Intravenous single shot of steroids to prevent postoperative inflammatory reaction in pediatric cata

1
Intravenous single shot of steroids to prevent
post-operative inflammatory reaction in pediatric
cataract surgery.  

• Arun K Jain MD, Jaspreet Sukhija MD, Ira Berry
  MD.
• Department of Ophthalmology
• Post Graduate Institute Of Medical Education and
  Research
• Chandigarh
• India 160012

2
Control of Postoperative Inflammation after
Pediatric Cataract Surgery Quest for Quality
of Vision After Pediatric Cataract Surgery ?
3
Pediatric cataract surgery

• Challenging- because
• Small eye IOL Power calculations
• Challenging surgery- more skillful
• More post operative inflammation
• Post operative visual rehabilitation
• Amblyopia therapy

4
More Inflammation after Pediatric cataract surgery

• Causes
• Greater postoperative inflammatory response-
  tissue reactivity
• Surgical trauma
• Type, material, placement of IOL
• Compliance with medication

5

• The routine use of microsurgical techniques,
  meticulous cleaning of lens material, and
  in-the-bag IOL placement have helped decrease the
  incidence of early postoperative inflammation
  after pediatric cataract surgery and IOL
  implantation.

6

• Reported incidence of postoperative fibrinous
  uveitis in pediatric cataracts - 19 to 81.8
  
• Increased fibrinous uveitis 57.5
• 
  Pandey et al . Boston , MA.
  May 2000.

7
Increased inflammation leads to

• Fibrinous membrane formation
• Pigment deposits on the IOL
• Posterior Synechiae formation.
• Eccentric/ irregular/immobile/fixed pupil
• Poor visual outcome

8

• Complications following pediatric cataract
  surgery continue to be a major concern. Increased
  inflammatory reaction is seen following pediatric
  intraocular surgery. Fibrinous uveitis is the
  most common early postoperative complication
  which usually becomes manifest in the first 24
  hours
• Burke et al 1 reported an incidence of 50
  fibrinous uveitis in traumatic and infantile
  cataract surgeries.
• Gimbel et al 2 showed that a childs eye
  manifested more inflammation as compared to
  adults eye.

9
Introduction

• Zwaan et al 3 reported the occurrence of iritis
  in all of their patients and fibrinous exudates
  in the anterior chamber in 13 of pediatric
  cataract surgeries (56.7 traumatic, 14.9
  congenital, 22 developmental).
• Sequelae of this exuberant reaction lead to poor
  visual outcome due to formation of updrawn pupil,
  posterior synechiae, pigmentary deposits on the
  intraocular lens (IOL) surface, eccentric/
  immobile/ fixed pupil and decentration of the
  IOL.
• Sharma et al 4 in their study, including
  congenital (43.6), traumatic (28.2) and
  developmental (28.2) cataracts, had updrawn
  pupil (38.5), decentered intraocular lens
  (33.3) and pupillary capture (30.8).
• Pandey et al 5-6 reported the incidence of
  postoperative fibrinous anterior uveitis ranging
  from 19-81.8 in congenital and traumatic
  cataract surgeries.

10
Introduction

• Various management strategies have been evaluated
  to control this increased postoperative
  inflammation with variable results.
• Gimbel 2 and Cassidy 7 showed that full
  atropinization and frequent steroid drops
  postoperatively were usually enough to control
  the inflammation.
• Raina et al 8-9 treated their patients of
  congenital and developmental cataract with depot
  steroids (subtenon triamcinolone 20 mg) at end of
  surgery and oral steroids (1 to 2mg/kg of
  prednisolone acetate) postoperatively for 2 weeks
  along with topical steroids with good results.10
• Use of heparin in irrigating solution has been
  studied by Brady 10 and Bayramlar 11 in pediatric
  cataract surgeries.

11

• Klais et al 12 documented the safe use of
  intraocular recombinant tPA in pediatric cataract
  surgery.
• Mechanical discission of inflammatory pupillary
  membranes has been described by Leung et al 13.
• Axial organised fibrin plaque, adherent to the
  intraocular lens may defeat the surgical goal of
  maintaining a clear visual axis to prevent
  amblyopia.
• Bound down, irregular,and decentered/eccentric
  pupil has been shown to interfere with quality of
  vision and modulation transfer function.14-16

12

• Intravenous bolus of 500mg of hydrocortisone
  along with injection of 20 mg of
  methylprednisolone in the retrobulbar space, on
  completion of the surgical procedure, has been
  safely used by BenEzra et al 17 in cataract
  surgery in children with chronic uveitis.
• We evaluated one time single shot of intravenous
  hydrocortisone (5 mg/kg of body weight) and
  dexamethasone (0.1 mg/kg of body weight) at the
  end of the cataract surgery to prevent
  exaggerated inflammatory reaction and formation
  of postoperative fibrinous membrane in children.

13
MATERIAL AND METHODS

• Twenty two eyes of 15 children with congenital
  or development cataract that underwent surgery at
  the Ophthalmology department of Post Graduate
  Institute of Medical Education and Research
  (Chandigarh, India) were prospectively enrolled.
  Informed consent was acquired from the parents.

14

• Complete systemic evaluation to rule out any
  syndromic abnormality was carried out.
• Ophthalmic examination included atropine
  retinoscopy, fundus examination with indirect
  ophthalmoscopy and slit lamp examination wherever
  the child was cooperative.
• Ultrasound examination for posterior segment was
  carried out in eyes with complete cataract and
  for measurement of the axial length of the eye.
• Dahns or SRK formula was used for IOL power
  calculations
• Only congenital and developmental cataracts were
  included in the study.

15

• Mydriasis was achieved with 0.5 cyclopentolate
  and 2.5-5.0 phenylephrine drops.
• Preoperatively topical tobramycin eye drops 0.3
  were instilled 3 times/ day for 3 days.

16

• All surgeries were performed by a single surgeon
  (AKJ).
• Under aseptic conditions, the eye was draped and
  superior rectus muscle bridled. A fornix based
  conjunctival flap was created superiorly and
  bipolar wet field cautery done. A partial
  thickness scleral groove was made 1.5-2.0 mm
  behind the surgical limbus and fashioned into a
  scleral tunnel with a crescent blade upto 1.5 mm
  inside the corneal tissue. The anterior chamber
  was entered with side ports and 1.4 sodium
  hyaluronate (Healon GV) injected. A 3.2 mm
  keratome was used to open the scleral tunnel into
  the anterior chamber. Anterior continuous
  curvilinear capsulorhexis (ACCC) was made and
  hydrodissection done. Cataractous lens was
  removed with phacoaspiration. Cortical matter
  aspiration and polishing was done with bi-manual
  irrigation-aspiration. The bag was filled with
  viscoelastic and posterior continuous curvilinear
  capsulorhexis (PCCC) done. Limited anterior
  vitrectomy (AV) was done and intraocular lens
  implanted (foldable or rigid after section
  enlargement) in the bag or in the sulcus. The
  anterior chamber was cleared of all viscoelastic
  and a single 10-0 nylon cross suture applied .

17

• Phacoaspiration with ACCC and in the bag IOL was
  done in 6 eyes. These eyes developed posterior
  capsule opacification from a period of 1 month to
  2.5 years post primary surgery for which pars
  plana membranectomy was done.
• Phacoaspiration with ACCC with PCCC with AV and
  in the bag IOL was done in 16 eyes.
• Nineteen eyes were implanted with HSM PMMA IOL
  (811C Pharmacia), 3 eyes with foldable acrylic
  lens (AcrySof, Alcon)

18

• At the end of surgery, subconjunctival injection
  of gentamicin 20mg and dexamethasone 2mg was
  given.
• A single intravenous shot of hydrocortisone
  5mg/kg and dexamethasone 0.1mg/kg was given.
• Postoperatively, topical cyclopentolate 2/ day,
  dexamethasone and antibiotic drops 6/ day
  alongwith combination of steroid and antibiotic
  ointment at night was given tapered over period
  of two months.
• Patients were followed up on days 1, 2, 5,
  weekly for 3 weeks , every two weeks for one
  month and then at intervals appropriate for the
  individual.

19

• Postoperatively anterior chamber reaction was
  assessed according to the following grades as
  slit lamp examination was not possible in all
  cases.
• It was based on the visibility of iris and lens
  details (Hogan et al 18) as given in table 1.

20
Table 1 Gradation system for assessment of
postoperative anterior chamber reaction. (Hogan
et al 18)
21

• Post operative anterior chamber reaction
  assessment
• Grade 0 Crystal clear iris details
• Grade 1 - Minimal reaction
• Grade 2 Mild reaction
• Grade 3 Moderate reaction
• Grade 4 Severe reaction

22

• Outcome measures
• Postoperative inflammation
• Posterior synechiae
• Mobility of pupil
• Centration of pupil
• Endophthalmitis

23
Results

• 22 eyes of 15 children with congenital or
  developmental cataract
• 7 had bilateral cataracts
• 3 months to 11 years
• Average age was 4.26 years
• The demographic data and the details of the
  surgical procedure performed are presented in
  Table 2 microsoft word.

24
Results

• All eyes except one eye had Grade 1 or less
  reaction in the anterior chamber on the first
  postoperative day. Fig I
• None of the eyes had fibrinous reaction
  postoperatively except for one eye , which
  developed fibrin reaction in pupillary area on
  third post operative day, because of
  noncompliance with topical steroids. Fig II It
  was controlled with extensive topical
  dexamethasone eye drops
• Pupil round and mobile Fig III in all cases
  except one 4.5 in which it was slightly peaked
  
• One eye developed minimal peaking of pupil
  resulting from pinpoint posterior synechia with
  capsulorhexis edge .
• Six eyes without primary PCCC subsequently
  underwent pars plana posterior capsulotomy with
  anterior vitrectomy.
• All the eyes eventually maintained clear visual
  axes with regular mobile pupils.
• None of the eyes developed endophthalmitis.

25
Figure I
First post operative day , less than garde I
anterior chamber reaction
26
Figure II
Fibrin on IOL in Pupillary area
27
Figure II
Five year follow up central, regular, mobile
pupil- undilated and dilated
28
Discussion

• Optimal results of a pediatric cataract surgery
  provide a clear visual axis with a round and
  mobile pupil to prevent amblyopia or give proper
  treatment, if it is present.
• A childs eye is known to exhibit increased
  reaction postoperatively. The cause of this
  fibrinoid uveitis is unknown, but it is
  characterized by presence of intracameral fibrin
  strands across the pupil which eventually lead to
  posterior synechiae, pigment deposition over the
  IOL, distortion of pupil and secondary membranes.
  This reaction is usually seen in the first 2 5
  days.

29

• The antiinflammatory activity of heparin is by
  inhibition of P selectin, which is responsible
  for the initial attachment of leukocytes to the
  vessel wall.
• This explains the effectiveness of heparin
  surface modified IOLs , heparinized irrigating
  solution , intracameral heparin and intravenous
  heparin.
• Bleeding as a consequence of use of heparin in
  the irrigating solution has been reported
• but now with the advent of purified low molecular
  weight heparin this complication is less.
• Promising results have been shown by Bayramlar
  et al 19 in pediatric ocular surgery.

30

• Fibrinolytic agents like streptokinase and tPA
  can be used once the fibrin has formed in the
  anterior chamber.
• Streptokinase is an enzyme produced by a strain
  of beta-hemolytic streptococci belonging to
  Lancefield group C. It is considerably cheaper
  than tPA which is a serine protease and converts
  clot specific fibrin bound plasminogen into
  plasmin.
• Adverse effects like toxicity to the corneal
  endothelium leading to corneal opacification has
  been reported with doses of 15000 30000 units.
• Mullaney 20 have reported successful use of
  intracameral streptokinase in adults and children
  without any adverse effect with doses ranging
  from 500 to 1000 IU.
• Mullaney 20 injected between 500 to 1000 IU of
  streptokinase in 8 children in whom intraocular
  fibrin formed from 1 to 4 days after cataract
  surgery despite topical steroid drops.

31

• Klais et al 12 have used tPA in children and have
  also highlighted possible complications of
  incomplete resolution, recurrence of membranes
  and corneal band keratopathy.
• Mechanical discission of membranes 13 and
  intraocular steroid delivery system have also
  been described.
• The procedures requiring an injection in the eye
  or mechanical discission after the fibrin has
  formed are plagued by risks of repeated general
  anesthesia exposure to the child.
• There are increased risks of infection and
  endophthalmitis after an injection of
  streptokinase or tPA in case the preparations are
  contaminated or a second surgery.

32

• Steroids have been used before systemically to
  prevent excess inflammatory reaction in patients
  of uveitis undergoing cataract surgery. 17
• BenEzra et al 17 used 20 mg of methyl
  prednisolone and 30 mg gentamicin in retrobulbar
  space alongwith intravenous bolus of 500 mg
  hydrocortisone and 1000 mg of cefazolin in
  pediatric cataract surgeries.
• High doses of intravenous steroids have been used
  in children for ocular (bilateral optic neuritis
  uveitis ) and non-ocular conditions (rheumatic
  diseases , asthma , transverse myelopathy ,
  nephrotic syndrome ).

33

• The importance of a round mobile pupil cannot be
  more stressed upon. It has been shown in various
  studies that ocular optical quality is pupil
  size, shape and centration dependent and shows
  loss in visual sensitivity with a decentered
  small pupil at low and intermediate spatial
  frequencies.14-16
• It has been known that when the pupil is made
  eccentric, spherical aberrations cause coma.21

34
Retinal information capacity and the function of
pupil Laughlin SB. Ophthalmic Phsiol
Opt.1992.161-4

• Conclusion of the Study
• When the pupil is opened to increase sensitivity
  there is a loss of image sharpness due to
  aberrations
• At each luminance there is a diameter broad
  range that maximizes the information capacity
• Primary function of pupillary light reflex is to
  maximize acuity over a wide range of luminances

35

• Modulation transfer functions in children pupil
  size dependence and meridional anisotropy.
  Carkeet A et al. Invest Ophthalmol Vis Sci.
  2003443248-56.
• Conclusion of the study
• Ocular optical quality is pupil dependent, shows
  slight meridional anisotropy

36

• Changes of higher order aberration with various
  pupil sizes in the myopic eye. Wang Yet al. J
  Refract Surg. 200319S270-4
• Coma-like aberrations increased less with pupil
  dilation.
• Spherical-like aberration showed only a small
  increase from 4 mm to 5 mm pupil size, but a
  larger increase from 5 mm to 6 mm pupil size

37
Optical modulation transfer and contrast
sensitivity with decentered small pupils in the
human eye. Artal Pet al. Vision Res. 1996
3575-86.

• Conclusion of the study
• The combination of the ocular transverse
  chromatic aberration and monochromatic
  aberrations accounts for the loss in visual
  sensitivity found with a decentered small pupil
  at low and intermediate spatial frequencies.

38

• Although we have implanted acrylic IOLs in only
  three out of twenty three eyes, we did not
  observe any increased inflammation in these eyes
  as compared to heparin surface modified PMMA IOLs
  (811C ).
• Safety of acrylic intraocular lens has been
  documented by Raina et al 9 and Vasavada et al 22
  in pediatric eyes.

39
Heparin-surface-modified intraocular lenses in
pediatric cataract surgery Prospective
randomized study Basti et al, JCRS, 1999,
782-787

• Lower incidence of inflammatory cell deposit
  formation in eyes with HSM PMMA IOLs
• Eleven eyes out of 68 had a coagulum over the
  anterior IOL surface
• None had greater than grade II anterior chamber
  inflammation co-existing with the coagulum.
• Acute anterior uveitis ( grade II) during the 1
  week postoperative evaluation was 8.5.

40
Role of optic capture in congenital cataract and
intraocular lens surgery in children. Vasavada
AR. JCRS 2000, 824-831

• 
  

• 40 eyes included in study
• IOL with a 5.25 mm optic (Slimplant LX 10 BD)
• Posterior synechias formed in 10 eyes (71.4) in
  the optic-capture group and 9 (34.6) in the
  no-capture group (P .04)
• In the optic-capture group, most synechias
  formed between the iris and posterior capsule
  over the IOL
• Posterior synechia formation occurred in 12 eyes
  (41.4) with bag-fixated haptics and in 7 (63.3)
  with sulcus-fixated haptics (P .46).
• Posterior synechias formed in all eyes with
  sulcus-fixated haptics and optic capture through
  the posterior capsulorhexis (n 4).

41
Posterior continuous curvilinear capsulorhexis
with and without optic capture of the posterior
chamber intraocular lens in the absence of
vitrectomy. Raina UK et al. JPOS.2002278-287

• 28 children, 1.5 to 12 year
• Per operative Sub conj. Genta. 20mg, dexa. 2mg,
  subtenon triamcinolone 20mg
• Post operatively oral 1to2 mg /kg of
  prednisolone acetate 2weeks
• Fibrinous membrane- 4eyes 13
• Posterior synechiae 4eyes

42
Functional outcomes of acrylic intraocular lenses
in pediatric cataract surgery. Raina
UK. JCRS. 2004, 1082-1091

• A higher incidence of inflammatory response and
  posterior capsule opacification (PCO) continues
  to be a major obstacle to early visual
  rehabilitation after pediatric cataract surgery
• Postoperative therapy
• Systemic antibiotics for 5 days
• Systemic steroids (1 to 2 mg/kg body weight)
  tapered over 4 to 6 weeks.
• All patients were prescribed topical antibiotics
  and full-strength topical steroids every 4 hours.
  
• Postoperative dilation was achieved
  intermittently using tropicamide alone or in
  combination with phenylephrine to prevent
  posterior synechia formation.

43
Functional outcomes of acrylic intraocular lenses
in pediatric cataract surgery. Raina
UK. JCRS. 2004, 1082-1091

• Conclusion of the Study
• The formation of posterior synechias for less
  than 3 clock hours occurred in 5 eyes (10.6) and
  subsequently released in 3 eyes with rigorous
  mydriatic therapy.
• Conclusion The use of depot steroids and
  systemic steroids in the immediate postoperative
  period may be the reason, why the rate of
  postoperative inflammation was lower in the study
  than in others.

44

• We report the use of one time intravenous bolus
  of hydrocortisone 5 mg/ kg of body weight with
  dexamethasone 0.1 mg/ kg of body weight at the
  end of surgery.
• The rationale of using a combination of
  hydrocortisone and dexamethasone is based on
  their pharmacokinetics and pharmacodynamics.
  Hydrocortisone has a short duration of action
  where as dexamethasone has a longer duration of
  action.

45

• Only 1 of 22 eyes (4.5) showed a fibrinous
  reaction which was then treated with extensive
  topical steroids.
• All patients had mobile and round , central pupil
  except one which had slight peaking of the pupil.
  
• The visual axis was clear in all of them, 6 eyes
  where primary posterior capsulotomy was not done,
  required pars plana membranectomy and anterior
  vitrectomy after which a clear axis was achieved.
  
• None of the cases developed endophthalmitis.

46
Conclusion

• Single intravenous bolus of dexamethasone and
  hydrocortisone, at the end of surgery is
  effective in controlling post operative
  inflammation and fibrinoid reactions effectively.
  
• It also helps to maintain pupillary shape,
  position,and its mobility .
• Further studies should be done to assess the
  quality of vision contrast sensitivity and
  higher order aberrations in eyes with regular,
  round and mobile pupils versus peaked , irregular
  , eccentric or bound down pupils following
  pediatric catarct surgery with IOL implantation

47
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48

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49

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50
Thank you