management of congenital cataract below 6 months of age · 40 eyes were operated for congenital...
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Dr. Nita Shah
Aayush Eye Clinic Microsurgery and Laser Centre
Mumbai, India
Management of Congenital Cataract below 6 months of age
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Financial Disclosure
The authors have no relevant financial
relationship with the products or
services described, reviewed, evaluated
or compared in this presentation.
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40 eyes were operated for Congenital Cataract
between age 1.5 months to 6 months in the last 8
years.
All were dense Amblyogenic Cataracts.
I am presenting my study in an effort to follow
International norms and fit them into the poor
socio economic scenario of these patients.
Introduction
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White reflex
Strabismus
Nystagmus
Poor Visual Fixation
Photophobia
Ocular Presentation
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Etiology
2
5
0
1
0
0
0
0
32
Associated Ocular Anomalies
Genetic(H/O consanguinity)
Hereditary
Maternal Infection
Toxic
Exposure
Metabolic
Trauma
Idiopathic
0 10 20 30 40
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Examination
Assessment of V/A
- Fixation Pattern
- Pupillary Rn
- Menace Reflex
Associated Ocular
findings
- Microcornea
- Microphthalmos
- Nanophthalmos
- Glaucoma
- Iris defects
- Subluxation
Pre operative Evaluation- Ocular
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Ocular Investigations
Keratometry
A-Scan
B-Scan for AL and DD
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Clinical Examination
Paediatric Reference for Anesthesia Fitness and
Associated systemic conditions e.g. Mental
Retardation, Congenital Heart Disease etc.
Investigations
CBC /ESR
Blood sugar
BUN / Sr. Creatinine
X-ray chest, ECG/2D ECHO
Torch titre
Urine for reducing sub & Amino Acids.
Plasma for Calcium, Phosphorus, Red Blood cell
transferase, Galactokinase levels.
Pre operative Evaluation- Systemic
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IOL selection
Size
Should conform to the bag to prevent decentration & pupillary capture.
Foldable Acrylic Hydrophobic /
Heparin coated
Less Pigment deposition /
inflammation
Power
IOL exchange
in case of refractive surprise
IOL selection
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Life is more precious than the eye and the Anaesthetist’s decision regarding fitness for GA and timing of Surgery was final.
Bilateral Cataract
- Gap of 72 hrs.
- Simultaneous bilateral surgery in high risk cases.
Anaesthesia
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IOP
Corneal Diameter
Fundus Examination
K – hand held
A Scan – to recheck AL
On table Assessment
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Intra-op problems
- Miosis
- Scleral collapse
- Vitreous Pressure
- Highly elastic Anterior Capsule
- Posterior Capsular Plaque
- Fibrin Release
Paediatric Cat Sx diff from adult
IOL not inserted
- Bag is not intact
- Pigment release
- Pupillary capture
- Iris chaffing
- P C rent
- Uveitis
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Surgical Steps Preparation of the eye.
Incision
- 2.2mm at12 o’clock
CCC
- Trypan Blue
- Healon-5
- Forceps or 26G cystitome or
Radio frequency diathermy
(Oertli, Berneck, Switzerland).
Aspiration of Cataract.
Capsule polishing.
In the bag Lens Implantation
Iridectomy / Vitrectomy
Wound Closure
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Why IOL? Contact Lens were difficult due to
- small palpebral aperture,
- MLN,
- low socioeconomic condition of parents.
IOL implants provide
- immediate,
- constant,
- high-quality,
- no-maintenance optical correction of similar
magnification to the natural lens.
- the glasses thus needed were of lower Dioptre,
cosmetically acceptable and less cumbersome than
Aphakic Glasses.
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Why IOL?
These are all important advantages in children in whom
Visual Rehabilitation and development are influenced by
the Paediatric issues of
- Amblyopia,
- Development of binocular function,
- Compliance,
- Convenience,
- Need for familial care.
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Steroids
Antibiotics
Pad/Shield
Anti Glaucoma drugs
Mydriatics
Evaluation of Residual
Refraction
Post op Management Regime
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External examination
- Wound Leak
- Inflammation
- Sec. Glaucoma
S/L examination
- Visual axis opacification
- PCO/Plaque
- IOL Decentration,
- Membrane
- Post. Synechiae
Fundus examination
Post op- Problems to look for
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Fixation
Vision
MLN
Refraction - Refractive
surprise / Myopic shift due to
growth of eye.
Markers to raise suspicion
of Onset & consolidation of
Amblyopia
Squint
Menace reflex in each eye
Alternate occlusion shows a
distressed child when better
eye is occluded
Amblyopia - Detection
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Occlude the less vision eye
- If Bilateral & less Vn Eye is 6/60 to 6/ 18 then 6
hrs intermittent occlusion with Vision Therapy.
- If Bilateral & less Vn Eye is 6/18 or better then 2
hrs intermittent occlusion with Vision Therapy.
Synaptophore exercises with occlusion in c/o
eccentric fixation or poor central fixation.
Atropinization in case of non compliance to Occlusion
alone.
Amblyopia-Management
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Intra Operative
Extension of Rhexis 01
PC rent 01
Floppy Iris 00
Scleral Collapse 00
Raised IOP 00
Post Operative
Amblyopia 15
Strabismus 20
Refractive Error > 3D 15
Posterior Synechiae 2
Manifest Latent
Nystagmus26
Retinal Detachment 0
Endophthalmitis 0
Posterior Capsular
Opacity30
Ocutome Posterior
Capsulotomy22
YAG Capsulotomy 8
Complications
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Visual acuity
Unilateral Cataract(CF) 02
Bilateral BCVA 38
HM - 1.0 08
1.0 – 0.6 15
0.5 – 0.3 11
0.2 – 0.1 08
Visco elastics
Viscoat 5
Discovisc 5
Healon-5 20
Healon GV 10
Methyl Cellulose 0
Results
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Conclusion
In the bag implant
A rigorous postoperative follow up and Visual Rehabilitation Regime
The fashioning of a strong capsulorrhexis using an adaptive viscoelastic
Posterior capsule left untouched for
- better in-the-bag IOL stability
- avoiding vitreous accessing the anterior chamber
- preventing post segment complications viz. RD
- ease of IOL exchange
Microincision surgery for tight wound closure
In this series we observed the importance of
No delay in surgery
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Thank You