Pseudo-accommodation in non-amblyopic children after bilateral cataract surgery and implantation with a monofocal intraocular lens: prevalence and possible mechanisms

BCLA CLEAR Presbyopia: Definitions

Presbyopia is often the first sign of ageing experienced by humans. Standardising terminology and adopting it across the BCLA CLEAR Presbyopia reports, improves consistency in the communication of the evidence-based understanding of this universal physiological process. Presbyopia can be functionally and psychologically debilitating, especially for those with poor access to eyecare. Presbyopia was defined as occurring when the physiologically normal age-related reduction in the eye's focusing range reaches a point that, when optimally corrected for far vision, the clarity of vision at near is insufficient to satisfy an individual's requirements. Accommodation is the change in optical power of the eye due to a change in crystalline lens shape and position, whereas pseudo-accommodation is the attainment of functional near vision in an emmetropic or far-corrected eye without changing the refractive power of the eye. Other definitions specific to vision and lenses for presbyopia were also defined. It is recommended that these definitions be consistently adopted in order to standardise future research, clinical evaluations and education.

Incidence and factors for pseudoaccommodation after monofocal lens implantation: the Monofocal Extended Range of Vision study

PURPOSE

To screen patients with a monofocal intraocular lens (IOL) for incidence of unaided 20/40 and 0.3 LogMAR for distance and near (pseudoaccommodation) and to find factors for pseudoaccommodation.

SETTINGS

University Hospitals Sussex NHS Foundation Trust, Brighton, United Kingdom.

DESIGN

Prospective study.

METHODS

This was a single-eye study ( ClinicalTrials.gov : NCT04011696). At 3 to 9 months, refraction, uncorrected and corrected distance and uncorrected near visual acuity (logMAR), spherical equivalent (SEQ), mesopic pupil size (PS), total eye spherical (Z 40 ), vertical coma (Z 3-1 ) aberrations, reading speed and smallest print size were assessed. Refractive astigmatism (RA) was classified as against-the-rule, with-the-rule, oblique and no astigmatism. Data on preoperative axial length (AL) and anterior chamber depth (ACD) were collected.

RESULTS

29 patients (9.6%, 95% CI, 6.5-13.5) had pseudoaccommodation. In cases vs controls, median SEQ, PS, total Z 40 , Z 3-1 , reading speed, smallest print size, preoperative ACD, preoperative AL were: -0.39 vs 0.0 diopters; 3.62 vs 4.10 mm; 0.01 vs 0.02 μm; 0.018 vs 0.022 μm; 106 vs 133 words per minute; 0.30 vs 0.50 logMAR; 2.94 vs 3.13 mm, 23.4 vs 23.7 mm, respectively. RA was not different between the groups. Univariate analysis revealed preoperative ACD (odds ratio [OR], 0.38, 95% CI, 0.16-0.94, P = .04), SEQ (OR, 0.61, 95% CI, 0.42-0.88, P = .01), total Z 40 (OR, 0.0003, 95% CI, 0.00-0.39, P = .03) and PS (OR, 0.39, 95% CI, 0.22-0.69, P < .041) to be significant. Whereas multivariable logistic regression identified: preoperative AL (OR, 0.62, 95% CI, 0.42-0.91, P = .02), SEQ (OR, 0.49, 95% CI, 0.31-0.78, P = .01), Z 40 (OR, 0.00, 95% CI, 0.0-0.01, P = .01) and PS (OR, 0.41, 95% CI, 0.23-0.75, P = .01) to be significant.

CONCLUSIONS

A combination of low myopic SEQ, lower Z 40 , shorter preoperative AL, and smaller PS increases the chances of pseudoaccommodation.

Premium intraocular lenses in children

Multifocal and toric intraocular lenses (IOLs) or the so-called premium IOLs are currently widely used in adult patients as a one-step refractive solution following cataract surgery. However, the decision to implant a premium IOL in a pediatric patient involves multiple factors affecting the child's visual development and is associated with several dilemmas and surgical challenges. The purpose of this review is to summarize these factors and analyse the influence of each of them on the visual outcomes following premium IOL implantation. A review of literature was conducted using the relevant keywords from various databases until 31^st January 2022. All pertinent studies with multifocal or toric IOL implantation in children were reviewed, and relevant articles were studied in detail for age, IOL power calculation, visual outcomes (refractive outcomes, contrast sensitivity and stereopsis) and complications such as dysphotic phenomena and others. A total of 17 relevant studies (10 case series/interventional studies and 7 case reports) on the subject were included. All studies showed a favourable refractive outcome; however, the data available was significantly less. Studies with earlier models of multifocal IOLs showed a higher incidence of IOL decentration and posterior capsule opacification; however, more recent studies with newer IOL models showed much better safety profiles. Toric IOLs showed promising results in all the studies evaluated. Premium IOLs have shown promising results in the pediatric age group. However, their long-term outcomes specifically concerning refractive shift, capsular contraction and role in the management of amblyopia needs to be explored further.