Proc. roy. Soc.' Med. Volume 69 April 1976
6
and clinical examination and from which various clues for the laboratory may arise. The recent development in our appreciation of the importance of galactose metabolism certainly encourages the view that detailed clinical and biochemical assessment in cataract may be more useful than is commonly supposed.
Surgery of the Lens (1) Timing of surgery: For cases in which the lens is totally opaque, there is no doubt that surgery should be undertaken as soon as it is technically feasible and this is usually at the age of about 3 months. For cases in which the lens is not completely opaque, the timing of surgery must rest upon the surgeon's judgment of the likely effect of the cataract on vision. Some children require early surgery, while in others, particularly those with lamellar cataract, surgery of the lens can be delayed until the demands of education make it necessary. The presence or absence of nystagmus can be a useful guide. (2) Bilateral surgery: In those cases in which cataract is present in both eyes and in which the decision to embark on surgery of the lens has been taken, it is essential to plan to operate on both eyes. To do otherwise is to subject the child to problems of uniocular aphakia. (3) Surgical techniques: There is universal acceptance of the principle that some form of extracapsular procedure must be used for the eyes of children. The classical methods of simple discission and linear extraction, although giving good results in many cases, are associated with significant complications: for example, thick residual membranes; uveitis and secondary glaucoma; vitreous loss. The introduction of lens aspiration has resulted in a substantial improvement in the surgical prognosis for surgery of the. lens in children.
272
REFERENCES Brown C A (1963) Transactions ofthe Ophthal'nological Society of the United Kingdom 83, 493 Buckingham R H & Pirie A (1972) Experimental Eye Research 14, 297 Chatterjee A (1973) In: The Human Lens in Relation to Cataract. Ciba Foundation Symposium 19. Elsevier/ Excerpta Medica/North-Holland; p 265 Harley J D & Herzberg R (1965) Lancet i, 1084 Harley J D, Irvine S, Mutton P & Gupta J D (1974) Lancet ii, 259 Harris J E & Becker B (1965) Investigative Ophthalmology 4, 709 Hull D (1969) Proceedings of the Royal Society of Medicine 62, 694 Kinoshita J H (1974) Investigative Ophthalnmology 13, 713 Levy M S, Krill A E & Beutler E (1972) American Journal of Ophthalmology 74, 41 Merin S & Crawford JD (1971) Archives of Ophthalmology 86,495 Nordmann J (1966) American Journal ofOphthalmology 61, 1256 O'Connor C P & Crawford J D (1967) Clinical Pediatrics (Philadelphia) 6, 94 Other A (1968) Acta ophthalmologica (Copenhagen) 46, 404 Philipson B T & Fagerholm P P (1973) In: The Human Lens in Relation to Cataract. Ciba Foundation Symposium 19. Elsevier/Excerpta Medica/North-Holland; p 45 Pirie A (1973) In: The Human Lens in Relation to Cataract. Ciba Foundation Symposium 19. Elsevier/ Excerpta Medica/North-Holland; p 298 Pirie A & Van Heyningen R (1964) Experimental Eye Research 3, 124 Presley G D & Sidbury J B (1967) American Journal ofOphthalmology 63, 1723 Schwartz V (I975) Biochemical Society Transactions 3, 234 von Bahr G (1940) Acta ophthalmologica (Copenhagen) 18, 170 (1963) Transactions of the Ophthalmological Society of the United Kingdom 83, 503
Mr N S C Rice (Institute ofOphthalmology, Judd Street, London WCJH 9QS)
The Surgery of Cataracts in Children
Mydriasis The production of a large pupil in cases in which the opacity is in the central part of the lens might seem to be a useful method of improving vision; such mydriasis can be achieved by topical application of a mydriatic drug or by a sector iridectomy. However, the result in most- cases is disappointing and these methods of treatment seem to be indicated rather rarely. An exception is the severely retarded child who also has cataract, and in whom sector iridectomy has been described as a useful method of treatment (Cant et al. 1974).
Technique ofLens Aspiration (1) Pre-operative management: It is essential that the pupil is widely dilated at the time of surgery and to achieve this gutte atropine 1 % should be instilled three times a day on the day before surgery and on the day of surgery. Immediately before surgery, gutta cyclopentolate 1 % can also be instilled. Gutte phenylephrine should be used only with care in young infants, because of its systemic effects. If satisfactory mydriasis cannot be achieved, a sector iridectomy should be performed. This is frequently necessary in cases of congenital rubella. It can be done at the same time as the lens aspiration or as a preliminary procedure. (2) A surgical microscope should be used if possible; it adds greatly to the precision and control with which this operation can be performed. (3) The eye is fixed with sutures through the superior and inferior rectus muscles and clamped to the head towels. (4) A limbal puncture is made at 6 or 12 o'clock, using a discission knife-needle (Fig 1). Into this opening is passed the bevelled end of a silicone rubber tube of outside diameter 0.025 inches (0.64 mm), so that the end is just within the
273
7
Section ofOphthalmology
Fig 1 Limbalparacentesis at 12 o'clock
Fig 3 Anterior capsulotomy
Fig 2 Insertion ofsilicone rubber tube through paracentesis
Fig 4 Aspirating cannula passed into suibstance of lens and aspiration in progress
anterior chamber (Fig 2); the tube is fixed to the eye with a 7/0 silk suture passed through the limbus behind the tube and tied around it. The silicone rubber tube is connected to a 5 ml syringe containing Ringer's solution; this is held by the assistant, who is thus able to keep the anterior chamber full of fluid. If an assistant is not available, the silicone rubber tube should be connected to an infusion bottle, which is suspended about 3 ft (1 m) above the patient's eye. (5) The discission knife-needle is passed through the limbus at 3 o'clock in the left eye and 9 o'clock in the right eye and an anterior capsulotomy is performed (Fig 3). Care must be taken not to interfere with the attachment of the fibres of the suspensory ligament on to the anterior surface of the periphery of the lens. (6) After withdrawal of the discission knife-needle an aspirating cannula, mounted on a 2 ml syringe (Gillette) is passed into the anterior chamber through the same limbal wound (Fig 4). Its tip is passed into the lens and the contents of the lens aspirated by suction. Care must be taken not to injure the posterior capsule and in this respect the surgical microscope is of great value. Suitable
Fig 5 Lens aspiration completed cannulas can be constructed from hypodermic needles by blunting the points and shortening the bevels. Convenient sizes to have available are gauges 17,12 and 1. (7) When the lens aspiration is completed, the cannula and silicone rubber tube are withdrawn (Fig 5). It is sometimes necessary to pass sutures of 7/0 catgut or 8/0 virgin silk superfic*lly
274
Proc. roy. Soc. Med. Volume 69 April 1976
through these wounds to prevent leakage of aqueous. (8) The postoperative management is usually uncomplicated and all that is required in most cases is gutte atropine 1 % once a day for 4-6 weeks. Posterior Capsulotomy Most eyes which have undergone a technically satisfactory lens aspiration require posterior capsulotomy within about a year. For this reason, a good case can be made for performing posterior capsulotomy routinely. It can be done conveniently at the same time as the cataract in the second eye is aspirated. The capsule is thin and a small central gap can be created without much manipulation and without herniation of vitreous into the anterior chamber. Under the third general
anesthetic, required for posterior capsulotomy of the second eye, the child should be refracted. Correction ofAphakia This remains one of the most taxing problems in the treatment of cataract in children. Spectacles offer the simplest solution, but there is considerable variation in the age at which children will accept them. Contact lenses offer better optical correction, but the management of both hard and soft lenses poses difficult problems, particularly for the parents. In the present state of our knowledge, the insertion of intraocular lens implants in infants' eyes would not seem to be justified. Refractive keratoplasty appears to offer a very satisfactory solution to the problem, but the technique is still in its infancy and requires a very sophisticated surgical technique. REFERENCE Cant J S, Rennie A G R, Dudgeon J & Foulds W S (1974) Transactions ofthe Ophthalmological Society oJ the United Kingdom 94, 291
8 Meeting 14 November 1974
The following papers were read: Retinal Nerve Fibre Atrophy and Demyelinating Disease Mr P E Cleary and Miss E S Gould (Moorfields Eye Hospital, London WCJ) Trabeculectomy Combined with Cataract Extraction Mr A 0 S M Harun (Birmingham and Midland Eye Hospital, Birmingham 3) The Lipids of Corneal Arcus Mr A R Fielder (Institute of Ophthalmology, London WC1) Relation between Pco2 and Intraocular Pressure Mr Malcolm LeMay (Western Infirmary, Glasgow) Immunosuppressives in Uveitis Mr W J Dinning (Institute of Ophthalmology, London WCJ) Meeting 12 December 1974
The following papers were read on The History of Ophthalmology:
History of Spectacles Mr G T Willoughby Cashell (Reading) Fistula Lacrimalis: Surgeons and Surgery Mr J Winstanley (St Thomas's Hospital, London SE]) The Order of St John of Jerusalem Dr Lionel Butler (Royal Holloway College, Egham, Surrey) History of Surgical Ophthalmology Mr J Stanley Cant (Tennent Institute of Ophthalmology, University of Glasgow) Meeting 9 January 1975
Meeting 10 October 1974
The following papers were read on The Future of Ophthalmology: An Ophthalmic Service for the Future Mr E C Zorab (Eye Hospital, Southampton, S09 4XW) The Training of an Eye Surgeon Mr A G Cross (Institute of Ophthalmology, London WClH9QS) Ophthalmology and the EEC Mr J R Hudson (Moorfields Eye Hospital, London WC1)
The following papers were read on Management of the Patient for Surgery: The London Surgeon's Approach Mr A D McG Steele (Moorfields Eye Hospital, London EC] V2PD) The Physician's Approach Dr A G Beckett (Royal Free Hospital, London NW3) The Nursing Sister's Approach Miss Shirley Guest (Royal Eye Infirmary, Plymouth, PL4 6PL) The Country Surgeon's Approach, Mr G J Romanes (Royal Eye Infirmary, Weymouth, Dorset)
6
and clinical examination and from which various clues for the laboratory may arise. The recent development in our appreciation of the importance of galactose metabolism certainly encourages the view that detailed clinical and biochemical assessment in cataract may be more useful than is commonly supposed.
Surgery of the Lens (1) Timing of surgery: For cases in which the lens is totally opaque, there is no doubt that surgery should be undertaken as soon as it is technically feasible and this is usually at the age of about 3 months. For cases in which the lens is not completely opaque, the timing of surgery must rest upon the surgeon's judgment of the likely effect of the cataract on vision. Some children require early surgery, while in others, particularly those with lamellar cataract, surgery of the lens can be delayed until the demands of education make it necessary. The presence or absence of nystagmus can be a useful guide. (2) Bilateral surgery: In those cases in which cataract is present in both eyes and in which the decision to embark on surgery of the lens has been taken, it is essential to plan to operate on both eyes. To do otherwise is to subject the child to problems of uniocular aphakia. (3) Surgical techniques: There is universal acceptance of the principle that some form of extracapsular procedure must be used for the eyes of children. The classical methods of simple discission and linear extraction, although giving good results in many cases, are associated with significant complications: for example, thick residual membranes; uveitis and secondary glaucoma; vitreous loss. The introduction of lens aspiration has resulted in a substantial improvement in the surgical prognosis for surgery of the. lens in children.
272
REFERENCES Brown C A (1963) Transactions ofthe Ophthal'nological Society of the United Kingdom 83, 493 Buckingham R H & Pirie A (1972) Experimental Eye Research 14, 297 Chatterjee A (1973) In: The Human Lens in Relation to Cataract. Ciba Foundation Symposium 19. Elsevier/ Excerpta Medica/North-Holland; p 265 Harley J D & Herzberg R (1965) Lancet i, 1084 Harley J D, Irvine S, Mutton P & Gupta J D (1974) Lancet ii, 259 Harris J E & Becker B (1965) Investigative Ophthalmology 4, 709 Hull D (1969) Proceedings of the Royal Society of Medicine 62, 694 Kinoshita J H (1974) Investigative Ophthalnmology 13, 713 Levy M S, Krill A E & Beutler E (1972) American Journal of Ophthalmology 74, 41 Merin S & Crawford JD (1971) Archives of Ophthalmology 86,495 Nordmann J (1966) American Journal ofOphthalmology 61, 1256 O'Connor C P & Crawford J D (1967) Clinical Pediatrics (Philadelphia) 6, 94 Other A (1968) Acta ophthalmologica (Copenhagen) 46, 404 Philipson B T & Fagerholm P P (1973) In: The Human Lens in Relation to Cataract. Ciba Foundation Symposium 19. Elsevier/Excerpta Medica/North-Holland; p 45 Pirie A (1973) In: The Human Lens in Relation to Cataract. Ciba Foundation Symposium 19. Elsevier/ Excerpta Medica/North-Holland; p 298 Pirie A & Van Heyningen R (1964) Experimental Eye Research 3, 124 Presley G D & Sidbury J B (1967) American Journal ofOphthalmology 63, 1723 Schwartz V (I975) Biochemical Society Transactions 3, 234 von Bahr G (1940) Acta ophthalmologica (Copenhagen) 18, 170 (1963) Transactions of the Ophthalmological Society of the United Kingdom 83, 503
Mr N S C Rice (Institute ofOphthalmology, Judd Street, London WCJH 9QS)
The Surgery of Cataracts in Children
Mydriasis The production of a large pupil in cases in which the opacity is in the central part of the lens might seem to be a useful method of improving vision; such mydriasis can be achieved by topical application of a mydriatic drug or by a sector iridectomy. However, the result in most- cases is disappointing and these methods of treatment seem to be indicated rather rarely. An exception is the severely retarded child who also has cataract, and in whom sector iridectomy has been described as a useful method of treatment (Cant et al. 1974).
Technique ofLens Aspiration (1) Pre-operative management: It is essential that the pupil is widely dilated at the time of surgery and to achieve this gutte atropine 1 % should be instilled three times a day on the day before surgery and on the day of surgery. Immediately before surgery, gutta cyclopentolate 1 % can also be instilled. Gutte phenylephrine should be used only with care in young infants, because of its systemic effects. If satisfactory mydriasis cannot be achieved, a sector iridectomy should be performed. This is frequently necessary in cases of congenital rubella. It can be done at the same time as the lens aspiration or as a preliminary procedure. (2) A surgical microscope should be used if possible; it adds greatly to the precision and control with which this operation can be performed. (3) The eye is fixed with sutures through the superior and inferior rectus muscles and clamped to the head towels. (4) A limbal puncture is made at 6 or 12 o'clock, using a discission knife-needle (Fig 1). Into this opening is passed the bevelled end of a silicone rubber tube of outside diameter 0.025 inches (0.64 mm), so that the end is just within the
273
7
Section ofOphthalmology
Fig 1 Limbalparacentesis at 12 o'clock
Fig 3 Anterior capsulotomy
Fig 2 Insertion ofsilicone rubber tube through paracentesis
Fig 4 Aspirating cannula passed into suibstance of lens and aspiration in progress
anterior chamber (Fig 2); the tube is fixed to the eye with a 7/0 silk suture passed through the limbus behind the tube and tied around it. The silicone rubber tube is connected to a 5 ml syringe containing Ringer's solution; this is held by the assistant, who is thus able to keep the anterior chamber full of fluid. If an assistant is not available, the silicone rubber tube should be connected to an infusion bottle, which is suspended about 3 ft (1 m) above the patient's eye. (5) The discission knife-needle is passed through the limbus at 3 o'clock in the left eye and 9 o'clock in the right eye and an anterior capsulotomy is performed (Fig 3). Care must be taken not to interfere with the attachment of the fibres of the suspensory ligament on to the anterior surface of the periphery of the lens. (6) After withdrawal of the discission knife-needle an aspirating cannula, mounted on a 2 ml syringe (Gillette) is passed into the anterior chamber through the same limbal wound (Fig 4). Its tip is passed into the lens and the contents of the lens aspirated by suction. Care must be taken not to injure the posterior capsule and in this respect the surgical microscope is of great value. Suitable
Fig 5 Lens aspiration completed cannulas can be constructed from hypodermic needles by blunting the points and shortening the bevels. Convenient sizes to have available are gauges 17,12 and 1. (7) When the lens aspiration is completed, the cannula and silicone rubber tube are withdrawn (Fig 5). It is sometimes necessary to pass sutures of 7/0 catgut or 8/0 virgin silk superfic*lly
274
Proc. roy. Soc. Med. Volume 69 April 1976
through these wounds to prevent leakage of aqueous. (8) The postoperative management is usually uncomplicated and all that is required in most cases is gutte atropine 1 % once a day for 4-6 weeks. Posterior Capsulotomy Most eyes which have undergone a technically satisfactory lens aspiration require posterior capsulotomy within about a year. For this reason, a good case can be made for performing posterior capsulotomy routinely. It can be done conveniently at the same time as the cataract in the second eye is aspirated. The capsule is thin and a small central gap can be created without much manipulation and without herniation of vitreous into the anterior chamber. Under the third general
anesthetic, required for posterior capsulotomy of the second eye, the child should be refracted. Correction ofAphakia This remains one of the most taxing problems in the treatment of cataract in children. Spectacles offer the simplest solution, but there is considerable variation in the age at which children will accept them. Contact lenses offer better optical correction, but the management of both hard and soft lenses poses difficult problems, particularly for the parents. In the present state of our knowledge, the insertion of intraocular lens implants in infants' eyes would not seem to be justified. Refractive keratoplasty appears to offer a very satisfactory solution to the problem, but the technique is still in its infancy and requires a very sophisticated surgical technique. REFERENCE Cant J S, Rennie A G R, Dudgeon J & Foulds W S (1974) Transactions ofthe Ophthalmological Society oJ the United Kingdom 94, 291
8 Meeting 14 November 1974
The following papers were read: Retinal Nerve Fibre Atrophy and Demyelinating Disease Mr P E Cleary and Miss E S Gould (Moorfields Eye Hospital, London WCJ) Trabeculectomy Combined with Cataract Extraction Mr A 0 S M Harun (Birmingham and Midland Eye Hospital, Birmingham 3) The Lipids of Corneal Arcus Mr A R Fielder (Institute of Ophthalmology, London WC1) Relation between Pco2 and Intraocular Pressure Mr Malcolm LeMay (Western Infirmary, Glasgow) Immunosuppressives in Uveitis Mr W J Dinning (Institute of Ophthalmology, London WCJ) Meeting 12 December 1974
The following papers were read on The History of Ophthalmology:
History of Spectacles Mr G T Willoughby Cashell (Reading) Fistula Lacrimalis: Surgeons and Surgery Mr J Winstanley (St Thomas's Hospital, London SE]) The Order of St John of Jerusalem Dr Lionel Butler (Royal Holloway College, Egham, Surrey) History of Surgical Ophthalmology Mr J Stanley Cant (Tennent Institute of Ophthalmology, University of Glasgow) Meeting 9 January 1975
Meeting 10 October 1974
The following papers were read on The Future of Ophthalmology: An Ophthalmic Service for the Future Mr E C Zorab (Eye Hospital, Southampton, S09 4XW) The Training of an Eye Surgeon Mr A G Cross (Institute of Ophthalmology, London WClH9QS) Ophthalmology and the EEC Mr J R Hudson (Moorfields Eye Hospital, London WC1)
The following papers were read on Management of the Patient for Surgery: The London Surgeon's Approach Mr A D McG Steele (Moorfields Eye Hospital, London EC] V2PD) The Physician's Approach Dr A G Beckett (Royal Free Hospital, London NW3) The Nursing Sister's Approach Miss Shirley Guest (Royal Eye Infirmary, Plymouth, PL4 6PL) The Country Surgeon's Approach, Mr G J Romanes (Royal Eye Infirmary, Weymouth, Dorset)
