pediatric and teen cl care

Key Strategies to Manage Pediatric Aphakes

BY JEFFREY J. WALLINE, OD, PHD, & MARJORIE J. RAH, OD, PHD

Congenital cataracts are rare, occurring in 1.6 of 10,000 children born in the United States. But the consequences can be devastating if children are not treated promptly. Dense amblyopia can develop quickly from the opacity or from uncorrected refractive error after cataract extraction.

It's rare that a parent will bring an infant to your office for contact lenses after cataract surgery. However, if you refer a child for cataract surgery, you may want to follow up. Use the following strategies to provide the care aphakic children need.

Achieve Maximum Benefit

You can use eyeglasses to correct vision in patients who have bilateral aphakia because relative image sizes will be similar in both eyes, but patients with unilateral aphakia need contact lenses. These patients see unequal image sizes because of high hyperopia in the aphakic eye; this disrupts development of binocular vision.

It's easiest to fit the contact lens immediately after cataract extraction, while the child is under general anesthesia. A +30.00D lens approximates the expected refractive error and should be placed on the eye for retinoscopy. Without the lens, refractive error measurements may not be accurate because of the effect of vertex distance of the diagnostic lens. Evaluate and adjust the lens fit at that time. Burton lamps are valuable in assessing the fit in these situations.

Children should begin wearing the contact lens as soon as possible to decrease the amblyopic effects of the uncorrected refractive error. Be sure to overcorrect the contact lens power +3.00D before the child can walk because the child's visual world is within 33cm at that time.

Weigh the Options

Choosing a lens can be difficult, but we now have far more options. The first step is choosing between GP and soft lenses. Lens power also affects choices. Silicone hydrogel lenses allow as much oxygen to reach the cornea as GP lenses do, but we do not have silicone hydrogels in high enough plus powers at this time. The only semi-soft lens material that meets the needs of patients with more than +20.00D of hyperopia is the Silsoft Super Plus (Bausch & Lomb), but it's only available in +3.00D steps from +23.00D to +32.00D. However, also consider the lens material the parent wears. If parents wear GP contact lenses, it will guide them in caring for the child.

Daily wear is the best option for ocular health, and it's helpful if the child is used to lens application and removal before becoming a strong, willful 2-year-old. However, some parents don't have the resources to apply and remove a contact lens, so an extended wear lens may be an alternative. The child may need to visit the office for lens removal and cleaning. Two pairs of lenses may be exchanged on a weekly basis, with one kept at the office for cleaning and disinfection.

Monitor Carefully

After the first few lens assessments, examine patients monthly to monitor changes in refractive error, compliance, amblyopia and ocular health. Begin patching shortly after a child begins wearing the lens and continue for several years. Also watch for glaucoma over several years, which occurs in approximately 10 percent of pediatric aphakes.

These strategies can help you become comfortable fitting an aphakic child with a contact lens. The treatment is medically necessary and will have a positive impact on the child's life. CLS

Dr. Walline is an assistant professor at The Ohio State University College of Optometry, where he conducts studies of pediatric contact lens wear. He is also a consultant or advisor and has received research funds from Paragon Vision Sciences and Vistakon. Dr. Rah is a staff optometrist at the Massachusetts Eye and Ear Infirmary Contact Lens Service where she specializes in medically necessary and other advanced contact lens designs.