APHAKIA REQUIRES high hyperopic correction when an intraocular lens (IOL) cannot be implanted, is contraindicated, or is delayed. Although GP lenses are common, specialty soft contact lenses (SCLs) are valuable for pediatric and adult patients due to their comfort, ease of handling, and suitability for specific clinical scenarios.
The pediatric patient: Since the 1970s, contact lenses have been the primary treatment for reducing deprivation amblyopia after pediatric lensectomy (Stark et al, 1979). The Infant Aphakia Study reported high compliance, concluding that CLs are ideal substitutes for IOLs because they eliminate sizing issues and the need to predict future refractive error, leading to fewer adverse events with comparable visual outcomes (Lambert et al, 2014).
Practitioners often rely upon silicone elastomer lenses for ease of fit, high oxygen permeability, and extended wear (Lambert et al, 2018). Interestingly, a prospective study from 2021 found that custom latheable silicone hydrogels and commercially available extended-range silicone hydrogel lenses were successfully refit in 59% of the children previously wearing silicone elastomer lenses, and were able to effectively meet the visual needs of these patients while improving comfort and cost-effectiveness (Shaikh et al, 2023).
The adult patient: Research indicates that adult aphakic patients using daily-wear SCLs achieve high success rates of 86% in those under age 70 who have good manual dexterity (Graham et al, 1988). Conversely, success dropped to 27% for those over 70, mainly due to handling difficulties. This cohort still had a low success rate, even when they were refit with extended-wear SCLs, which carried a 6x higher risk of infection and complications (Graham et al, 1988).
Clinical Considerations
Oxygen permeability: Because high plus powers increase lens thickness, using materials that have higher Dk/t is essential to minimize hypoxic stress (Lira et al, 2015).
Fit and movement: Customizing base curve and diameter is vital, especially in infants, who have steeper and smaller corneas than adults (Trivedi and Wilson, 2008). Infants and young children also require extra hyperopic power for near viewing distances, which need to be adjusted as the child develops. With adults, standard SCL fitting guidelines generally apply.
Handling and wear schedules: Manual dexterity is the primary predictor of success in adults. High-plus lenses can be more challenging to handle due to their thickness; thorough training improves adherence. In children, caregiver training is essential, as small palpebral apertures present an additional challenge (Moore, 1994). All caregivers also should be educated on how to recognize problems (eg, redness, secretions, photophobia, or irritation). Daily wear remains preferred, but regular monitoring is necessary if extended wear is needed for patient success. It’s also crucial that pediatric patients always have at least 1 spare lens to maintain continuous correction and prevent amblyopia.
Follow-up: Inquire about lens care and replacement/loss. Monitor for signs of lens surface deposits, neovascularization, subtle edema, a papillary response, or conjunctival hyperemia, and adjust the material, lens replacement schedule, or lens modality—including switching to GP lenses if there is evidence of complications. Children, especially infants, need to be seen more frequently than adults because their eyes grow rapidly and require CL adjustments to account for this, their refractive error, and vision development. The most rapid growth occurs during the first 18 months of life (Moore, 1987).
Conclusion
Specialty soft lenses remain a proven method for aphakia rehabilitation in the absence of cornea irregularity. Success relies on material choice, individualized fitting, comprehensive patient/caregiver education, and vigilant follow-up. When these elements are aligned, SCLs restore vision in aphakic patients throughout their lifespan.
References
1. Stark WJ, Kracher GP, Cowan CL, Taylor HR, Hirst LW, Oyakawa RT, Maumenee AE. Extended-wear contact lenses and intraocular lenses for aphakic correction. Am J Ophthalmol. 1979 Sep;88:535-542. doi: 10.1016/0002-9394(79)90511-7
2. Infant Aphakia Treatment Study Group; Lambert SR, Lynn MJ, Hartmann EE, et al. Comparison of contact lens and intraocular lens correction of monocular aphakia during infancy: a randomized clinical trial of HOTV optotype acuity at age 4.5 years and clinical findings at age 5 years. JAMA Ophthalmol. 2014 Jun;132(6):676-682. doi: 10.1001/jamaophthalmol.2014.531
3. Lambert SR, Kraker RT, Pineles SL, et al. Contact lens correction of aphakia in children: a report by the American Academy of Ophthalmology. Ophthalmology. 2018 Sep 1;125(9):1452-1458. doi: 10.1016/j.ophtha.2018.03.014
4. Shaikh N, Stec M, Bohnsack BL. Soft contact lens options in the management of pediatric aphakia- A quantitative and qualitative assessment. Cont Lens Anterior Eye. 2023;46:101874. doi: 10.1016/j.clae.2023.101874
5. Graham CM, Dart JK, Wilson-Holt NW, Buckley RJ. Prospects for contact lens wear in aphakia. Eye (Lond). 1988;2(Pt 1):48-55. doi: 10.1038/eye.1988.12
6. Lira M, Pereira C, Oliveira MECD, Castanheira EM. Importance of contact lens power and thickness in oxygen transmissibility. Cont Lens Anterior Eye. 2015 Apr 1;38(2):120-126. doi: 10.1016/j.clae.2014.12.002
7. Trivedi RH, Wilson ME. Keratometry in pediatric eyes with cataract. Arch Ophthalmol. 2008;126(1):38-42. doi: 10.1001/archophthalmol.2007.22
8. Moore BD. Paediatric cataracts – diagnosis and treatment. Optom Vis Sci. 1994 Mar;71:168-173. doi: 10.1097/00006324-199403000-00004
9. Moore BD. Mensuration data in infant eyes with unilateral congenital cataracts. Am J Optom Physiol Opt. 1987 Feb;64:204-210. doi: 10.1097/00006324-198703000-00007