Eyeworld

EW CATARACT/IOL 44 February 2011 by Maxine Lipner Senior EyeWorld Contributing Editor Infants' eye view: Contact lenses versus IOLs for aphakia F or aphakic infants, contact lenses may provide equally good acuity with fewer complications, according to Scott R. Lambert, M.D., professor of ophthalmology and pe- diatrics, Emory University, Atlanta. Study results from the Archives of Ophthalmology, posted online on May 10, 2010, showed that while there was no difference in visual acuity at 1 year, there tended to be a need for additional surgeries in in- fants who received IOLs. These days, use of IOLs in chil- dren has become commonplace. "Over the years there have been more children treated with intraocu- lar lenses even though that's not ap- proved by the FDA," Dr. Lambert said. "I think that nearly all ophthal- mologists now treat children who are 2 years and older with intraocu- lar lenses." It is not this toddler age group that is so much in question, however. "The controversy has al- ways been in the really young chil- dren because there are some issues," Dr. Lambert said. "Their eyes are growing so it's difficult to know what power lens to put in, and they have historically had more compli- cations and reoperations." Considering an IOL trend Investigators were spurred by this trend of using IOLs in younger chil- dren. "There was interest in sur- geons putting intraocular lenses in babies as a way to treat their aphakia after cataract surgery. The question was whether this is better than using contact lenses, which is what we typically used in young children and babies," Dr. Lambert said. Included in the randomized, multi-center trial were 114 infants between the ages of 1 and 6 months who were assigned to undergo re- moval of a unilateral congenital cataract. Infants who did not un- dergo primary IOL implantation re- ceived a rigid gas-permeable contact lens to correct their aphakia. Fifty- seven patients were randomized to each treatment group. Investigators determined that while the rewards were similar, there were greater complications for those infants receiving the IOLs. "We found that visual acuity was statisti- cally the same in the contact lens and the intraocular lens patients," Dr. Lambert said. "However, the children who had intraocular lenses had more complications intraopera- tively and required more additional surgeries after the original proce- dure." At the 1-year mark, results showed that 16% of IOL recipients experienced one or more intraopera- tive complications compared with 11% of contact lens patients. This was primarily due to a greater degree of iris prolapse in the IOL group, with a 21% complication rate com- pared with just 4% in the contact lens group. Also, those in the IOL group experienced far more adverse events, with 77% of such patients having complications compared with just 25% of those in the con- tact lens group. The most common complica- tions were lens reproliferation, de- velopment of pupillary membranes, and corectopia. Lens reproliferation was an issue in 42% of eyes in the IOL group and just 2% of eyes where contact lenses were worn. When it came to pupillary membranes, this affected 30% of eyes in the IOL group but none in the contact lens group. In addition, corectopia was an issue for 19% of those in the IOL group compared with just 2% in the contact lens group. Additional procedures tended to be more frequently needed in the IOL group, with 63% of patients needing one or more additional in- traocular operations compared with only 12% of contact lens recipients. Clinical considerations Dr. Lambert sees the clinical implica- tions here as fairly clear-cut. "I think that surgeons should be very careful putting intraocular lenses in babies because there are additional risks in- volved," he said. "Certainly, inexpe- rienced surgeons should not be doing this." He acknowledged that these results are preliminary, how- ever. "Until we have a larger follow- up we're not saying not to do this, we just want surgeons to be aware that there are some additional risks and that certainly those risks need to be discussed with the family be- fore performing the surgery," Dr. Lambert said. He hopes that others come away from the study with the understand- ing that for infants with aphakia, contact lenses are a very viable op- tion. "The take-home message is that contact lenses are pretty well tolerated," Dr. Lambert said. "The children did quite well with them." One downside to using contact lenses in such infants, however, may be the cost. "As part of the study, the patients were given the contact lenses," Dr. Lambert said. "In real life, however, contact lenses are quite expensive and a lot of insur- ance companies don't cover them, so cost becomes an issue for many people." Overall, Dr. Lambert stressed that longer-term study is needed here. "The key question is what hap- pens to these children over the long run, and we won't know that for a few more years," he said. "We're going to follow up with these chil- dren until they are 5 years old, so one group might end up doing a lot better or worse over time." EW Editors' note: Dr. Lambert has financial interests with Bausch & Lomb (Rochester, N.Y.). Contact information Lambert: 404-778-3709, slamber@emory.edu Study shows fewer complications with contacts

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