Paediatric cataract is the major cause of blindness in children, about 200,000 children globally, with an approximated prevalence from 3 to 6/10,000 live births.1 Most of the pediatric cataracts especially with positive family history occur bilaterally.2 Cataract is one of the commonest cause of development of amblyopia in children.3 Prompt diagnosis and treatment are of crucial significance to prevent the development of irreversible amblyopia.4 Simultaneous bilateral cataract surgery (SBCS), in which the Ophthalmologist operates on both the eyes in same day in same session, versus the delayed sequential bilateral cataract surgery (DSBCS), in which both the eyes are operated as a separate procedure on different days, is a controversial subject in researches.5-8
Simultaneous bilateral congenital cataract surgery
was found to be safe for the children with
negligible chance of developing endophthalmitis
by maintaining proper aseptic measures.
Multiple studies have proven SBCS to be more efficient, negligible chances of amblyopia, fast rehabilitation, reduced patient visits and cost-effective than DSBCS for patients and the healthcare system.7,9,10 On the other hand, some studies were published which suggested DSBCS to avoid the dreadful complication that is endophthalmitis in both the eyes or bilateral visual compromise due to occurrence of toxic anterior segment syndrome.11-13 With the use of proper preoperative measures, microsurgical technique, preoperative and postoperative prophylactic antibiotic, the occurrence of endophthalmitis has been decreased up to negligible level.12 Furthermore, patient in amblyopic age with cataract in both eyes who have two back to back surgeries within a short duration of interval cannot alleviate the possibility of postoperative endophthalmitis that can be developed within 3 weeks after the surgery, so chances of developing endophthalmitis are also present in DSBCS.14 The occurrence of endophthalmitis after cataract surgery especially in children who have greater chances of developing postoperative inflammation, delay in second eye surgery may lead to amblyopia and to prevent general anesthesia related issues in children, SBCS is suggested by taking proper aseptic measures. The objective of this study was to observe the safety of SBCS in pediatric patients under general anesthesia in a single session in terms of developing postoperative endophthalmitis.
MATERIAL AND METHODS:
After the acceptance by Institutional Review Board (IRB) of Dow University of Health Sciences Approval, this observational case series was conducted from 1stFebuarary,2019 to 31stJanuarary, 2020 at the Department of Ophthalmology Unit 1, Dow medical college, Dow University of Health Sciences and Dr. Ruth KM Pfau Civil Hospital Karachi. A total of 60 eyes of 30 patients were included in the study, who had been operated for bilateral congenital cataract in a single session by one surgeon dealing in the pediatric cases. The children included in this study were below the age of 12 months, of either gender and were diagnosed with bilateral congenital cataracts. An informed written consent was explained and signed by the parents/guardians. Patients were excluded who had corneal abnormalities or haziness, high intraocular pressure, congenital anomalies like coloboma of iris, lens, or retina, Peter’s anomaly, aniridia etc. or history of any ocular/birth injury. All patients had an ocular examination before cataract surgery including visual acuity testing, retinoscopy, hand held slit lamp examination, indirect ophthalmoscopy and investigations including B-scan ultrasonography as well as TORCH profile, other investigations for systemic association and metabolic disorders causing congenital cataract and blood tests regarding fitness for general anesthesia. Preoperative topical antibiotic (Tobramycin 0.3%) four times a day was started two days before the surgery. The eyes were dilated with phenylephrine 1% tropicamide 0.5% eye drops. Patients were operated under general anesthesia. General anesthesia was given by laryngeal mask airways in all cases. Each eye was operated as a separate procedure i.e. after the first eye was operated, the surgical drapes were removed, and the other eye was prepped and draped. Surgeon and operation theater technician observed proper sterlization. Surgery on the second eye was carried out with a new set of disposable fluids, instruments and medicines. Each eye was operated independently, anterior capsulotomy was followed by lens aspiration, posterior capsulotomy and anterior vitrectomy with cutter. All patients were left aphakic. Subconjunctival antibiotic (gentamicin 5mg), steroid (dexamethasone 1mg) and infraorbital steroid (kenacort 10 mg)were given at the end of surgery. All the patients were given postoperative topical atropine sulphate 1% 3 times a day for one week, topical antibiotic (tobramycin 0.3%) and topical steroids (prednisolone acetate 1%) two hourly for one week, 4 times a day for four weeks and three times a day for 1 week. They were assessed and examined by the surgeon postoperatively the next day and all follow-ups for any signs of inflammation and surgical complications using hand held slit lamp biomicroscope. Retinoscopy was done on second follow-up visit and glasses number was prescribed. Patients were followed up after first week, second week, fourth week and eighth week postoperatively. Data was analyzed through SPSS version 22, mean and standard deviation was calculated for all continuous variables. Frequency and percentage was calculated for all categorical variables like gender and complications.
In our study,a total of 60 eyes of 30 patients were included. The mean age of patients was 7.5 ± 3.74 months at the time of surgery (Fig.1). There is predominance of male gender, i.e.male=16 (53.3%), female=14 (46.7%) (Table.1). All the patients had a minimum post-operative follow up of 2 months.10 eyes (16.66%) showed moderate to severe inflammation in first week follow-up. The cause of inflammation was found to be using postoperative medication improperly, it was managed by educating the parents to instill in both eyes alternatively means in right eye first then in left eye, in subsequent instillation, instill in left eye first, then in right so that both eyes has proper availability of the medications. 2 eyes of two patients out of 60 eyes (3.33%) did not get improvement until third follow-up visit. One patient’s eye developed inflammatory pupillary membrane and one patient’s eye developed decentered pupil (Table. 1). 58 out of 60 eyes (96.67%) did not develop any complications post-operatively while all 30 patients did not develop any complications related to general anesthesia. There was no incidence of endophthalmitis and secondary glaucoma in any case (0%).
To the best of our knowledge, no such study was conducted so far in pediatric population in Pakistan. Congenital cataract is a leading cause of preventable blindness in children.1 The implementation of early surgical intervention in congenital cataract cases can lead to prevention of amblyopia.3,4 Due to the cost effectiveness of simultaneous bilateral cataract surgery, it is gaining familiarity in the Western world and now in the Asian continent too. But it is a controversial topic, it is not usually performed due to the dreadful complication of developing bilateral endophthalmitis.15 In our study, there was not a single case of endophthalmitis, as also shown in a multicenter case series of 344 bilateral intraocular surgeries.16 Also Malvankar et al. in their meta-analysis reported SBCS had no case of endophthalmitis.17 Another study conducted in Pennsylvania, United States of America, reported their experience regarding simultaneous intraocular surgeries in pediatric age group and found no case of endophthalmitis.18 In contrast, a review of 96 patients with bilateral cataracts was done by Gradin and Mundia of Kenya, reported the incidence of endophthalmitis in the postoperative period which was about 0.16%.19 In Pakistan, no study was done except a case report by Jahangir et al demonstrated the benefits of simultaneous bilateral cataract surgery in pediatric population especially when the health condition does not allow for repeated general anesthesia.20 In our study, a 6 month old male patient had developed inflammatory pupillary membrane within 1 week postoperatively in his right eye, which was managed by intensive use of topical steroids, another patient had decentered pupil. Similar complications of inflammatory membrane formation in five out of forty patients, was observed by Magli A et al during their retrospective study.21 Another study was done by Jackson et al in 2019, reported postoperative complications in pediatric cases including inflammatory pupillary membrane causing re-operations.22 To avoid such complications, we emphasize the use of sub-conjunctival injection of dexamethasone at the end of surgery. In the literature also, studies shown severe anterior chamber reaction in the immediate postoperative period specially in children, along with improper medications which may result in formation of inflammatory pupillary membrane causing defective vision. Hence the use of steroids at the end of surgery in the form of subconjunctival dexamethasone, posterior sub-tenon or infraorbital triamcinolone acetonide and topical steroids in postoperative period is highly recommended.23-24 The utilization of this simultaneous cataract surgery of both eyes in a single session is reasonably valid in infants as to overcome the risk of developing amblyopia, and complications and side effects of general anesthesia. In our study, no complication or death was observed in any of the cases related to anesthesia intra-operative and postoperatively. It is reported that the SBCS alleviate the need of second surgery under general anesthesia, causing least chances of developing general anesthesia risks and complications.25 There are reports showing incidence of bilateral endophthalmitis after SBCS19, however some has reported no case of bilateral endophthalmitis in their studies.26,27 Lansingh V et al supported the use of simultaneous bilateral cataract surgeries in their literature review, provided that better surgical skills and strict sterile techniques are required along with more research on simultaneous bilateral cataract surgery especially in the developing world.28 The potential limitations of our study are small sample size and short follow- up duration. Although no case of endophthalmitis has occurred in our series, further studies are needed to assess the safety of simultaneous bilateral cataract surgery in children.
Simultaneous bilateral congenital cataract surgery is a better way to deal with bilateral cataracts in pediatric population and has less chances of developing endophthalmitis by maintaining strict discipline in terms of intra-operative aseptic measures.
Acknowledgement. The authors thank all the staff of the Department of Ophthalmology, Dr. Ruth KM Pfau Civil Hospital, Karachi for assistance and support provided during the research work.