American Journal of Medicine and Medical Sciences 2023, 13(4): 488-492
DOI: 10.5923/j.ajmms.20231304.28
Some Aspects of Complications of Congenital
Cataract Surgery
Khamraeva L. S.
1,*
, Bobokha L. Yu.
2
, Makhmudova D. T.
2
1
Candidate of Medical Sciences, Associate Professor of the Department of Ophthalmology, Pediatric Ophthalmology, Tashkent Pediatric
Medical Institute, Tashkent, Uzbekistan
2
Assistant of the Department of Ophthalmology, Pediatric Ophthalmology, Tashkent Pediatric Medical Institute, Tashkent, Uzbekistan
Abstract
Cataract in children, which is one of the leading causes of primary blindness, is a clouding of the lens. The
prevalence of cataracts in developed countries, as well as in Russia, is 1.6–2.4 per 100,000 children. Intraocular lens (IOL)
implantation has become widespread in recent decades and is considered the most optimal method for correcting aphakia.
Despite the introduction of new high-tech methods of surgical treatment of congenital cataracts, there is currently a fairly
high percentage of complications. All of the above does not reduce the urgency of the problem of treating children with
congenital cataract (CC) and requires further research.
Keywords
Congenital cataract, Cataract extraction, Intraocular lens, Pseudophakic myopia, Pseudophakia, Secondary
cataract, Cataract extraction complications, Posterior capsule fibrosis, Inflammatory reactions, Anterior chamber moisture,
Often sick children
1. Introduction
Cataract in children, which is one of the leading causes of
primary blindness, is a clouding of the lens. The prevalence
of cataracts in developed countries, as well as in Russia, is
1.6–2.4 per 100,000 children [1,2,3,4]. Among the causes
of blindness in children, congenital cataracts (CC) account
for 7.5–8.0% (in economically developed countries) to
27.4% (in socially disadvantaged regions). Due to cataracts,
the development of the visual analyzer is disrupted
and amblyopia is formed, the treatment of which requires
significant and prolonged efforts on the part of
ophthalmologists and parents [2,5,6]. The main factor in
determining the timing of surgical intervention, both in
bilateral and unilateral cataracts, is the severity of lens
opacities, determined by the form of CC, affecting the
formation of visual functions of the child in the sensitive
period. On the one hand, having operated on a child with
partial lens opacity and high residual visual acuity in the
first months of life, we deprive him of the possibility of
normal physiological development of visual functions and
accommodation, on the other hand, performing surgery at a
late date with pronounced lens opacity, for example, the
total form of CC leads to the development of high-grade
obscuration amblyopia and gross, often irreversible changes
in the visual analyzer. Implantation of an intraocular lens
* Corresponding author:
lola251167@mail.ru (Khamraeva L. S.)
Received: Apr. 7, 2023; Accepted: Apr. 20, 2023; Published: Apr. 22, 2023
Published online at http://journal.sapub.org/ajmms
(IOL) has become widespread in recent decades and is
considered the most optimal method of correcting aphakia,
since IOLs are devoid of the disadvantages of eyeglass and
contact correction [7,8]. When choosing a method for
correcting aphakia in young children, the following main
circumstances are taken into account: anatomical and
functional features of the growing eye (the existence of a
sensitive period, modeling of the refractive effect according
to age), the constancy of correction [9,10]. Primary
implanted IOL, unlike glasses and contact lenses, is the most
optimal method of correction of induced aphakia, allowing
to create all conditions for the completion of age-related
organogenesis of the eye, morphological and functional
development of the visual system. We believe that the
principles of "medicine of the future" are quite acceptable
for children with CC and their parents, which are based
on four fundamental principles: personalization, prediction,
prevention
and
participativeness
(4P-medicine).
Personalization is an individual approach to the patient. The
latest scientific developments are used for this purpose: a
thorough analysis and analysis of the genetic and
physiological characteristics of a particular person. Based on
genetic testing and the collection of parental (genealogical)
analysis, biomarkers affecting the development of the
disease are tracked. As part of the implementation of this
principle, the creation of a patient's genetic passport is
becoming widespread. Prediction is the identification of
predispositions based on such a passport and the creation of
a forecast health. Having knowledge about the individual
characteristics of the human genome, it is possible to
identify risk factors and determine the degree of probability
American Journal of Medicine and Medical Sciences 2023, 13(4): 488-492
489
of developing a particular disease. Prevention is the next step
after determining the risk factors. Its essence is either to
prevent or to reduce the risk of developing the disease. The
forecasts made on the basis of genetic analysis allow us to
develop a set of preventive measures, and a personalized
approach allows us to make it the most effective.
Participation, or involvement of the patient, in this case his
parents, in the treatment process. The patient should be
motivated to participate in prevention and treatment and take
responsibility for their health. Popularization of a healthy
lifestyle, awareness of risks and opportunities - this is the
basis for the implementation of this principle in practice. The
implementation of the principles of 4P medicine is possible
thanks to fundamental scientific research and understanding
of the pathogenesis of the disease based on the identification
of functional, molecular and cellular changes that allow to
assess the ongoing pathological processes, determine the
degree of risk of developing the disease and develop a set of
preventive measures. The creation of numerous databases on
molecular biology, biochemistry, and genetics will allow
analyzing the data of specific patients and developing
accurate individual prevention and treatment strategies [11].
2. Materials and Methods
Complications
of
CC
extraction.
Intraoperative
complications, complications of the early postoperative
period (6-10 days from the moment of surgery) and late
postoperative complications (up to 9 years after surgery)
are distinguished, and complications associated with IOL
implantation can also be singled out separately.
Intraoperative complications. The most dangerous
complication that can occur during the removal of the CC is
the loss of the vitreous div. The increased risk of this
complication is due to age-related features of the lens and
eye, among which the thinness of the posterior capsule and
the anterior border membrane of the vitreous div, as well as
the presence of the ligament of the Viger between them, are
important [9,10,12,13]. In addition, during the operation, an
exudative reaction may develop with the loss of fibrin
threads in the pupil and on the iris. Analysis of the causes of
exudative reactions that developed during the operation itself
showed that all children had a virus-induced form of CC, the
cause of which was infection of the mother during pregnancy
with cytomegalovirus and herpes simplex viruses [14].
Complications of the early postoperative period include:
hemorrhage into the anterior chamber or vitreous div,
pupillary block, iritis, iridocyclitis, keratopathy, iridocorneal
and vitreocorneal synechiaes. These complications are noted
in 8.0-26.4% of cases [1,15]. An analysis of the literature
shows that in the structure of all complications after CC
aspiration, inflammatory reactions range from 5.5 to 48.1%
of cases. More often an exudative reaction develops, less
often anterior uveitis. At the same time, exudation with fibrin
deposition on the IOL and iris in childhood develops more
often and much more intensively than in adults due to the
pronounced reactivity of the tissues of the child's eye,
especially the iris and increased vascular permeability.
Factors determining the occurrence of an exudative
inflammatory reaction during IOL implantation may be a
long duration of surgical intervention, traumatization of
tissues during surgery, the use of a large number of
viscoelastics, iris retractors, sphincterotomy, activation of
latent infections [16]. Often, even after the least traumatic
operation, a temporary inflammatory reaction is observed
as a result of inevitable surgical trauma and damage to the
blood-intraocular fluid barrier. The initial anatomical
parameters have a significant impact on the nature of
the course of the postoperative period. According to
L.B. Kononov, the most common inflammatory reactions
are observed in the eyes of children with anterior
microphthalmos of I-II degree, as well as with posterior
microphthalmos: with a decrease in axial length (AL) by
1.5-2.5 mm, the frequency of postoperative iritis increases
by 2 times [17].
The risk factors for the development of complications
in the early postoperative period also include allergic
conditions and the presence of foci of chronic infection,
and the risk group includes children who are often sick
children (OSC). OSC is a group of dispensary observation of
children of early and preschool age, mainly of the II-health
group, with a polygenic hereditary predisposition to an
increased incidence of acute respiratory infections due to
immunological immaturity of the div, manifested by a
decrease in IFN, IL2, IgG–antidiv response [18]. The
results of our studies of chamber moisture (CM), conducted
in 54 children with CC, showed that there was a significant
increase in the protein content of OSC in CM before cataract
extraction, while a negative correlation was established
between the protein content in CM and blood. At the same
time, postoperative complications, in the form of a cellular
reaction with exudation in the moisture of the anterior
chamber, were noted more often in OSC [19].
3. Result and Discussion
It is necessary to note the peculiarity of inflammatory
reactions in children - a tendency to exudation, a sluggish
progressive fibroplastic process with the formation of
synechiae, which are noted already on the 1st-2nd day
after surgery and subsequently lead to pupil deformation,
in severe cases - to pupil overgrowth, pupillary block,
secondary glaucoma.
Such characteristic
signs of
iridocyclitis in adults as precipitates on the posterior surface
of the cornea, turbidity of the anterior chamber moisture in
children with CC occur in isolated cases. It is also important
that the inflammatory process often proceeds without
external signs of inflammation - photophobia, pericorneal
injection [7,10]. Anterior and posterior synechiae, according
to the literature, account for 2.5 to 19.6% of cases.
Pupillary block is a relatively rare complication of surgical
interventions and most often occurs when the integrity of the
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Khamraeva L. S.
et al.
: Some Aspects of Complications of Congenital Cataract Surgery
posterior capsule of the lens is violated. The pathogenetic
essence of the complication is a violation of communication
between the anterior and posterior chambers. Obturation of
the pupil and colobus can be caused by exudate, blood, air,
remaining lens masses, vitreous. The factors predisposing to
the complication may also be wound filtration, detachment
of the vascular membrane, posterior detachment of the
vitreous div, rigid atrophic iris. Pupillary block can
develop both in the early and late postoperative period [7].
Given the prevalence of post-inflammatory forms of
secondary glaucoma in young children, reconstructive
surgical interventions are more often required: dissection of
splices and excision of fibrin films in the pupil and anterior
chamber angle in combination with iridectomy and anterior
vitrectomy. In older children, in most cases, fistulizing
operations are required: trabeculectomy, deep sclerectomy.
As a result of surgical intervention with a follow-up period of
up to 5-6 years, compensation of intraocular pressure is
achieved in 89.1% of children. In addition, the frequent
complications of the postoperative period in children with
CC, due to anatomical features, early surgical treatment of
cataracts with IOL implantation, immaturity of their immune
system, include proliferative reactions that cause the
development of secondary cataracts, which reduces visual
functions and requires repeated surgical intervention [20]. In
the structure of this complication, fibrosis of the posterior
capsule of the lens, regenerative secondary cataract and their
combinations are distinguished. The frequency of secondary
cataracts in the surgical treatment of CC, according to the
literature, ranges from 20 to 90% of cases and, according to
many ophthalmologists, prevails during operations at an
early age [6,21,22].
The high frequency of inflammatory postoperative
reactions after cataract removal often leads to the
development of secondary glaucoma, leading to a decrease
in the functional results of the operation [1,23]. Various
methods of surgical treatment of secondary aphakic
glaucoma in children do not provide long-term stabilization
of intraocular pressure (IOP) and preservation of high visual
functions [7]. According to our data, a comparative analysis
conducted in 75 children aged 2 to 17 years with cataract,
aphakia, pseudophakia, dislocation of IOL, as well as 12
healthy children, showed significant changes in the
hydrodynamic parameters of the eyes of patients with
pseudophakia: an increase in true IOP with dislocation of
IOL and, conversely, its decrease in the normal position of
artificial the lens. The development of secondary
pseudophakic glaucoma was an indication for reoperations.
In our opinion, the "hypotension" of the eye in pseudophakia
requires further study [24].
Complications of the late postoperative period include:
secondary cataract, secondary glaucoma, retinal detachment,
subatrophy of the eyeball. The literature describes cases of
secondary glaucoma in artificial eyes. Although a number of
researchers believe that IOL implantation is a kind of
prevention of the development of secondary glaucoma. In
the structure of secondary cataracts, fibrosis of the posterior
capsule of the lens, regenerative secondary cataract and their
combinations are distinguished. The frequency of secondary
cataracts in the surgical treatment of CC ranges from 20 to
90% of cases and, according to many ophthalmologists,
prevails during operations at an early age [6,8,9,22,25]. It is
generally believed that a large variation in the frequency of
secondary cataracts depends on the age of the child,
concomitant ocular and systemic diseases, features of
microsurgical cataract extraction technique, the presence of
IOL and its type, and the timing of postoperative follow-up.
According to a number of authors, the important factors
of high risk of secondary cataracts are childhood age,
traumatic surgical technique. Fibrosis of the posterior
capsule, secondary cataracts, immunologically determined
inflammatory-proliferative reactions after cataract extraction
are a characteristic feature of childhood [15]. There are clear
age-specific features of the structure and timing of the
formation of secondary cataracts in children: the younger the
child's age, the faster and more often this complication is
formed. In younger children, secondary cataracts are more
often observed in the form of fibrosis of the posterior capsule,
which occurs at an earlier time, while in older children
regenerative secondary cataracts that occur at a later time
predominate [26].
The main criteria determining the indications for the
removal of secondary cataracts in infants and young children
are the optical condition of the pupillary region, which
makes it difficult to perform ophthalmoscopy, a change in
the fixation of the gaze and the appearance of strabismus.
In older children, the degree of visual acuity reduction
compared to the maximum achieved as a result of surgical
pleoptic treatment is also taken into account. Indications for
the removal of secondary cataracts are: full forms without an
optical opening or with small through holes that do not
perform optical functions, translucent full forms, partially
passable to light, but sharply reducing visual acuity (by more
than 0.05 compared to the maximum achieved as a result of
surgical pleoptic treatment of CC), in small patients with the
impossibility of ophthalmoscopy is partial, but centrally
located forms of cataracts. Currently, the most progressive
method of treating secondary cataracts in children is YAG-
laser destruction, the advantage of which is a minimum of
side effects and possible complications. Instrumental
surgical capsulotomy is used only in isolated cases when it is
technically impossible to perform it [20].
A complication specific to implantation surgery is the
dislocation of the posterior chamber IOL and the
decentralization of its optics. The cause of this complication
may be a mixed "Bag-sulcus" fixation as a result of a surgical
defect during IOL implantation or as a consequence of
deformation of the capsule bag with fibroplastic processes
occurring in it. The cause of dislocation of the IOL during
primary
implantation
is
postoperative
iridocyclitis.
Dislocation of the lens by the type of "pupil capture" is
accompanied by the development of "uvea touch" syndrome,
in which there is chronic sluggish uveitis with periodic
precipitation of fine-point pigment and non-pigment
American Journal of Medicine and Medical Sciences 2023, 13(4): 488-492
491
precipitates on the posterior surface of the lens or clouding
of the anterior layers of the vitreous div in the case of
posterior capsulorhexis [10,12,15]. There may be such
changes as: "tertiary cataract"- the spread of Elschnig balls
over the surface of the hydrophobic IOL, fibrous deposits
directly on the posterior surface of the artificial lens after
dissection of the posterior capsule of the lens, a violation of
the transparency of the lens due to the migration of giant
cells of foreign bodies to its surface [27]. Therefore, to date,
many issues of early intraocular correction in children with
CC remain debatable, which is due to the peculiarities of
children's eyes: the complexity of calculating the optical
strength of the implanted IOL in young children, the
technical possibility of performing a low-traumatic operation
taking into account the age-related anatomical and optical
parameters of the eye and the increased risk of developing
exudative-proliferative reactions after surgery, especially in
patients of the first months of life. The results of our own
research indicate that abnormal refractive changes
(pseudophacial myopia) may be a manifestation of an
inadequately selected IOL associated with the calculation of
its optical strength according to a single formula for all
children - both with and without the risk of abnormal
refractogenesis, as well as with the presence of obscuration
or refractive amblyopia [28].
4. Conclusions
The above dictates the need to determine reliable
(significant) risk factors for the development of
pseudophacial myopia (the indicators of the ocular AL at the
time of implantation of the IOL are higher than the age norm
by more than 0.2 mm; a child from the first pregnancy;
AL/CR ratio ≥3.0; myopia of the paired eye; strabismus
more than 4, etc. dpt; hereditary burden; strain of
phonocardiography: pressure ≤180 mmHg at the time of
IOL implantation) [29]. A restrained attitude to intraocular
correction in children after CC extraction is associated
with a high risk (from 5.5 to 48.1% and from 4.5% to 100.0%)
of developing an inflammatory reaction in the early
postoperative period [5]. The specificity of the inadequate
response to surgical trauma in children is due to the
functional immaturity of the immune system [30]. The
peculiarities of the topography of the ligamentous apparatus
of the lens, increased motor activity of children, and
as a consequence a high risk of eye injury, lead to dislocation
of the IOL, significantly increasing the subsequent
development of complications such as intraocular
hypertension, which may raise the question of repeated
surgical intervention [24,31].
The analysis of the conducted studies shows that
secondary implantation of IOL into the aphakic eye of a child,
compared with primary implantation, is more traumatic and
requires a number of additional interventions in the form of
separation of posterior synechiae and junctions in the capsule
sac, vitrectomy, which in turn increases the duration of
surgical intervention and intraocular manipulations [32-37].
Thus, the introduction of new technologies into the
process of pediatric cataract surgery today, unfortunately,
does not fully eliminate complications, and in some cases
gives birth to new ones, which dictates the need for further
search for rational solutions for the prevention and treatment
of adverse outcomes.
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