| Newsletter Volume 6 |
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CASE REPORT: CHILDREN AND GRAFTS AND IOLS? The next several issues of the newsletter will address the some topic. Should we (can we) put IOLs in children who require combined corneal/lens surgery? Over the last year I have received numerous inquiries regarding this issue. It was the lead topic at the last PKA Meeting at the AAO. To shed light on this issue, we will start by presenting some cases. The first case is submitted courtesy of Dr. Adam Kaufman, Cincinnati, Ohio. CASE 1 CASE 2 Both of these cases present a number of questions regarding surgical management. The first patient will need better wound closure and lens extraction. Eventually the cornea will scar and the patient would then be left with an aphakic eye and a scarred cornea. Since the other eye is normal, significant amblyopia could be expected to develop. Case 2 is in some ways a mirror image of Case 1, except that the patient is several years down the road. This patient had a primary repair of the corneal laceration with extraction of the cataractous lens when she was still in the amblyopic age group. According to her parents, up until her initial injury, she had normal vision in each eye. Currently her parents are interested in visual rehabilitation of her eye. She requires a penetrating keratoplasty and correction for aphakia along with anti-amblyopia therapy. Each case presents us with a clinical conundrum an aphakic (or potentially aphakic) eye in a child who requires a corneal transplant. Therefore, is an intraocular lens indicated in either case? If an intraocular lens is indicated, should the IOL be placed primarily or secondarily after the eye heals from the initial surgery? If an IOL is indicated, several methodologic problems must be overcome. First, how do we determine the power of the IOL? Children are difficult to examine. Do we take keratometry readings based on the contralateral normal eye? Do we base them on our "usual average K" that we obtain after penetrating keratoplasty? Should we expect that the K readings on the child's eye will evolve in the same fashion as they would in an adult eye or might they change as the child grows. The next problem is how do we determine the axial length? Presumably, we would use the axial length from the good eye. In the older child, this might be possible in the office. In the younger child, it would probably have to be done in the operating room when the child is under anesthesia. Once the IOL power is determined, what size and style of intraocular lens is to be used? Additionally, if the posterior capsule is not intact, is an anterior chamber lens feasible; is a suture fixated lens acceptable (and if it is, do we confidently know where to anatomically suture a lens)? If a posterior chamber lens is possible, must it be placed into the capsular bag or can it be safely placed in the sulcus of a child whose eye may still be growing? Another issue is what to do about the posterior capsule. In most primary pediatric cataract surgical procedures, the center of the posterior capsule is removed at the time of surgery and a vitrectomy is performed. Is this a procedure that we wish to do in a pediatric transplant, particularly in an eye that is acutely inflamed (as in Case 1)? The posterior capsule will opacify in most children with cataract surgery. If the goal of the surgical procedure is to prevent amblyopia, or as in Case 2, to quickly rehabilitate vision, should a primary capsulotomy be performed? Another decision to be made is once an IOL is placed in a child, should one aim for emmetropia or should one make the eye ametropic in anticipation that it will grow. Finally, what is the youngest age at which an IOL can be considered (in cases such as these)? To summarize, we are confronted with the issue of do we use an intraocular lens in a child undergoing corneal transplant surgery. Rather than answer the question in this newsletter, I would like to solicit responses from the members of the association. Dr. Norman Medow gave a very nice discussion of these issues at the last PKA breakfast at the American Academy of Ophthalmology meeting. I will report his comments to you in a future newsletter. For now I would hope that we could generate a sufficient number of responses to get a consensus. I request that written responses of your management of these two patients be sent to me (mail or e-mail). In your response, please answer the following questions: What age would you consider an IOL in a pediatric PKP? How do you determine the IOL power? Where do you place the IOL? Would you consider anything other than a posterior chamber IOL? Would you suture Another issue is what to do about the posterior an IOL in position? In trauma, should an IOL be used capsule. In most primary pediatric cataract surgical size optic, what size diameter, what type loops, primarily or secondarily? What IOL do you use. i.e., procedures, the center of the posterior capsule is what removed at the time of surgery and a vitrectomy is per- what type configuration? To help us with this, please fill out the data sheet. Since we began the PKA, STORZ has been very supportive. Currently, they are helping us with instrument design. By the next academy meeting, we hope to introduce some new instruments that have been modified for use in pediatric corneal transplant surgery. If you have any ideas in this area, contact me, your local STORZ Representative or Blake Michaels (Group Marketing Manager, Instruments/Implants) at STORZ (314-861-3016). Also, for those of you implanting IOLs in children, STORZ now has available IOL powers from - 18 to +45 in five models. Contact your local STORZ Representative or call Customer Service at 800-325-9500. GRAFTS AND IOLS-RESEARCH PROJECT July 11, 1997 Dear Doctor: I am currently a second year ophthalmology resident at New York Medical College, Valhalla, New York. As part of my senior research project, I will be working with Dr. Gerald Zaidman and the Pediatric Keratoplasty Association on a study of pediatric keratoplasty and intraocular lens implantation. As you may know, this is a new and controversial area of research. Our goal is to collect cases of children who have had or will need penetrating keratoplasty and also have cataracts that will require cataract surgery with an intraocular lens. Subsequently, if we collect sufficient data, we hope to be able to draw some conclusions regarding lens implant surgery in children with keratoplasties. I am writing to ask your assistance in this endeavor. If you have any patient that may qualify for this study, could you please fill out the accompanying data sheet and fox or mail it to Dr. G. Zaidman, Ophthalmology, Westchester County Medical Center, Valhalla, New York 10595, fax (914) 285-7445. Thank you very much in advance for your time and assistance.
P.S. You may receive a follow up phone call from us. Patient's initials ______________________________________________________________ Date of birth ______________________________________________________________ Diagnosis
______________________________________________________________ Age at diagnosis _____________________________________________________________ Visual acuity Other anterior segment pathology (please describe)
Date of corneal transplant (or anticipated date) ____________________________________ Date of cataract and IOL surgery (or anticipated date) ______________________________
Keratometry (how determined)
__________________________________________________ Axial length (how determined)
__________________________________________________ Posterior capsule management (please describe)
_________________________________ Postoperativegraft clear? Yes______
No______ Amblyopia therapy? Yes______ No______ Doctor's name _______________________________________________________________ THANK YOU FOR YOUR HELP 7/97 SFA-6452 | |||||||||||||||||||||||||||||||||||||||||||
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A 9 year old
girl was examined with a dense central corneal scar secondary to a prior corneal
laceration. The patient had suffered a penetrating injury to the cornea about 3 years
earlier. At the time of the initial injury, the lens was also ruptured. The patient's
original surgical procedure consisted of repair of the corneal laceration and removal of
the lens fragments. The posterior capsule was (according to the referring physician) noted
to be intact and no intraocular foreign body was present. When the patient was referred to
the New York Medical College Cornea Service, she had a quiet and uninflamed eye with a
visual acuity of hand motion. She was orthophoric. A dense central corneal scar was
present. The pupil was round but synechiae were noted from the iris to a Soemmering's
cataract. The posterior capsule appeared to be intact. The intraocular pressure was
normal. Funduscopic examination revealed a flat retina but no details could be seen.