Dr. Jaspreet Sukhija, J09047, Dr. Savleen, Dr. Jagat Ram, Dr.Jitender Jinagal
Jaspreet Sukhija, MD, Savleen Kaur, MD, Jagat Ram,MD, Sonam Yangez, MD, Sidharth Madaan,MD, Jatinder Jinagal,MD.
Department of Ophthalmology, Post Graduate Institute of Medical Education and Research
Chandigarh-India
Introduction
Posterior capsule opacification (PCO) is the most common and amblyogenic complication after pediatric cataract surgery. Amongst the several foldable IOLs, hydrophobic acrylic material is proven to be the most biocompatible in children as well as adults. With a vast array of foldable hydrophobic acrylic IOLs of different manufacturers now available, we decided to compare some of them on their effect on the visual axis opacification (VAO) and compatibility after pediatric cataract surgery.
Methods
Patients were divided into 4 groups depending on the type of IOL implanted. Group 1: SA60AT (AcrySof, Alcon, Fort Worth, TX); group 2: Hoya IOL(Hoya-PS AF-1Series; Model PC-60AD;Hoya, Japan); group 3: Sensar IOL (Abbott Medical Optics Inc., CA) and group 4: MA60AC, (AcrySof, Alcon, Fort Worth, TX). The inclusion criteria were patients diagnosed with congenital cataract who underwent phacoaspiration and intraocular lens implantation with a minimum follow up of one year.
The main outcome studied was any visual axis opacification and/or fibrinous complications like IOL deposits, synechiae or the like.
All surgeries were performed under general anaesthesia using standard technique. These children were examined for visual axis obscuration (VAO), synechiae formation, intraocular pressure, fundus examination and any other finding. Children were prescribed spectacles and patching as needed. Refractive error was calculated as the spherical equivalent, defined as the algebraic power of sphere plus half the cylindrical power. Patients with severe PCO obscuring visual axis underwent membranectomy under general anesthesia. Statistical analyses were performed using SPSS program.
Results
257 eyes of 159 children were included in the study. The mean age at the time of surgery was 11.63 + 7.916 months (range 6 months to 23 months). Overall there was a male preponderance of 75.5%. 29 eyes of 16 children underwent phacoaspiration with implantation of SA60 AT (AcrySof, Alcon, Fort Worth, TX);75 eyes of 45 children received Hoya IOL (Hoya-PS AF-1Series; Model PC-60AD;Hoya, Japan), 70 eyes of 46 patients received Sensar (Abbott Medical Optics Inc., CA) and 83 eyes of 52 children received MA60AC (AcrySof, Alcon, Fort Worth, TX. At mean follow up of 18.31 + 15.037 months, 22.4% of the patients required resurgery for visual axis obscuration. Mean time to membranectomy post cataract surgery was 8.32 + 6.3 months. The major perioperative complications included failure to implant the IOL in the bag and/or extended anterior or posterior capsulotomy.
We also evaluated all complications together (one complication vs no complication) and found no statistically significant difference amongst all groups (p=0.147). No significant difference in rate of visual axis obscuration was found between the IOLs after adjusting for age (odds ratio 1.173;p=0.76) and perioperative complications, (odds ratio=1.214;p=0.66). None of the study patients developed glaucoma or retinal detachment.
Discussion
It is safe to assume that lenses of an identical material, but with different designs may not produce the same clinical results. In children however, there is little evidence to support the advantages of one IOL design over the others.
We compared the rates of PCO with 4 different types of IOLs used during cataract surgery in children less than two years of age. All these IOLs had hydrophobic acrylic optic but differed in their manufacture and design . The risk of intervention for VAO was found not to significantly differ between IOL types. In older children where primary posterior capsulotomy has not been performed the square edge and not the IOL material has been shown to be a significant factor in decreasing the rate of PCO. In our series IOL “brand” did not play a key role in VAO prevention in the presence of primary posterior capsulotomy and anterior vitrectomy. All IOL’s were hydrophobic acrylic with a sharp edge configuration.
The relative merit of single piece over three piece IOLs in occurrence of PCO is still debatable. Some studies in adults report higher incidence of PCO in single piece than three piece IOLs as the thin haptics of three piece designs allow better adhesion of anterior and posterior capsules compared to bulky haptics of single piece designs. In our study the three piece IOL’s of from different commercial sources performed equally well as compared to single piece. The single piece SA60AT IOL developed visually threatening PCO later in the post operative period, although it was not statistically significant.
All our patients underwent phacoaspiration with complete rhexis IOL overlap, adequately sized anterior as well as posterior capsulorrhexis, combined with anterior vitrectomy. A meticulous cortical clean up combined with in the bag IOL ensured a substantial reduction in VAO. Perioperative complications in our study were found to increase the risk of VAO. We chose the age group less than 2 years because of the increasing trend in primary IOL implantation in children less than 2 years of age. However this age group is still a grey zone with high rates of fibrinous and inflammatory complications, PCO and secondary membranes. In conclusion, our findings suggest low rate of VAO in children less than 2 years implanted with hydrophobic acrylic IOL’s. The differing ‘make’ and ‘edge design’ of various hydrophobic acrylic IOL’s has no significant effect on formation of PCO amongst them in this age group. More important in decreasing VAO when using these IOL’s is primary posterior capsulotomy and anterior vitrectomy with endocapsular IOL implantation.
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