Visual acuity development after the implantation of unilateral intraocular lenses in infants and young children

Myopic shift, refractive, and visual outcomes after 5 years of infantile cataract surgery: Our experience and review of literature

PURPOSE

After infantile cataract surgery, axial elongation, induces a myopic shift that cannot be fully compensated by corneal flattening and the rate is unpredictable owing to the non-linear growth of the eye. The current prospective study assesses the myopic shift and visual outcomes in children undergoing cataract surgery in infancy over a follow-up period of 5 years.

MATERIALS AND METHODS

A prospective study conducted at a tertiary eye care center to evaluate the five-year myopic shift, refractive and visual outcomes in infants, who underwent surgery for congenital cataract in infancy. The visual acuity, myopic shift and biometric changes are compared between the aphakia and pseudophakia group.

RESULTS

The mean best-corrected visual acuity (BCVA) recorded in logMAR at 5 years for aphakia group was 0.92±0.44 and for pseudophakia group was 0.66±0.42. (pvalue: 0.002102). The myopic shift was noted to be -5.9+/-5.16 in the aphakia group whereas it was -9.01+/- 3.11 in the pseudophakia group (P value= 0.002101) at 5 years after surgery for infantile cataract.

CONCLUSION

IOL implantation in eyes of infants undergoing cataract surgery is feasible in eyes that strictly satisfy the pre-operative inclusion criteria and the visual outcomes in these eyes are better compared to aphakia group at 5 years follow up. Eyes with primary IOL implantation had a higher myopic shift compared to ones without primary IOL implantation. Eyes undergoing primary IOL implantation, need higher under correction compared to the current available formulae.

Whole Exome Sequencing of 20 Spanish Families: Candidate Genes for Non-Syndromic Pediatric Cataracts

Non-syndromic pediatric cataracts are defined as opacification of the crystalline lens that occurs during the first years of life without affecting other organs. Given that this disease is one of the most frequent causes of reversible blindness in childhood, the main objective of this study was to propose new responsible gene candidates that would allow a more targeted genetic approach and expand our genetic knowledge about the disease. We present a whole exome sequencing (WES) study of 20 Spanish families with non-syndromic pediatric cataracts and a previous negative result on an ophthalmology next-generation sequencing panel. After ophthalmological evaluation and collection of peripheral blood samples from these families, WES was performed. We were able to reach a genetic diagnosis in 10% of the families analyzed and found genes that could cause pediatric cataracts in 35% of the cohort. Of the variants found, 18.2% were classified as pathogenic, 9% as likely pathogenic, and 72.8% as variants of uncertain significance. However, we did not find conclusive results in 55% of the families studied, which suggests further studies are needed. The results of this WES study allow us to propose LONP1, ACACA, TRPM1, CLIC5, HSPE1, ODF1, PIKFYVE, and CHMP4A as potential candidates to further investigate for their role in pediatric cataracts, and AQP5 and locus 2q37 as causal genes.

Assessment of long-term visual outcomes in aphakic children wearing scleral contact lenses

BACKGROUND

Timely management of aphakic children is critical for the rehabilitation of adequate visual gain. This study aims to evaluate the long-term efficacy of scleral contact lenses in terms of visual outcomes, complications, and compliance in aphakic children.

METHODS

Retrospective data review of children with congenital or acquired cataract, or subluxated crystalline lenses, who underwent lensectomy from 2004 to 2018 and who used scleral contact lenses for refractive correction. Collected data from the follow up period included recorded aphakic refraction and visual acuity, complications following scleral contact lens wear documented in the clinic and ophthalmic emergency room and compliance to lens wear according to parental feedback on every visit in the clinic.

RESULTS

76% of cases, with final best corrected visual acuity (BCVA) of 20/40 or better achieved in seventeen eyes (34%). The rate of amblyopia was 50%. Strabismus developed in 56% of children, and those had less favourable visual outcomes (0.43 ± 0.4 LogMAR without strabismus and 0.8 ± 0.5 LogMAR with strabismus, p = 0.015). No corneal infections were documented during the follow up. Main adverse effect on the ocular surface was superficial punctate keratopathy (n = 16). Compliance was good in 48 children (96%)- except for two cases, the scleral lenses were tolerated well by all children.

CONCLUSION

Scleral contact lenses are an effective means of visual rehabilitation in aphakic children after lensectomy and may be used long-term with good compliance of wear, excellent visual outcomes, and tolerable adverse events.

Surgical interventions for bilateral congenital cataract in children aged two years and under

BACKGROUND

Congenital cataracts are lens opacities in one or both eyes of babies or children present at birth. These may cause a reduction in vision severe enough to require surgery. Cataracts are proportionally the most treatable cause of visual loss in childhood, and are a particular problem in low-income countries, where early intervention may not be possible. Paediatric cataracts provide different challenges to those in adults. Intense inflammation, amblyopia (vision is obstructed by cataract from birth which prevents normal development of the visual system), posterior capsule opacification and uncertainty about the final trajectory of ocular growth parameters can affect results of treatment. Two options currently considered for children under 2 years of age with bilateral congenital cataracts are: (i) intraocular lens (IOL) implantation; or (ii) leaving a child with primary aphakia (no lens in the eye), necessitating the need for contact lenses or aphakic glasses. Other important considerations regarding surgery include the prevention of visual axis opacification (VAO), glaucoma and the route used to perform lensectomy.

OBJECTIVES

To assess the effectiveness of infant cataract surgery or lensectomy to no surgery for bilateral congenital cataracts in children aged 2 years and under.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL; which contains the Cochrane Eyes and Vision Trials Register; 2022, Issue 1); Ovid MEDLINE; Ovid Embase; the ISRCTN registry; ClinicalTrials.gov and the WHO ICTRP. The date of the search was 25 January 2022.

SELECTION CRITERIA

We included all randomised controlled trials (RCTs) that compared infant cataract surgery or lensectomy to no surgery, in children with bilateral congenital cataracts aged 2 years and younger. This update (of a review published in 2001 and updated in 2006) does not include children over 2 years of age because they have a wider variety of aetiologies, and are therefore managed differently, and have contrasting outcomes.

DATA COLLECTION AND ANALYSIS

We used standard methods expected by Cochrane. Two review authors extracted data independently. We assessed the risk of bias of included studies using RoB 1 and assessed the certainty of the evidence using GRADE.

MAIN RESULTS

We identified three RCTs that met our inclusion criteria with each trial comparing a different aspect of surgical intervention for this condition. The trials included a total of 79 participants under 2 years of age, were conducted in India and follow-up ranged from 1 to 5 years. Study participants and outcome assessors were not masked in these trials. One study (60 children) compared primary IOL implantation with primary aphakia. The results from this study suggest that there may be little or no difference in visual acuity at 5 years comparing children with pseudophakia (mean logMAR 0.50) and aphakia (mean logMAR 0.59) (mean difference (MD) -0.09 logMAR, 95% confidence intervals (CIs) -0.24 to 0.06; 54 participants; very low-certainty evidence), but the evidence is very uncertain. The evidence is very uncertain as to the effect of IOL implantation compared with aphakia on visual axis opacification (VAO) (risk ratio (RR) 1.29, 95% CI 0.23 to 7.13; 54 participants; very low-certainty evidence). The trial investigators did not report on the cases of amblyopia. There was little evidence of a difference betwen the two groups in cases of glaucoma at 5 years follow-up (RR 0.86, 95% CI 0.24 to 3.10; 54 participants; very low-certainty evidence). Cases of retinal detachment and reoperation rates were not reported. The impact of IOL implantation on adverse effects is very uncertain because of the sparse data available: of the children who were pseudophakic, 1/29  needed a trabeculectomy and 8/29 developed posterior synechiae. In comparison, no trabeculectomies were needed in the aphakic group and 2/25 children had posterior synechiae (54 participants; very low-certainty evidence).  The second study (14 eyes of 7 children under 2 years of age) compared posterior optic capture of IOL without vitrectomy versus endocapsular implantations with anterior vitrectomy (commonly called 'in-the-bag surgery'). The authors did not report on visual acuity, amblyopia, glaucoma and reoperation rate. They had no cases of VAO in either group. The evidence is very uncertain as to the effect of in-the-bag implantation in children aged under 1 year. There was a higher incidence of inflammatory sequelae: 4/7 in-the-bag implantation eyes and 1/7 in optic capture eyes (P = 0.04, 7 participants; very low-certainty evidence). We graded the certainty of evidence as low or very low for imprecision in all outcomes because their statistical analysis reported that a sample size of 13 was needed in each group to achieve a power of 80%, whereas their subset of children under the age of 1 year had only 7 eyes in each group. The third study (24 eyes of 12 children) compared a transcorneal versus pars plana route using a 25-gauge transconjunctival sutureless vitrectomy system. The evidence is very uncertain as to the effect of the route chosen on the incidence of VAO, with no cases reported at 1 year follow-up in either group. The investigators did not report on visual acuity, amblyopia, glaucoma, retinal detachment and reoperation rate. The pars plana route had the adverse effects of posterior capsule rupture in 2/12 eyes, and 1/12 eyes needing sutures. Conversely, 1/12 eyes operated on by the transcorneal route needed sutures. We graded the outcomes with very low-certainty because of the small sample size and the absence of a priori sample size calculation.

AUTHORS' CONCLUSIONS

There is no high level evidence for the effectiveness of one type of surgery for bilateral congenital cataracts over another, or whether surgery itself is better than primary aphakia. Further RCTs are required to inform modern practice about concerns, including the timing of surgery, age at which surgery should be undertaken, age for implantation of an IOL and development of complications, such as reoperations, glaucoma and retinal detachment. Standardising the methods used to measure visual function, along with objective monitoring of compliance with the use of aphakic glasses/contact lenses would greatly improve the quality of study data and enable more reliable interpretation of outcomes.

Femtosecond laser-assisted anterior capsulotomy in children undergoing cataract surgery: a large case series

Objective

To evaluate safety and postoperative visual outcomes of low-energy femtosecond laser-assisted (FLA) anterior capsulotomy in paediatric cataract surgery.

Methods and analysis

We report a retrospective single-centre consecutive case series of 51 eyes of 33 paediatric cataract patients with a mean age of 3.22 years (range: 2 months to 13 years) who underwent cataract surgery with FLA anterior capsulotomy, using FEMTO LDV Z8 femtosecond laser (Ziemer Ophthalmic Systems). Anterior laser capsulotomy, phacoaspiration and intraocular lens implantation were performed in all eyes. Both intraoperative and long-term postoperative complications, along with long-term monocular corrected distance visual acuity (CDVA), were assessed during average follow-up period of 32.96 months (range: 13–69 months).

Results

In 48 out of 51 eyes, a well-sized and well-located anterior capsulotomy was achieved without intraoperative complications. Anterior capsule tears occurred in three eyes; however, they did not extend posteriorly and the intraocular lens were placed in the bags without any further complications. Posterior capsular opacification developed in 45.10% of eyes (23 out of 51) and was subsequently treated with neodymium:yttrium-aluminum-garnet (Nd:YAG) laser capsulotomy. Mean CDVA at final follow-up was 20/40 (range: 20/63 to 20/32) in unilateral cases younger than 12 months, 20/40 (range: 20/1000 to 20/25) in unilateral cases older than 12 months, 20/66 (range: 20/400 to 20/32) in bilateral cases younger than 12 months and 20/40 (range: 20/200 to 20/20) in bilateral cases older than 12 months.

Conclusions

Paediatric cataract surgery with low-energy FLA anterior capsulotomy is a procedure with long-term safety, resulting in significant improvement in CDVA.

Intraocular lens power calculation formula in congenital cataracts: Are we using the correct formula for pediatric eyes?

The major challenge these days in pediatric cataract surgery is not the technique of surgery or intraocular lens (IOL) used but the postoperative refractive error. Amblyopia occurring due to postoperative refractive error which the child has; destroys the benefit obtained by a near-perfect and timely surgery. Even if we settle the debate as to what should be the ideal postoperative target refraction, there is a postoperative surprise that is not explained by our conventional insights of an accurate power calculation in children. The role of IOL power calculation formulae in affecting the postoperative refractive error should not be underestimated. Therefore, which age-appropriate formula is to be used for children is unclear. This review is an update on major IOL power calculation formulas used in pediatric eyes. We have tried to define why we should not be using these formulas made for adult eyes and review the literature in this regard.

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.

[Long-term functional outcomes after congenital cataract extraction with intraocular lens implantation in children of the first year of life]

PURPOSE

To study best corrected visual acuity (BCVA) and identify its relationship with various factors in eyes with pseudophakia in long-term periods after removal of congenital cataract (CC) in the first year of life.

MATERIAL AND METHODS

The study included 54 children (72 eyes) aged 4 to 12 years who had undergone CC removal with intraocular lens (IOL) implantation at the age of 2-11 months. Examination included: visual acuity testing, Flicker ERG 30 Hz electroretinography (MBN, Russia), optical coherence tomography (HRT-OCT) on the Heidelberg Spectralis (Heidelberg Engineering, Germany) platform.

RESULTS

The best results were obtained after removal of bilateral congenital cataract (BCC): BCVA in 58.0% of cases was 0.15-0.3, and in 12.0% of cases - 0.4-0.8. BCVA was 0.1 or less in 95.5% of cases and only one child had 0.2 after removal of unilateral congenital cataract (UCC). The best BCVA was achieved in children operated on the 2-5 month of age (BCVA more than 0.3 in 68.7%; only children from that group had 0.5-0.8), without any concomitant pathology and with normal indicators of ERG Flicker 30 Hz. Deviations from physiological formation of the macula were revealed using OCT. The direct relationship was shown between BCVA, and the maximal retinal thickness in parafovea and choroidal thickness in the subfoveal area.

CONCLUSION

BCVA significantly varies after CC removal with IOL implantation in infancy: 0.02-0.8. The main factors influencing BCVA in that case are: laterality of cataract, child age at the time of operation, duration of visual deprivation, concomitant eye pathology and refractive amblyopia accompanying incomplete correction of aphakia.

Secondary glaucoma and visual outcome after paediatric cataract surgery with primary bag-in-the-lens intraocular lens

PURPOSE

To determine predictors of secondary glaucoma and poor visual outcome in children undergoing cataract surgery with bag-in-the-lens (BIL)-IOL implantation.

METHODS

Medical records were retrospectively analysed for children with primary implantation with BIL-IOL during 2009-2013.

RESULTS

The study included 109 eyes. Median age at surgery was 2.5 years (range 2 weeks-14.1 years), 26.6% being ≤12 weeks of age (= early group). Median follow-up time was 2.8 years (7 months-5.8 years). 15 eyes (13.8%) developed glaucoma, 14 (48.3%) in the early group and 1 (1.3%) in the late group (p < 0.001). Within the early group, mean time for surgery differed significantly. Patients developing glaucoma had cataract surgery at 3.5 ± 1.1 weeks (mean ± SD) and the non-glaucoma patients at 5.7 ± 3.3 weeks (p = 0.024). In the entire cohort, 21 eyes (19.3%) had conditions associated with glaucoma; 57.1% of these developed glaucoma compared to 3.4% without these conditions (p < 0.001). Corrected distance visual acuity (CDVA) (decimal) of ≥0.5 was seen in 50 eyes (48.5%), median 0.63 in the late group and 0.15 in the early group. Glaucoma eyes in the early group (surgery at 3.5 weeks) achieved 0.56 median (range, 0.4-1.0) logMAR, (0.28 decimal) CDVA, whereas non-glaucoma eyes (surgery at 5.7 weeks) achieved 0.89 median (range 0.7-1.6) logMAR (0.13 decimal) CDVA; p = 0.016. Glaucoma development in infants between 5 weeks and 2 years of age was 6.7% (n = 2/30).

CONCLUSIONS

Comorbidity strongly increases the risk of secondary glaucoma. Surgery during the first month is correlated with better CDVA outcome and glaucoma. After 5 weeks of age, glaucoma rate is low with the BIL-IOL.

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.

Outcome of primary intraocular lens implantation in infants: Complications and rates of additional surgery

PURPOSE

To study the requirement of additional surgery and adverse events in infants having primary intraocular lens (IOL) implantation.

SETTING

Tertiary care institute, Chandigarh, India.

DESIGN

Prospective observational noncomparative case series.

METHODS

Infants who had phacoaspiration, primary posterior capsulotomy, anterior vitrectomy, and primary IOL implantation were evaluated for complications and the need for additional surgery over a 3-year period. The main outcome measures were the rate of complications, adverse events, and need for additional surgery.

RESULTS

Sixty infants (100 eyes) with a mean age of 7.13 months ± 2.32 (SD) (range 3 to 12 months) were studied. The mean follow-up was 41.2 ± 3.5 months. Indication of additional surgery included visual axis opacification in 13 eyes, pupillary membrane/IOL decentration in 4 eyes, and iris prolapse in 4 eyes. Adverse events included pigment on the IOL in 14 eyes and iridolenticular adhesions in 9 eyes. Ocular hypertension was observed in 2 eyes. The IOL was placed in sulcus or by optic capture in 14 eyes. There was no difference in additional surgery and adverse events between infants aged 6 months or younger versus those older than 6 months (P = .734).

CONCLUSION

There was a low incidence of adverse events and additional surgery requirement in infants who had cataract surgery with primary IOL implantation.

FINANCIAL DISCLOSURE

None of the authors has a financial or proprietary interest in any material or method mentioned.

Management of cataracts and ectopia lentis in children: Practice patterns of pediatric ophthalmologists in India

Purpose:

To analyze the current practice patterns of Indian pediatric ophthalmologists in the management of lens anomalies. This study was conducted in a tertiary eye care hospital and involved an online questionnaire survey for practicing pediatric ophthalmologists in India.

Methods:

A questionnaire was devised by the authors, which included the various options available for the management of lens anomalies in children. The questionnaire was sent to each of them using an online portal. Commercial software (Stata ver. 13.1; StataCorp, College Station, TX, USA) was used for statistical analysis.

Results:

In unilateral cataracts in children aged <6 months, 85.42% of surgeons did not prefer to insert an intraocular lens (IOL). In the age group of 6–12 months, almost half of them preferred to insert an IOL. In the age group of 12–24 months and >24 months, 92.63% and 88.54%, respectively, preferred to insert an IOL. In bilateral cataracts, in children aged <6 months, 91.84% of surgeons did not prefer to insert an IOL, whereas in the age group of 6–12 months, 69.39% did not prefer to insert an IOL. In the age group of 12–24 months and >24 months, 80.61% and 90.82%, respectively, preferred to insert an IOL. Seventy-four percent of surgeons preferred to use a single-piece hydrophobic acrylic IOL.

Conclusion:

The management of lens anomalies by pediatric ophthalmologists in India varies with laterality and appears to be comparable to that followed worldwide.

Visual Outcome and Related Factors in Bilateral Total Congenital Cataract Patients: A Prospective Cohort Study

This study is to evaluate the visual outcome and identify its crucial related factors in children undergoing cataract surgery for bilateral total congenital cataract (CC). This prospective study included consecutive bilateral total cataract patients undergoing primary surgery at Zhongshan Ophthalmic Center (ZOC), Guangzhou, China from Jan 2010 to May 2014. Visual outcome was estimated by best-corrected visual acuity (BCVA) at last follow-up. Potential related factors, including gender, age at last follow-up, age at primary surgery, surgical procedure, postoperative complications (PCs), frequency of follow-up and changes in spectacles were evaluated. Eighty-eight children (176 eyes) were included in the cohort. The mean post-operative BCVA (logMAR) was 1.07 ± 0.53 at the mean follow-up duration 31.07 ± 19.36 months. Multivariable generalized estimating equations (GEEs) showed BCVA was significantly associated with PCs, age at last follow-up and age at primary surgery. Partial correlation analysis indicated age at primary surgery was positively correlated with BCVA controlling for the other factors, both for the whole age range (R = 0.415, P < 0.001) and age >6 months (R = 0.867, P < 0.001). Better visual acuity was related to early primary surgery and low PC occurrence in children with bilateral total CC. Timely surgical intervention and strict control of PCs would be potential steps to achieving better visual outcome.

Surgical outcomes of congenital and developmental cataracts in Japan

PURPOSE

To retrospectively analyze the surgical outcomes of congenital/developmental cataracts in Japan.

METHODS

A mail questionnaire was sent to facilities engaged in surgical treatment of congenital cataracts.

RESULTS

Twenty-nine facilities reported on 809 eyes of 508 patients with congenital/developmental cataracts. Three hundred fifty-nine eyes underwent intraocular lens implantation (pseudophakia group), while 450 eyes were left aphakic (aphakia group). The average age at surgery was significantly higher in the pseudophakia group (70 ± 53 months) than in the aphakia group (14 ± 24 months) (P < 0.0001). A significantly larger proportion of patients with unilateral cataract (52.0 %) received IOL implantation than did those with bilateral cataracts (42.6 %) (P = 0.0224). The prevalence of associated ocular disorders, such as nystagmus, microcornea, nanophthalmos, and persistent fetal vasculature, was significantly higher in the aphakia group than in the pseudophakia group. Postoperatively, glaucoma developed more frequently in the aphakia group (5.8 %) than in the pseudophakia group (0.7 %) (P = 0.0003). Posterior capsule opacification developed more frequently in the pseudophakic eyes even when both posterior capsulotomy and anterior vitrectomy were performed, especially in patients aged 1 year or younger. Postoperative visual acuity was significantly better in the pseudophakia group than in the aphakia group, both in the unilateral and in the bilateral cases.

CONCLUSIONS

Surgeons tended to select IOL implantation, rather than to leave the eye aphakic, in patients who were older at the time of surgery, had fewer coexisting ocular disorders, and suffered from unilateral cataract. Under such circumstances, pseudophakic eyes obtained significantly better postoperative visual acuity than did aphakic eyes.

Optical correction of aphakia following unilateral infantile cataract removal

PURPOSE

To compare primary intra-ocular lens (IOL) implantation with use of press-on spherical lens for aphakia correction following unilateral infantile cataract removal.

METHODS

Sixty infants with a unilateral cataract underwent cataract surgery and were randomly assigned to the IOL (A group) or no IOL group (B group). Residual refractive error was corrected with spectacles in the A group and a press-on spherical lens was used to treat aphakia in the B group. Grating visual acuity (VA) was measured and patients were followed for up to 1 year.

RESULTS

LogMAR VA in the operated eyes of both groups was significantly better 1 year than 1 month after surgery. Mean logMAR VA difference between 1 year and 1 month after surgery was higher in the A group (0.457 ± 0.110) than in the B group (0.323 ± 0.114, p < 0.0001). Serious inflammation occurred significantly more often in the A group than in the B group (p = 0.007). Visual axis opacity occurred more often in the A group than in the B group (pupillary membrane: A: six eyes, 20%, B: none, p = 0.024; lens reproliferation: A: 10 eyes, 33%, B: two eyes, 7%, p = 0.021). Glaucoma occurred equally in both groups (p = 0.612). No other complications occurred.

CONCLUSIONS

Primary IOL implantation appears to be a relatively safe, effective optical correction strategy following unilateral cataract extraction in this age group. Patients for whom an IOL is not suitable can be treated with a press-on spherical lens for optical correction.

The role and efficacy of secondary intraocular lenses in the treatment of monocular infantile cataracts

PURPOSE

To determine if and when a secondary intraocular lens (IOL) can be beneficial to the successful treatment of a monocular infantile cataract.

METHODS

This retrospective study reviewed medical records of children undergoing treatment of a monocular congenital cataract from 1996 to 2009 at one pediatric ophthalmology practice. Patients had unilateral cataracts removed by age 8 months and a secondary IOL inserted prior to 6 years of age. At the final visit, the children had to perform linear Snellen visual acuity testing.

RESULTS

Of 11 identified patients, 8 had treatment onset by age 4 months and 3 between 5 and 7 months of age. These 3 children had final acuities of 20/500 (n=2) and hand motion (n=1). Those undergoing treatment prior to age 5 months had Snellen acuities of 20/30 to 20/400. The best results were obtained by patients who were compliant with contact lenses and patching before insertion of a secondary IOL.

CONCLUSIONS

If treatment of a monocular congenital cataract begins by 4 months of age (ie, the critical period for visual development) and patients remain compliant with occlusion therapy and an aphakic contact lens, then they will likely do well after IOL implantation. Furthermore, it appears that insertion of a secondary IOL will maintain vision that was established with a contact lens and patching and perhaps prevent deterioration that might still occur if compliance issues develop. However, secondary IOL placement will not dramatically improve the final visual result from that developed with occlusion and a contact lens.

Complications in the first 5 years following cataract surgery in infants with and without intraocular lens implantation in the Infant Aphakia Treatment Study

PURPOSE

To compare rates and severity of complications between infants undergoing cataract surgery with and without intraocular lens (IOL) implantation.

DESIGN

Prospective randomized clinical trial.

METHODS

A total of 114 infants were enrolled in the Infant Aphakia Treatment Study, a randomized, multi-center (12) clinical trial comparing the treatment of unilateral aphakia in patients under 7 months of age with a primary IOL implant or contact lens. The rate, character, and severity of intraoperative complications, adverse events, and additional intraocular surgeries during the first 5 postoperative years in the 2 groups were examined.

RESULTS

There were more patients with intraoperative complications (28% vs 11%, P = .031), adverse events (81% vs 56%, P = .008), and more additional intraocular surgeries (72% vs 16%, P < .0001) in the IOL group than in the contact lens group. However, the number of patients with adverse events in the contact lens group increased (15 to 24) in postoperative years 2-5 compared to the first postoperative year, while it decreased (44 to 14) in years 2-5 compared to the first postoperative year in the IOL group. If only one half of the patients in the contact lens (aphakic) group eventually undergo secondary IOL implantation, the number of additional intraocular surgeries in the 2 groups will be approximately equal.

CONCLUSION

The increased rate of complications, adverse events, and additional intraocular surgeries associated with IOL implantation in infants <7 months of age militates toward leaving babies aphakic if it is considered likely that the family will be successful with contact lens correction.

Comparison of contact lens and intraocular lens correction of monocular aphakia during infancy: a randomized clinical trial of HOTV optotype acuity at age 4.5 years and clinical findings at age 5 years

IMPORTANCE

The efficacy and safety of primary intraocular lens (IOL) implantation during early infancy is unknown.

OBJECTIVE

To compare the visual outcomes of patients optically corrected with contact lenses vs IOLs following unilateral cataract surgery during early infancy.

DESIGN, SETTING, AND PARTICIPANTS

The Infant Aphakia Treatment Study is a randomized clinical trial with 5 years of follow-up that involved 114 infants with unilateral congenital cataracts at 12 sites. A traveling examiner assessed visual acuity at age 4.5 years.

INTERVENTIONS

Cataract surgery with or without primary IOL implantation. Contact lenses were used to correct aphakia in patients who did not receive IOLs. Treatment was determined through random assignment.

MAIN OUTCOMES AND MEASURES

HOTV optotype visual acuity at 4.5 years of age.

RESULTS

The median logMAR visual acuity was not significantly different between the treated eyes in the 2 treatment groups (both, 0.90 [20/159]; P = .54). About 50% of treated eyes in both groups had visual acuity less than or equal to 20/200. Significantly more patients in the IOL group had at least 1 adverse event after cataract surgery (contact lens, 56%; IOL, 81%; P = .02). The most common adverse events in the IOL group were lens reproliferation into the visual axis, pupillary membranes, and corectopia. Glaucoma/glaucoma suspect occurred in 35% of treated eyes in the contact lens group vs 28% of eyes in the IOL group (P = .55). Since the initial cataract surgery, significantly more patients in the IOL group have had at least 1 additional intraocular surgery (contact lens, 21%; IOL, 72%; P < .001).

CONCLUSIONS AND RELEVANCE

There was no significant difference between the median visual acuity of operated eyes in children who underwent primary IOL implantation and those left aphakic. However, there were significantly more adverse events and additional intraoperative procedures in the IOL group. When operating on an infant younger than 7 months of age with a unilateral cataract, we recommend leaving the eye aphakic and focusing the eye with a contact lens. Primary IOL implantation should be reserved for those infants where, in the opinion of the surgeon, the cost and handling of a contact lens would be so burdensome as to result in significant periods of uncorrected aphakia.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT00212134

Predictors of adherence to occlusion therapy 3 months after cataract extraction in the Infant Aphakia Treatment Study

BACKGROUND

Little information is available on factors that predict adherence to patching in infants. We evaluated data from the Infant Aphakia Treatment Study, a randomized clinical trial of treatment for infants with unilateral congenital cataracts, to investigate factors associated with successful adherence to patching protocols.

METHODS

In the Infant Aphakia Treatment Study, patching was prescribed 1 hour daily per month of age until 8 months of age and 50% of waking hours thereafter. A centrally located staff member inquired about the patient's adherence to patching in a phone interview with the primary caregiver. Analyses used χ(2) tests of independence and logistic regression to identify predictors of reported adherence and of achieving adherence rates of at least 75% ("good") and 90% ("excellent").

RESULTS

A total of 104 caregivers provided data on patching 3 months after surgery, at which time 60% reported patching at least 75% of the prescribed time. Reported adherence was not associated with the type of treatment (P = 0.73) but was better in children with private insurance (P = 0.01) and for children with mothers reporting lower levels of parenting stress (P = 0.03).

CONCLUSIONS

Most caregivers reported being able to adhere to prescribed patching shortly after extraction of a unilateral congenital cataract. The type of correction (intraocular lens vs contact lens) was not associated with the amount of patching achieved, whereas family socioeconomic status and maternal stress appeared to play a role.

Congenital and infantile cataract: aetiology and management

Congenital cataract is the commonest worldwide cause of lifelong visual loss in children. Although congenital cataracts have a diverse aetiology, in many children, a cause is not identified; however, autosomal dominant inheritance is commonly seen. Early diagnosis either on the post-natal ward or in the community is important because appropriate intervention can result in good levels of visual function. However, visual outcome is largely dependent on the timing of surgery when dense cataracts are present. Good outcomes have been reported in children undergoing surgery before 6 weeks of age in children with unilateral cataract and before 10 weeks of age in bilateral cases. Placement of an artificial intraocular lens implant after removal of the cataract has become established practice in children over 2 years of age. There remains debate over the safety and predictability of intraocular lens implantation in infants. Despite early surgery and aggressive optical rehabilitation, children may still develop deprivation amblyopia, nystagmus, strabismus, and glaucoma. The diagnosis and management of congenital cataracts has improved substantially over the past 30 years with a concurrent improvement in outcomes for affected children. Many aspects of the pre-, intra-, and postoperative management of these patients continue to be refined, highlighting the need for good quality data and prospective collaborative studies in this field.

Long-term visual acuity and initial postoperative refractive error in pediatric pseudophakia

OBJECTIVE

To examine the long-term best-corrected visual acuity (BCVA) in children who, during the amblyogenic period, underwent cataract extraction with intraocular lens (IOL) implantation and to see if initial postoperative refractive error following cataract extraction correlates with long-term BCVA.

DESIGN

Retrospective chart review.

PARTICIPANTS

Thirty-six eyes of 26 patients were included in the study. At least 2 years of follow-up, an age , 8.5 years at time of IOL implantation, an ability to participate in subjective visual acuity measurement, and an absence of congenital glaucoma and significant trauma were required for inclusion in the study.

METHODS

Retrospective review of pseudophakic patients' charts at a tertiary care centre, with attention to initial and long-term pseudophakic refractive error, long-term BCVA, total myopic shift, length of follow-up, age at IOL implantation, and unilateral or bilateral cataract extraction with IOL implantation.

RESULTS

Initial pseudophakic spherical equivalent (SE) showed a significant nonlinear relationship with most recentBCVAin unilateral cases and no relationship in bilateral cases (interaction p 0.001). Unilateral cases with initial pseudophakic SE between +1.75 D and +5.00 D showed better long-term BCVA than those with values below +1.75 D or above +5.00 D; this was irrespective of the refractive error of their fellow eye.

CONCLUSIONS

In patients receiving lens implants in the first 8 years of life, we recommend aiming for low early postoperative hyperopia, taking into consideration each patient's situation and age.

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

OBJECTIVE

To compare the visual outcomes and adverse events of contact lens with primary intraocular lens (IOL) correction of monocular aphakia during infancy.

METHODS

In a randomized, multicenter (12 sites) clinical trial, 114 infants with a unilateral congenital cataract were assigned to undergo cataract surgery between 1 to 6 months of age either with or without primary IOL implantation. Contact lenses were used to correct aphakia in patients who did not receive IOLs. Grating visual acuity was tested at 1 year of age by a masked traveling examiner.

MAIN OUTCOME MEASURE

Grating visual acuity at 1 year of age.

RESULTS

The median logMAR visual acuity was not significantly different between the treated eyes in the 2 groups (contact lens group, 0.80; IOL group, 0.97; P = .19). More patients in the IOL group underwent 1 or more additional intraocular operations than patients in the contact lens group (63% vs 12%; P < .001). Most of these additional operations were performed to clear lens reproliferation and pupillary membranes from the visual axis.

CONCLUSIONS

There was no statistically significant difference in grating visual acuity at age 1 year between the IOL and contact lens groups; however, additional intraocular operations were performed more frequently in the IOL group.

APPLICATION TO CLINICAL PRACTICE

Until longer-term follow-up data are available, caution should be exercised when performing IOL implantation in children aged 6 months or younger given the higher incidence of adverse events and the absence of an improved short-term visual outcome compared with contact lens use.

Visual results and complications of primary intraocular lens implantation in infants aged 6 to 12 months

BACKGROUND

To present the visual results and the complications of primary intraocular lens (IOL) implantation in infants aged 6 to 12 months between January 2002 and July 2007.

METHODS

A total of 26 consecutive eyes, of 16 infants with cataract aged 6 to 12 months, were reviewed in the study. All patients had cataract extraction with anterior and posterior capsulorrhexis combined with anterior vitrectomy and primary hydrophobic acrylic IOL implantation. Six infants (six eyes) had unilateral congenital cataract and ten (20 eyes), bilateral cataract. Visual acuity and complications were recorded throughout the 46.4-month mean follow-up (range 22 to 79 months).

RESULTS

All eyes had primary IOL implantation. The mean best-corrected visual acuity (logMAR) was 0.98 +/- 0.18,0.50 +/- 0.14 and 0.61 +/- 0.25 for unilateral, bilateral and all eyes respectively at the last follow-up. IOLs were implanted in the capsular bag of 25 eyes (96.2%) and in the sulcus of the remaining one eye (3.8%). Seven eyes (26.9%) developed visual axis opacification (VAO), and four eyes required secondary pars plana vitrectomy (PPV). IOL opacification occurred in one eye 54 months after implantation. Late onset open-angle glaucoma developed in one eye, and required trabeculectomy surgery. The predictors of good best-corrected visual acuity (BCVA) included partial cataract, bilateral cataract, absence of strabismus or nystagmus, and good amblyopic treatment. The greatest annual myopic change (5.15 +/- 2.08 D) was observed during the first 12 months after surgery. In unilateral cases, there was no significant difference in the axial length between the cataractous eye and the fellow normal eye both at the time of surgery (P = 0.891) and final follow-up (P = 0.693).

CONCLUSIONS

Primary IOL implantation was safe and effective for infantile cataract surgery. Total or unilateral cataract, nystagmus or strabismus, and inadequate amblyopic therapy were predictors of poor BCVA. Significant myopic shifts occurred especially in infants in the first year of surgery. The pseudophakic eye had a similar growth rate, as measured by axial length, to that of the fellow normal eye, in unilateral cases.

Eye muscle surgery for infantile nystagmus syndrome in the first two years of life

Purpose:

To report visual and elctrophysioloigcal effects of eye muscle surgery in young patients with infantile nystagmus syndrome (INS).

Methods:

Prospective, interventional case cohort of 19 patients aged under 24 months who were operated on for combinations of strabismus, an anomalous head posture, and nystagmus. All patients were followed at least nine months. Outcome measures, part of an institutionally approved study, included Teller acuity, head position, strabismic deviation, and eye movement recordings, from which waveform types and a nystagmus optimal foveation fraction (NOFF). Computerized parametric and nonparametric statistical analysis of data were perfomed using standard software on both individual and group data.

Results:

Age averaged 17.7 months (13.1-month follow-up). Thirteen (68%) patients had associated optic nerve or retinal disease. 42% had amblyopia, 68% had refractive errors. Group means in binocular Teller acuity (P < 0.05), strabismic deviation (P < 0.05), head posture (P < 0.001), and the NOFF measures (P < 0.01) from eye movement recordings improved in all patients. There was a change in null zone waveforms to more favorable jerk types. There were no reoperations or surgical complications.

Conclusions:

Surgery on the extraocular muscles in patients aged less than two years with INS results in improvements in multiple aspects of ocular motor and visual function.

Advances in the management of congenital and infantile cataract

Congenital and infantile cataracts produce deprivation amblyopia and can thus cause lifelong visual impairment. Successful management is dependent on early diagnosis and referral for surgery when indicated. Accurate optical rehabilitation and postoperative supervision are essential.The timing of surgery and its relationship to the duration of deprivation is important. Unilateral congenital cataract surgery within 6 weeks of birth produces the best outcomes. The equivalent 'latent' period for bilateral visual deprivation may be longer at around 10 weeks. Visual deprivation has a significant impact on the development of fixation stability. Major form deprivation, even after early surgery, leads to nystagmus. This is mostly manifest latent nystagmus (MLN). The latent period for fixation stability may be as short as 3 weeks. Preoperative congenital nystagmus (CN) can convert to more benign MLN after surgery. Infantile IOL implantation is becoming increasingly accepted. A satisfactory long-term refractive result requires that allowance be made for childhood axial growth and myopic shift. In a series of 25 infants (33 eyes) implanted before 12 months of age, the mean myopic shift at 12 months was 4.83 D. This increased to 5.3 D in infants implanted before 10 weeks. The initial desired refractive outcome following IOL implantation is thus hypermetropia, with the degree dependent on the age of the child. Glaucoma or ocular hypertension is a common complication following paediatric cataract surgery. Microphthalmia and surgery in early infancy are risk factors. Tonometry results may be influenced by the increased corneal thickness seen in aphakic and pseudophakic children. The long-term prognosis of eyes with aphakic glaucoma is not necessarily poor but intraocular pressure control may require three or more medications. Surgical intervention appears to be necessary in over a quarter of eyes. Posterior capsule opacification (PCO) is common in infants undergoing primary lens implantation. Primary capsulotomy and anterior vitrectomy reduce the risk of PCO. In the absence of anterior vitrectomy, primary posterior capsulotomy does not prevent visual axis opacification. Further developments will continue to be driven by clinical research. The prevention of capsule opacification and cellular proliferation may in future be achieved by the use of devices to specifically target epithelial cells at surgery.

Pediatric cataract extraction with intraocular lens implantation: visual acuity outcome when measured at age four years and older

PURPOSE

Assessment of visual outcome of pediatric eyes that underwent cataract extraction with primary intraocular lens (IOL) implantation at a single center.

METHODS

A retrospective review of charts of 510 consecutive pediatric patients that underwent cataract extraction was performed. Exclusion criteria were traumatic cataract, secondary IOL implantation, retinopathy of prematurity, severe developmental delay, age less than 4 years at last follow-up, and follow-up less than 6 months. In bilateral cases, only right eye data were included.

RESULTS

One hundred thirty-nine eyes met inclusion criteria. Median age at surgery was 5.12 years (range, 0.03-16.92); median age at last follow-up was 9.05 years, and median follow-up was 3.65 years. Sixty-six of 139 (47.5%) patients had unilateral cataracts compared with 73/139 (52.5%) bilateral cases. The median visual acuity of all eyes was 20/30, with median visual acuity of unilateral and bilateral cases being 20/40 and 20/25, respectively. Older patients achieved better visual acuity (unilateral cases: p = 0.003; bilateral cases: p = 0.07). Eyes with a greater interocular axial length difference achieved poorer visual acuity. Forty-five patients had a final visual acuity worse than 20/40. Of these, 34 (76%) had a diagnosis of amblyopia as the sole cause. Nineteen of 139 (13.7%) eyes had final visual acuity worse than 20/200. Eighteen patients required strabismus surgery, and 22 required additional intraocular surgery.

CONCLUSIONS

Better visual acuity was associated with bilateral cataract, older age at surgery, and normal interocular axial length difference. Amblyopia was the major cause of residual visual deficit.

Refractive outcomes after primary intraocular lens implantation in infants

BACKGROUND

Intraocular lens (IOL) implantation is becoming increasingly accepted as a primary procedure in infants.

AIM

To evaluate the accuracy of IOL power calculation, the rate of myopic shift and the refractive outcome after primary IOL implantation in infants aged <12 months at the time of cataract surgery.

METHOD

A retrospective case review of 25 patients (8 with bilateral cataracts and 17 with unilateral cataracts) who underwent cataract surgery with primary IOL implantation at <12 months of age. Outcomes measured were actual early postoperative refraction, lens power calculation error, myopic shift and refractive outcome.

RESULTS

In 83% of cases, actual postoperative refraction was within 2 dioptres (D) of the target refraction. Lens power calculation error did not depend on axial length, age at surgery or target refraction. Mean (SD) myopic shift was 5.43 (3.7) D in the first 12 months after surgery, but was significantly greater when surgery was performed at <10 weeks of age.

CONCLUSION

This study demonstrates that IOL power can be calculated with reasonable accuracy in infants using current formulas. Factors such as age at the time of surgery, axial length, whether surgery is unilateral or bilateral, and the presence of systemic pathologies do not seem to influence the accuracy of lens power calculation or myopic shift up to 36 months of age.

Surgical interventions for bilateral congenital cataract

BACKGROUND

Congenital cataracts are opacities of the lens in one or both eyes of children that cause a reduction in vision severe enough to require surgery. Cataract is the largest treatable cause of visual loss in childhood. Paediatric cataracts provide different challenges to those in adults. Intense inflammation, amblyopia and posterior capsule opacification can affect results of treatment. Two treatments commonly considered for congenital cataract are lensectomy and lens aspiration.

OBJECTIVES

The objective of this review was to assess the effects of surgical treatments for bilateral symmetrical congenital cataracts. Success was measured according to the vision attained and occurrence of adverse events.

SEARCH STRATEGY

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) on The Cochrane Library, which contains the Cochrane Eyes and Vision Group Trials Register (2005, Issue 2), MEDLINE (1966 to June 2005), EMBASE (1980 to June 2005, week 27), LILACS (6 July 2005), the Science Citation Index and the reference list of the included studies. We also contacted trial investigators and experts in the field for details of further studies.

SELECTION CRITERIA

We included all prospective, randomised controlled trials that compared one type of cataract surgery to another, or to no surgery, in children with bilateral congenital cataracts aged 15 years or younger.

DATA COLLECTION AND ANALYSIS

Two authors extracted data. No meta-analysis was performed.

MAIN RESULTS

Four trials met the inclusion criteria. All trials were concerned with reducing the development of visual axis opacification (VAO). This was achieved with techniques that included an anterior vitrectomy or optic capture. Posterior capsulotomy alone was inadequate except in older children.

AUTHORS' CONCLUSIONS

Evidence exists for the care of children with congenital or developmental bilateral cataracts to reduce the occurrence of visual axis opacification. Further randomised trials are required to inform modern practice about other concerns including the timing of surgery, age for implantation of an intraocular lens and development of long-term complications such as glaucoma and retinal detachment.