January-February 2020

CATARACT

Research Highlight
Unplanned returns to the OR for pediatric cataracts


by Maxine Lipner Senior Contributing Writer


Inflammatory membrane in a microphthalmic eye

Visual axis opacification in an infant
Source (all): M. Edward Wilson, MD

Vitreous strand to the cataract wound
Source: M. Edward Wilson, MD

 

Unplanned returns to the operating room within 90 days of initial cataract surgery in children occur at a rate of 3.3%, as determined by a study’s1 results, according to M. Edward Wilson, MD.
Investigators of this study thought it was important to understand how often surgeons unexpectedly returned to the OR with patients in order to counsel parents, Dr. Wilson said. “We also wanted to see if any of these returns to the OR were preventable,” he explained, adding that the chance of reoperation was something that was missing from the literature for the most part.
The retrospective review included children who had undergone cataract surgery or a secondary IOL procedure by one surgeon for whom investigators had charts. This amounted to 1,392 eyes of 989 patients.

By the numbers

Investigators found 48 unplanned reoperations in the review, involving 46 eyes of 43 patients. When reoperations occurred, it was almost always in the first year of life or involved a traumatic cataract, Dr. Wilson reported. Children with trauma had a 2.5% greater chance of reoperation, while those who underwent cataract surgery in the first year of life were three times more likely to need reoperation. “If [the patient] didn’t have surgery in the first year and didn’t have a trauma as the reason they needed the surgery, then we could tell parents that in all other settings the unplanned reoperation rate was 1.1%,” Dr. Wilson said.
The more complicated the trauma and the more the iris manipulation, the more likely the patient might have to go back to the OR. “That’s not necessarily a bad thing; it’s just something to prepare the family for ahead of time,” Dr. Wilson said. Also, to help reduce the reoperation rate, Dr. Wilson stressed the need to pay attention to the possibility of an intraocular pressure spike. Care to completely remove any high viscosity ophthalmic viscosurgical device (OVD) is important. In addition, returns to the OR can be reduced by using intracameral triamcinolone to make sure a vitreous wick is not present.
Reopacification of the posterior capsule in children with trauma is also common in cases involving a primary posterior capsulorhexis, Dr. Wilson said. “I think that if we know it’s a higher risk group from this series, we can try to remove all the OVD, pretreat if we think there is going to be a pressure rise, look more carefully for retained vitreous, and use plenty of anti-inflammatory medication,” he said. Also, carefully watching patients postoperatively can help. In high-risk cases, he advised emphasizing to parents the importance of returning for all postoperative exams due to the potential of needing to return to the OR.

Positive signs

Dr. Wilson found many of the results from the study promising. “We had 1,392 eyes, and yet we saw very little pupillary block glaucoma,” he said, adding this was true even though in pediatric care peripheral iridotomies are not performed. Dr. Wilson was pleased there were no cases of endophthalmitis and there were few cases of elevated IOP (n=11), most of which were managed medically. Likewise, there were just seven inflammatory membranes found.
Vitreous wick occurred six times, but there were no reoperations for this situation after the first year of life. For cases where vitrectomy is required within the first year of life, Dr. Wilson recommended using diluted triamcinolone to visualize the vitreous. Dr. Wilson also pointed out that there were no returns to the OR for wound leaks found, something he attributes to the fact that all wounds are sutured in pediatric cases.
Overall, Dr. Wilson views the study as an important resource. “The bottom line is that now we have numbers that are reliable that surgeons can quote to parents who want more information,” he said.

About the doctor

M. Edward Wilson, MD
Professor of ophthalmology and pediatrics
Storm Eye Institute, Medical University of South Carolina
Charleston, South Carolina

Reference

1. Jackson CM, et al. Unplanned returns to the operating room within three months of pediatric cataract-related intraocular surgery: indications and risk factors. J AAPOS. 2019;23: 224.e1–224.e4.

Relevant disclosures

Wilson
: None

Contact

Wilson: wilsonme@musc.edu

Unplanned returns to the OR for pediatric cataracts Unplanned returns to the OR for pediatric cataracts
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