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Cataract extraction has become the most common pediatric intraocular surgery performed in the United
States. Recent advances in instrumentation and technique have led to a significant decrease in complication
rates, resulting in a greater emphasis on refractive
1940
outcomes.1,2 This has also resulted in widespread implantation of a posterior chamber intraocular lens
(IOL) in the capsular bag at the time of initial cataract
extraction,3,4 a procedure with low rates of complications such as pupil capture, fibrinous uveitis, and capsule fibrosis.2,46 The trend of expanded IOL use has
been observed in all pediatric ages; however, the most
significant increases are in the very youngest children.
A 2001 survey of members of the American Association
for Pediatric Ophthalmology and Strabismus and the
American Society of Cataract and Refractive Surgery1
indicate a 13-fold increase in the number of respondents
implanting IOLs in children 2 years of age and younger
over an 8-year period between 1993 and 2001.
Implantation of IOLs in children involves several
unique challenges not present in adult cataract surgery.
Childrens eyes continue to undergo significant growth
and change during postoperative years, resulting in refractive changes that complicate the prediction of
0886-3350/08/$dsee front matter
doi:10.1016/j.jcrs.2008.07.019
postoperative refraction and IOL power.79 Most surgeons thus aim for an age-dependent degree of postoperative hyperopia to allow for myopic shift as the eye
grows.6,1012 Furthermore, pediatric cataract surgery
is usually performed under general anesthesia and frequently requires axial length (AL) and keratometry
measurements in eyes that cannot fixate or centrate.10
Finally, available IOL calculation formulas are designed for adult eyes and may not be accurate in younger patients, who have steeper, narrower corneas,
shorter ALs, and shallower anterior chambers.13,14
This study was designed to determine the accuracy
of postoperative predicted refractive outcomes in pediatric patients having cataract surgery with primary
placement of an IOL in the posterior capsular bag.
Comparisons were made with other variables historically considered important in cataract surgery to determine whether any of them significantly correlate
to predictions of refractive outcomes. These data are
intended to aid surgeons in their predictions of desired
power of an IOL during pediatric cataract surgery.
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Data Collection
The patients date of birth, sex, date of surgery, type of cataract, affected eye, keratometry readings, AL, and corneal diameter were recorded. Target refraction was age dependent;
younger children were generally targeted for a higher
amount of residual hyperopia.
Outcome data were collected 4 to 8 weeks postoperatively
after the corneal suture had dissolved and a stable refraction
was obtained. All refractions were performed manually using the retinoscope by an experienced pediatric ophthalmologist. The spherical equivalent of the residual refractive error
was recorded in diopters (D). Prediction error (PE) for each
surgery was calculated as follows: PE (D) Z predicted postoperative refraction (D) actual postoperative refraction (D).
Statistical Analysis
Variables were summarized by the number of observations, mean and standard deviation, minimum, median,
and maximum. The Pearson correlation coefficient was
used to assess the strength of correlation between the absolute value of the prediction error and continuous measurements. The absolute value of the prediction error was
modeled using a mixed model with terms for age at time
of surgery, keratometry (K) mean, AL, formula used, surgeon, A-scan type, and random effect for patient. The random patient effect incorporates into the model the
correlation of repeated measurements from the same patient.
Residual plots were examined for possible violation of model
assumptions of normality and homogeneity of variance for
error terms.
Separate analyses for groups defined by age at the time of
surgery (%2 years, O2 years) were also performed. For each
age group, the absolute value of the prediction error was
modeled by a repeated-measures analysis of covariance
model. Terms in the model included K mean, AL, and
A-scan type.
An additional analysis of subgroups defined by AL was
conducted. Shorter length was defined as 20.0 mm or less,
normal length as 20.0 to 23.0 mm, and longer length as
greater than 23.0 mm. For each AL group, the absolute value
of the prediction error was modeled by a repeated-measures
analysis of covariance model. Terms in this model included
K mean, age at the time of surgery, and A-scan type.
RESULTS
Two hundred three eyes of 160 sequential patients between the ages of 18 days and 18 years were identified
in the study. Table 1 shows the patients characteristics. The mean absolute value of the prediction error
(MAE) was 1.08 D G 0.93 (SD) (Table 2), indicating
that this representative pediatric patient had roughly
a 1.00 D difference in actual versus predicted postoperative refraction (Figure 1).
Correlation of the continuous variables with the
absolute value of the prediction error resulted in 2
significant variables: age at time of surgery (r Z
0.24, P Z .0006) and corneal curvature (K mean)
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Value
Eye, n (%)
Right
Left
Sex, n (%)
Male
Female
Mean age (y) at surgery G SD
Mean AL (mm) G SD
Mean corneal diameter (mm) G SD
Surgeon, n (%)
D.A.P.
D.E.N
IOL formula, n (%)
SRK II
SRK/T
Holladay 1
A-scan, n (%)
Contact
Immersion
108 (53.2)
95 (46.8)
113 (55.6)
90 (44.4)
5.52 G 4.19
21.54 G 2.19
11.34 G 0.71
128 (63.0)
75 (37.0)
85 (41.9)
92 (45.3)
26 (12.9)
138 (68.0)
65 (32.0)
Mean SD
Predicted postop
2.44 2.54
refraction (D)
Actual postop
2.44 2.84
refraction (D)
Prediction error
0.05 1.42
of refractive outcome (D)
Absolute value
1.08 0.93
of prediction error (D)
Age at surgery (y)
5.52 4.19
K mean (D)
44.53 1.99
Axial length (mm)
21.54 2.19
K Z keratometry
Min
Median Max
5.00
1.93
10.00
6.00
2.12
12.00
4.06
0.04
6.00
0.00
0.86
6.00
0.06
33.00
16.84
4.72
44.50
21.45
18.30
51.25
30.47
Figure 2. Mean absolute value of the prediction error by age at time
of surgery.
1943
Group
Estimate
Standard Error
P Value
1.05
0.06
0.09
0.05
0.19
0.02
0.04
0.04
d
.0009
.0127
.2129
0.03
0.07
0.23
0.20
.8863
.7248
0.04
0.17
.8005
0.06
0.20
.7794
Age
%2 y (n Z 43)
Intercept
K mean
Axial length
A-scan type (contact
is reference)
Immersion
O2 y (n Z 160)
Intercept
K mean
Axial length
A-scan type (contact
is reference)
Immersion
Axial length
%20.0 mm (n Z 41)
Intercept
K mean
Age at surgery
A-scan type (contact
is reference)
Immersion
O20.0 to %23.0 mm
(n Z 114)
Intercept
K mean
Age at surgery
A-scan type (contact
is reference)
Immersion
O23.0 mm (n Z 48)
Intercept
K mean
Age at surgery
A-scan type (contact
is reference)
Immersion
Standard
Error
P
Value
1.44
0.13
0.004
0.37
0.10
0.13
.1953
.9783
0.27
0.35
.4544
0.96
0.07
0.06
0.09
0.04
0.04
.0839
.1406
0.02
0.15
.8763
1.42
0.13
0.02
0.33
0.09
0.07
.1546
.7475
0.30
0.40
.4594
0.97
0.04
0.04
0.08
0.04
0.02
.2963
.0207
0.03
0.15
.8500
1.40
0.07
0.08
0.28
0.07
0.04
.3192
.0620
0.10
0.37
.7841
Estimate
measurements are performed under general anesthesia.10 Furthermore, IOL calculations are not designed
for children, who have steeper narrower corneas,
shorter ALs, and shallower anterior chambers.13,14
Finally, the myopic shift and desired residual postoperative hyperopia in pediatric cataract patients are not
adequately predicted by commonly used IOL calculation formulas.15,21
Clearly, significant inherent and technical difficulties deter accurate calculations of appropriate IOL
power and desired postoperative refraction during
pediatric cataract surgery. This study was intended
to determine the accuracy of postoperative predicted
1944
refractive outcomes in pediatric patients having cataract surgery with primary placement of an IOL. Comparisons were made with the IOL formula used, age at
the time of surgery, K mean, A-scan biometry technique, AL, and surgeon.
1945
A-Scan Biometry
We also found immersion A-scan biometry to be
slightly more accurate than contact biometry in relation to MAE, although the difference did not reach statistical significance (P Z .7794). This is the only known
comparison of the 2 techniques in pediatric patients
and contrasts with most studies in adults, which
show significantly increased accuracy of the immersion A-scan in terms of the targeted postoperative refraction.3739 The decreased accuracy of the contact
technique has been attributed to inadvertent indentation of the cornea by the ultrasound probe, thus shortening the actual AL.38 The supine and sedated state of
patients measured in our study is a limitation; nonetheless, the data support the multifaceted differences
between adult and pediatric cataract surgery.
Axial Length
Axial length was not found to be significantly associated with prediction error, which is consistent with
results in a previous study of infants younger than
12 months.25 However, Tromans et al.22 found prediction error to be significantly greater in eyes with an AL
less than 20.0 mm. A recent study by Trivedi and Wilson40 reported that eyes with an AL than shorter than
that in the fellow eye had a postoperative rate of axial
growth exceeding the growth rate in the eye with the
longer AL, resulting in a trend toward AL differences
toward zero. These results were independent of age at
time of surgery and, taken as a whole, suggest that differences in AL equilibrate over time.
We subdivided ALs into short, normal, and long
lengths (Table 4) to further define significant comparisons. However, the only association was between prediction error and age at time of surgery in patients
with a normal AL (O20.0 mm and %23.0 mm). Because younger age is largely associated with a shorter
AL and MAE was found to increase with decreased
age, one would expect a correlation between age at
time of surgery and MAE in patients with an AL less
than 20.0 mm. However, these results show the complexity of the variables analyzed in this study and
point to the multifaceted nature of pediatric cataract
patients and IOL calculations.
Surgeon
There were no significant differences in prediction
error between the 2 primary surgeons, which is consistent with findings in previous studies of the same physicians.15 Both share a similar surgical technique with
some minor individual preferences; however, this
did not affect the postoperative prediction error. Future studies with a larger number of surgeons and
1946
37.
38.
39.
40.
1947