Management of congenital cataract

Investigations
Treatment

1. MANAGEMENT OF CONGENITAL CATARACT Y.T. MANIKANTA ROLL NO: 174

2. I. I I. Deta i le d hi s to r y Comp l et e o c u l a r e x ami n at i o n - I. U C V A, B C V A, pupillar y re a c tion intr a - o c ula r tension, fundus examina t ion I I . B s c a n ultra s ono g raphy to exclud e po s terior s e gment abn o rmality lik e g r o wth/ retinoblastoma I II . A sc a n to determin e axia l lengt h o f the eye IV. R etinos c op y , to de r emin e the refra c ti v e status V. cover test to e x clude squint V I . Early photog r aph s to k n o w on s e t o f c a tara c t INVESTIGATIONS

3. Labora t or y investigations :  (For b i l ater a l cases)  B loo d T est  Full bloo d c o unt, Blood glu c o s e (FBS / R BS)  Serum c a lciu m an d pho s pho r u s  RB C tran s fe r as e and Gala c tokinase levels  T ORCH test  H e pati t i s B v i rus  Uri n e an a lys is:  For re du c in g s u b s tance for gala c tosaemia  For amin o acid s (to e x clude Low e syndrome i n su s pect e d ca s es) Unilateral Pedi at ri c cases a r e m ostl y id i opathic.  N o nee d o f la b in v estigation

4. NON-SU R GICA L TR E A TMENT  Use d fo r pa rtial ca tar a c t s  Part ia l cata r ac t les s t ha n 3 mm an d p e rice n tr a l cataracts re s pond  Pupi l lar y d i l atat i o n w ith 2.5 % ph e nyl e phrin e an d par t t i me occlusio n o f goo d eye  Cyclopen t olat e can b e add e d onc e o r tw i ce a da y if req uired  Prolonged cyclo p eg i a (dai l y at rop i ne ) can in d uc e amblyo p ia  Pup i llar y dil a ta t io n i s r eserve d for preve r ba l ( 1 -6 ye a rs) w i th pa rtial ca tar a c t s an d bo r de r lin e amblyo p ia  If significant a m blyop i a persists , cataract e x t ractio n shou l d b e pe r fo r m ed

5. WHE N T O OPE R A TE?? 1. Bila teral d en s e cataracts : - requ i re earl y surgery a t 4-6 w e ek s o f a g e to p revent d e ve l o p ment o f stimu l u s d e priv a tion amb l yo p ia 2. Bila teral p art i al cataracts -may no t r eq u ir e surgery o r requ i re on l y a t a late r date

6. GENERA L TE C HNIQ U ES  Dee p gene r a l an a esthes i a i s required  Ped i at r i c cata r act s ar e so f t – l e n s material can b e asp i rated throu g h incision s th a t ar e 1 - 1.5m m l o n g a t the l i mbus ;  can b e sub j ec te d to l e nsectom y thr ou g h par s p l ana  A l arge r wou n d i s neede d to int r oduc e I O L  T unne l should b e secu r el y su tur ed to preven t d ehiscenc e of woun d wit h iri s inca r ce r a tion

7. SPECIFIC TECHNIQU E S Th e re a r e tw o approach e s P a rs p l a n a approach L i mbal ap p roach P a rs pla n a a p proa c h i s b e i n g a b a n d o n e d grad u a l l y in favour o f l imba l ap p roach a s limba l ap p roach a l l o w s better preservatio n o f the caps u l a r ba g for i n- the- ba g I O L p l acement.

8. P AR S PLAN A APP R O A CH In dica t ion s :  neonate s an d infan t s <2yea r s o f age  wit h B/L cata r ac t s  for w ho m I O L implantatio n i s no t in t ende d im m ediately

9. LIMBAL APP R O A CH  M os t versa t il e te chnique  Advant ages:  visu a l i zation o f the i nst ruments  the a b i l it y to pres e rve t h e posteri o r ca p su l e w h en des i red, and  the l ac k o f d isrupti o n o f the vitreous un l es s p l an n ed.

10. APHAKIC COR R ECTION IN CHILDREN  Spectacles  Contac t l e nses  IOLs

11. SPEC T A CLES  Satis f ac tor y on l y i n c ase s o f B/L ap h akia  M os t develo p goo d visual acuity  Cosme t icall y no t acceptable  Poor op t ica l qualit y o f h i g h –p l u s l e nses

12. CO N T A C T LENSES  Bet t e r op t ica l co r re c tion th a n spec t acles  Diopt r i c powe r can b e ad j us te d th rou ghou t th e l ife  Di f fic ul t to manage an d cos tly  Los s o f l e nses  Fr equen t infe c tions  Poor f oll o w up  Thus m os t imp r ac tical

13.  B oth the b i o met ry an d the a g e o f the ch i l d deter m i n e the ch o ic e o f the I O L d i o p tr i c p o w e r .  A g e <2 years- a x i a l l e ngt h an d the keratom et ri c (K) read i ng s chan g e rapi d ly  A g e 2 -8 years- chan g e s ar e slo w e r an d more moderate.  E x pecte d l a rge Myopic Sh i ft  AI M FOR U N D E R C OR R ECTION SELECTION OF IOL

14. GU I DELINES F O R THE CHO I CE OF INT R AOC U L A R LE NS DI O PT R IC POWER C H ILDR E N L E SS T H AN 2 Y E A R S OLD D o b i ometr y an d u n d e rcorrect b y 2 % Us e a x i a l l e ngt h measurements on ly: - 17mm , 2 5 D - 1 8 m m , 2 4 D - 1 9 mm, 2 3 D - 20mm , 2 1 D - 2 1 m m , 1 9 D C H ILDR E N B E TWE E N 2 A N D 8 Y E A R S OLD D o b i o met ry an d un d ercor r ec t b y 10%

15. IOL Impl a ntati o n in children  After the c atarac t h a s bee n asp i rated, a n e l ective posterio r capsu l ectom y - ante r io r vitrec to my i s per f or m ed.  S u lc u s impl a ntatio n i s eas i e r an d als o a l l o w s a n eas i er e x p l antatio n - may b e do n e i n neonate s an d i n fants l e ss than 1 y e a r o f a ge . But w it h the n e w e r folda b l e I O Ls , in the b a g impl a ntatio n i s the p r efer r e d techn i qu e.  An in -the- ba g I O L i s more d i f ficult to e x p l ant , this option shou l d b e chos e n for i nfant s a b ov e 1 year o f a ge bec a us e they a re les s l i kely to n ee d a n I O L e x chan ge, prov i d e d they ar e u n d e rcorrected b y 2 %.

16. IOL Im p la n ta t ion in chil d ren  In the ba g techn i qu e requ i res b ot h ante r i o r an d posterior capsu l or r he x is e s  T h e I O L h a ptic s ar e pl a ced i n t h e ba g forn i ces, w h i l e the opti c i s prot r ud e d thr ou g h bot h capsu l or r he x is e s to b e captured bene ath the p osterio r capsu l e rem na nts.  T assi g no n ha s develope d a special IO L cal l e d bag - i n -the- len s .  The techn i qu e cons ists o f creating a n anterio r an d posterior capsu l or r he x i s . T h e spec i a l l y des i gn e d I O L has , a t its peri p her y , a groov e tha t conta i n s bot h anterio r an d posterior ca p su l e rims

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