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SURGICAL TREATMENT OUTCOMESOF CONGENITAL AND JUVENILE

CATARACTS

CASAER P. *, CASTEELS I.*, FOETS B.*

SUMMARY

Purpose: Evaluation of visual outcome after lens as-

piration with or without intraocular lens implanta-tion for isolated congenital and juvenile cataract inchildren aged 6 years and younger.Material and Methods: Retrospective review of 48children with isolated congenital and juvenile cata-ract who were surgically treated between January1993 and December 2002 and had a minimal fol-low-up of 12 months.Results: In the group of children with unilateral cata-ract, 33% (3 out of 9 children) of aphakic childrenand 45.5% (5 out of 11 children) of pseudophakicchildren attained a final best corrected visual acuityof 20/200 and 20/60 respectively. In the group ofchildren with bilateral involvement, 35% (6 out of17 children) of aphakic children have a final best

corrected visual acuity of 20/30 and 63.7% (7 outof 11 children) of pseudophakic children have a fi-nal best corrected visual acuity of 20/25 or more.Conclusion: The results of this study emphasize theneed for early surgery and good organisation of post-surgical care in patients with pediatric cataract tooptimise visual outcome. Furthermore patients withisolated unilateral congenital cataract surgically treat-ed at an average age of 15 months without primarylens implantation and with variable and low com-pliance have suboptimal results. The effect of earlysurgery with primary lens implantation on the longterm visual outcome in pediatric cataract needs tobe further evaluated.

SAMENVATTING

Doel: Evaluatie van de visuele resultaten na lensas-

piratie met en zonder primaire intra-oculaire lens-implantatie voor gesoleerd congenitaal en juvenielcataract in kinderen zes jaar en jonger.Materiaal en methoden: Retrospectieve studie van48 kinderen met gesoleerd congenitaal en juvenielcataract die heelkundig behandeld werden tussen Ja-nuari 1993 en December 2002.Resultaten: In de groep patintjes met unilateraalcataract bereikten 33% (3 van de 9 patintjes) vande afake kinderen en 45.5% (5 van de 11 patint-jes) van de pseudofake kinderen een best gecorri-geerde visuele acuiteit van respectievelijk 20/200 en20/60. De groep patintjes met bilateraal cataractbereikten een best gecorrigeerde visus van 20/30 in

35% (6 van de 17 kinderen) van de afake kinderenen een best gecorrigeerde visus van 20/25 of beterin 63.7% (7 van de 11 kinderen) van de pseudo-phake kinderen.Besluit: De resultaten van deze studie beklemtonenhet belang van vroege interventie en goede organi-satie van de postoperatieve opvolging in patintjesmet pediatrisch cataract ter optimalisering van hetvisuele resultaat. We zien dat patintjes met geso-leerd unilateraal congenitaal cataract heelkundig be-handeld op een gemiddelde leeftijd van 15 maan-den zonder primaire lens implantatie en gepaardgaand met een variabele en lage compliantie eensuboptimaal visueel resultaat hebben. Het lange ter-mijneffect van vroege heelkunde met primaire intra-

oculaire lensimplantatie op het visuele resultaat dientverder gevalueerd te worden.

RESUME

But: Evaluer les rsultats fonctionnels de la chirur-gie de la cataracte avec et sans implant de cristallinartificiel chez lenfant de moins de 6 ans.Matriel et Mthodes: Analyse rtrospective de 48enfants avec une cataracte isole congnitale et ju-

zzzzzz

* Department of Ophthalmology, St Rafael UZ, Leuven,Belgium received: 23.05.05

received: 23.05.05accepted: 18.08.05

47Bull. Soc. belge Ophtalmol., 297, 47-57, 2005.

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vnile, qui ont t traits de janvier 1993 dcem-bre 2002.Rsultats: Dans le groupe d enfants avec une cata-racte unilatrale, 33% (3 des 9 patients) des en-fants aphaques et 45,5% (5 des 11 patients) desenfants avec un implant, dveloppaient une acuitvisuelle corrige respectivement de 20/200 et 20/60. Le groupe d enfants avec cataracte bilatraleavait une vision corrige de 20/30 pour 35% (6/17enfants) des enfants aphaques, et une vision corri-ge de 20/25 ou mieux pour 63,7% (7/11 enfants)des enfants pseudophaques.Conclusion: Cette tude permet de rappeler limpor-tance dune intervention prcoce et dune bonne or-ganisation des soins postopratoires des enfants aveccataracte pdiatrique, afin doptimaliser le rsultat

visuel. Les enfants avec cataracte congnitale iso-le unilatrale oprs vers lge de 15 mois, sansimplantation primaire dun cristallin artificiel, et aveccompliance variable, ont un rsultat visuel subop-timal. Le rsultat fonctionnel long terme dune op-ration prcoce avec implantation dans la chambrepostrieure, demande une valuation ultrieure.

KEY WORDS

congenital cataract - juvenile cataract -surgery - outcome

MOTS-CLS

cataracte congnitale - cataracte juvnile -chirurgie - rsultats fonctionnels

INTRODUCTIONCongenital cataract is a common cause of poorvision in infants. Improved surgical methodsand the insight in the importance of early de-tection, allowing early treatment as well as ap-propriate optical correction and amblyopia treat-ment, have improved visual outcome of child-hood cataracts. In spite of this knowledge, thetreatment of childhood cataract still remains achallenge. Even with early and intensive treat-ment, the visual outcome of unilateral cataractcan be disappointing. Bilateral dense cataractsattain better visual results if operated before theage of eight weeks (9,10). Less severe bila-

teral lens opacities may have better outcome ifintervention is delayed. We retrospectively re-viewed infants and children with unilateral orbilateral cataracts without associated ocular orsystemic disease, who underwent surgery beforethe age of 6 years between 1993 and 2002 atthe University Hospital Leuven, Belgium. Visu-al outcome and complications are reported.

METHODSWe reviewed the records of all children aged 6years and younger who underwent cataract sur-

gery between January 1993 and December2002 at the University Hospital Leuven, Bel-gium. One hundred and seven records were re-viewed. Children with associated ocular anom-alies, systemic or mental disorders, less than12 months follow-up and absence of follow-up at our department were excluded (Table 1).Forty-eight patients were eligible for inclusionin this study.

Table 1: Exclusion criteria

Nopatients

Nopatients

Retinoblastoma 2 Aniridia 1Uveitis with secondary cataract 3 Microphthalmia 2PHPV 13 Disorders of the eye as a whole 1Traumatic cataract 4 (microphthalmia, cataract, glaucoma)Marfan syndrome 4 Psychomotor retardation 3Cockayne syndrome 2 of unknown originConradi syndrome 1 Epilepsy 2Rubella syndrome 1 Secondary lens implantation 3Dubowitz syndrome 1 Follow-up less than 12 months 7Down syndrome 1 Surgery in other Hospital 2Hallerman-Streiff-Franois syndrome 1 Others 5

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Four subgroups are considered. Unilateral cat-

aract was present in 20 patients. Eleven in-fants were treated with primary IOL implanta-tion (unilateral pseudophakia, group P1), 9 in-fants were primary corrected with contact lens-es (unilateral aphakia, group A1). Bilateral cat-aracts were present in 28 patients. Eleven chil-dren were treated with primary IOL implantation(bilateral pseudophakia, group P2), 17 wereprimary corrected with contact lenses (bilater-al aphakia, group A2).

The protocol followed at the University Hospi-tal Leuven for children presenting with cata-ract is described below. Preoperatively all pa-

tients underwent a full ophthalmological as-sessment including visual acuity, eye motilityand position, slit lamp examination, dilated fun-doscopy, retinoscopy, keratometric reading andA-scan ultrasound determination of axial length.To assess vision we used age appropriate tests.Correction was worn during the testing. In somepreverbal patients, monocular and binocular fix-ation behaviour was assessed and a Snellen vi-sual acuity was assigned to each fixation pat-tern as described by Bradford et al (5). The pu-pils were dilated with cyclopentolate 0,5%, fun-doscopy and streak retinoscopy were per-

formed. In children with asymmetric cataracts,a trial of occlusion was recommended to elim-inate the possibility of superimposed amblyo-pia. If vision was difficult to assess, we reas-sessed the child after a short period. In smalland very uncooperative children, ocular exam-ination under general anaesthesia was per-formed. Surgery was planned if the lens opac-ities were severe enough to interfere signifi-cantly with visual development. Babies or chil-dren with unilateral cataracts were not referredto the paediatrician; all the bilateral cases with-out a positive family history were referred to thepaediatric department for a complete work-up.

Informed consent was obtained for all patientsfrom the parents after discussion of the risks,benefits and postoperative care.Children in group A2 (bilateral aphakia) under-went surgery for the second eye within 1 week(mean 3.9 days) without occlusion and with-out optical correction of the first eye during theinterval between the operation on the first andon the second eye. Contact lenses were insert-ed at the time of the second operation. In group

P2 (bilateral pseudophakia) the average time

between surgery of the first eye with the poor-er vision and the second eye was 3.2 months(2-7months).Intraocular lens power was calculated with theSRK II formula. In unilateral cataract the IOLpower was aimed at emmetropia in the earlypostoperative period for immediate visual re-habilitation. In bilateral cases we tried to ob-tain a slight hypermetropia in accordance to ageand expected eye growth. In most patients weused heparin coated PMMA lens (Pharmacia,811C or 812C), more recently we use the sin-gle and three piece acrylic foldable IOL (AlconLaboratories Inc., SA60AT or MA30BA).

Surgery was performed by one surgeon (BF),experienced in both surgical procedures. Gen-eral anaesthesia was used in all patients. Thepupils were dilated with cyclopentolate 0.5%and phenylephrine 5% instillated three timesstarting one hour before surgery.Because of the variability of the eye position un-der anaesthesia a superior bridle suture is ben-eficial. In children with bilateral congenital cat-aracts who needed surgery in the first 12 weeksof life, a standard lensectomy and anterior vit-rectomy without IOL was performed. Childrenwith unilateral cataract under the age of one

were also left aphakic. Two corneal stab inci-sions were made at the 2 and 10 oclock posi-tion. After filling the anterior chamber with Hea-lont (10 mg/ml, Pharmacia Ophthalmics, Upp-sala, Sweden), the anterior capsule was opened.If possible a continuous curvilinear capsulorhex-is with forceps was performed; otherwise a can-opener technique was used. The lens materialwas aspirated using a bimanual irrigation-as-piration technique. With a vitrectomy tip theposterior capsule was opened centrally and ananterior vitrectomy was performed. In all cas-es a peripheral iridectomy was made at thetwelve oclock position. Corneal incisions were

closed with a Nylon 10.0 suture. Optical cor-rection of the aphakia with contact lenses (Sil-soft super plus, Bausch & Lomb) was standard.When the decision to implant an IOL was made,a partial thickness 3.2 mm limbal tunnel wasperformed. A manual anterior continuous cap-sulorhexis was performed using forceps. In whitecataracts trypan blue staining was used to vi-sualise the capsule. An irrigation and aspira-tion hand piece was used to aspirate the lens

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material. The posterior capsule was left intact

in specific situations (older children, earlier cas-es, higher vitreous pressure) or a posterior rhex-is with or without an anterior vitrectomy wasdone. The capsular bag was filled with Heal-ont and the IOL was placed in the capsularbag. The tunnel was closed watertight with Ny-lon 10.0 sutures.At the end of the procedure depot steroid (Cele-stone Chronodoset) was injected subconjunc-tivally. An antibiotic ointment and one drop ofAtropine 1% was placed, the eye was patchedand a shield was placed over the eye. Postop-eratively all children received a combinationsteroid- antibiotic eye drop four to six times dai-

ly for two weeks after which it was tapered

slowly tailored to the patients needs. Topicalatropine sulphate 0.5% eye drops were usedonce or twice daily for two weeks. Follow-upvisits were planned at day one, day four, dayeight and then every two weeks until week 6followed by controls at 4 monthly intervals. In-traocular pressures were measured every 3-6months using Goldmann or Perkins tonometry.Amblyopia treatment was initiated immediate-ly after surgery following the Great Ormond Streetocclusion protocol for unilateral and bilateralcataract (6). The refractive correction was pre-scribed 6 weeks after surgery. Bifocals or mul-tifocals were adapted depending on the case.

Table 2: Visual acuity and compliance with occlusion therapy in children after lensectomy for unilateral cataract(group A1).

Patientn=9

eye Present.(months)

Surgery(months)

aetiology preop VA postop VA Follow-up Occlusion

MB OS 2 3 C PL 20/50 65 Good

DWC OD 2 3 C PL

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RESULTS

Forty-eight patients (76 eyes) with a minimumof 12 months follow-up were included in thestudy. Twenty-eight patients (58.3%) had bi-lateral and 20 patients (41.7%) had unilaterallens opacities. In the group with bilateral lensopacities, cataracts were congenital in 17 pa-

tients. All of them were treated by lensectomywithout consecutive IOL implantation. The re-maining 11 children had bilateral juvenile cata-ract and were implanted primarily with a pos-terior chamber IOL. In the unilateral cataractgroup, 9 eyes underwent a lensectomy, 8 ofthose were congenital in origin, one juvenile. Aposterior chamber IOL was implanted in the re-maining 11 eyes, 4 of those were congenitallens opacities, 7 juvenile. Cataracts present-

ing and diagnosed after the age of 1 year arespecified as juvenile cataracts.

VISUAL OUTCOME

Unilateral cases (n=20)

The mean age at surgery was 15 months (range

3-44 months) for the unilateral aphakic groupand 45 months (range 8-68 months) for theunilateral pseudophakic group. Mean follow-up period was 67.5 months (range 18-98months). The visual acuity attained followingcataract surgery for group A1 and group P1 isshown in Table 2 and 3.In the unilateral aphakic group (group A1, n=9)only 3 eyes (33.3%) attained a visual acuity of20/200 or more. Poor vision in this group was

Table 4: Visual acuity after bilateral lensectomy for bilateral cataract (group A2).

Patientn=17

eye Pr esent.(months)

surger y(months)

aetiology preopVA

postopVA

Follow up(months)

Occlusion

VM OD 6 days 2 C PL 20/30 106 GoodOS 2 C PL 20/30 106

SoN OD 16 days 2 C PL 20/100 100 PoorOS 2 C PL 20/30 100

SS OD 15 days 2 C FF 20/50 72 GoodOS 2 C FF 20/50 72

SN OD 9 days 2 C PL 20/100 21 NoneOS 2 C PL 20/100 21

DuK OD 1 2,5 C searching 20/25 103OS 2,5 C searching 20/25 103

AB OD 2,5 2,5 C PL

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in a part attributed to late presentation in 2 pa-tients andlow compliance withocclusion thera-py in 5 (56%) of 9 children. In the unilateralpseudophakic group (group P1, n=11) 5 eyes(45.5%) attained a visual acuity of 20/60 or

more. One child (9%) attained a visual acuityof less than 20/200 fifty-four months after sur-gery despite good follow-up and compliance toocclusion therapy.

Table 5: Visual acuity after bilateral IOL implantation for bilateral cataract (group P2).

Patientn=11

eye Pr esent.(months)

Surgery(months)

Type ofIOL

aetiology PreopVA

postopVA

Follow up(months)

MM OD 24 28 H J 20/100 20/30 52

OS 25 Phaco S J 20/400 20/60 49

CE OD 36 38 H J 20/100 20/30 12

OS 36 H J LP 20/30 12

VL OD 39 40 H J

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Bilateral cases (n=28)

The mean age at surgery was 4.7 months (2-19 months) for the bilateral aphakic group and52 months (25-72 months) for the bilateralpseudophakic group. Mean follow-up periodwas 82.1 months (range 23-140 months). Thevisual acuity attained for group A2 and groupP2 is shown in Table 4 and 5.In the bilateral aphakic group (group A2, n=17)the final best corrected visual acuity of the worseeye was better than 20/60 in 6 (35.3 %) pa-tients, 6 (35.3%) children attained a visualacuity of 20/30 or better in the best eye. In thebilateral pseudophakic group (group P2, n=11)

final best corrected visual acuity of the worseeye was better than 20/60 in 10 patients(90.9%), 7 (63,7%) children attained a visualacuity of 20/25 or more in the best eye.

Opacification of the posterior capsule (PCO) oranterior hyaloid face occurred in 57.6% of chil-dren treated with a posterior chamber IOL. Se-venty one percent of children who underwentlens extraction with primary posterior capsulo-tomy without anterior vitrectomy developed PCOcompared to 32% where an anterior vitrecto-my was performed (Table 7). Ten patients re-quired secondary YAG laser capsulotomy. In 5of those patients reopacification of the capsu-lotomy occurred requiring surgical capsuloto-my to clear the visual axis. Thirteen patientsunderwent a secondary surgical capsulotomywhen the capsule was thought to be too thickor the child too uncooperative for YAG lasercapsulotomy.

In the immediate postoperative period four eyesdeveloped a mild fibrinous uveitis that resolvedrapidly and with topical steroids in three eyes.Two eyes developed a more serious inflamma-tion: one eye (OJ, Group P2) developed en-

dophthalmitis five days postoperatively. Topi-cal, intravenous antibiotic therapy and subcon-junctival injection of steroids, vancomycin andamukin were necessary to quieten the eye. Thetreatment was tapered over the next few weeksuntil the eye became quiet again. Two and ahalf months later the patient presented withposterior capsular opacification. A surgical cap-sulotomy was performed with recurrence of theendophthalmitis two months afterwards. We re-

startedthetopicalandsystemicantibioticthera-py. The endophthalmitis resolved rapidly un-

der this treatment. Another patient (GD, GroupA2) developed an endophthalmitis 16 monthsafter cataract surgery. An anterior chamber rin-sing combined with a vitrectomy and intraoc-ular antibiotics was performed. Postoperative-ly a subconjunctival injection with antibioticsand corticosteroids was given, followed by steroidantibiotics eye drops. Both cases were pro-bably suture-related because they resolved underintensive treatment.One patient with bilateral aphakia presentedwith a unilateral iris bombans 8 days postop-eratively because of synechiae formation be-

tween the iris and the residual lens capsule.The child was treated with a secondary surgi-cal iridectomy and postoperative topical Timop-tol 0.5% eye drops. Two bilateral aphakic chil-dren developed glaucoma 3,5 and 6,5 yearspostoperatively and are treated with topicaltherapy. Cystoid macular oedema or retinal de-tachment has not been observed so far.

DISCUSSIONChildhood cataract has an estimated preva-lence of 1.2 to 2.3 per 10 000 births. In caseof bilateral cataracts 1/3 is inherited without

systemic abnormalities. Other causes includemetabolic disorders such as galactosemia, chro-mosomal abnormalities such as trisomy 21, in-trauterine insults such as congenital Rubella.They can be part of a systemic syndrome suchas Hallermann-Streiff-Franois syndrome andLowe syndrome. On the other hand unilateralcataracts are not usually inherited or associat-ed with systemic disease; PHPV and posteriorlenticonus are frequent. They may occur with

Table 7: PCO after implantation of an IOL in the treat-ment of pediatric cataract

No PCO PCO Post-operativemonths*

No PPC (n = 7) 0 7 (100%) 12,3 (3-19)

PPC - AV (n = 7) 2 (29%) 5 (71%) 10,2 (1-27)

PPC+ AV (n = 19) 12 (63%) 7 (37%) 16,5 (3-29)

PCO: posterior capsular opacification, AV: anterior vitrec-tomy, PPC: primary posterior capsulorhexis*: time in months to appearance of significant PCO aftersurgery

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congenital infections, such as congenital rubel-la. The majority of cases however are idiopath-ic. Slit-lamp examination is mandatory to ex-clude asymmetrical bilateral cataracts (28). In

all cases of childhood cataract examination ofthe parents is mandatory.Our group consists of patients with heteroge-neity in the type of cataract, differences in agesat surgery and variable compliance with thera-py. Our results are probably representative forthe real outcome of surgical treated childhoodcataracts as a group (Table 8).

The amblyogenic factors in congenital unilate-ral cataracts are not only visual deprivation butalso unequal competition between the two eyes.The latter becomes important once the visual

deprivation is prolonged to 12 to 30 weeks oflife (3). Attaining good visual results in unilate-ral cataract demands early surgery during thefirst two months, prompt aphakic correction,aggressive amblyopia treatment, and good com-pliance (2,4,12). None of the children with uni-lateral cataract in our series was operated be-fore the age of 2 months because of presenta-tion after that age in most of them. Further-more, we had to cope with significant varia-tions in age of surgery and compliance withtherapy, as were Lundvall and Kugelberg (19)who reported similar results. Treating unilate-ral cataract is a difficult decision that has to be

taken with full consent of the parents and inthe best interest of the baby (27). The neo-nates diagnosed with bilateral cataracts are op-erated as soon as possible with less than oneweek time between the two eyes. The best cor-rected visual acuity in the worse eye was 20/60 or more in 35.3% in those infants at a meanage of 6.5 years (range 21 to 114 months).This result is comparable to other reports con-cerning children with bilateral congenital cat-

aracts without co-morbidity (10,18,26). For ju-venile bilateral cataracts visual outcome is moresatisfactory. All those infants, who were prima-rily implanted with an IOL, attained a visual

acuity of more than 20/60 in the worse eye,moreover 54,5% attained a visual acuity of 20/25 or more in the worse eye, similar to otherreports (6,8,23). Primary IOL implantation inlate bilateral cataracts showed a higher inci-dence of visual acuity better than 20/63 com-pared to aphakic contact lens correction (17).At our department extended wear contact lens-es are used to correct aphakia in cases whereno IOL is implanted. In cases of contact lensintolerance we change the contact lenses foraphakic spectacles, followed by bifocal glass-es at the age of 3-3.5 year. Implanting IOLs in

children aged two years and older is now wide-ly accepted (28). Lambert and Lynn (16) re-ported that primary IOL implantation in casesof unilateral cataract surgery during the first sixmonths of life results in an improved visual out-come but a higher rate of complications requir-ing reoperation compared with children treat-ed with contact lenses. IOL implantation is nowalso accepted as a safe alternative for the treat-ment of bilateral cataracts under the age of 2years (23). However we still have to wait to seethe long-term effects of this management of bi-lateral congenital cataracts. In accordance withJoseph and Yair Morad (13) we would like to

stress the fact that contact lens use should con-tinue to receive serious consideration as treat-ment option for paediatric aphakia followingcataract surgery, especially in children young-er than 2 years old. In this group surgical com-plication rates following primary IOL implan-tation may be highest and refractive outcomesmost unpredictable because of rapid oculargrowth before this age (11).

Table 8: Final monocular visual acuity

Group < 20/400

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At our department infants with unilateral cata-

ract aged six months and older and childrenwith bilateral cataracts aged two years and old-er are always primary implanted with an IOL.Today we increasingly use primary IOL implan-tation in younger age groups from 6 months on-wards, depending on the axial length. There isa general agreement about the fact that prima-ry posterior capsulotomy with anterior vitrec-tomy is necessary to prevent or delay opacifi-cation of the visual axis in children (14,31). Inthe adult eye the influence of the IOL on theoccurrence of PCO is well recognized (7,22),with the newer Acrysoft foldable acrylic IOL(Alcon) resulting in a lower rate of PCO

(29,30,33). Ram and associates (25) conclud-ed that the management of the posterior cap-sule rather than IOL design and material influ-ences the incidence of PCO after cataract sur-gery in children. Postoperative uveitis can be aharbingerofcomplicationssuchascystoidmacu-lar oedema, synechia formation, glaucoma, PCOand sometimes corneal decompensation.Endophthalmitis following intraocular surgeryin children is not uncommon, a survey of over500 paediatric ophthalmologists suggested anincidence of 7 per 10 000 cases (32). We hadto cope with two cases of serious ocular inflam-

mation; both probably suture-related.Glaucoma is a well recognized sequela of con-genital cataract surgery, but there is still a lackof adequate information regarding its presen-tation, risk factors and management. The re-ported prevalence of postoperative glaucomavaries between 6% and 26% of eyes amongchildren operated before, as well as after 1 yearof age (20,21,26). The incidence of primaryopen angle glaucoma seems to be lower in old-er children undergoing primary IOL implanta-tion following cataract surgery (1) in contrastto infants undergoing similar surgery during thefirst 4 weeks of life (15,24,34).

CONCLUSION

Theoverallresultsofpatientswithpediatriccata-ract treated with primary IOL implantation arebetter compared to those left aphakic.Bilateral childhood cataracts without associat-ed ocular or systemic disease can attain func-tional visual results in case of early surgery with

attention to the posterior capsule and anterior

vitreous, immediate optical correction, inten-sive occlusion treatment and good compliance.A vision of 20/200 seems to be a realistic goalfor the group of patients with unilateral con-genital cataract, surgically treated without pri-mary IOL implantation at an average age of 15months, associated with variable and low com-pliance. Therefore, early surgery during the firsttwo months, prompt aphakic correction, ag-gressive amblyopia treatment, and good com-pliance are necessary to attain good visual re-sult in this group of patients. The decision totreat unilateral cataract is one that has to betaken with full consent of the parents and in

the best interest of the baby.Whether early surgery with primary IOL im-plantation and improvement of compliancestrategy improves the results on long term needsto be further investigated.

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Address for correspondence:P. CASAER, I. CASTEELS,Department of Ophthalmology,St Rafael UZ,Kapucijnenvoer 33,B-3000 Leuven, Belgium.Email: Ingele.Casteels@uz.kuleuven.ac.beTel: (0032)16/332660Fax: (0032)16/332367

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