Glaucoma after cataract extraction and posterior chamber lens implantation in children

Glaucoma after cataract extraction and posterior chamber lens implantation in children Kathryn M. Brady, FRCOphth, C. Scott Atkinson, MD, Laura A. Kilty, MD, David A. Hiles, MD

ABSTRACT Purpose: To evaluate the incidence of postoperative glaucoma in children who have cataract extraction and posterior chamber intraocular lens (IOL) implantation. Setting: Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania, USA. Methods: The incidence of glaucoma of all etiologies was evaluated in 45 eyes of 37 selected consecutive patients aged 1 to 18 years who had cataract extraction and posterior chamber IOL implantation from 1991 to 1994. Mean follow-up was 23 months (range 6 to 38 months). Nineteen patients had traumatic and 18 had developmental cataract. Exclusion criteria were microcornea smaller than 9.0 mm in diameter, preoperative glaucoma, or poor pupil dilation. The surgical technique comprised a continuous curvilinear anterior capsulorhexis in most cases, extracapsular aspiration by Ocutome® or phacoemulsification, and retention of the posterior capsule. A peripheral iridectomy was done in 7 eyes (16%). Postoperative medications included topical atropine combined with topical, subconjunctival, and systemic corticosteroids and antibiotics. Results: Three patients with traumatic cataract developed postoperative glaucoma during the follow-up. One developed pseudophakic pupillary block; however, a peripheral iridectomy prevented glaucoma. Two other patients developed lateonset glaucoma: one secondary to angle recession and the other to peripheral anterior synechias. No patient with developmental cataract developed glaucoma. Conclusion: Careful patient selection, atraumatic surgical technique, continuous curvilinear capsulorhexis, in-the-bag IOL placement, postoperative atropine, and topical and systemic corticosteroids significantly lower the incidence of pseudophakic pupillary block and glaucoma. Although no patient developed glaucoma, lifelong follow-up is mandatory to detect chronic open-angle and traumatic angIe-recession glaucoma. J Cataract Refract Surg 1997; 23:669-674

P

ediatric aphakic glaucoma is one of the most frequent and serious postoperative complications of traumatic and developmental cataract surgery in children. I - 7 Glaucoma can be divided into three categories: Reprint requests to David A. Hiles, MD, 29192 North J07th Way, Scottsdale, Arizona 85262, USA.

early-onset pupillary block leading to acute angle closure; late-onset chronic angle closute; late-onset chronic open angle. 5 Pseudophakia may also be a complicating factor. 8 •9 This paper reports our experience with pediatric pseudophakic glaucoma in a carefully selected group of consecutive patients who had cataract extraction com-

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bined with posterior chamber intraocular lens (IOL) implantation between 1991 and 1994.

Patients and Methods A retrospective review was done of 37 charts of consecutive patients who had 45 cataract procedures with posterior chamber IOL implantation between 1991 and 1994 at the Pediatric Ophthalmology Clinic of Children's Hospital of Pittsburgh. Nineteen (51 %) patients had traumatic and 18 (49%) had developmental cataracts. Evaluated were preoperative examination results concerning inflammation, synechias, and angle-anatomy abnormalities that might predispose an eye to postoperative glaucoma. No patient had preoperative glaucoma. Postoperative examinations focused on iridopseudophakic relationships, angle anatomy, intraocular pressure (lOP), and optic-disc configuration to assess for the presence of pseudophakic pupil block or increased lOP. By definition, early-onset glaucoma, usually pupillary block, occurred within the first 6 postoperative months; late-onset open-angle or angle-closure glaucoma occurred after the sixth postoperative month. Patient selection criteria for surgery included visual acuity of20/50 or worse, the onset of strabismus, or an abnormal fixation pattern in those too young or uncooperative to participate in visual acuity testing. In addition, all children were 1 year or older at the time of surgery, had corneal diameters larger than 9.0 mm, and had an axial lens opacity of 3.0 mm or larger. Informed consent was obtained before surgery in all cases. The risks, benefits, and alternative treatments were discussed with the parents and with children able to understand the procedure. Patients had extracapsular Ocutome® or phacoemulsification cataract extraction with posterior chamber IOL implantation under general endotracheal anesthesia as previously reported. 10 Early in the series, a can-opener anterior capsulotomy was most often used. An Ocutome capsulotomy was fashioned in some eyes with traumatic rupture of the anterior capsule from previous trauma or in eyes in which coexisting ocular pathology precluded a clear view of the capsule. Continuous curvilinear capsulorhexis (Ccq, based on the method of Gimbel and Neuhann,11,12 became the 670

procedure of choice as the surgeons became more experienced in its use. The IOL was implanted under viscoelastic and in the bag when possible. Peripheral iridectomies were performed in some eyes that had signs of previous inflammation or synechias associated with ocular trauma. Subconjunctival cefazolin and dexamethasone were injected into the inferior cul-de-sac at the conclusion of the operation. Postoperative tobramycin- dexamethasone drops were instilled every 2 hours while awake for 1 week and tapered as the patient's condition permitted. Atropine 1% drops were instilled twice daily for the first 2 postoperative weeks. Oral prednisolone was prescribed at a dosage of 1 mg/kg/ day for 5 days, reduced by one third for 5 days, and then reduced again by one third for the final 5 days. 10 Intraocular pressures were recorded with a T onoPen® or by Goldmann applanation or Schiotz tonometry at each postoperative visit when possible. Some patients were intermittently uncooperative and a finalvisit lOP could not be recorded. If signs of increased pressure occurred, an examination under anesthesia was performed. Follow-up ranged from 6 to 38 months (mean 23 months).

Results Traumatic Cataracts Nineteen (51%) patients had 20 traumatic cataracts, with 18 being unilateral. Patient 16 developed bilateral cataracts after total body radiation before a bone marrow transplantation for leukemia (Table 1). Eleven eyes sustained penetrating injury, 5 had blunt trauma, and 2 developed iatrogenic cataracts after vitreo retinal surgery. Of the 11 eyes with penetrating injury, 3 had simultaneous corneal laceration repair, cataract extraction, and posterior chamber IOL implantation (patients 8, 10, 15). The other 8 eyes had primary repair of the corneal laceration with subsequent cataract extraction and posterior chamber IOL implantation as indications arose. Three eyes had elective peripheral iridectomies at the time of cataract surgery. Thirteen eyes had Ocutome anterior capsulotomies, six had CCc, and one had a can-opener capsulotomy. Sixteen eyes had the IOL

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Table 1. Characteristics of patients with traumatic cataract. Patient

Eye

Age at Surgery (Years)

1t 2 3 4 5 6 7:j: 8 9 10§ 11 12 13 14 15 16

RE LE RE RE RE LE RE RE LE LE RE RE LE RE LE RE LE RE RE RE

2 4 4 4 5 6 6 7 7 9 9 10 10 11 11 12 12 13 14 14

17 18 19

Capsulotomy

Ocutome

eee

Ocutome

eee

Ocutome Ocutome Can opener Ocutome Ocutome Ocutome

eee

Ocutome Ocutome Ocutome

eee eee eee

Ocutome Ocutome Ocutome

IOL Position

Peripheral Iridectomy

Number of Nd:YAGs*

Last Visit (Months)

Follow-up (Months)

In bag In bag In bag In bag In bag Sulcus In bag In bag In bag Sulcus In bag In bag Sulcus In bag In bag In bag In bag Sulcus In bag In bag

No No No No No No Yes Yes No No No No No No No No No No Yes No

2

35 17

27 14 31 10 27 18 12 38 6 15 19 19 29 34 12 11 12 21 28 24

1 2 2

2

18 14 17 5 16 21 30 10 10 14 14 14 10 10 11 16 10

RE = right eye; LE = left eye 'Number of Nd:YAG laser capsulotomies tlnflammatory peripheral synechias occluding angle :j:Pseudophakic pupillary block §8 clock hours of angle recession

loops placed in the bag, and four eyes had one or both loops placed in the sulcus (patients 6, 10, 13, 17). Twelve eyes had a neodymium:YAG (Nd:YAG) laser posterior capsulotomy, with four eyes requiring repeat laser treatment based on previously established criteria. 13 Three patients developed postoperative glaucoma; two patients had predisposing conditions. Patient 1 had severe trauma including corneoscleral laceration, hyphema, cataract, inflammatory peripheral anterior synechia (PAS), and retinal folds. She developed dense secondary membranes, had a surgical membranectomy, and later suffered a retinal detachment. Patient 10 had a blunt injury with iridodialysis, 8 clock hours of angle recession, macular commotio, and cataract with anterior lens capsular rupture. Early in the postoperative period, he developed pupillary block with iris capture for which lysis of posterior synechias and 10L repositioning were performed. He was the only patient with a sulcus-fixated 10L who required 10L repositioning. Patient 7 developed iris capture and pseudophakic pupillary block with secluded pupil in the early postoperative period but

failed to develop glaucoma; a peripheral iridectomy was in place. However, a pars plana excision of a secondary membrane and anterior vitrectomy were done later. Despite these procedures and medications, patients 1 and 10 retained elevated lOP at the last follow-up.

Developmental Cataracts Twenty-five eyes of 18 patients (49%) had developmental cataracts, with 15 eyes of8 patients having bilateral cataract surgery (Tables 2 and 3). Patient 36 had surgery in his fellow eye before this series began. T wenty-two eyes had CCC, 2 had a can-opener capsulotomy, and 1 had an Ocutome anterior capsulotomy. Two patients with unilateral cataracts and none with bilateral cataracts had a peripheral iridectomy. All 10Ls were placed in the bag. Seventeen eyes received an Nd:YAG laser posterior capsulotomy; 9 eyes required a repeat laser capsulotomy. No eye in either group of developmental cataract patients developed pseudophakic pupillary block or any other type of glaucoma during the follow-up, which ranged from 6 to 37 months.

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GLAUCOMA AFTER CATARACT AND IOL SURGERY Table 2.

eharacteristics of patients with unilateral congenital/developmental cataract.

Patient

Eye

20 21 22 23 24 25 26 27 28 29

RE RE LE RE RE RE LE RE LE RE

Age at Surgery (Years)

Capsulotomy

eee eee eee eee eee eee eee eee eee eee

2 3 4 8 8 8

12 18

IOL Position

In In In In In In In In In In

bag bag bag bag bag bag bag bag bag bag

Peripheral Iridectomy

Number of Nd:YAGs*

Last Visit (Months)

Follow-up (Months)

No Yes No No No No No No No Yes

3 2

10

2

17

13 14 8 30 26 9 31 25 26 23

11 18

RE = right eye; LE = left eye 'Number of Nd:YAG laser capsulotomies

Discussion Pediatric aphakic/pseudophakic glaucoma remains a challenge. Its etiology, pathogenesis, incidence, onset, diagnosis, and successful treatment often elude us. 1,5 Although pupillary block and acute angle-closure glaucoma frequently occur within the first few weeks or months of surgery, open-angle glaucoma may arise many years later, emphasizing the need for lifelong follow-up of these patients. 1,3-6 Posterior synechias leading to pupillary block glaucoma, with or without angle closure, occurs often in the early postoperative period. It is a well-documented complication of extracapsular cataract extraction and posteTable 3.

Eye

30

LE RE RE LE RE LE RE LE RE LE RE LE LE LE RE

32 33 34 35 36 37

Chronic angle closure is a rarer form of glaucoma and is most often associated with microcornea, PAS, and poor pupil dilation. 5,14 None of these patients was included in this series. Open-angle glaucoma is more common and can occur many years after the original intraocular surgery, which in itself is a major predisposing factor. 4 - 6 Most often, the angles appear normal; however, other factors have been implicated such as postoperative inflammation, retained lens cortex, coexisting angle anomalies associated with anterior segment malformation, inade-

eharacteristics of patients with bilateral congenital/developmental cataract.

Patient

31

rior chamber IOL implantation and other intraocular procedures such as secondary membrane surgery?,5,8,9

Age at Surgery (Years)

1% 3 3 3 4 4 4 4 5 5 6 6 12 14 15

Capsulotomy

IOL Position

Peripheral Iridectomy

Ocutome eee eee eee eee eee eee eee eee eee eee eee ean opener eee ean opener

In bag In bag In bag In bag In bag In bag Sulcus In bag In bag In bag In bag In bag In bag In bag In bag

No No No No No No No No No No No No No No No

Number of Nd:YAGs*

Last Visit (Months)

Follow-up (Months)

2 1 2 2 1 3

18 17 15 15 20 20 16 17

34 16 24 24 23 22 28 27 6 6 24 23 37 34 21

RE = right eye; LE = left eye 'Number of Nd:YAG laser capsulotomies

672

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16 17 17 16 17

GLAUCOMA AFTER CATARACT AND IOL SURGERY

quate postoperative mydriasis, PAS, and vitreous plugs in the peripheral iridectomy or pupil. 1-9 Some types of cataracts, including anterior polar, posterior subcapsular, and lamellar, seem to protect the eye from glaucoma. Traumatic cataracts can also prevent glaucoma if other structures are functioning. 5 Predisposing factors that increase the risk of glaucoma are intraocular surgery performed on eyes younger than 1.25 years, poor pupil dilation, and microcornea smaller than 9.0 mm. 3 ,5,10 Our series of carefully preselected patients reinforces this observation as no patient with developmental cataract developed glaucoma during the course of this study. Pseudophakia also increases the risk of posterior synechias to the 10L, which may lead to iris capture, IOL displacement, and angle closure. 8 ,9 Performing CCC with secure in-the-bag IOL placement reduces this · . 81011 compIlCatIOn.' , In a study by Mills and Robb, 5 the type of cataract surgery, with or without vitrectomy, did not seem to influence the onset of glaucoma. This finding disagrees with results of earlier studies. 1,3.4 A peripheral iridectomy may prevent pupillary or pseudophakic block. Some authors believe that all children should receive a peripheral iridectomy including those with a posterior chamber IOL, particularly when there is a defect in the posterior capsule or when zonules are disrupted, which predispose to vitreous plugging. 4 ,5,7,15,16 An increased incidence of pseudophakic pupillary-block glaucoma can occur in children when there is excessive postoperative inflammation7-9 We strongly believe that aggressive use of corticosteroids and pupil dilation with atropine reduce the complications of pupillary block and iris capture secondary to operative inflammation. 8, 1 0 Early in the series, we performed occasional peripheral iridectomies, particularly in traumatic cases with significant previous intraocular inflammation and synechia formation. However, with continued observation of our patients, we found no need for routine peripheral iridectomies. Therefore, peripheral iridectomies are now done only in eyes with evidence of preoperative inflammation or already-formed posterior synechias after remote trauma. In our series of 45 pediatric cataract procedures and posterior chamber IOL implantation, only one patient (#7) who had a corneal laceration developed postoperative iris capture and pseudophakic pu-

pillary block. This did not progress to pupillary block glaucoma as there was a peripheral iridectomy in place, emphasizing the proper indication for such a procedure. Late-onset glaucoma occurred in two patients with traumatic cataract. Patient 1 had preoperative inflammatory PAS occluding the angle following an extensive corneosclerallaceration. Patient 10 had a traumatic angle recession of8 clock hours after blunt trauma, iridodialysis, and hyphema. In our study, 17 patients had an Nd:YAG laser posterior capsulotomy to open an opacified posterior capsule. 1O ,13 No patient developed chronic open-angle glaucoma after this procedure. We believe that the risk of pseudophakic block and its associated glaucoma may be reduced by performing CCC and placing the IOL loops in the bag. Sulcus fixation, or one loop in the bag and one in the sulcus, leads to IOL displacement, tilt, iris contact with adhesion, and pupillary block. 8 In addition, the routine use of postoperative atropine mydriasis and aggressive prevention of inflammation with operative subconjunctival and postoperative topical and systemic steroids greatly reduce the risk of synechia formation and pupillary block. Lifelong follow-up of these patients, particularly those suffering trauma, is essential.

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chronic glaucoma, retinal detachment and secondary membrane surgery in pediatric aphakic patients. Ophthalmology 1984; 91:1238-1241 Walton OS. Glaucoma secondary to operation for childhood cataract. In: Epstein DL, ed, Chandler and Grant's Glaucoma, 3rd ed. Philadelphia, PA, Lea and Febiger, 1986;521-525 Keech RV, Cibis-Tongue A, Scott WE. Complications after surgery for congenital and infantile cataracts. Am J Ophthalmol1989; 108:136-141 Simon JW, Mehta N, Simmons ST, et al. Glaucoma after pediatric lensectomy/vitrectomy. Ophthalmology 1991; 98:670-674 Mills MO, Robb RM. Glaucoma following childhood cataract surgery. J Pediatr Ophthalmol Strabismus 1994; 31:355-360 Asrani SG, Wilensky JT. Glaucoma after congenital cataract surgery. Ophthalmology 1995; 102:863-867 Eustis HS Jr, Walton RC, Ball SF. Pupillary block glaucoma following pediatric cataract extraction. Ophthalmic Surg 1990; 21:413-415 Hiles OA, Hered RM. Modern intraocular lens implants

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in children with new age limitations. J Cataract Refract Surg 1987; 13:493-497 Vajpayee RB, Angra SK, Titiyal JS, et al. Pseudophakic pupillary-block glaucoma in children. Am J Ophthalmol 1991; 111:715-718 Brady KM, Atkinson CS, Kilry LA, Hiles DA. Cataract surgery and intraocular lens implantation in children. AmJ Ophthalmoll995; 120:1-9 Gimbel HV, Ferensowicz M, Raanan M, DeLuca M. Implantation in children. J Pediatr Ophthalmol Strabismus 1993; 30:69-79 Gimbel HV, Neuhann T. Development, advantages, and methods of the continuous circular capsulorhexis technique. J Cataract Refract Surg 1990; 16:31-37 Atkinson CS, Hiles DA. Treatment of secondary posterior capsular membranes with the Nd:YAG laser in a pediatric population. AmJ Ophthalmoll994; 118:496501 Parks MM, Johnson DA, Reed GW. Long-term visual results and complications in children with aphakia; a

function of cataract type. Ophthalmology 1993; lOO: 826-840 15. Samples JR, Bellows AR, Rosenquist RC, et al. Pupillary block with posterior chamber intraocular lenses. Arch Ophthalmoll987; 105:335-337 16. Tomey KF, Traverso CEo The glaucomas in aphakia and pseudophakia. Surv Ophthalmoll991; 36:79-112 From the Department of Ophthalmology Children s Hospital of Pittsburgh, and University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA. Presented at the annual meeting ofthe American Association for Pediatric Ophthalmology and Strabismus, Orlando, Florida, USA, April 1995. Supported in part by grants from the Fight for Sight Children sEye Services ofChildren sHospital ofPittsburgh by Fight for Sight, Inc., New York, New York, USA. None ofthe authors has aproprietary interest in any imtrument or device described.

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