Prospective analysis of pediatric pseudophakia: myopic shift and postoperative outcomes

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.

Pediatric IOL power calculation: Factors and considerations

This narrative review aims to compare and document various studies on pediatric intraocular lens (IOL) power calculation, highlighting the differences from adult IOL power calculations and assessing the need for accurate ophthalmic biometry and targeted refraction to improve visual outcomes and reduce amblyopia risk. A comprehensive search of the PubMed database was conducted using keywords such as "pediatric cataract surgery," "IOL power calculation," "ocular biometry," and "IOL formulas." Relevant articles were identified by evaluating titles and abstracts, followed by full-text examination. References were reviewed for thorough coverage. Pediatric eyes pose unique challenges for IOL power calculation due to smaller size, changing axial length, and corneal curvature. Accurate biometry, particularly axial length and keratometry, is crucial. Studies comparing IOL formulas, primarily developed for adults, show varying prediction errors in pediatric cases. Newer-generation formulas such as Barrett's Universal II and Kane demonstrate superior accuracy compared to older formulas (e.g., SRK/T). Undercorrection strategies account for myopic shifts due to eye growth, but consensus on the best formula and target refraction is lacking. Premium IOLs, such as multifocal and toric, offer benefits but require further long-term evaluation. Accurate IOL power calculation is critical for optimal visual outcomes in pediatric cataract surgery. While newer IOL formulas show promise, the unpredictable nature of eye growth and myopic shifts complicates long-term predictions. Premium IOLs offer potential advantages but necessitate careful consideration. Continuous advancements in IOL technology and personalized approaches to target refraction are essential to improve the quality of life of pediatric patients.

Postoperative Axial Length Prediction Model in Children With Congenital Cataract and Intraocular Lens Implantation

Purpose: To develop a prediction model for postoperative axial length (AL) in Asian children with congenital cataracts undergoing primary/secondary intraocular lens (IOL) implantation. Design: Retrospective observational study. Methods: Data were collected from children who underwent cataract surgery for congenital cataracts at the Eye Hospital of Wenzhou Medical University between 2006 and 2020. All participants completed preoperative and at least 1-year of postoperative follow-up. SPSS 26.0 software was used to analyze the variable factors affecting AL growth and the interactions among these factors. A generalized estimating equation (GEE) was employed to assess the correlation between the AL and related univariates over time. The univariate model was applied to build a multivariate model to predict the postoperative AL. Two validation sets were used to verify the accuracy of the formula. Results: The study involved 86 children, accounting for 148 eyes. The median age at the time of surgery was 3.00 years, with a median age of 9.50 years at the final follow-up visit. The median duration of follow-up was 5.00 years. The preoperative and final follow-up mean ALs were 21.79 ± 1.77 and 23.36 ± 1.90 mm, respectively. Taking the predicted AL (Y) as the dependent variable and the age at surgery (X 1), age at review (X 2), and preoperative AL (X 3) as the independent variables, the prediction model was established as Y = 0.20 - 0.473 × X 1 + 0.446 × X 2 + 0.993 × X 3 - 0.014 × (X 2 - X 1)∗X 2. Conclusions: This model predicts AL growth in children following congenital cataract surgery and IOL implantation, helping ophthalmologists select appropriate IOL power.

Understanding post-operative refractive outcome in pediatrics after IOL implementation: factors and predictors

BACKGROUND

In pediatric ophthalmology, calculating intra-ocular lens (IOL) power can be challenging. It is important to predict if the post-surgery refractive error (RE) will meet the intended refractive goal. In this study, we aimed to investigate the factors and predictors influencing RE outcomes in children undergoing IOL implantation.

METHODS

This was a retrospective cross-sectional cohort study that involved 47 eyes with congenital cataracts underwent IOL implantation. Each patient underwent follow-up visits at two months and two years' post-surgery. The IOL power calculations were conducted using the Holladay 1 formula, and both the prediction error (PE) and absolute prediction error (APE) were calculated.

RESULTS

The mean age was 6.52 ± 4.61 years, with an age range of 1-15 years. The mean IOL power was 20.31 ± 6.57 D, and the mean post-operative refraction was 1.31 ± 2.65 D. The mean of PE and APE were 0.67 ± 1.77 and 1.55 ± 1.06 D, respectively. Whereas PE was correlated to axial length with an R-value of - 0.29 (P = 0.04). The calculation method had a significant negative relationship with APE and PE, with coefficients of - 1.05 (P = 0.009) and - 1.81 (P = 0.009), respectively.

CONCLUSION

High astigmatism was associated with greater errors in the refractive outcome. The calculation methods had the most considerable impact on the post-operative RE. The customization of surgical approaches to accommodate individual characteristics is crucial. Further research with diverse subgroups is needed to comprehensively understand the influence of each factor.

Outcome of intraocular lens exchange for the management of myopic shift in pseudophakic children

PURPOSE

To evaluate the visual outcome of intraocular lens (IOL) exchange for the management of myopic shift in pseudophakic children.

METHODS

The medical records of children who underwent IOL exchange for myopic shift were examined. The preoperative data, operative details and the postoperative outcome were analyzed.

RESULTS

Twenty-one eyes (16 patients) were identified. Mean age at cataract extraction was 20 ± 26 months (range, 2-84 months). Twelve patients (6 unilateral, 6 bilateral) had primary IOL implantation. Mean age at IOL exchange was 7.3 ± 3.2 years. Mean spherical equivalent (SE) at IOL exchange was -14 ± 5 D (range, -7 to -21 D): Mean SE at IOL exchange was -13.64 ± 4.99 D, -12 ± 1.53 D, and -15.5 ± 4.7 D in unilaterally pseudophakic cases (8 patients), in the eye that underwent unilateral IOL exchange (3 patients) in bilaterally pseudophakic cases, and in bilateral IOL exchange cases (5 patients), respectively. Mean axial length at IOL exchange was 24 ± 1.3 mm (range, 23 to 27 mm). Following IOL exchange, mean SE was reduced to -2 ± 1.8 D (range, -4 to +2.5 D). An average of three logMAR line improvement in the best-corrected visual acuity was observed in 12/16 eyes of patients for whom pre- and post-exchange visual acuity were available, while visual acuity remained unchanged in 4 eyes. Mean logMAR visual acuity improvement was 0.35 and 0.49 in unilateral and bilateral pseudophakic cases, respectively.

CONCLUSIONS

IOL exchange is a safe procedure that should be considered to improve visual rehabilitation in pseudophakic patients with myopic shift.

Refractive surgeries in children: Debunking the controversy and assessing the safety and efficacy

New innovations in adults' refractive surgeries have revolutionized the field, offering improved outcomes and enhanced patient experiences. While traditionally considered contraindicated in pediatric populations, emerging research suggests that this notion may not always hold true. Challenges, indications, safety, and other topics will be addressed in this review article.

Rare micropupil secondary to congenital cataract surgery favoring the development of the affected eye: a case report

BACKGROUND

Congenital microcoria has been extensively reported and usually leads to visual dysfunction or blindness. However, micropupil development secondary to cataract surgery has never been reported. Here, we describe a rare case of micropupil development in infancy that occurred secondary to combined cataract extraction and intraocular lens implantation for treatment of congenital cataract. When the patient reached adulthood, the affected eye not only gained good vision but also showed better ocular development and refractive status than the fellow eye.

CASE PRESENTATION

A 17-year-old boy presented to our outpatient clinic with decreased vision in his left eye related to congenital cataract surgery at 6 months of age. The affected eye had exhibited a pinhole pupil since the third month postoperatively. The condition had been managed with observation and regular monocular occlusion treatment. Upon presentation to our clinic, the best-corrected visual acuity (BCVA) in his fellow eye was 0.0 logMAR(20/20) with a refraction of - 5.75 diopters cylinder/-2.25 diopters sphere, and the BCVA in his affected eye was 0.5 logMAR(20/40) with a refraction of 0.00 diopters. Ophthalmic examination of the affected eye revealed a pinhole pupil (approximately 0.5 mm) with high light reflex sensitivity but no response to pupil-dilating drugs. The patient underwent pupilloplasty of the affected eye under corneal surface anesthesia. Postoperative examination revealed better ocular development in the affected eye than in the fellow eye (axial length: 24.21 vs. 27.02 mm, respectively) as well as better refractive status in the affected eye (BCVA of 0.0 logMAR(20/20) with a refraction of - 2.23 diopters cylinder/-3.00 diopters sphere vs. 0logMAR(20/20) with a refraction of -5.75 diopters cylinder/-2.25 diopters sphere).

CONCLUSIONS

We have reported a rare case of micropupil development secondary to congenital cataract surgery, which is an uncommon complication, especially in children. However, unlike congenital microcoria, the secondary pinhole pupil may have reduced imaging haze and halos, possibly favoring the development of the affected eye. This case provides further insight into the treatment of congenital cataract.

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.

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.

Strabismus development after pediatric cataract surgery associated with age at surgery, intraocular lens implantation, and visual acuity outcome

PURPOSE

Approximately half of the children operated on for cataracts develop strabismus. We determined what factors predict its development.

METHODS

In a retrospective, cross-sectional study, children who underwent cataract surgery before age 5 between 2010 and 2017 in a tertiary center in Brazil were identified from medical records. Subsequently, patients were invited for an ophthalmological examination to assess visual acuity, refraction, and strabismus (constant or intermittent heterotropy of any magnitude). In addition, age at surgery, cataract laterality, intraocular lens implantation, surgical complications, nystagmus, anisometropia, and elapsed time between surgery and the present examination were assessed using logistic regression.

RESULTS

Surgery was performed in 74 eyes of 46 patients (21 males). The median age at surgery was 6.4 (3.7-29.6) months, and the interval between surgery and this examination was 32.5 (18.0-53.0) months. Strabismus was present in 33 (72%) patients, 35% had esotropia and 33% exotropia. One patient had strabismus surgery before the examination. Age at surgery (OR 0.95; p-value .018), IOL implantation (OR 0.08; p-value .027), and current visual acuity on the worse eye (OR 1.16; p-value .036) were associated with strabismus.

CONCLUSIONS

Strabismus development after pediatric cataract surgery is associated with age at surgery, intraocular lens implantation, and visual-acuity outcomes of the worse eye.

Primary versus secondary intraocular lens implantation following removal of congenital/de al of congenital/developmental catar elopmental cataracts: outcomes after acts: outcomes after at least 4 years

BACKGROUND

The aim of this study is to evaluate the long-term outcomes of primary and secondary intraocular lens (IOL) implantation following removal of congenital/developmental cataracts.

METHODS

One hundred and forty-four patients aged under 16 years who were followed up between 2003 and 2021 were analyzed retrospectively. The long-term results of children who underwent surgery before 2 years of age for congenital or developmental cataracts and underwent secondary IOL implantation after 2 years of age and those who underwent cataract surgery with primary IOL implantation after 2 years of age were compared. Patients with traumatic, secondary cataracts and cataracts due to ocular anomalies were not included in the study.

RESULTS

We evaluated 64 patients (mean age 9.5 ± 4.5 years) with secondary IOL implantation and 80 patients (mean age 12.8 ± 4.1 years) with primary IOL implantation in the study. Distance and near best-corrected visual acuities were significantly better in the primary IOL group than the secondary IOL group (p < 0.001). Incidence of strabismus after primary IOL surgery was significantly lower and presence of binocular vision was more often than the secondary IOL group (p = 0.002). There was no significant difference between the two groups in terms of refraction and myopic shift (p = 0.242, p = 0.172, respectively). Mean refractive changes were significant in unilateral cases of secondary IOL group and primary IOL group (p = 0.013, p = 0.049, respectively) and myopic shift was also greater in both groups of unilateral cases than the fellow eyes (p = 0.023, p = 0.012, respectively).

DISCUSSION

Visual outcomes and binocular vision were better, and the incidence of strabismus was also much less in the primary IOL group.

Long-term Results of Congenital Cataract Surgery with Primary Intraocular Lens Implantation: A Case-Control Study of Three Age Groups

Purpose

To analyze the results of ocular refraction at the age of 7 years in children after congenital cataract surgery with intraocular lens (IOL) implantation.

Methods

A study of ocular biometric data of 143 eyes who underwent lens aspiration with IOL implantation in unilateral (23 eyes) and bilateral (60 eyes) congenital cataracts was performed. All children were divided into groups according to the age categories at the time of surgery: Group A (0-12 months) - 43 eyes; Group B (12-36 months) - 45 eyes; and Group C (older than 36 months) - 55 eyes. An empirical reduction of the implanted IOL power was performed: an undercorrection of 20% in children aged 0 to 36 months and 10% less in children aged 36 to 60 months.

Results

By age 7 years, the mean elongation ± standard deviation (SD) in Group A was 3.93 ± 1.64 mm, 2.13 ± 0.94 mm in Group B, and 0.95 ± 0.76 mm in Group C (18.7%, 9.5%, and 4.1% of the baseline axial length, respectively). There was no significant difference in axial elongation between unilateral and bilateral congenital cataracts (P = 0.32). The mean absolute refraction error (MAE) at last examination was 3.99 ± 2.12 diopter (D), 2.46 ± 1.48 D, and 1.59 ± 1.31 D in Groups A, B, and C, respectively. In infants younger than 7 months of age, by age 7 years, the mean elongation ± SD was 3.27 ± 2.86 mm (25.5%) and MAE was 3.44 ± 2.1 D. The prevalence of preoperative corneal astigmatism of 1.0 D or more was 48.95%, 2.0 D or more was 27.27%, and 3.0 D or more was 5.6%. There was no significant difference in preoperative corneal astigmatism between unilateral (1.62 ± 0.77 D) and bilateral (1.78 ± 0.90 D) congenital cataracts (P = 0.56, 95% confidence interval = -0.50-0.28). Best-corrected visual acuity (BCVA) more than 20/40 was in 53.49%, 55.55%, and 74.54% in Groups A, B, and C, respectively.

Conclusions

Although IOL power was calculated in accordance with children's age, at the age of 7 years, there was a different degree of ametropia because of the biometric changes of the growing eye, and a higher rate of ametropia was observed more in the younger age group than in the elder age groups.

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.

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

PURPOSE

To evaluate whether pediatric eyes that deviate from age-adjusted normative biometry parameters predict variation in myopic shift after cataract surgery.

METHODS

This is a single institution longitudinal cohort study combining prospectively collected biometry data from normal eyes of children <10 years old with biometry data from eyes undergoing cataract surgery. Refractive data from patients with a minimum of 5 visits over ≥5 years of follow-up were used to calculate myopic shift and rate of refractive growth. Cataractous eyes that deviated from the middle quartiles of the age-adjusted normative values for axial length and keratometry were studied for variation in myopic shift and rate of refractive growth to 5 years and last follow-up visit. Multivariable analysis was performed to determine the association between myopic shift and rate of refractive growth and factors of age, sex, laterality, keratometry, axial length, intraocular lens power, and follow-up length.

RESULTS

Normative values were derived from 100 eyes; there were 162 eyes in the cataract group with a median follow-up of 9.6 years (interquartile range: 7.3-12.2 years). The mean myopic shift ranged from 5.5 D (interquartile range: 6.3-3.5 D) for 0- to 2-year-olds to 1.0 D (interquartile range: 1.5-0.6 D) for 8- to 10-year-olds. Multivariable analysis showed that more myopic shift was associated with younger age (P < .001), lower keratometry (P = .01), and male gender (P = .027); greater rate of refractive growth was only associated with lower keratometry measures (P = .001).

CONCLUSIONS

Age-based tables for intraocular lens power selection are useful, and modest adjustments can be considered for eyes with lower keratometry values than expected for age.

Biometry and corneal aberrations after cataract surgery in childhood

Background

To report long‐term biometric and refractive outcomes in a group of Danish children after surgery for childhood cataract.

Methods

Children between 7 and 18 years who had undergone uni‐ or bilateral cataract surgery at the Department of Ophthalmology, Rigshospitalet, Denmark, were examined in this cross‐sectional study. Swept source optical coherence tomography (OCT) based optical biometry (IOLmaster 700) and anterior tomography (Pentacam) was performed. Healthy fellow eyes from those with unilateral cataract were used as controls.

Results

We included 56 children in the study with a median age at surgery of 43.8 months (1.6–137.6). The amount of higher order aberrations was significantly increased in operated eyes (median root mean square 0.461 μm [range 0.264–1.484]) compared with non‐operated eyes (median root mean square 0.337 μm [range 0.162–0.498], p < 0.001). Younger age at surgery was positively associated with more higher order aberrations at follow‐up (p < 0.001), but we found no significant associations between the amount of higher order aberrations and visual acuity or contrast vision. Longer axial length was associated to glaucoma while shorter axial length was associated to strabismus (p < 0.001).

Conclusions

Eyes operated for childhood cataract have higher order aberrations compared with non‐operated eyes. Higher order aberrations are complex refractive errors that cannot be corrected by normal lenses and may contribute to poor visual outcomes for the children. We found an association between young age at surgery and higher order aberrations.

Congenital cataract surgery: long-term refractive outcomes of a new intraocular lens power correction formula

PURPOSE

The final refraction after intraocular lens (IOL) implantation remains a challenge in the management of paediatric cataracts. No consensual guidelines exist for the choice of IOL power. The aim of this study was to validate a method of IOL power calculation by evaluating the final refractive error in all patients with IOL implantation operated at our institution.

METHODS

We retrospectively studied all children under 7 years of age who underwent cataract surgery with IOL implantation at our institution between 2010 and 2015. Intraocular lens (IOL) power was calculated as follows: After B-scan determination of the emmetropic IOL power, a reduction of 40%, 35%, 30%, 25%, 20%, 15%, 10% and 5% was applied to children 0-3, 3-6, 6-12, 12-18, 18-24, 24-30, 30-36, 36-48 months, respectively. The following data were collected: follow-up, age at surgery, uni- or bilaterality, implanted IOL power and final refraction.

RESULTS

During this period, 81 children (125 eyes) met the inclusion criteria with a median follow-up of 60 months (36-97). The median age at surgery was 6.61 months (0.76-48). We included 52 children with bilateral cataract (96 eyes) and 29 children with unilateral cataract (29 eyes). The mean implanted IOL power was 23.3 ± 4.6 diopters (D). The mean spherical equivalent at last follow-up was 0.07 ± 3.5 D.

CONCLUSION

Our undercorrection formula for IOL implantation after congenital cataract surgery leads to long-term refractive results globally close to emmetropia.

Overcoming myopic shift by the initial inductive hypermetropia in pediatric cataract surgery

Purpose:

To assess the outcome of under-correction of intraocular lens (IOL) power in pediatric cataract surgery.

Methods:

We collected clinical data of 103 patients (181 eyes), all aged ≤15 years, who had undergone cataract surgery by a surgeon during 2006–2016. The mean duration of follow-up was 73 ± 38 months (range: 24–108). IOL power was calculated by Hoffer Q formula in axial length (AL) <21 mm and SRKT formula in AL ≥21 mm and then modified based on this approach: 7D initial inductive hypermetropization in children ≤1-year-old, 5D in 1–3, 3.5D in 3–5, 2.5D in 5–7, 1.5D in 7–9, 1D in 9–10, and 0 in children >10 years old.

Results:

The mean age of all children at surgery time was 5.85 ± 4.56 years (range: 1–178 months). There was a mean myopic shift of −6.379 D in the ≤1 year, −5.532 in the 1–3, −3.194 in the 3–5, −2.301 in the 5–7, −1.06 in the 7–9, −1.567 in the 9–10, and 0.114 in the >10-year-old age group. In 125 eyes (69.1%) of 181, the final SE was between −2 and +2 D, and 21 eyes (11.6%) achieved the goal of emmetropization. Mean best-corrected visual acuity logarithm of the minimum angle of the resolution was 0.30 in children ≤1 year, 0.39 in 1–3, 0.21 in 3–5, 0.18 in 5–7, 0.14 in 7–9, 0.16 in 9–10, and 0.11 in children >10 years old.

Conclusion:

This study shows a larger myopic shift in younger children. Using our approach, all age groups could finally achieve acceptable final refraction.

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

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

Update on Intraocular Lens Formulas and Calculations

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

Presence of Posterior Staphyloma in Congenital Cataract Children

Purpose: To investigate the prevalence of posterior staphyloma (PS) in congenital cataract children and its role in predicting postoperative axial elongation.Materials and Methods: Preoperative prevalence of PS in 520 congenital cataract patients was reviewed and compared with that of the healthy eyes of 300 unilateral traumatic cataract children after 1:1 propensity score matching. Then, 32 pseudophakic children with preoperative PS and 48 age-matched pseudophakic controls without preoperative PS were followed up after the surgery, to compare their axial growth rates and refractive changes.Results: Congenital cataract was significantly associated with the presence of PS (OR: 14.88, P = .009) after propensity score matching. Even in congenital cataract eyes with axial length <26 mm, 5% were identified with PS on B-scan: ≤22 mm: 3%, 22-24 mm: 5% and 24-26 mm: 13%. Eyes with preoperative PS exhibited faster postoperative axial growth than those without, especially in bilateral cases or in children undergoing surgery before 8 years old (≤4 years: 0.53 ± 0.33 vs 0.30 ± 0.21 mm/y P = .028; 4-8 years: 0.37 ± 0.26 vs 0.23 ± 0.15 mm/y P = .044). Myopic shift after surgery was also more significant in children with preoperative PS than in those without (-1.10 ± 0.50 vs -0.60 ± 0.47D/y, P < .001).Conclusions: Congenital cataract is a risk factor for PS. Preoperative PS in pediatric cataract eyes may be an indicator of excessive postoperative axial elongation, especially in bilateral cases or in cases undergoing cataract surgery at a younger age. Our findings may also promote better clinical decision-making in intraocular lens power selection for pediatric population.

Biometric changes in Indian pediatric cataract and postoperative refractive status

Purpose:

To prospectively evaluate the biometric changes in Indian pediatric cataract and postoperative refractive status.

Methods:

A total of 147 patients were recruited into three groups: age <6 months, age between 7 months and 18 months, and age between 19 and 60 months and prospectively observed for 6 months. Exclusion criteria were preterm birth, microphthalmia, microcornea, megalocornea, uveitis, glaucoma, and traumatic or complicated cataract. Axial length and keratometry, the primary outcome measures, were taken preoperatively under general anesthesia before surgery. These children were followed up for 6 months to look for refractive and biometric changes. T-test and linear regression with the logarithm of independent variables were done.

Results:

All unilateral cataractous eyes (n = 25) and randomly selected bilateral cases (n = 122) were included in the analysis, for a total of 147 eyes. Mean age was 17.163 ± 13.024 months; axial length growth was 0.21, 0.18, 0.06 mm/month, and keratometry decline was 0.083, 0.035, 0.001 D/month in age groups 0–6, 7–18, and 19–60 months, respectively. The visual acuity improved in log MAR from 1.020 to 0.745 at 6 months postoperatively. There was statistically significant (Spearman's correlation coefficient = –0.575, P < 0.001) between age and postoperative refraction. There were no intraocular lens (IOL)-related complications seen in the immediate postoperative period. Peripheral opacification was seen in 102 eyes and central opacification in 1 eye at a 6-month follow-up.

Conclusion:

Indian eyes have a lower rate of axial length growth and keratometry change in comparison with western eyes implying smaller undercorrection in emmetropic IOL power for Indian pediatric eyes to achieve a moderate amount of hyperopia.

Axial length development in children

AIM

To study ocular axial lengths in pediatric subjects without intraocular pathology.

METHODS

An Institutional Review Board-approved consecutive retrospective chart review of axial lengths measured in pediatric subjects who underwent examination under anesthesia due to positive family history of retinoblastoma or other inherited ocular disease. Only subjects without any intraocular pathology in either eye were included. Subjects were stratified into age groups. An axial length model using a logarithmic regression algorithm was calculated.

RESULTS

Data from 330 eyes of 165 subjects were included in the study. The mean age at the time of examination was 30.62 (SD 18.04)mo. The steepest increase in axial length was present during the first 10mo of life. After 36mo, there was no statistically significant axial length growth.

CONCLUSION

This study presents the biggest series of pediatric axial lengths in healthy eyes. The axial length model developed with these data may assist in the diagnosis and management of a wide variety of pediatric ophthalmic diseases.

Factors influencing myopic shift in children after intraocular lens implantation

Introduction:

Intraocular lenses have always been a controversial topic in pediatric cataract surgery. In the early 1990s in the post-Soviet states of Eastern Europe, intraocular lenses promised an easier full-time correction and amblyopia treatment. Since 1991, ophthalmologists in Latvia have been implanting intraocular lenses in infants. Amount of the postoperative myopic shift and its influencing factors, analyzed in this article, are important indicators of congenital cataract treatment.

Materials and methods:

A retrospective chart review off 85 children (137 eyes) who underwent foldable posterior chamber intraocular lens implantation at the Clinical University Hospital in Riga, Latvia, from 1 January 2006 until 31 December 2016, was performed. Depending on the age at surgery, patients were divided into six groups: 1–6, 7–12, 13–24, 25–48, 49–84, and 85–216 months.

Results:

The largest and more variable myopic shift was found in a group of diffuse/total and nuclear cataract with surgery before the age of 6 months. There was a statistically significant correlation between the acquired best-corrected visual acuity and the amount of myopic shift (rs = 0.33; p < 0.001). Comparing the amount of myopic shift in two groups of different intraocular lens implantation target refraction tactics, we did not find statistically significant differences. Comparing the amount of myopic shift and implanted intraocular lens power, a negative, statistically significant correlation was found.

Conclusion:

The earlier the cataract extraction surgery and intraocular lens implantation is performed, the larger the myopic shift. The morphological type of cataract, best-corrected visual acuity, secondary glaucoma, and intraocular lens power influence the amount of myopic shift.

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.

Refractive outcomes of cataract surgery in primary congenital glaucoma

AIM

To evaluate refractive outcomes of cataract surgery with intraocular lens (IOL) implantation in operated eyes of primary congenital glaucoma (PCG).

DESIGN

A retrospective case-control study.

METHODS

Patients of PCG who developed cataract following trabeculectomy with trabeculotomy were recruited. Preoperative biometry was recorded and refractive outcomes of the patients in terms of spherical equivalent (SE) and prediction error were noted at 3 and at 12 months following surgery. The refractive outcomes were compared with non-glaucomatous eyes of children in similar age group who underwent lens aspiration with IOL implantation (controls).

RESULTS

The median age of the children with PCG (n = 31) at the time of cataract surgery was 60 months, similar to controls (n = 29); 48 months (p = 0.3). The SE in PCG eyes at 12 months was comparable to controls (p = 0.18). The prediction error (postoperative SE - predicted SE) at 3 months (p = 0.018) and at 12 months (p = 0.03) among PCG eyes was higher and more myopic compared with controls. The range of prediction error at 12 months in PCG eyes was - 8.6 to + 5.8 D (median - 2.0 D), whereas in controls it was - 4.2 to + 6.3 D (median + 0.5 D). For each mmHg intraocular pressure (IOP) increase there was 0.42 mm increase in axial length among PCG eyes and a 0.24 mm increase among controls (p < 0.001).

CONCLUSIONS

After IOL implantation there was a greater prediction error and a greater myopic shift among PCG eyes. Eyes of children with PCG are more prone to refractive surprises as their axial length changes are more sensitive to IOP fluctuation.

Predicting Factor of Visual Outcome in Unilateral Idiopathic Cataract Surgery in Patients Aged 3 to 10 Years

Purpose

To report the surgical results of unilateral pediatric cataracts from uncertain causes in relatively older children and to identify factors related to better visual outcomes.

Methods

We retrospectively evaluated the medical records of 39 patients who underwent surgery between the ages of 3 and 10 years for unilateral pediatric cataracts of no known cause. All patients underwent primary intraocular lens implantation and postoperative amblyopia treatment. A postoperative final visual acuity better than 20 / 30 was considered to be a good visual outcome.

Results

The mean age of patients was 6.0 ± 1.8 years at the time of surgery. The mean preoperative visual acuity was 1.07 ± 0.71 logarithm of the minimum angle of resolution (range, 0.15 to 3.00), while the mean final postoperative visual acuity was 0.47 ± 0.54 logarithm of the minimum angle of resolution (range, 0.00 to 2.00). Of 39 patients, 18 (46.2%) achieved a good visual outcome. Only the preoperative visual acuity maintained a significant association with a good visual outcome according to our multivariate analysis (p = 0.040). A preoperative visual acuity of 20 / 100 or better was found to increase the chance of achieving a good visual outcome by 13.79-fold (95% confidence interval, 1.13 to 167.58).

Conclusions

The visual outcome of unilateral pediatric cataract surgery for cataracts with no specific cause identified in patients after three years of age could be satisfactory, especially with a preoperative visual acuity of 20 / 100 or better.

Intraocular lens implantation in children with unilateral congenital cataract in the first 4 years of life

PURPOSE

To describe the outcome of phacoaspiration with intraocular lens implantation in children with unilateral congenital cataract in the first 4 years of life.

METHODS

A retrospective chart review of children with visually significant unilateral congenital cataract presenting in the first 4 years of life was done. Children with a minimum postsurgical follow-up of 1 year were included. Outcome measures were mean spherical equivalent, visual axis clarity, visual acuity and complications till the last follow-up.

RESULTS

Ninety-three children met the inclusion criteria. The mean age of surgery was 13.23 ± 11.89 months and the mean follow-up period was 24.37 ± 17.35 months. Nearly 40% of children presented during their first year of life. No difference was noted between the subgroups in terms of age ( p = 0.310), sex ( p = 0.475) or laterality ( p = 0.349). Surgical membranectomy was performed in 22 eyes (23.6%) after an average period of 4.85 ± 2.58 months after surgery. One eye underwent piggy back intraocular lens and four eyes underwent intraocular lens exchange after a mean duration of 50 months (range 40-60 months). The mean visual acuity was 0.79 ± 0.11 (log MAR chart). A total of 60.7% of these children ( n = 31) achieved best corrected visual acuity or 20/80 or better.

CONCLUSION

The results of our study suggest that primary intraocular lens implantation in children with unilateral congenital cataract gives good structural and functional results. Besides a meticulous surgery, visual outcome is affected by the time of presentation and postoperative compliance to amblyopia therapy.

Relationship between preoperative axial length and myopic shift over 3 years after congenital cataract surgery with primary intraocular lens implantation at the National Institute of Ophthalmology of Peru, 2007-2011

Objective

To determine the relationship between the preoperative axial length and the myopic shift over 3 years after congenital cataract surgery with primary intraocular lens implantation and other related factors.

Methods

In this retrospective cohort study, the axial length was measured and assigned into 2 groups (>21.5 mm and ≤21.5 mm), visual axis obscuration, laterality of cataract, age of surgery and follow-up time were assessed and compared to the myopic shift.

Results

The mean myopic shift was 3.6 (standard deviation [SD]: 2.3) diopters (D) in all patients; 3.2 (3.3) and 3.9 (3.2) D for each group respectively (p=0.359). In unilateral cataracts the mean myopic shift was 6.3 D and in bilateral cases was 3.0 D (p=0.001). In bilateral cataracts, the shift was 2.6 D (SD: 2.0) and 3.4 D (SD: 1.8), respectively (p=0.098).

Conclusion

There was no relationship between the initial axial length and the myopic shift in all patients. Unilateral cataracts had a greater myopic shift over 3 years.

Long-term Results in Pediatric Developmental Cataract Surgery with Primary Intraocular Lens Implantation

OBJECTIVES

The aim of this study was to evaluate the outcomes of pediatric developmental cataract surgery with primary intraocular lens (IOL) implantation.

MATERIALS AND METHODS

Patients between 2 and 16 years old who underwent cataract surgery with primary IOL implantation were retrospectively evaluated. Age at time of surgery, pre- and postoperative best corrected visual acuities, postoperative ocular complications, and any accompanying ocular pathologies were obtained from the patients' charts. Mean refractive changes and degree of myopic shift were analyzed according to the age groups. Operated eyes were also compared with the fellow eyes in unilateral cases.

RESULTS

A total of 101 eyes of 65 patients were included. The average age at time of surgery was 76±40 months and the average follow-up period was 44±30 months. Among the 78 eyes that could be assessed for visual acuity improvement, 66 (84.6%) of them showed ≥2 lines of improvement. The difference in the mean refractive change between the 2-5 years old and 8-16 years old age groups was found to be statistically significant. However, the mean refractive change per year was not found to be significant between the same age groups. In unilateral cases, the operated eyes showed a greater myopic change than the fellow eyes, with no statistically significant difference. The most common postoperative complication was visual axis opacity.

CONCLUSION

Good visual outcomes can be achieved following pediatric cataract surgery with primary IOL implantation. Optic axis opacities were the most common postoperative complications. Overall, refractive changes following surgery are inevitable, and more prominent in younger age groups.

Follow-up patterns and associated risk factors after paediatric cataract surgery: observation over a 5-year period

Purpose

To study the pattern of compliance to follow-up of children less than 5 years of age undergoing surgery for congenital and developmental cataract over a period of 5 years.

Methods

It is a retrospective study of children less than 5 years of age undergoing cataract surgery between January and December 2010 for congenital or developmental cataract and followed up until 31 December 2015. Age, sex, distance from hospital and urban or rural habitat, delay in presentation, socioeconomic status, laterality, morphology and type of cataract, implantation of intraocular lens and interventions done were noted. Compliance to follow-up at postoperative 1 week, 1 month, 3 months, 6 months, 1 year and then once a year until 5 years were recorded.

Results

169 patients were included in the study. The median follow-up was 22 months. Median age at surgery was 10 months and had a negative correlation with total follow-up. Male-to-female ratio was 1.82. Logarithmic curve of follow-up was noticed with 85%, 61%, 55%, 52%, 39% and 28% patients attending 1 month, 3 months, 6 months, 1 year, 3 years and 5 years of follow-up, respectively. Low socioeconomic group had poor follow-up compared with higher socioeconomic group (P=0.009), but the curve of follow-up was similar in both groups; multiple interventions group had better follow-up (P<0.0001).

Conclusion

Curve of loss to follow-up is logarithmic in children undergoing paediatric cataract surgery. Age at surgery and low economic status are the most important factors associated with poor follow-up.

Pediatric cataract

Pediatric cataract is a leading cause of childhood blindness. Untreated cataracts in children lead to tremendous social, economical, and emotional burden to the child, family, and society. Blindness related to pediatric cataract can be treated with early identification and appropriate management. Most cases are diagnosed on routine screening whereas some may be diagnosed after the parents have noticed leukocoria or strabismus. Etiology of pediatric cataract is varied and diagnosis of specific etiology aids in prognostication and effective management. Pediatric cataract surgery has evolved over years, and with improving knowledge of myopic shift and axial length growth, outcomes of these patients have become more predictable. Favorable outcomes depend not only on effective surgery, but also on meticulous postoperative care and visual rehabilitation. Hence, it is the combined effort of parents, surgeons, anesthesiologists, pediatricians, and optometrists that can make all the difference.

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

PURPOSE

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

DESIGN

Prospective randomized clinical trial.

METHODS

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

RESULTS

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

CONCLUSIONS

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

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Validation of Guidelines for Undercorrection of Intraocular Lens Power in Children

PURPOSE

Initial undercorrection of intraocular lens (IOL power) is a common practice in children undergoing pediatric cataract surgery. However, the long-term refractive status of these children is largely unknown. The purpose of this study is to analyze the long-term refractive status of these children.

DESIGN

Retrospective observational study.

METHODS

We analyzed records of children (<7 years of age) who underwent cataract surgery with a primary IOL implantation and had completed follow-up to ≥7 years of age. Data were collected regarding demographics, etiology of cataract, method of undercorrection, and serial follow-up refractions. Prediction error was defined as refractive error minus emmetropia. The main outcome measure was prediction error at 7 years of age.

RESULTS

Eighty-four eyes of 56 children (28 unilateral and 28 bilateral cases) met the study criteria. The median age at surgery was 3.3 years (interquartile range 2.7-5 years), and the median follow-up period was 3.75 years. At 7 years of age, the median absolute prediction was 1.5 diopters (interquartile range 0.75-2 diopters). Seven of 84 (8.3%) children achieved emmetropia while an equal proportion were myopic (45%) or hypermetropic (46%). Prediction error (adjusted for using both eyes) at 7 years of age was not significantly different in any group (P > .05). Maximum myopic shift was observed in children <2 years of age. Age at surgery was the only significant factor that influenced prediction error (â = -0.32; P = .001).

CONCLUSION

This study suggests that children undercorrected using guidelines suggested by Enyedi and associates may achieve an acceptable refractive error at 7 years of age. However, in children <2 years of age, more hypermetropia may be observed. More studies are needed to validate various methods of undercorrection and compare with other guidelines.

Comparison of the rate of refractive growth in aphakic eyes versus pseudophakic eyes in the Infant Aphakia Treatment Study

PURPOSE

To compare the rate of refractive growth (RRG) between aphakic eyes and pseudophakic eyes in the Infant Aphakia Treatment Study (IATS).

SETTING

Twelve clinical sites across the United States.

DESIGN

Randomized clinical trial.

METHODS

Patients randomized to unilateral cataract extraction with contact lens correction versus intraocular lens (IOL) implantation in the IATS had their rate of refractive growth (RRG3) calculated based on the change in refraction from the 1-month postoperative examination to age 5 years. The RRG3 is a logarithmic formula designed to calculate the RRG in children. Two-group t tests were used to compare the mean refractive growth between the contact lens group and IOL group and outcomes based on age at surgery and visual acuity.

RESULTS

Longitudinal refractive data were studied for 108 of 114 patients enrolled in the IATS (contact lens group, n = 54; IOL group, n = 54). The mean RRG3 was similar in the contact lens group (-18.0 diopter [D] ± 11.0 [SD]) and the IOL group (-19.0 ± 9.0 D) (P = .49). The RRG3 value was not correlated with age at cataract surgery, glaucoma status, or visual outcome in the IOL group. In the aphakia group, only visual outcome was correlated with refractive growth (P = .01).

CONCLUSIONS

Infants' eyes had a similar rate of refractive growth after unilateral cataract surgery whether or not an IOL was implanted. A worse visual outcome was associated with a higher RRG in aphakic, but not pseudophakic, eyes.

FINANCIAL DISCLOSURE

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

Benchmarks for outcome indicators in pediatric cataract surgery

PurposeThe purpose of this study was to establish benchmarks for outcome indicators that may help ascertain the quality of pediatric cataract surgery with primary intraocular lens (IOL) implantation.Patients and methodsA retrospective chart review of patients older than 2 years undergoing cataract surgery with primary IOL implantation, by multiple surgeons in a tertiary-care center, from November 2005 to February 2016 was conducted. Patients with ocular comorbidities that would affect the outcomes were excluded. The outcome measures chosen were as follows: (1) final best corrected Snellen visual acuity (BCVA) in patients who had bilateral cataract surgery analyzed at the last clinic visit; (2) prediction error (PE)=expected refraction-actual refraction. Mean PE and mean absolute PE were assessed 1 month postoperatively, irrespective of age or laterality.ResultsMean age at surgery was 8.3±4.6 years and mean follow-up duration was 3.7±2.7 years. The results of outcome measures were as follows: (1) BCVA was 20/40 or better in 96% (n=124 eyes, mean patient age: 8.3±4.6 years). Remaining five eyes had amblyopia with two eyes having BCVA worse than 20/100 that did not respond to amblyopia treatment. (2) Mean PE was 0.3±1.1 D and mean absolute PE was 0.9±0.7 D. PE was within ±0.5 D in 43.0%, ±1.0 D in 66%, and ±2.0 D in 95% (n=235 eyes).ConclusionGood visual acuity after cataract surgery should be expected for children with bilateral cataracts, setting a high benchmark similar to that recommended in adult cataract surgery. Prediction error is greater in pediatric eyes than in adult eyes, setting a lower benchmark. This study establishes benchmark for outcome indicators in pediatric patients older than 2 years undergoing cataract surgery with primary IOL implantation.

Long-term results after primary intraocular lens implantation in children operated less than 2 years of age for congenital cataract

PURPOSE

To study the long-term outcome of cataract surgery with primary intraocular lens (IOL) in children <2 years.

MATERIALS AND METHODS

Retrospective analysis of bilateral cases that were operated before 2 years age for congenital cataract. All underwent primary posterior capsulotomy with anterior vitrectomy and primary IOL implantation. Only those with a follow-up of at least 8 years were evaluated.

RESULTS

Twenty-six eyes of 13 children with bilateral cataract met the inclusion criteria. Average age at surgery was 14.15 months with a mean follow-up of 102 months. Average preoperative axial length (AL) was 19.93 mm. There was a refractive shift from a mean spherical equivalent of 1.64 D at 2 weeks after surgery to -1.42 D measured at last follow-up. Twenty-four eyes out of 26 (92%) achieved final visual acuity (VA) of 6/18 or more at last follow-up with 19/26 (73%) having acuity of 6/12 or greater. Raised intraocular pressure was documented in one eye only. Average AL recorded at last follow-up was 22.21 mm.

CONCLUSION

Primary IOL implantation in children <2 years is a safe surgical procedure with excellent long-term results. The myopic shift is well-controlled and final VA achieved is reasonably good.

Changing refractive outcomes with increasing astigmatism at longer-term follow-up for infant cataract surgery

PurposeTo present longer-term refractive and ocular health outcomes for patients who had primary intraocular lens (IOL) insertion following infant cataract surgery.Patients and methodsA retrospective review of all infant cataract cases at a tertiary children's hospital between 2003 and 2006 was conducted. Surgery was performed before 12 months of age. IOL power was calculated using the SRK/T formula targeting hyperopia based on the child's age; children under 3 months were targeted at +9.0 D, between 3 and 6 months at +6.0 D, and between 6 and 12 months at +3.0 D. Locally weighted scatterplot smoothing and mixed models were used.ResultsA total of 12 eyes from 9 children were included (4 bilateral and 5 unilateral). Spherical equivalent refraction decreased dramatically in the first 2 years of life, with milder changes from age 2 to 4 years and minimal changes thereafter. Cylinder increased until age 5 years at ∼0.57 dioptres/year (95% confidence intervals 0.27-0.87 D, P<0.001). Lens reproliferation was the commonest complication (58%). All children eventually developed strabismus.ConclusionEarly and frequent refraction is critical in the first 2 years of life to try and compensate for the rapid changes encountered in the growing eye. Astigmatism may be another important consequence to manage.

Intraocular lens exchange for high myopia in pseudophakic children

PurposeThe purpose of this study was to examine the preoperative factors and postoperative outcomes following intraocular lens (IOL) exchange for high myopia in pseudophakic children.MethodsThe medical records of all patients undergoing IOL exchange for high myopia were retrospectively reviewed.ResultsA total of 15 eyes were identified that had undergone an IOL exchange for myopic shift. Average age of cataract extraction (CE) was 5.4 months. In all, 10/15 had a unilateral cataract. IOL exchange usually occurred at an average of 6 years following cataract surgery. The average spherical equivalent (SE) of the refractive error at that time was -9.6 D. Following IOL exchange, SE was -1.3 D. A two-line reduction in best-corrected visual acuity was observed in 1/13 of our patients for whom pre- and post-exchange data were available. The average axial length (AL) of the eye undergoing the IOL exchange was 24.0 mm, average AL in the non-operative eye was 22.1 mm. On average, the operative eyes grew 4.4 mm and the non-operative eyes 3.02 mm. No adverse events were seen in the operative eyes.ConclusionYounger age at the time of CE creates a greater likelihood of AL elongation and predisposes a child to myopic shift. IOL exchange should be considered an option to reduce anisometropia and associated aniseikonia to improve visual outcomes. Successful visual rehabilitation and predictable post-exchange refractions were seen with our patients.

Visual Outcomes and Complications of Piggyback Intraocular Lens Implantation Compared to Aphakia for Infantile Cataract

Purpose:

To evaluate the long-term visual outcomes and complications of the piggyback intraocular lens (IOL) implantation compared to aphakia for infantile cataract.

Patients and Methods:

In a comparative study from 1998 to 2007, piggyback IOL implantation (piggyback IOL group) was performed for 14 infants (23 eyes) with infantile cataract and 20 infants (32 eyes) who were aphakic (aphakia group) after infantile cataract surgery. Data were collected on logMAR visual acuity, and postoperative complications over a mean follow-up time of 6.2 ± 1.7 years and 5.8 ± 1.7 years.

Results:

The mean age at surgery was 7.5 ± 0.6 months and 6.0 ± 3.3 months for the piggyback and the aphakic group respectively (P > 0.05). At the last follow-up visit, visual acuity was 0.85 ± 0.73 (median = 0.70, interquartile range = 0.3–1.32) in the piggyback IOL group and 0.89 ± 0.56 (median = 0.86, interquartile range = 0.50–1.24) in the aphakic group (P > 0.05). There was a positive relationship between age and visual outcomes in the aphakic group (r = 0.4, P = 0.04) but not in the piggyback IOL group (P = 0.48). There was no significant difference between the mean myopic shift in the piggyback IOL group (∑5.28 ± 1.06 D) and the aphakic group (∑5.10 ± 1.02 D) (P > 0.05). The incidence of reoperation due to complications in piggyback IOL group was higher than aphakic group (%48 vs. %16, respectively, P ≤ 0.01). However, in patients older than 6 months, this risk was not significantly different compared to the aphakic group.

Conclusions:

Although piggyback IOL implantation for infantile cataract is optically acceptable as a treatment option, there is no significant difference in visual outcomes compared to aphakia. The incidence in reoperation due to complications in patients aged 6 months or younger is higher than those treated with aphakia.

New-generation multifocal intraocular lens for pediatric cataract

BACKGROUND/AIMS

To evaluate multifocal intraocular lens (MIOL) implantation in children.

METHODS

This is a retrospective study evaluating refractive, visual and safety results of MIOL in pediatric cataract surgery. Average follow-up was 25.73 ± 10.5 months. Surgery included 12 o'clock clear corneal incision, anterior capsulorhexis, lens material aspiration and MIOL implantation (SN6AD3; Alcon).

RESULTS

We included 34 cataract eyes of 26 pediatric patients aged 2-15 years, of which 14 (54%) were unilateral. Best near visual acuity (BNVA) and best distance visual acuity (BDVA) improved significantly in 100% of eyes (p = 0.0001). BDVA was above 0.8 in 31.25% (5/16) of bilateral cases. Significant stereopsis improvement was observed postoperatively in bilateral cases only (p = 0.01).

CONCLUSION

MIOL implantation is a safe alternative to monofocal pseudophakia for pediatric cataract with a very low complication rate. Significant BNVA, BDVA and stereopsis improvement can be achieved, particularly in bilateral cases.

MESSAGE

This study shows significant BDVA, BNVA and stereopsis improvement, especially in bilateral cases, after MIOL implantation for pediatric cataracts.

[Pediatric cataract surgery in Malawi]

PURPOSE

The aim of this study was to evaluate the postoperative refractive status after pediatric cataract surgery with age-determined intraocular lens (IOL) implantation in children (age 0-8 years) in Malawi.

MATERIALS AND METHODS

Hospital-based retrospective study from January to June 2011 analyzing age, sex, origin, type of cataract surgery, IOL power and postoperative refractive status. In the absence of biometry, IOL powers were chosen according to the child's age and IOL availability.

RESULTS

A total of 58 eyes from 33 children were surgically treated of which 25 (76%) were bilateral and 8 (24%) unilateral. Best refractive outcome was achieved with a 25 diopter (D) IOL implanted in children 5-8 years old. None of the children aged 1-7 years achieved the previously calculated target refraction. Results showed a marked myopic variability. The range of postoperative refraction was from - 15 D to + 12.5 D and a large number of children (n=11, 33%) did not attend for follow-up.

CONCLUSION

Implanting IOLs according to age groups is not a suitable surgical strategy even in resource-poor settings. Refractive outcomes were too variable with a marked myopic shift. Biometry and keratometry are required in order to undertake pediatric cataract surgery. Developing regional pediatric centres should be a focus of the VISION 2020 initiative.

[Treatment of pediatric cataracts. Part 2: IOL implantation, postoperative complications, aphakia management and postoperative development]

There is a lot of uncertainty concerning intraocular lens (IOL) implantation for pediatric cataracts. The appropriate age which ocular abnormalities are contraindications and according to which formula IOL should be calculated are controversial. In addition to the imperative of identifying postoperative complications, such as secondary cataract formation and secondary glaucoma in a sufficiently timely manner, a modern management of aphakia with refractive compensation and occlusion is necessary. Some easy rules can help prevent pitfalls.

Refractive accuracy after intraocular lens implantation in pediatric cataract

AIM

To analyze the factors that influence the prediction error (PE) after intraocular lens (IOL) implantation in pediatric cataract.

METHODS

The medical records of cataract patients of no more than 14 years old who had primary IOL implantation were reviewed from 2006 to 2010. The PE, absolute value of PE (APE), and predictability between in different axial length, mean corneal curvature, corneal astigmatism, and age at the surgery were analyzed.

RESULTS

Seventy-five children (119 eyes) were included, with a mean age of (5.09±2.54) years. At the follow-up of (1.19±0.69) months, the mean postoperative PE was (-0.22±1.12) D, and APE was (0.87±0.73)D. The PE in eyes with an axial length >20mm but ≤22mm were significantly under-corrected than that in eyes with longer axis, and the APE in eyes with an axial length ≤20mm was more obvious compared with the others. The correlations between PE and axial length, as well as corneal astigmatism, and between APE and axial length were significant. The predictability was significantly poorer in the eyes with an axial length ≤20mm than the others.

CONCLUSION

The axial length is closely related with the PE after IOL implantation in pediatric cataract patients, especially when it is ≤20mm, PE is more significant. The formula that is more suitable to very short axial length should be explored.

Effectiveness of a short message reminder in increasing compliance with pediatric cataract treatment: a randomized trial

OBJECTIVE

Regular follow-up is essential to successful management of childhood cataract. We sought to assess whether a mobile phone short message service (SMS) for parents of children with cataract could improve follow-up adherence and the proportion of procedures performed in timely fashion.

DESIGN

Randomized, controlled trial. This trial is registered with ClinicalTrials.gov, NCT01417819.

PARTICIPANTS

We included 258 parent-child pairs involved in the Childhood Cataract Program of the Chinese Ministry of Health.

METHODS

Participants were randomized (1:1) to a mobile phone SMS intervention or standard follow-up appointments. All participants were scheduled to attend ≥ 4 follow-up appointments according to the protocol. Parents in the intervention group received SMS automated reminders before scheduled appointments. The control group parents did not receive SMSs or any alternative reminder of scheduled appointments. Regular ocular examinations and analyses were performed by investigators masked to group allocation; however, study participants and the manager in charge of randomization and sending SMSs were not masked.

MAIN OUTCOME MEASURES

Number of follow-up appointments attended, additional surgeries, laser treatments, changes in eyeglasses prescription, and occurrence of secondary ocular hypertension.

RESULTS

Among parent-child participants, 135 were randomly assigned to the SMS intervention and 123 to standard appointments. Attendance rates for the SMS group (first visit, 97.8%; second, 91.9%; third, 92.6%; fourth, 83%) were significantly higher than those for the control group (first visit, 87.8%; second, 69.9%; third, 56.9%; fourth, 33.3%). The increase in attendance rate for total number of follow-up visits with SMS reminders was 47.2% (relative risk [RR] for attendance, 1.47; 95% confidence interval [CI], 1.16-1.78; P = 0.003). The number needed to remind (NNR) to gain 1 additional visit by 1 child was 3 (95% CI, 1.8-4.2). A total of 247 clinical interventions were carried out in the SMS group and 134 in the control group (RR, 1.68; 95% CI, 1.37-1.99; P = 0.007). The NNR to result in 1 additional clinical intervention was 5 (95% CI, 3.5-6.5).

CONCLUSIONS

The SMS reminders significantly improved follow-up adherence in pediatric cataract treatment. Using readily available mobile phone resources may be an effective and economic strategy to improve management of childhood cataract in China.

FINANCIAL DISCLOSURE(S)

The authors have no proprietary or commercial interest in any of the materials discussed in this article.