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Arch Ophthalmol. 2000;118:850-851.

Intraocular lens implantation in children has become increasingly common after cataract surgery with encouraging visual results.¹ However, thickening of the posterior capsule along the visual axis remains a common and major problem that can lead to irreversible amblyopia.² Laser capsulotomy is not always possible for pediatric patients and surgical removal is often necessary. The thickened membrane can be approached anteriorly through the limbus or posteriorly through the pars plana. A limbal approach can render the intraocular lens unstable and the pars plana approach is usually more difficult owing to the lower scleral rigidity in children.³ It is more common for the eyeball to collapse with leakage through the wounds intraoperatively. Sutureless pars plana vitrectomy through self-sealing sclerotomies has been successfully performed in adults.⁴ This study aimed at evaluating prospectively the safety and efficacy of sutureless pars plana anterior vitrectomy through self-sealing sclerotomies in children with thick posterior pseudophakic membrane.

Report of a Case
A total of 8 eyes in 5 children were recruited from the Prince of Wales Hospital, Hong Kong, China, from March 1, 1998, to December 31, 1998. The children's mean age was 22 months (age range, 8-48 months) and the follow-up time ranged from 3 to 12 months (mean follow-up, 9 months). All patients had congenital cataract with cataract extraction performed by phaco-assisted aspiration. Primary posterior chamber intraocular lens was inserted with subsequent thickening of the posterior capsule along the visual axis deemed necessary for surgical removal. A 2-port pars plana approach was adopted as illumination was adequate from the operating microscope. Self-sealing sclerotomies were constructed in the same fashion as those described by Chen.⁴ Only the 2 superior sclerotomies were necessary, one for irrigation and the other for the vitreous cutter, avoiding the inferior sclerotomy that was often the main source of leakage as reported by Milibak and Suveges.⁵ Scleral tunnels of 2 mm long were created 3.5 to 4.5 mm posterior to the limbus and the actual sclerotomy sites were 1.5 to 2.5 mm from the limbus depending on the age of the patient. The integrity of the wound closure was tested by inspection and none of the sclerotomy sites required suturing. No intraoperative or postoperative complication was encountered.

Comment
Although the scleral rigidity in children is lower, the self-sealing effect of this technique was good with the integrity of the eyeballs well maintained. Sudden changes in intraocular pressure during operation are reduced, minimizing complications like intraoperative hemorrhage, vitreous herniations, and others. Suture-related problems, such as loosening, exposure, and infections, are also avoided. This would have been more difficult to manage in children where extra sessions under general anesthesia may become necessary. The exposure for surgery in younger children could be suboptimal; scleral tunnels were created without difficulty 4.5 mm posterior to the limbus in our cases. This can be further optimized by the modified technique described by Chen⁶ and Kwok et al⁷ for eyes with small palpebral fissures. The sutureless sclerotomy approach appears to be safe and effective and with its additional values in pediatric patients, it can be considered in selected cases.

AUTHOR INFORMATION
This study was supported in part by the Mr W. K. Lee Eye Foundation, Hong Kong, China.

Dennis S. C. Lam, FRCS, FRCOphth; John K. H. Chua, MBBS, FRCS; Alfred T. S. Leung, FRCS, FRCOphth; Dorothy S. P. Fan, MBChB, FRCS; Joan S. K. Ng, MBChB, FRCS
Hong Kong, China

Srinivas K. Rao, MD
Chennai, India

Corresponding author: Dennis S. C. Lam, FRCS, RECOphth, , Department of Ophthalmology and Visual Sciences, The Chinese University of Hong Kong, Hong Kong Eye Hospital, 147K, Argyle St, Kowloon, Hong Kong,China (e-mail: dennislam{at}cuhk.edu.hk).

REFERENCES
1. Cavallaro BE, Madigan WP, O'Hara MA, Kramer KK, Bauman WC. Posterior chamber intraocular lens use in children. J Pediatr Ophthalmol Strabismus. 1998;35:254-267. WEB OF SCIENCE | PUBMED 2. Pearson RV, Aylward GW, Marsh RJ. Outcome lensectomy: results and complications. Br J Ophthalmol. 1991;75:482-486. FREE FULL TEXT 3. Quinn GE, Young TL. Retina and vitreous. In: Isenberg SJ, ed: The Eye in Infancy. St Louis, Mo: Mosby-Year Book Inc; 1994:407. 4. Chen JC. Sutureless pars plana vitrectomy through self-sealing sclerotomies. Arch Ophthalmol. 1996;114:1273-1275. FREE FULL TEXT 5. Milibak T, Suveges I. Complications of sutureless pars plana vitrectomy through self-sealing sclerotomies. Arch Ophthalmol. 1998;116:119. FREE FULL TEXT 6. Chen JC. Complications of sutureless pars plana vitrectomy through self-sealing sclerotomies. Arch Ophthalmol. 1998;116:119. FREE FULL TEXT 7. Kwok AKH, Tham CCY, Lam DSC, Li M, Chen JC. Modified sutureless sclerotomies in pars plana vitrectomy. Am J Ophthalmol. 1999;127:731-733. FULL TEXT | WEB OF SCIENCE | PUBMED

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