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IOLs in congenital cataract surgery have become standard of care
Considering age and circumstances can help selection of an appropriate IOL for an infant or child.
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There currently are no absolute contraindications for IOL implantation in children, according to M. Edward Wilson Jr., MD.
“Intraocular lenses are really the standard of care for children after uncomplicated cataract surgery at ages beyond infancy,” Dr. Wilson said. “I would also say it is an acceptable alternative for infants, especially those without complex microphthalmia.”
In 2003, Dr. Wilson and colleagues surveyed 554 surgeons who implant IOLs in children, including members of the American Society of Cataract and Refractive Surgery and the American Association for Pediatric Ophthalmology and Strabismus (AAPOS). Twenty-nine percent of the ASCRS surgeons and 38% of the AAPOS surgeons reported implanting IOLs in patients less than 12 months old.
“I suspect if we repeated that survey today, the numbers would be larger,” Dr. Wilson said.
There are still relative contraindications and areas that need to be studied further, he said.
“This would include active uveitis, the absence of capsular support, complex microphthalmia and even [implantation] in infancy,” Dr. Wilson said. “Those are areas where we’re still studying, and depending on the situation, especially in the developing world and other places, the implantation is still done.”
Infant aphakia treatment
Dr. Wilson and colleagues are currently studying the primary implantation of IOLs in the first 6 months of life in the Infant Aphakia Treatment Study funded by the National Eye Institute.
“Importantly, we went to the extra trouble to get an investigational device exemption from the Food and Drug Administration so they could follow the study with us,” Dr. Wilson said. “I think that the Infant Aphakia Treatment Study will also collect some informative data on amblyopia treatment and parental stress.”
Preferred IOL material
In the 2003 survey, the same 554 surgeons were polled on what IOL material they prefer to use routinely for children. Most preferred acrylic.
“There was an 84% response rate with acrylic, and the hydrophobic acrylics over the hydrophilic 38 to 1,” he said. “The most commonly used lenses in children, as far as I can tell, are the Alcon AcrySof series, and they come in SA, SN and MA types.”
The SA-60 and SN-60 are single-piece acrylic IOLs with a 6-mm-diameter optic; they should be used for capsule fixation only, Dr. Wilson said.
“I really think that this lens is easiest for implantation in young children,” he said. “It goes in as a tight, compact package, and you can really place this exactly where you want it.”
Special circumstances
Other lenses are recommended for special circumstances, Dr. Wilson said.
“For sulcus placement, as I indicated, the three-piece AcrySof is used,” he said. “I try to capture the optic through the anterior capsulorrhexis or, if I can, through the anterior and posterior capsulorrhexes to keep it from decentering.”
Dr. Wilson noted that the Verisyse/Artisan iris-fixated phakic IOL from Advanced Medical Optics/Ophtec now has FDA approval as a myopic phakic implant.
“We need to remember it was originally a pediatric aphakic IOL,” Dr. Wilson said. “It has a long track record, and we hope that at some point it will be added to our usage.”
In cases where foldable IOLs are cost-prohibitive, inexpensive PMMA lenses can be substituted, he said.
“They can be stiff and large, and I would consider sulcus placement with optic capture in those patients for safety and applicability,” Dr. Wilson said.
Multifocal IOLs
Dr. Wilson cautioned that multifocal lenses should not be used in patients younger than teen age.
Multifocal IOLs are based on simultaneous vision, with multiple images formed on the retina, he said, and the brain has to select the image it wants to see.
“I’m worried that uncorrected refractive error … with two blurred images, neither one of which is in focus, might be worse than uncorrected refractive error when the glasses aren’t being worn in a monofocal implant,” he said.
For Your Information:
- M. Edward Wilson, MD, can be reached at Storm Eye Institute, 167 Ashley Ave., Charleston, SC 29425; 843-792-7622; fax: 843-792-1166; e-mail: wilsonme@musc.edu. Dr. Wilson has no direct financial interest in the products mentioned in this article, nor is he a paid consultant for any companies mentioned.
- Alcon, maker of the AcrySof IOL, can be reached at 6201 S. Freeway, Fort Worth, TX 76134-2099; 817-293-0450; fax: 817-568-6142; www.alconlabs.com.
- Ophtec, manufacturer and marketer of the Artisan IOL, can be reached at 6421 Congress Ave., Suite 112, Boca Raton, FL 33487; 561-989-8767; Web site: www.ophtec.com.
- Advanced Medical Optics, marketer of the Verisyse IOL, can be reached at 1700 E. St. Andrew Place, P.O. Box 25162, Santa Ana, CA 92799-5162; 714-247-8200; Web site: www.amo-inc.com.
- Daniele Cruz is an OSN Staff Writer who covers all aspects of ophthalmology.