Secondary IOLs in children: now or later?

Delaying intraocular lens (IOL) implantation in children with congenital cataracts until refraction has stabilised can provide a better refractive outcome than primary surgery, according to a 10-year follow-up study of patients in in the Infant Aphakia Treatment study (IATS), said Scott R Lambert MD, Stanford University School of Medicine, Palo Alto, California, US. “Fewer than half of children randomised to aphakia in the IATS underwent secondary IOL implantation. Delaying 1OL implantation to an age of five or more years was associated with lower refractive error at age 10.5 years,” Dr Lambert told the ESCRS/WSPOS symposium during the 38th Congress of the ESCRS. The IATS study is a 12-centre clinical trial involving 114 infants with unilateral congenital cataract who were randomised to undergo cataract surgery either with or without IOL implantation at ages ranging from four weeks to seven months. Secondary IOL implantation was only allowed in children below 4.5 years of age if they were contact lens intolerant, Dr Lambert said. He noted that at 10.5 years, 30 of the 57 children in the aphakia group remained aphakic and 24 had undergone secondary IOL implantation. The median age at second IOL surgery was 5.4 years (range 1.7 to 10.3 years). A further two patients were lost to follow-up, and one had phthisis bulbi. Dr Lambert noted that there was no significant difference in median best-corrected logMAR visual acuity between those who remained aphakic (0.8, range 0.1 to 2.9) and those who underwent secondary IOL implantation (0.9, range 0.2 to 1.7). However, for eyes undergoing IOL implantation after the 4.5-year study visit, the mean refraction at age 10.5 years was significantly better, at -3.2D (range -9.9 to 1.1D), than in eyes that underwent primary IOL implantation at -5.5D (range -26.5 to 3.0D) (p=0.03). To illustrate the good results that can be achieved with aphakia, Dr Lambert presented a case study of a congenital cataract patient who underwent lensectomy at six weeks of age. The infant was first fit with +29.0D Silsoft contact lens and switched to a silicone hydrogel lens at five years of age. At age 16 years, the patient had a best-corrected visual acuity of 20/20 in both eyes. She had a refraction of +14D in her aphakic eye, in which she wore a +18D contact lens. In addition, she was orthotropic and had high-grade stereopsis of 40 seconds of arc, he said. Scott R Lambert: lambert7@stanford.edu