Info

• The vitreous is more adherent to the retina and to the posterior capsule than in adults. This adherence has important implications for management: maneuvers that do not usually lead to complications in adults (i.e., PVD or removal of the posterior capsule) do pose a fairly high risk in children.

• The pars plana region is located more anteriorly in children. The younger the child, the closer to the limbus should the site of the sclerotomy be (Table 2.16.1). An accurate method to determine the site is to use the light pipe: transscleral illumination shows a dark ring representing the pars plana area.

2.16.2.6.2 General Comments

In eyes with IOFB injuries, the presenting visual acuity is lower and the rate of retinal detachment is higher in children than in adults; both differences are statistically significant [58].

Trauma is the most important cause of rhegmatogenous retinal detachment and was the indication for 30% of pediatric vitrectomies in one study, and it appears to be statistically significantly less effective in children under 10 years than in the adult population (35 vs 73%, respectively [24]).

In children, unlike in adults, the etiology of Terson syndrome is almost exclusively traumatic subdural, rather than spontaneous subarachnoidal, hemorrhage (see Chap. 3.3) [33].

Fig. 2.16.1 Protruding IOFB in a child. A protruding IOFB represents a unique management challenge. The risks associated with keeping the IOFB in situ until optimal conditions for removal are available (see Chap. 1.8) must be balanced against the risks of suboptimal removal conditions. In a cooperating adult, it is possible to refer the patient if the attending ophthalmologist decides not to intervene. It must be thoroughly explained to the patient that no physical pressure must be applied on the eye, and a proper shield1 must be placed over the eye before transportation. In a young child, such a referral may be very risky unless the child can be securely restrained. If such a restraint is not feasible, it is probably advisable to remove the IOFB acutely, even if the conditions are not optimal2, and then refer the child for secondary reconstruction

Fig. 2.16.1 Protruding IOFB in a child. A protruding IOFB represents a unique management challenge. The risks associated with keeping the IOFB in situ until optimal conditions for removal are available (see Chap. 1.8) must be balanced against the risks of suboptimal removal conditions. In a cooperating adult, it is possible to refer the patient if the attending ophthalmologist decides not to intervene. It must be thoroughly explained to the patient that no physical pressure must be applied on the eye, and a proper shield1 must be placed over the eye before transportation. In a young child, such a referral may be very risky unless the child can be securely restrained. If such a restraint is not feasible, it is probably advisable to remove the IOFB acutely, even if the conditions are not optimal2, and then refer the child for secondary reconstruction

1 If the standard shield cannot be applied because the protruding object is too long, a shield can be fashioned from a Styrofoam cup.

2 The removal must still take place in the controlled and sterile environment of an OR.

2.16.2.6.3 Management Pearls

• Closure of corneal (even scleral) wounds before referral is much more important in the young: the risk of the child rubbing the eye while in transit, and cause tissue extrusion or ECH, is higher. For the same reason, children with a protruding IOFB (Fig. 2.16.1) must not be referred until the object has been removed in an emergency procedure.

• If the anterior lens capsule is violated, the IOP may rapidly rise to very high levels; the younger the child, the greater the risk. The con dition may be so severe as to make emergency surgery necessary (see Chaps. 2.7, 2.18).

• If a child has bilateral traumatic cataracts, consideration should be given to performing lens removal in both eyes in the same surgical session: general anesthesia is technically difficult and potentially dangerous. The eyes must be prepared separately.

• Capsulorhexis is risky if there is capsular fibrosis; the vitrectomy probe is the safest method of creating an anterior (or posterior) capsulec-tomy.

• Since the nucleus is soft in children, simple aspiration for a traumatic cataract without posterior capsule injury is adequate.

• If a posterior capsular lesion is present, the vitrectomy probe should be used for lens removal (lensectomy; see Chap. 2.7) to avoid traction on the anterior vitreous [35]. Whether a limbal or pars plana approach is chosen, is based on the surgeon's preference [2] and on the accompanying pathologies.

• Since both the anterior and the posterior capsules are prone to opacify - the rate of postoperative opacification of the posterior capsule can reach as high as 100% [11] - and to opacify early [6], a large capsulectomy is recommended [60].

• The creation of a posterior capsulectomy must be preceded by anterior vitrectomy or performed with the vitrectomy probe. Posterior capsu-lorhexis must not be performed in children.

• Because of the strong connections between the posterior lens capsule and the anterior vitreous,16 ICCE should never be attempted in children.

• Several methods are available to restore the eye's refractive power after lens removal: prescription glasses; contact lenses; epikeratophakia; and IOL implantation [27]. The IOL implantation is the preferred option method [6], but the age at which this becomes feasible has not been determined.

16 And the peripheral retina.

0 0

Post a comment