Jpn J Ophthalmol DOI 10.1007/s10384-015-0385-1
CLINICAL INVESTIGATION
A survey of the surgical treatment of congenital and developmental cataracts in Japan Toshiyuki Nagamoto1,2 • Tetsuro Oshika3 • Takashi Fujikado4 • Tatsuro Ishibashi5 Miho Sato6 • Mineo Kondo7 • Daijiro Kurosaka8 • Noriyuki Azuma9
•
Received: 2 February 2015 / Accepted: 6 April 2015 Japanese Ophthalmological Society 2015
Abstract Purpose To understand the current practice pattern for the surgical treatment of congenital/developmental cataracts in Japan. Methods A mail questionnaire was sent to facilities engaged in thesurgical treatment of congenital cataracts in Japan. Results Thirty-four facilities reported their preferred methods for the surgical treatment of congenital cataracts, including data from 809 eyes of 508 patients who had undergone surgery. More than 85 % of the respondents answered that they would consider surgery even if the visual prognosis was not promising because of possible form& Tetsuro Oshika [email protected] 1
Department of Ophthalmology, Kyorin University School of Medicine, Tokyo, Japan
deprivation amblyopia. The most commonly performed surgical maneuvers were scleral tunnel incision (88.4 %), 3.0-mm or smaller incision (78.8 %), manual anterior continuous curvilinear capsulorhexis (90.2 % success rate), posterior capsulotomy (92.5 % for patients aged B6 years), anterior vitrectomy by the limbal approach (85.9 % for patients aged B6 years), and wound closure with sutures (93.2 %). Posterior capsulotomy and vitrectomy were not usually performed in patients aged [6 years. Implantation of an intraocular lens (IOL) was mostly indicated in patients aged 2 years or older. Implantation of an acrylic foldable IOL (76.6 %) into the capsular bag (89.7 %) was the most common practice among the surgeons. Conclusions Small incision surgery with implantation of an acrylic foldable IOL into the capsular bag combined with posterior capsulotomy was the preferred surgical treatment of choice for congenital/developmental cataracts.
2
Nagamoto Eye Clinic, Tokyo, Japan
Keywords Congenital cataract Developmental cataract Cataract surgery Intraocular lens
3
Department of Ophthalmology, Faculty of Medicine, University of Tsukuba, 1-1-1 Tennoudai, Tsukuba, Ibaraki 305-8575, Japan
Introduction
4
Department of Applied Visual Science, Osaka University Graduate School of Medicine, Osaka, Japan
5
Department of Ophthalmology, Graduate School of Medicine, Kyushu University, Fukuoka, Japan
6
Department of Ophthalmology, Hamamatsu University School of Medicine, Shizuoka, Japan
7
Department of Ophthalmology, Mie University Graduate School of Medicine, Tsu, Mie, Japan
8
Department of Ophthalmology, Iwate Medical University, Morioka, Iwate, Japan
9
Department of Ophthalmology and Cell Biology, National Center for Child Health and Development, Tokyo, Japan
Congenital/developmental cataracts are one of the common treatable causes of visual disability in children, and early detection and timely treatment are of crucial importance to prevent irreversible, lifelong visual dysfunction, such as form-deprivation amblyopia [1–5]. In cases of moderateto-dense cataract, surgical intervention needs to be considered before the critical period of visual development expires, which generally extends to a few months after birth [2–5]. Vigorous treatment of amblyopia needs to be started without delay after surgery to achieve good visual results in children [6–8]. With recent advances in
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microsurgical technologies, instrumentation, viscoelastic agents, visual rehabilitation regimens, and our understanding of the growth of pediatric eyes, surgical outcomes for childhood cataract have improved dramatically [9–13]. However, the indication for and selection of an intraocular lens (IOL) remain controversial, as does the management of the posterior capsule and the anterior vitreous. Recent reports by the Infant Aphakia Treatment Study Group raise several issues concerning aphakic correction after cataract surgery in children, such as postoperative complication rates [14], stereopsis outcomes [15], cost of IOL versus contact lens treatment [16], baseline characteristics of the patients and families [17], and long-term visual acuity [18]. Thus, surgical treatment and postoperative management continue to be challenging for physicians as well as for families. In a previous report, we analyzed the clinical characteristics of congenital/developmental cataract before surgery in Japan [19]. The aim of the current study was to determine the trends and preferences in the surgical management of congenital/developmental cataracts by means of a nationwide mail questionnaire survey.
Patients and methods A mail questionnaire was sent to 49 facilities known to be conducting surgical treatment of congenital/developmental cataracts in Japan in order to ask about cases with congenital/developmental cataracts operated on between January 2005 and December 2009. Thirty-four facilities provided responses on their strategies for dealing with congenital cataracts, and 29 facilities replied regarding actual surgical cases of congenital cataract. Excluded from the reported cases were patients aged 20 years and older, patients who did not undergo surgery, patients diagnosed with diseases other than congenital/developmental cataracts, and cases of secondary implantation of IOL. Data on the remaining 809 eyes of 508 patients were used for the subsequent analyses. The average age at surgery was 38.8 ± 48.2 months (mean ± SD; range 0–233). Because it is difficult to distinguish accurately between congenital and developmental cataracts, both of these clinical entities were included in the current study. The study received approval from the institutional review committee of the Kyorin University School of Medicine.
amblyopia, 29 of the 34 facilities (85.3 %) responded that they would consider surgery if informed consent was obtained in full from the patient’s family. The remaining 5 facilities (14.7 %) responded that they would not recommend surgery in such cases. As for the minimum patient age at which the respondents would consider IOL implantation, 14 facilities (41.2 %) replied 2 years and 8 facilities (23.5 %) stated that there was no age limit (Table 1). In total, 28 facilities (82.4 %) answered that IOL implantation is indicated when patients are aged 2 years or older. Twenty-five facilities returned responses to a question about the critical period for surgical treatment to minimize the effect of visual deprivation and to provide optimal orthoptics for congenital cataract. For unilateral congenital cataract, 7 facilities (28.0 %) responded that 6 weeks after birth was the critical period; 7 facilities (28.0 %), 8 weeks; 3 facilities (12.0 %), 4 weeks; and 3 facilities (12.0 %), 12 weeks. Overall, 13 facilities (52.0 %) responded that the critical period was 6 weeks or less after birth. For bilateral congenital cataract, 7 facilities (28.0 %) responded that the critical period was 12 weeks after birth; 3 facilities (12.0 %), 10 weeks; 2 facilities (8.0 %), 8–10 weeks; 2 facilities (8.0 %), 8 weeks; 2 facilities (8.0 %), 6 weeks; and 2 facilities (8.0 %), 16 weeks. Overall, 12 facilities (48.0 %) responded that the critical period was 10–14 weeks after birth. The data on surgical procedures in individual cases were analyzed for 809 eyes. Limbal and pars plana approaches were employed in 715 (88.4 %) and 91 (11.2 %) eyes, respectively. No answer was available for 3 eyes. In patients aged 2 years or older, the limbal approach was selected in 97.1 % of the cases. An IOL was implanted in 359 eyes (44.4 %) (pseudophakia group), while 450 eyes (55.6 %) became aphakic after the surgery (aphakia group). In the pseudophakia group, the limbal approach was used in 100 % of the cases.
Table 1 Minimum patient age at which the respondents would consider IOL implantation Minimum age No age limit
8 (23.5 %)
6 months
1 (2.9 %)
1 year
3 (8.8 %)
1.5 years
Results When asked about the indication for surgery in patients with congenital cataracts whose visual prognosis appears to be poor (\20/200) owing to anticipated form-deprivation
123
Number of facilities (%)
2 (5.9 %)
2 years
14 (41.2 %)
3 years
3 (8.8 %)
5 years
1 (2.9 %)
6 years No response
1 (2.9 %) 1 (2.9 %)
A survey of the surgical treatment…
In the aphakia group, the limbal and pars plana approaches were employed in 79.8 and 20.2 % of the eyes, respectively. Excluding those cases for which data were unavailable, the incision size was analyzed in each group. In the limbal approach group, the incision was 3.0 mm or smaller in 514 of the 652 eyes (78.8 %). A 3.0-mm or smaller incision was used in 204 of the 323 eyes (63.2 %) in the pseudophakia group and in 310 of the 329 eyes (94.2 %) of the aphakia group. Sutures were placed to close the limbal incision in 718 eyes (92.1 %). The suture closure was used in 303 of the 351 eyes (86.3 %) of the pseudophakia group and in 415 of the 419 eyes (99.0 %) of the aphakia group. In patients aged 6 years or younger, 229 of the 249 eyes (92.0 %) of the pseudophakia group and 405 of 409 eyes (99.0 %) of the aphakia group received suture closing of the wound. Among the cases in which information about the anterior capsulotomy procedure was available, continuous curvilinear capsulorhexis (CCC) was successfully completed in 407 of the 451 eyes (90.2 %). The success rate was 96.0 % (291/303 eyes) in the pseudophakia group and 78.3 % (116/148 eyes) in the aphakia group. Since posterior capsulotomy and anterior vitrectomy were mainly performed in patients aged younger than 7 years, the data in that age group were analyzed. Posterior capsulotomy was conducted in 208 of the 254 eyes (81.9 %) of the pseudophakia group and in 430 of the 436 eyes (98.6 %) of the aphakia group. Anterior vitrectomy was performed in 175 of the 254 eyes (68.1 %) of the pseudophakia group and in 416 of the 434 eyes (95.9 %) of the aphakia group. The percentage of eyes that received IOL implantation was 11.3 % in patients aged younger than 1 year, 27.1 % in patients aged 1 year, 45.2 % in patients aged 2 years, 76.2 % in patients aged 3 years, and 87.3 % in patients 100
IOL implantation rate (%)
90 80 70 60 50 40 30 20 10 0
CLINICAL INVESTIGATION
A survey of the surgical treatment of congenital and developmental cataracts in Japan Toshiyuki Nagamoto1,2 • Tetsuro Oshika3 • Takashi Fujikado4 • Tatsuro Ishibashi5 Miho Sato6 • Mineo Kondo7 • Daijiro Kurosaka8 • Noriyuki Azuma9
•
Received: 2 February 2015 / Accepted: 6 April 2015 Japanese Ophthalmological Society 2015
Abstract Purpose To understand the current practice pattern for the surgical treatment of congenital/developmental cataracts in Japan. Methods A mail questionnaire was sent to facilities engaged in thesurgical treatment of congenital cataracts in Japan. Results Thirty-four facilities reported their preferred methods for the surgical treatment of congenital cataracts, including data from 809 eyes of 508 patients who had undergone surgery. More than 85 % of the respondents answered that they would consider surgery even if the visual prognosis was not promising because of possible form& Tetsuro Oshika [email protected] 1
Department of Ophthalmology, Kyorin University School of Medicine, Tokyo, Japan
deprivation amblyopia. The most commonly performed surgical maneuvers were scleral tunnel incision (88.4 %), 3.0-mm or smaller incision (78.8 %), manual anterior continuous curvilinear capsulorhexis (90.2 % success rate), posterior capsulotomy (92.5 % for patients aged B6 years), anterior vitrectomy by the limbal approach (85.9 % for patients aged B6 years), and wound closure with sutures (93.2 %). Posterior capsulotomy and vitrectomy were not usually performed in patients aged [6 years. Implantation of an intraocular lens (IOL) was mostly indicated in patients aged 2 years or older. Implantation of an acrylic foldable IOL (76.6 %) into the capsular bag (89.7 %) was the most common practice among the surgeons. Conclusions Small incision surgery with implantation of an acrylic foldable IOL into the capsular bag combined with posterior capsulotomy was the preferred surgical treatment of choice for congenital/developmental cataracts.
2
Nagamoto Eye Clinic, Tokyo, Japan
Keywords Congenital cataract Developmental cataract Cataract surgery Intraocular lens
3
Department of Ophthalmology, Faculty of Medicine, University of Tsukuba, 1-1-1 Tennoudai, Tsukuba, Ibaraki 305-8575, Japan
Introduction
4
Department of Applied Visual Science, Osaka University Graduate School of Medicine, Osaka, Japan
5
Department of Ophthalmology, Graduate School of Medicine, Kyushu University, Fukuoka, Japan
6
Department of Ophthalmology, Hamamatsu University School of Medicine, Shizuoka, Japan
7
Department of Ophthalmology, Mie University Graduate School of Medicine, Tsu, Mie, Japan
8
Department of Ophthalmology, Iwate Medical University, Morioka, Iwate, Japan
9
Department of Ophthalmology and Cell Biology, National Center for Child Health and Development, Tokyo, Japan
Congenital/developmental cataracts are one of the common treatable causes of visual disability in children, and early detection and timely treatment are of crucial importance to prevent irreversible, lifelong visual dysfunction, such as form-deprivation amblyopia [1–5]. In cases of moderateto-dense cataract, surgical intervention needs to be considered before the critical period of visual development expires, which generally extends to a few months after birth [2–5]. Vigorous treatment of amblyopia needs to be started without delay after surgery to achieve good visual results in children [6–8]. With recent advances in
123
T. Nagamoto et al.
microsurgical technologies, instrumentation, viscoelastic agents, visual rehabilitation regimens, and our understanding of the growth of pediatric eyes, surgical outcomes for childhood cataract have improved dramatically [9–13]. However, the indication for and selection of an intraocular lens (IOL) remain controversial, as does the management of the posterior capsule and the anterior vitreous. Recent reports by the Infant Aphakia Treatment Study Group raise several issues concerning aphakic correction after cataract surgery in children, such as postoperative complication rates [14], stereopsis outcomes [15], cost of IOL versus contact lens treatment [16], baseline characteristics of the patients and families [17], and long-term visual acuity [18]. Thus, surgical treatment and postoperative management continue to be challenging for physicians as well as for families. In a previous report, we analyzed the clinical characteristics of congenital/developmental cataract before surgery in Japan [19]. The aim of the current study was to determine the trends and preferences in the surgical management of congenital/developmental cataracts by means of a nationwide mail questionnaire survey.
Patients and methods A mail questionnaire was sent to 49 facilities known to be conducting surgical treatment of congenital/developmental cataracts in Japan in order to ask about cases with congenital/developmental cataracts operated on between January 2005 and December 2009. Thirty-four facilities provided responses on their strategies for dealing with congenital cataracts, and 29 facilities replied regarding actual surgical cases of congenital cataract. Excluded from the reported cases were patients aged 20 years and older, patients who did not undergo surgery, patients diagnosed with diseases other than congenital/developmental cataracts, and cases of secondary implantation of IOL. Data on the remaining 809 eyes of 508 patients were used for the subsequent analyses. The average age at surgery was 38.8 ± 48.2 months (mean ± SD; range 0–233). Because it is difficult to distinguish accurately between congenital and developmental cataracts, both of these clinical entities were included in the current study. The study received approval from the institutional review committee of the Kyorin University School of Medicine.
amblyopia, 29 of the 34 facilities (85.3 %) responded that they would consider surgery if informed consent was obtained in full from the patient’s family. The remaining 5 facilities (14.7 %) responded that they would not recommend surgery in such cases. As for the minimum patient age at which the respondents would consider IOL implantation, 14 facilities (41.2 %) replied 2 years and 8 facilities (23.5 %) stated that there was no age limit (Table 1). In total, 28 facilities (82.4 %) answered that IOL implantation is indicated when patients are aged 2 years or older. Twenty-five facilities returned responses to a question about the critical period for surgical treatment to minimize the effect of visual deprivation and to provide optimal orthoptics for congenital cataract. For unilateral congenital cataract, 7 facilities (28.0 %) responded that 6 weeks after birth was the critical period; 7 facilities (28.0 %), 8 weeks; 3 facilities (12.0 %), 4 weeks; and 3 facilities (12.0 %), 12 weeks. Overall, 13 facilities (52.0 %) responded that the critical period was 6 weeks or less after birth. For bilateral congenital cataract, 7 facilities (28.0 %) responded that the critical period was 12 weeks after birth; 3 facilities (12.0 %), 10 weeks; 2 facilities (8.0 %), 8–10 weeks; 2 facilities (8.0 %), 8 weeks; 2 facilities (8.0 %), 6 weeks; and 2 facilities (8.0 %), 16 weeks. Overall, 12 facilities (48.0 %) responded that the critical period was 10–14 weeks after birth. The data on surgical procedures in individual cases were analyzed for 809 eyes. Limbal and pars plana approaches were employed in 715 (88.4 %) and 91 (11.2 %) eyes, respectively. No answer was available for 3 eyes. In patients aged 2 years or older, the limbal approach was selected in 97.1 % of the cases. An IOL was implanted in 359 eyes (44.4 %) (pseudophakia group), while 450 eyes (55.6 %) became aphakic after the surgery (aphakia group). In the pseudophakia group, the limbal approach was used in 100 % of the cases.
Table 1 Minimum patient age at which the respondents would consider IOL implantation Minimum age No age limit
8 (23.5 %)
6 months
1 (2.9 %)
1 year
3 (8.8 %)
1.5 years
Results When asked about the indication for surgery in patients with congenital cataracts whose visual prognosis appears to be poor (\20/200) owing to anticipated form-deprivation
123
Number of facilities (%)
2 (5.9 %)
2 years
14 (41.2 %)
3 years
3 (8.8 %)
5 years
1 (2.9 %)
6 years No response
1 (2.9 %) 1 (2.9 %)
A survey of the surgical treatment…
In the aphakia group, the limbal and pars plana approaches were employed in 79.8 and 20.2 % of the eyes, respectively. Excluding those cases for which data were unavailable, the incision size was analyzed in each group. In the limbal approach group, the incision was 3.0 mm or smaller in 514 of the 652 eyes (78.8 %). A 3.0-mm or smaller incision was used in 204 of the 323 eyes (63.2 %) in the pseudophakia group and in 310 of the 329 eyes (94.2 %) of the aphakia group. Sutures were placed to close the limbal incision in 718 eyes (92.1 %). The suture closure was used in 303 of the 351 eyes (86.3 %) of the pseudophakia group and in 415 of the 419 eyes (99.0 %) of the aphakia group. In patients aged 6 years or younger, 229 of the 249 eyes (92.0 %) of the pseudophakia group and 405 of 409 eyes (99.0 %) of the aphakia group received suture closing of the wound. Among the cases in which information about the anterior capsulotomy procedure was available, continuous curvilinear capsulorhexis (CCC) was successfully completed in 407 of the 451 eyes (90.2 %). The success rate was 96.0 % (291/303 eyes) in the pseudophakia group and 78.3 % (116/148 eyes) in the aphakia group. Since posterior capsulotomy and anterior vitrectomy were mainly performed in patients aged younger than 7 years, the data in that age group were analyzed. Posterior capsulotomy was conducted in 208 of the 254 eyes (81.9 %) of the pseudophakia group and in 430 of the 436 eyes (98.6 %) of the aphakia group. Anterior vitrectomy was performed in 175 of the 254 eyes (68.1 %) of the pseudophakia group and in 416 of the 434 eyes (95.9 %) of the aphakia group. The percentage of eyes that received IOL implantation was 11.3 % in patients aged younger than 1 year, 27.1 % in patients aged 1 year, 45.2 % in patients aged 2 years, 76.2 % in patients aged 3 years, and 87.3 % in patients 100
IOL implantation rate (%)
90 80 70 60 50 40 30 20 10 0
