Manual small incision cataract surgery in bilateral pediatric cataracts in rural population

Soumya Ramani; Y Ksheeraja; RH Deepthi; Chris Diana Pius

doi:10.4103/pajo.pajo_12_23

CASE REPORT

Year : 2023 | Volume : 5 | Issue : 1 | Page : 13

Manual small incision cataract surgery in bilateral pediatric cataracts in rural population

Soumya Ramani, Y Ksheeraja, RH Deepthi, Chris Diana Pius
Department of Ophthalmology, M. S. Ramaiah Medical College Hospital, Bengaluru, Karnataka, India

Date of Submission	01-Mar-2023
Date of Decision	21-Mar-2023
Date of Acceptance	19-Apr-2023
Date of Web Publication	11-May-2023

Correspondence Address:
R H Deepthi
Department of Ophthalmology, M. S. Ramaiah Medical College, Bengaluru, Karnataka
India

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/pajo.pajo_12_23

Abstract

The main purpose of this study is to describe the visual outcomes in children with bilateral cataracts undergoing small incision cataract surgery and is mainly focused on children with bilateral cataracts from poorer backgrounds who tend not to receive adequate and timely medical attention. This could lead to issues such as amblyopia. However, it is important to provide surgical care even at a later date to afford some visual redemption. When affordability is the weakest link in the treatment, a manual small incision cataract surgery (MSICS) can be an ideal manner to treat bilateral cataracts. In this study, we highlight the good visual outcome post-MSICS with polymethylmethacrylate lens implantation, primary posterior capsulotomy, and anterior vitrectomy in children with bilateral cataracts who have presented at ages beyond 5 years.

Keywords: Amblyopia, bilateral cataracts, manual small incision cataract surgery, pediatric cataract, rigid polymethylmethacrylate intraocular lens

How to cite this article:
Ramani S, Ksheeraja Y, Deepthi R H, Pius CD. Manual small incision cataract surgery in bilateral pediatric cataracts in rural population. Pan Am J Ophthalmol 2023;5:13

How to cite this URL:
Ramani S, Ksheeraja Y, Deepthi R H, Pius CD. Manual small incision cataract surgery in bilateral pediatric cataracts in rural population. Pan Am J Ophthalmol [serial online] 2023 [cited 2023 Jun 3];5:13. Available from: https://www.thepajo.org/text.asp?2023/5/1/13/376672

Introduction

A cataract is the most common surgically treatable cause of pediatric blindness in many low-resource countries^[1],[2] accounting for 10.7%–14% of pediatric blindness globally.^[3] Compared to high-income nations (0.42–2.05/10,000), low-income economies had a higher prevalence of childhood cataracts (0.63–13.6/10,000). No gender or laterality differences exist in the prevalence.^[4]

Before 6 weeks of age, unilateral cataracts should ideally be addressed, and before 8 weeks of age, bilateral cataracts should be operated.^[5] When symmetric cataracts are present, the second eye is operated within 1 week after the first eye, and when a child is systemically fragile, it can be done in one sitting.^[6]

Unfortunately, there may be delays in diagnosis and surgery, as well as technical restrictions, in low-income nations, which frequently lead to poor outcomes.^[7] Due to deprivation amblyopia, difficulties faced during surgery, and a lack of opportunities for rehabilitation, including access to timely and appropriate refraction, a sizable number of children continue to be blind.^[8] On the other hand, skilled and meticulous surgery can result in fewer postoperative problems.^[9]

Manual small incision cataract surgery (MSICS) is a surgery commonly employed in developing countries to ease the burden of cataracts as it is a quick and low-cost procedure. The visual prognosis in children following MSICS has been found to be satisfactory, with around 75% of the operated eyes regaining functional vision.^[10] The purpose of this case series was to highlight the utilization of MSICS and rigid polymethylmethacrylate (PMMA) lens (which is most commonly available in developing countries) in the treatment of bilateral pediatric cataracts and to evaluate the postoperative visual outcomes achieved by the use of this technique.

Methods

A 6-year-old female child, diagnosed with bilateral lamellar cataract, underwent right eye cataract surgery first. Preoperative vision OD was counting fingers (CF) at 3 m. The child tested positive for cytomegalovirus (IgG antibody). In the left eye, an inferonasal coloboma was seen. The rest of the posterior segment findings were found to be normal. A MSICS with posterior chamber intraocular lens (PCIOL) (rigid PMMA lens) was performed with posterior capsulorhexis (PCR), along with anterior vitrectomy (AV) (MSICS + PCIOL + PCR + AV). Postoperative vision on the 1^st day was 6/9 in the operated eye. This child was followed up after 1 week, 1 month, and yearly after the surgery. The vision was found to be 6/12 at 6 months and then dropped to 6/18 at 2 years due to posterior capsular opacification (PCO), for which Nd-YAG capsulotomy was done. The vision then improved to 6/9 and continued to remain so after the procedure. The child is still under follow-up.

Sibling of this first case, a 12-year-old female was also diagnosed with bilateral lamellar cataract operative vision which was CF at 3 m and CF at 1 m in the right and left eye, respectively. She underwent bilateral cataract surgery (MSICS + PCIOL + PCR + AV). The postoperative vision was 6/12 and 6/18 in both eyes on day 1 of surgery. At 1 month, vision improved to 6/9 in both eyes. At 12-month postsurgery, best-corrected visual acuity (BCVA) was found to be 6/18 and 6/12 in right and left eye, respectively. A posterior capsule opacity (PCO) in both eyes was noted in both eyes for which Nd-YAG capsulotomy was done. BCVA following this was 6/9 in both eyes. The child and her sibling were then called for regular follow-ups as mentioned in the previous case. The vision has been 6/9 for the past 5 years.

Another case of a 5-year-old female patient with BCVA of 6/60 in both eyes had alternating esotropia with a lamellar cataract in both eyes. This child underwent MSICS + PCIOL + PCR + AV in both eyes within 1 month. Postoperative vision on day 1 was found to be 6/36 and 6/18 in right and left eye, respectively. BCVA at 1 month was found to be 6/12 in both eyes. At 10-month postsurgery, BCVA dropped to 6/18 due to the formation of a PCO for which Nd-YAG capsulotomy was performed. However, BCVA remained 6/18 postcapsulotomy. The child was followed up for 3 years and then lost for follow-up. During the follow-up, the vision has remained 6/18.

The sibling of the above case, a 9-year-old female also had a bilateral congenital lamellar cataract. The preoperative vision was 6/60 in both eyes. This child underwent bilateral MSICS + PCIOL + PCR + AV. On postoperative day 1, vision could not be assessed, however, on day 2 postsurgery, OU BCVA was 6/12 vision. Three-year postsurgery, the BCVA dropped to 6/18 due to PCO. She also underwent Nd-YAG capsulotomy in both eyes and BCVA improved to 6/6 in both eyes. Both the siblings were asked to come for regular follow-up visits and were followed up for 3 years.

Another 13-year-old boy presented with diminution of vision in OU for the past 6 years. Vision loss was gradually progressive and painless in nature. There were no systemic complaints or history of intake of any medication. He had not been vaccinated regularly but had taken only Bacille Calmette–Guérin. His mother gives a history of pregnancy-induced hypertension, but an otherwise uneventful pregnancy following which the child was delivered at term by normal vaginal delivery. There was neither any history of fever with rash in the early childhood period or malnutrition. The child had one younger sibling who had no visual symptoms; nevertheless, the child has not been screened for any ocular abnormalities.

On examination, visual acuity was OU perception of light and projection of rays accurate. There was no clinical evidence of strabismus with rest of the examination being unremarkable except that lens examination showed bilateral lamellar cataract. He underwent OS MSICS + PCIOL + PCR, AV. The left eye surgery was followed by right eye cataract surgery within a week. The postoperative vision was 6/36 in both eyes which improved to 6/9 on the pinhole. The child was lost to follow-up 1 week following surgery.

In another instance, a 13-year-old boy presented with a diminution of both eyes for the past 5 years. He was a known case of left hemiparetic cerebral palsy with a seizure disorder for the past 5 years and was on multiple oral antiepileptics. Pregnancy was uneventful and was delivered at 38 weeks by normal delivery. He was required to stay in the neonatal intensive care unit in view of birth asphyxia. There was a history of developmental delay. The child had no first- and second-degree relatives with similar complaints.

Visual acuity was OD CF at 1 m and OS CF at 2 m. Examination of the anterior segment was unremarkable except for the lens of both eyes having lamellar cataracts. The patient was then taken up for OD surgery. On postoperative day 1, visual acuity was 6/18 which improved to 6/12 with refraction. The patient could only be followed up to postoperative day 3 following which he was discharged and was lost to follow-up.

In another setting, an 8-year-old boy was brought with diminution of vision. Pre-and postnatal periods were uneventful for both the mother and child. There was no significant history. The child had one older sibling aged 10 years who did not have any ocular complaints.

Examination showed visual acuity to be OU CF at 2 m. With the exception of both eyes' lenses having lamellar cataracts, the anterior segment's examination revealed nothing notable. Fundus was remarkably normal. After that, the patient had OD SICS, which included rigid PMMA intraocular lens insertion, anterior vitrectomy, and posterior capsulorrhexis. On postoperative day 1, visual acuity was 6/12 with Snellen's chart. The patient was lost to follow-up following discharge.

Although it is recommended to follow-up on such cases closely as chances of postoperative inflammation are higher in the pediatric age group, due to logistical issues; these two patients were not followed up both at the screening site/out-patient setting in the said hospital.

For all the children, the SRK/T formula was used and an IOL undercorrection by 10% from the original was done as all of them were over 2 years.

As a pre-emptive measure to prevent postoperative inflammation, all the patients were given subconjunctival dexamethasone sodium phosphate injection (4 mg/ml, 0.2 ml) intraoperatively after the surgery, oral steroids (prednisolone sodium phosphate – 5 mg/ml at a dose of 1 mg/kg body weight in two divided doses), topical medications such as homatropine 1% two doses, prednisolone acetate 1% from postoperative day 1 – given hourly for the 1^st week and tapered thereafter.

Postoperative care for patients who were screened and sent to us through outreach camps was then monitored at the same setups in their outpatient departments monthly and were called subsequently for follow-up.

[Figure 1] and [Figure 2] show the presence of bilateral cataract and OD lamellar cataract taken before surgery and postoperatively, respectively.

Figure 1: Photograph taken on slit-lamp biomicroscopy. Right eye shows the presence of lamellar cataract

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Figure 2: Anterior segment photograph on postoperative day 1 (all photographs were obtained after receiving oral consent from the patient and the guardian)

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All the above-mentioned cases were done under general anesthesia and were performed by a single experienced surgeon after obtaining written consent by the patient (if he/she was above 18 years) or by the parent/guardian of the said patients (if under 18 years of age).

Discussion

Successful treatment of visually significant congenital or early developing cataracts depends on effective surgical intervention. The best surgical strategy is anticipated to change based on the patient's age and the presence of coexisting diseases, among other things. Access to health-care services and ophthalmological follow-up are crucial factors for best visual outcomes.^[11]

In pediatric cataracts, a good anterior, adequate posterior capsulorhexis along with anterior vitrectomy are a key to minimize the risk of visual axis opacification and the need for subsequent additional surgical procedures.^[12] It is advised to use phacoemulsification for pediatric cataract surgery whenever phacoemulsification equipment and skilled doctors are available.^[13]

However, in developing nations as ours, affordability and accessibility to these resources can be scarce. Therefore, to tackle this, the Government of India has put forth the National Programme for Control of Blindness and Visual Impairment, which offers grants-in-aid for cataract surgeries done in government/private/nongovernmental organizations sectors in the form of reimbursement per surgery amounting to ₹2000.^[14] This poses as a financial barrier as not all preoperative investigations, for example, toxoplasmosis, rubella, cytomegalovirus, herpes simplex and hiv, syphilis (TORCH) titers, machinery, and foldable lenses can be covered under this. Although the situation is suboptimal, the use of easily available and cost-effective techniques such as MSICS with the use of rigid PMMA lenses proves beneficial. This case series outlines the use of MSICS in the treatment of congenital and developmental cataracts, particularly in rural patients who underwent the surgery under government-sponsored scheme.

The timing of the procedure and visual rehabilitation are crucial factors for how pediatric patients see after cataract surgery.^[15] Older age at the time of surgery has been linked to worse visual outcomes for bilateral infantile cataracts.^[16] However, it is not advisable to preclude surgeries in such cases despite their delayed presentation.

In our case series, all the children presented after the age of 5 years with bilateral cataracts which would have most likely resulted in poor visual outcomes. Late detection can be owed to their geographical barriers, lack of awareness in the parents, unaffordability, lack of access to primary eye care practitioners in rural setup. Hence, most pediatric cataracts may remain undetected until a late stage by when amblyopia may have set in. Despite their late presentation, we opted for prompt surgical intervention keeping in mind guarded visual prognosis.

In patients with bilateral cataracts, the earlier consensus was to treat them earlier in order to have a better visual outcome.^[17] However, another study demonstrated that amblyopia therapy even if initiated in children older than 8 years proved to show improvement in visual acuity.^[18] Taking this into account, amblyopia therapy was initiated in some of our patients and was found to be advantageous.

Although it has been proven that MSICS is a good surgical technique and has good visual outcomes in adults, there have been very few reports of it being equally effective in the pediatric age group. Hence, it becomes important to create awareness and adopt techniques like the MSICS, in cases where monetary and financial issues pose a burden. Despite the evolution in cataract surgical techniques, simpler and cost-effective surgery like the MSICS is therefore still invaluable.^[13]

All things considered; it becomes equally important to meticulously evaluate the causes for childhood cataracts. To rule out genetic, systemic associations, metabolic disorders, and infections, laboratory orders including but not limited to TORCH titers, venereal disease research laboratory, and genetic testing are recommended. However, due to financial constraints, all of the above tests could not be opted for in all our patients.

Comprehensive long-term postoperative care for our patients was not possible due to attrition. Refraction, prescription of eyeglasses, therapy of amblyopia, and monitoring for glaucoma and corneal decompensation and posterior capsular opacification (PCO) are important parts of postoperative care. We would like to highlight that despite adequate posterior capsulorhexis, the formation of a PCO was still noted probably owing to different patient-related factors, ocular and systemic conditions, residual cortical fibers, and adjuncts that influenced the development of PCO. Parents and relatives should therefore be counseled about the importance of regular examinations and follow-ups.

It is important that they should also be encouraged to bring the siblings of affected children for screening. Further financial aid in pediatric cataracts for unaffordable patients could lead to better management in terms of investigations and surgical armamentarium.

Conclusion

Favorable visual outcomes are possible in pediatric patients with cataracts who present at a later-than-ideal age group. MSICS with implantation of rigid PCIOL with anterior vitrectomy is an effective and safe method of treating pediatric cataracts. Short-term visual outcomes are fair, but it is important to keep the child under close follow-up for better visual outcome. This can be achieved by counseling the families, subsidizing follow-up visits, and mobilizing health-care services for easy accessibility.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patients have given their consent for their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Acknowledgment

The authors would like to thank Dr. Ananth S Bhandary, HOD, Department of Ophthalmology, MS Ramaiah Medical College for his constant support and guidance throughout.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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