Lecture: Congenital Cataracts: What Do You Need to Know?

DR SUH: Thank you. Hi, good morning. I’m so excited. My name is Donny Suh. I’m an Orbis volunteer faculty. For about 20 years. And it’s just been an amazing journey. And today we’re gonna talk about congenital cataract. How do we make the diagnosis and how do we manage. And I think we had 2300 people sign up today. So it’s gonna be a big party! And I know some of you — it’s gonna be early. Some of you — it’s gonna be late. But I’m just so glad that all of you were able to join. Thank you. So, you know, this is gonna be a pretty long talk. So I’m gonna try to finish this in about 40 minutes. And if there’s any particular areas that you want to hear more, please send us feedback. And then we could actually do another webinar in the near future. So without further ado, I think I’m just going to get started here. I’m gonna share my slides. Okay. I have no financial interests in any of the topics that will be discussed today. So first question: What is your profession? I would like to know who I’m talking to today. We’re gonna give you ten seconds to answer this question. And then I’ll tell you the response. And I only have seven questions today. You guys don’t have to think very much this morning. All right, perfect, thank you. Can the audience see the response? Perfect. And how many cases of congenital cataracts do you perform in a month? Is it 1, 2 to 4, 5 to 10, 10 to 20, greater than 20? This just gives me an idea. Next question — how long have you practiced in the field of ophthalmology? For those who are residents or technicians or non-ophthalmology? Perfect, thank you. All right. So when we posted this webinar, we asked you to make a comment. And based on those comments, I’ve prepared these lectures. And as you can imagine, we had 2300 people that signed up. People wanted to know so many different topics. The topics that I needed to cover was very diverse. So I kind of narrowed it down to the most commonly asked questions. So we’re gonna talk about the embryology. Like how does it occur, and how do we work up those patients. And then timing of the surgery, lens or no lens, and then pre- and postoperative considerations. And talk about the surgical techniques. So that’s how we broke it down. First let’s talk about how the whole thing happens. The lens starts embryologically, from a surface ectoderm, like the skin. And it forms a little placode, and this placode starts invaginating. This is surface ectoderm that invaginates, forms a little bit, and eventually breaks off and forms a vesicle. And this vesicle turns later into a lens. And this process starts at 4 weeks of gestation. So in some cases, even before some of the ladies find out that they’re pregnant. So the lens is already beginning to form. And between the 20 to 29 weeks of gestation, you can actually start to see these cataracts through a transvaginal or transabdominal ultrasound. So you can actually make a diagnosis of severe total cataracts. And this lens that is created is pretty amazing. It can transmit light from 390 to 1200 nanometers. But of course, we can only see 390 to 740 nanometers because of the limitations of our photoreceptors. Like very few structures in your body, it doesn’t have vasculature, and lens is one of them. Lens, cornea, cartilage. There are certain tissues that have no vascularity. That enables us to see right through. But it’s not just a lack of vascularity that gives us that clear transparency. But it’s the architecture of the lens cells and the protein. We’re just gonna talk about it briefly. At birth, this lens is only 65 milligrams. It’s pretty small. By the time we’re at 90, it can actually go up to 250 milligrams. So 4 times the weight. So the lens continues to grow to 4 times its size and weight. And mostly the lens is composed of water soluble protein. That’s the reason why we can suck it out pretty easily, in congenital cataracts. And it’s composed of various crystallins, very tightly packed in an organized fashion, and that’s what gives the transparency. It’s the organized packing. And it’s mostly composed of alpha and beta crystallin. And the opacity is mostly a function of the alpha crystallin, from a genetic basis or from aging, from chronic UV exposure. And these crystallins are encoded in various genes in your chromosomes, and these chromosomes also express skeletal, heart, kidney, and brain tissues. And that is the reason why, by us looking at the eyes, we can infer and see what’s going on in other parts of the body. And that’s the reason why genetic testing can be very, very helpful. So the newborns, the axial length from the front to the back is 16.8 millimeters, on average. In adults, it continues to grow. So by the age of 18, it’s almost fully developed. And it’s about 23.6. So there’s a 40% increase. And the majority of that growth occurs in your first year of life. Okay? Well, because there’s a significant change in the axial growth, the lens has to change, to accommodate that distance. If the lens stayed in this original shape, the focal point is gonna stay here. And then we would all be wearing very thick glasses. Myopic glasses. So to compensate for the extra growth, the lens becomes flatter and longer. And that’s what happens. This is important for us to understand when we start doing procedures. The lens changes significantly in the first year, as I told you earlier, to compensate for that axial length, to something like this. How common is congenital cataracts? Well, in developed countries, it’s not as common as in countries that are developing. And over the last 20 years, I’ve actually been truly surprised by the volume, just the pure volume, of congenital cataracts that I’ve seen. In some countries that I’ve actually visited, it’s not unusual for one pediatric ophthalmologist to perform 10 to 12 congenital cataracts a day. A day. In the United States, of course, to the best of my knowledge, I do not know of anyone who does that, and I actually do about 2 to 3 a week. And I thought that was pretty high volume. But no, it was a truly humbling experience. So some of the techniques that I’ve learned over the years, that I would like to share with you, is just by me talking to great surgeons from India, from North Africa, from China, from various countries, where these cataracts are much more common. It is — the cataract is one of the most common treatable causes of blindness. And it’s thought that about a third of the cases of blindness in infants is due to congenital cataract. And as we all know, if it’s untreated, due to the cortical visual pathway atrophy, the vision loss can actually be permanent. So that is the reason why we try to do these cataracts as soon as possible. So how do they present to us? Typically if there’s a positive family history, moms or grandparents would know about it, and as soon as the baby is born, they would bring the child in for an exam, to make sure they don’t have cataracts. But also, here in the States, everyone has a phone now these days. And these phones, when they take a picture of their beautiful babies, and they see a white reflex, abnormal, asymmetrical reflex, so they would bring them in. And then fetal ultrasound, which I’ve shown you earlier. And in diabetic patients, in older kids, they can actually have fairly rapid decline in their vision. And also, they can be picked up on a routine vision screening, with vision screeners getting better and better these days. We can pick up cataracts or other types of visual pathway obstructions at an earlier age. So how do we describe these cataracts? First, when you see these cataracts, you’ve got to determine if it’s truly unilateral or bilateral. Or you may think it’s unilateral, but when you look carefully on the other eye, you may see small cataracts that make it very difficult to detect. So it’s really a bilateral case with the asymmetrical presentations. And I find many of the congenital unilateral cataracts — it’s that situation. And then you have to determine whether this is congenital or whether this is something that’s acquired, whether it’s from a trauma, whether it’s from the development, and then you’ve got to determine: Where is the cataract? Is it partial or complete? And is it something that is stable? That doesn’t grow? Or if it’s something that’s progressive. That you may have to intervene. So these are the things that you’ve got to think about. And then finally, you’ve got to think about if this is a completely isolated cataract, or if it’s related to some other systemic disease. We just talked about the chromosomes, the genes that develop the lens — they’re also involved for coding various tissues in your body, including the heart, the brain, the kidney. So those are the things that we think about. For the bilateral cataracts, this is actually the slide that I actually had 20 years ago, when I was giving lectures. And it really hasn’t changed very much. About a quarter is hereditary. So most commonly, it’s autosomal dominant. A quarter is associated with some type of disease. It’s a hereditary disease, whether it’s Lowe’s or Alpert’s, it’s associated with other organs. Or hearing. We used to say about half was idiopathic. We just never knew. But as you know, that has changed significantly over the last 10 years, with the advent of genetic testing and the way it’s actually getting cheaper and cheaper to perform. With genetic testing, the majority of those cases that we considered idiopathic — now we actually are able to identify the genes. Up to 80% of the time. So what are some of the etiologies? For unilateral cataracts, idiopathic is still most common, but trauma. In many countries around the world that I’ve traveled, it’s actually more common than idiopathic. Because the trauma — you see many children on a small motorcycle, riding with their parents. And sometimes they hit a rock, and the child may endure a significant trauma, and develop traumatic cataract. And this is extremely common in many places around the world. And then posterior lenticonus, persistent fetal vasculature. We used to call them primary hyperplastic primary vitreous, and uveitis. And they can actually be associated with prematurity, or we can induce it. It could be iatrogenic. Meaning with a laser. Hitting the lens accidentally. And then from other ocular pathology. Another question is: Do you routinely perform genetic testing for congenital cataract patients? Yes or no? Okay, perfect, perfect. Thank you. So I’m gonna say I think this is true for the majority of the places I’ve traveled, even in the United States. Genetic testing is not routinely done universally. And in some places around the world, this service is not even available. Good. When do you refer patients for genetic testing? For those who actually do genetic testing. All cases, all bilateral cases, or unilateral cases, and only those people that you’re suspecting genetic disorders? Okay. The response is kind of spaced out. Perfect. For bilateral cataracts, the various chromosomes — it can be associated with the various chromosomes, but of course these patients with trisomy 21, 13, and 18 will have other clinical and facial features. And then other facial syndromes — Hallermann-Streiff, et cetera, and various infections, for example, rubella. In certain parts of the world, like Vietnam, where vaccination was not routinely performed, rubella induced cataract is very common, along with hearing loss and glaucoma. Toxoplasmosis, herpes, CMV, varicella, and syphilis. So depending on the region, these cataracts induced by infections can be common, compared to others here. So here in the states, we don’t see them as often. And then metabolic disorders. Galactosemia is one of the most common metabolic disorders, with Fabry’s and Wilson’s, with diabetes, chondrodysplasia punctata, and MPS. These are common things we’ve seen here. And in The Middle East. And musculoskeletal disorder, Sengers, with hypertrophic cardiomyopathy, one of the reasons we sometimes perform chest x-rays, and renal syndromes. So how do we evaluate these patients? I perform a careful family history. And sometimes these cataracts and their parents can be — although they’re congenital, but they’re fairly mild, and they may not even have known it. So I would actually examine the mom and dad, if they’re present, and look for any signs of congenital cataract. Meaning like a nuclear or lamellar type of cataracts, or anterior polar. I would ask for child growth, systemic issues, any type of arthritis, or history of significant trauma, especially unilateral cases. And then for physical examinations, I would actually ask for these things, but I refer these patients to a pediatrician, for complete physical evaluations. But the things that they would need to focus on, that you need to help them with, is any type of hearing issues, mental retardations, developmental delay, kidney disease, or any type of craniofacial abnormalities that can be tied to a chromosomal abnormality. And when we do ocular examinations, of course we talk about laterality, and make sure you look at both eyes carefully. And measure the corneal diameter, because that can determine whether you put the lens in or not, and look at the corneal diameters and look at the cornea carefully, because sometimes this posterior embryotoxon from anterior segment dysgenesis can be difficult to detect. So you may have to change your surgical plans. Iris configurations, make sure there’s no sense of iris abnormalities, any type of ectopia, and anterior chamber depth. These patients — especially these congenital cataracts with the lens bulging, the anterior chamber depth can be severely compromised. And you can potentially damage the endothelial layer of the cornea. And then lens position. Make sure there’s no signs of any zonule dehiscence, displacing the lens. Because that can potentially change your surgical techniques. And then look at the cataract morphology. We want to talk about it just a little bit. And most, I would say, very importantly — posterior segment. We have to rule out any potential mass. Also retinal detachment in patients with persistent fetal vasculature, with the traction. So these patients — we have to look at persistent hyaloid vessels, starting from the lens, reaching the optic nerve, and causing any tractions. Check the intraocular pressures, to look for glaucoma, and if you cannot visualize the posterior segment, then ultrasound. Very, very important. Ultrasound, not just the posterior pole in all areas. It’s extremely important. And typically for laboratory studies, I typically do not do workup for unilateral cases. Strictly unilateral cases. I’m not talking about asymmetrical. But just purely unilateral with a clear history of trauma. And there’s no other systemic findings. And I have them do a complete physical evaluation by the pediatrician, and there’s no concern. I typically do not do genetic testing in these patients. Unless there’s something that concerns me. And also bilateral cataracts with a positive family history that is clear. I do not perform genetic testing. But if in bilateral cases with a positive family history, with any type of medical conditions, the medical history is just not clear, or if I feel that there are other conditions that can be associated with the cataract, then I refer these patients for genetic testing. But pretty much everything else, I refer the patients for genetic testing. In terms of the workup, it’s a morphology based workup. It’s more focused workup. The TORCH titers will be important, along with varicella and VDRL, depending on age and family situations. And metabolic workup — I check their urine. This is something I do on a routine basis. Electrolytes. Calcium, phosphorus, glucose, ferritin, and chest x-ray if it’s needed. I discuss this with the pediatrician. And geneticist for workup. Especially any patients with dysmorphia, craniofacial abnormalities, problems with feeding, a geneticist can be very helpful, because I want to make sure they don’t have any heart defect before I put them to sleep, or I don’t want them going into any kidney issues after surgery. And for congenital cataracts, the next gen sequencing test from a commercial lab can identify up to 80% of patients with genetic disorders leading to cataracts. But the challenges are the costs of test and insurance coverage. This is a challenge even for the geneticist. But more and more, insurance companies are allowing these tests to be performed. So that’s the reason we’re actually able to perform more of these tests. Types of cataracts. Anterior polar cataracts. Typically the small cataracts are less than 3 millimeters. And it can be unilateral, bilateral, but these cataracts are anterior and they’re typically less than 3 millimeters. So they tend to be non-surgical candidates. But it can cause significant astigmatisms. So you have to check them for amblyopia. But there are various types of anterior cataracts, anterior polar, pyramidal, lenticonus, subcapsular, and PFV, involving only the anterior segment of the lens. Nuclear cataracts — typically 3 millimeters or larger, they tend to be more visually significant and many times inherited. These patients do carry a potential risk of glaucoma. Here’s a nuclear cataract and a nuclear cataract that’s more advanced. And lamellar cataract is a discrete, round-shaped cataract. That’s affecting one or more layers of the developing lens cortex. Surrounding the nucleus. The vision can vary significantly, but for the most part, they function okay. And have a pretty good prognosis. But these lamellar cataracts can progress and develop more of a lamellar slash nuclear cataract that becomes visually significant. And PSC — posterior subcapsular cataract. These are typically more acquired. Due to steroids, for a rheumatologic disorder, JIA, with a chronic inflammation, radiation exposure. Many of my patients, almost all of my patients with rhabdomyosarcomas, who received significant radiation, develop these cataracts, and they can be progressive. And also NF type 2 can have these types of cataracts. Sectoral cataract — so it can be just certain segments. It’s typically idiopathic. But you do have to worry about occult posterior segment tumors. Ask about the blunt trauma. Or retinal coloboma that’s associated with cataract. This is more of a developmental problem. Peripheral vacuolar cataract. These are something — people who do ROP exams might see. You may see these small cortical vacuolar cataract. And that’s typically — not central, but peripheral. And those cataracts can definitely be observed without any concern. Posterior lenticonus is a progressive thinning of — typically the central, but it can be offcenter — of the posterior capsule, and then it can have… When you do retinoscopy, these are very easy to pick up. It’s got that oil droplet reflex, and it’s typically unilateral, and you’ve got to think about Lowe syndrome for these patients. For the anterior lenticonus, you’ve got to think about the Alpert’s. And I don’t have to tell you — these cases can be dangerous, because the posterior capsule has a significant thinning. So especially when you’re doing hydrodissection, this posterior capsule, which is already thin to begin with, can rupture very easily. And sometimes these posterior lenticonus may be not identified because of cataract. You can’t see it. And then as you remove the lens, you may be able to see this bulging of the posterior capsule. And trying to perform a posterior capsulotomy can be challenging. And then PFV. It’s got different — it can actually be very mild, just a dot, or it can actually go all the way to retinal detachment. These patients typically have smaller eyeball, microphthalmia, and it’s typically unilateral, and they can have elongation of the ciliary bodies, because of the traction, and these patients typically have poorer prognosis, and the surgeries can be more challenging. Just because of the — anatomically, they’re different than just other non-PFV cases. And these plaques, these opacities, can be extremely hard. It can be fibrous. Fibrovascular tissue. So if you try to remove it, it can bleed, the anterior chamber can be filled with blood, and compromising your view. And also, with just a traditional vitrector, it may be very difficult to remove. It doesn’t matter how hard you try. Even with a second instrument, as you’re pushing these plaques, if you will, into the vitrector, they may not come in. So you may actually have to — in some cases, you just have to break it into small pieces and manually remove. And it’s one of the most common causes of unilateral cataracts. Many times it’s idiopathic. But if it’s bilateral, it can be associated with a systemic and neurological abnormality. So these patients actually — if you see patients with bilateral PHPV or PFV, they definitely need further evaluations. And hopefully with a geneticist, if possible. And there’s a huge spectrum. So you cannot say — I actually read some of these journals, and say: My surgical outcome of the PFV is this. And it’s much better than this that’s been previously reported. No. You cannot compare PFV. Even you cannot compare PFV to other PFVs. Because every case is so unique. But overall, they tend to have a poor visual prognosis. Especially if it involves the posterior segment. And retinoblastoma needs to be considered. When you see something like this, with a vasculature that’s growing, overlying the surface of this lesion, of course the retinoblastoma has to be considered, and ultrasonography would be needed. But patients with retinoblastoma, the microphthalmia would be unusual. How do we manage these patients? Most anterior opacities do not require surgery. But they do need amblyopic treatment, because of the irregular astigmatism that’s commonly found. The younger the patient, the denser the cataract has to be, before considering surgery. So if I see a patient that’s borderline, I tend to observe. So what does borderline mean? So if I see a cataract that’s less than — it’s 3 millimeters or less, and it’s not quite centered, then I tend to observe. And then what you can do is you can actually initiate patching therapy. So when you initiate patching therapy, if the child is completely — is not able to walk, is not able to do the things that he or she can normally perform, then that is something you have to consider when you’re contemplating surgery. You have to consider behaviors. And refract them. Consider if glasses might be helpful, especially in subluxated lenses. This is very important. The reason I put this picture in there is that pediatric cataract surgery is not adult cataract surgery. It’s truly different. I’ve actually enjoyed — I love cataract surgeries, but they’re very, very different. I don’t perform adult cataract surgeries, but when I did them, when I was in training, I loved them. But pediatric cataracts are definitely different and there are things you have to consider. Many of us who are on the webinar today are general ophthalmologists. So I want to just talk about some of the things that are different, that you have to consider before approaching pediatric cataract surgery. First of all, many times in pediatric cataracts, you have to determine the etiology. Whether it’s microbial, infectious, you have to determine what you think caused the cataract. It’s not normal for a baby to be born with a congenital cataract. So you’ve got to explain it. And also, it’s fairly rare, unlike adults. And then anterior and posterior capsule is extremely elastic. And the eyeball is small. And of course, this is gonna have — as you’re doing the surgery, you’ve got to think about these things. Because the eyeball is much more elastic. You’re gonna have to close the surgical incisions. And the visual outcome — the surgery in some way is actually the easy part. It’s the post-op care that’s — I think — that’s far, far more important. And I’ve actually been doing medical missions for 20 years, over 30 different locations, all over the world. And I’ve seen amazing surgeons that can perform these cataract surgeries. I’m not exaggerating — in five minutes. In five minutes. But when these patients come back for vision check, they’re not very good. Because there’s a lack of post-op care for these patients. So that is so critical. So critical. So the surgery is just the first part. But there are many more parts that you need to consider for these patients, for you to be a truly effective congenital cataract surgeon. So the surgery itself is important. But the post-op care is, I think, in my opinion, even more important. Even more important. And post-op care can be complicated in these pediatric patients. It’s very labor-intensive, because these kids are typically not very happy when they come to see you. And here you’re trying to mess with their eyes. These patients — sometimes they need two or three surgeries, especially for these PFV patients. And these patients, unlike adult patients, when you do cataract surgeries, these patients are typically referred to the local optometrist or ophthalmologist. But for these congenital cataracts, they pretty much have to come see you. So they become your lifelong friends. So this is very different than adult surgeries. And then they require general anesthesia. They have a smaller palpebral fissure. Especially some of these kids, the palpebral fissure is so tight, it’s not unusual for us to perform lateral canthotomy. And you have to close all the surgical incisions. And the anterior chamber tends to be shallow. Normally in infants, it’s 1.2 millimeters, versus 3 to 4 millimeters in adults. So you’re working in a tighter space. So that’s the reason why sometimes I see these patients with the endothelial scars after congenital cataract. Because it’s very easy to touch that endothelium and damage it. And then pupils don’t dilate that well. By the way, I’m gonna just tell you that I have a fairly low threshold of using pupil expanders. There are various pupil expanders out there. You can use what they call a John Graether pupil expander, or just iris hooks, whatever, but visualization is extremely critical. You have to think about whether you’re gonna leave the patient aphakic, or you’re gonna put the lens in. That’s not even something you think about in adult patients. Posterior capsule management is another big topic. That’s just the patient. And then when you get to the parents, the anxiety and fear level is tremendous. And there’s tremendous guilt. Because when we have — for a second, think of yourself as a parent. Just put yourself in their shoes. You have a child that you brought to this world, and you expected this child to be perfect. And the child is born blind, has a cataract. There’s a tremendous guilt. The parents go through: What did I do? So the psychosocial impact is far greater than the actual disease itself. As a matter of fact, the health-related quality of life questionnaire for children and parents — the level of stress these patients go through and parents go through is comparable to heart defect! Patients born with heart defect! Or going through liver transplant. Just think about the stress level these patients go through. For us, this is something we see on a regular basis. But for the parents, this is a life changing event. The psychosocial scores — it was comparable to children undergoing acute lymphocytic leukemia treatment as well. For the parents’ perspective. So you say — when I see these children, I say: Your child has a congenital cataract, and we may be able to fix it, by doing this and this and this. But what they actually hear is this: There is something wrong with your child. Your child’s eye. And she may go blind for the rest of her life. This is what they hear. So there is a tremendous disconnect. And then parents are gonna go home and they’re gonna do internet search. And as you know, everything you see on the Internet is true. Right? No! Of course not. They will see everything out there. And they come back with information that doesn’t even make sense. And you’re gonna have to spend even more time trying to get the consent. You just have to be prepared. This is not one of those things that you can just go in, and have patients on an assembly line and just go through. It doesn’t work that way. And that is part of the reason why many of the adult cataract surgeons have difficulty with pediatric patients. It’s not so much the surgical technique. These techniques they can learn. But dealing with the other issues that come with it is what is difficult. So if you could just think it through, especially for the general ophthalmologist, who do adult cataracts, just put yourself in their shoes. But the impact that you’re gonna have on these children is tremendous. It’s gonna change their life. Completely. Because as we all know, 75% of the child’s development hinges on good vision. 75%. Vision. I think we’re in a tremendous — I think that’s a tremendous privilege. So that leap, that gap, we need to narrow it. So when to intervene? Dense cataracts. I typically remove them as soon as possible. And we’re gonna talk about the timing. But if you see signs of nystagmus, that tends to have a slighter poorer prognosis, but can result after surgery. I’ve seen it over and over and over. And partial cataracts. It’s a judgment call. If it’s 3 millimeters or greater, I tend to lean toward doing the surgery. As I said, patching trial can be helpful. And then more central and more posterior, more visually significant. And when you try to retinoscope — if you can’t refract, typically babies will have difficulties seeing. And also with the direct ophthalmoscope, it can be helpful. If you can’t see the fundus, neither can the baby. Next question. Timing of the unilateral cataract. At birth? 2 weeks? 2 to 4 weeks? 4 to 10? 10 to 16? I have to tell you, I’ve actually given many webinars, Zoom conferences. It is very difficult. I can’t see the expressions of the audience. The next one. How about bilateral cataracts? At birth, less than 2 weeks, 2 to 4, 4 to 8, or 8 to 12? Okay. Slightly later. But it’s all across the board. And then timing between bilateral cataracts. Do you perform on the same day, 1, 2, 4, or 8 weeks apart? Thank you. About a week, I would say, is the most common. But it’s significant. The second most common is the same day. Perfect, thank you. And last question. At what age do you try to place IOL in congenital cataracts? Specifically in the unilateral cases? Never, from birth, 6 to 11 months, 1 to 2, or greater than 2? Greater than 2. Thank you. And for bilateral cataracts, when do you put them in? Same choices. Sorry, there’s construction going on in the hospital. So the response is pretty much the same. Thank you. So timing of the surgery. For the unilateral dense cataracts, the party line, just on average, I would say from my discussion from various colleagues around the country, just like what we just witnessed, I would say most commonly it’s 4 to 10 weeks of age. But that depends on the health of the baby. If the baby has medical issues, that may be postponed. And as we all know, I’m not gonna bore you with the various datas on the risk of glaucoma with the earlier cataract surgery. But I do think it’s real. So less than 4 weeks I try not to do surgery. And on the survey, I think some of the participants wrote — they actually do surgery even at birth. So I think it’s reasonable — I would like to recommend that you wait at least four weeks from birth, before considering surgery. And then for bilateral cataracts, you’ve got a little bit more time. So two to three months. And I think that was the number one response. And then I would say that’s pretty much the party line. And the short time intervals between the cases. In the States, I would say somewhere between 1 to 4 weeks. That’s common. And here in the States, we typically do not recommend bilateral surgeries on the same day. But if you ask me: Is there data to substantiate that? Is there hard data? Is this evidence-based? I’m gonna say no. That’s a pretty soft call. The incidence of endophthalmitis and blindness from these cataract surgeries is so low. We just don’t have enough data to really support, to completely refute and completely discourage the bilateral cataracts on the same day. As I’ve traveled to 30 different places, all over the world, the things that you really have to think about is the cost. Some of these patients, they cannot physically afford to have two separate surgeries. That’s impossible. And then you do have to think about the risk of anesthesia. Of course, the surgeries typically do not take very long. The risk of the anesthesia having any type of neurodevelopment issues is extremely small, but that is something that is in the back of many parents. So instead of having two surgeries, just combine it with one. I think that’s a reasonable argument. And then the travels. I’ve actually been to Chile. It’s a beautiful country. But for some of the patients to travel for two, three days, to get to where you are, and for them to go back and take another three days to go back home — these farmers cannot take that much time off. It’s just physically impossible. And there may be some location barriers. It depends on the locations. And also, places in North Africa, these babies have to be carried through the desert. Literally desert. To come to see you. They’re not gonna be able to make that trip twice. And then also you’ve got to think about the availability of the health care. IOLs or no IOL. Considerations. Typically for bilateral — what are the things you’ve got to think about? For unilateral cases, I tend to push for IOL. If you don’t put IOL, these patients have to wear contact lenses, or wear glasses that would cause significant anisoconia, as a result of the anisometropia. So this is gonna be difficult. For bilateral cases, if you decide not to put an IOL, I’ve actually seen on the survey — some of the participants never put an IOL. For bilateral cataracts, that is something to consider. For patients with nystagmus, contact lenses may be difficult to fit. With the patients with the nystagmus, especially if they have poorer vision already. And dry eyes. Some of these kids live in a very dry environment. Or if they had radiation therapy and these goblet cells on the conjunctiva are damaged, and they don’t produce enough tears. So contact lenses may not be possible for these kids. So that’s some of the things you’ve got to think about. Many places, this is something we don’t even think about — many places do not have these contact lenses, for aphakia available. At all. Even in the States, these contact lenses are not cheap. They’re hundreds of dollars. So that’s a financial barrier that you have to think about, when you’re doing these surgeries. So for those places where they do not have the contact lenses available, I’ve noticed that they tend to put the lens in much earlier. But there are some of the other issues that you have to think about. And also, if a patient has any active uveitis, or even poorly controlled uveitis, I would say IOL is contraindicated in those situations. And for me, they have to be completely controlled for six months. It has to be completely clear before even I consider intraocular lens. This is one of the situations many times — you can get away with it. But if you have one bad case, and I’ve actually had one, that I didn’t put the lens in, but the case did not go well. And the patient developed significant iritis, following IOL implant, developed phthisis, and we enucleated the eye. When you have these cases, you tend to be much more cautious. Patients with a small eye, corneal diameter 9 millimeters or less, it’s physically difficult to put the lens in. So those patients — and also, the risk of glaucoma is high. So I would not put a lens in, in these patients. And then if the child is less than 7, 7 months of age, I do not put the lens in. As a matter of fact, for me, my practice, anyone less than 12 months, I do not put the lens in. We actually have many surgeons here in the States who put lenses in, even at 7 months, but anyone less than 7 months, based on the data that we have from the studies, probably it’s hard to justify putting a lens in, just because of the risk of visual axis obscurations, and the patient needing additional surgeries, without significant benefit. The visual outcome. There’s no significant improvement with the IOL. So for me, I put the lens in. Kids are typically older. About 12 months of age. Corneal diameter has to be greater than 9 millimeters. And then the lens diameter is also important too. So some of these patients that I do surgery — if the lens diameter is less than 8 millimeters, I do not put the lens in. Once the IOL placement is decided, what are the things you’ve got to think about? You’ve got to measure the axial length and keratometry, just to get that information, exam under anesthesia may be needed right before the surgery. The errors in measurement can occur. Because of the lack of the fixation of the infant under general anesthesia. So you have to guesstimate where the visual axis is, and that can be somewhat challenging, especially if a patient has a posterior staphyloma, or any type of irregularity on the back surface of the retina. And there are various ways of obtaining axial length, through the biometry. The conventional way, and then with the applanation or immersion, or the optical biometry. But I would say for the majority of pediatric patients, we use the conventional applanation method. There are some disadvantages to the conventional contact method. But for what we do, for what I do, this is what I use. But it’s very important that when you check the axial length of these babies, using the contact method, that you do not compress the cornea. The eyeballs are very soft anyway, so just a slight depression can actually give you wrong measurements. 1 millimeter error would cause 3 diopters of miscalculation. But if it’s a short eye, that number can go up to 3.75. So just by depressing the cornea just slightly, that can give you a wrong information. That’s why the well trained biometrist I think is very important. And then contact lens, if they’re wearing contact lens, they need to be out for at least two weeks. Choosing the IOL. I’m gonna tell you, every place I’ve traveled, they have different IOLs. In the United States, we only have a few choices. But around the world, these lenses are made from different companies, and there are so many out there. But overall, I preferred the acrylic material. Acrylic material. And of course, the SA and SNs are the Alcon models. The acrylic materials are foldable, you can fit them through a smaller surgical wound. But there are other options out there, because acrylic material is not available. So obviously you’ve got to use what is available to you. In terms of the IOL calculations, I’m just gonna talk for a few more minutes. And then I think I’m gonna have to finish this at a different — I’m gonna give another seminar, if that’s okay with you guys. IOL calculations can be very difficult. Because of the growth of the eyeball. The growth of the eye follows a logarithmic curve, with the greatest changes in the first two years. I’m gonna show you a graph. So here, as you can see, this growth — this is the projected lenticular refractive changes. This is what the lens is going through. So from all the way to 16 diopters and down to plano, over the age of zero to 20. So you try to put a lens in here, or a lens in here, then you’ve got to guesstimate what the patient’s gonna end up, before deciding what lens to put in. So the problems with the current formula — whatever you have — we’re basically acting as a fortune teller. We’re anticipating the ocular growth with significant individual variability. And also, you don’t know what the other eye is doing. There could be a significant difference between different families, with some patients, some families, they have a significant myopia, that’s more prominent in those particular families, versus the others, that’s more prominent with hyperopia. So that curve is just a nomogram. It’s not individualized. And that’s why I’m trying to calculate the IOL, and it can be very challenging, because the shift can be up to 20 diopters. The two schools of thought. One, there’s a group of people that I’ve actually seen who try to go for emmetropia at the time of surgery, which I probably would not recommend, because they would end up with a significant myopic correction later in life. And the other is they undercorrect these patients to a certain extent, which I tend to go with. And aim for 6 to 10 hyperopia. But this is the graph that I actually — everyone has their own graph, and this table — this is a table that I go by. At the age of 1, I try to go for somewhere between 4 and 6 hyperopia, by undercorrecting, by 2, I go for 3.5 to 4, and so on and so on. So the rule of thumb — this is what I do. I just go with the 6 minus the age. So here, at the age of 1, I would go for 4 to 5. But there’s some range here. And when they’re 6, here, actually, it’s +2. So it could be actually somewhere between plano to +2. So which formula? I would just recommend, because of the lack of time, SRT — it’s SRK/T, sorry. That should be K. In most patients is what I would recommend. There’s really no one particular formula that’s far superior, over the others. I’m sorry. I had to give a lot of — kind of like the background. And I’m gonna talk about the surgical technique at the next webinar. And I’m gonna just share two slides, and then I’ll probably end it here. I would recommend: Keep it simple. Simple can be harder than complex, and you have to work hard to get your thinking clean, to make it simple, but it’s worth it at the end, because once you get there, you can move a mountain. And this is actually a quote from Steve Jobs. And I completely agree with that. 100%. So these are the instruments that I use for all cases. Every single case. So I keep it very simple. I think this is key. When I go to some of the other countries, it’s probably even less than that. They actually probably go with even smaller numbers of instruments, with non-disposables, which I think I truly have tremendous respect for. And then watch your posture. I cannot tell you enough. For a lot of the ophthalmologists, we have such a bad posture. You can just look at them, and they just walk around like this. Because we’re so used to working in a very tight space. And when you’re doing these cases, you have to watch your posture. Because more ergonomic you are, the more relaxed you’re gonna be, and your breathing is gonna be better, and you’re gonna enjoy the process. You’re gonna enjoy. So don’t think of this as something — I need to get in there and get out as soon as possible. No, enjoy the process. Enjoy the journey. So I think that is extremely important. And then I’m gonna just talk about the surgical techniques, and why we actually have to do capsulotomy in certain ways, and I’m gonna approach it from a more physics perspective. And how we’re gonna do the — remove the anterior capsule, the posterior capsule, how we did the lensectomy. And then the IOL choices, how do we place the IOL, and I’m gonna show you some videos, of different surgical techniques that I’ve seen over the years, by various surgeons, and I will discuss what I’ve done 20 years ago, and what I’m doing now. That’s different. And then I’ll talk about the surgical management, and how I perform YAG lasers in some of the kids who are not cooperative, and then talk about the vision rehab, vision outcome, and the glaucoma risk, and then strabismus, and finally I’ll finish with the points to remember. And then this is a slide that I probably will share with you again. Don’t try to imitate someone else. You know, one of my favorite quotes by Martin Luther King, especially right now. This is very timely. If you cannot fly, don’t act like you’re gonna fly. Just run. If you cannot run, just walk. And enjoy the walk. And if you can’t even walk, then crawl. And by all means, you need to keep on moving. And enjoy the journey. Someone who crawls does not need to look at someone flying and be envious. What I’m trying to tell you is that: Develop your own surgical technique that feels comfortable, and simplify it and perfect it. So I’m gonna share with you some of the techniques that I do. But take everything I say, and try to convert it into your own style. And don’t try to imitate someone. And that’s where I think, when someone who is supposed to be walking, trying to fly, that’s when you get into trouble. So I will talk about that. Sorry. It’s actually — it’s actually — I’m gonna stop sharing here. We actually have 835 participants. With many questions. I don’t think I’m gonna have time to go over the questions. But I promise you, I will do another webinar. With Orbis. And at that point, I will finish my talk, and then I’ll address many of the questions. And I will answer — I will go through the questions, and I’ll prepare those. I’ll prepare the answers. And then I’ll address them at that point. Is that okay? >> Yep, great. Thank you.

DR SUH: Yeah. Again, I cannot thank you enough. Like I said, I think we had 2300, 2,300 people, who registered. What that means is we’re gonna have many of them probably — they’re gonna be watching this video later. And I hope they enjoy it. But I look forward to seeing you at the second webinar. That we’re gonna plan. I think it’s already — I think we already identified the date. It’s gonna be in August. Okay? >> Yep. We will alert everyone soon on that. Thank you very much.

DR SUH: At that point, I will make my video about 30 minutes. And then I’ll go through 30 minutes of Q and A. >> Perfect. Thank you, Dr. Suh.

DR SUH: Thank you, everyone. I really enjoyed — I hope to — through our international meetings, I hope to get to meet some of you. And I’m truly honored. We actually had participants from all over the world. Literally all over the world. Except for — I think it was North Korea. I was hoping I would find somebody from North Korea. But anyway, thank you very much! And I look forward to talking to you soon.