Global Practice Patterns in the Management of Infantile Cataracts

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.

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.

Establishing a novel lens opacities classification system based on ultrasound biomicroscopy (UBM) for pediatric cataracts: reliability and availability

BACKGROUND

This study sought to develop and validate a lens opacities classification system based on ultrasound biomicroscopy (UBM) imaging to grade pediatric cataracts.

METHODS

The study was conducted at Guangzhou Children's Hospital, Guangzhou Women and Children's Medical Center. UBM images of patients at the hospital from September 2013 to November 2014 were used in this study. We summarized the characteristics of lenticular opacification in each of the following 4 zones: the anterior capsule (A); the cortex (C); the nucleus (N); and the posterior capsule (P). The UBM data and intraoperative videos were compared, and sensitivity, specificity, accuracy, and positive and negative predictive values were determined for our Lens Opacities Classification System based on UBM for Pediatric Cataracts (LOCS-UP) detection. Two physicians classified pediatric cataracts (anterior capsule, cortex, and posterior capsule) by extracting 146 images from the UBM database. Patients' data were recorded to calculate the kappa coefficients. The LOCS-UP was developed.

RESULTS

Under this standard, all types of pediatric cataracts can be classified and acquired a code by the LOCS-UP. The LOCS-UP had the highest sensitivity (100%) and specificity (98.96%) in naming the anterior capsule and the lowest sensitivity (50%) and specificity (89.59%) in naming the posterior capsule. Its consistency at naming the anterior capsule was satisfactory (Kappa coefficient: 0.70), and it was also able to name the nucleus, cortex, and posterior capsule (0.56, 0.58, and 0.48, respectively).

CONCLUSIONS

LOCS-UP could name pediatric cataracts by providing an unique digital encoding, which could reflect characteristics exactly for different local lens anomalies to all kinds of pediatric cataract patients. This method provides detailed and accurate information about Patients' lenses.

CLEAR - Medical use of contact lenses

The medical use of contact lenses is a solution for many complex ocular conditions, including high refractive error, irregular astigmatism, primary and secondary corneal ectasia, disfiguring disease, and ocular surface disease. The development of highly oxygen permeable soft and rigid materials has extended the suitability of contact lenses for such applications. There is consistent evidence that bandage soft contact lenses, particularly silicone hydrogel lenses, improve epithelial healing and reduce pain in persistent epithelial defects, after trauma or surgery, and in corneal dystrophies. Drug delivery applications of contact lens hold promise for improving topical therapy. Modern scleral lens practice has achieved great success for both visual rehabilitation and therapeutic applications, including those requiring retention of a tear reservoir or protection from an adverse environment. This report offers a practical and relevant summary of the current evidence for the medical use of contact lenses for all eye care professionals including optometrists, ophthalmologists, opticians, and orthoptists. Topics covered include indications for use in both acute and chronic conditions, lens selection, patient selection, wear and care regimens, and recommended aftercare schedules. Prevention, presentation, and management of complications of medical use are reviewed.

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.

Cataract management in children: a review of the literature and current practice across five large UK centres

Congenital and childhood cataracts are uncommon but regularly seen in the clinics of most paediatric ophthalmology teams in the UK. They are often associated with profound visual loss and a large proportion have a genetic aetiology, some with significant extra-ocular comorbidities. Optimal diagnosis and treatment typically require close collaboration within multidisciplinary teams. Surgery remains the mainstay of treatment. A variety of surgical techniques, timings of intervention and options for optical correction have been advocated making management seem complex for those seeing affected children infrequently. This paper summarises the proceedings of two recent RCOphth paediatric cataract study days, provides a literature review and describes the current UK 'state of play' in the management of paediatric cataracts.

Outcomes of Bilateral Cataract Surgery in Infants 7 to 24 Months of Age Using the Toddler Aphakia and Pseudophakia Treatment Study Registry

PURPOSE

To evaluate outcomes of bilateral cataract surgery in children aged 7 to 24 months and compare rates of adverse events (AEs) with other Toddler Aphakia and Pseudophakia Study (TAPS) registry outcomes.

DESIGN

Retrospective clinical study at 10 Infant Aphakia Treatment Study (IATS) sites. Statistical analyses comparing this cohort with previously reported TAPS registry cohorts.

PARTICIPANTS

Children enrolled in the TAPS registry between 2004 and 2010.

METHODS

Children underwent bilateral cataract surgery with or without intraocular lens (IOL) placement at age 7 to 24 months with 5 years of postsurgical follow-up.

MAIN OUTCOME MEASURES

Visual acuity (VA), occurrence of strabismus, AEs, and reoperations.

RESULTS

A total of 40 children (76 eyes) who underwent bilateral cataract surgery with primary posterior capsulectomy were identified with a median age at cataract surgery of 11 months (7-23); 68% received a primary IOL. Recurrent visual axis opacification (VAO) occurred in 7.5% and was associated only with the use of an IOL (odds ratio, 6.10; P = 0.005). Glaucoma suspect (GS) was diagnosed in 2.5%, but no child developed glaucoma. In this bilateral cohort, AEs (8/40, 20%), including glaucoma or GS and VAO, and reoperations occurred in a similar proportion to that of the published unilateral TAPS cohort. When analyzed with children aged 1 to 7 months at bilateral surgery, the incidence of AEs and glaucoma or GS correlated strongly with age at surgery (P = 0.011/0.004) and glaucoma correlated with microcornea (P = 0.040) but not with IOL insertion (P = 0.15).

CONCLUSIONS

Follow-up to age 5 years after bilateral cataract surgery in children aged 7 to 24 months reveals a low rate of VAO and very rare glaucoma or GS diagnosis compared with infants with cataracts operated at < 7 months of age despite primary IOL implantation in most children in the group aged 7 to 24 months. The use of an IOL increases the risk of VAO irrespective of age at 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.

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.