Globe Axial Length Growth at Age 5 Years in the Infant Aphakia Treatment Study

PURPOSE

To report the longitudinal change in axial length (AL) from the time of unilateral cataract surgery at age 1 to 7 months to age 5 years, and to compare AL growth of operated eyes with that of fellow unoperated eyes.

DESIGN

Comparative case series.

PARTICIPANTS

Infants enrolled in the Infant Aphakia Treatment Study (IATS).

METHODS

The AL at baseline and age 5 years and change in AL were analyzed relative to treated versus fellow eye, visual outcome, and treatment modality (contact lens [CL] vs. intraocular lens [IOL]). Eyes with glaucoma or glaucoma suspect were excluded from primary analysis but reported separately.

MAIN OUTCOME MEASURES

The AL growth from preoperative to age 5 years.

RESULTS

Seventy patients were eligible; however, AL data for both eyes were available for 64 patients at baseline and 69 patients at age 5 years. The AL was significantly different between treated and fellow eyes preoperatively (18.1 vs. 18.7 mm, P < 0.0001) and at the final follow-up (21.4 vs. 22.1 mm, P = 0.0004). The difference in AL growth between treated and fellow eyes was not significant (3.3 vs. 3.5 mm, P = 0.31). The change in AL in eyes was similar with both treatments (CL 3.2 mm and IOL 3.4 mm, P = 0.53) and did not correlate with visual outcomes (P = 0.85). Eyes receiving additional surgery to clear the visual axis opacification grew significantly more compared with eyes not receiving surgery to clear the visual axis (3.8 vs. 2.7 mm, P = 0.013). Patients with glaucoma showed significantly more eye growth (5.7 mm) than those without glaucoma (3.3 mm) and glaucoma suspects (4.3 mm).

CONCLUSIONS

Eyes treated for monocular cataract in infancy have axial growth similar to that of fellow eyes, despite having a shorter AL at the time of surgery. The change in AL in eyes was similar with both treatments (CL and IOL), did not correlate with visual outcomes, and was higher in eyes receiving additional surgery to clear the visual axis or eyes diagnosed with glaucoma.

Management of Pediatric Aphakic Glaucoma With Vitrectomy and Tube Shunts

PURPOSE

To review the impact of vitrectomy and tube shunts on mean intraocular pressure (IOP) and number of glaucoma medications in pediatric aphakic glaucoma.

METHODS

A retrospective review of pediatric patients who underwent combined vitrectomy and glaucoma tube shunt surgery for aphakic glaucoma was conducted. Inclusion criteria were: age 18 years or younger, diagnosis of aphakic glaucoma, preoperative IOP data, and postoperative IOP data for at least 6 months. Mean IOP lowering at 1 year, number of glaucoma medications at 1 year, and surgical complications, including tube occlusion in the postoperative period, were noted.

RESULTS

The mean ± standard deviation preoperative IOP was 33.9 ± 10.6 mm Hg (range: 18 to 57 mm Hg) with a mean of three topical IOP-lowering medications. A total of 5 (36%) Ahmed and 9 (64%) Baerveldt tube shunts were placed. One of the Baerveldt tube shunt procedures was combined with revision of a traumatically dislocated tube. The mean IOP at 12 months postoperatively was 16.6 ± 5.8 mm Hg (range: 6 to 28 mm Hg; P < .01, t = 3.74, df = 13) with a mean of 2.3 glaucoma medications. There were no cases of tube occlusion, corneal decompensation, endophthalmitis, or retinal detachment over the 12 months of follow-up.

CONCLUSIONS

Combined vitrectomy and placement of a glaucoma tube shunt can be safe and effective in lowering IOP based on mean IOP values and number of glaucoma medications at 1 year. [J Pediatr Ophthalmol Strabismus. 2016;53(6):339-343.].

Association Between Occlusion Therapy and Optotype Visual Acuity in Children Using Data From the Infant Aphakia Treatment Study: A Secondary Analysis of a Randomized Clinical Trial

IMPORTANCE

Patching has been a mainstay in treating unilateral congenital cataract. However, its efficacy has not been rigorously assessed.

OBJECTIVE

To examine the association between patching and visual acuity in a cohort of children treated for unilateral congenital cataract.

DESIGN, SETTING, AND PARTICIPANTS

This study was a secondary analysis of a randomized clinical trial (Infant Aphakia Treatment Study) of infants born from August 1, 2004, through December 31, 2008, who were treated with 1 of 2 treatments for unilateral congenital cataract and followed up to 5 years of age. Data analysis was performed from March 1, 2013, to March 1, 2016.

INTERVENTIONS

Cataract extraction and randomization to receipt of an intraocular lens vs being left aphakic for the first 5 years of life.

MAIN OUTCOMES AND MEASURES

Caregivers reported patching in the previous 48 hours in quarterly semistructured telephone interviews. The mean number of hours of patching per day was calculated from surgery to the first birthday (n = 92) and between 12 and 48 months of age (n = 102). Monocular optotype acuity was assessed at 4½ years of age by a traveling examiner using the Aphakia Treatment Study HOTV protocol.

RESULTS

The Infant Aphakia Treatment Study enrolled 114 children; 57 were randomized to each treatment group. At 4½ years of age, optotype visual acuity was assessed in 112 children. The current analyses exclude an additional 3 children (2 who had adverse events that limited visual potential and 1 who had Stickler syndrome), leaving 109 total children analyzed (59 female [54.1%] and 92 white [84.4%]). Caregivers reported patching their children a mean (SD) of 3.73 (1.47) hours per day in the first year of life and 3.43 (2.04) hours per day thereafter. An association between reported patching and treatment was not identified (mean difference in first year, -0.29 hours per day; 95% CI, -0.90 to 0.33 hours per day; mean difference between 12 and 48 months of age, -0.40 hours per day; 95% CI, -1.20 to 0.40 hours per day). Visual acuity was associated with reported hours of patching in the first year of life (r = -0.32; 95% CI, -0.49 to -0.13) and between 12 and 48 months of age (r = -0.36; 95% CI, -0.52 to -0.18). However, patching accounted for less than 15% of the variance in logMAR acuity at 4½ years of age.

CONCLUSIONS AND RELEVANCE

These results support the association of occlusion throughout the preschool years with improved visual acuity in infants treated for unilateral congenital cataract. However, similar visual outcomes were achieved with varying amounts of patching. These conclusions should be interpreted in the context of limitations related to generalizability from incomplete data collected in a clinical trial.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT00212134.

[State-of-the-art cataract surgery and intraocular optical correction]

The paper provides current knowledge on cataract epidemiology worldwide and in the Russian Federation, including issues of cataractogenesis and prevention. An overview of medical equipment for preoperative and intraoperative diagnostics is provided. Key aspects of the conventional ultrasonic phacoemulsification method as well as the most marked trends in correction of aphakia with intraocular lenses and in design of the latter are presented. Major laser-assisted techniques, including those that imply the use of femtosecond laser systems, and results that they yielded to date are discussed in detail.

[Secondary IOL implantation in aphakic children after early surgery for congenital cataracts]

The purpose of the study was to develop differentiated approach for secondary intraocular lens (IOL) implantation in children after congenital cataract extraction in infancy.

MATERIAL AND METHODS

Secondary IOL implantation was performed in 42 children (56 eyes) aged from 1.5 to 6 years who underwent congenital cataract surgery at the age of 2-10 months. A total of 19 children had unilateral involvement. In 14 cases of bilateral aphakia the implantation was performed on both eyes. In 9 children a single-step cataract extraction with unilateral IOL implantation was followed by a delayed IOL implantation on the previously operated contralateral eye. The posterior lens capsule was intact in 39 eyes, while in 17 it had various congenital defects. Capsule opacification was found in 34 eyes, either congenital (8 eyes) or acquired (26 eyes). Along with conventional ophthalmic assessment, other examinations that are essential for IOL power calculation (autorefractomentry and ultrasound biomicroscopy - UBM) and posterior chamber assessment (UBM) were performed. The injection of either monoblock (Acrysof SN60 WF; SN60AT, (Alcon)) or tripartite (Acrysof MA60AC (Alcon)) intraocular lens was done through a tunnel corneal incision. Monitoring period varied from 6 months to 4 years.

RESULTS

The choice of surgical tactics, IOL model and fixation method depended on the integrity of the capsular bag, condition of the posterior capsule, and presence of iridocapsular adhesions. Intracapsular IOL implantation was performed in 28.2% of eyes with intact posterior capsule and in 11.8% of eyes with the capsule defects. In three eyes with no capsular support IOLs were sutured to the sclera. In most children (76.8%) posterior chamber reconstruction had to be performed due to iridocapsular adhesions.

CONCLUSION

The choice of surgical tactics and the extent of surgical intervention for the purpose of secondary IOL implantation in children who underwent congenital cataract extraction are individual and depend on the integrity of the capsular bag.

Longitudinal change in aphakic refraction after early surgery for congenital cataract

PURPOSE

To characterize the longitudinal changes of refraction in aphakic eyes after early surgery for congenital cataract and to evaluate longitudinally measured aphakic refraction (individual vs group mean) as a noninvasive indicator of postoperative disturbances in ocular development.

METHODS

Records of children who had cataract surgery during their first year of life between 1980 and 1995 were obtained from a prospective, population-based study of congenital cataract. Only children with regular follow-up were included. Postoperative aphakic refraction was calculated at the corneal plane. Data were obtained up to 36 months of age.

RESULTS

The study included 28 children (49 eyes) who underwent surgery at a median age of 2.8 months (range, 0-9 months). The decrease of aphakic refraction at the corneal plane followed a logarithmic trend (R(2) = 0.95). A total of 36 eyes followed this pattern, with no growth in 8 eyes and an increased growth rate in 1 eye with uncontrolled glaucoma and 4 eyes of 2 children with Down syndrome.

CONCLUSIONS

Most aphakic eyes follow a predictable, logarithmic change in refraction in the first 3 years of life, Longitudinal monitoring of refraction may prove to be a useful, noninvasive screening method for early detection of disturbances in aphakic eye growth.

Aphakic glaucoma after congenital cataract surgery

OBJECTIVE

To describe the largest series of patients who developed aphakic glaucoma after lensectomy for congenital cataracts.

METHODS

A retrospective review was performed of all patients seen by a pediatric glaucoma specialist between October 1, 1970, and November 30, 2002. Patients with intraocular pressures greater than 25 mm Hg after lensectomy were studied. Patients with either conditions independently associated with glaucoma or any signs of glaucoma before lensectomy were excluded.

RESULTS

We studied 170 eyes of 117 patients. The mean +/- SD follow-up period was 8.6 +/- 7.6 years. The most common cataract types were complete (40.8%) and nuclear (22.5%). For the lensectomies, 103 eyes underwent modern vitrectomy techniques, and 10 underwent older techniques. Lensectomies were performed in 80.6% of eyes before age 1 year. Onset of glaucoma after lensectomy was by 1 year in 37.1% of eyes, by 6 years in 75.9%, and by 33 years in 100%. Of eyes that had gonioscopy, 93.9% had open angles. Glaucoma surgery was needed in 57.1% of eyes. The median final visual acuity was 20/400.

CONCLUSIONS

Most cases of aphakic glaucoma are of the open-angle type. Various risk factors are suggested, and the prognosis is guarded. Lifelong follow-up is needed to screen for glaucoma.

Transscleral fixation of posterior chamber intraocular lenses in the absence of capsular support

PURPOSE

To evaluate the safety and efficacy of a modified technique of transscleral fixation of posterior chamber intraocular lenses (IOLs) in the management of unilateral aphakia and in cases of IOL exchange.

SETTING

El-Maghraby Eye Hospital, Jeddah, Saudi Arabia.

METHODS

This prospective study comprised 41 eyes of 41 patients who had transscleral fixation of a posterior chamber IOL using a modified technique. Of these patients, 36 had unilateral aphakia and 5 had pseudophakia requiring lens exchange. Patient age ranged from 40 to 80 years. Follow-up was 12 months.

RESULTS

Uncorrected visual acuity improved in all patients. Best corrected visual acuity was unchanged in 87.8% of patients, improved by two to four Snellen lines in 9.8%, and decreased by one or two Snellen lines in 2.4%. Most complications were minor and managed medically; only two patients required further surgical intervention.

CONCLUSION

Our modified technique is safe and effective. We recommend evaluation of longer term results.

[Intraocular correction of the aphakia in fragmentation wounds of the eye]

The authors analyze the problem of intraocular correction in patients with penetrating missile wounds of the eyeball. A total of 292 patients were examined; besides clinical, electrophysiologic and ultrasonic methods were used, as well as endothelial microscopy. In cases with nonremoved intraocular foreign bodies x-ray examination and computer tomography were employed. The patients were divided into 2 groups. Group 1 (n = 195) included patients with posttraumatic cataracts and a history of removed foreign body, Group 2 (n = 97) consisted of those with posttraumatic cataracts and a foreign body present in the eye. Traumatic cataract extraction was performed in all the patients. Implantation of an intraocular lens was found possible in 43 patients (18 ones from Group 1 and 25 from Group 2). Basing on clinical experience gained in the management of these patients, the authors have defined the indications for intraocular correction in this patient population.

[The first results of the contact lens correction of aphakia in young infants]

Soft contact lenses (SCL) were used for the correction of aphakia in young children. Eleven surgeries were carried out in 7 children with congenital cataracts (aspiration in 2 cases and transciliary lensectomy in the rest). SCLs were made individually of gel with 70% water content by mechanical treatment, their parameters differing from the commercial 'aphakic' lenses. These SCL parameters were chosen with consideration for the data of measurements of the corneal curvature and diameter, carried out during surgery and then specified by trials. To determine the optic force of SCL, a special formula and skiascopy were used. Only in one case the parents refused from SCL application, being satisfied with the cosmetic effect of surgery; in the rest cases SCLs were tolerated satisfactorily as evidenced by a follow-up of 3 to 8 months. SCL wearing improved the visual function, that manifested in a more stable fixation, reduction and stabilization of strabismus angle, development of an ability to recognise closely situated small articles. These results are in fact tentative; further studies will be aimed at a more accurate assessment of the visual function and of the corneal status (including the status of the endothelium).

Optic disc edema with aphakic cystoid maculopathy masquerading as ischemic optic neuropathy

Two patients with visual loss after cataract extraction were found to have prominent pallid optic disc edema, peripapillary hemorrhage, and cystoid maculopathy. A diagnosis of anterior ischemic optic neuropathy, with coincidental aphakic cystoid macular edema, was initially considered. The clinical course, however, favored a diagnosis of visual loss secondary to maculopathy. In both cases, fluorescein angiography disclosed leakage of fluorescein dye from macula, optic disc, and peripapillary foci. Fluorescein angiography and stereo color photographs of 51 patients with aphakic cystoid maculopathy were reviewed to determine the incidence of optic disc edema. Although optic disc swelling was rarely recognized on fundus photography, optic disc hyperfluorescence was observed in 75% of cases.

Examination of the pseudophakic patient

The use of intraocular lens implants in cataract surgery is rapidly increasing. Doctors of optometry will be performing examinations on pseudophakic patients. Observations and techniques particular to pseudophakic patient care are presented. The following discussion will assist the clinician in examination and proper management of these patients.

Pars plana vitrectomy for aphakic cystoid macular edema

The authors used a combined limbal and pars plana vitrectomy approach to treat 17 consecutive eyes (16 patients) with chronic aphakic cystoid macular edema associated with vitreous incarceration in the cataract wound. Criteria for surgery included: decreased visual acuity to 20/50 or worse; cystoid macular edema confirmed by fluorescein angiography; persistent edema of 6 months or longer; and visible vitreous incarceration in the limbal wound. The vitreous was successfully removed from the limbal wound in 16 of 17 eyes. Postoperatively, vision improved by two lines or more in 11 eyes (65%). The surgical technique is described.

Clinical performance of a disability glare tester

A glare tester was described previously and was found, in the presence of cataracts, to be almost twice as predictive as was Snellen measurement for determining visual acuity outdoors. The current study tests the reproducibility of glare test scores and the influence of refractive error and contrast sensitivity on such scores when used in a clinical environment. Although the effects of visual acuity and impaired contrast sensitivity were found to be statistically significant components of glare test scores, the magnitudes of their effects were found to be clinically insignificant. Sequential retesting of physiologically stable eyes or, in the case of progressive cataracts, within intervals short enough to preclude discernible lenticular changes indicated that, for the most part, reproducibility of glare testing was comparable to that of visual acuity testing.

Peripheral refraction in aphakic eyes

Peripheral refraction was measured in aphakic eyes and control eyes of approximately the same age, using a Topcon refractometer. In addition, two aphakic eyes in young patients were also measured and compared with data obtained on young patients by Millodot using the same technique. It was found that aphakic eyes have much less oblique astigmatism than phakic eyes of the same age, suggesting a large contribution to the crystalline lens. The total oblique astigmatism of the eyes increases with age but that of the cornea remains approximately the same, thus implying that this increase with age is also accounted for by the lens. Moreover, the total oblique astigmatism of old eyes is nearly the same as the theoretical value, suggesting that with age the lens becomes more spherical.

Apparent accommodation in pseudophakic eyes after implantation of posterior chamber intraocular lenses

We measured apparent accommodation in 42 pseudophakic eyes (34 patients) after implantation of posterior chamber intraocular lenses. The mean apparent accommodation was 2.03 +/- 1.03 diopters. The mean accommodative power of 16 phakic eyes used as controls was 2.91 +/- 1.29 diopters. The diameter of the pupil appeared to be the most important factor in apparent accommodation--the smaller the pupil, the greater the apparent accommodation. Apparent accommodation was inversely proportional to the pupillary diameter. There was no correlation, however, between apparent accommodation and corrected visual acuity, refractive error, corneal astigmatism, or axial length. There was a negative correlation between apparent accommodation and anterior chamber depth.

Visual results in aphakic children

Sixty-five patients less than 10 years of age had cataract surgery on 99 eyes. The visual prognosis depended on the cataract type and whether the treatment was undertaken during the critical period for development of the fixation reflex. All patients received the same surgical technique, aggressive optical correction, and occlusion therapy, if needed. Partial cataracts were the most frequent and the two largest groups were lamellar and axial. The visual outcome was excellent for the lamellar cataracts, whereas axial cataracts were the most amblyogenic. Obtaining a good visual result demanded an understanding of the complexities of amblyopia.

Outcome of cataract surgery. II. Visual functioning in aphakic patients

The degree rehabilitation obtained by cataract surgery was evaluated by visual acuity and by Visual Functioning Index, which measures the patients' ability of performance of every-day tasks that are dependent on vision. Examinations and Index-scoring were done pre- and post-operatively and at one year follow-up in a non-selected, consecutive series of 114 cataract patients. 82% of the patients obtained a final visual acuity of 0.5 or more. Index scoring at follow-up was significantly improved and indicated that 74% had achieved normal or near-normal visual functioning. Furthermore, we compared visual functioning in monaphakics and biaphakics. Remarkably we found that basic visual functioning as measured by the Index seems equally good in the 2 groups except for the statistically significant better ability for selftransportation in biaphakics. The biaphakic patients, however, were much more satisfied with the outcome than monaphakic. It seems likely that basic visual functioning is gained by first eye surgery and that the more delicate visual functioning and a subjective 'vision-comfort' is the effect of second eye surgery.

A new glare tester for clinical testing. Results comparing normal subjects and variously corrected aphakic patients

A simple, inexpensive, readily available, easy-to-service clinical glare tester combines an audioviewer able-top projector with a series of specially made slides. Each slide supplies a constant glare source and a variable-contrast, central target. The device was evaluated on 161 normal subjects, 144 patients with cataracts, and 110 aphakic patients whose visual acuity was corrected with spectacles or intraocular lenses. Results showed that aphakic patients, irrespective of the mode of correction, were statistically more glare sensitive than normal phakic patients. Further results confirmed earlier studies that demonstrated that glare sensitivity also increased with age in normal eyes. Broad potential exists for using this method of glare testing in industry, transportation media, and medicolegal and and clinical ophthalmologic studies.

Iris fluorescein angiography and Irvine Gass' syndrome

Iris fluorescein angiography and fundus fluorescein angiography were performed three months to three years after cataract extraction in two series of aphakic eyes--32 eyes with vitreous adherence to the wound, and 32 with no vitreous adherence to the wound. In these series there is a significant correlation between dye leakage on iris fluorescein angiography and vitreous adherence to the corneal wound since dye leakage was observed in 40.6% of eyes with vitreous adherence to the wound and only 3.1% of eyes with no vitreous adherence to the corneal wound. On the other hand cystoïd macular edema was observed in 100% of eyes with vitreous adherence to the wound associated with dye leakage on iris fluorescein angiography and in only 10% of eyes with vitreous adherence to the wound but no dye leakage on iris fluorescein angiography.