Commentary: Steroids in pediatric cataract surgery

Pediatric eyes are prone to inflammation, and the fibrinous response is further provoked by cataract surgery and intraocular lens (IOL) implantation.[1,2] Topical steroids are almost as essential as appropriate surgical techniques in such cases. However, missed doses and non-compliance due to behavioral problems lead to the subtherapeutic administration of topical anti-inflammatory medications in children.

A randomized control trial published in the present issue compares the efficacy, safety, and compliance of postoperative topical steroids and adjunctive intracameral (I/C) triamcinolone acetonide and posterior sub-Tenon (PST) triamcinolone in modulating postoperative inflammation after surgery in 48 eyes of children aged 5 to 10 years.[3] The study concludes that PST triamcinolone is an effective alternative to topical steroid drugs for modulating postoperative inflammation in children undergoing cataract surgery.

Many studies have illustrated the efficacy of depot steroid preparations in adults undergoing cataract surgery.[4,5] Sub-Tenon’s triamcinolone provides sustained corticosteroid levels and eliminates the risks associated with poor patient compliance to drops. It may also give higher concentrations close to the macula and thus reduce the incidence of macular edema.

While this might be true for this relatively older age group, similar results cannot be extrapolated for children aged less than four years, where posterior sub-Tenon has not yet been extensively studied. A randomized controlled study is questionable in young children because it may be unethical to withhold topical steroid therapy given these patients’ inevitable severe postoperative inflammation.[6]

The biggest drawback of depot steroid preparations is intractable glaucoma, which may present as early as three days—as in steroid responders—to many years later, especially in eyes undergoing congenital cataract surgery.[7] The present study does not show a statistically significant difference in the intraocular pressure (IOP) among the three groups at 12 weeks of follow-up. But a longer follow-up is needed for better conclusions in this regard. There is no way to remove the depot drug, especially in scenarios with suspected infections and raised IOP. Other side effects include accidental injection directly into the choroidal or retinal circulation, perforation of the globe, and occlusion of the central retinal artery. Infrequently subconjunctival hemorrhages, orbital fat atrophy, conjunctival infections and ulceration, and ptosis have also been reported.

The other drug which can curb inflammatory response in children is intracameral triamcinolone.[8] The suspended particles of intracameral triamcinolone can be seen for up to five days, but this might not be true in all patients. Suturing and manipulation might lead to some drug leaking from the anterior chamber, and the dosing might not be universally the same in all patients.

It is not only the child’s age but also the type of cataract that can have a bearing on the postoperative inflammatory response in children. Children with preexisting posterior capsule defects, dense posterior capsule plaque, or posterior persistent fetal vasculature may have a different inflammatory response. Patients with intraoperative complications, like placement of IOL in the sulcus, may also have affected the outcome measures. Intraoperative posterior capsulotomy and vitrectomy can also have a bearing on the outcomes in such studies.[9] The present study does not detail why posterior capsulotomy was not performed and whether triamcinolone was used to stain the vitreous or not.

The case series is insufficiently powered with other deficiencies, like lack of perioperative anti-glaucoma medications to PST group, lack of inter-group statistical analysis and P values, lack of objective measurement of flare, and methodology of randomization.

Steroids in any form are the mainstay of a postoperative regime in a child undergoing cataract surgery. Till we have sufficient type I evidence to recommend PST or intracameral triamcinolone in children as an alternative to drops, these drugs must be used with caution. It is difficult to accurately grade inflammation and objectively record IOP in younger children. Suppression of adrenocorticotropic hormone (ACTH) or cortisol levels in children has also not been studied with these depot drugs. Hence, combining intracameral agents with topical drops is best to get a better therapeutic response in the current scenario. Posterior sub-Tenon can be studied in a more significant number of patients and, till then, reserved for a select few older kids.