1. SWONS Exeter 2005 Paediatric cataract Tony Quinn Consultant Ophthalmologist West of England Eye Unit Royal Devon & Exeter Hospital

2. SWONS Exeter 2005 Outline What sort of cataract? Why do children get cataracts? What else could it be? What else occurs in association? Should we operate? What options are there? How soon should we treat? Complications? Controversies? IOL Implants? Outcomes? Our local results?

3. SWONS Exeter 2005 What sort of cataract? Nuclear, lamellar, powdery, subcapsular, sutural, total Can start off mild and become more dense Obscures retinal image May cause amblyopia

4. SWONS Exeter 2005 Why do children get cataracts? Gene mistake Inherited Associated with other genetic conditions (Paediatrician workup) Trauma Uveitis Intrauterine infections

5. SWONS Exeter 2005 What else could it be? “white pupil” differential diagnosis Retinoblastoma Retinopathy of prematurity Coat’s disease Persistent fetal circulation

6. SWONS Exeter 2005 What else occurs in association? Main problem is amblyopia Eye growth Strabismus

7. SWONS Exeter 2005 Should we operate? What options are there? Unilateral cataract: ? treatment Bilateral cataract: Treat if visually significant: Can you see in? Is opacity >=3mm? anterior or posterior ? Amblyopia, abnormal eye growth

8. SWONS Exeter 2005 How soon should we treat? <4 weeks may cause more glaucoma More than 10 weeks may cause irreversible amblyopia, nystagmus Unilateral about 6 weeks Depends on how dense

9. SWONS Exeter 2005 Surgery

10. SWONS Exeter 2005 Complications? Infection, bleeding, GA risk, loss of eye… Big risks: Re-op Glaucoma Retinal detachment Amblyopia Strabismus Glasses(bifocals) or Contact lens for sure

11. SWONS Exeter 2005 What do we tell the parents? Lifetime journey Very hard work Lots of drops early, then glasses and patching for years May not work well (unilateral) Long term risks Risk to other eye (sympathetic)

12. SWONS Exeter 2005 Controversies? IOL Implants? IOL implants: when to use? Minimum age Minimum corneal diameter How long will they last? Rigid (?Heparin coated) or foldable? Where to place the lens? Dealing with posterior capsule

13. SWONS Exeter 2005 Outcomes? Excellent results possible IOLs may be better overall than contact lenses. Not much in it Refract, Refract, Refract!!! May need EUA Tonopen for awake IOP

14. SWONS Exeter 2005 Our local results? Methods Consecutive infant cataract surgery 00 - 03 9 infants, 15 eyes Mean age at surgery 21 weeks (4-42w) All posterior chamber, 13 in bag, 2 in sulcus 1 lost to follow up after 6 weeks

15. SWONS Exeter 2005 Methods primary pars plana Vx IOL: Heparin PMMA in 5, Acrysof MA 60 BM in 10 (both 6 mm optic) Healon 5 in 14, Healon GV in 1 CCC in 14, MVR = 1 1 patient corneal diam 9.5 2 patients (4 eyes) nystagmus and strabismus pre-op

16. SWONS Exeter 2005 Refractive target +4 to +8D, (SRK-T) but max +30D IOL Unilat Down +1.8D

17. SWONS Exeter 2005 Refractive outcomes: mean followup 26.5 mo

18. SWONS Exeter 2005 Vision outcomes mean 26.5 mo

19. SWONS Exeter 2005 Complications of surgery Strabismus in 6 of 8 (1 lost to follow-up) Iris capture 1/14 Repeat posterior capsulectomy 6/14 Anterior capsule phimosis 1/14 Glaucoma nil mean 33 mo f/u. Mean IOP =14, range 10- 17mmHg Retinal detachment nil IOL decentred nil

20. SWONS Exeter 2005 Conclusions IOL implants in infants are possible with good visual and refractive outcomes Myopic shift with time in most: ?emmetropisation Mildly microphthalmic child showed almost no reduction in initial hypermetropia with time High rate of strabismus Nearly half re-op for “PCO”