Pediatric and Teen CL Care

Unilateral Aphakia in Infants

BY CHRISTINE W. SINDT, OD, FAAO

The infant aphakia treatment study (IATS) was designed to provide empirical evidence of whether optical treatment with an intraocular lens (IOL) or a contact lens, after unilateral cataract surgery during infancy, is associated with a better visual outcome (IATS Group, 2010). It was a randomized, multicenter (12 sites) clinical trial involving 114 infants who had unilateral congenital cataracts. The study ran from Dec. 2004 to Jan. 2009.

Study Findings

Following is a summary of the IATS conclusions:

• There was no significant difference in the median visual acuity of operated eyes in children who underwent primary IOL implantation versus those left aphakic. However, there were significantly more adverse events and additional intraoperative procedures in the IOL group. For infants younger than 7 months of age who have a unilateral cataract, the IATS group recommends leaving the eye aphakic and using a contact lens. Primary IOL implantation should be considered only when the cost and handling of a contact lens would be so burdensome as to result in significant periods of uncorrected aphakia (IATS Group, 2014).

• At the age of 1 year, following cataract extraction in infants, contact lens correction and no IOL placement were associated with a significant decrease in postoperative corneal astigmatism compared to IOL placement (Wall et al, 2014).

• Compliance with patching during the first six months after surgery was associated with better visual acuity at 12 months of age (Drews-Botsch et al, 2012).

• Most caregivers reported being able to adhere to prescribed patching. The type of correction (IOL versus contact lens) was not associated with the amount of patching achieved, whereas lower socioeconomic status and increased maternal stress appeared to increase noncompliance (Drews-Botsch et al, 2012).

• IOL versus contact lens did not have a significant impact on caregiver stress during infancy, or on the change in stress during the child’s first two years of life (Celano et al, 2013).

• Forty-two eyes were treated with a silicone elastomer lens, 12 eyes were treated with a GP material, and three were treated with both. Contact lenses were worn successfully with few adverse events. The visual acuity results were identical, independent of the contact lens material or modality. GP lenses needed replacement more often (Russell et al, 2012).

• For IATS patients up to 12 months of age, cataract surgery coupled with IOL implantation and spectacle correction was 37.5% (~$4,000) more expensive compared to cataract surgery coupled with contact lens correction (Carrigan et al, 2013).

• IOL placement does not prevent early development of strabismus after congenital cataract surgery. However, strabismus was less likely to develop in infants whose cataract was removed at an earlier age (Bothun et al, 2013).

• The type of optical correction did not influence stereopsis outcomes. However, two other factors did: age at surgery and visual acuity in the treated eye at age 4.5 years. Early surgery for unilateral congenital cataract and visual acuity better than or equal to 20/40 appear to be more important compared to the type of initial optical correction used for the development of stereopsis (Hartmann et al, 2014).

• There was no difference in nystagmus between the treatment groups (Felius et al, 2014).

A Clear Winner

The IATS shows that contact lenses and aggressive patching remain the best option for infants who have unilateral aphakia. Now we just need more practitioners willing to fit them. CLS

For references, please visit www.clspectrum.com/references and click on document #229.

Dr. Sindt is a clinical associate professor of ophthalmology and director of the contact lens service at the University of Iowa Department of Ophthalmology and Visual Sciences. She is the past chair of the AOA Cornea and Contact Lens Council. She is a consultant or advisor to Alcon Vision Care and Vistakon and has received research funds from Alcon. You can reach her at christine-sindt@uiowa.edu.