Eyeworld

MARCH 2020 | EYEWORLD | 39 C Contact Repka: mrepka@jhmi.edu O utcomes from cataract surgery in children younger than 13 years can be complicated by amblyopia, de- velopment of glaucoma, visual axis opacification, and other conditions, results from a study investigating the procedure in a pediatric popu- lation suggest. 1 The prospective observational study included 880 children who underwent lens removal before age 13. In this interim report, investigators discussed the 1-year outcomes. "Many people thought we mostly performed cataract surgery in infants, but it turned out that about half of the children were over age 3," Michael Repka, MD, said, adding that this shows there are a number of school-age children un- dergoing cataract surgery. In children over age 3, mean visual acuity was about 20/40. Pediatric outcomes Amblyopia occurred in 51% of patients, Dr. Repka said, explaining that at this age the developing brain can be compromised by a vision-impairing cataract. "The children with the highest rate [of amblyopia] were, as expect- ed, those with just one eye having cataract and undergoing cataract surgery in infancy or very early in childhood," he said. Glaucoma occurred in 6% of cases after cataract surgery. Dr. Repka said this tends to be around 12% with younger children. "We expect that this rate is going to grow in frequency," he said. Dr. Repka hypothesized that glaucoma development in these cases could be linked to the surgery itself or caused by abnormalities of the anterior segment, which may have caused the cataract and issues with the aqueous filtra- tion system. Cataract surgery often is not the only oph- thalmic procedure that these children undergo. About 17% need an operation for something else during the first postoperative year. "We're trying to do a surgery that doesn't lead to the need for additional surgery, but here we have nearly 1 in 5 getting it," Dr. Repka said. "Usually it was for issues with the posterior capsule that had clouded up, a well-recognized complica- tion." While steps are taken to try to prevent posterior opacification in children, they're not always effective. "This is because their lens be- haves differently," he said. "Secondary opacifi- cation develops much more vigorously." Clinical issues From a clinical perspective, Dr. Repka thinks the study reinforces the need to frequently monitor visual acuity, refractive error, and state of the posterior capsule in young cataract sur- gery patients for years after surgery. "These are children who, once operated on, are at risk for many problems, which need ongoing, intense ophthalmic care," he said. For the parents who are responsible for getting these children to vis- its for treatment, there's a substantial post-sur- gery burden. "That's very different from the adult who has cataract surgery and once they get out of the postoperative window, complica- tion rates are very low," Dr. Repka said. While older children may require less additional care, one area where this may not be true is with regard to the postoperative clearing of the posterior capsule, Dr. Repka pointed out. "We don't open the posterior capsule of a 5-year-old at the primary surgery because we know they can't sit and do a laser in the office," he said, adding that while it simplifies the surgical portion initially, nearly 100% will need a YAG capsulotomy later on. In contrast, only about a third of adult cataract patients need a YAG within a year. With this in mind, Dr. Repka recommends that ophthalmologists who manage pediatric cataract patients need to take on long-term follow-up. "It's something that you have to be committed to," he said. "In many ways, cataract surgery itself is the easiest part," Dr. Repka said, adding that after the surgery is complete, "you've barely begun" the journey in the care of these patients. by Maxine Lipner Senior Contributing Writer Study investigates outcomes of cataract surgery in children About the doctor Michael Repka, MD Professor of ophthalmology Johns Hopkins University Wilmer Eye Institute Baltimore, Maryland References 1. Repka MX, et al. Visual acuity and ophthalmic outcomes in the year after cataract surgery among children younger than 13 years. JAMA Ophthalmol. 2019;137:817–824. Relevant disclosures Repka: None RESEARCH HIGHLIGHT

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