Glaucoma after Pediatric LensectomyjVitrectomy JOHN w. SIMON, MD,t NALIN MEHTA, MD,t STEVEN T. SIMMONS, MD,t ROBERT A. CATALANO, MD,t LLOYD L. LININGER, PhD2
Abstract: Glaucoma after pediatric cataract surgery, once well recognized, now occurs only rarely after modern lensectorny/vitrectomy. The authors performed directed glaucoma evaluations of 34 eyes of 26 children. Based on intraocular pressures of 26 mmHg or greater, glaucoma was diagnosed in 8 (24%) eyes of 7 (27%) children. Glaucoma was found more commonly among children followed more than 60 months and was diagnosed up to 105 months after surgery. Typically, the glaucoma was open angle and asymptomatic. Four children had had previously normal pressures recorded. With longer follow-up, it is likely that more children will be diagnosed with glaucoma after lensectomy / vitrectomy procedures. The authors believe such patients should be followed as glaucoma suspects for the rest of their lives. Ophthalmology 1991; 98:670-674
For many years, late glaucoma has been recognized as a common problem after surgery for pediatric cataract.l'" In a review of 15 studies of pediatric aphakia performed between 1943 and 1975, Francois' found an average incidence ofglaucoma of 5.5%, with some authors reporting an incidence of 13 to 16%. Often, glaucoma is not recognized until years after cataract removal. During the late 1970s, microscopically controlled, automated lensectomy/vitrectomy gradually replaced oneand two-staged needling as a method of pediatric cataract extraction.' Lensectomy/vitrectomy remains the most commonly used technique today." It was hoped that by removing lens and capsular remnants more effectively, such surgery would minimize postoperative inflammation and pupillary block and would decrease the incidence of glaucoma. 3,5-7
In fact, initial reports have been encouraging. Parks" found no cases of chronic glaucoma among 99 eyes operated on with the Ocutome. Whereas Chrousos and associates' found a 6.1% incidence ofglaucoma after various other surgical techniques, no cases were apparent among 54 eyes operated on with the Ocutome. In a longer follow-up study that was undertaken recently, Keech and associates" found an 11% incidence of glaucoma after lensectomy/vitrectomy, During the past 2 years, we encountered several children with late glaucoma after lensectomy/vitrectomy, Because most had no specific symptoms to suggest glaucoma, we were prompted to call in other pediatric patients with aphakia for a directed glaucoma evaluation.
PATIENTS AND METHODS Originally received: November 5, 1990. Revision accepted: January 9, 1991. 1
2
Department of Ophthalmology, Albany Medical College, Albany. Department of Biometry and Statistics, State University of New York, Albany.
Supported in part by training grant EY0703702 and research grant EY05816 from the National Institutes of Health, National Eye Institute, Bethesda, Maryland, to the Albany Medical College Department of Ophthalmology, and by an unrestricted grant from Research to Prevent Blindness, Inc, New York, New York. Reprint requests to John W. Simon, MD, Albany Medical College, Department of Ophthalmology, Albany, NY 12208.
670
The families of 42 consecutive children who underwent cataract surgery (before the age of 11 years) at the Albany Medical Center between 1981 and 1987 were contacted by mail. A letter was sent in which we expressed our concern that these children might be at risk ofglaucoma and suggested that these children return for examination. The 26 patients (34 eyes) that we studied ranged in age from 1 week to 127 months (x = 26 months) at the time of surgery and from 17 to 134 months (x = 83.6 months) at the time of glaucoma evaluation. In patients with aphakic glaucoma that was previously documented, the time of
SIMON et al •
PEDIATRIC GLAUCOMA
Table 1. Eyes with Glaucoma Patient No.
Age (mos) at SX
Age (mas) at OX
lOP (mmHg)
1 2 3 4 5 (00) 5 (OS) 6 7
58 1 12 2.5 3.5 3.5 5 1.8
127 80 82 72 101 109 82 17
26 40 30 44 32 27 50 27
lOP of Fellow Eye (mmHg)
10 23 10 27* 32' 15 14
CD
CR
CR/T
0.4 0.8 0.6 0.15 0.4 0.5 0.8 0.7
- 0.35t +10.25 +2.5 +8.0 +13.25 +14.0 +10.0 +20.0
-0.05 -0.07 +0.02 -0.10 -0.08 -0.04 -0.12 -0.13
SX = tensectomv/vitrectomy surgery; OX = glaucoma diagnosis; lOP = intraocular pressure; CD = cup-to-disc ratio; CR (in spherical equivalent); CR/T = change in cycloplegic refraction (see text); 00 = right eye; OS = left eye. * Bilateral glaucoma in bilateral aphakia. t Following epikeratophakia.
= cycloplegic refraction
etry and IS patients (18 eyes) could not cooperate for gonioscopy. One child was evaluated under anesthesia. In cooperative patients, computerized image analysis of the optic nerve head (Topcon Imagenet System, Paramus, NJ) and automated visual fields (Humphrey, Octopus) were performed.
RESULTS
Fig 1. Optic nerve analysis from the left eye of patient 5 shows glaucomatous cupping.
glaucoma evaluation was taken as the time glaucoma was first diagnosed. All patients were evaluated by us (JWS and STS), following a standard protocol. Demographic data were tabulated from a chart review and included characterizations of both cataract types and surgical procedures, including operative and postoperative complications. All procedures were limbal lensectomy/vitrectornies, performed by JWS or RAe with the Ocutome, which followed closely the method described by Parks. 6 Previously recorded intraocular pressures were tabulated. Routine examination included cycloplegic refraction , which was compared with the last similar measurement performed at least I year earlier, and best corrected visual acuity, Glaucoma evaluation included assessment of corneal diameter, slit-lamp examination, applanation tonometry, and estimation of glaucomatous optic nerve damage (if any). Two patients (3 eyes) were unable to cooperate for applanation tonom-
Based on intraocular pressures of 26 mmHg or greater, glaucoma was diagnosed in 8 (24%) eyes of7 (27%) children . We selected this relatively conservative threshold to include in the glaucoma group only those patients whose pressures were clearly elevated. Visual field and optic disc analysis in this age group was difficult. As shown in Table I, pressures ranged from 26 to 50 mmHg (x = 34 mmHg) in patients with glaucoma. Of the eyes with glaucoma, four had elevated pressure at the first successful measurement. However, four had had previously documented normal pressures before the pressure elevations became apparent. In several cases, these normal pressures were documented on numerous occasions. No bilaterally aphakic patient had unilateral glaucoma, although asymmetric pressures were noted in this subgroup occasionally. No unilaterally aphakic patient had bilateral glaucoma. Patient 6 presented with asymmetric cataracts and underwent surgery on only one eye. A pressure of 50 mmHg was noted in the operated eye 67 months postoperatively. The felloweye, with its partial cataract, has had normal pressures consistently. Using logistic regression, glaucomatous optic nerve damage was associated typically with elevated pressures (P = 0.01).8 The cup-to-disc ratio in glaucomatous eyes averaged 0.54 (range, 0.15 to 0.80). In eyes without glaucoma, this ratio averaged 0.19 (range, a to 0.50). Most patients were too young to undergo optic disc photograph y or visual field testing. The optic nerve analysis and computerized visual field of patient 5 are shown in Figures I and 2. 671
OPHTHALMOLOGY
•
MAY 1991
Cataract types are summarized in Table 2. Surgical complications included vitreous at the wound (four eyes), secondary membranes requiring removal (two eyes), and transient vitreous hemorrhage (one eye). Two eyes had retinal detachments, one associated with trauma and the other associated with persistent hyperplastic primary vitreous. Peripheral iridectomies were performed in only two eyes. Slit-lamp examination showed lens remnants in four eyes. Heterochromia was noted in two patients, ectropion uveae in one eye, microphthalmos in two eyes, and increased corneal diameter in one eye (patient 8). One eye that did have glaucoma (patient 1) had undergone epikeratophakia. All other eyes were corrected with contact lenses or with spectacles. With the exception of patient 1, eyes with glaucoma ranged in spherical equivalent from +2.5 diopters (D) to +20.0 D (x = + 11.14 D). Eyes without glaucoma ranged from +6.0 D to +21.0 D (x = + 13.78 D). The two means were not statistically different (P = 0.26). The rate of change in refraction for eyes with glaucoma ranged from -0.12 Dzyear to +0.02 Dzyear (x = -0.07 Dyyear). For eyes without glaucoma, refraction changed from -0.23 Dryear to +0.09 Dzyear (x = -0.05 Dzyear). Best corrected visual acuities ranged from 20/30 to hand motions (x = 20/510) for eyes with glaucoma and 20/30 to hand motions (x = 20/510) for eyes without glaucoma. Except for a few peripheral anterior synechiae, gonioscopy showed open angles in 15 of 16 eyes. One child (patient 8) had unsuspected angle closure with broad peripheral anterior synechiae 15 months postoperatively. Her corneal diameter was 12.75 mm (compared with 12.0 mm in the fellow eye), and she had mild photophobia. No other child had photophobia or corneal enlargement, and none had breaks in Descemet's membrane. One asymptomatic child (patient 4) had mild microcystic corneal edema. The relationship between the diagnosis of glaucoma and other variables that may be prognostic was investigated using logistic regression.f No association could be found between glaucoma and age at surgery, cataract type, microphthalmos, abnormal slit-lamp appearance, surgical complication, visual acuity, refractive error, or refractive change. With the exception of the one eye with angle closure, glaucoma first became apparent 69 to 105 months (x = 82 months) after surgery. Of 14 eyes followed less than 60 months since lensectomy, this was the only one (7%) with glaucoma. Of 17 eyes followed longer than 60 months, 7 (41 %) had glaucoma. This difference is significant by chisquare analysis (P = 0.03). Figure 3 shows a "survival function," depicting the incidence of glaucoma diagnosis by time since surgery.
DISCUSSION Reports of pediatric lensectomy/vitrectomy suggest an improved prognosis when compared with previous sur-
672
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VOLUME 98
•
NUMBER 5
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Abstract: Glaucoma after pediatric cataract surgery, once well recognized, now occurs only rarely after modern lensectorny/vitrectomy. The authors performed directed glaucoma evaluations of 34 eyes of 26 children. Based on intraocular pressures of 26 mmHg or greater, glaucoma was diagnosed in 8 (24%) eyes of 7 (27%) children. Glaucoma was found more commonly among children followed more than 60 months and was diagnosed up to 105 months after surgery. Typically, the glaucoma was open angle and asymptomatic. Four children had had previously normal pressures recorded. With longer follow-up, it is likely that more children will be diagnosed with glaucoma after lensectomy / vitrectomy procedures. The authors believe such patients should be followed as glaucoma suspects for the rest of their lives. Ophthalmology 1991; 98:670-674
For many years, late glaucoma has been recognized as a common problem after surgery for pediatric cataract.l'" In a review of 15 studies of pediatric aphakia performed between 1943 and 1975, Francois' found an average incidence ofglaucoma of 5.5%, with some authors reporting an incidence of 13 to 16%. Often, glaucoma is not recognized until years after cataract removal. During the late 1970s, microscopically controlled, automated lensectomy/vitrectomy gradually replaced oneand two-staged needling as a method of pediatric cataract extraction.' Lensectomy/vitrectomy remains the most commonly used technique today." It was hoped that by removing lens and capsular remnants more effectively, such surgery would minimize postoperative inflammation and pupillary block and would decrease the incidence of glaucoma. 3,5-7
In fact, initial reports have been encouraging. Parks" found no cases of chronic glaucoma among 99 eyes operated on with the Ocutome. Whereas Chrousos and associates' found a 6.1% incidence ofglaucoma after various other surgical techniques, no cases were apparent among 54 eyes operated on with the Ocutome. In a longer follow-up study that was undertaken recently, Keech and associates" found an 11% incidence of glaucoma after lensectomy/vitrectomy, During the past 2 years, we encountered several children with late glaucoma after lensectomy/vitrectomy, Because most had no specific symptoms to suggest glaucoma, we were prompted to call in other pediatric patients with aphakia for a directed glaucoma evaluation.
PATIENTS AND METHODS Originally received: November 5, 1990. Revision accepted: January 9, 1991. 1
2
Department of Ophthalmology, Albany Medical College, Albany. Department of Biometry and Statistics, State University of New York, Albany.
Supported in part by training grant EY0703702 and research grant EY05816 from the National Institutes of Health, National Eye Institute, Bethesda, Maryland, to the Albany Medical College Department of Ophthalmology, and by an unrestricted grant from Research to Prevent Blindness, Inc, New York, New York. Reprint requests to John W. Simon, MD, Albany Medical College, Department of Ophthalmology, Albany, NY 12208.
670
The families of 42 consecutive children who underwent cataract surgery (before the age of 11 years) at the Albany Medical Center between 1981 and 1987 were contacted by mail. A letter was sent in which we expressed our concern that these children might be at risk ofglaucoma and suggested that these children return for examination. The 26 patients (34 eyes) that we studied ranged in age from 1 week to 127 months (x = 26 months) at the time of surgery and from 17 to 134 months (x = 83.6 months) at the time of glaucoma evaluation. In patients with aphakic glaucoma that was previously documented, the time of
SIMON et al •
PEDIATRIC GLAUCOMA
Table 1. Eyes with Glaucoma Patient No.
Age (mos) at SX
Age (mas) at OX
lOP (mmHg)
1 2 3 4 5 (00) 5 (OS) 6 7
58 1 12 2.5 3.5 3.5 5 1.8
127 80 82 72 101 109 82 17
26 40 30 44 32 27 50 27
lOP of Fellow Eye (mmHg)
10 23 10 27* 32' 15 14
CD
CR
CR/T
0.4 0.8 0.6 0.15 0.4 0.5 0.8 0.7
- 0.35t +10.25 +2.5 +8.0 +13.25 +14.0 +10.0 +20.0
-0.05 -0.07 +0.02 -0.10 -0.08 -0.04 -0.12 -0.13
SX = tensectomv/vitrectomy surgery; OX = glaucoma diagnosis; lOP = intraocular pressure; CD = cup-to-disc ratio; CR (in spherical equivalent); CR/T = change in cycloplegic refraction (see text); 00 = right eye; OS = left eye. * Bilateral glaucoma in bilateral aphakia. t Following epikeratophakia.
= cycloplegic refraction
etry and IS patients (18 eyes) could not cooperate for gonioscopy. One child was evaluated under anesthesia. In cooperative patients, computerized image analysis of the optic nerve head (Topcon Imagenet System, Paramus, NJ) and automated visual fields (Humphrey, Octopus) were performed.
RESULTS
Fig 1. Optic nerve analysis from the left eye of patient 5 shows glaucomatous cupping.
glaucoma evaluation was taken as the time glaucoma was first diagnosed. All patients were evaluated by us (JWS and STS), following a standard protocol. Demographic data were tabulated from a chart review and included characterizations of both cataract types and surgical procedures, including operative and postoperative complications. All procedures were limbal lensectomy/vitrectornies, performed by JWS or RAe with the Ocutome, which followed closely the method described by Parks. 6 Previously recorded intraocular pressures were tabulated. Routine examination included cycloplegic refraction , which was compared with the last similar measurement performed at least I year earlier, and best corrected visual acuity, Glaucoma evaluation included assessment of corneal diameter, slit-lamp examination, applanation tonometry, and estimation of glaucomatous optic nerve damage (if any). Two patients (3 eyes) were unable to cooperate for applanation tonom-
Based on intraocular pressures of 26 mmHg or greater, glaucoma was diagnosed in 8 (24%) eyes of7 (27%) children . We selected this relatively conservative threshold to include in the glaucoma group only those patients whose pressures were clearly elevated. Visual field and optic disc analysis in this age group was difficult. As shown in Table I, pressures ranged from 26 to 50 mmHg (x = 34 mmHg) in patients with glaucoma. Of the eyes with glaucoma, four had elevated pressure at the first successful measurement. However, four had had previously documented normal pressures before the pressure elevations became apparent. In several cases, these normal pressures were documented on numerous occasions. No bilaterally aphakic patient had unilateral glaucoma, although asymmetric pressures were noted in this subgroup occasionally. No unilaterally aphakic patient had bilateral glaucoma. Patient 6 presented with asymmetric cataracts and underwent surgery on only one eye. A pressure of 50 mmHg was noted in the operated eye 67 months postoperatively. The felloweye, with its partial cataract, has had normal pressures consistently. Using logistic regression, glaucomatous optic nerve damage was associated typically with elevated pressures (P = 0.01).8 The cup-to-disc ratio in glaucomatous eyes averaged 0.54 (range, 0.15 to 0.80). In eyes without glaucoma, this ratio averaged 0.19 (range, a to 0.50). Most patients were too young to undergo optic disc photograph y or visual field testing. The optic nerve analysis and computerized visual field of patient 5 are shown in Figures I and 2. 671
OPHTHALMOLOGY
•
MAY 1991
Cataract types are summarized in Table 2. Surgical complications included vitreous at the wound (four eyes), secondary membranes requiring removal (two eyes), and transient vitreous hemorrhage (one eye). Two eyes had retinal detachments, one associated with trauma and the other associated with persistent hyperplastic primary vitreous. Peripheral iridectomies were performed in only two eyes. Slit-lamp examination showed lens remnants in four eyes. Heterochromia was noted in two patients, ectropion uveae in one eye, microphthalmos in two eyes, and increased corneal diameter in one eye (patient 8). One eye that did have glaucoma (patient 1) had undergone epikeratophakia. All other eyes were corrected with contact lenses or with spectacles. With the exception of patient 1, eyes with glaucoma ranged in spherical equivalent from +2.5 diopters (D) to +20.0 D (x = + 11.14 D). Eyes without glaucoma ranged from +6.0 D to +21.0 D (x = + 13.78 D). The two means were not statistically different (P = 0.26). The rate of change in refraction for eyes with glaucoma ranged from -0.12 Dzyear to +0.02 Dzyear (x = -0.07 Dyyear). For eyes without glaucoma, refraction changed from -0.23 Dryear to +0.09 Dzyear (x = -0.05 Dzyear). Best corrected visual acuities ranged from 20/30 to hand motions (x = 20/510) for eyes with glaucoma and 20/30 to hand motions (x = 20/510) for eyes without glaucoma. Except for a few peripheral anterior synechiae, gonioscopy showed open angles in 15 of 16 eyes. One child (patient 8) had unsuspected angle closure with broad peripheral anterior synechiae 15 months postoperatively. Her corneal diameter was 12.75 mm (compared with 12.0 mm in the fellow eye), and she had mild photophobia. No other child had photophobia or corneal enlargement, and none had breaks in Descemet's membrane. One asymptomatic child (patient 4) had mild microcystic corneal edema. The relationship between the diagnosis of glaucoma and other variables that may be prognostic was investigated using logistic regression.f No association could be found between glaucoma and age at surgery, cataract type, microphthalmos, abnormal slit-lamp appearance, surgical complication, visual acuity, refractive error, or refractive change. With the exception of the one eye with angle closure, glaucoma first became apparent 69 to 105 months (x = 82 months) after surgery. Of 14 eyes followed less than 60 months since lensectomy, this was the only one (7%) with glaucoma. Of 17 eyes followed longer than 60 months, 7 (41 %) had glaucoma. This difference is significant by chisquare analysis (P = 0.03). Figure 3 shows a "survival function," depicting the incidence of glaucoma diagnosis by time since surgery.
DISCUSSION Reports of pediatric lensectomy/vitrectomy suggest an improved prognosis when compared with previous sur-
672
•
VOLUME 98
•
NUMBER 5
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