Epilenticular lens implantation versus extracapsular cataract extraction and lens implantation in children

Epilenticular lens implantation versus extracapsular cataract extraction and lens implantation in children B. Ghosh, MD, A.K. Gupta, MS, Sanjeev Taneja, MS, Aloke Gupta, MS, Shahana Mazumdar, MS

ABSTRACT Purpose: To compare the results of epilenticular posterior chamber intraocular lens (IOL) implantation and pars plana lensectomy with those of extracapsular lens aspiration and posterior chamber IOL implantation in eyes with pediatric cataracts. Setting: Guru Nanak Eye Centre, New Delhi, India. Methods: Forty eyes with childhood cataract of varied etiology were divided into two groups of 20 eyes each, matched by age, sex, and type of cataract. Group A had epilenticular IOL implantation with pars plana lensectomy. Group 8 had extracapsular lens aspiration with posterior chamber IOL implantation. Follow-up ranged from 1 to 3 years. Results: All 20 eyes in Group A maintained a clear pupillary axis from the immediate postoperative period to the last follow-up. In Group 8, 80% of eyes developed varying degrees of posterior capsule opacification (PCO), which hampered vision. In Group A, 95% of eyes had a visual acuity of 6/12 or better; only 45% of eyes in Group 8 achieved a visual acuity of 6/60 or better. Conclusion: Although patients in both groups had good visual recovery, those having epilenticular IOL implantation with pars plana lensectomy maintained a clear pupillary axis and did not develop PCO, preventing the need for secondary intervention. J Cataract Refract Surg 1997; 23:612-617

T

he excellent visual results of intraocular lens (IOL) implantation in eyes with senile cataract have not been obtained in cases of childhood cataract because of complications peculiar to that age group.I-3 Posterior capsule opacification (PCO), one of the most common and serious complications, is caused by proliferating anterior lens epithelial cells4 and scaffolding on the poste-

From Guru Hanak Eye Centre, Maulana Azad Medical College, Hew Delhi, India. Reprint requests to Aloke Gupta, MS, C-II1226, Vasant Kunj, Hew Delhi-ll0070, India. 612

rior capsule, anterior vitreous face, and the anterior and posterior 10L surfaces. 5,6 The high incidence of PCO led to the concept of performing a primary posterior capsulotomy and anterior vitrectomy at the time of cataract extraction and 10L implantation in children?-9 Epilenticular lens implantation, an extension of the concept described by Tablante and coauthors lO in 1988, basically consists of a pars plana lensectomy preceded by epilenticular lens implantation into the ciliary sulcus. However, few studies of the technique's efficacy are available. Most patients treated at our center are from the lower socioeconomic strata and are often referred from

J CATARACT REFRACT SURG-VOL 23, SUPPLEMENT 1 1997

EPILENTICULAR IMPLANTATION VERSUS ECCE

remote villages. These patients are commonly lost to follow-up and not available for timely secondary procedures. Thus, we sought a one-time primary procedure that would result in a clear pupillary axis in most patients in a fairly predictable manner. Previously, the procedure we commonly followed in cases of pediatric cataract was lens aspiration and in-the-bag IOL implantation. Our initial experience with primary posterior capsulotomy was not encouraging because of occlusion of the capsulotomy. This prompted us to begin using epilenticular IOL implantation. This prospective study compared the results of epilenticular IOL implantation with those of lens aspiration and posterior chamber IOL implantation in eyes with various types of childhood cataract.

Patients and Methods Forty eyes with childhood cataract of varied etiology were divided into two groups, matched by age, sex, and type of cataract. Group A (n = 20) had epilenticular IOL implantation and Group B (n = 20), lens aspiration with posterior chamber IOL implantation. Patient age ranged from 3 to 11 years and follow-up, from 1 to 3 years (mean 1.60 years). Twenty-two eyes had traumatic cataract (11 in each group); 18 had developmental cataract (9 in each group). Table 1 shows the associated ocular findings in eyes with traumatic cataract. Preoperatively, a detailed history was taken including duration of diminution of vision, past visual status and trauma, other significant ocular or systemic complaints, and birth and family information. The workup consisted of thorough systemic and local examinations, visual acuity with or without best correction (when possible), presence of squint and ocular fixation, and a detailed slitlamp examination (when possible). If possible, Table 1. Findings associated with traumatic cataracts. Number of Eyes Finding Comeal scar/opacity Iris holes/tears Synechias Capsular rupture Lens matter in anterior chamber

Group A (n 20)

Group B (n 20)

9 4 5 9 4

11

=

=

5 5 9 7

the posterior segment was assessed by direct and indirect ophthalmoscopy and ultrasonography. Intraocular lens power was calculated echographically in older, cooperative children or as recommended by Gordon and Donzis 11 in young, uncooperative children. All parents gave informed consent. Surgery was performed using general endotracheal anesthesia. Pupils were dilated preoperatively with phenylephrine hydrochloride 5%, cyclopentolate hydrochloride 1%, and flurbiprofen sodium 0.03% eyedrops.

Surgical Technique In Group A, a wide, fornix-based conjunctival flap was made from 3 to 9 o'clock. Episcleral bleeders were cauterized and two partial thickness sclerotomies made at the 10 and 2 o'clock positions 3.0 mm from the limbus. The anterior chamber was filled with viscoelastic, and a midlimbal corneoscleral section of 6.0 to 7.0 mm was made. Then, a posterior chamber IOL was placed over the cataractous lens. Eyes with an intact anterior capsule had an anterior capsular incision under the IOL with an irrigating cystotome placed at this stage. In eyes with traumatic cataract, any synechias (anterior or posterior) were broken or cut and free-floating lens matter in the anterior chamber was aspirated to ensure the pupillary margins were visible for IOL introduction. The incision was then closed with 10-0 monofilament in a continuous fashion but with a temporary knot. During IOL placement, the pupil constricted slightly due to manipulation. Viscoelastic was then aspirated and the anterior chamber re-formed with Ringer's lactate containing adrenaline 1: 1000 (0.3 mL in 500 mL Ringer's) to dilate the pupil sufficiently for lensectomy. Full-thickness sclerotomies were made, and a pars plana lensectomy was performed. First, the lenticular matter was removed intercapsularly. Then, the anterior and posterior capsules were nibbled. A shallow anterior vitrectomy was performed. A 360 degree peripheral rim of anterior and posterior capsules and cortex was left. The corneoscleral suture was made permanent, and the sclerotomies were closed with an 8-0 monofilament suture. The conjunctiva was sutured back. Subconjunctival antibiotic and steroids were injected at the end of the surgery.

J CATARACT REFRACT SURG-VOL 23, SUPPLEMENT 11997

613

EPILENTICULAR IMPLANTATION VERSUS ECCE

Table 2.

Table 3. Postoperative complications.

Intraoperative complications and observations.

Number of Eyes

Number of Eyes Group A (n = 20)

Finding

Scleral collapse, vitreous upthrust Need for synechiotomy Adherent anterior and posterior capsules Posterior capsule tear* Posterior capsule plaque Loose lens material aspiration Pigment release

7 5

Group B (n = 20)

9 4 2

4 4 2 2

*Not large enough to prevent IOL implantation

Complication

Up to 1 month postoperative Transient corneal striae Exudative membrane Pupillary capture Vitritis Iris prolapse 1 to 12 months postoperative

peo

Group A (n = 20)

Group B (n = 20)

9

9 9 4

2 2 2 2

2 16

4

Pupillary capture

In Group B, 13 eyes had in-the-bag 10L placement by the envelope technique. These eyes had an intact anterior capsule or if the capsule was ruptured, had inferior flaps sufficient to allow in-the-bag 10L placement. No eye had anterior-posterior capsule adhesion. In the other 7 eyes, capsular bag fixation was not possible. Thus, the 10L was fixated in the sulcus after a canopener capsulotomy was made. Primary posterior capsulotomy was not done in any of these eyes. Fifteen eyes in Group A received a three-piece, modified J-loop 10L with a poly(methyl methacrylate) (PMMA) optic and polypropylene loops. Five eyes received an all-PMMA, C-loop lens. In Group B, 16 eyes received a three-piece, J-loop 10L and 6 eyes, an allPMMA, C-loop lens. Optic size ranged from 6.0 to

Table 2 shows intraoperative complications and observations, and Table 3, postoperative complications. All 20 eyes in Group A maintained a clear pupillary axis from the immediate postoperative period to the last follow-up (Figures 1 and 2). Pupillary capture occurred in 2 eyes in Group A in the early postoperative period but spontaneously resolved. The peripheral cortical matter enveloped between the anterior and posterior capsules did not cause an inflammatory reaction. In Group B,

Figure 1. (Ghosh) The pupillary axis in a patient with epilenticular IOL implantation is clear 6 months postoperatively.

Figure 2. (Ghosh) The pupillary axis in a patient with epilenticular IOL implantation is clear 24 months postoperatively.

614

6.5 mm. Overall diameter was 13.5 or 14.0 mm. The 10L power ranged from 18.0 to 31.0 diopters.

Results

] CATARACT REFRACT SURG-VOL 23. SUPPLEMENT 1 1997

EPILENTICULAR IMPLANTATION VERSUS ECCE

Table 4. Postoperative best corrected visual acuity. Number of Eyes

Visual Acuity 4 months postoperative LP to HM FC to 6 m Better than 6/60 1 year postoperative 6/60 to 6/36 6/24 to 6/18 6/12 or better

Group A (n = 20)

Group B (n = 20)

2 9 19*

19

91

5 13

LP = light perception, HM = hand motions; FC = counting fingers *All eyes had a visual acuity of 6/12 or better

Figure 3. (Ghosh) Posterior capsule opacification 3 months postoperatively in an eye with extracapsular lens aspiration and posterior chamber IOL implantation.

1Four eyes had a visual acuity of 6/12 or better

80% of eyes developed varying degrees of PCO that hampered vision (Figure 3). Table 4 shows postoperative visual acuities in both the groups. At 4 months, 95% of eyes in Group A and 20% in Group B had a visual acuity of 6/12 or better. After neodymium:YAG (Nd:YAG) capsulotomy in 10 Group B eyes and pars plana secondary capsulectomy in 2, 65% of eyes in Group B had a visual acuity of 6/12 or better at the end of 1 year. Ninety percent of eyes in both groups achieved some degree of binocular vision. One eye in each group did not have good vision postoperatively because of traumatic macular scarring.

The most serious vision-impairing complication, however, is PCO. 15 ,16 That 80% of the patients having lens aspiration in our study developed PCO confirms that this technique, combined with posterior chamber 10L implantation, may not be the best choice in this age group. In addition, many children are not cooperative enough to have Nd:YAG laser capsulotomy and often, the membranes are so thick they warrant a second surgical intervention. Therefore, the current consensus is that PCO is inevitable unless the posterior capsule is opened and an anterior vitrectomy performed at the time of surgery in these eyes,8,1?-19

Discussion Posterior chamber 10Ls provide the best visual rehabilitation after cataract surgery and have many advantages over heavy spectacles, contact lenses, and epikeratophakia. Lens aspiration with 10L implantation in young eyes can lead to several intraoperative and postoperative problems. In our experience, the younger the patient, the higher the incidence of positive vitreous pressure, making anterior chamber maneuvers more difficult. The synechias and capsulocortical bands in eyes with traumatic cataract add to the problem. These complications lead to the well-documented higher incidence of inflam. after ped"latnc cataract surgery." 3 12 13 I n add'1matlon tion, capsule contraction can cause pupillary capture. 14

Several techniques to prevent such complications have been described, including lensectomy and vitrectomy with anterior chamber 10L implantation,20 posterior capsulotomy and shallow anterior vitrectomy at the time of cataract extraction before or after posterior chamber 10L implantation,21-23 limbal-approach retropseudophakic vitrectomy, 18 and scleral tunnel in-thebag 10L insertion with pars plana posterior . 24H owever, WIt . h pnmary . capsuIectomyand vttrectomy. capsulotomy and anterior vitrectomy, particularly if the 10L is placed in the bag, 10L dislocation can occur, with an incidence offrom 3 to 20%.3,24,25 In addition, the posterior capsule tears may extend during anterior vitrectomy and if the procedure is done through the anterior route, vitreous adhesion and incarceration in the wound can occur, increasing the risk of cystoid macular edeml6 and retinal detachment?? Thus, some surgeons are reluctant to disturb the vitreous during lens implantation.

J CATARACT REFRACT SURG-VOL 23, SUPPLEMENT 1 1997

615

EPILENTICULAR IMPLANTATION VERSUS ECCE

Posterior capsulorhexis with optic capture does not disturb the vitreous yet maintains a clear pupillary axis. However, according to Gimbel and DeBroff, 28 who developed the technique, the procedure is technically demanding. They recommend evaluation of more cases with longer follow-up. Epilenticular 10L implantation is a primary procedure that is easier to perform, provides a stable, wellcentered 10L, and most important, maintains a clear visual axis. Because the 10L is placed over the cataractous lens in the ciliary sulcus, its insertion is independent of the posterior capsule's status. Although ciliary-sulcusfixated 10Ls may not be ideal as capsule-supported 10Ls for any age group, they can still be considered an acceptable alternative. In addition, 10L insertion is ensured, particularly in cases of unilateral trauma in which the posterior capsule's status is not known or in which there is a large tear. The surgical procedure is minimally affected by the scleral collapse and positive vitreous pressure. Also, because there is less anterior chamber manipulation, the subsequent anterior chamber reaction is less. The optimal posterior capsulotomy size has not been determined. There are several reports of secondary membranes occluding a child's visual axis after primary 20 "24 30 Th ere. posten.or capsu1ectomy an d vttrectomy. fore, a procedure in which a large caps ulotomy is possible without compromising posterior chamber 10L stability or centration would be ideal. In our study, epilenticular 10L implantation achieved these goals while providing a clear pupillary axis in all eyes. T ablante and coauthors (personal communication, 1992), in a study of 47 eyes with epilenticular 10L implantation, also did not find evidence of retropseudophakic membrane. In the present study, 65% of eyes having lens aspiration and posterior chamber 10L implantation achieved a visual acuity of 6/12 or better after a second intervention. This agrees with the results of Sinskey and coauthors,9 who found similar best corrected acuity in 73.0% of eyes with developmental cataract and 62.5% with traumatic cataract after extracapsular cataract extraction and posterior chamber 10L implantation with or without posterior capsulotomy. Surprisingly, in our study, the epilenticular group had even better visual results, with 95% achieving a visual acuity of 6/12 or better. Our study therefore provides a strong basis for evaluating epilenticular 10L implantation in a larger series 616

of pediatric cataract with longer follow-up. This technique guarantees posterior chamber 10L placement in all types of childhood cataract, overcoming most intraoperative problems peculiar to this age group.

References 1. Menezo JL, Taboada JF, Ferrer E. Complications of in-

2.

3.

4.

5.

6.

7.

8.

9.

10.

11. 12.

13.

14.

15. 16.

traocular lenses in children. Trans Ophthalmol Soc UK 1985; 104:546-552 Maida JW, Sheets JH. Pseudophakia in children: a review of results of eighteen implant surgeons. Ophthalmic Surg 1979; 10(12):61-66 Hiles DA, Watson BA. Complications of implant surgery in children. Am Intra-Ocular Implant Soc J 1979; 5:24-32 McDonnell PJ, Zarbin MA, Green WR. Posterior capsule opacification in pseudophakic eyes. Ophthalmology 1983; 90:1548-1553 Cobo LM, Ohsawa E, Chandler D, et al. Pathogenesis of capsular opacification after extracapsular cataract extraction. An animal model. Ophthalmology 1984; 91:857863 Nishi O. Fibrinous membrane formation on the posterior chamber lens during the early postoperative period. J Cataract Refract Surg 1988; 14:73-77 Oliver M, Milstein A, Pollack A. Posterior chamber lens implantation in infants and juveniles. Eur J Implant Refract Surg 1990; 2:309-314 Parks MM. Posterior lens capsulectomy during primary cataract surgery in children. Ophthalmology 1983; 90: 344-345 Sinskey RM, Stoppel JO, Amin P. Long-term results of intraocular lens implantation in pediatric patients. J Cataract Refract Surg 1993; 19:405-408 Tablante RT, Cruz EDG, Lapus JV, Santos AM. A new technique of congenital cataract surgery with primary posterior chamber intraocular lens implantation. J Cataract Refract Surg 1988; 14:149-157 Gordon RA, Donzis PB. Refractive development of the human eye. Arch Ophthalmol1985; 103:785-789 Vasavada A, Chauhan H. Intraocular lens implantation in infants with congenital cataracts. J Cataract Refract Surg 1994; 20:592-598 Brady KM, Atkinson CS, Kilty LA, Hiles DA. Cataract surgery and intraocular lens implantation in children. AmJ Ophthalmol1995; 120:1-9 Bucci FAJr, Lindstrom RL. Total pupillary capture with a foldable silicone intraocular lens. Ophthalmic Surg 1991; 22:414-415 Apple DJ, Solomon KD, Tetz MR, et al. Posterior capsule opacification. Surv OphthalmoI1992; 37:73-116 Gupta AK, Grover AK, Gurha N. Traumatic cataract

J CATARACT REFRACT SURG-VOL 23. SUPPLEMENT 1 1997

EPILENTICULAR IMPLANTATION VERSUS ECCE

17.

18.

19.

20.

21.

22.

23. 24.

surgery with intraocular lens implantation in children. J Pediatr Ophthalmol Strabismus 1992; 29:73-78 Morgan KS, Karcioglu ZA. Secondary cataracts in infants after lensectomies. J Pediatr Ophthalmol Strabismus 1987; 24:45-48 Mackool RJ, Chhatiawala H. Pediatric cataract surgery and intraocular lens implantation: a new technique for preventing or excising postoperative secondary membranes. J Cataract Refract Surg 1991; 17:62-66 Gimbel HV, Ferensowicz M, Raanan M, DeLuca M. Implantation in children. J Pediatr Ophthalmol Strabismus 1993; 30:69-79 Hiles DA, Hered RW. Modern intraocular lens implants in children with new age limitations. J Cataract Refract Surg 1987; 13:493-497 Hemo Y, BenEzra D. Traumatic cataracts in young children; correction of aphakia by intraocular lens implantation. Ophthalmic Paediatr Genet 1987; 8:203-207 Dahan E, Salmenson BD. Pseudophakia in children: precautions, technique, and feasibiliry. J Cataract Refract Surg 1990; 16:75-82 Lischetti P. New technique for posterior capsulotomy. Eur J Implant Refract Surg 1990; 2:77-79 Buckley EG, Klombers LA, Seaber JH, et al. Manage-

25.

26.

27.

28.

29.

30.

ment of the posterior capsule during pediatric intraocular lens implantation. Am J Ophthalmol 1993; 115:722728 Dutton JJ, Baker JD, Hiles DA, Morgan KS. Visual rehabilitation of aphakic children. Surv Ophthalmol1990; 34:365-384 Hoyt CS, Nickel B. Aphakic cystoid macular edema; occurrence in infants and children after transpupillary lensectomy and anterior vitrectomy. Arch Ophthalmol 1982; 100:746-749 Koenig SB, Ruttum MS, Lewandowski MF, Schultz RO. Pseudophakia for traumatic cataracts in children. Ophthalmology 1993; 100:1218-1224 Gimbel HV, DeBroff BM. Posterior capsulorhexis with optic capture: maintaining a clear visual axis after pediatric cataract surgery. J Cataract Refract Surg 1994; 20: 658-664 Apple DJ, Loftfield K, Mamalis N, et al. Biocompatibiliry of implant materials: a review and scanning electron microscopic study. Am Intra-Ocular Implant Soc J 1984; 10:53-66 Wright KW, Christensen LE, Noguchi BA. Results of late surgery for presumed congenital cataracts. Am J Ophthalmol 1992; 114:409 -415

J CATARACT REFRACT SURG-VOL 23, SUPPLEMENT 1 1997

617