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Management of IOLs in Pediatric Cataracts: When, How, Where, and Which type of IOL.

Management of IOLs in Pediatric Cataracts: When, How, Where, and Which type of IOL. José A. Cristóbal, María A. del Buey, León Remón, Francisco J. Ascaso. Department of Ophthalmology “Lozano Blesa” Clinical University Hospital, Zaragoza, SPAIN.

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Management of IOLs in Pediatric Cataracts: When, How, Where, and Which type of IOL.

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  1. Management of IOLs in Pediatric Cataracts: When, How, Where, and Which type of IOL. José A. Cristóbal, María A. del Buey, León Remón, Francisco J. Ascaso. Department of Ophthalmology “Lozano Blesa” Clinical University Hospital, Zaragoza, SPAIN No author has a financial or proprietary interest in any material or method mentioned. 1

  2. Purpose To describe the different possibilities of treatment in pediatric cataract with IOL implantation; analyzing the type of IOL, the position of the haptics (sulcus or in the bag), the position of the optic (in the bag or into the vitreous), the posterior capsulorrhexis and anterior vitrectomy (depending on the age and cooperation of the patient) and the use of multifocal IOLs in special cases. 2

  3. When to perform surgery? WE RECOMMEND EARLY SURGERY In case of great risk of deep amblyopia:congenital, central, dense, wide, total,… (with significant visual impairment). Technique:Lens phacoaspiration CARACTERISTICS OF PEDIATRIC CATARACT SURGERY Small eye, elastic capsule, quick capsular opacification, difficulty in IOL power calculation, postoperative treatment of amblyopia very hard. Cataract surgery in children needs special considerations in the use of IOLs and also in lens power calculation. It is necessary to do a very careful surgery, having always in mind the necessity of transparency in the visual axis and a good state of eyeball in case of the possibility of future surgery. 3

  4. How to perform surgery? Posterior Capsulorrhexis Anterior Vitrectomy Luxation of the optic MANEUVERS TO AVOID POSTOPERATIVE OPACIFICATION OF VISUAL AXIS. They are necessary in non-cooperative children (usually under five years of age), when there is no possibility of doing a Nd YAG laser posterior capsulotomy in the slit lamp. MANEUVERS Anterior Capsulorrhexis • Causes of opacification: • Epitelial cells proliferation and migration in posterior capsule • Inflamatory membranes • Anterior vitreous opacification 4

  5. CONGENITAL PEDIATRIC CATARACT ASSOCIATED WHITH OTHER ABNORMALITIES. A six-month-old baby with bilateral cataract, microphthalmos and iris abnormalities. TREATMENT: BILATERAL CATARACT EXTRACTION WITHOUT IOL Aphakic Spectacles Removal of fibrosis over the lens surface, anterior capsulorrhexis, manualaspiration of lens material, posterior capsulorrhexis and central anterior mechanical vitrectomy. Silicone contact lenses correction 5

  6. CONGENITAL PEDIATRIC CATARACT ASSOCIATED WHITH OTHER ABNORMALITIES. A two-year-old child with total monolateral pediatric cataract. The Echography shows persistent fetal vessels. TREATMENT: CATARACT EXTRACTION WITH MONOFOCAL IOL IN “SULCUS” AND POSTERIOR OPTICAL LUXATION Anterior capsulorrhexis, phacoaspiration of lens, incomplete posterior capsulorrexis preserving the central vessel, anterior vitrectomy, IOL in “sulcus” with the optic into the vitreous displacing the vessel. 6

  7. Which type of IOLs? WE RECOMMEND INTRAOCULAR LENS IMPLANTATION ALWAYS IF POSSIBLE CHILDREN UNDER 2 YEARS OF AGE DESIGN MONOFOCAL “3 PIECES” IOL WITH HAPTICS IN SULCUS AND THE OPTIC IN THE BAG OR LUXATED INTO THE VITREUS POWER UNDERCORRECTION 20% CHILDREN BETWEEN 2 AND 4 YEARS OF AGE DESIGN MONOFOCAL “3 PIECES” IOL IN THE BAG OR WITH THE OPTIC LUXATED INTO THE VITREUS POWER EMMETROPIA – UNDERCORRECTION 10% Luxation of the optic 7

  8. MULTIFOCAL DIFRACTIVE IOLS IN CHILDREN Good visual prognosis Ideal capsular support Posibility of good biometric calculation Enough ocular development MF IOL ¿WHEN? Clear visual axis in a child two years after surgery. Surgery in a polar evolutive central cataract. Anterior and posterior capsulorrhexis removing polar opacification. Multifocal IOL in the capsular bag. Since 2004, we have had a good experience in children with monocular cataract (developmental, evolutive, traumatic…) and emmetropic contralateral eye. It is our choice to improve binocularity and even stereopsis for distance and near vision. 8

  9. Conclusion • In our experience, the best option to manage with pediatric cataract is to implant an IOL after cataract extraction, unless the presence of associated ocular abnormalities make it inadvisable . • Visual recovery will be faster than in pediatric aphakic eyes and less "hard". Controversy still persists about the appropriate power of the IOL and how to calculate it. José A. Cristóbal MD, PhD, FEBO. Clinical University Hospital Zaragoza, SPAIN <joseangelcristobal@yahoo.es> 9

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