Predictive Factors of Complications and Visual Outcomes after Pediatric Cataract Surgery: A Single Referral Center Study from Türkiye

Volkan Dericioğlu; Mehmet Orkun Sevik; Elif Bağatur Vurgun; Eren Çerman

doi:10.4274/tjo.galenos.2023.50951

ABSTRACT

Objectives:

To evaluate the predictive factors of complications and visual acuity outcomes in pediatric cataract patients.

Materials and Methods:

This retrospective, observational clinical study included 80 eyes of 50 patients treated for pediatric cataracts between 2010 and 2020. The eyes were divided into Group I (congenital cataracts, n=38) and Group II (developmental cataracts, n=42). Group II was also divided into Group IIA (aphakic, n=21) and Group IIB (pseudophakic, n=21). The effects of the age, laterality, cataract morphology, intraocular lens implantation, preoperative nystagmus/strabismus, and intraoperative anterior hyaloid rupture on complications and final best-corrected visual acuity (BCVA; logMAR) were evaluated.

Results:

The median (interquartile range) age and follow-up time were 28 (5-79) months and 60 (29-84) months, respectively. There was a significant difference in mean final BCVA between Group I (0.79±0.46) and Group II (0.57±0.51) (p=0.047); however, no difference was observed between Group IIA and Group IIB (p=0.541). Having congenital cataract (p=0.045), preoperative nystagmus/strabismus (p=0.042), total/mature cataract (p<0.001), and postoperative complications (p=0.07) were significantly associated with final BCVA. However, in multivariate analysis, only total/mature cataract (β: 0.52, p<0.001) and having any complication (β: 0.24, p=0.018) were associated with final BCVA. Congenital cataract and intraoperative anterior hyaloid rupture were the only significant risk factors of postoperative complications on univariate (p=0.027 and p=0.003, respectively) and binary logistic regression analysis (odds ratio [OR]: 2.95 [95% confidence interval: 1.07-8.15], p=0.036 and OR: 4.28 [95% confidence interval: 1.55-11.77], p=0.005, respectively).

Conclusion:

Total/mature cataract and the presence of any postoperative complication adversely affected the final BCVA. Having a congenital cataract and intraoperative anterior hyaloid membrane rupture increased the risk of complications.

Keywords:

Pediatric cataract, congenital cataract, developmental cataract, surgery, complication, visual outcomes

Introduction

The factors affecting the long-term outcomes of congenital and developmental pediatric cataracts are frequently studied in the literature, with the most commonly investigated parameters being age at surgery, bilaterality, and intraocular lens (IOL) implantation.^1,2,3 Although congenital and unilateral cataracts were generally accepted as affecting visual outcomes, recent long-term studies with IOL implantation and aphakic treatment resulted in comparable success rates in final visual acuity.^1,2,3 However, it is difficult to make prospective observations or definite conclusions about all factors influencing final visual acuity, such as cataract morphology, preoperative nystagmus or strabismus, and occlusion therapy compliance.

The most common complications after pediatric cataract surgeries are inflammatory reactions in the anterior chamber and visual axis opacifications (VAO), and one of the most severe complications is secondary glaucoma.^4,5,6,7 As complications after pediatric cataract surgeries result in worse visual outcomes, it is essential to recognize and manage the factors associated with complication development.^1,8 For this purpose, the most commonly investigated parameters are age at diagnosis, anterior vitrectomy, IOL implantation, and techniques of IOL implantation.^{9,10,11,12,13,14}

The present study aimed to evaluate the effects of age at diagnosis, laterality, cataract morphology, preoperative nystagmus or strabismus, IOL implantation, and unintentional intraoperative anterior hyaloid rupture on complication rates and best-corrected visual acuities (BCVA) after pediatric cataract surgeries.

Materials and Methods

Results

There were 99 patients (161 eyes) with pediatric cataracts during the study period. After excluding the non-eligible patients, 50 patients (80 eyes) were included in the study analysis (Figure 1). Of them, 22 patients (38 eyes) were diagnosed with congenital cataracts before the age of 12 months, underwent cataract extraction without IOL implantation, and received contact lenses for refractive correction (Group I). The other 28 patients (42 eyes) were diagnosed with developmental cataracts after the age of 12 months and treated with cataract extraction (Group II). Among the patients in Group II, 14 patients (21 eyes) were left aphakic and treated with contact lens correction (Group IIA), and 14 patients (21 eyes) had primary IOL implantation during the cataract surgery (Group IIB). The overall median follow-up time was 60 (IQR: 29-84) months. The demographical and clinical data of the groups are presented in Table 1.

Discussion

In this study, total/mature cataract morphology and development of postoperative complications were significantly associated with final BCVA after pediatric cataract surgery. In addition, having a congenital cataract and unintentional intraoperative anterior hyaloid rupture leading to anterior vitrectomy increased the risk of postoperative complication development.

Total/mature cataracts are among the most common pediatric cataracts, with a worse visual prognosis, and early surgical intervention is recommended to prevent deprivation amblyopia.^16,17,18,19 The overall final BCVA of the total/mature cataract eyes in our study (1.11±0.58 logMAR) was comparable with the mean BCVA in a study conducted by Zhang et al.²⁰ (1.07±0.53 logMAR, n=156 eyes), and slightly worse than in a study conducted by Lin et al.²¹ (0.89±0.30 logMAR, n=88 eyes). Although we noted that total/mature cataracts had a significantly shorter time from diagnosis to surgery, regression analysis revealed that they were significantly associated with worse final BCVA. Among the eyes with a final BCVA worse than 1.0 logMAR, 54.8% (17/31) had total/mature cataract morphology, which was 85% (17/20) of the eyes with total/mature cataracts. That might have been a result of more severe obscuration of visual stimulus by total/mature cataracts than by other cataract morphologies, leading to profound deprivation amblyopia, which is generally more severe than strabismic or anisometropic amblyopia.²²

In our study, the development of any complication was also associated with final BCVA, which supports the published literature.^1,8 In our study, the overall complication rate was 35% (28/80 eyes), with a 22.5% (n=18) second surgery rate. These rates are comparable with the Pediatric Eye Disease Investigator Group study, which had a complication rate of 33.6% excluding amblyopia and a second surgery rate of 17% in 1132 eyes.²³ We found that having a congenital cataract diagnosed and treated before 12 months of age was a significant risk factor for complications. Studies in the literature also report that younger age is associated with an increased complication risk.^4,5 Studies have recently focused on the relationship between surgery at a younger age with or without primary IOL implantation and the development of secondary glaucoma.^24,25,26 Solmaz et al.²⁷ reported a significantly lower mean age at surgery in patients who developed glaucoma, but they did not observe a difference in glaucoma incidence between aphakic and pseudophakic cases. We observed secondary glaucoma in only 3 eyes (3.75%), all of which were in the aphakic congenital cataract group. Reported rates of secondary glaucoma vary between 2% and 58% in the literature.²⁸ Our relatively low rate was comparable with that reported in a multicenter study by Nagamoto et al.²⁹ (3.54%; 25/706 eyes), which also demonstrated a significantly higher rate in aphakic patients (p=0.003).

VAO occurred in a total of 8 eyes (10%) in our study, with comparable rates between the eyes that had only posterior CCC (n=4, 8.2%) and posterior CCC with anterior vitrectomy (n=4, 12.9%) (p=0.491). The incidence of VAO was reported to be 100% in eyes without posterior CCC and was reduced by performing posterior CCC and anterior vitrectomy.^18,30,31 Demirkılınç Biler et al.³² reported that while VAO was seen in 34.3% of eyes (23/67) that underwent posterior capsulotomy and anterior vitrectomy, the prevalence was 76.4% (n=26/34) in eyes without posterior capsulotomy. Similarly, Batur et al.^#*#ref33#*# found a 70% rate of posterior capsular opacification and 50% VAO in eyes without posterior CCC. A recent meta-analysis including 11 randomized controlled trials concluded that anterior vitrectomy minimizes the risk of VAO in pediatric cataracts.⁹ However, in our study, the positive effect of adding anterior vitrectomy to posterior CCC on VAO could not be demonstrated as other previous studies.^10,11,12

Hosal and Biglan¹³ found that only age at surgery was significantly associated with membrane formation after pediatric cataract surgery, with a 4.74-fold increase in patients younger than one year of age. We also observed a higher rate of membrane formation in patients before the age of 12 months (Group I, congenital cataracts) (10.5% vs. 2.3%, compared to Group II, p=0.105). There was also a higher rate of membrane formation in eyes with intraoperative anterior hyaloid rupture leading to anterior vitrectomy compared to eyes with intact anterior hyaloid membrane (12.9% vs. 2.2%, p=0.051) in our study. In contrast, Hosal and Biglan¹³ suggested that primary posterior CCC combined with a planned anterior vitrectomy was protective against secondary membrane formation. In a recent study that controlled for individual variations in inflammatory factors among patients by performing posterior CCC without anterior vitrectomy and posterior IOL capture in one eye and posterior CCC with anterior vitrectomy and in-the-bag IOL implantation in the fellow eye of the same patient, Kaur et al.¹⁴ observed significantly more inflammatory complications in the anterior vitrectomy group (p=0.004). They hypothesized that anterior vitrectomy might contribute to fibrinous complications.¹⁴ We think that uncontrolled rupture of the anterior hyaloid membrane might result in more interaction between the anterior vitreous and aqueous humor, causing more inflammatory and fibrinous reactions in the anterior chamber.

Conclusion

This retrospective, observational, single-center study revealed that total/mature cataract morphology and the presence of any postoperative complications adversely affected the final visual acuity of pediatric cataract patients. Moreover, having a congenital cataract or intraoperative anterior hyaloid membrane rupture independently increased the risk of complications in these patients.

Study Limitations

The main limitations of our study are its retrospective nature and limited sample size. However, the effect sizes of statistical comparisons were given to determine the difference between factors regardless of the number of cases. Although the results are not sufficient to be generalized, they shed light on the factors associated with final visual acuity and the development of complications in pediatric cataract patients.

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