Banded technique for pediatric traumatic cataract surgery

Abstract

We describe a technique for pediatric traumatic cataract management in cases in which part of the anterior capsule has been ruptured. The technique requires creating a 2-incision push–pull capsulorhexis in the intact anterior capsule. The capsulorhexis is made in a manner that converts the edge of the ruptured anterior capsule into a band of capsule that holds the intraocular lens (IOL) in the bag, reducing the incidence of early, intermediate, or late postoperative lens–iris capture. It also reduces the chances of IOL displacement.

Trauma is a major cause of monocular blindness worldwide, and cataract formation is a well-documented response to trauma in children.^1–3 Several complications have been reported after intraocular lens (IOL) implantation in pediatric eyes having surgery for traumatic cataract. Complications include fibrinous uveitis, pupillary capture of the IOL, IOL tilt, and visual axis opacification.^4–8

We describe what is, to our knowledge, a new approach for the surgical management of pediatric traumatic cataracts to reduce and/or prevent pupil–lens capture and IOL decentration.

SURGICAL TECHNIQUE

Under general anesthesia, 2 microvitreoretinal blade stab incisions are made 100 degrees apart at the limbus into the anterior chamber. An ophthalmic viscosurgical device (OVD) (sodium hyaluronate 1.4% [Healon GV]) is then injected to maintain the anterior chamber, and the anterior capsule is stained using trypan blue 0.06% solution. This is done after all the iris adhesions (if present) around the rupture site on the anterior capsule are broken with the OVD

A 2-incision push–pull capsulorhexis⁹ is created in the intact capsule proximal to the rupture in such a way that a narrow band of capsule remains between the new capsulorhexis and the site of rupture (Figure 1). Using the vitrector with the cutter off, as much lens material as possible is aspirated. The posterior capsule integrity is assessed. If intact, a 2-incision push–pull capsulorhexis is created in the posterior capsule, after which an anterior vitrectomy us performed. In cases in which the posterior capsule also has a rupture, an anterior vitrectomy is performed, taking care not to damage the posterior capsule remnants further. To make sure there was no vitreous in the anterior chamber, integrated intraoperative optical coherence tomography (OCT) is used in most cases.

Figure 1.

Images before and after lens aspiration. Note the capsule rupture (star), narrow band of anterior capsule (white arrows), borders of the anterior capsulorhexis not involving the site of rupture (fine black arrows), and areas of the intact anterior capsule (black dots). Left: Before lens aspiration. Right: After lens aspiration. The black arrowheads show the edges of the traumatic rupture of the posterior capsule.

The corneal incision is extended, and 3-piece hydrophobic IOL is placed in the bag through the ruptured opening of the anterior capsule (Figures 1 and 2) or through the 2incision push–pull capsulorhexis (Figures 3 and 4), whichever is larger. Either way, the trailing haptic is placed so that the IOL is under the band (Video 1, available at http://jcrsjournal.org). The main corneal wound is closed with 3 sutures (10–0 polyglactin) and the paracentesis with a single suture (10–0 polyglactin). This is followed by OVD removal.

Figure 2.

A: Area of anterior capsule rupture (white stars) and the intact anterior capsule (black dots) in the eye in Figure 1. B: Stable IOL under the band. C: Intraoperative anterior segment OCT showing a narrow band of anterior capsule (white arrows) over the IOL (white triangle heads). Note that the optic is well away from the pupil plane. D: Anterior segment photograph showing a narrow band of anterior capsule (white arrows) that has moved out of the visual axis at the 6-month follow-up. The image in C has been rotated to fit the frame, and the image in D has been rotated to show the band in an identical location (OCT = optical coherence tomography; IOL = intraocular lens).

Figure 3.

A: Area of anterior capsule rupture (white star) in another case. B: Margins of anterior capsulorhexis (black arrows), a narrow rim of anterior capsule over the IOL (white arrows), and a posterior capsulorhexis (gray arrows). C: Postoperative anterior segment photograph showing a narrow rim band of anterior capsule over the IOL (white arrows) that has moved out of the visual axis through contraction at the 3-month follow-up. Note that the different orientation between C and A and B is because A and B are taken with the operating microscope and C through an anterior slitlamp camera (IOL = intraocular lens).

Figure 4.

A: Area of anterior capsule rupture (white star) with a total cataract in the fifth patient. Narrow band of intact anterior capsule restraining the IOL (white arrows) and posterior capsulorhexis (gray arrow). C: Anterior segment photograph showing the band of anterior capsule (white arrows) that has moved out of the visual axis at the 11.5-month follow-up. The image has been rotated to show the band in an identical location; note that the band has moved out of the visual axis (IOL = intraocular lens).

Intracameral preservative-free dexamethasone is given together with subconjunctival cefazolin sodium, subconjunctival dexamethasone, and orbital floor triamcinolone (1 mg/kg). A drop of tobramycin and dexamethasone and a drop of cyclopentolate are placed in the eye, and the eye is padded and closed. A single stat dose of acetazolamide (4 to 7 mg/kg body stat) is administered intravenously.

Results

This technique was used in 5 children. The mean age at surgery was 8.5 years (range 2 to 15 years).

The preoperative distance visual acuity ranged from hand motions (HM) to 20/800. There were 4 cases with a penetrating injury and 1 with a blunt injury. Four patients had primary corneal wound repair followed by secondary cataract surgery with IOL implantation. The mean time between the injury and cataract repair was 47 days (range 32 to 59 days).

The 1-day postoperative visual acuity ranged from HM to 20/125. The visual acuity at final follow-up ranged from 20/20 to 20/125. The follow-up ranged from 40 days to 17 months. The IOL was in stable position at the final follow-up in all patients, with no evidence of IOL displacement or lens–iris capture. No patient required a neodymium:YAG capsulotomy to the band. The narrow band contracted away from the visual axis in all cases (Figures 2 to 4).

DISCUSSION

Traumatic cataracts account for 12% to 29% of all pediatric cataracts.^1–3 Pediatric traumatic cataracts are often accompanied by increased inflammation; amblyopia; injury to the cornea, uveal tissue, and angle structures; anterior and/or posterior lens capsule rupture; lens dislocation; and posterior segment complications. A successful surgical intervention in these cases poses a therapeutic challenge.

Surgical management of traumatic cataract in children with an IOL can be complex because of the of increased risk for postoperative complications.^4,5 Lens–iris capture occurs where the anterior capsule opening is larger than the IOL; the incidence ranges from 26% to 35%.^2,8 When possible, posterior optic capture is a good technique to stabilize the IOL; however, anterior capsule rupture is often accompanied with a posterior capture tear or rupture and posterior optic capture is not possible. To reduce the risk for lens–iris capture, we developed the banded technique to keep the IOL posterior and away from the pupil. Although this technique has not been used in adult cases because our practice is purely pediatric, theoretically it should work just as well.

In our technique describes, a narrow band of anterior capsule is created. This band restrains the IOL in the bag, preventing IOL pupillary capture and IOL tilt, and minimizes contact with uveal structures, leading to a stable IOL with less postoperative complications. Also, because it is positioned in the capsular bag, the IOL does not cause complications such as reduced endothelial counts, pupillary capture, IOL tilt or decentration, or postoperative uveitis resulting from uveal touch. This reduces the risk for posterior segment complications such as vitreous hemorrhage and retinal detachment. The key to the technique is the ability to perform a small oval capsulorhexis in the intact anterior capsule. The 2-incision push–pull capsulorhexis⁹ appears to be useful in achieving this. Thus far, we have not come across a case in which the technique has not been applicable and an IOL could not be placed in the bag, However, theoretically if the anterior capsule rupture is greater than one half of the whole anterior lens capsule surface, IOL placement might be difficult to complete. None of our cases had traumatic cataract surgery sooner than 4 weeks after the injury. Whether this technique could be used for primary repair requires further evaluation. However, the 2-incision push–pull capsulorhexis would likely be even more useful under these circumstances because the distal stab of the technique would define how close the capsulorhexis is to the ruptured edge.

WHAT WAS KNOWN.

•In cases of pediatric traumatic cataract in which the anterior capsule has ruptured, IOL implantation, when performed, often leads to IOL or pupil capture and/or IOL decentration because the anterior capsule opening is larger than the IOL optic.

WHAT THIS PAPER ADDS.

•The new banded technique for implanting an IOL in such cases reduces the chances of IOL or pupil capture and/or IOL decentration.