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W. Jordan Piluek, Douglas Fredrick; Posterior Capsule Management in Pediatric Cataract Surgery. Invest. Ophthalmol. Vis. Sci. 2013;54(15):2993.
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In children and infants with cataracts, the goals of cataract extraction include not only improved vision, but also prevention of amblyopia. To this end, primary posterior capsulotomy and anterior vitrectomy (PPC + AV) is routinely performed at the time of cataract extraction and intraocular lens implantation (CE-IOL) to avoid post-surgical visual axis opacities. The purpose of this study is to determine if these additional procedures, which carry inherent risks, are necessary in children and to delineate the risk factors that can help determine surgical success.
95 eyes of 73 children were included in this retrospective, interventional, consecutive case series. Data collected included age, type of cataract, type of IOL, visual acuity, time to visual axis opacity requiring laser capsulotomy or surgery, and laser energy required. Chi-square and ANOVA statistical analysis was utilized.
When PPC + AV was not performed, 20% developed a posterior-capsular opacity (PCO) in the first post-operative month and 90% within the first year, however after the initial YAG laser posterior capsulotomy, only 5% had recurrence. In contrast to older studies that indicated that pediatric PCO required high laser energy or surgical membranectomy, the mean energy needed for successful treatment was low. 50% of uveitic cataracts compared to only of 4.2% of congenital cataracts developed visual axis opacity not amenable to laser treatment and needed repeat surgery. Factors associated with increased risk of PCO formation were age under 7 (p<0.05) and uveitis (p<0.02), but not trauma (p>0.05).
The necessity of PPC + AV is not supported across the board in the pediatric population requiring CE-IOL. YAG laser is more effective than has been shown in prior studies with energy similar to that used in adults. The goal of cataract management should not be “one-stop” surgery, but rather surgeons should approach the pediatric cataract with an expectation to have to perform post-operative laser posterior capsulotomy early to avoid the delayed need for higher energy laser treatments or surgery. It is most advantageous to avoid PPC + AV in older children and possibly in younger children who may require YAG laser posterior capsulotomy under anesthesia, but have a low risk of re-opacification. Consider PPC + AV in children who have dense fibrous posterior capsules and children of any age with uveitic cataract.
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