Deviations From Age-Adjusted Normative Biometry Measures in Children Undergoing Cataract Surgery: Implications for Postoperative Target Refraction and IOL Power Selection

Refractive Change at 5 Years in the Toddler Aphakia and Pseudophakia Study

PURPOSE

To report refractive change at 5 years of age in children with pseudophakic eyes operated on before 2 years of age.

DESIGN

Retrospective case series at 10 Infant Aphakia Treatment Study (IATS) sites.

PARTICIPANTS

Children who underwent cataract surgery with primary intraocular lens (IOL) placement during the IATS enrollment years, including infants 1 to younger than 7 months of age with bilateral cataract and all children 7 to 24 months of age, regardless of laterality.

METHODS

Change in spherical equivalent refractive error (in diopters [D]) was calculated from 1 month after surgery to 5 years of age and was compared for patients with unilateral and bilateral (first eye only) cataract and for children 1 to < 7 months versus 7-24 months of age at surgery.

MAIN OUTCOME MEASURES

Refractive change (D) from surgery to 5 years of age.

RESULTS

Ninety-six children were included: 50 children with unilateral cataract (surgery at age 7-24 months) and 46 children with bilateral cataract (n = 20 with surgery at age 1 to < 7 months; n = 26 with surgery at age 7-24 months). Median refractive change was significantly greater for eyes in the bilateral group undergoing surgery at age 1 to < 7 months (7.50 D; range, 2.5 to 15 D) versus age 7 to 24 months (1.94 D; range, -1.88 to 7.75 D; P < 0.001). For children 7-24 months of age at surgery, median change was similar between those with unilateral cataract (3.25 D; range, -1.75 to 13.5 D) versus bilateral cataract (1.94 D; range, -1.88 to 7.75 D; P = 0.053). By 5 years of age, no eyes in the 1 to < 7 month age group had less than 2.5 D myopic shift, but in the 7-24 month age group, 62% of patients with bilateral cataract and 38% of patients with unilateral cataract showed less than 2.5 D myopic shift.

CONCLUSIONS

Greater magnitude and variability in refractive change was found in pseudophakic eyes undergoing surgery at 1 to < 7 months of age and for patients with unilateral cataract, which should be considered when choosing IOL power and initial postoperative target refraction for infants and toddlers.

FINANCIAL DISCLOSURE(S)

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

Myopic Shift over 5 Years after Pediatric Lensectomy with Primary Intraocular Lens Implantation

PURPOSE

To report the change in refractive error over 5 years after primary intraocular lens (IOL) placement by age at surgery and to identify factors associated with the change in refractive error after 5 years.

DESIGN

Prospective observational study at 61 pediatric eye care practices.

PARTICIPANTS

One hundred eighty-six eyes of 152 children undergoing primary IOL implantation before 13 years of age for nontraumatic cataract.

INTERVENTIONS

Cataract surgery with primary IOL placement.

MAIN OUTCOME MEASURES

Five-year change in refractive error (spherical equivalent) by age at surgery and by immediate postoperative myopia versus emmetropia or hyperopia.

RESULTS

Mean spherical equivalent myopic shift was -5.99 diopters (D; 95% confidence interval [CI], -7.64 to -4.34 D) when surgery was performed at 0 to younger than 1 year of age (n = 13), -3.53 D (-4.57 to -2.48 D) at 1 to younger than 2.5 years of age (n = 28), -1.91 D (-2.55 to -1.26 D) at 2.5 to younger than 4 years of age (n = 36), -2.04 D -2.60 to -1.49 D) at 4 to younger than 7 years of age (n = 60), and -0.83 D (-1.27 to -0.40 D) at 7 to younger than 13 years of age (n = 49; P < 0.01 for each comparison with the oldest group). Variability of myopic shift also decreased with increasing age (P < 0.01). In eyes of children 4 to younger than 13 years of age (small sample size precluded analysis of children younger than 4 years), significantly less mean change in refractive error was found over 5 years in eyes with myopia immediately after surgery (-0.69 D; 95% CI, -1.48 to 0.10 D; n = 27) than eyes with emmetropia or hyperopia immediately after surgery (-1.70 D; 95% CI, -2.10 to -1.31 D, n = 82; difference, -1.01 D [95% CI, -1.89 to -0.14 D]; P = 0.03).

CONCLUSIONS

In this large, prospective cohort study of children younger than 13 years undergoing cataract surgery with primary IOL placement, greater and more variable myopic shift was found in children undergoing surgery at a younger age. Our finding of less myopic shift over 5 years in eyes with unintended immediate postoperative myopia deserves further study to guide IOL power selection more accurately.

FINANCIAL DISCLOSURE(S)

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

Comparison Between Monofocal and Aspheric Monofocal Intraocular Lens With Higher Order Aspheric Optic in Pediatric Patients: Early Outcomes

PURPOSE

To retrospectively compare the visual acuity outcomes for far, intermediate, and near vision of an aspheric monofocal intraocular lens (IOL) with higher order aspheric optic with a monofocal IOL in pediatric patients.

METHODS

Thirty-eight eyes of 38 patients (mean age: 9.0 ± 2.3 years) affected by monolateral infantile cataract were evaluated 6 months after surgery performed with simultaneous IOL implantation. The Tecnis Eyhance ICB00 aspheric monofocal IOL (Johnson & Johnson Vision) was implanted in 17 eyes (Tecnis Eyhance group, mean age: 8.9 ± 2.5 years) and the Tecnis PCB00 monofocal IOL (Johnson & Johnson Vision) was implanted in 21 eyes (control group, mean age: 9.1 ± 2.2 years). Corrected visual acuity expressed in logarithm of the minimum angle of resolution (logMAR) was assessed for distance (CDVA) and, expressed in Jaeger standard, for intermediate (DCIVA) and near vision (CNVA). DCIVA was measured with distance correction and without addition. The Mann-Whitney test for two independent samples was performed, and a P value less than .05 was considered statistically significant.

RESULTS

Six months postoperatively, mean CDVA was 0.20 ± 0.2 logMAR and mean DCIVA and CNVA were 5 ± 1 and 2 ± 1 Jaeger, respectively, in the Tecnis Eyhance group. In the control group, mean CDVA was 0.21 ± 0.2 logMAR and mean DCIVA and CNVA were 8 ± 1 and 3 ± 1 Jaeger, respectively. Only DCIVA showed a significant statistical difference between groups (P < .0001).

CONCLUSIONS

In pediatric patients, the aspheric monofocal IOL with higher order aspheric optic seems to provide better intermediate distance visual acuity than a monofocal one, whereas no significant difference was observed for CDVA and CNVA. [J Refract Surg. 2024;40(10):e724-e727.].

Intraocular lens calculation using the ESCRS online calculator in pediatric eyes undergoing lens extraction

PURPOSE

To evaluate the ESCRS online calculator for intraocular lens (IOL) calculation in children undergoing lens extraction and primary IOL implantation.

SETTING

Department of Ophthalmology, Goethe-University Frankfurt, Frankfurt am Main, Germany.

DESIGN

Retrospective, consecutive case series.

METHODS

Eyes that received phacoemulsification and IOL implantation (Acrysof SN60AT) due to congenital or juvenile cataract were included. We compared the mean prediction error (MPE), mean and median absolute prediction error (MAE, MedAE) of formulas provided by the recently introduced online calculator provided by the ESCRS with the SRK/T formula, as well as the number of eyes within ±0.5 diopters (D), ±1.0 D, ±2.0 D of target refraction. Postoperative spherical equivalent was measured by retinoscopy 4 to 12 weeks postoperatively.

RESULTS

60 eyes from 47 patients with a mean age of 6.5 ± 3.2 years met the inclusion criteria. Mean axial length was 22.27 ± 1.19 mm. Mean preoperative spherical equivalent (SE) was -0.25 ± 3.78 D, and mean postoperative SE was 0.69 ± 1.53 D. The MedAE was lowest in the SRK/T formula (0.56 D, ± 1.03) performed significantly better ( P = .037) than Hoffer QST and Kane, followed by BUII (0.64 D, ± 0.92), Pearl DGS (0.65 D, ± 0.94), EVO (0.69 D, ± 0.94), Hoffer QST (0.75 D, ± 0.99), and Kane (0.78 D, ± 0.99). All of those were significantly above zero ( P < .001). 41 eyes received an intraoperative optic capture (68%). When excluding eyes that did not receive intraoperative optic capture (n = 19; 32%), the MedAE was shown to be lower.

CONCLUSIONS

Using modern IOL calculation formulas provided by the ESCRS calculator provides good refractive predictability and compares for most of the formulas with the results with SRK/T. In addition, the formulas seem to anticipate the postoperative refraction better for eyes that receive a posterior optic capture.

Accuracy of Modern and Traditional Intraocular Lens Power Calculation Formulas in Pediatric Cataract Surgery

Purpose

To compare the accuracy of modern intraocular lens (IOL) power calculation formulas with that of older formulas, such as SRK/T and Hoffer Q, in pediatric cataract surgery.

Methods

This retrospective study included 100 eyes of 100 children who underwent routine cataract surgery with primary IOL implantation in a bag. This study used four IOLMaster 700 integrated formulas: SRK/T, Hoffer Q, Haigis, and Barrett Universal II (BUII). In addition, the following formulas were used: EVO 2.0, Hill RBF 3.0, Hoffer QST, Kane, and PEARL DGS, which are available online.

Results

There was a statistically significant difference between SRK/T and most other formulas, except for Hoffer Q, Hoffer QST, and BUII (p < 0.05). SRK/T yielded the lowest median absolute error (MedAE) of 0.63 D. This was followed by the BUII (0.66 D), Hoffer Q, and Hoffer QST (0.68 D). SRK/T also yielded the highest percentage of cases within ± 0.50 D (43% of the cases). For patients aged 2 to 5 years, SRK/T formula yielded statistically significantly better results than all other included formulas (p < 0.05) with MedAE = 0.44 D, 58.33% and 87.50% of the cases were within ± 0.50 D and ± 1.0 D of intended refraction, respectively.

Conclusion

The SRK/T formula showed the best IOL power calculation results in pediatric cataract surgery, followed by BUII, Hoffer Q, and Hoffer QST. In children aged 2-5 years, the SRK/T formula outperformed all other formulas, followed by the BUII and Hoffer QST formulas. In children older than 5 years, there was no statistically significant difference between the different formulas (p > 0.05); Hoffer Q and SRK/T showed slightly better MedAE in this age group (5-10 years).

Association Between Preoperative Ocular Parameters and Myopic Shift in Children Undergoing Primary Intraocular Lens Implantation

Purpose

To evaluate the association between preoperative ocular parameters and myopic shift following primary intraocular lens (IOL) implantation in pediatric cataracts.

Methods

Eyes from pediatric patients undergoing bilateral cataract surgery with primary IOL implantation were included. Eyes were grouped by age at surgery and subdivided into three axial length (AL) subgroups and three keratometry subgroups. Mixed-effects linear regression was utilized to assess the trend in myopic shift among subgroups. Multivariable analysis was performed to determine factors associated with myopic shift.

Results

A total of 222 eyes were included. The median age at surgery was 4.36 years (interquartile range [IQR], 3.16-6.00 years) and the median follow-up was 4.18 years (IQR, 3.48-4.64 years). As preoperative AL increased, a decreased trend was observed in myopic shift and rate of myopic shift (P = 0.008 and P = 0.003, respectively, in the 4 to <6 years old group; P = 0.002 and P < 0.001, respectively, in the ≥6 years old group). Greater myopic shift and rate of myopic shift were associated with younger age at surgery (P = 0.008 and P = 0.008, respectively). Both myopic shift and rate of myopic shift were negatively associated with AL.

Conclusions

Age at surgery and preoperative AL were associated with myopic shift in pediatric cataracts following primary IOL implantation. Adjusting the target refraction based on preoperative AL could potentially improve patients' long-term refractive outcome.

Translational Relevance

This study may help to guide the selection of postoperative target refraction according to age at surgery and preoperative ocular parameters for pediatric cataracts.

Postoperative longitudinal refractive changes in children younger than 8 years with ectopia lentis and Marfan syndrome

PURPOSE

To evaluate the postoperative longitudinal refractive changes in children younger than 8 years with ectopia lentis and Marfan syndrome (MFS).

SETTING

Zhongshan ophthalmic center, Guangzhou, China.

DESIGN

Retrospective cohort study.

METHODS

Medical data of patients diagnosed with ectopia lentis and MFS that underwent surgery younger than 8 years were collected. Refractive errors and ocular biometric parameters were collected preoperatively and at each follow-up visit. Patients were stratified into groups according to age at surgery, and only the eye operated on first was selected. Multivariate analysis was performed to determine the association between refractive shift and potential risk factors.

RESULTS

In total, 54 eyes of 54 patients were enrolled. The median age at surgery was 6.21 years (interquartile range [IQR], 5.25 to 6.85), and the median follow-up was 2.0 years (IQR, 1.2 to 2.8 years). At age 8 years, patients demonstrated a median myopic shift ranged from -1.75 diopters (D) (IQR, -2.75 to -1.00 D) for the 4-year-old group to -0.13 D (IQR, -0.50 to -0.06 D) for the 7-year-old group. Multivariate analysis showed that greater myopic shift was associated with younger age at surgery ( P = .004), male sex ( P = .026), and shorter preoperative axis length ( P = .005).

CONCLUSIONS

A tendency toward increasing postoperative myopic was demonstrated in children with ectopia lentis and MFS, with the greatest myopic shift in the younger age groups. If the goal is to reach emmetropia by age 8 years, the immediate postoperative hypermetropic targets should be 1.75 D for age 4 years, 1 D for age 5 years, 0.5 D for age 6 years, and 0 to 0.25 D for age 7 years.

Axial length and corneal curvature of normal eyes in the first decade of life

BACKGROUND/AIMS

To establish normative curves for axial length and corneal curvature in the first decade of life.

METHODS

This is a cross-sectional study from a single institution in the United States. Children from 0- to 10-years of age with no underlying ocular pathology were prospectively enrolled to obtain ultrasound biometry and hand-held keratometry while under anaesthesia for an unrelated procedure. Older cooperative children had optical biometry obtained in-office. Logarithmic quantile regression models were used to determine the change in axial length and average keratometry as a function of age.

RESULTS

Single-eye measurements from 100 children were included. 75% of children were White and 49% female. Median axial length ranged from 20.6 mm (IQR, 20.2 to 21.1 mm) at age one year to 23.1 mm (IQR, 22.5 to 23.8 mm) at age ten years. Median average keratometry ranged from 44.1 D (IQR, 42.6 to 45.4 D) at age one year to 43.5 (IQR, 42.2 to 44.0 D) at age ten years. As age increased, there was a significant increase in axial length (0.74 mm per doubling of age; 95% CI, 0.62 to 0.82 mm), and a non-significant trend towards lower average keratometry (-0.21 D per doubling of age; 95% CI, -0.62 to 0.08 D).

CONCLUSIONS

We provide a set of normative charts for axial length and corneal curvature which may facilitate the identification of eyes outside the normal range and assist in the management of ocular conditions such as glaucoma or cataract.

Comparison of baseline biometry measures in eyes with pediatric cataract to age-matched controls

PURPOSE

To compare baseline biometry measurements in eyes with pediatric cataract versus age-matched controls METHODS: This is a cross-sectional study conducted at a tertiary care hospital that included two arms-prospective arm to collect data from normal eyes and retrospective arm for eyes with pediatric cataract. In the prospective arm, biometry measurements were obtained in healthy children aged 0 to 10 years. Children under the age of four had measurements under anesthesia for an unrelated procedure, while older children had in-office measurements using optical biometry. For comparison, biometric data was collected in children with pediatric cataract through record review. One eye of each patient was randomly selected. Axial length (AL) and keratometry (K) were compared by age and laterality. The medians were compared using Wilcoxon rank-sum tests and variances using Levene's test.

RESULTS

There were 100 eyes in each arm, 10 eyes in each age bin of 1-year interval. There was more variability in baseline biometry in eyes with pediatric cataract and a trend for longer AL and steeper K in cataract eyes than aged-matched controls. The difference in AL means was significant in age group 2-4 years, and variances were significant across all age groups (p=0.018). Unilateral cataracts (n=49) showed a trend toward greater variability in biometry than bilateral cataracts, but this did not reach statistical significance.

CONCLUSION

Baseline biometry measures are more variable in eyes with pediatric cataract compared to age-matched controls with a trend toward longer AL and steeper K.

A Comprehensive Review of Pediatric Glaucoma Following Cataract Surgery and Progress in Treatment

Glaucoma following cataract surgery (GFCS) remains a serious postoperative complication of pediatric cataract surgery. Various risk factors, including age at lensectomy, intraocular lens implantation, posterior capsule status, associated ocular/systemic anomaly, additional intraocular surgery, and a family history of congenital cataract and GFCS, have been reported. However, the optimal surgical approach remains unclear. This review evaluates the diagnostic criteria, classification, risk factors, mechanism, and surgical management, especially the efficacy of minimally invasive glaucoma surgery, in GFCS, and aims to propose an optimal clinical management strategy for GFCS. The results of our review indicate that ab interno trabeculotomy (goniotomy) may be the most appropriate first-line treatment for GFCS.

The contribution of intraocular lens calculation accuracy to the refractive error predicted at 10 years in the Infant Aphakia Treatment Study

PURPOSE

To determine the relative contribution of intraocular lens (IOL) calculation accuracy and ocular growth variability to the long-term refractive error predicted following pediatric cataract surgery.

METHODS

Pseudophakic eyes of children enrolled in the Infant Aphakia Treatment Study (IATS) were included in this study. Initial absolute prediction error (APE) and 10-year APE were calculated using the initial biometry, IOL parameters, postoperative refractions, and mean rate of refractive growth. The cohort was divided into children with a low-initial APE (≤1.0 D) and a high-initial APE ( >1.0 D). The 10-year APE was compared between the two groups using the Mann-Whitney U test. Linear regression was used to estimate the variability in prediction error explained by the initial IOL calculation accuracy.

RESULTS

Forty-two children with IOL placement in infancy were included. Seventeen eyes had a low initial APE, and 25 eyes had a high initial APE. There was no significant difference in APE 10 years following surgery between individuals with a low initial APE (median, 2.67 D; IQR, 1.61-4.12 D) and a high initial APE (median, 3.45 D; IQR, 1.64-5.10 D) (P = 0.7). Initial prediction error could explain 12% of the variability in the prediction error 10 years following surgery.

CONCLUSIONS

IOL calculation accuracy contributed minimally to the refractive error predicted 10 years after cataract surgery in the setting of high variability in the rate of refractive growth.