Corneal edema after pediatric cataract surgery

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Corneal Edema After Pediatric Cataract Surgery J o h n W. Simon, M D , D a r r e n M i t e r , Jitka Z o b a l - R a t n e r , M D , David H o d g e t t s , C O , C O M T , a n d M i c h a e l W. Belin, M D

Introduction:We have encountered idiopathic corneal edema in four patients (five eyes) after pediatric lensectomy. This problem has not been previously described in the pediatric ophthalmology literature. Methods: Clinical and operative records were reviewed. The children, who ranged in age from 15 months to 6years, underwent apparently uncomplicated limbal lensectomy without lens implantation. After surgery, all received subconjunctival hydrocortisone (12.5 rag) and 2 to 4 drops daily of topical prednisolone acetate. The corneal edema developed between 2 and 14 days after surgery. Results:The condition cleared in all patients during a 5- to 14-day course of intensive topical steroids. No sequelae have been apparent. Final visual acuities are 20/30 or better in the three children (four eyes) old enough for recognition acuity testing. The fifth eye has excellent central fixation. Conclusions:We suspect that the corneal decompensation was a manifestation of sterile inflammation. Two of the children had a history of iritis. Difficulty measuring cellular response at the slit-lamp examination and instilling eyedrops at home may have contributed to the complication. Postoperative corneal decompensation can be responsive to topical steroids, which we now prescribe more intensively even in apparently quiet eyes. (J AAPOS 1997;1:102-4)

orneal edema is a well-recognized complication of cataract surgery in adult patients but has rarely been described after such surgery in children.-14 We describe five eyes of four children who were seen with corneal stromal and epithelial edema during the first month after lensectomy. The condition cleared in all after treaunent with topical steroids.

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MATERIALS AND METHODS All the children underwent uncomplicated lensectomy through a limbal incision. A peripheral iridectomy and a shallow anterior vitrectomy were performed. The only solutions used intraocularly were a 1:1,000,000 dilution of epinephrine in balanced salt solution, less than 1 ml acetylcholine chloride (Miochol), and Millipore-filtered air. The bottle height of the intraocular infusion was adjusted to maintain the anterior chamber but was not greater than 4 feet above the patient's eye. Surgical insmunents did not come in contact with the endothelium, and no preexisung corneal abnormality was found in any patient. All four children were given postoperative injections ofhydrocortisone (12.5 rag) and gentamicin (10 rag) beneath the inferior bulbar conjunctiva. All were treated with topical prednisolone acetate 1% and with 1 or 2 drops of atropine sulfate 1%

From the Albany ~ledical Center's Lions Eye Institute, Albany, New York. Address reprim requests to John ~ Simon, MD, Lions Eye Institute, Albany Medical Center, Ophthalmology, 3 Y Hackett Blvd., Albany, NK 12208. Copyright© 1997 by theAmericanAssociationfor PediatricOphthalmologyand Strabismus. 1091-8Y31/9755.00 + 0 75/1/80301

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daily during the postoperative period. NO loss of anterior chamber was seen, and the intraocular pressures remained normal. CASE REPORTS Case 1 A 6-year-old girl who failed vision screening was found to have bilaterallamellar cataracts thatwere worse in the left eye. The visual acuity measured 20/50 in the right eye and 20/200 in the left eye. Lensectomy was performed through a single incision with use of the Ocutome vitreous cutter (Ocutome; Coopervision, Irvine, Calif.). On the first postoperative day, the visual acuity in the left eye improved to 20/50, and topical prednisolone acetate twice daily was prescribed. On the ninth postoperative day, the child complained of light sensitivity, and the cornea was edematous. Her visual acuity had fallen to hand motions. No cellular response could be seen in the anterior chamber. The intraocular pressure measured 14 mm Hg. The prednisolone acetate was increased to six times daily. Over the next 2 weeks, the corneal haze gradually cleared, the visual acuity improved to 20/30, and the steroids were gradually discontinued. Case 2 A 15-month-old girl was noted to squint her left eye in bright lights for approximately 1 month. Examination disclosed bilateral partial, nuclear cataracts that were more advanced in the left eye. Lensectomy was performed by using the Premiere vitreous cutter (Premiere; Karl Storz, St. Louis, Me.) through a single limbal incision.

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The child was given topical prednisolone acetate twice daily for the first postoperative week. The eye was quiet and the media were clear, with a sharp retinoscopic reflex. The drops were discontinued after 10 days. On the fourteenth day she was seen for routine follow-up and contact lens fitting. She had been noted to be slightly light sensitive that morning. Examination showed diffuse corneal haze, through which questionable cells and flare could be seen. Applanation tensions could not be measured accurately, but the eyes were symmetrically soft by palpation. The child was given hourly prednisolone acetate drops, and the daily atropine was restarted. Over the subsequent 5 days, the media graduallycleared. A silicone contact lens was fitted, and amblyopia treatment was begun. The child's behavior with the patch over her right eye was normal at home. On ophthalmologic examination, her fixation was central, steady, and maintained in each eye. Case 3

A 4-year-old girl had light sensitivity, chronic injection, and poor vision develop over 3 weeks. Examination showed bilateral fibrinoid uveitis, which cleared with intensive topical steroids, but a dense cataract was subsequently apparent in the left eye. The child's pediatric evaluation disclosed juvenile rheumatoid arthritis. The preoperative visual acuity was hand motions. At surgery, the anterior chamber was shallow. Posterior synechiae were broken with use ofa cyclodialysis spatula and hydrodissection with Viscoat viscoelastic (Alcon, Ft. Worth, Texas). Four sphincterotomies were performed to facilitate lensectomy, which was completed through a single limbal incision with use of the Premiere instrument. On the first postoperative day, the visual acuity had improved to 20/40. A moderate anterior chamber reaction was noted. Despite hourly topical prednisolone acetate, the cornea became edematous and the visual acuity slipped to 20/80 on the second day. The intraocular pressure measured 3 mm Hg. Over the course of the next week, the inflammation gradually subsided and the visual acuity improved to 20/30. The topical steroid was tapered to three drops daily. Approximately 3 months later, a cataract in the right eye had progressed in similar fashion. The preoperative visual acuity measured 2/100. Lensectomy was performed with the Premiere instrument through a single limbal incision. Again, the shallow anterior chamber and posterior synechiae were managed with Viscoat, the collar button, and sphincterotomies. On the first postoperative day, the visual acuity had improved to 20/30. Again despite hourly steroid drops, the cornea became edematous during the subsequent week. Iritis was persistent, and the visual acuity slipped to 20/70. The intraocular pressure measured 12 mm Hg. During the second postoperative week, the inflammation subsided, the visual acuity improved, and the steroids were tapered. Seven months after the first operation, the child has

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20/20 vision in each eye through her contact lenses and has only minimal inflammation with 2 drops of prednisolone acetate daily.

Case 4 A 3-year-old boy was referred for treatment of a dense cataract in the left eye that had developed over several weeks. The child had been treated for sarcoid uveitis under an experimental protocol with retinal S-antigen and both systemic and topical steroids. A lensectomy had been performed on the right eye 1 month previously with minimal postoperative inflammation. Before surgery, the visual acuity measured 1/400. The inflammation in the left eye was controlled with oral prednisone 0.5 mg/kg daily and topical prednisolone acetate six times daily. At surgery, posterior synechiaewere broken by using a cyclodialysis spatula. Lensectomywas then performed through a single limbal incision with the Premiere instrument. After surgery, the oral steroid was increased to 1.5 mg/kg daily and the topical steroid to hourly. On the third postoperative day, the visual acuity measured 20/40 and inflammation was minimal. On the ninth postoperative day, the cornea had become grossly edematous, and the visual acuity had fallen to counting fingers. Pachymetry measured 0.75 mm, and intraocular pressure measured 10 mm Hg. Topical prednisolone acetate was continued hourly, with systemic prednisone, for the next 2 weeks. The cornea cleared gradually, the pachymetry decreased to 0.63 mm, and the visual acuity improved to 20/25. DISCUSSION

Corneal edema is frequently encountered after cataract surgery in adults. Underlying conditions that may contribute include increased intraocular pressure, Fuchs' dystrophy, uveitis, retained lens fragments, toxicity of intracameral injections, endothelial trauma during surgery or from contact with a lens implant, loss of anterior chamber, and vitreouscorneal touch. 5 These conditions have not been associated with corneal decompensation in children after lensectomy. Except uveitis, none of these conditions pertained among our patients. Corneal edema has, however, been described in association with postoperative endophthalmitis in both children and adults. Although we were initially concerned that our patients may have had this complication, the edema presented as long as 14 days after surgery, and no hypopyon was visible through the corneal haze. Sterile inflammation certainly contributed to the corneal decompensation in the patients in Cases 3 and 4, who had been previously treated for iritis. We suspect it was a factor in all cases. Children are recognized to mount an exaggerated inflammatory response after intraocular surgery. Diagnosis and management of postoperative inflammation in young children can be difficult. They tend to resist careful slit-lamp examination, and it can be difficult for

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parents to instill eyedrops frequently. Fortunately, the corneal edema cleared after several days of intensive topical steroids in all five eyes we report. Three of the four children have tolerated contact lenses (the patient in Case 4 is wearing aphakic spectacles), and all have recovered excellent visual function. Corneal edema after pediatric cataract surgery can be present as long as 2 weeks after surgery. It can be temporary and responsive to topical steroids, and it need not reflect serious underlying pathologic conditions. It has previously been our practice to prescribe topical steroids sparingly during the postoperative period, tailoring treatment to the amount of inflammation apparent clinically. Because of our experience with these patients, we now prescribe topical steroids expectantly every few hours during the first weeks after surgery.

Journal ofAAPOS Volume I Number 2June 1997 References 1. Lambert SR, Drack AV. Infantile cataracts. Sure Ophthalmol 1996;40:427-58. 2. Votruba M, Lumb RJ, Markham RH. Corneal endothelial cell counts in children after surgery for congenital cataract. Invest OphthalmolVis Sci 1995;36(suppl):36. 3. RozenmanY, F01berg R, Nelson LB, Cohen EJ. Painful bullous keratopathy followingpediatric cataract surgery with intraocular lens implantation.OphthalmicSurg 1985;16:372-4. 4. NuytsRMMA,EdelhauserHF, Pels E, BreebaartAC. Toxic effects of detergents on the corneal epithelium. Arch Ophthalmol 1990;108:1158-62. 5. JaffeNS,JaffeMS,JaffeGF. Cataractsurgeryand its complications, 5th ed. Philadelphia:Mosby; 1990. p. 412-29.

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