Daniel E. Neely

The Infant Aphakia Treatment Study: Design and Clinical Measures at Enrollment

OBJECTIVE To compare the use of contact lenses and intraocular lenses (IOLs) for the optical correction of unilateral aphakia during infancy. METHODS In a randomized, multicenter (12 sites) clinical trial, 114 infants with unilateral congenital cataracts were assigned to undergo cataract surgery with or without IOL implantation. Children randomized to IOL treatment had their residual refractive error corrected with spectacles. Children randomized to no IOL treatment had their aphakia treated with a contact lens. MAIN OUTCOME MEASURES Grating acuity at 12 months of age and HOTV visual acuity at 4 1/2 years of age. APPLICATION TO CLINICAL PRACTICE This study should determine whether either treatment for an infant with a visually significant unilateral congenital cataract results in a better visual outcome. RESULTS Enrollment began December 23, 2004, and was completed January 16, 2009. The median age at the time of cataract surgery was 1.8 months. Fifty patients were 4 to 6 weeks of age at the time of enrollment; 32, 7 weeks to 3 months of age; and the remaining 32, more than 3 to less than 7 months of age. Fifty-seven children were randomized to each treatment group. Eyes with cataracts had shorter axial lengths and steeper corneas on average than the fellow eyes. CONCLUSIONS The optimal optical treatment of aphakia in infants is unknown. However, the Infant Aphakia Treatment Study was designed to provide empirical evidence of whether optical treatment with an IOL or a contact lens after unilateral cataract surgery during infancy is associated with a better visual outcome.

Guidelines for automated preschool vision screening: a 10-year, evidence-based update.

In 2003 the American Association for Pediatric Ophthalmology and Strabismus Vision Screening Committee proposed criteria for automated preschool vision screening. Recent literature from epidemiologic and natural history studies, randomized controlled trials of amblyopia treatment, and field studies of screening technologies have been reviewed for the purpose of updating these criteria. The prevalence of amblyopia risk factors (ARF) is greater than previously suspected; many young children with low-magnitude ARFs do not develop amblyopia, and those who do often respond to spectacles alone. High-magnitude ARFs increase the likelihood of amblyopia. Although depth increases with age, amblyopia remains treatable until 60 months, with decline in treatment effectiveness after age 5. US Preventive Services Task Force Preventative Services Task Force guidelines allow photoscreening for children older than 36 months of age. Some technologies directly detect amblyopia rather than ARFs. Age-based criteria for ARF detection using photoscreening is prudent: referral criteria for such instruments should produce high specificity for ARF detection in young children and high sensitivity to detect amblyopia in older children. Refractive screening for ARFs for children aged 12-30 months should detect astigmatism >2.0 D, hyperopia >4.5 D, and anisometropia >2.5 D; for children aged 31-48 months, astigmatism >2.0 D, hyperopia > 4.0 D, and anisometropia >2.0 D. For children >49 months of age original criteria should be used: astigmatism >1.5 D, anisometropia>1.5 D, and hyperopia >3.5 D. Visually significant media opacities and manifest (not intermittent) strabismus should be detected at all ages. Instruments that detect amblyopia should report results using amblyopia presence as the gold standard. These new American Association for Pediatric Ophthalmology and Strabismus Vision Screening Committee guidelines will improve reporting of results and comparison of technologies.

Refractive change in pediatric pseudophakia: 6-year follow-up☆

Purpose: To evaluate the long‐term evolution of refractive error changes in eyes of children who have primary intraocular lens (IOL) implantation to allow more accurate prediction of what IOL power should be implanted at a given age. Setting: Department of Ophthalmology, Indiana University School of Medicine, Indianapolis, Indiana, USA. Methods: This study comprised all children between 2 and 15 years of age who had posterior chamber IOL implantation and who were followed for a minimum of 4 years postoperatively. Thirty‐eight eyes of 27 patients with a mean follow‐up of 6.1 years were evaluated. All refractions were performed manually by an experienced pediatric ophthalmologist. Results: Children operated on at age 2 or 3 years had a mean myopic shift of 4.60 diopters (D) (range 0.50 to 10.75 D) over a mean of 5.8 years postoperatively. Children operated on at age 6 or 7 years had a mean myopic shift of 2.68 D (range 0.50 to 6.60 D) over a mean of 5.3 years. Children operated on at age 8 or 9 years had a mean myopic shift of 1.25 D (range −0.75 to 2.60 D) over a mean of 6.8 years. Patients operated on between ages 10 and 15 years had a mean shift of 0.61 D (range 0 to 1.90 D) over a mean of 5.7 years. Conclusions: The mean rate of myopic shift decreased throughout childhood, and the range of shift among individuals narrowed as patient age increased. However, the ability to predict future myopic shift for a given individual remains difficult, especially in younger patients.

Intermediate-term results of endoscopic diode laser cyclophotocoagulation for pediatric glaucoma ☆ ☆☆ ★

INTRODUCTION Endoscopic diode laser cyclophotocoagulation (EDLC) is a new treatment modality for glaucoma. Experience with this surgical procedure in children is limited. We report our results after 3 years of follow-up and review the safety of this procedure in pediatric patients. METHODS EDLC was performed on 10 eyes of 8 children who had either aphakic glaucoma or refractory congenital glaucoma. Patients were treated in 2 groups. An initial group of 5 eyes with poor visual prognosis underwent a conservative treatment of no more than 180 degrees of ciliary processes. After an observational period, a second group of 5 eyes with better visual potential was treated more aggressively. Most eyes in the second group received cyclophotoablation to 270 degrees of ciliary processes. Patients were followed up until time of failure or for a minimum of 3 years. RESULTS At 3 years of follow-up, 50% of eyes that received a single treatment of endolaser had an intraocular pressure (IOP) of < or =22 mm Hg with or without glaucoma medications. Twenty percent had an IOP < or =22 mm Hg without any glaucoma medications. Five eyes were treated successfully with a mean IOP of 17.8 +/- 3.4 mm Hg at 36 months of follow-up. The remaining 5 eyes were considered treatment failures with postoperative IOPs >22 mm Hg, despite adjunctive glaucoma medications. Mean time to treatment failure was 10.5 months (range, 3.7-22.2 months). No sight-threatening complications occurred. None of the eyes became hypotonus or caused undue discomfort during the postoperative period. CONCLUSION EDLC is a relatively safe and effective procedure for the management of difficult pediatric glaucoma. Results are comparable to other cyclodestructive modalities. Although not observed in this study, it should be cautioned that phakic eyes might be at increased risk for surgical complications.

Glaucoma-Related Adverse Events in the Infant Aphakia Treatment Study: 1-Year Results

OBJECTIVES To report the incidence of glaucoma and glaucoma suspects in the IATS, and to evaluate risk factors for the development of a glaucoma-related adverse event in patients in the IATS in the first year of follow-up. METHODS A total of 114 infants between 1 and 6 months of age with a unilateral congenital cataract were assigned to undergo cataract surgery either with or without an intraocular lens implant. Standardized definitions of glaucoma and glaucoma suspect were created and used in the IATS. RESULTS Of these 114 patients, 10 (9%) developed glaucoma and 4 (4%) had glaucoma suspect, for a total of 14 patients (12%) with a glaucoma-related adverse event in the treated eye through the first year of follow-up. Of the 57 patients who underwent lensectomy and anterior vitrectomy, 5 (9%) developed a glaucoma-related adverse event; of the 57 patients who underwent an intraocular lens implant, 9 (16%) developed a glaucoma-related adverse event. The odds of developing a glaucoma-related adverse event were 3.1 times higher for a child with persistent fetal vasculature and 1.6 times higher for each month of age younger at cataract surgery. CONCLUSIONS Modern surgical techniques do not eliminate the early development of glaucoma following congenital cataract surgery with or without an intraocular lens implant. Younger patients with or without persistent fetal vasculature seem more likely to develop a glaucoma-related adverse event in the first year of follow-up. Vigilance for the early development of glaucoma is needed following congenital cataract surgery, especially when surgery is performed during early infancy or for a child with persistent fetal vasculature. Five-year follow-up data for the IATS will likely reveal more glaucoma-related adverse events. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT00212134.

Accuracy of biometry in pediatric cataract extraction with primary intraocular lens implantation.

PURPOSE: To determine the accuracy of predicted postoperative refractive outcomes in pediatric patients having cataract surgery with intraocular lens (IOL) implantation and to compare them with other variables historically considered important in cataract surgery. SETTING: Tertiary care referral hospital. METHODS: This retrospective review comprised 203 eyes of 153 consecutive pediatric patients (≤18 years old) having cataract extraction with primary posterior chamber IOL implantation in the capsular bag. All cases were performed by 1 of 2 surgeons, and all refractions were performed manually by an experienced pediatric ophthalmologist using a retinoscope. RESULTS: In all patients, the mean absolute value (MAE) of the prediction error was 1.08 diopters (D) ± 0.93 (SD). Age at time of surgery and corneal (K) mean curvature were significantly correlated with the absolute value of the prediction error (P = .0006 and P = .0088, respectively). A multiple regression model showed that age at time of surgery and K mean curvature were the only 2 variables significantly associated with MAE; axial length, formula, surgeon, and A‐scan type were not significantly associated with prediction error. CONCLUSIONS: Data from 203 consecutive primary pediatric IOL implantations showed the heterogeneous nature of the variables involved in predictions of refractive outcomes in this population. The complexities of this issue support the need for specific methods of measurement and an IOL calculation formula for the pediatric population.

Prevalence and course of strabismus through age 6 years in participants of the Early Treatment for Retinopathy of Prematurity randomized trial

PURPOSE To present strabismus data for children who participated in the Early Treatment for Retinopathy of Prematurity (ETROP) randomized trial. METHODS The prevalence of strabismus, categorized as present or absent, was tabulated for all children with history of high-risk prethreshold retinopathy of prematurity (ROP) who participated in the ETROP randomized trial and were examined at 9 months to 6 years of age. Relationships among strabismus and demographic measures, eye characteristics, and neurodevelopmental factors were analyzed. RESULTS Among the 342 children evaluated at 6 years, the prevalence of strabismus was 42.2%. Even with favorable acuity scores in both eyes, the prevalence of strabismus was 25.4%, and with favorable structural outcomes in both eyes the prevalence of strabismus was 34.2%. Of children categorized as visually impaired as the result of either ocular or cerebral causes, 80% were strabismic at the 6-year examination. Of 103 study participants who were strabismic at 9 months, 77 (74.8%) remained so at 6 years. Most strabismus was constant at both the 9-month (62.7%) and the 6-year examination (72.3%). After multiple logistic regression analysis, risk factors for strabismus were abnormal fixation behavior in one or both eyes (P < 0.001), history of amblyopia (P < 0.003), unfavorable structural outcome in one or both eyes (P = 0.025), and history of anisometropia (P = 0.04). Strabismus surgery was performed for 53 children. By 6 years, the cumulative prevalence of strabismus was 59.4%. CONCLUSIONS Most children with a history of high-risk prethreshold ROP develop strabismus at some time during the first 6 years of life.

MANAGEMENT OF ECTOPIA LENTIS IN CHILDREN

Marfan syndrome, homocystinuria, trauma, and simple ectopia lentis are the most common causes of pediatric lens subluxation. Many patients are best treated with a careful refraction of the phakic or aphakic pupillary axis. For those patients not achieving satisfactory refractive results, endocapsular lensectomy using modern automated vitreous cutting devices is relatively safe and successful. Given the lack of postoperative capsular support and our current level of intraocular lens technology, postoperative optical correction is most safely achieved with aphakic contact lenses or spectacles.

Accuracy of IOL calculations in children: A comparison of immersion versus contact A-scan biometery

PURPOSE To evaluate the accuracy of pediatric IOL calculations performed under general anesthesia by using immersion A-scan biometry and to compare the results to those obtained using contact A-scan biometry. METHODS A retrospective review of 203 consecutive cases of pediatric cataract extraction with primary IOL implantation within the capsular bag; mean patient age was 5.52 +/- 4.19 years (range, 18 days to 18 years). Axial length measurements were performed with the contact A-scan biometry in 138 eyes, whereas immersion technique biometry was used in the remaining consecutive 65 eyes. Preoperative predictive target refraction was compared with the refractive result obtained at the 2-month postoperative visit. RESULTS The mean of the absolute value lens prediction error for all eyes was 1.08 +/- 0.93 D from the desired postoperative refractive result. Lens prediction error for the contact A-scan subgroup was 1.11 +/- 0.90 D, whereas the immersion A-scan subgroup was less at 1.03 +/- 0.98 D. This result was not statistically significant (p = 0.6442). Statistically significant correlations were found between increased lens prediction error and age at time of surgery or corneal curvature. CONCLUSIONS This retrospective, noncomparative pilot study showed no significant difference in IOL prediction error when comparing the postoperative refractive results obtained with immersion versus contact A-scan biometry in pediatric IOL calculations.

Stereopsis Results at 4.5 Years of Age in the Infant Aphakia Treatment Study

PURPOSE To determine whether stereopsis of infants treated for monocular cataracts varies with the type of optical correction used. DESIGN Randomized prospective clinical trial. METHODS The Infant Aphakia Treatment Study randomized 114 patients with unilateral cataracts at age 1-7 months to either primary intraocular lens (IOL) or contact lens correction. At 4.5 years of age a masked examiner assessed stereopsis on these patients using 3 different tests: (1) Frisby; (2) Randot Preschool; and (3) Titmus Fly. RESULTS Twenty-eight patients (25%) had a positive response to at least 1 of the stereopsis tests. There was no statistically significant difference in stereopsis between the 2 treatment groups: Frisby (contact lens, 6 [11%]; IOL, 7 [13%]; P = .99), Randot (contact lens, 3 [6%]; IOL, 1 [2%]; P = .62), or Titmus (contact lens, 8 [15%]; IOL, 13 [23%]; P = .34). The median age at surgery for patients with stereopsis was younger than for those without stereopsis (1.2 vs 2.4 months; P = .002). The median visual acuity for patients with stereopsis was better than for those without stereopsis (20/40 vs 20/252; P = .0003). CONCLUSION The type of optical correction did not influence stereopsis outcomes. However, 2 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 the presence of visual acuity better than or equal to 20/40 appear to be more important than the type of initial optical correction used for the development of stereopsis.