|Year : 2016 | Volume
| Issue : 1 | Page : 13-18
Evaluation of visual outcomes after pediatric cataract surgery in a Tertiary Eye Care Hospital in Western Maharashtra
Rishikeshi Nikhil, Tripathi Shubhi, Kaduskar-Aney Anushree, Taras Sudhir, Deshpande Madan
Department of Pediatric Ophthalmology and Strabismus, PBMA'S H.V. Desai Eye Hospital, Pune, Maharashtra, India
|Date of Submission||05-Jun-2015|
|Date of Acceptance||09-Oct-2015|
|Date of Web Publication||19-Jan-2016|
PBMA'S H.V. Desai Eye Hospital, Survey Number 93, Mohammadwadi, Tarawde Vasti, Hadapsar, Pune - 411 060, Maharashtra
Source of Support: None, Conflict of Interest: None
Background: A review of pediatric cataract cases operated between January 2007 and May 2008 in a Tertiary Eye Care Hospital in Western Maharashtra was done. Aim: To evaluate postoperative visual status for distance and near after pediatric cataract surgery. Settings and Design: Retrospective and prospective medical record retrieval type of cohort study. Materials and Methods: The demographic data, preoperative, intraoperative, and postoperative details were noted. The surgical procedure included cataract extraction with intraocular lens implantation with primary posterior capsulorrhexis and anterior vitrectomy in most of the cases. The visual status of eyes was evaluated before and 6 weeks after surgery. Statistical Analysis: Univariate and multivariate type of statistical analysis using SPSS software. Results: Three hundred and sixteen eyes of 250 children were included in the study. Sixty-six children had bilateral, and 184 children had unilateral cataract. Most common were congenital cataracts seen in 124 eyes (39.2%). Distant vision following surgery was more than 6/60 in 86 eyes (49.1%). Aided near vision of N12 and above was seen in 75 eyes (68%). The common causes for noncompliance with spectacles were heavyweight, repeated breakage, and peer pressure. Conclusion: Early detection and management of cataract in children is the key to good visual outcomes. Postoperative care should include a special emphasis on near vision. Improved coordination is needed between parents, school teachers, and the pediatric eye care center to improve the compliance with spectacles.
Keywords: Near vision, pediatric cataract, spectacles, visual outcomes
|How to cite this article:|
Nikhil R, Shubhi T, Anushree KA, Sudhir T, Madan D. Evaluation of visual outcomes after pediatric cataract surgery in a Tertiary Eye Care Hospital in Western Maharashtra. J Clin Ophthalmol Res 2016;4:13-8
|How to cite this URL:|
Nikhil R, Shubhi T, Anushree KA, Sudhir T, Madan D. Evaluation of visual outcomes after pediatric cataract surgery in a Tertiary Eye Care Hospital in Western Maharashtra. J Clin Ophthalmol Res [serial online] 2016 [cited 2022 May 29];4:13-8. Available from: https://www.jcor.in/text.asp?2016/4/1/13/174345
Childhood blindness is one of the priority eye diseases within the disease-control strategy of the "VISION 2020" initiative.  In developing countries such as India, 7.4-15.3% of childhood blindness is due to cataract. ,, The prevalence of cataract in children has been estimated between 1 and 15/10,000 children. , Visual impairment at an early age has far reaching implications on a child's life. It can hinder education, hamper personality development, and deprive the individual of career opportunities, thus increasing the socioeconomic burden on the family and the community.  Pediatric cataract surgery is often the first step of a long, complex visual rehabilitation program. Previously, an established mindset took into account only distance vision improvement after surgery, but a new wave of insight has swept the pediatric ophthalmologists, who now give equal importance to near work since the world of a child is more focused on his immediate surroundings, and if he/she is of school-going age, then his/her scholarly requirements have to be taken into consideration. This has implications on visual recovery as well as on their performance. A number of studies have been carried out on visual outcomes ,, and complications , following cataract surgeries in children. The outcome of pediatric cataract surgery in many developing countries remains poor as a result of late detection, inadequate surgical facilities for children, lack of pediatric anesthesia, and inadequate follow-up. Scant literature is available regarding assessment of spectacle compliance in school-going children as a part of refractive error screening programs, , but no literature is available regarding spectacle compliance following pediatric cataract surgery to the best of our knowledge. The aim of this study was to assess the visual outcome both for distance and near, complications and evaluation of compliance for spectacles after pediatric cataract surgery.
| Materials and Methods|| |
A part retrospective and part prospective medical record retrieval type of study was performed at a Tertiary Eye Care Hospital in Western Maharashtra from January 2007 to May 2008. All walk-in patients presenting to the Pediatric Unit of the hospital, along with the children screened at various screening camps organized under the Sarva Shiksha Abhiyaan (SSA)-Education for all scheme were included. Children <16 years of age with cataract (irrespective of etiology) were the study population. The Ethical Committee members of the hospital were briefed about the rationale of the study, nature of the procedures, and the benefits that could be availed. There being neither any ethical considerations nor conflicts of interest the ethical committee clearance was obtained.
Vision of each eye was assessed with the help of various visual acuity charts depending on the child's age and the level of intelligence; Snellen charts for school-going children, Cambridge cards for preschool children (3-5 years), Cardiff cards for toddlers (1-2 years), and lea symbols for infants. If a child was unable to recognize the symbol in the top line of the Snellen chart kept at 6 metre distance, we asked him/her to count the number of fingers of the examiner at 3-, 2- and 1 metre distances. The perception and projection of light were tested in all the four quadrants. The presented vision was recorded. Refraction was tried wherever possible to check improvement in vision. Both unaided and aided visual acuities were recorded. Complete anterior segment examination was done with the aid of slit lamp, and a hand-held slit lamp was used for infants. Ocular alignment was recorded in terms of Hirschberg corneal reflex test. The cornea was examined for the presence of congenital abnormalities such as microcornea, any corneal opacity and its relation to visual axis, presence of any lamellar laceration/full-thickness corneal tear and wound of entry in cases of trauma. The type and density of opacification of the lens were noted, along with presence of any subluxation, dislocation or zonular dehiscence. Posterior segment examination was done either using a +90D lens in conjunction with the slit-lamp or indirect panretinal ophthalmoscope and a +20D lens. Ultrasound B-scan was done in all cases where posterior segment visualization was not possible by either of the above techniques and in all cases of traumatic cataract. In cooperative children, keratometric readings were obtained, and intraocular lens (IOL) power was calculated. In small and uncooperative children, biometry was performed under anesthesia. The standard pediatric cataract surgery done in the institute was cataract extraction/aspiration with posterior chamber IOLs (PCIOLs) implantation. Primary posterior capsulorrhexis with anterior vitrectomy (PPC + AV) was done in all children <6 years of age and in children who were considered uncooperative for subsequent laser capsulotomy.
IOL implantation was not done in children <2 years of age, in those cases only cataract extraction/aspiration with PPC + AV was done. In cases with traumatic etiology, cataract extraction was combined with synechiolysis and iridectomy was performed if needed. In cases with co-existing corneal tear, the repair was done in the same sitting.
All the children who underwent surgery were examined the next day on slit-lamp. Visual acuity was assessed appropriately and recorded. In select cases (those with excessive iris tissue handling, traumatic etiology, cases where vitrectomy was done), oral steroids (1 mg/kg body weight) were started on the day of surgery as a single morning dose after breakfast. Oral antibiotics and oral anti-inflammatory drugs were given in all cases for a period of 5 days from the day of surgery. The topical regimen consisted of steroid-antibiotic combination eye drops 1 hourly (1% prednisolone acetate with 0.3% ofloxacin) along with mydriatic agent twice or thrice daily (either 2% homatropine eye drops or eye ointment atropine 1%). The stronger mydriatic agent was routinely used in infants and in cases with traumatic etiology. Oral steroids were tapered over the 2-week duration. Tapering of topical steroids was done over a period of 6 weeks. Mydriatic agents were stopped after 1 week. The follow-up was scheduled on day 1, day 3, 1 week and 6 weeks postsurgery. In all follow-up visits, uncorrected visual acuity was noted, and a thorough slit-lamp examination was carried out. Complications, if any, were noted and appropriately managed. At 6 weeks, refraction was carried out, and best-corrected visual acuity (BCVA) both for distance and near was determined. Spectacle prescription was given with appropriate near addition. Postoperative amblyopia treatment, wherever applicable, was given in the form of 6 hours of compulsory patching at home. Near tasks were given to the child during that time span for at least an hour. Spectacle compliance was noted at 6 months postoperatively, with the reason for noncompliance being noted if spectacles were not used.
We used univariate and multivariate types of statistical analysis to find out factors that influenced visual outcome after pediatric cataract surgery. SPSS software (SPSS Statistics for Windows, Version 17.0.Chicago: SPSS Inc.) was used for this purpose.
| Results|| |
This study included 250 children and 316 eyes with cataract. The mean age of the study population at the time of surgery was 7.6 years, with a standard deviation of 4.2 years. The youngest child to undergo surgery was 2 months of age, and the oldest child was 16 years of age [Table 1]. This study included 174 eyes of 138 male children and 142 eyes of 112 female children, thereby pointing toward a small gender bias in presentation of pediatric cataract. 105 children (42%) were direct walk-in patients presenting to the pediatric outpatient department, whose parents paid the entire cost of surgery. 145 children (58%) were recruited from pediatric screening camps who were operated free of cost. 184 children (73.6%) had unilateral cataract while 66 children (26.4%) had bilateral cataract.
Congenital cataract was the most common type of pediatric cataract observed [Table 2]. Of the 124 eyes with congenital cataract, 8 eyes had coloboma including one child who had persistent fetal vasculature; 10 eyes had microcornea, 3 eyes had the subluxated lens, and microspherophakia was seen in 1 case; 1 child each was diagnosed as having Down syndrome and galactosemia.
The greatest proportion of cases, nearly 79%, had a preoperative visual acuity between <3/60 and perception of light. In seven eyes of five children with age from 2 to 6 years, preoperative visual acuity could not be recorded, as the children were irritable [Figure 1].
Nine eyes underwent only cataract extraction and were left aphakic, the indication of surgery being either cataract associated with other congenital anomalies such as microphthalmos/microcornea or subluxated lens. Thirty-two eyes underwent cataract extraction along with primary posterior capsulorrhexis and anterior vitrectomy [Figure 2]. Except in four cases, all 28 cases were of children <2 years of age. The other four children who were left aphakic were-one child aged 3 years with traumatic cataract with adherent leukoma, a 7-year-old child with microcornea, coloboma, and microspherophakia; two children aged 10 and 12 years had subluxated cataract and were managed with cataract extraction and vitrectomy. Ninety-seven eyes underwent cataract extraction with IOL implantation with primary posterior capsulorrhexis and anterior vitrectomy. In one case of traumatic cataract with adherent leukoma with repaired corneal tear, synechiolysis and pupilloplasty were combined with routine cataract extraction. One case of complicated cataract was managed by pupilloplasty. Adherent leukoma was managed by iridectomy in two cases of traumatic cataract. In two cases, there was preexistent posterior capsular dehiscence including a case with posterior lenticonus, which was managed by anterior vitrectomy and a bigger optic diameter IOL was implanted in the bag. In three cases of traumatic etiology, iridectomy was performed. In a case of congenital cataract, posterior capsular rent occurred, which had dislocated IOL in the vitreous cavity as a sequel, managed by pars plana vitrectomy and IOL explantation on the first postoperative day. This same child had a vitreous hemorrhage at 6 weeks postoperatively. Two cases of traumatic etiology had a primary corneal tear repair with cataract extraction and IOL implantation done in the same sitting. In one case of traumatic absorbed cataract, scleral-fixated PCIOL implantation was done. Three cases underwent cataract extraction with PCIOL implantation and squint correction in the same sitting.
Two cases were subjected to cataract extraction with PCIOL implantation and trabeculectomy done simultaneously, out of which one case was preoperatively diagnosed as having Peter's anomaly, and the other case had a traumatic etiology.
175 eyes (55.4%) completed the 6-week follow-up. As mentioned previously, 145 children in this study were from the pediatric screening camps and were inhabitants of remote areas. They were brought to the tertiary center only for the surgery and were operated free of cost. The majority of them did not revert back to the center for follow-ups due to financial constraints. Those completing follow-ups were mostly walk-in patients.
The postoperative vision of 175 eyes was analyzed [Figure 3]. 48 eyes (27%) had vision ≥6/18. In 38 eyes (22%), the vision was between 6/60 and 6/18. 23 eyes (13%) had visual acuity between 6/60 and 3/60. In 54 eyes (31%), the vision was <3/60. In seven eyes of five children, all aged <4 years, visual acuity could not be assessed as they were uncooperative at the time of examination.
Out of the 175 eyes which had completed the 6-week follow-up, in 55 eyes (31%) near add was not applicable, since either a majority of these children were <2 years of age or in whom near vision could not be assessed. Near vision could not be assessed even in nine children who were older as they were uncooperative for assessment. Of the remaining 111 eyes, 24 eyes (22%) had a near vision of N6, 30 eyes (27%) had a near vision of N8, and 13 eyes (12%) had a near vision of N10. Eight eyes (7%) had a near vision of N12, two eyes (2%) had a near vision of N18, and six eyes (5%) had a near vision of N36.
In 66 eyes (39%), the postoperative course was uneventful. Eighty-five eyes (48.6%) had posterior capsular opacification (PCO). In 46 eyes (26.2%), optic capture was seen at 6 weeks. [Figure 4] represents the outcomes after cataract surgery at a glance and [Table 3] represents the visual outcomes after pediatric cataract surgery as per the etiology of cataract.
|Figure 4: Scatter diagram at a glance showing the improvement, deterioration, and no change in the visual acuity following cataract surgery|
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| Discussion|| |
Pediatric cataract surgery differs from adult cataract surgery in many ways-there may be a delay in presentation associated with amblyopia, the sclera is less rigid, the axial length and refractive status of the eye keep on changing, chances of postoperative inflammation and PCO are higher. Hence, visual results of pediatric cataract surgery are less spectacular than adult cataract surgery. Nonetheless, the intervention is very much needed, as a child's vision restored is a great achievement in terms of blind person-years saved.
Congenital cataract was also reported as the commonest cause of pediatric cataract by a study conducted in Spain  whereas a study from central India  reports trauma as the leading cause of pediatric cataract [Table 4]. The postoperative visual acuity results of 27% of patients having BCVA ≥6/18 compare favorably with reports from Central India,  Tanzania,  and Nepal  [Table 5]. In a study reporting the outcomes of traumatic cataracts from rural India, 43% patients had BCVA ≥6/18.  A study from south India reports 39.5% patients having BCVA ≥6/18. 
|Table 5: Comparison of postoperative visual acuity of this study versus other studies|
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As many patients were recruited through camps of SSA and followed up in their respective districts, the follow-up at the base hospital was 85% at 1 week and 55.4% at 6 weeks. This was comparable with the Tanzanian study in which 66.9% attended the 2-week follow-up and 42.9% attended 10-week follow-up  and the Nepalese study in which follow-up was 94% at 1 month and 63% at the end of 3 months.  In another Tanzanian study, a multivariate analysis revealed that sex (being a boy), close proximity to a hospital, and minimal delay in presentation for surgery all independently predicted good follow-up at 2 weeks; only distance from a hospital and preoperative vision (not blind in the operative eye) predicted good 10-week follow-up. 
In a study conducted in Miraj (Maharashtra) to study the barriers to follow-up in pediatric cataract surgery,  the authors reported a poor follow-up of only 20.6%. Lack of affordability was a major cause for poor follow-up. In this study, out of the 132 eyes (42%) of the direct walk-in patients, only 33 eyes (25%) were lost to follow-up whereas 108 eyes (58.7%) lost to follow-up were of children who were recruited from the various pediatric screening camps organized under the aegis of SSA - Education for all scheme and were operated free of cost. They followed up at their respective health centers. These patients were from screening camps conducted at different geographical locations and from remote areas, so they could not be traced if they did not revert back to the tertiary center. Hence, no postoperative data is available for these patients.
In this study, near addition was not required in 55 eyes. Infants who underwent only cataract extraction and were left aphakic were given aphakic glasses incorporating the near addition rather than prescribing bifocals as their area of visual demand differed from older children. Their visual area of interest is restricted to maximum 3 metre. Hence, bifocals were not prescribed. Excluding these cases, aided near vision of N12 and above was seen in 68%, but a point worth mentioning here is that near add was not given in 25%, thus greater awareness has to be inculcated even in the ophthalmologist fraternity that near vision is equally important in the life of a child for his social and academic improvement and that greater functional success could be achieved by proper implementation of this measure.
Due to poor cooperation, visual acuity both for distance and near could not be recorded in 7% and 9% cases. In other studies also, inability to record visual status has been mentioned, and even alternative methods such as observing a child's behavior and assessing visual functions have been suggested. ,
Analysis of complications in the present study revealed PCO in 48.6% of eyes, as in nearly 41% cases anterior vitrectomy with primary posterior capsulotomy was performed, thereby rendering the central visual axis clear. This explains the low rate of PCO as compared to the R P center study (87.2%)  where all the children recruited were referred for management of complications following surgery performed elsewhere. In a study from Maharashtra, 63.2% (163 eyes out of 258) children who had not undergone posterior capsulorrhexis developed PCO.  In this study, only 12.40% (32 eyes out of 258) underwent posterior capsulorrhexis with anterior vitrectomy. The high rate of PCO in the study can be attributed to this factor. PCO was managed by Nd: YAG capsulotomy in 11% cases and surgical membranectomy in 3.5% cases.
In a study conducted at Postgraduate Institute Chandigarh [Table 6], postoperatively 25 eyes with an intact capsule and 5 eyes that had PPC + AV developed PCO regardless of the material of IOL implanted, the difference being statistically significant (P < 0.05). 
Whereas, in our study, PCO was seen in 21% of eyes with PPC +AV whereas 33% of eyes developed PCO without PPC + AV.
| Conclusions|| |
Our study revealed that the majority of pediatric cataracts are developmental in origin. Cataract extraction with IOLs implantation with PPC + AV is the procedure of choice for management of pediatric cataract.
Ophthalmic assistants at primary health centers had followed and refracted the children operated in our study. This data was not shared with the hospital and was not included in the present study. This was a major limitation of the study.
Cataracts associated with anterior segment abnormalities have a poor postoperative outcome.
Early diagnosis and prompt surgical intervention are extremely important in the management of pediatric cataract, as also adequate visual rehabilitation in the form of spectacles with both distance and near correction.
PCO is the most common postoperative complication after pediatric cataract surgery.
The parents need to be counseled about the importance of postoperative care, follow-up, refraction and compliance of spectacle wear. A mechanism should be set up to improve coordination between parents, school teachers, ophthalmic assistants, and the pediatric eye care center to re-examine and manage the operated children.
Dr. Gadkari Salil (M. S. Senior Consultant, Department of Vitreo Retina, Director Medical Research, PBMA'S H. V. Desai Eye Hospital, Pune, Maharashtra, India).
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4]
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]