A randomized clinical trial comparing contact lens with intraocular lens correction of monocular aphakia during infancy: grating acuity and adverse events at age 1 year

Incidence and predisposing factors of intraocular Lens tilt following secondary ciliary sulcus implantation in children: An ultrasound biomicroscopic study

PURPOSE

To evaluate the incidence and causes of intraocular lens (IOL) tilt and changes in anterior chamber angle after secondary IOL sulcus implantation following congenital cataract removal.

METHODS

A retrospective observational study was conducted on children who underwent secondary sulcus IOL implantation following pediatric cataract removal in the period from 2017-2020 in Cairo university Hospitals. Children were examined for IOL position, centration, and tilt. Intraocular pressure (IOP) measurement, fundus and gonioscopic examination was performed. Ultrasound biomicroscopy (UBM) was performed on both eyes in children with clinically detected tilt.

RESULTS

Ciliary sulcus secondary IOL implantation was performed in 102 eyes (57 children). IOL tilt was detected clinically in 16 eyes of 14 children (15.7%). UBM showed clinically undetected tilt in the fellow eye in additional 4 eyes. The mean angle of tilt was 12.8 ± 3.9° in clinically detected tilt compared to 7.5 ± 1.2° in UBM detected tilt. Mean anterior chamber depth (ACD) was 2.4 ± 0.5 mm IOP was >21 mmHg in 1.9% of eyes. Narrowing of the anterior chamber angle (ACA) after sulcus implantation occurred in 40% of eyes with open angle. Sulcus proliferations and obliterated sulcus were detected in all 20 eyes. Sommering's ring was found in 7 eyes (35%). Axial length, corneal diameter, and presence of persistent fetal vasculature did not affect IOL position.

CONCLUSION

The presence of residual lens matter or an obliterated ciliary sulcus is associated with a higher incidence of IOL malposition following ciliary sulcus implantation.

Complications, Visual Acuity, and Refractive Error 3 Years after Secondary Intraocular Lens Implantation for Pediatric Aphakia

PURPOSE

To report the cumulative incidence of complications and to describe refractive error and visual acuity (VA) outcomes in children undergoing secondary intraocular lens (IOL) implantation after previous surgery for nontraumatic cataract.

DESIGN

Pediatric cataract registry.

PARTICIPANTS

Eighty children (108 eyes: 60 bilateral, 48 unilateral) undergoing lensectomy at younger than 13 years of age.

METHODS

Annual data collection from medical record review through 5 years after lensectomy.

MAIN OUTCOME MEASURES

Cumulative incidence of newly emergent complications after secondary IOL implantation; refractive error and VA by 5 years after lensectomy.

RESULTS

Median follow-up after secondary IOL implantation was 2.7 years (interquartile range [IQR], 0.8-3.3 years; range, 0.6-5.0 years) for bilateral and 2.1 years (range, 0.5-6.4 years) for unilateral cases. A common complication after secondary IOL implantation was a glaucoma-related adverse event (GRAE; glaucoma or glaucoma suspect); the cumulative incidence was 17% (95% confidence interval [CI], 3%-29%) in bilateral cases and 12% (95% CI, 0%-23%) in unilateral cases. The cumulative incidence of surgery for visual axis opacification was 2% (95% CI, 0%-7%) for bilateral cases and 4% (95% CI, 0%-10%) for unilateral cases. The median prediction error within 90 days of implantation was 0.88 diopter (D; IQR, -0.50 to +3.00 D) less hyperopic than intended among 21 eyes for bilateral cases and 1.50 D (IQR, -0.25 to +2.38 D) less among 19 unilateral cases. The median spherical equivalent refractive error at 5 years (at a median of 5.1 years of age) in eyes receiving a secondary IOL was +0.50 D (IQR, -2.38 to +2.94 D) for 48 bilateral cases and +0.06 D (IQR, -2.25 to +0.75 D) for 22 unilateral cases. Median monocular VA at 5 years was 20/63 (IQR, 20/50-20/100) for bilateral cases (n = 42) and 20/400 (IQR, 20/160-20/800) for unilateral cases (n = 33).

CONCLUSIONS

Eyes with secondary IOL implantation have a risk of developing new GRAEs. Five years after lensectomy (approximately 2.5 years after secondary IOL implantation), the average refractive error was less hyperopic than desired given the anticipated further myopic shift before refraction stabilizes.

FINANCIAL DISCLOSURE(S)

Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.

Management of Contact Lenses and Visual Development in Pediatric Aphakia

Congenital cataract is among the main causes of treatable vision loss in childhood. The first weeks and months of life are a critical time for the development of vision. Therefore, early cataract surgery and effective multifaceted treatment of the resulting aphakia in the early stages of life are of great value for the management of vision development. Among the treatment models, contact lenses (CL) have an important place in infancy and early childhood up to the age of 2 years. Although good visual gains were not considered very likely, especially in unilateral aphakia, important steps have been taken in the treatment of pediatric aphakia thanks to the surgical techniques developed over time and the increasing experience with optical correction systems, especially CLs. This review examines current developments in the types of CL used in pediatric aphakia, their application features, comparison with other optical systems, the features of amblyopia treatment in the presence of CL, and the results obtained with family compliance to CL wear and occlusion therapy in the light of existing studies.

Long-term Prognosis of Pediatric Ocular Disease

Several problems differentiate the treatment of children, especially those with congenital ocular disease, from adults, including the absence of complaints and the complication of systemic diseases. However, the most challenging is the continuing developing anatomical and functional development and immaturity in children. Consequently, the timing of disease onset and treatment can greatly affect the prognosis, and the prognosis cannot be confirmed without long-term follow-up periods. The prognosis for unilateral congenital cataract is very poor. However, some cases achieved good vision with successful refractive correction and amblyopia therapy, suggesting that long-term parental enthusiasm and adherence are important for the visual prognosis. Penetrating keratoplasty is rarely performed in children, and outcomes at our hospital have been extremely poor for congenital corneal opacity over the past 28 years. The visual prognosis is also poor for large limbal dermoids approaching the center of the cornea, which did not respond to preoperative amblyopia therapy. Consequently, early excision, lamellar keratoplasty, wearing of hard contact lenses, and amblyopia therapy were considered necessary. Treatment of pediatric ocular disease should consider the pros and cons, methods, and timing, especially the development of the pediatric eye and the time of onset of the disease.

What we have learned from the Infant Aphakia Treatment Study: The 49th Annual Frank D. Costenbader Lecture

Unilateral congenital cataracts lead to deprivation amblyopia, which can be severe. Until the 1970s, they were believed to be always associated with poor visual outcomes. However, advances in our understanding of the plasticity of the infant brain and the development of better surgical techniques allowed good visual outcomes to be obtained in a few of these patients. The Infant Aphakia Treatment Study (IATS) was conducted to provide empirical evidence regarding the best type of optical correction to be used following surgical extraction of the cataract. Specifically, infants were randomly assigned to either be left aphakic and to wear contact lenses or an intraocular lens (IOL) was implanted and the residual refractive error was corrected with spectacles. The study found that good visual acuity and stereopsis could be achieved in some patients in both treatment groups. Early cataract surgery, consistent optical correction and part-time patching of the fellow eye are important elements needed to achieve good visual outcomes. However, excess patching of the fellow eye may interfere with the development of stereopsis. More adverse events occurred after IOL implantation, particularly visual axis opacification, compared with the infants who were left aphakic. Glaucoma-related adverse events occurred in 40% of eyes after a 10-year follow-up and were not associated with IOL implantation. Further research is needed to increase the percentage of children with unilateral congenital cataracts who achieve good visual outcomes.

Complications Occurring Through 5 Years Following Primary Intraocular Lens Implantation for Pediatric Cataract

Importance

Lensectomy with primary intraocular lens (IOL) implantation is often used in the management of nontraumatic pediatric cataract, but long-term data evaluating the association of age and IOL location with the incidence of complications are limited.

Objective

To describe the incidence of complications and additional eye surgeries through 5 years following pediatric lensectomy with primary IOL implantation and association with age at surgery and IOL location.

Design, Setting, and Participants

This prospective cohort study used Pediatric Eye Disease Investigator Group cataract registry data from 61 institution- and community-based practices over 3 years (June 2012 to July 2015). Participants were children younger than 13 years without baseline glaucoma who had primary IOL implantation (345 bilateral and 264 unilateral) for nontraumatic cataract. Data analysis was performed between September 2021 and January 2023.

Exposures

Lensectomy with primary IOL implantation.

Main Outcome and Measures

Five-year cumulative incidence of complications by age at surgery (<2 years, 2 to <4 years, 4 to <7 years, and 7 to <13 years) and by IOL location (sulcus vs capsular bag) were estimated using Cox proportional hazards models.

Results

The cohort included 609 eyes from 491 children (mean [SD] age, 5.6 [3.3] years; 261 [53%] male and 230 [47%] female). Following cataract extraction with primary IOL implantation, a frequent complication was surgery for visual axis opacification (VAO) (cumulative incidence, 32%; 95% CI, 27%-36%). Cumulative incidence was lower with anterior vitrectomy at the time of IOL placement (12%; 95% CI, 8%-16%) vs without (58%; 95% CI, 50%-65%), and the risk of undergoing surgery for VAO was associated with not performing anterior vitrectomy (hazard ratio [HR], 6.19; 95% CI, 3.70-10.34; P < .001). After adjusting for anterior vitrectomy at lens surgery, there were no differences in incidence of surgery for VAO by age at surgery (<2 years, HR, 1.35 [95% CI, 0.63-2.87], 2 to <4 years, HR, 0.86 [95% CI, 0.44-1.68], 4 to <7 years, HR, 1.06 [95% CI, 0.72-1.56]; P = .74) or by capsular bag vs sulcus IOL fixation (HR, 1.22; 95% CI, 0.36-4.17; P = .75). Cumulative incidence of glaucoma plus glaucoma suspect by 5 years was 7% (95% CI, 4%-9%), which did not differ by age after controlling for IOL location and laterality.

Conclusions and Relevance

In this cohort study, a frequent complication following pediatric lensectomy with primary IOL was surgery for VAO, which was associated with primary anterior vitrectomy not being performed but was not associated with age at surgery or IOL location. The risk of glaucoma development across all ages at surgery suggests a need for long-term monitoring.

Secondary Intraocular Lens Implantation (IOL) in Children- What, Why, When, and How?

PURPOSE

To provide a comprehensive review on secondary IOL implantation in children who have undergone primary surgery at an early age and are aphakic aiming at answering common dilemmas among pediatric ophthalmologists.

METHOD OF LITERATURE REVIEW

A systematic literature search was done using keywords like secondary intraocular implantation, congenital cataractand surgical aphakia. Various novel case reports, retrospective case studies and review articles covering different aspects of secondary IOL implantation were searched and reviewed using PubMed and Google scholar journal search engines.

RESULTS

This article highlights various aspects of secondary IOL implantation like the appropriate timing should be when the child is entering preschool, with the proper technique being in bag fixation is the most preferred method with least associated complications and the IOL type should be decided based on the fixation site.

CONCLUSION

Secondary IOL implantation can accomplish good and stable long-term outcomes in children. It is the most accepted mode of optical correction once the appropriate age is achieved.

Outcomes of bilateral cataract surgery in children 2-7 years of age: a comparison to surgery in toddlers and infants

PURPOSE

To evaluate the outcomes of bilateral cataract surgery in children 2-7 years of age in our institution and to compare them to the bilateral infant and toddler outcomes of the Toddler Aphakia Pseudophakia Study (TAPS) registry.

METHODS

The medical records of children who underwent bilateral cataract surgery between the ages of 2 and 7 years of age with a minimum of 2 years' postoperative follow-up were reviewed retrospectively. Patients with a history of trauma or subluxated lenses were excluded. Main outcome measures were best-corrected visual acuity, strabismus requiring surgery, adverse events, and reoperations.

RESULTS

A total of 114 eyes of 57 children were included. Median age at surgery was 4.4 years. At the visit closest to 10 years of age, the median best-corrected visual acuity of the better-seeing eye was 0.05 logMAR (20/22); of the worse-seeing eye, 0.18 logMAR (20/30). Strabismus surgery was performed in 1 patient. Among first-operated eyes, adverse events occurred in 4 eyes (7%), which was significantly less than in the TAPS cohort of 1-7 months (P = 0.0001) and the TAPS cohort of 7 months to 2 years (P = 0.01). No eye developed glaucoma or was labeled glaucoma suspect. Unplanned intraocular reoperations were needed in 4 first-operated eyes (3 membranectomy/vitrectomy for removal of opacifications and 1 lysis of vitreous wick).

CONCLUSIONS

Compared to infants and toddlers, bilateral cataract surgery performed between 2 and 7 years of age was associated with significantly fewer adverse events and excellent visual acuity.

Pediatric cataract surgery: Rate of secondary visual axis opacification depending on intraocular lens type

PURPOSE

To assess the time course of secondary visual axis opacification (VAO) that led to additional surgery after primary intraocular lens (IOL) implantation in children and to describe further surgical outcomes. Comparison of different lens types.

DESIGN

Single center, retrospective analysis of children aged 1-14 years who underwent cataract surgery with primary IOL implantation. The surgical technique was either in-bag IOL placement with primary posterior capsulotomy and anterior vitrectomy or bag-in-lens IOL placement. We excluded eyes with visually significant ocular comorbidities.

SUBJECTS

Total of 135 eyes of 95 children. Of these, 64 had received an acrylic three-piece IOL, 51 an acrylic single-piece IOL, and 20 an acrylic single-piece bag-in-lens IOL. The median ages at surgery were 53 months (IQR 35-75), 52 months (27-65), and 60 months (40-84) in the 3-piece, 1-piece, and bag-in-lens group, respectively.

METHODS

Analysis of medical records. We used the Kaplan-Meier method and a cox proportional hazards model with pre-defined adjustments for age at surgery, year of surgery, and socioeconomic deprivation (GISD score by postal code) to analyze VAO-free survival by lens type. Patients were invited to attend a clinical visit to achieve longer follow-ups.

MAIN OUTCOME MEASURES

The rate of survival without VAO that required clearing of the visual axis after cataract surgery with primary IOL implantation. Any other surgical complications.

RESULTS

The overall median follow-up was 19 months (IQR 3-58). There were 13 cases of VAO, occurring at a median of 10 months (IQR 10-12) after surgery. Of these, 1 eye had a 3-piece in-bag IOL, 10 eyes had 1-piece in-bag IOLs, and 2 eyes had bag-in-lens IOLs. The adjusted hazard ratio was 32.8 (95% CI: 3.3-327, p=0.003) for 1-piece acrylic IOLs and 19.6 (1.22-316, p=0.036) for bag-in-lens IOLs, compared to 3-piece acrylic in-bag IOLs. Two eyes with bag-in-lens surgery (10%) had an iris capture. There was one case of endophthalmitis. We found no cases of postoperative retinal detachment or new glaucoma.

CONCLUSIONS

Children with secondary visual axis opacification that required a procedure to clear the visual axis generally presented within fifteen months. Opacification rates were lowest when a 3-piece acrylic IOL was used.

Experiences of Treatment With Contact Lenses in Aphakic Children With Unilateral Congenital Cataract: A Retrospective Study

BACKGROUND AND OBJECTIVES

Congenital cataract is a condition compromising the eye's crystalline lens in infants and is usually diagnosed at birth. It can lead to irreversible vision loss if not promptly detected and treated, especially in unilateral cases. Nowadays, children with congenital cataracts can undergo surgical removal of their opacified crystalline lenses, and visual rehabilitation is mandatory to prevent deep amblyopia. Contact lenses, predominantly of rigid gas-permeable (GP) type, are gaining more popularity for this matter.

METHOD

In this retrospective cohort study, unilateral aphakic children younger than 6 years referred to the Contact Lens Clinic at Farabi Eye Hospital from November 2011 to September 2019 were included.

RESULTS

Seventy-six unilateral aphakic children with congenital cataracts (57.9% boys and 42.1% girls) rehabilitated with GP were studied. The mean age of diagnosis and referral to the contact lens clinic were 20.0±19.8 and 32.0±24.4 weeks, respectively, while the mean follow-up time was 12.44±26.28 months. The mean visual acuity for children capable of cooperating at the last follow-up was 0.98±0.62 log MAR. Among the participants, eight children (9.7%) were diagnosed as glaucoma suspects. The mean initial base curve and power of GP lenses were 7.86±0.39 mm and 23.29±5.52 diopters, respectively. Only 21 parents (27.6%) reported nonadherence to the scheduled part-time patch program.

CONCLUSION

The results of this study showed GP-based optical treatment after early diagnosis, surgical removal of congenital cataracts, and a long-term close follow-up to be well tolerated by children and their parents, with acceptable parents' compliance and can thus be introduced as a safe and effective method to achieve desirable visual outcomes.

Visual outcomes and complications in infantile cataract surgery: a real - world scenario

Objective

To evaluate visual outcomes and complications of infantile cataract surgery through a 1-year follow-up period in a real world scenario.

Methods and analysis

Prospective observational study evaluating infants with cataract undergoing surgery.

Results

We analysed 173 eyes of 97 infants (76 bilateral); median age 18.7 weeks, (IQR: 11–33.9 weeks). Toxoplasmosis, rubella, cytomegalovirus and herpes infection was the most common aetiology in both unilateral 10 (47.6%) and bilateral 43 (55.1%) cases, followed by familial and syndromic cases. Fifty-four eyes (29.5%) received primary intraocular lens (IOL) implantation.

Seventy-five infants (76%) were less than 6 months of age. At 1-year follow-up, mean log MAR best-corrected visual acuity was 1.00±0.08 and 1.21±0.03 in unilateral and bilateral cases respectively (p=0.012), which was not statistically significant. At 1-year follow-up, pseudophakic(1.09±0.05) eyes had a better mean log MAR visual acuity comparing aphakes(1.24±0.04) clinically but was not statistically significant after the application of Bonferroni correction (p=0.012). The mean myopic shift of −2.9 D±0.39 and −4.53 D±0.55 over 1 year was noted in aphakes and pseudophakes, respectively (p=0.016). Visual axis opacification and glaucoma were the most common complications noted in pseudophakes and aphakes, respectively.

Conclusion

Primary IOL implantation in selected cases of infantile cataract is a feasible option, particularly in cases when optimal aftercare and refractive rehabilitation of aphakia are not possible.

Scleral-fixated intraocular lens implants-evolution of surgical techniques and future developments

Varied options are available for the implantation of secondary intraocular lens implants in the absence of zonular or capsular support. Loss of the capsule can occur in the context of complicated cataract surgery, trauma or inherited conditions such as Marfan syndrome or pseudoexfoliation. Approaches to overcome this include optical measures such as the use of spectacles or contact lenses, and surgical therapy incorporating the use of anterior chamber, iris-fixated or scleral-fixated lenses. Surgical techniques to implant scleral-fixated lenses have undergone various modifications, since the first publication of sutured intrascleral fixation described in the 1980s. However, despite the advances in surgical techniques, studies are limited either by their retrospective nature, small sample size and most importantly small duration of follow-up. This comprehensive review aims to amalgamate the evolution of various surgical techniques with regards to intrascleral lens fixation and suggests areas for future development.

Advisability of primary intraocular lens implantation for infants under 2: A systematic review and meta-analysis

PURPOSES

The present meta-analysis compared the postoperative visual performance of primary intraocular lens (IOL) implantation and primary aphakia in cataract infants.

METHODS

PubMed, Embase, Science Direct and Cochrane Library were searched, and postoperative visual acuity (VA) and complications were extracted and pooled.

RESULTS

Three randomised controlled trails (RCTs) and five retrospective studies were included. The postoperative VA of children younger than 4.5 years in primary IOL group was better than that in primary aphakia group [MD = -0.14, 95% CI: (-0.23, -0.06), P = .90]. The subgroup analysis based on RCTs and on unilateral cataract surgery revealed the same result. There was no significant difference in the incidence of glaucoma, strabismus, retinal detachment and nystagmus between primary IOL group and primary aphakia group [OR = 1.02, 95% CI: (0.62, 1.68), P = .48 for glaucoma; OR = 0.76, 95% CI: (0.30, 1.90), P = .05 for strabismus; OR = 0.49, 95% CI: (0.07, 3.30), P = .34 for retinal detachment; OR = 1.26, 95% CI: (0.68, 2.36), P = .92 for nystagmus]. The proportion of patients requiring postoperative visual axis opacification (VAO) clearing was higher in primary IOL group than that in primary aphakia group [OR = 9.22, 95% CI: (4.74, 17.96), P = .16].

CONCLUSION

For infants under 2 years of age, primary IOL implantation would provide more visual benefits compared with primary aphakia did, though the benefits would taper off with the age reaching 4.5 years. Moreover, the current study revealed a higher VAO incidence r in primary IOL implantation group.

Commentary review: challenges of intraocular lens implantation for congenital cataract infants

As an indispensable part of congenital cataract surgery, intraocular lens (IOL) implantation in infantile patients has long-term positive impacts on visual rehabilitation, as well as postoperative complications inevitably. Timing of IOL implantation in infantile congenital cataract patients is not simply a point-in-time but a personalized decision that comprehensively takes age at surgery, risks of postoperative complications, and economic condition of family in consideration, and combines with choosing suitable IOL type and power. For infants with well-developed eyeballs and good systemic conditions, IOL implantation at six months of age or older is safe and effective. Otherwise, secondary IOL implantation may be a safer choice.

Service evaluation: orthoptic-led teaching of soft contact lens handling for parents in the management of pediatric aphakia

To gauge parental satisfaction of an orthoptic-led specialist service for teaching soft contact lens (CL) handling in the management of children with pediatric aphakia. 20 families attending the contact lens clinic completed a satisfaction questionnaire to enquire about their experience of learning how to insert and remove their child's CL. Families were questioned on their experiences with preoperative counseling, practical teaching, additional support and the patient literature that was provided by the orthoptists in the CL clinic. Qualitative data and free comments were analyzed. 18/20 (90%) said they had received good practical insertion and removal teaching. 19/20 (95%) felt they received good emotional support. Only 6/20 (30%) families agreed with the statement that they found learning insertion and removal difficult. 15/20 (75%) families did not feel rushed, and 18/20 (90%) said they could learn at their own pace. All except one family (95%) achieved daily CL handling within a few months, with ongoing support from a multi-disciplinary team. One family surveyed was much earlier in their postoperative journey, but was on track to achieve this imminently. All families (100%) felt they were appropriately counselled preoperatively regarding the need for training and daily CL handling. 95% found the provided written information useful. 8/20 (40%) reported they found insertion harder than removal, 4/20(20%) reported they found removal harder. Teaching insertion and removal skills is an important aspect of managing paediatric aphakia and presents many challenges. Most parents eventually cope well and achieve daily CL handling within a few months, with support from a multi-disciplinary team. Families surveyed were all competent and were satisfied with their experience. The parental satisfaction survey gave our team confidence that our orthoptic-led service works well, orthoptists have the knowledge and skills to provide technical training to parents alongside vital emotional support, and contact lens handling is a rewarding extended role for orthoptists in a multi-disciplinary team.

Safety of intracameral moxifloxacin in the pediatric population: an equivalence study

PURPOSE

To investigate whether the safety of intracameral moxifloxacin (IC-Mox) was equivalent to subconjunctival antibiotics (SC-Abs) in pediatric lens surgery.

SETTING

The Hospital for Sick Children, Toronto, Canada.

DESIGN

Retrospective consecutive cohort study.

METHODS

This equivalence study compared 95% CI in the difference between the preoperative and postoperative safety variables of best corrected visual acuity (BCVA), intraocular pressure (IOP), central corneal thickness (CCT), endothelial cell density (ECD), corneal edema, and anterior chamber (AC) inflammation in IC-Mox with SC-Abs. The zone of clinical equivalence for BCVA was set at ±0.2 logarithm of the minimum angle of resolution, IOP at ±3 mm Hg, CCT at ±30 μm, and ECD at ±400 cells/mm.

RESULTS

The charts of 358 patients undergoing lens-related surgeries were reviewed. Of 317 eyes (215 patients) included, 170 eyes received IC-Mox and 147 eyes had SC-Abs. The mean age was 4.9 and 5.1 years with a mean follow-up of 19 and 34.4 months (P < .001) in IC-Mox and SC-Ab groups, respectively. The 95% CIs for the change from preoperative to postoperative safety parameters between IC-Mox and SC-Abs were all in the zones of clinical equivalence (BCVA, P = 0.75; highest IOP in the first 6 weeks postoperatively, P = 0.27; IOP at the last visit, P = 0.74; CCT, P = 0.89; and ECD, P = 0.76). During the first 6 weeks postoperatively, there was no difference in corneal edema (P = .69) and AC flare (P = .4) between IC-Mox and SC-Ab groups, whereas AC cellular activity was significantly higher in the SC-Ab group (P = .028).

CONCLUSIONS

IC-Mox prophylaxis in pediatric patients showed equivalent postoperative safety outcomes when compared with SC-Abs. The use of IC-Mox (250 μg) for endophthalmitis prophylaxis appears to be safe in the pediatric population.

The Myopic Shift in Aphakic Eyes in the Infant Aphakia Treatment Study After 10 Years of Follow-up

OBJECTIVES

To report the myopic shift in the aphakic eyes of a cohort of children who underwent unilateral cataract surgery during infancy and were then followed longitudinally for 10.5 years.

METHODS

One-half of the children enrolled in the Infant Aphakia Treatment Study (IATS) were randomized to aphakia and contact lens correction after unilateral cataract surgery. They then underwent ocular examinations using standardized protocols at prescribed time intervals until age 10.5 years.

RESULTS

Thirty of 57 children randomized to aphakia remained aphakic at age 10.5, having undergone unilateral cataract surgery at a median age of 1.6 (IQR: 1.1-3.1) months. The median refractive error (RE) in the 57 eyes randomized to aphakia immediately after cataract surgery was 19.01 D (IQR: 16.98-20.49) compared to 10.38 D (IQR: 7.50-14.00) for the 30 eyes that remained aphakic at age 10.5 years. The mean change in RE in aphakic eyes was -2.11 D/year up to age 1.5 years, -0.68 D/year from 1.5 to 5.0 years, and -0.35 D/year from age 5 to 10.5 years. At age 10.5 years, 18 patients continued to wear a contact lens correction (silicone elastomer, n=6; gas permeable, n=6; hydrogel, n=5; and silicone hydrogel, n=1) (median RE, 12.50 D), 9 wore only spectacles (median RE, 4.00 D), and 4 wore no correction (median RE, 11.25 D) to correct their aphakic eye.

CONCLUSIONS

The RE in aphakic eyes decreased by 44% from infancy to age 10.5 years. About two-thirds of children who remained aphakic at age 10.5 years continued to wear a contact lens.

Outcomes of secondary intraocular lens implantation in the Infant Aphakia Treatment Study

PURPOSE

To report outcomes of secondary intraocular lens (IOL) implantation in the Infant Aphakia Treatment Study (IATS).

SETTING

Multicenter clinical practice.

DESIGN

Secondary analysis of patients enrolled in a randomized clinical trial.

METHODS

Details regarding all secondary IOL surgeries conducted in children enrolled in the IATS were compiled. Visual outcomes, refractive outcomes, and adverse events at the age of 10½ years were evaluated. Comparisons were made with eyes that remained aphakic and with eyes randomized to primary IOL placement.

RESULTS

The study included 114 infants, 57 in the aphakic group and 57 in the primary IOL group; 55 of 57 patients randomized to aphakia with contact lens correction were seen for the 10½-year study visit; 24 (44%) of 55 eyes had secondary IOL surgery. Median age at IOL surgery was 5.4 years (range 1.7 to 10.3 years). Mean absolute prediction error was 1.00 ± 0.70 diopters (D). At age 10½ years, the median logarithm of the minimum angle of resolution visual acuity (VA) was 0.9 (range 0.2 to 1.7), similar to VA in the 31 eyes still aphakic (0.8, range 0.1 to 2.9); the number of eyes with stable or improved VA scores between the 4½-year and 10½-year study visits was also similar (78% secondary IOL eyes; 84% aphakic eyes). For eyes undergoing IOL implantation after the 4½-year study visit (n = 22), the mean refraction at age 10½ years was -3.20 ± 2.70 D (range -9.90 to 1.10 D), compared with -5.50 ± 6.60 D (n = 53, range -26.50 to 3.00 D) in eyes with primary IOL (P = .03).

CONCLUSIONS

Delayed IOL implantation allows a more predictable refractive outcome at age 10½ years, although the range of refractive error is still large.

Clinical characteristics and treatment of secondary glaucoma, glaucoma suspects and ocular hypertension after congenital cataract surgery

OBJECTIVE

To evaluate changes in intraocular pressure after congenital cataract surgery in a real-world setting.

METHODS

This retrospective case series included all children aged 0-2 years undergoing lens extraction due to congenital cataract. Development of an elevated intraocular pressure was divided into three groups: secG, suspG and OHT. Further, risk factors for IOP changes, the therapeutic approach and functional outcome were assessed during follow-up.

RESULTS

One hundred and sixty-one eyes of 110 patients aged 0-2 years were included, whereof 29 eyes of 17 children developed secondary glaucoma (secG; 11 eyes/8 patients), glaucoma suspect (suspG; three eyes/three patients) or ocular hypertension (OHT; 15 eyes/10 patients). No difference in surgrical procedure (p = 0.62) was found, but age at cataract surgery differed significantly (p = 0.048), with the secG group (1.74 ± 1.01 months) being the youngest (suspG: 3.93 ± 1.80 months; OHT group: 5.91 ± 5.36 months).Secondary surgical intervention was significantly higher in the secG (4.64 ± 3.41) followed by the suspG (2.00 ± 2.65) and OHT groups (0.40 ± 0.74; p < 0.001). Postoperative complications including nystagmus (p = 0.81), strabismus (p = 0.98) and amblyopia (p = 0.73) showed no difference, in contrast to visual axis obscuration which was more common in the secG group (p = 0.036).

CONCLUSION

Initial lensectomy and anterior vitrectomy procedure together with or without IOL implantation seems to have no influence for the development of IOP changes after pediatric cataract surgery. However, children who developed secondary glaucoma had cataract surgery significantly earlier, within the first 2-3 months of life. Glaucoma surgery was required to achieve final IOP control in most eyes. The development of secondary glaucoma was also associated with a significant increase in surgical re-treatments.

Update on Intraocular Lens Formulas and Calculations

Investigators, scientists, and physicians continue to develop new methods of intraocular lens (IOL) calculation to improve the refractive accuracy after cataract surgery. To gain more accurate prediction of IOL power, vergence lens formulas have incorporated additional biometric variables, such as anterior chamber depth, lens thickness, white-to-white measurement, and even age in some algorithms. Newer formulas diverge from their classic regression and vergence-based predecessors and increasingly utilize techniques such as exact ray-tracing data, more modern regression models, and artificial intelligence. This review provides an update on recent literature comparing the commonly used third- and fourth-generation IOL formulas with newer generation formulas. Refractive outcomes with newer formulas are increasingly more and more accurate, so it is important for ophthalmologists to be aware of the various options for choosing IOL power. Historically, refractive outcomes have been especially unpredictable in patients with unusual biometry, corneal ectasia, a history of refractive surgery, and in pediatric patients. Refractive outcomes in these patient populations are improving. Improved biometry technology is also allowing for improved refractive outcomes and surgery planning convenience with the availability of newer formulas on various biometry platforms. It is crucial for surgeons to understand and utilize the most accurate formulas for their patients to provide the highest quality of care.

Long-term Effect of Intraocular Lens vs Contact Lens Correction on Visual Acuity After Cataract Surgery During Infancy: A Randomized Clinical Trial

Importance

Although intraocular lenses (IOLs) are often implanted in children, little is known whether primary IOL implantation or aphakia and contact lens correction results in better long-term visual outcomes after unilateral cataract surgery during infancy.

Objective

To compare long-term visual outcomes with contact lens vs IOL correction following unilateral cataract surgery during infancy.

Design, Setting, and Participants

This multicenter randomized clinical trial enrolled 114 infants with a unilateral congenital cataract who underwent cataract surgery with or without primary IOL implantation between 1 and 6 months of age. Data on long-term visual outcomes were collected when the children were age 10.5 years (July 14, 2015, to July 12, 2019) and analyzed from March 30 through August 6, 2019.

Interventions

Intraocular lens implantation at the time of cataract surgery.

Main Outcomes and Measures

Best-corrected visual acuity using the electronic Early Treatment Diabetic Retinopathy Study (E-ETDRS) testing protocol. Analysis was performed on an intention-to-treat basis.

Results

Best-corrected visual acuity was measured at age 10.5 years for 110 of the 114 patients (96%) enrolled as infants. The participants included 58 girls (53%) and 52 boys (47%). Overall, 27 of the children (25%) had good (logMAR 0.30 [Snellen equivalent, 20/40] or better) visual acuity in the treated eye (12 [22%] in the IOL group and 15 [27%] in the aphakia group), but 50 children (44%) had a visual acuity of logMAR 1.00 (Snellen equivalent, 20/200) or worse (25 [44%] in the IOL group and 25 [44%] in the aphakia group). The median logMAR acuity in the treated eye was similar in children randomized to receive an IOL at the time of cataract extraction (0.89; interquartile range [IQR], 0.33-1.43 [Snellen equivalent, 20/159]) and those who remained aphakic (0.86; IQR, 0.30-1.46 [Snellen equivalent, 20/145]) (IQR, 0.30-1.46; P = .82). Although the overall difference in median visual acuity between the 2 groups was small, the estimate was imprecise (99% CI for the difference in medians was -0.54 to 0.47).

Conclusions and Relevance

As in previous phases of the study, visual acuity outcomes were highly variable with only 27 children (25%) achieving excellent visual acuity in their treated eye and 50 children (44%) having poor vision in the treated eye. Implanting an IOL at the time of cataract extraction was neither beneficial nor detrimental to the visual outcome.

Trial Registration

ClinicalTrials.gov Identifier: NCT00212134.

Visual Acuity and Ophthalmic Outcomes in the Year After Cataract Surgery Among Children Younger Than 13 Years

Importance

Cataract is an important cause of visual impairment in children. Outcomes reported from a large clinical disease-specific registry can provide real-world estimates of visual outcomes and rates of adverse events in clinical practice.

Objective

To describe visual acuity and refractive error outcomes, as well as rates of amblyopia, glaucoma, and additional eye surgery, during the first year after lensectomy in children.

Design, Setting, and Participants

A prospective observational study was conducted from June 18, 2012, to July 8, 2015, at 61 pediatric eye care practices among 880 children younger than 13 years at the time of lensectomy in at least 1 eye with follow-up within 15 months after surgery. Statistical analysis was performed from December 12, 2016, to December 14, 2018.

Exposures

Lensectomy with or without implantation of an intraocular lens.

Main Outcomes and Measures

Visual acuity as well as rates of amblyopia, glaucoma, suspected glaucoma, and other intraocular surgery.

Results

Among the 880 children (432 girls and 448 boys; mean [SD] age at annual follow-up, 4.9 [3.8] years) in the study, lens surgery was bilateral in 362 (41.1%; 95% CI, 37.9%-44.4%) children and unilateral in 518 (58.9%; 95% CI, 55.6%-62.1%). An intraocular lens was implanted in 654 of 1132 eyes (60.2%; 95% CI, 57.0%-63.4% [proportions reported for eye-level outcomes account for the potential correlation induced by enrolling both eyes of some individuals; for participants who received bilateral surgery, these numbers will differ from the quotient of the number of cases divided by the total sample size]). Amblyopia was identified in 449 children (51.0%; 95% CI, 47.7%-54.3%). In children age 3 years or older, mean visual acuity was 0.30 logMAR (about 20/40) in 153 bilateral pseudophakic eyes, 0.49 logMAR (about 20/63) in 141 unilateral pseudophakic eyes, 0.47 logMAR (about 20/63) in 21 bilateral aphakic eyes, and 0.61 logMAR (about 20/80) in 17 unilateral aphakic eyes. Mean visual acuity improved with older age at surgery in eyes with bilateral pseudophakia by 0.2 logMAR line (99% CI, 0.02-0.4; P = .005) and by 0.3 logMAR line (99% CI, 0.04-0.60; P = .004) in eyes with unilateral pseudophakia. A new diagnosis of glaucoma or suspected glaucoma was made in 67 of 1064 eyes that did not have glaucoma prior to lensectomy (5.9%; 95% CI, 4.6%-7.7%); 36 of 273 eyes with bilateral aphakia (13.2%; 95% CI, 9.0%-19.0%), 5 of 308 eyes with bilateral pseudophakia (1.5%; 95% CI, 0.6%-4.2%), 14 of 178 eyes with unilateral aphakia (7.9%; 95% CI, 4.7%-12.8%), and 12 of 305 eyes with unilateral pseudophakia (3.9%; 95% CI, 2.2%-6.8%). Additional intraocular surgery, most commonly vitrectomy or membranectomy to clear the visual axis, was performed in 189 of 1132 eyes (17.0%; 95% CI, 14.8%-19.6%).

Conclusions and Relevance

Amblyopia was frequently observed during the first year after lensectomy in this cohort of children younger than 13 years. For children age 2 years or older at surgery visual acuity was typically less than normal for age and was worse with unilateral cataract. Management of visual axis obscuration was the most common complication requiring surgical intervention during the first year after surgery.

Rigid Gas-Permeable Contact Lenses Fitting Philosophy for Unilateral Aphakic Infants

PURPOSE

To provide fitting guidelines with suggested powers and base curves (BCs) and diameters for initial rigid gas-permeable (RGP) contact lenses (CLs) selection for unilateral aphakic infants based on age.

METHODS

Records of 52 children (52 eyes) with RGP CLs to unilateral aphakia between 2014 and 2019 were evaluated. Refractive status was assessed by standard retinoscopy. The original BC and diameter were determined by keratometric readings and fluorescein pattern under sedation. Correlation analysis was performed between age and CLs parameters. Linear regression analysis was used to develop a model for estimating power with the help of infant's age. Subgroup analysis was performed by grouping the eyes into four groups according to age. Lens adjustments and adverse events were also evaluated.

RESULTS

The median age was 9.0 months (interquartile range [IQR], 5.25-13.0 months). The mean power and BC and diameter of the initial RGP CLs were 25.46±4.83 diopters, 7.57±0.40 mm, and 9.48±0.23 mm, respectively. All these parameters showed correlations with infant's age (Pearson r=-0.676, 0.367, and 0.497, respectively; P=0.000, 0.008, and 0.000, respectively). Regression analysis revealed that CL power =31.66 to 0.62×age (P<0.001). The median follow-up was 7.50 months (IQR, 3.0-11.0 months). Lens adjustments took about every 3 months before 1 year of age and every 5 months afterward (F=3.442; P=0.024). The RGP CLs provided ideal fit characteristics, and no severe lens-related adverse event occurred except only one patient had mild conjunctivitis.

CONCLUSIONS

Our empirical RGP CLs fitting philosophy presented that aphakic infant's age can be used to determine the initial lens if accurate biometry cannot be obtained initially.

Association of Contact Lens Adherence With Visual Outcome in the Infant Aphakia Treatment Study: A Secondary Analysis of a Randomized Clinical Trial

Importance

Although contact lenses have been used for decades to optically correct eyes in children after cataract surgery, there has never been a prospective study looking at contact lens adherence in children with aphakia, to our knowledge.

Objective

To evaluate contact lens adherence and its association with visual outcome in a cohort of children treated for unilateral cataract surgery.

Design, Setting, and Participants

Secondary analysis of a multicenter randomized clinical trial of 57 infants born from August 22, 2004, to April 25, 2008, who were randomized to 1 of 2 treatments and followed up to age 5 years. Data analysis was performed from August 9, 2016, to December 7, 2017.

Interventions

Unilateral cataract extraction and randomization to implantation of an intraocular lens vs contact lens to correct aphakia.

Main Outcomes and Measures

Contact lens adherence was assessed by a 48-hour recall telephone interview that was administered every 3 months starting 3 months after surgery to age 5 years. A traveling examiner assessed visual acuity in patients at aged 4.5 years. Adherence to prescribed contact lens use was estimated as the mean percentage of waking hours as reported in 2 or more interviews for each year of life.

Results

Of 57 infants who were randomized to contact lens treatment, 32 (56%) were girls, and 49 (86%) were white. A total of 872 telephone interviews were completed. In year 1, a median of 95% participants wore their contacts lenses nearly all waking hours (interquartile range [IQR], 84%-100%); year 2, 93% (IQR, 85%-99%); year 3, 93% (IQR, 85%-99%); year 4, 93% (IQR, 75%-99%); and year 5, 89% (IQR, 71%-97%). There was a tendency for poorer reported adherence at older ages (F = 3.86, P < .001). No differences were identified when the results were analyzed by sex, insurance coverage, or age at cataract surgery. Using linear regression, children who wore the contact lens for a greater proportion of waking hours during the entire study period tended to have better visual acuity at age 4.5 years, even after accounting for adherence to patching (partial correlation = -0.026; P = .08).

Conclusions and Relevance

These results confirm that it is possible to achieve a high level of aphakic contact lens adherence over a 5-year period in children.

Trial Registration

clinicaltrials.gov Identifier: NCT00212134.

Visual outcome and surgical results in children with Marfan syndrome

IMPORTANCE

To determine visual and surgical results in children with Marfan syndrome.

BACKGROUND

Marfan syndrome involves ocular complications which can lead to visual disturbance and amblyopia. Data about the visual and surgical results in children with Marfan syndrome is vital for the clinical management of these patients.

DESIGN

Retrospective data analysis.

PARTICIPANTS

Eighty-two eyes of 41 patients with a genetically proved diagnosis of Marfan syndrome.

METHODS

Medical records of patients with Marfan syndrome were reviewed between 2007 and 2017. Ocular complications, visual acuity (VA) of patients with/without lensectomy and surgical method were evaluated.

MAIN OUTCOME MEASURES

VA outcomes of patients with Marfan syndrome with/without surgical repair of ectopia lentis.

RESULTS

In 27 (66%) of the 41 patients a bilateral subluxation of the lens was visible and 14 (52%) patients received lensectomy. The mean age at initial presentation was 12.3 ± 9 years and mean follow-up was 3 years (range 1-7). VA varied from 1.2 to -0.1 logMAR at first examination. At initial presentation, mean VA was 0.1 ± 0.7 logMAR in patients with a normal lens status (n = 14) and 0.3 ± 0.5 logMAR in patients with subluxation of the lens (n = 27) (P < .01). VA improved from 0.2 ± 0.5 logMAR to 0.1 ± 0.5 logMAR (P = .06) in children with subluxation of the lens who did not need a lensectomy (n = 12) and from 0.5 ± 0.5 logMAR to 0.2 ± 0.5 logMAR (P = .02) in patients who were referred to lensectomy with/without secondary lens implantation.

CONCLUSIONS AND RELEVANCE

In Marfan syndrome subluxation of the lens was found in the majority of children. Improvement of VA resulted in children with subluxation of the lens and following lensectomy.

Primary IOL implantation in children: the effect of the Infant Aphakia Treatment Study on practice patterns

We report the long-term effects on practice patterns at a single institution before (1995-2004) and after (2009-2018) publication of the results of the Infant Aphakia Treatment Study (IATS). The medical records of children <7 months of age who underwent cataract surgery at the Medical University of South Carolina were reviewed. The main outcome measure was the treatment with primary IOL or primary aphakia at the time of surgery. A total of 273 eyes of 183 patients were analyzed. Of the unilaterally affected eyes, primary IOL was the treatment of choice in 28 of the pre-IATS cases (61%) and 3 of the post-IATS cases (6%). In bilaterally affected eyes, primary IOL was the treatment of choice in 18 of the pre-IATS cases (47%) and 11 of the post-IATS cases (23%). According to a year-wise calculation, treatment with primary IOL began to decrease in 2010 and 2011, following publication of the 1-year results of the IATS in 2010. A drastic decrease in primary IOL occurred in 2015, following publication of the 5-year results.

Mushroom keratoplasty and contact lens application: Strategy for management of a pediatric eye injury

We show the challenging visual rehabilitation of a penetrating eye injury in a child with wide central corneal scar and aphakia. A 9-year-old male patient underwent combined surgery, including membranectomy with pupilloplasty and mushroom penetrating keratoplasty. Corneal transparency was restored; aphakia and irregular astigmatism were corrected first with a rigid gas-permeable contact lens (CL) and then, successfully, with hybrid CL. We discuss the surgical treatment used to restore corneal transparency and the choice of the best CL to overcome irregular astigmatism and aphakia.

Elevated intraocular pressure in paediatric cataract surgery in a reference centre

OBJECTIVE

To study elevated postoperative intraocular pressure (PIOP) after paediatric cataract surgery in a reference centre and to compare the results obtained with the most relevant world literature.

MATERIALS AND METHODS

A retrospective observational study was conducted, collecting information from clinical records of 99 patients (142 eyes) operated on due to unilateral or bilateral paediatric cataracts between 2000 and 2008.

RESULTS

The proportion of eyes with PIOP≥20mmHg and bilateral cataracts was higher, 79.3%, than the proportion of eyes with PIOP≥20mmHg and a unilateral cataract, 20.7% (P=.032). The proportion of eyes with PIOP≥20mmHg between the eyes with cataract surgery before one month of age was higher, 50%, than between the eyes in which the cataract surgery was performed after one month of age, 17.2% (P=.009). PIOP values≥20mmHg were associated with a lower best corrected visual acuity at 5 years after cataract surgery (P=.020). The proportion of eyes with PIOP≥20mmHg and without intraocular lenses was higher, 69%, than the proportion of eyes with PIOP≥20mmHg and intraocular lenses, 31% (P<.001).

CONCLUSIONS

A PIOP>20mmHg was observed in 20.4% of eyes in a 5-year follow-up period, appearing more frequently in eyes with bilateral cataract than unilateral, and in aphakic eyes more than pseudophakic eyes. Elevation of the PIOP was associated with the performance of cataract surgery at early ages.

Pediatric Nd:YAG laser capsulotomy in the operating room: review of 87 cases

AIM

To report a large series of children having Nd:YAG laser capsulotomy in the operating room using the lateral decubitus position.

METHODS

Medical records of children who underwent Nd:YAG laser capsulotomy in the operating room at Ann & Robert H. Lurie Children's Hospital of Chicago between September 2008 and April 2017 were reviewed. Induction of general anesthesia and intubation was performed in the supine position after which the patient was placed in lateral decubitus position. The Nd:YAG laser capsulotomy was performed using a standard protocol. At the completion of the procedure, the patient was turned back into the supine position and extubated.

RESULTS

This study included 87 eyes of 60 patients. Patient's age ranged from 1 to 18y (mean 6.4±4.1y). In most cases (84/87, 97%), the procedure was performed under general anesthesia. In all cases, good focus on the membrane was achieved, and the procedure was performed successfully. There were no intraoperative ocular or anesthesia-related complications.

CONCLUSION

When performing Nd:YAG laser capsulotomy in the operating room, the lateral decubitus position allows an easy and safe approach without the risk of potentially devastating complications that have been associated with the previously described sitting and prone positions.

[Refraction in pseudophakic eyes after surgical treatment of congenital cataracts]

The optimal method of correcting aphakia in infants with congenital cataract (CC) is intraocular correction. Considering the growth of the eyes, most authors implant an IOL with lower dioptric power to try to anticipate the refractive indices after the growth, which in some cases do not match the prediction.

PURPOSE

To evaluate the achieved refraction and its relation to the anterior-posterior axis of pseudophakic eyes after extraction of CC in children of up to one year of age.

MATERIAL AND METHODS

The study included 115 children (159 eyes) examined 1 to 11 years after the extraction of bilateral or unilateral CC at the age of 2-11 months. Optical power of the implanted IOL had been calculated using SRKII formula for hypercorrection to result in emmetropic or weak myopic refraction by the time the eye growth finishes. The subjects underwent autorefractometry on Retinomax K-Plus 3 device and ultrasonic biometry on Humphrey 835 A/B-scan system.

RESULTS

The incidence of unplanned refraction in children aged 1 to 3 years was 61.2%, aged 3 years to 5 years 11 months - 24.4%, and in children of 6-11 years - 50.0%; it was associated with pronounced unplanned eye growth in 48.6% of cases with bilateral CC and in 27.3% of cases with unilateral CC.

CONCLUSION

The main cause of unplanned refraction in pseudophakic eyes in children with CC is unpredictable increase of the length of anterior-posterior axis after surgery.

Updates on managements of pediatric cataract

Purpose

A comprehensive review in congenital cataract management can guide general ophthalmologists in managing such a difficult situation which remains a significant cause of preventable childhood blindness. This review will focus on surgical management, postoperative complications, and intraocular lens (IOL)-related controversies.

Methods

Electrical records of PubMed, Medline, Google Scholar, and Web of Science from January 1980 to August 2017 were explored using a combination of keywords: "Congenital", "Pediatric", "Childhood", "Cataract", "Lens opacity", "Management", "Surgery", "Complication", "Visual rehabilitation”, and "Lensectomy". A total number of 109 articles were selected for the review process.

Results

This review article suggests that lens opacity obscuring the red reflex in preverbal children and visual acuity of less than 20/40 is an absolute indication for lens aspiration. For significant lens opacity that leads to a considerable risk of amblyopia, cataract surgery is recommended at 6 weeks of age for unilateral cataract and between 6 and 8 weeks of age for bilateral cases. The recommended approach in operation is lens aspiration via vitrector and posterior capsulotomy and anterior vitrectomy in children younger than six years, and IOL implantation could be considered in patients older than one year. Most articles suggested hydrophobic foldable acrylic posterior chamber intraocular lens (PCIOL) for pediatrics because of lower postoperative inflammation. Regarding the continuous ocular growth and biometric changes in pediatric patients, under correction of IOL power based on the child's age is an acceptable approach. Considering the effects of early and late postoperative complications on the visual outcome, timely detection, and management are of a pivotal importance. In the end, the main parts of post-operation visual rehabilitation are a refractive correction, treatment of concomitant amblyopia, and bifocal correction for children in school age.

Conclusions

The management of congenital cataracts stands to challenge for most surgeons because of visual development and ocular growth. Children undergoing cataract surgery must be followed lifelong for proper management of early and late postoperative complications. IOL implantation for infants less than 1 year is not recommended, and IOL insertion for children older than 2 years with sufficient capsular support is advised.

Global Practice Patterns in the Management of Infantile Cataracts

OBJECTIVES

Surveys are an important tool to assess the impact of research on physicians' approach to patient care. This survey was conducted to assess current practice patterns in the management of infantile cataracts in light of the findings of the Infant Aphakia Treatment Study.

METHODS

Pediatric ophthalmologists were emailed a link to the survey using newsletters from American Association of Pediatric Ophthalmology and Strabismus, World Society of Pediatric Ophthalmology and Strabismus, and the Pediatric Listserv. The 17-question survey was anonymous and active during July to August 2016.

RESULTS

One hundred twenty-five respondents (North America, 65%; Asia, 12%; Europe, 9%; and other, 14%) reported operating on pediatric cataracts. Most practice in a university setting (55%). There was a strong consensus that unilateral cataract surgery should be performed between ages 4 to 6 weeks and aphakic contact lenses should be used to optically correct their eyes, particularly in children ≤6 months of age. For bilateral cataracts, there was a trend for surgeons to perform cataract surgery at an older age than unilateral cataract surgery. Surgeons who performed less than 5 versus greater than 20 pediatric cataract surgeries/year were more likely to use aphakic contact lenses in children undergoing cataract surgery more than 6 months of age (62% vs. 35%, P=0.04). Most respondents (73%) indicated that the Infant Aphakia Treatment Study had changed how they manage unilateral congenital cataracts.

CONCLUSION

Most pediatric cataract surgeons perform congenital cataract surgery between ages 4 to 6 weeks and use aphakic contact lenses for initial optical correction in infants less than 6 months. Surgeons have equal preference for intraocular lenses and contact lenses in infants more than 6 months of age.

Long-term results of secondary intraocular lens implantation in children under 30 months of age

Purpose

To report the long-term outcome of early secondary intraocular lens (IOL) implantation following congenital cataract extraction in a large number of eyes.

Methods

Data of aphakic children under 30 months of age who underwent secondary IOL implantation and had at least one year of follow-up after the surgery was reviewed. In all of the patients, a foldable three-piece acrylic IOL was implanted in the ciliary sulcus by the same surgeon using the same technique. The database studied included refractive and visual acuity (VA) outcomes and complications.

Results

Fifty patients (75 eyes) were included. The average age at the time of cataract extraction was 94.20 ± 44.94 days and 20.7 ± 6.0 months in the secondary IOL implantation. After 82.32 ± 48.91 months, the VA was 0.58 ± 0.35 LogMAR and the spherical equivalent was −2.20 ± 4.19 D. There was a negative correlation between a longer follow-up period and myopia at the SE measured (P = .001). The most frequent complications included glaucoma and corectopia. Performing the secondary IOL implantation ≤ 20 months of age was not a risk factor for glaucoma development (P = 0.095).

Conclusion

Secondary IOL implantation under 30 months of age is an option for children with unsatisfactory management of the optic treatment. A predictable IOL power calculation and satisfactory visual outcomes compared to results of later secondary IOL implantation are possible.

Intraocular lens optic capture in pediatric cataract surgery

Posterior capsule opacification (PCO) remains the most common complication of pediatric cataract surgery despite continuous efforts to reduce its incidence. For this reason, pediatric cataract surgeons have expended considerable effort into preventing and mitigating PCO. The intraocular lens (IOL) optic capture technique has been used for the prevention of PCO after pediatric cataract surgery for more than 20y, but there is still no professional consensus. However, recent research has shown encouraging results. The IOL optic capture technique can be performed without anterior vitrectomy to prevent PCO, even in younger children. The type and characteristics of IOLs used for optic capture technique, the location of IOL and the complications of IOL optic capture in children are here reviewed.

Correlation of monocular grating acuity at age 12 months with recognition acuity at age 4.5 years: findings from the Infant Aphakia Treatment Study

PURPOSE

To determine whether grating acuity at age 12 months can be used to predict recognition acuity at age 4.5 years in children treated for unilateral congenital cataract enrolled in the Infant Aphakia Treatment Study (IATS).

METHODS

Traveling testers assessed monocular grating acuity at 12 months of age (Teller Acuity Card Test [TACT]) and recognition acuity at 4.5 years of age (Amblyopia Treatment Study Electronic Visual Acuity Testing, HOTV) in children treated for visually significant monocular cataract in the IATS. Spearman rank correlation was used to evaluate the relationship between visual acuities at the two ages in the treated eyes.

RESULTS

Visual acuity data at both ages were available for 109 of 114 children (96%). Grating acuity at 12 months of age and recognition acuity at 4.5 years of age were significantly correlated for the treated eyes (r_spearman = 0.45; P = 0.001). At age 4.5 years, 67% of the subjects who had grating acuity at 12 months of age within the 95% predictive limits in their treated eye demonstrated recognition acuity better than 20/200. Similarly, at age 4.5 years 67% of the subjects who had grating acuity at age 12 months below the 95% predictive limits in their treated eye demonstrated recognition acuity of 20/200 or worse.

CONCLUSIONS

A single grating acuity assessment at age 12 months predicts recognition acuity in a child treated for unilateral congenital cataract in only two-thirds of cases. Clinicians should consider other factors, such as patching compliance and age at surgery, when using an early grating acuity assessment to modify treatment.

The Infant Aphakia Treatment Study Contact Lens Experience to Age 5 Years

PURPOSE

To describe our experience treating a cohort of unilateral aphakic infants with contact lenses in the Infant Aphakia Treatment Study (IATS).

MATERIALS AND METHODS

Fifty-seven of the 114 infants in the IATS were randomized to contact lens wear; all were followed until age 5 years, although a few had lapses in care. An examination under anesthesia, including keratometry, was performed at the time of enrollment and at approximately 1 year of age; keratometry was performed again at 5 years of age. A traveling examiner assessed visual acuity at approximately 1 year of age and again at 4.5 years of age.

RESULTS

Twenty-four treated eyes (46%) wore silicone elastomer (SE) contact lenses, 11 eyes (19%) rigid gas permeable (GP) contact lenses and 17 eyes (29%) wore both lens types at various points of time. Median logMAR visual acuity was +0.70 (interquartile range (IQR), +0.30 to 1.20) in the SE group and 2.03 (IQR, +0.20 to 2.28) in the GP group at age 4.5 years. The mean (±SD) keratometric power of the treated eyes was 46.3±2.8 diopter (D) at baseline, 44.6±2.3 D at 1 year of age, and 44.3±1.7 D at 5 years of age. Keratometric astigmatism of treated eyes was 1.98±1.37 D at baseline, 1.62±0.98 D at 1 year of age, and 2.00±1.00 D at 5 years of age. Thirteen contact lens-related adverse events occurred among 7 patients after age 1 year.

CONCLUSIONS

A cohort of infants with unilateral aphakia successfully wore contact lenses with relatively few adverse events.

Outcome of Pediatric Cataract Surgeries in a Tertiary Center in Switzerland

Purpose

To determine and to analyze the outcome of pediatric cataract surgery.

Methods

A retrospective chart review of individuals aged up to 10 years who underwent cataract surgery between January 1, 2004, and December 31, 2014, at the UniversityHospital Zurich, Switzerland.

Results

63 children (94 affected eyes) with bilateral (68/94) or unilateral (26/94) cataract were identified. Surgery was performed at a median age of 1.5 months (IQR: 1.3–2.6 months) for the aphakic group (45/94) and of 50.7 months (IQR: 38.0–78.4 months) for the IOL group (49/94). At the last follow-up visit (median 31.1 months, IQR: 18.4–50.2 months), visual acuity was better in bilateral than in unilateral cataract cases. Posterior capsular opacification (PCO) was diagnosed in 30.9% of eyes without a significant difference in the IOL and aphakic groups (p = 0.12). Aphakic glaucoma was diagnosed in 12/45 eyes at a median of 6.8 months (IQR 2.1–13.3 months) after surgery. Microcornea (5/12) and anterior segment anomalies (8/12) were associated with glaucoma development (p < 0.05).

Conclusion

Laterality and timing of surgery influence the outcome of pediatric cataract surgery. PCO was the most frequent postoperative complication. Aphakic glaucoma is often associated with ocular developmental abnormalities and a poor visual outcome.

Anisometropia at Age 5 Years After Unilateral Intraocular Lens Implantation During Infancy in the Infant Aphakia Treatment Study

PURPOSE

To report the prevalence of anisometropia at age 5 years after unilateral intraocular lens (IOL) implantation in infants.

DESIGN

Prospective randomized clinical trial.

METHODS

Fifty-seven infants in the Infant Aphakia Treatment Study (IATS) with a unilateral cataract were randomized to IOL implantation with an initial targeted postoperative refractive error of either +8 diopters (D) (infants 28 to <48 days of age) or +6 D (infants 48-210 days of age). Anisometropia was calculated at age 5 years. Six patients were excluded from the analyses.

RESULTS

Median age at cataract surgery was 2.2 months (interquartile range [IQR], 1.2, 3.5 months). The mean age at the age 5 years follow-up visit was 5.0 ± 0.1 years (range, 4.9-5.4 years). The median refractive error at the age 5 years visit of the treated eyes was -2.25 D (IQR -5.13, +0.88 D) and of the fellow eyes +1.50 D (IQR +0.88, +2.25). Median anisometropia was -3.50 D (IQR -8.25, -0.88 D); range -19.63 to +2.75 D. Patients with glaucoma in the treated eye (n = 9) had greater anisometropia (glaucoma, median -8.25 D; IQR -11.38, -5.25 D vs no glaucoma median -2.75; IQR -6.38, -0.75 D; P = .005).

CONCLUSIONS

The majority of pseudophakic eyes had significant anisometropia at age 5 years. Anisometropia was greater in patients that developed glaucoma. Variability in eye growth and myopic shift continue to make refractive outcomes challenging for IOL implantation during infancy.

The Long Term Outcome of the Management of the Posterior Capsule in Pseudophakic Children

This is a long term study of the treatment of the posterior lens capsule in the management of bilateral cataract extraction and insertion of 42 intraocular lenses in 21 children. The purpose of the current study was to compare the long-term outcome of eyes treated by the two different methods of surgery of the posterior lens capsule in bilateral cataract and intraocular lens implantation in children. The author performed an independent ocular exam on the children selected from a consecutive series at 4 different institutions, followed for a minimum of 5 years. The eyes of children in Subgroup A (n=24), had surgery in which an intact capsule was left at the time of initial surgery. The eyes of patients in Subgroup B (n=18) received a primary central lens capsulectomy and limited anterior vitrectomy at the time of the initial surgery. The eyes of Subgroup A (mean age 7.7 years) were found to be in children older than those eyes in Subgroup B (mean age 3.9 years) (P=.001). The eyes in the two subgroups also differed in the necessity of a secondary YAG laser capsulectomy. Twenty one of the 24 eyes in Subgroup A had received a secondary YAG laser capsulectomy and no eyes of the patients in Subgroup B had required a secondary YAG laser capsulectomy at the time of the author's examination (P=.001). A central capsulectomy during the initial surgery was more likely to be chosen for surgery on eyes of younger children (P=.001).

Myopic Shift 5 Years after Intraocular Lens Implantation in the Infant Aphakia Treatment Study

PURPOSE

To report the myopic shift at 5 years of age after cataract surgery with intraocular lens (IOL) implantation for infants enrolled in the Infant Aphakia Treatment Study (IATS).

METHODS

Refractions were performed at 1 month and every 3 months postoperatively until age 4 years and then at ages 4.25, 4.5, and 5 years. The change in refraction over time was estimated by linear mixed model analysis.

RESULTS

Intraocular lens implantation was completed in 56 eyes; 43 were analyzed (median age, 2.4 months; range, 1.0-6.8 months). Exclusions included 11 patients with glaucoma, 1 patient with Stickler syndrome, and 1 patient with an IOL exchange at 8 months postoperatively. The mean rate of change in a myopic direction from 1 month after cataract surgery to age 1.5 years was 0.35 diopters (D)/month (95% confidence interval [CI], 0.29-0.40 D/month); after age 1.5 years, the mean rate of change in a myopic direction was 0.97 D/year (95% CI, 0.66-1.28 D/year). The mean refractive change was 8.97 D (95% CI, 7.25-10.68 D) at age 5 years for children 1 month of age at surgery and 7.22 D (95% CI, 5.54-8.91 D) for children 6 months of age at surgery. The mean refractive error at age 5 years was -2.53 D (95% CI, -4.05 to -1.02).

CONCLUSIONS

After IOL implantation during infancy, the rate of myopic shift occurs most rapidly during the first 1.5 years of life. Myopic shift varies substantially among patients. If the goal is emmetropia at age 5 years, then the immediate postoperative hypermetropic targets should be +10.5 D at 4 to 6 weeks and +8.50 D from 7 weeks to 6 months. However, even using these targets, it is likely that many children will require additional refractive correction given the high variability of refractive outcomes.

Current Status of IOL implantation in pediatric eyes: an update

INTRODUCTION

Pediatric cataracts are a huge problem worldwide, and with improving techniques and technology, the surgical treatment and postoperative visual rehabilitation are improving. Despite intraocular lenses(IOLs) being the standard of care for adult cataract surgery, this issue is still somewhat controversial, particularly in young children and infants due to lack of unequivocal evidence. This review therefore summarises the findings from recent studies on the aspect of IOL implantation in pediatric eyes. Areas covered: An extensive literature search was undertaken for published articles on congenital/developmental pediatric cataracts, and IOL implantation, where literature pertinent to traumatic and subluxated cataracts was not included in the review. Pubmed was used for literature search, and keywords entered were : pediatric, cataract surgery, intraocular lens, persistent fetal vasculature, outcomes, complications, visual performance with intraocular lenses. Expert commentary: Recent literature supports IOL implantation in most cases of congenital / developmental pediatric cataracts, and it seems like the way forward. However, the jury is still out on IOL implantation in infants, particularly in bilateral cataracts. Thus, surgeons must be extremely cautious in planning primary IOL implantation in infant eyes, and if they do perform IOL implantation, rigorous followup is mandatory.