The Journal Club article this month is an article giving a comprehensive review on congenital cataract. The Eye Team in Nelson have recently researched standard practices when a unilat cataract case presented first to clinic age 1. He had some binocular function, no squint, reduced unioc vision, normal eyes and we wondered if he may be a case for psedophakia rather than aphakia. 

This article looks long, but there is a lot on surgical techniques and glaucoma treatments which are interesting but can be skimmed – however the overall messages for treatments and evidence bases are valuable.

Quick overview:

1. Early referral essential. Often not early enough

2. Operate in first 6-7 weeks unilat 

3. Under 2 leave aphakic – high risk of opacification if IOL and further stimulus deprivation and likely second surgical procedure for this

4. Over 2 IOL an option

5. Equal risk for glaucoma with pseudophakia or aphakia but 4x risk glaucoma with surgery age 4 weeks or earlier

6. CL preferable to glasses due to aberrations in bilat cataract and due to aberrations/aniso in unilat.

Preferably refraction correction 1 week post op

7. As a guide, for unilat start occlusion 1 week post op with correction 1 hour per day per month of life up to 6 months then 6 hours per day until age 5

8. Strictly adhered to post operative drops routine

9. Topical drops to treat glaucoma if found and long term follow up for this into adulthood

Below is a selection of 3 current cases I am seeing in Nelson/Wairau. All have presented their own challenges. 

1. Surgery unilat cataract age 13/12, YAG laser for contracted capsule age 19/12, capsulectomy age 2 years. Now 2.5, Aphakia, contact lens, patching 4 hours, compliant, LXT, nil binoc, no glaucoma so far. In view of capsular constriction IOL insertion not recommended

2. Surgery unilat cataract age 10 weeks. Now 3.5 years

Aphakia, contact lens, patching 2-4 hours hit and miss, glaucoma (latanoprost+timolol), best corrected VA 6/48, LXT, nil binoc. Family keen for IOL.

3. Surgery unilat cat age 10 weeks. Now 11 years. Secondary PCIOL age 7, dislocated lens entering AC, pupil distortion, light sensitivity. VA HM only. Family keen for further surgery to remove IOL or try for AC IOL with minimising pupil size effect – however may well be complications with infection and structure of eye not suitable to support ACIOL.

I also think brutal honesty about the implications of treatment is essential and do not embark on anything as an Orthoptist without a dedicated experienced Optometrist who is willing to go above and beyond for these patients and families. Access to multiple CL replacements is essential and back up spex for use when patching a good idea.  Often media checks are difficult in this young age group but any capsule contraction or opacification needs to be picked up and treated asap to allow maximum visual acuity.