LETTERS
postoperative inflammation in patients without a history of uveitis,1–3 there is not enough data about this subject in uveitic patients in the literature.4 In our opinion, very good visual results with a relatively low complication rate can be achieved after cataract surgery using perioperative subconjunctival steroid injection along with a systemic steroid in uveitic patients.5 We hope that the comments of Dr. Caglar and others help strengthen future prospective comparative studies of perioperative intracameral triamcinolone acetonide, subconjunctival steroid injection, and systemic steroid use in the treatment of inflammation after cataract surgery in uveitic patients.dMustafa Kosker, MD, Gulten Sungur, MD, Tuba Celik, MD, Nurten Unlu, MD, Saban Simsek, MD REFERENCES 1. Gills JP, Gills P. Effect of intracameral triamcinolone to control inflammation following cataract surgery. J Cataract Refract Surg 2005; 31:1670–1671 2. Cleary CA, Lanigan B, O’Keeffe M. Intracameral triamcinolone acetonide after pediatric cataract surgery. J Cataract Refract Surg 2010; 36:1676–1681 3. Dixit NV, Shah SK, Vasavada V, Vasavada VA, Praveen MR, Vasavada AR, Trivedi RH. Outcomes of cataract surgery and intraocular lens implantation with and without intracameral triamcinolone in pediatric eyes. J Cataract Refract Surg 2010; 36:1494–1498 4. Li J, Heinz C, Zurek-Imhoff B, Heiligenhaus A. Intraoperative intraocular triamcinolone injection prophylaxis for postcataract surgery fibrin formation in uveitis associated with juvenile idiopathic arthritis. J Cataract Refract Surg 2006; 32:1535– 1539 5. Kosker M, Sungur G, Celik T, Unlu N, Simsek S. Phacoemulsification with intraocular lens implantation in patients with anterior uveitis. J Cataract Refract Surg 2013; 39:1002–1007
Lateral canthotomy for femtosecond laser–assisted cataract surgery in infants After reading the article by Dick and Schultz.1 on performing femtosecond laser–assisted cataract surgery in infants, we have concerns regarding the need for lateral canthotomy, as well as the ethics review process that led to this research in the pediatric setting. The authors describe 4 cases of congenital cataract that had femtosecond laser–assisted cataract surgery with anterior and posterior capsulotomy. At least 1 of the cases required lateral canthotomy for application of the fluid-filled optical interface required to undergo laser docking,1 with the paper reading as though all cases required this: “cases 2 to 4 proceeded as per case 1.” A previous study by O'Keefe and Nolan2 also describes the use of lateral canthotomy in children having laser in situ keratomileusis. The paper by Dick et al.1 suggests that the femtosecond laser is a promising solution to address difficulty
167
obtaining optimal size, shape, and function of manual anterior and posterior capsulorhexes (considering the elastic nature of the pediatric capsular bag). Lateral canthotomy, however, is typically not necessary in any cataract surgery and should be avoided in children particularly. There is currently little available evidence on the risks, sequelae, or long-term complications of lateral canthotomy in infants, particularly as it is normally reserved as an emergency decompressive procedure performed for the management of orbital compartment syndrome.3 The majority of lateral canthotomies heal well without significant scarring.4 However, the canthal tendons play a critical functional role and assist in the growth of the palpebral fissure, which typically continues until puberty.5 The impact of a lateral canthotomy on these critical functional roles when the child reaches adulthood, especially older age, has not been determined. Potential problems of lateral canthotomy include risk for inadvertent structure damage in less experience hands, orbital cellulitis, orbital hemorrhage, peripalpebral scarring and phimosis, loss of aesthetics of the lateral canthus, and long-term structural lower-lid suspension problems. It is difficult to understand how an experimental procedure can be performed in an infant, particularly in the setting of requiring lateral canthotomy to proceed, irrespective of perceived capsulotomy benefits. There remains no supportive long-term evidence of significant benefit from femtosecond laser–assisted cataract surgery in adults. The short-term benefits demonstrated through reduced effective phacoemulsification time6,7 are less relevant in the pediatric setting in which lens material is typically aspirated without phacoemulsification energy. Furthermore, the absence of any study on the long-term sequelae of lateral canthotomy in infants makes the ethical approval process for the research presented more problematic. This is as research and treatment are different, with different objectives, procedures, and justifications as well as a different risk/benefit ratio, such that the goal of research can compete ethically with the care of participants.8 Likewise, an informed decision to participate in research has to come from a parent/guardian, can be more complex, and requires a greater level of competence and understanding.8 The risks may be greater in research or more uncertain because of the experimental context where the effectiveness and safety of femtosecond laser–assisted cataract surgery are not well known.8 There is insufficient information regarding the ethics review process in Dick and Schultz's1 submission. It seems improbable that, with sufficient information, an ethics board would approve experimental use of new technology in an infant, particularly where that experimental procedure requires an unnecessary and potentially harmful surgical procedure.
J CATARACT REFRACT SURG - VOL 40, JANUARY 2014
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LETTERS
Independent of ethical concerns of femtosecond laser–assisted cataract surgery in children, the use of lateral canthotomy to proceed with any cataract surgery raises additional clinical concerns to those outlined above. In a well-controlled population study, Ng et al.9 showed a more than 5-fold increased risk for post-cataract surgery endophthalmitis associated with concurrent eyelid surgery. This risk is potentially relevant to femtosecond laser–assisted cataract surgery in which lateral canthotomy has been performed. In addition to the pediatric setting, there are anecdotal reports of adults with small palpebral apertures (especially Asian eyes) requiring lateral canthotomy to proceed with femtosecond laser–assisted cataract surgery. While appropriate antibiotic prophylaxis in this setting remains paramount to decrease the risk for post-cataract surgery endophthalmitis,10 it remains important to avoid additional risks where possible. Regardless of risks, the technology should be reserved for patients in whom it will benefit the most while doing the least amount of harm. The development of a smaller interface may allow this technology to be available to a broader population of patients, but lateral canthotomy should be avoided until such a time, particularly while the safety and outcomes of femtosecond laser–assisted cataract surgery remain to be determined. Until such studies have been performed, an inability to dock with the current interface should be a contraindication to femtosecond laser–assisted cataract surgery rather than a “disadvantage” of the procedure. Robin G. Abell, MBBS Allister R. Howie, BMedSci Brendan J. Vote, FRANZCO Tasmania, Australia REFERENCES 1. Dick HB, Schultz T. Femtosecond laser–assisted cataract surgery in infants. J Cataract Refract Surg 2013; 39: 665–668 2. O’Keefe M, Nolan L. LASIK surgery in children. Br J Ophthalmol 2004; 88:19–21. Available at: http://www.ncbi.nlm.nih.gov/pmc/ articles/PMC1771964/pdf/bjo08800019.pdf. Accessed October 9, 2013 3. McClenaghan FC, Ezra DG, Holmes SB. Mechanisms ad management of vision loss following orbital and facial trauma. Curr Opin Ophthalmol 2011; 22:426–431 4. Knoop K, Trott A. Ophthalmologic procedures in the emergency departmentdpart I: immediate sight-saving procedures. Acad Emer Med 1994; 1:408–412 5. Krastinova D, Kelly MB, Mihaylova M. Surgical management of the anophthalmic orbit, part 1: congenital. Plast Reconstr Surg 2001; 108:817–826 6. Abell RG, Kerr NM, Vote BJ. Toward zero effective phacoemulsification time using femtosecond laser pretreatment. Ophthalmology 2013; 120:942–948 7. Abell RG, Allen PL, Vote BJ. Anterior chamber flare after femtosecond laser–assisted cataract surgery. J Cataract Refract Surg 2013; 39:1321–1326
8. Spriggs M. Understanding Consent in Research Involving Children: the ethical issues; a Handbook for Human Research Ethics Committees and Researchers. Available at: http://www.mcri.edu. au/media/62539/handbook.pdf. Accessed October 9, 2013 9. Ng JQ, Morlet N, Bulsara MK, Semmens JB. Reducing the risk for endophthalmitis after cataract surgery: population-based nested case-control study; Endophthalmitis Population Study of Western Australia sixth report. J Cataract Refract Surg 2007; 33:269–280 10. Shorstein NH, Wintrhop KL, Herrinton LJ. Decreased postoperative endophthalmitis rate after institution of intracameral antibiotics in a northern California eye department. J Cataract Refract Surg 2013; 39:8–14
Reply : In their letter to the editor, Drs. Abell, Howie, and Vote provide a valuable contribution to an exciting emerging field of ophthalmic surgery. The number of children having surgery for congenital or juvenile cataract is small, and the number of cataract surgeons striving to preserve these children's vision and protecting them from amblyopia is even smaller. We appreciate any stimulus to a discussion about cataract surgery in infants even though the contribution does not seem to be backed up by sufficient resilient scientific clinical trials. It is probably worthwhile to reflect on the ethical and legal situation ophthalmologists (surgical as well as conservative) find themselves in when treating children. Most interventions are off-label; they have been developed for adult patients, and their safety and efficacy have been evaluated in adult patients. This holds true not only for surgical interventions like vitrectomy, antiglaucomatous operations, and, yes, the removal of a congenital cataract, but also for a number of medical treatments. Which intraocular pressure-lowering medication and which antibiotics have been expressively approved by the regulatory bodies for 1 year olds? Endophthalmitis is without doubt the worst-case scenario that every cataract surgeon fears for good reason. We cannot, however, compare apples and oranges when discussing this serious matter. The cited study of Ng et al.1 was based on operations dating as far back as 1980, which means intracapsular cataract extractions (5.9%) and extracapsular cataract extractions (38.5%) using a broad superior corneal incision and a high rate of posterior capsule breach (7.8% to 8.8%). The authors claim (and prove statistically) that eyelid procedures performed at the same time as cataract surgery considerably improved the risk (odds ratio Z 5.66) for endophthalmitis. Among the interventions mentioned in this paper (on which Abell, Howie and Vote base their warning of a potential endophthalmitis risk in femtosecond laser–assisted cataract surgery performed in infants) are 2 ectropion repairs, 1 blepharoplasty, and 1 chalazion incision by curettage. The latter is striking: An eyelid disease defined as a conglomeration of germs in an infected
J CATARACT REFRACT SURG - VOL 40, JANUARY 2014
postoperative inflammation in patients without a history of uveitis,1–3 there is not enough data about this subject in uveitic patients in the literature.4 In our opinion, very good visual results with a relatively low complication rate can be achieved after cataract surgery using perioperative subconjunctival steroid injection along with a systemic steroid in uveitic patients.5 We hope that the comments of Dr. Caglar and others help strengthen future prospective comparative studies of perioperative intracameral triamcinolone acetonide, subconjunctival steroid injection, and systemic steroid use in the treatment of inflammation after cataract surgery in uveitic patients.dMustafa Kosker, MD, Gulten Sungur, MD, Tuba Celik, MD, Nurten Unlu, MD, Saban Simsek, MD REFERENCES 1. Gills JP, Gills P. Effect of intracameral triamcinolone to control inflammation following cataract surgery. J Cataract Refract Surg 2005; 31:1670–1671 2. Cleary CA, Lanigan B, O’Keeffe M. Intracameral triamcinolone acetonide after pediatric cataract surgery. J Cataract Refract Surg 2010; 36:1676–1681 3. Dixit NV, Shah SK, Vasavada V, Vasavada VA, Praveen MR, Vasavada AR, Trivedi RH. Outcomes of cataract surgery and intraocular lens implantation with and without intracameral triamcinolone in pediatric eyes. J Cataract Refract Surg 2010; 36:1494–1498 4. Li J, Heinz C, Zurek-Imhoff B, Heiligenhaus A. Intraoperative intraocular triamcinolone injection prophylaxis for postcataract surgery fibrin formation in uveitis associated with juvenile idiopathic arthritis. J Cataract Refract Surg 2006; 32:1535– 1539 5. Kosker M, Sungur G, Celik T, Unlu N, Simsek S. Phacoemulsification with intraocular lens implantation in patients with anterior uveitis. J Cataract Refract Surg 2013; 39:1002–1007
Lateral canthotomy for femtosecond laser–assisted cataract surgery in infants After reading the article by Dick and Schultz.1 on performing femtosecond laser–assisted cataract surgery in infants, we have concerns regarding the need for lateral canthotomy, as well as the ethics review process that led to this research in the pediatric setting. The authors describe 4 cases of congenital cataract that had femtosecond laser–assisted cataract surgery with anterior and posterior capsulotomy. At least 1 of the cases required lateral canthotomy for application of the fluid-filled optical interface required to undergo laser docking,1 with the paper reading as though all cases required this: “cases 2 to 4 proceeded as per case 1.” A previous study by O'Keefe and Nolan2 also describes the use of lateral canthotomy in children having laser in situ keratomileusis. The paper by Dick et al.1 suggests that the femtosecond laser is a promising solution to address difficulty
167
obtaining optimal size, shape, and function of manual anterior and posterior capsulorhexes (considering the elastic nature of the pediatric capsular bag). Lateral canthotomy, however, is typically not necessary in any cataract surgery and should be avoided in children particularly. There is currently little available evidence on the risks, sequelae, or long-term complications of lateral canthotomy in infants, particularly as it is normally reserved as an emergency decompressive procedure performed for the management of orbital compartment syndrome.3 The majority of lateral canthotomies heal well without significant scarring.4 However, the canthal tendons play a critical functional role and assist in the growth of the palpebral fissure, which typically continues until puberty.5 The impact of a lateral canthotomy on these critical functional roles when the child reaches adulthood, especially older age, has not been determined. Potential problems of lateral canthotomy include risk for inadvertent structure damage in less experience hands, orbital cellulitis, orbital hemorrhage, peripalpebral scarring and phimosis, loss of aesthetics of the lateral canthus, and long-term structural lower-lid suspension problems. It is difficult to understand how an experimental procedure can be performed in an infant, particularly in the setting of requiring lateral canthotomy to proceed, irrespective of perceived capsulotomy benefits. There remains no supportive long-term evidence of significant benefit from femtosecond laser–assisted cataract surgery in adults. The short-term benefits demonstrated through reduced effective phacoemulsification time6,7 are less relevant in the pediatric setting in which lens material is typically aspirated without phacoemulsification energy. Furthermore, the absence of any study on the long-term sequelae of lateral canthotomy in infants makes the ethical approval process for the research presented more problematic. This is as research and treatment are different, with different objectives, procedures, and justifications as well as a different risk/benefit ratio, such that the goal of research can compete ethically with the care of participants.8 Likewise, an informed decision to participate in research has to come from a parent/guardian, can be more complex, and requires a greater level of competence and understanding.8 The risks may be greater in research or more uncertain because of the experimental context where the effectiveness and safety of femtosecond laser–assisted cataract surgery are not well known.8 There is insufficient information regarding the ethics review process in Dick and Schultz's1 submission. It seems improbable that, with sufficient information, an ethics board would approve experimental use of new technology in an infant, particularly where that experimental procedure requires an unnecessary and potentially harmful surgical procedure.
J CATARACT REFRACT SURG - VOL 40, JANUARY 2014
168
LETTERS
Independent of ethical concerns of femtosecond laser–assisted cataract surgery in children, the use of lateral canthotomy to proceed with any cataract surgery raises additional clinical concerns to those outlined above. In a well-controlled population study, Ng et al.9 showed a more than 5-fold increased risk for post-cataract surgery endophthalmitis associated with concurrent eyelid surgery. This risk is potentially relevant to femtosecond laser–assisted cataract surgery in which lateral canthotomy has been performed. In addition to the pediatric setting, there are anecdotal reports of adults with small palpebral apertures (especially Asian eyes) requiring lateral canthotomy to proceed with femtosecond laser–assisted cataract surgery. While appropriate antibiotic prophylaxis in this setting remains paramount to decrease the risk for post-cataract surgery endophthalmitis,10 it remains important to avoid additional risks where possible. Regardless of risks, the technology should be reserved for patients in whom it will benefit the most while doing the least amount of harm. The development of a smaller interface may allow this technology to be available to a broader population of patients, but lateral canthotomy should be avoided until such a time, particularly while the safety and outcomes of femtosecond laser–assisted cataract surgery remain to be determined. Until such studies have been performed, an inability to dock with the current interface should be a contraindication to femtosecond laser–assisted cataract surgery rather than a “disadvantage” of the procedure. Robin G. Abell, MBBS Allister R. Howie, BMedSci Brendan J. Vote, FRANZCO Tasmania, Australia REFERENCES 1. Dick HB, Schultz T. Femtosecond laser–assisted cataract surgery in infants. J Cataract Refract Surg 2013; 39: 665–668 2. O’Keefe M, Nolan L. LASIK surgery in children. Br J Ophthalmol 2004; 88:19–21. Available at: http://www.ncbi.nlm.nih.gov/pmc/ articles/PMC1771964/pdf/bjo08800019.pdf. Accessed October 9, 2013 3. McClenaghan FC, Ezra DG, Holmes SB. Mechanisms ad management of vision loss following orbital and facial trauma. Curr Opin Ophthalmol 2011; 22:426–431 4. Knoop K, Trott A. Ophthalmologic procedures in the emergency departmentdpart I: immediate sight-saving procedures. Acad Emer Med 1994; 1:408–412 5. Krastinova D, Kelly MB, Mihaylova M. Surgical management of the anophthalmic orbit, part 1: congenital. Plast Reconstr Surg 2001; 108:817–826 6. Abell RG, Kerr NM, Vote BJ. Toward zero effective phacoemulsification time using femtosecond laser pretreatment. Ophthalmology 2013; 120:942–948 7. Abell RG, Allen PL, Vote BJ. Anterior chamber flare after femtosecond laser–assisted cataract surgery. J Cataract Refract Surg 2013; 39:1321–1326
8. Spriggs M. Understanding Consent in Research Involving Children: the ethical issues; a Handbook for Human Research Ethics Committees and Researchers. Available at: http://www.mcri.edu. au/media/62539/handbook.pdf. Accessed October 9, 2013 9. Ng JQ, Morlet N, Bulsara MK, Semmens JB. Reducing the risk for endophthalmitis after cataract surgery: population-based nested case-control study; Endophthalmitis Population Study of Western Australia sixth report. J Cataract Refract Surg 2007; 33:269–280 10. Shorstein NH, Wintrhop KL, Herrinton LJ. Decreased postoperative endophthalmitis rate after institution of intracameral antibiotics in a northern California eye department. J Cataract Refract Surg 2013; 39:8–14
Reply : In their letter to the editor, Drs. Abell, Howie, and Vote provide a valuable contribution to an exciting emerging field of ophthalmic surgery. The number of children having surgery for congenital or juvenile cataract is small, and the number of cataract surgeons striving to preserve these children's vision and protecting them from amblyopia is even smaller. We appreciate any stimulus to a discussion about cataract surgery in infants even though the contribution does not seem to be backed up by sufficient resilient scientific clinical trials. It is probably worthwhile to reflect on the ethical and legal situation ophthalmologists (surgical as well as conservative) find themselves in when treating children. Most interventions are off-label; they have been developed for adult patients, and their safety and efficacy have been evaluated in adult patients. This holds true not only for surgical interventions like vitrectomy, antiglaucomatous operations, and, yes, the removal of a congenital cataract, but also for a number of medical treatments. Which intraocular pressure-lowering medication and which antibiotics have been expressively approved by the regulatory bodies for 1 year olds? Endophthalmitis is without doubt the worst-case scenario that every cataract surgeon fears for good reason. We cannot, however, compare apples and oranges when discussing this serious matter. The cited study of Ng et al.1 was based on operations dating as far back as 1980, which means intracapsular cataract extractions (5.9%) and extracapsular cataract extractions (38.5%) using a broad superior corneal incision and a high rate of posterior capsule breach (7.8% to 8.8%). The authors claim (and prove statistically) that eyelid procedures performed at the same time as cataract surgery considerably improved the risk (odds ratio Z 5.66) for endophthalmitis. Among the interventions mentioned in this paper (on which Abell, Howie and Vote base their warning of a potential endophthalmitis risk in femtosecond laser–assisted cataract surgery performed in infants) are 2 ectropion repairs, 1 blepharoplasty, and 1 chalazion incision by curettage. The latter is striking: An eyelid disease defined as a conglomeration of germs in an infected
J CATARACT REFRACT SURG - VOL 40, JANUARY 2014
