EyeWorld is the official news magazine of the American Society of Cataract & Refractive Surgery.
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March 2012 EW CATARACT 59 only when the infant gets to about 3-4 D of myopia, he said. Biometry measurements are used to determine when the infant eye would return to emmetropia without the additional lens, with the planned removal per- formed at that time, Dr. Wilson added. continued on page 62 A congenital nuclear cataract Source: Jules Stein Eye Institute search and are somewhat better pre- pared, he said. Bag or sulcus placement? After cataract removal, the pediatric patient may or may not receive an IOL, depending on age, said M. Edward Wilson, M.D., Pierre Gautier Jenkins professor and chair, ophthalmology department, and director, Albert Florens Storm Eye Institute, Medical University of South Carolina, Charleston. "My default strategy in the first 6 months of life is a contact lens [CL], but I talk about IOLs and glasses and piggybacking implants. We don't want to traumatize the eye any more than we have to," he said. "The least traumatic thing we can do is remove the lens, with no implant, through two small paracen- tesis openings without ever having to take the instruments out of the eye. It's quick and it's easy and it's atraumatic. When I do it that way, I put the CL on at the end of the sur- gery, and I don't patch or shield," he said. Unlike an adult IOL implanta- tion, in congenital cataract surgery, placing the lens in the bag may be challenging, Dr. Lambert said. Post- op, children will be on steroids for much longer than adults, typically for about a month, he said. Although surgeons aim for in- the-bag placement, "sometimes the bag is not as well-defined in a child as it is in an adult," Dr. Medow said. Surgical challenges The posterior capsule in children opacifies within 30 minutes or so, meaning surgeons must remove it at the time of surgery. Anterior cham- ber lenses are generally not consid- ered since the chamber is "very narrow and very close to the cornea," Dr. Medow said. "All IOLs in the anterior cham- ber have a bit of flexibility and over a period of years, the IOL is going to consistently hit the cornea and de- compensate down the road. It's pos- sible that when they're 16 they'll need a new IOL or at 20 need a cornea transplant," Dr. Medow said. Dr. Wilson will consider piggy- backing with a planned removal in patients with unilateral cataract where the parents can't manage CLs or glasses. "These eyes are really small, and placing one IOL is difficult enough, never mind two. I've probably done 60-70 over the years. It can be done safely, but it's more surgically aggres- sive," he said. Calculations are still based on the best estimate of the growth curve in the eye and placing the eventual permanent lens in the capsular bag, with any temporary lens placed in the sulcus. The concept is to have em- metropia when the infant comes out of surgery and introduce spectacles