Outcomes of pediatric cataract surgery with ... - CyberLeninka

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Journal of the Formosan Medical Association (2017) xx, 1e6

Available online at www.sciencedirect.com

ScienceDirect journal homepage: www.jfma-online.com

ORIGINAL ARTICLE

Outcomes of pediatric cataract surgery with triamcinolone-assisted vitrectomy Tzu-Hsun Tsai a,b, Chia-Ying Tsai a, Jehn-Yu Huang a,c, Fung-Rong Hu a,c,* a Department of Ophthalmology, National Taiwan University Hospital, Taipei, Taiwan, Republic of China b Graduate Institute of Clinical Medicine, College of Medicine, National Taiwan University, Taipei, Taiwan, Republic of China c Department of Ophthalmology, National Taiwan University College of Medicine, Taipei, Taiwan, Republic of China

Received 24 November 2016; received in revised form 12 January 2017; accepted 17 January 2017

KEYWORDS anterior vitrectomy; pediatric cataract; triamcinolone acetonide

Purpose: To evaluate outcomes in pediatric patients undergoing lensectomy, posterior capsulotomy, and triamcinolone-assisted vitrectomy for congenital cataract. Methods: This retrospective study included 34 patients younger than 72 months who underwent lensectomy, posterior capsulotomy, and triamcinolone-assisted vitrectomy with or without intraocular lens (IOL) implantation for cataract at the National Taiwan University Hospital from July 2006 to December 2012. Results: Fifty-one eyes from 34 patients with cataract (unilateral in 17 patients, bilateral in 17 patients) were included. The mean age at surgery was 26.74 months (range: 2e72 months). The mean postoperative follow-up was 27.8 months (range: 6e72 months). Primary IOL implantation was performed in 25 eyes, 21 of which had the IOL implanted in the capsular bag. Fifty eyes had a central round pupil. The median logarithm of the minimum angle of resolution visual acuity was 0.3 in patients with unilateral cataract and 0.1 in those with bilateral cataract. Three eyes (5.9%) developed visual axis opacification (VAO) and required further surgery. Univariate analysis using Fisher’s exact test indicated that surgery in the first 12 months of life was significantly associated with development of VAO (p Z 0.047). The incidence of postoperative VAO was approximately 15.8% in this age group. Conclusion: Triamcinolone-assisted vitrectomy can be used in pediatric cataract surgery without serious long-term adverse effects. While the incidence of VAO is low, it appears unavoidable in approximately one-sixth of patients who undergo surgery before 12 months of age. Copyright ª 2017, Formosan Medical Association. Published by Elsevier Taiwan LLC. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

Conflicts of interest: No author has a financial or proprietary interest in any material or method mentioned. * Corresponding author. Department of Ophthalmology, National Taiwan University Hospital, 12F, No. 7, Zhongshan South Road, Taipei City, 100, Taiwan, Republic of China. E-mail address: [email protected] (F.-R. Hu). http://dx.doi.org/10.1016/j.jfma.2017.01.009 0929-6646/Copyright ª 2017, Formosan Medical Association. Published by Elsevier Taiwan LLC. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/). Please cite this article in press as: Tsai T-H, et al., Outcomes of pediatric cataract surgery with triamcinolone-assisted vitrectomy, Journal of the Formosan Medical Association (2017), http://dx.doi.org/10.1016/j.jfma.2017.01.009

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Introduction Childhood cataract is one of the leading causes of blindness and severe visual impairment in children, and is problematic in developing countries in terms of morbidity, economic loss, and social burden.1 The prevalence of childhood cataract is estimated to be 1.03 per 10,000 children, and approximately 314,000 new cases are reported each year.2 Although surgically treatable, management of cataract in children is challenging because of the increased elasticity of the ocular tissues, robust inflammatory reactions, and a more reactive vitreous face.3,4 The rate of posterior capsular opacification following simple cataract extraction is high,5 so combined lens extraction, posterior capsulotomy, and anterior vitrectomy are routinely performed in younger patients.6,7 Complications, including pupil synechia, intraocular lens (IOL) decentration, and visual axis opacification (VAO), still occur despite modern surgical techniques. Appropriate vitreous management during surgery is crucial for successful pediatric cataract surgery. Triamcinolone acetonide (TA) is a water-insoluble steroid molecule, granules of which become trapped in the gel-like structure of the vitreous upon intraocular injection and enhance visualization of the vitreous.8 TA has been used in vitreoretinal surgery to stain the transparent vitreous, which assists surgeons in separating the posterior vitreous from the retina.9,10 In cataract surgeries complicated by rupture of the posterior chamber, TA can be applied in the anterior chamber to render the prolapsed vitreous more visible.11 Triamcinolone-assisted vitrectomy in pediatric cataract surgery was first described in 2009 by Shah et al.12 In a subsequent 1-year retrospective study, use of intracameral triamcinolone in pediatric cataract surgery was associated with less inflammation of the anterior chamber, and no patients developed VAO postoperatively.13 In this study, we evaluated the visual outcomes of pediatric cataract surgery with triamcinolone-assisted vitrectomy and analyzed the incidence of and risk factors for complications following this technique.

Methods Data were collected retrospectively from 34 patients with congenital cataract who underwent lensectomy, posterior capsulotomy, and triamcinolone-assisted anterior vitrectomy between July 2006 and December 2012. All patients were younger than 72 months at the time of treatment. All surgeries were performed by the same surgeon (THT) at the National Taiwan University Hospital, Taipei, Taiwan. The Ethics Review Committee at the National Taiwan University Hospital approved the study. Written informed consent was obtained from all guardians/caregivers. All patients underwent surgery soon after a diagnosis of cataract was confirmed. We excluded patients with a concurrent retinal or corneal abnormality and those with a systemic metabolic disorder. All patients were followed up for more than 6 months postoperatively. The surgical technique began with a clear corneal incision at 10 o’clock. Using the two-handed-technique, a second clear corneal stab incision was then made using a microvitreoretinal blade at 2 o’clock for accommodation

T.-H. Tsai et al. of a handheld irrigation instrument. After injection of 1.4% sodium hyaluronate (Healon GV; Advanced Medical Optics, Santa Ana, CA, USA), an anterior capsulotomy was performed manually using a bent 27-gauge needle and a microcapsule forceps. Hydrodissection was performed via injection of a balanced salt solution into the peripheral cortex through a 30-gauge cannula. A 20-gauge vitrector handpiece was used to remove lens material and perform the posterior capsulotomy and anterior vitrectomy. The TA was prepared as follows: 0.3 mL of TA suspension (40 mg/ mL, Kenalog-40 injection; Bristol-Myers Squibb Company, Princeton, NJ, USA) was drawn into a sterile 1 mL syringe attached to a 27-gauge needle after shaking the ampoule to disperse the TA particles evenly. Next, the syringe was positioned upside down, which allowed the TA crystals to precipitate against the plunger in the lower portion of the syringe. The supernatant was then discarded from the syringe by slowly advancing the plunger to the 0.05 mL mark. Finally, the needle was discarded and sterile balanced saline solution was drawn into the syringe to the 1 mL mark. Approximately 0.1e0.2 mL of TA was injected through a clear corneal incision to stain the anterior vitreous for improved visualization prior to vitrectomy; a further injection was administered to confirm the absence of residual vitreous strands. A foldable three-piece or onepiece AcrySof IOL (MA60AC or SA60AT, respectively; Alcon, Fort Worth, TX, USA) was implanted in the capsular bag after injection of the viscoelastic material, mainly in the patients aged 2 years and older. The corneal wounds were sutured using 10-0 nylon (Alcon, Fort Worth, TX, USA). Postoperatively, a 1% prednisolone acetate ophthalmic suspension (1%, Pred Forte; Allergan, Westport, County Mayo, Ireland) was applied hourly for 3 days, and thereafter four times daily for the following week. This was then substituted with a 0.1% betamethasone disodium phosphate ophthalmic solution (0.1%, Rinderon; Taiwan Shionoqi & Co., Ltd., Taipei, Taiwan) for 1 month. A 0.3% gentamicin ophthalmic solution (0.3%, Garamycin; Schering-Plough, Brussels, Belgium) was applied four times a day for 1 month, and an ophthalmic ointment combining a steroid and antibiotic (neomycin and polymyxin B sulfates, and dexamethasone; Maxitrol; Alcon, Fort Worth, TX, USA) was used once a day at bedtime for 1 week. Cycloplegic refraction was performed during follow-up visits at 1 day, 1 week, 1 month, and every 3 months thereafter postoperatively, and spectacles were prescribed if necessary. Intraocular pressure (IOP) was measured using a Tono-Pen (Reichert Ophthalmic Instruments, Depew, NY, USA). VAO was evaluated under a slit lamp, and a red reflex examination was performed using a retinoscope. VAO was defined as a fibrous or proliferative cell growth that was either observed under retroillumination or led to a dull retinoscopic reflex. Examination under anesthesia was performed in patients who could not tolerate examination in the outpatient clinic. For further analysis of the incidence and risk factors leading to complications, patients were divided into two groups based on their age at surgery, i.e., or > 12 months. Data were collected on position of IOL implantation, pupil centration, visual acuity (if measurable) during follow-up visits, presence of increased IOP, and VAO.

Please cite this article in press as: Tsai T-H, et al., Outcomes of pediatric cataract surgery with triamcinolone-assisted vitrectomy, Journal of the Formosan Medical Association (2017), http://dx.doi.org/10.1016/j.jfma.2017.01.009

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Triamcinolone-assisted vitrectomy in children The statistical analysis was performed using SPSS version 17.0 software for Windows (SPSS Inc., Chicago, IL, USA). The categorical data were tested for statistically significant differences using the Chi-square test or Fisher’s exact test. Continuous data were analyzed using the Mann-Whitney U test because the data were found not to be normally distributed. Statistical significance was set at p < 0.05.

Results We evaluated 51 eyes of the 34 patients recruited for this study. Table 1 summarizes the patient demographic data grouped according to age at time of surgery. Follow-up examinations were performed, on average, 27.8 months (range 6e72) following surgery. Primary IOL implantation was performed in 25 eyes, and 21 (84%) had the IOL implanted in the bag. Postoperatively, 50 eyes (98%) had a central round pupil. Only three eyes (5.9%) developed VAO that required further surgery. The subgroup analysis included 19 eyes of 12 patients who had undergone surgery at 12 months or younger and 32 eyes of 22 patients who had undergone surgery at older than 12 months. There was no statistically significant difference in sex or laterality between the two subgroups. The VAO rate was 15.8% in patients younger than 12 months at the time of surgery. The mean time until detection of postoperative VAO was 1 month. No patient aged over 12 months at the time of surgery, either with or without IOL implantation, required further surgery for management of VAO during follow-up. Patients under 12 months of age were found to have a significantly higher risk of developing VAO postoperatively (p Z 0.047; Table 2). Increased IOP was observed in three patients after surgery. One patient showed a transient increase in IOP for 1 day postoperatively because of residual viscoelastic substance. Another patient developed glaucoma at 4 years old (3 years and 8 months after surgery). The third patient had congenital glaucoma and underwent trabeculectomy after cataract surgery. No patients developed endophthalmitis or retinal detachment during the study period. Best corrected visual acuity (BCVA) was measurable in 30 eyes postoperatively. More than half (70%) of the eyes had a BCVA better than 0.3 logMAR (logarithm of the minimum angle of resolution) and 43.3% had a BCVA better than 0.1. logMAR. The median logMAR visual acuity was 0.3 in Table 1

3 Table 2 (VAO).

Risk factor analysis for visual axis opacification

Male/Female OD/OS Age at OP (months)b /> 12 months First IOL No/Bag/Sulcus Post-OP high IOP No/Yes

VAO (þ) (3 eyes)

VAO (e) (48 eyes)

p (two-sided)

1/2 1/2 9.3 4.6 3/0

28/20 24/24 28.4 22.2 16/32

0.571a > 0.99a 0.186c 0.047*a

3/0/0

23/22/3

0.216d

2/1

45/3

0.221a

IOL Z intraocular lens; IOP Z intraocular pressure; OD Z right eye; OP Z operation; OS Z left eye. * Indicates statistical significance. a By Chi-square test. b Data presented as mean standard deviation. c By Mann-Whitney U test. d By Fisher’s exact test.

patients with unilateral cataract and 0.1 in those with bilateral cataract (Table 3, Table 4; Figure 1A,B). Eight patients had strabismus prior to cataract surgery. At the end of follow-up, 12 patients were observed to have strabismus.

Discussion This retrospective study evaluated the outcomes of cataract surgery with triamcinolone-assisted vitrectomy in patients younger than 72 months of age. Satisfactory outcomes were achieved, including improved postoperative visual acuity, a low complication rate with a high proportion of in-the-bag IOL (84%), and intact pupillary configuration (98%). The only significant risk factor for VAO was a younger age at surgery; undergoing surgery before 12 months of age was associated with a higher incidence of VAO. VAO or posterior capsular opacification is the most frequent complication following cataract surgery in children.5,14 In addition to the intense postoperative

Patient demographic data.

Age (months)

12

> 12

Total

Patients (n) Unilateral/Bilateral Female/Male Age at surgery (months)b Eyes (n) OD/OS VAO

12 5/7 6/6 5.7 3.2 19 9/10 3

22 12/10 10/12 42.0 17.9 32 16/16 0

34

29.2 22.7 51

p 0.473a 0.800a < 0.001*c 0.856a 0.047*d

OD Z right eye; OS Z left eye; VAO Z visual axis opacification. * Indicates statistical significance. a By Chi-square test. b Data are presented as mean standard deviation. c By Mann-Whitney U test; dBy Fisher’s exact test.


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T.-H. Tsai et al. Table 3

Postoperative visual acuity in patients with unilateral cataract according to age at examination.

VA/age (months)

36e47.9, n (%)

48e59.9, n (%)

60e71.9, n (%)

>72, n (%)

Total, n (%)

20/25 (logMAR 0.1)

2 (40) 0 3 (60) 0

0 0 0 1 (100)

0 2 (100) 0 0

0 1 (25) 1 (25) 2 (50)

2 3 4 3

(16.7) (25) (33.3) (25)

logMAR Z logarithm of the minimum angle of resolution; VA Z visual acuity.

Table 4

Postoperative visual acuity in patients with bilateral cataract according to age at examination.

VA/age (months)

36e47.9, n (%)

48e59.9, n (%)

60e71.9, n (%)

>72, n (%)

Total, n (%)

20/25 (logMAR 0.1)

0 2 (100) 0 0

1 1 2 2

0 0 2 (50) 2 (50)

0 0 0 6 (100)

1 (5.6) 3 (16.7) 4 (22.2) 10 (55.6)

(16.7) (16.7) (33.3) (33.3)

logMAR Z logarithm of the minimum angle of resolution; VA Z visual acuity.

Figure 1 Visual acuity in patients following surgery according to age. (A) Patients with unilateral cataract. (B) Patients with bilateral cataract.

inflammatory response in young children, the reactivity of epithelial cells in the lens is high, and both lead to the proliferation of a fibrous membrane on the anterior surface of the vitreous and development of VAO.14,15 Preventing VAO in young children is critical because VAO impedes visual rehabilitation. Secondary membranectomy or Nd:YAG laser capsulotomy under general anesthesia is required if VAO is severe enough to hinder visual rehabilitation.5 Primary posterior capsulotomy and anterior vitrectomy have

been routinely performed during recent decades in children younger than 6 years receiving cataract surgery, and have decreased the incidence of VAO.6,7,16,17 The reported incidence of VAO following these techniques varies from 9.2% to 37.9%,7,15,18e21 depending on the patient inclusion criteria used, choice of IOL implant, and duration of followup. Instead of performing manual posterior continuous curvilinear capsulorhexis, we used a vitrector to perform the posterior capsulotomy because we considered vitrectorhexis to be an easier and more predictable method that can be performed without needing to fill extra ophthalmic viscosurgical devices. Moreover, using vitrectorhexis, anterior vitrectomy can be performed with the same vitrector following completion of capsulotomy, thereby preventing fluctuation of the anterior chamber pressure during change of instruments. Identification of the vitreous during anterior vitrectomy is difficult because of its transparent appearance; thus, it is also difficult to know if this step of the procedure has been appropriately completed. Vitrectomy using triamcinolone staining was first developed by Burk et al.22 in 2003, and has proven useful for direct observation of vitreous behavior. Shah et al.12 introduced this technique into pediatric cataract surgery in 2009, and it was found to be safe and effective in subsequent studies.13,23 We also found a low incidence of VAO using this technique; however, the risk was not entirely eliminated. Our findings indicated that undergoing cataract surgery in the first year of life was associated with an increased postoperative risk of developing VAO (p Z 0.047). Other variables, including gender, laterality, whether the IOL implant was primary or secondary, and increased IOP after surgery were not significant risk factors for development of VAO. IOL implantation is widely considered to be a risk factor for VAO.24e27 The inflammatory reaction is higher in young children after implantation of an IOL and the biocompatibility of the material used in the IOL affects the appearance of VAO.26 However, in this study, no patient older than 12 months, regardless of whether or not an IOL was implanted, developed VAO after surgery. Children younger than 12 months of


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Triamcinolone-assisted vitrectomy in children age have robust postoperative inflammatory responses and highly active lens epithelial cells that proliferate rapidly and migrate across the central visual axis to form VAO. Moreover, in the smaller eyes, it was more difficult to judge the appropriate size of the posterior capsulotomy, so the need for a sufficiently clear visual axis had to be weighed against that of adequate capsular support for future IOL implantation. In the group of patients who underwent surgery when aged younger than 12 months, we did not find any common characteristics in the 3 eyes that developed VAO when compared with the 16 other eyes. However, all 3 eyes were found to have VAO within 1 month postoperatively, which might be related to an inadequately sized posterior capsulotomy. Steroids were shown to decrease vascular permeability and stabilize damage at the blood-retinal barrier by suppressing vascular endothelial growth factor and prostaglandins.28 Intraocular triamcinolone injections are widely used for macular edema caused by retinal vascular disease or uveitis to reduce the inflammatory reaction.29e31 Use of intracameral triamcinolone is reported to decrease inflammation of the anterior segment postoperatively in children who have undergone surgery for traumatic cataract32 and is associated with a lower rate of cystoid macular edema and residual vitreous strands in the anterior chamber in adult patients with cataract and a posterior capsule rupture.11 There has been a report of preservatives such as benzyl alcohol in TA suspensions leading to the necrosis of cells in the retinal pigment epithelium and triggering mitochondrial apoptosis.33 To reduce the risk of cytotoxic effects on intraocular tissue, we removed the vehicles prior to diluting the TA and injected only 1e3 mg, which is within the safe dose range stated in the animal study.34 Further, Spitzer et al.35 reported that TA only has cytotoxic effects in the retina when there is close contact between the TA crystals and the cell membrane. Most of the TA granules were removed along with the vitreous during the vitrectomy, thus decreasing the chance of direct contact between TA and retinal cells. Three of our patients had increased IOP following surgery. Aside from one patient with congenital glaucoma and another with residual viscoelastic substance, one patient developed aphakic glaucoma 3 years and 8 months postoperatively. The timing of onset of glaucoma in this patient suggests that an association with TA is unlikely. Ventura et al.36 also found that injection of TA at the end of surgery for congenital cataract in children younger than 2 years did not significantly affect IOP or central corneal thickness in the year following surgery. However, Wilson et al.37 reported a case of bilateral cataracts with glaucoma in one eye, which had retained TA. Removing all of the TA granules at the end of vitrectomy is important, not only to reduce the cytotoxicity of TA but also to reduce the risk of elevated IOP. The main limitations of our study are its retrospective nature and the lack of a control group. However, this study does provide long-term follow-up information for thorough evaluation of this surgical technique and can serve as a reference in clinical practice. Further prospective, randomized, larger-scale studies are necessary for better assessment of this surgical technique. In conclusion, staining with TA facilitates identification of vitreous strands in pediatric cataract surgery without serious

5 long-term adverse effects. The antiinflammatory effect of TA might play a role in the prevention of postoperative VAO. Age at the time of surgery is related to the incidence of VAO. Although the incidence of visual obscuration is low, it remains unavoidable in approximately one-sixth of patients who undergo surgery before 12 months of age.

Acknowledgments This work was supported by the Ministry of Science and Technology, R.O.C. (NSC 102-2420-H-002-016-MY2).

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