Intraocular Lens

Infants: Contact lenses or intraocular lens implantation?

Lambert et al. (Infant Aphakia Treatment Study Group) (Arch Ophthalmol. 2010;128(7):810-8) performed a randomized, multicenter (12 sites) clinical trial in infants with unilateral congenital cataract, assigned to undergo cataract surgery between 1 and 6 months of age, either with or without primary IOL implantation. Contact lenses (CLs) were used to correct aphakia in patients who did not receive IOLs. No statistically significant difference was found in grating visual acuity at age 1 year between IOL and CL groups; however, additional intraocular operations were performed more frequently in the IOL group.

Lu et al . (Graefes Arch Clin Exp Ophthalmol.2010;248(5):681-6) studied the visual results and complications of primary IOL implantation in infants aged 6-12 months and reported that it is safe and effective for infantile cataract surgery. Total or unilateral cataract, nystagmus, strabismus, and inadequate amblyopia therapy were predictors of poor BCVA.

Ram et al . (Indian J Ophthalmol.2007;55(3):185-9) reported that meticulously performed primary IOL implantation and primary posterior capsulorhexis with anterior vitrectomy in the first two years of life is a safe and effective method of aphakic correction.

Lundvall et al . (J Cataract Refract Surg.2006;32(10):1672-7) evaluated the complications and visual results in eyes undergoing cataract extraction with IOL implantation in the first year of life. They found that after-cataract with membrane formation was the main complication in infants with primary IOL implantation.

Birch et al . (JAAPOS 2005;9(6):527-32) reported that IOLs and aphakic CLs provide similar visual acuity development after surgery for a unilateral cataract. They suggested that IOLs may support better visual acuity development when compliance with CL wear is moderate to poor or when a cataract is extracted after 1 year of age.

Lambert et al . (Br J Ophthalmol. 2004;88(11):1387-90) compared optotype acuities and re-operation rates in children corrected with CL and with IOL following unilateral cataract extraction during infancy. They found that optotype acuities were similar in both the groups; however, children in the IOL group underwent more re-operations.

Which intraocular lens should be implanted?

Aasuri et al . (Indian J Ophthalmol. 2006;54(2):105-9), in a comparative evaluation of acrylic and polymethyl methacrylate (PMMA) lenses in pediatric cases, reported that the incidence of posterior capsular opacification (PCO) and postoperative uveal inflammation is significantly less with acrylic lenses.

Rowe et al . (Br J Ophthalmol. 2004;88(4):481-5) reported that compared to acrylic, PMMA IOLs were significantly associated with perioperative complications. They noted that primary implantation of foldable soft acrylic IOLs in pediatric eyes allowed fewer perioperative complications than rigid PMMA IOLs.

Basti et al . (J Cataract Refract Surg. 1999;25(6):782-7) conducted a prospective, randomized, controlled clinical trial and reported a lower incidence of inflammatory cell deposit formation in eyes with heparin surface modified PMMA IOLs. They concluded that these IOLs have greater biocompatibility than unmodified IOLs in pediatric cataract surgery.

Koraszewska-Matuszewska et al . (Klin Oczna 2003;105(5):273-6) reported that heparin surface modified IOLs are more advantageous than PMMA lenses in young patients as they reduce postoperative inflammation and delay the incidence of PCO in children.

Brar et al . (Clin Experiment Ophthalmol. 2008;36(7):625-30), in a randomized controlled study, reported that square-edge PMMA IOLs offer a significant cost advantage over acrylic lenses at similar rates of PCO formation following pediatric cataract surgery.

Nihalani et al . (J Cataract Refract Surg. 2006;32(9):1527-34) reported that 1-piece AcrySof IOL provided satisfactory visual axis clarity, produced an acceptable inflammatory response, and maintained centration in pediatric eyes.

Beauchamp et al . (JAAPOS 2007;11(2):166-9) compared standard nontinted AcrySof foldable acrylic IOL and blue light filtering tinted IOL in children. They reported that transient inflammation is higher with implantation of tinted versus nontinted IOLs, but long-term inflammatory sequelae are roughly equal, as is the rate of PCO.

Grueterich et al . (J Cataract Refract Surg. 2008;34(4):591-5) reported that insertion of Acri. Smart (46S) IOL through sub-2.0 mm paracentesis minimizes manipulation in juvenile eye.

Intraocular lens power calculation: Which formula should be used?

Mezer et al . (J Cataract Refract Surg 2004;30:603-610) evaluated refractive outcomes in pediatric patients using five IOL calculation formulae (SRK, SRK II, SRK/T, Hoffer Q, and Holladay). They observed that all five IOL power calculation formulas were unsatisfactory in achieving the target refraction in pediatric patients. However, the SRK formula showed poor to moderate agreement between the predicted and the actual refraction, whereas the SRK II formula provided fair to good agreement.

Neely et al . (JAAPOS 2005;9(2):160-5) analyzed the lens calculation errors in children predicted by four formulas (SRK II, SRK/T, Holladay I, and Hoffer Q). They noted that newer theoretic IOL calculation formulae did not outperform older regression models. Each formula demonstrated a high degree of variability, with SRK II being the least variable and Hoffer Q being the most variable, particularly among the youngest group of children with AL less than 19 mm.

Eibschitz et al . (Ophthalmology2007;114(2):383-6) noted significant differences in IOL power prediction among the Hoffer Q, Holladay I, and SRK II formulae in pediatric range of AL and keratometry values. The Holladay I and Haigis formulae were found to be similar in their IOL power prediction. The SRK/T was comparable with Holladay I and Haigis formulae, but still differed in high keratometry values.

Kora et al . (Nippon Ganka Gakkai Zasshi 2002;106:273-280) evaluated the accuracy of prediction of refraction using four IOL power calculation formulae (SRK, SRK II, SRK/T, and Holladay) in pediatric patients. They concluded that all the formulae were less accurate in patients with AL of 22 mm or shorter. They also found that the SRK formula had the best preoperative prediction of refraction compared to SRK/T and Holladay formulae.

Tromans et al . (Br J Ophthalmol.2001;85(8):939-41) noted larger errors in IOL power calculation in eyes with AL less than 20 mm and in children less than 36 months of age.

Nihalani et al . (Ophthalmology2010;117(8):1493-1499) reported that Hoffer Q was predictable for the highest number of pediatric eyes. They also noted that most formulae gave an undercorrection, except for Hoffer Q.

Refractive goal

Dahan et al . (J Cataract Refract Surg. 1997;23 Suppl 1:618-23), in a retrospective study, advised to categorize the children as (1) children younger than 2 years of age or (2) children older than 2 years. For the first group, in whom AL and keratometry readings change rapidly, they advised to undercorrect by 20%. For the second group, in whom the changes are slower and more moderate, they advised to undercorrect by 10%.

Wilson et al . (J Cataract Refract Surg.2003;29(9):1811-20) surveyed ASCRS and JAAPOS members in 2001. They concluded that most surgeons aim for moderate hyperopia (?3 D and <7 D) in infants at 6 months of age and mild (<3 D) to moderate hyperopia in infants at 12 months.

Enyedi et al . (Am J Ophthalmol. 1998;126:772-81) recommended a postoperative goal of +6 D for a 1 year old, +5 D for a 2 year old, +4 D for a 3 year old, +3 D for a 4 year old, +2 D for a 5 year old, +1 D for a 6 year old, plano for a 7 year old and -1 to -2 D for an 8 year old or older children.

Crouch et al . (JAAPOS 2002;6(5):277-82) recommended that the refractive goal should be +4 D for less than 2 years, +2 to +3 D for 2-4 years of age, +1 to +2 D for 4-6 years of age and up to +1 D for 6-8 years of age.

Multifocal intraocular lenses in children

Lin et al . (Eye (Lond) 2010;24(6):1107) reported that multifocal IOL implantation was successful in treating the amblyopia and in reshaping the patient’s personality.

Jacobi et al . (Ophthalmology2001;108(8):1375-80) studied pediatric patients aged 2-14 years with multifocal IOL implantation with more than 1 year of follow-up. They found that only 22% children reported permanent use of an additional near correction. The remaining children were either using distance correction only (44%) or no glasses at all (33%). It was concluded that multifocal IOL implantation is a viable alternative to monofocal pseudophakia in this age group.

Sutured intraocular lenses in children

Bardorf et al . (JAAPOS 2004;8(4):318-24) reported that trans-scleral sutured IOL implantation is safe and effective for correcting aphakia in pediatric eyes that lack adequate capsular support.

Asadi et al . (Ophthalmology 2002;109:2315-2324) described long-term results of scleral fixation of posterior chamber (PC) IOLs in children and reported a high rate of complications.

Ganesh et al . (Ophthalmic Surg Lasers Imaging 2009;40(4):354-60) noted that scleral-fixated PC IOLs are beneficial for children with aphakia without posterior capsular support, who are lacking other means of visual rehabilitation.

Sinha, Rajesh, et al. “Management of congenital cataract: A review.” Indian Journal of Ophthalmology, vol. 58, no. 6, Nov.-Dec. 2010, p. 563. Gale Academic OneFile, https://link-gale-com.i.ezproxy.nypl.org/apps/doc/A241320149/AONE?u=nypl&sid=AONE&xid=80b30689. Accessed 22 Mar. 2020.