Satish Gupta

Results of a Prospective Evaluation of Three Methods of Management of Pediatric Cataracts

BACKGROUND Although a variety of approaches to manage cataracts in children have been studied, no consensus exists on the optimum approach. The authors, therefore, conducted a prospective, nonrandomized, consecutive study to evaluate three most commonly adopted methods of management of pediatric cataracts. METHODS Lensectomy anterior vitrectomy (LAV), extracapsular cataract extraction with intraocular lens implantation (ECCE + IOL) and ECCE, primary posterior capsulotomy, anterior vitrectomy with IOL (ECCE + PPC + AV + IOL) were the surgical procedures performed. Aphakia in the LAV group was corrected with spectacles or contact lenses. Intraoperative and postoperative results were analyzed. Discrete variables among the three groups were compared using chi square test. RESULTS One hundred ninety-two eyes were included in the study. There was no statistically significant difference in the intraoperative complications in the three groups. During a mean follow-up period of 11.3 months, postoperative obscuration of the visual axis was seen in 43.7% of eyes in the ECCE + IOL group and in 3.65% of eyes in the ECCE + PC + AV + IOL (p < 0.001). Two of the seven patients in the LAV group in whom contact lenses were prescribed developed corneal infiltrates. Severe postoperative anterior uveitis occurred in 15.9% and 13.8% of eyes in the ECCE + PPC + AV + IOL and ECCE + IOL groups, respectively. None of the eyes that underwent LAV developed this complication (P < 0.001). There was no statistically significant difference in the incidence of retinal detachment, endophthalmitis, or glaucoma in the three groups. CONCLUSION Of the three approaches, ECCE + PPC + AV + IOL was conducive to at least short-term maintenance of a clear visual axis, provided optimum refractive correction, and was not associated with increased risk of short-term complications. Continued follow-up of these eyes is necessary to conclude on the long term results of this technique.

Penetrating keratoplasty in children.

Purpose. To determine the success of penetrating keratoplasty in the presence of various pediatric corneal abnormalities. Methods. We performed a retrospective study of pediatric corneal grafts at L.V. Prasad Eye Institute, Hyderabad, India. Outcome of pediatric corneal transplantation was evaluated in terms of anatomic and optical success and factors contributing to poor graft survival. On the basis of the corneal pathology, patients were divided into three categories: congenital, acquired nontraumatic, and acquired traumatic. Results. A retrospective analysis of 154 penetrating keratoplasties performed in 140 children, aged 14 years or younger, was done. The average follow-up was 1.3 years (range, 1 week–5 years). Grafts remained clear in 102 (66.2%) of 154 eyes. Clear grafts were achieved in 30 (63.8%) of 47 eyes with congenital opacities, 12 (54.5%) of 22 eyes with opacities from trauma, and 60 (70.6%) of 85 eyes with acquired nontraumatic opacities. Most (26 of 52) of the graft failures occurred during the first 26 weeks after surgery. Survival analysis revealed the probability of a graft remaining clear at the end of 26 weeks as 80% (SE, 3.39%). Poor graft survival could be correlated with those younger than 5 years (p = 0.0341) and performance of anterior vitrectomy (p = 0.0002). Most grafts failed because of allograft rejection (42.3%), infectious keratitis (26.9%), or secondary glaucoma (13.4%). Postoperatively, 53 eyes had ≥20/400 vision, 29 of which had ≥20/50. Vision could not be assessed in 33 eyes because of the young age. Conclusion. Whereas anatomic success of pediatric keratoplasty is increasing, optical success continues to remain less than satisfactory. Early surgical intervention and intensive amblyopia therapy may promote visual recovery.

Management of traumatic cataract in children

Purpose: To evaluate the presentation, mode of management, and clinical outcome of traumatic cataract in children. Setting: L.V. Prasad Eye Institute, Hyderabad, India. Methods: One hundred thirty‐seven children (<16 years) who developed traumatic cataract, seen between January 1988 and December 1993, were retrospectively analyzed. Nature of injury, type of cataract, management, and outcome were evaluated. Results: The study group comprised 110 boys and 27 girls. Average follow‐up was 11.7 months (range 1 week to 60 months). Most injuries (54.7%) were caused by a stick or a bow and arrow. Most (53.2%) of the cataracts were total. Corneal scarring (60.5%) and iris‐related problems (49.6%) were the most common associated findings. Extracapsular cataract extraction with intraocular lens (IOL) implantation was performed in 65.67% of patients. Visual acuity improved from 20/200 or worse in 97.7% of patients preoperatively to 20/60 or better in 74.1 % of patients postoperatively. Seventeen patients had associated posterior segment insult; most failed to recover satisfactory vision. Posterior capsule opacification (PCO) was noted in 42.9% of patients. Conclusions: Extracapsular cataract extraction with IOL implantation provides satisfactory results in children with traumatic cataract. Associated posterior segment complications and development of PCO are the major obstacles to visual rehabilitation.

Traumatic wound dehiscence after penetrating keratoplasty.

Eighteen eyes with wound dehiscence after penetrating keratoplasty were studied. Keratoplasty was performed for corneal scarring (n = 8), dystrophies (n = 6), graft failure (n = 2), and corneal edema (n = 2). The mean duration between keratoplasty and wound dehiscence was 6.54 months. All eyes underwent wound repair with or without iris excision, lensectomy, and vitrectomy. Grafts remained clear in eight eyes. Five eyes developed phthisis bulbi. Visual acuity was better than 20/200 in seven eyes. There was no site (quadrant) specificity for dehiscence. Trivial trauma resulted in dehiscence in 10 of the 18 eyes. The major determinants of visual outcome were the force of trauma and status of the posterior segment. Dehiscence of the graft-host junction in all cases reflects its persistent weakness after surgery.

Etiology of ptosis after cataract surgery

Purpose: To determine whether using a lid speculum with a superior rectus bridle suture in cataract surgery results in levator rectus aponeurosis dehiscence caused by strong fascial attachments between the levator and superior rectus muscles. Setting: L.V Prasad Eye Institute, Hyderabad, India. Methods: This study comprised 220 patients having cataract extraction with posterior chamber intraocular lens implantation. The patients were randomly assigned to one of two groups. In the first group (n = 108), a lid speculum was used during surgery. In the second group (n = 112), no speculum was used. All patients had a superior rectus bridle suture. The occurrence of ptosis was analyzed by a masked observer who was not involved in the surgery. Results: The incidence of ptosis was significantly higher in the speculum (44.4%) than in the no‐speculum (23.3%) group (P = .0009). Conclusion: The results indicate that the opposing forces created by the lid speculum and bridle suture can cause levator aponeurosis dehiscence because of the strong fascial attachments between the superior rectus and levator muscles. The occurrence of ptosis in the no‐speculum group implies a multifactorial etiology, however.

Heparin-surface-modified intraocular lenses in pediatric cataract surgery: Prospective randomized study

PURPOSE To evaluate the performance of heparin-surface-modified (HSM) intraocular lenses (IOLs) in pediatric eyes after cataract surgery. SETTING L.V. Prasad Eye Institute, Hyderabad, India. METHODS This prospective, randomized, double-masked, controlled clinical trial comprised 90 children aged 2 to 14 years with cataract. The patients were consecutively randomized to receive an HSM (Group 1) or an unmodified (Group 2) poly(methyl methacrylate) (PMMA) IOL. Extracapsular cataract extraction (ECCE) with IOL implantation was performed in children 8 years and older and ECCE with primary posterior capsulotomy, anterior vitrectomy, and IOL implantation in children younger than 8 years. Outcome parameters were inflammatory cell deposits on the IOL surface, posterior synechias, and anterior chamber reaction. RESULTS Follow-up data were available for 73, 70, 60, and 68 patients at 1 week, 1 month, 3 months, and 6 months, respectively. Significantly fewer cell deposits were noted in Group 1 at 1, 3, and 6 months (P < .001). Synechia formation and anterior chamber reaction were comparable in the 2 groups. CONCLUSION The lower incidence of inflammatory cell deposit formation in eyes with HSM PMMA IOLs indicates that these IOLs have greater bicompatibility than unmodified IOLs in pediatric cataract surgery.

Nocardial necrotizing scleritis after trauma. Successful outcome using cefazolin.

Nocardial necrotizing scleritis is uncommon, but potentially sight threatening. We report the occurrence of necrotizing scleritis in a 58-year-old farm worker after he sustained trauma with vegetable matter. Microbiological studies isolated Nocardia asteroides, sensitive only to cefazolin. Clinically the patient responded well to this drug, attaining a final visual acuity of 20/40, with complete resolution of the scleritis. Early isolation and testing for antibiotic sensitivity were responsible for the successful management of this patient.

Cataract formation after penetrating keratoplasty

Purpose: To assess the incidence and risk factors for developing cataract after penetrating keratoplasty (PKP). Setting: L.V. Prasad Eye Institute, Hyderabad, India. Methods: This retrospective analysis of 251 phakic patients who had PKP between 1987 and 1994 assessed the incidence of and risk factors for cataract formation. Patients were assigned to one of two groups: Group 1 (n = 96), patients with keratoconus and corneal dystrophy; Group 2 (n = 88), patients with corneal scar and adherent leucoma. Preoperative, intraoperative, and postoperative lens details were noted. Data on intraoperative iris procedures (excess manipulation, pupilloplasty, synechiolysis, peripheral iridectomy) and postoperative topical steroid usage were assessed. Results: Sixty‐seven patients were excluded because of incomplete lens status data. Of the remaining 184 patients, 45 (24.45%) developed cataract. Most cataracts (n = 31) developed within the first year of surgery. The incidence of cataract was significantly higher in Group 2 (n = 29) than in Group 1 (n = 16) (P = .0102). There was no significant between‐group difference in mean steroid dose (P = .7064); however, the mean dose was significantly higher in eyes with cataracts (563 ± 234 units) than in those without (479 ± 127 units) (P = .0352). In Group 2, 9 of 20 patients who had synechiolysis, 1 of 3 who had pupilloplasty, and 2 of 5 who had peripheral iridectomy developed cataract. In Group 1, no patient had irisrelated procedures. Conclusion: Excessive steroid use and intraoperative iris manipulations are major risk factors for cataract formation after PKP.

Globe rupture during digital massage after peribulbar anesthesia

Abstract A 75‐year‐old woman developed globe rupture with extrusion of intraocular contents during digital massage after periocular injection of an anesthetic. The rupture was repaired. At the last follow‐up 6 months after surgery, visual acuity was 20/160. The retina was attached, and the vitreous hemorrhage was resolving. This complication of peribulbar anesthesia and digital massage highlights the importance of using quantitative techniques to induce hypotony during peribulbar anesthesia.

Secondary capsule-supported intraocular lens implantation in children.

Purpose: To evaluate surgical problems, postoperative complications, and visual results of secondary posterior chamber intraocular lens (IOL) implantation in children. Setting: L.V. Prasad Eye Institute, Hyderabad, India. Methods: A retrospective study was done of secondary IOL implantation in 27 children (35 eyes) who were not satisfied with aphakic glasses and were intolerant of or reluctant to use contact lenses. The extent of posterior capsular support was assessed prior to surgery. Additional surgical procedures were posterior synechiolysis (11 eyes), anterior vitrectomy (8 eyes), pupilloplasty (2 eyes), and membranectomy (2 eyes). Results: Postoperative complications included wound leak (1 eye), uveitis (5 eyes), peripheral anterior synechias (2 eyes), and retinal detachment (1 eye). Visual acuity improved or remained at the preoperative level in 34 eyes. Conclusion: Secondary posterior chamber IOL implantation is an effective optical modality for managing pediatric aphakia. Observation must continue to determine the long‐term safety of the procedure.