison with the control group, there was no significant difference in near acuity, CS, refraction, or colour vision between the two groups. However, there was a statistically significant difference in terms of distance visual acuity (p = 0.03). Conclusions: Laser treated eyes with favourable structural outcome have a good visual outcome. The results show a long term benefit from diode laser photocoagulation in preserving distance and near vision in eyes with threshold ROP.

Ocular significance of intraventricular haemorrhage in premature infants

AIM To document ocular outcome in premature infants with intraventricular haemorrhages (IVH). METHODS 68 preterm infants with IVH were examined. RESULTS Mean gestational age was 28.1 weeks (range 24–35). Mean birth weight was 1045.9 g (630–2240). Mean follow up was 54.6 months (6–150). IVH is graded from 1 to 4 based on the severity of haemorrhages. The incidence of ocular abnormalities was compared between low grade IVH (grade 1 and 2) and high grade IVH (grade 3 and 4). Of the 68 infants with IVH, ROP occurred in 33 infants (48.5%); 13 (43.3%) had low grade IVH; 20 (52.6%) had high grade IVH. Strabismus developed in 30 infants (44.1%); 14 (46.6%) had low grade IVH; 16 (42.1%) had high grade IVH. Infants with high grade IVH were at significant greater risk than infants with low grade IVH for the development of optic atrophy (31.5%v 16.6%), hydrocephalus (57.8%v 10%). CONCLUSION This study highlights the serious significance of all grades of IVH with the higher incidence of optic atrophy and hydrocephalus with high grade IVH.

Longer term visual outcome of eyes with retinopathy of prematurity treated with cryotherapy or diode laser

AIMS Visual outcome of 66 eyes in 37 patients who had undergone treatment with either cryotherapy or diode laser for threshold retinopathy of prematurity was assessed. METHODS 17 patients, representing 30 eyes treated with cryotherapy, were examined at between 56 and 98 months corrected age (median 68 months). 20 patients representing 36 eyes treated with diode laser, were examined at between 30 and 66 months corrected age (median 51 months). Structural outcome was categorised as: optimal—flat posterior pole; suboptimal—macular ectopia, optic nerve hypoplasia, retinal fold involving the macula, and retinal detachment involving the macula. RESULTS Optimal structural outcome was, in the absence of amblyopia, associated with optimal visual acuity (of 6/12 or better) in all cases, with most eyes achieving a visual acuity of 6/9 or 6/6. Suboptimal structural outcome was invariably associated with suboptimal visual acuity. Amblyopia was present in eight out of 20 cryotherapy treated eyes and in five out of 26 laser treated eyes with an optimal structural outcome. Refractive errors were significantly less in laser treated eyes as was the incidence of anisometropic amblyopia. CONCLUSION Eyes treated with either cryotherapy or diode laser for threshold retinopathy of prematurity with optimal structural outcome are associated with development of optimal visual acuity—that is, 6/12 or better. Treatment with either cryotherapy or laser does not in itself reduce the visual potential of these eyes.

Fundus Fluorescein Angiography in the Screening for and Management of Retinopathy of Prematurity

OBJECTIVES To describe the characteristics of fundus fluorescein angiography in retinopathy of prematurity (ROP) and to explore the possible benefits of fundus fluorescein angiography over conventional indirect ophthalmoscopy in the screening for and management of ROP. PATIENTS AND METHODS Beginning in January 2003, 23 consecutive patients were recruited for a nonrandomized, investigational trial. Fifty-one sessions of fundus fluorescein angiography were performed as part of ROP screening. RESULTS Fundus fluorescein angiography caused no adverse effect. Clear angiograms were easily obtained. There was delayed arm-to-eye fluorescein transit. Leakage of fluorescein was observed in all stage 2 and stage 3 ROP. The leakage resolved soon after treatment. Arteriovenous tufts were found far posterior to the ROP ridge and were a feature of severe ROP. CONCLUSIONS Some vascular pathology observed on angiograms cannot be seen on indirect ophthalmoscopy. There was delayed arm-to-eye transit and fluorescein transit within the eyes. Fundus fluorescein angiography allows more objective assessment of disease stage and zone. Regression of ROP is clearly observed on fundus fluorescein angiography.

Hydroxyapatite orbital implant exposure in children

PURPOSE Hydroxyapatite orbital implants are buried implants that may be integrated into the overlying prosthesis after enucleation. We report problems encountered using these implants during a 14-year period in a pediatric population. METHODS Retrospective analysis of a pediatric population from 1987 through 2001. RESULTS Indications for enucleation (N = 19) included retinoblastoma (n =17), persistent hyperplastic primary vitreous (n =1), and painful blind eye (n =1). Conjunctival erosion (36.84%) and consequent implant exposure (15.70%) were the main problems identified in this study. There were no cases of orbital infection. Management included resuturing and scleral patching. CONCLUSION Conjunctival erosion of hydroxyapatite implants contributed to significant morbidity in 19 children who underwent enucleation and hydroxyapatite orbital implant.

Ahmed valve drainage implant surgery in the management of paediatric aphakic glaucoma

Background: Paediatric aphakic glaucoma presents months or years after cataract surgery in children and is a major long term complication. The results of surgical treatment are poor and many children require multiple and repeat procedures with poor visual outcomes. Methods: 13 children (19 eyes) had Ahmed valve implantation surgery, nine of the children had previous procedures such as cycloablation or trabeculectomy. Mitomycin was used at surgery in some patients and valve needling with Healon GV and 5-fluorouracil in some blebs after surgery. SF6 gas was also used at the time of surgery in most children to reform the anterior chamber. Results: 12 of the children (18 eyes) achieved intraocular pressure control of 15 mm Hg or less with a valve alone or with additional medical therapy. Conclusion: Ahmed valve implantation surgery alone or in combination with medical therapy is successful and safe in the management of paediatric aphakic glaucoma.

Artisan iris-claw lenses for the correction of aphakia in children following lensectomy for ectopia lentis

Purpose To describe the results of Artisan iris-claw lens implants in children with aphakia following lensectomy for ectopia lentis. Method We measured visual acuity, refractive error and endothelial cell counts and recorded complications in a group of children after insertion of Artisan iris-claw implants. Results Artisan implants were implanted in eight eyes of five children. Mean follow-up was 28 months (range: 4–58 months). The mean preoperative LogMAR best-corrected visual acuity was 0.21±0.2, and postoperatively, mean LogMAR uncorrected visual acuity was 0.04±0.09 (p=0.04). Mean endothelial cell count was 3312±277 cells preoperatively and 2913±268 cells postoperatively, representing a mean cell loss of 14.2% (p<0.001). Mean defocus equivalent was 11.38±1.04 preoperatively and 2.34±0.66 postoperatively. We encountered no postoperative complications in any of the eyes. Conclusion Artisan iris-claw implants are safe and effective in the correction of aphakia in children following lensectomy for ectopia lentis, enabling good spectacle-free distance vision in 75% of eyes with no postoperative complications.