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How to do a good job in the perioperative management of children with congenital cataract?

Posting time:2022-12-02 06:12:24

How to do a good job in the perioperative management of children with congenital cataract?

Editor's note Congenital cataract is a common eye disease that seriously affects the visual development of infants and young children. For congenital cataracts that significantly affect vision, cataract extraction should be performed as soon as possible, and glasses should be worn after surgery, and amblyopia training should be performed. Because the organs and tissues of infants and young children are not yet fully developed, the reserve capacity of physiological functions is poor, and the treatment methods are different from adults, and their tolerance to surgery is limited. Therefore, perioperative care of infants and young children should be strengthened to increase the success rate of surgery. and reduce complications. Today, the 2022 Vision China International Forum on Vision Health Innovation and Development was held in Xiamen. During the meeting, Professor Zhao Yun'e from the Ophthalmology and Optometry Hospital Affiliated to Wenzhou Medical University gave a lively lecture focusing on the perioperative management of children with congenital cataract. . What are the daunting challenges of surgery for children with congenital cataracts? Preoperative Challenge 1 Due to the poor cooperation of infants and young children, local examinations such as visual function evaluation, slit lamp examination, cataract severity assessment, biological measurement, intraocular pressure measurement, optometry, etc. are difficult to operate, which leads to difficulties in diagnosis and surgical decision-making. . Challenge 2 Because children with congenital cataract may be accompanied by systemic diseases, incomplete heart development, and weak respiratory resistance, full systemic evaluation and preparation are required before surgery. Challenge 1 During the perioperative period, the infant's eyeball is not fully developed, the structure is crowded, and the dilator major muscle is not fully developed, so the pupil is not easy to dilate, and the posterior capsular tear and anterior segment vitrectomy need to be carried out at the same time to prevent postoperative recurrence. Increase the difficulty of surgical operation. Postoperative Challenge 1 Due to the poor cooperation of infants and young children, postoperative examination is difficult, and complications are easily missed. Challenge 2 patients with congenital cataract cannot improve their visual acuity after treatment for a variety of reasons, but the most common reason is neglect of postoperative amblyopia treatment. Therefore, long-term visual function training is required after surgery. The above challenges run through the treatment of congenital cataracts, which lead to patients prone to complications and difficult visual rehabilitation. Careful and patient analysis, full and accurate inspection, and seeking standardized and effective management strategies can provide patients with better diagnosis and treatment plans and bring more benefits. good postoperative results. How to meet these challenges? The standardized management of the perioperative period cannot be overemphasized. Preoperative: examination, diagnosis, preoperative preparation examination and diagnosis: to judge whether it is a cataract? It is very important to ask the medical history. Carefully inquire about the family history of the child, gaze situation, mobility, whether there is photophobia, squinting, tilting the head and so on. Careful inspection is also very important. Vision, eye position, and nystagmus are indispensable. The pupils must be dilated during the inspection. The inspection methods can be direct ophthalmoscopy, slit lamp, B-ultrasound, and Doppler ultrasound if necessary. What should I do if my baby doesn't cooperate? Look into your eyes when you are awake, look inside your eyes when you are asleep. Try to improve the examination as much as possible in order to obtain an accurate diagnosis. Prof. Zhao Yun'e examines the indications and contraindications of surgery for children: Do you want surgery? When is the surgery? Dense visual axis opacities greater than 3mm, once found, surgery as soon as possible, within 6-8 weeks. There are obvious obstacles to fundus examination and refraction examination in such patients. Non-dense axial opacities and lamellar opacities can be treated with mydriasis to monitor cataract progression and axial development. For monocular cataracts, the timing of surgery should be advanced appropriately, 4-6 weeks in severe cases. It should also be noted that surgery within one month greatly increases the risk of glaucoma. If systemic disease is present, consultation and general assessment are required. While waiting for the operation, give guidance on precautions; conduct anesthesia consultation and assessment, and explain the precautions before and after anesthesia; communicate with the family members of the child before operation, and explain the possible risks and benefits of the operation; provide postoperative nursing education and guidance, and explain the postoperative Precautions. Routine measurements are required once surgery has been decided, whether or not an IOL has been implanted. For example, after intranasal sedation, measure the eye axis, corneal curvature, corneal thickness, and intraocular pressure to understand these baseline data and provide reference for future eye axis growth, intraocular pressure changes, and optometry. After general anesthesia, the corneal diameter was measured and the angle of the chamber was checked. Corneal diameter measurement can identify whether it is a small cornea, which can be used as a reference for implantation of IOL; the development of angle examination may have a prediction and reminder for future glaucoma. Check the condition of the chamber angle During operation: check and safety During the operation, the first priority is to ensure the patient's eye safety and systemic safety; carefully check the operation eye before operation; ensure the safety of the operation field during operation; 23G lens incision + anterior vitrectomy (+IOL implantation); during the operation, care should be taken to protect the cornea of ​​the child and reduce the damage to the cornea and other tissues. Postoperative: amblyopia training, complication management and postoperative functional rehabilitation training require optometry + amblyopia training. Optometry, optometry every 3 months within the age of 3. For monocular aphakia, RGP is recommended, covering the contralateral healthy eye, or a relatively good eye, basically covering half of the month's age. What should I pay attention to after optometry? ①Postoperative aphakia: optometry the next day, if the corneal curvature of both eyes is close to the axis of the eye, order glasses directly (glasses production takes time). ② Intraocular lens: generally residual hyperopia, the degree is not high. Optometry the day after the first eye surgery, refraction the next day after the second eye surgery, and optometry 1 week after the surgery. If the difference between the two degrees is relatively large, it can be slightly delayed. Postoperative complication management Complications that may exist in the early postoperative period include bacterial endophthalmitis, incision leakage and low intraocular pressure, anterior chamber inflammation and exudation, and hormone-induced intraocular hypertension. Complications such as VAO, PCO, intraocular lens clamping, displacement, glaucoma, and mesh detachment may occur in the mid-to-long term after surgery. Coping strategies for postoperative complications: prescribed medication during operation, standardized operation during operation, and standardized inspection after operation ① Regular monitoring of intraocular pressure, combined with changes in axial axis and refractive status, timely detection of glaucoma or suspected glaucoma; regular B-ultrasound And fundus photography to understand the fundus situation. ②Prevention and treatment of visual axis area opacity (VAO): strong anti-inflammatory and active pupils can reduce the incidence of VAO. VAO can be treated with YAG laser, but anterior vitrectomy is required if laser is not available. ③ Another very important point is that the implantation position of the intraocular lens - implantation in the capsular bag is an important guarantee for the long-term stability of the intraocular lens. It is concluded that congenital cataract surgery is related to the bright future and future of children, and it is necessary to be responsible, rigorous and serious. Think carefully before the operation, fully and strictly grasp the indications of the operation, understand the characteristics of the operation, carefully check and design the operation, weigh the pros and cons, and act according to the technical capabilities. Careful management after surgery, close observation of the cornea, pupil, intraocular lens, measurement of intraocular pressure, eye axis, fundus, B-ultrasound examination, to prevent complications. On the basis of accurate refractive correction, persistent eyeglass fitting, amblyopia training, and eye position correction are required. Prof. Zhao Yun'e, combined with her valuable diagnosis and treatment experience, edited the popular science monograph "Searching for the Light - The Medical Path of Congenital Cataract", and put forward her own expectations for "early detection, early treatment, and correct diagnosis and treatment" of congenital cataract. I hope that parents who have a premature baby at home can understand how to better take care of the premature baby through this book, help the baby get more timely and standardized treatment, and look forward to a bright future together with the baby. "Let's work together with parents to protect the light of children!"

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