David A. Plager

A randomized clinical trial comparing contact lens with intraocular lens correction of monocular aphakia during infancy: grating acuity and adverse events at age 1 year.

OBJECTIVE To compare the visual outcomes and adverse events of contact lens with primary intraocular lens (IOL) correction of monocular aphakia during infancy. METHODS In a randomized, multicenter (12 sites) clinical trial, 114 infants with a unilateral congenital cataract were assigned to undergo cataract surgery between 1 to 6 months of age either with or without primary IOL implantation. Contact lenses were used to correct aphakia in patients who did not receive IOLs. Grating visual acuity was tested at 1 year of age by a masked traveling examiner. MAIN OUTCOME MEASURE Grating visual acuity at 1 year of age. RESULTS The median logMAR visual acuity was not significantly different between the treated eyes in the 2 groups (contact lens group, 0.80; IOL group, 0.97; P = .19). More patients in the IOL group underwent 1 or more additional intraocular operations than patients in the contact lens group (63% vs 12%; P < .001). Most of these additional operations were performed to clear lens reproliferation and pupillary membranes from the visual axis. CONCLUSIONS There was no statistically significant difference in grating visual acuity at age 1 year between the IOL and contact lens groups; however, additional intraocular operations were performed more frequently in the IOL group. APPLICATION TO CLINICAL PRACTICE Until longer-term follow-up data are available, caution should be exercised when performing IOL implantation in children aged 6 months or younger given the higher incidence of adverse events and the absence of an improved short-term visual outcome compared with contact lens use.

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.

Unilateral intraocular lens implantation during the first six months of life

PURPOSE The purpose of this study was to determine the incidence of postoperative complications and the occurrence of myopic shift in infantile eyes after cataract surgery and implantation of an intraocular lens (IOL). METHODS Cataract surgery and IOL implantation was performed on 11 infants with unilateral congenital cataracts who had a mean age of 10+/-6 weeks at 5 clinical centers. IOLs with a mean power of 26.2+/-2.3 D were implanted using a standardized protocol. The infants were then followed up for a mean of 13+/-6 months for postoperative complications and longitudinal changes in their refractive error. RESULTS Eight of the 11 eyes had postoperative complications and were treated with a reoperation. Complications included open-angle glaucoma (n = 2), lens reproliferation into the visual axis (n = 2), pupillary membranes (n = 2), and corectopia (n = 2). A younger age at the time of surgery was positively correlated with the development of a postoperative complication requiring a reoperation (P = .03). A mean myopic shift of 5.49 D occurred in these eyes a year after surgery. No preoperative factors could be identified that correlated with the magnitude of the myopic shift. CONCLUSION IOL implantation during infancy is associated with a high complication rate frequently requiring reoperation. A large myopic shift typically occurs that necessitates an initial or a late overcorrection with spectacles or a contact lens, depending on the power of the IOL implanted. Until ongoing randomized trials are completed, we recommend that surgeons exercise caution before implanting IOLs in the eyes of infants.

A comparison of the rate of refractive growth in pediatric aphakic and pseudophakic eyes

OBJECTIVE To compare the rate of refractive growth in pseudophakic childrens eyes to that of aphakic eyes. DESIGN Multicenter, retrospective observational case series. PARTICIPANTS 83 patients with pseudophakic eyes (100 eyes) and 74 patients with aphakic eyes (106 eyes), with an age of surgery between 3 months and 10 years and a minimum follow-up time of 3 years or more, depending on the age at surgery. METHODS A logarithmic model was used to analyze the rate of refractive growth for each eye. MAIN OUTCOME MEASURES Age at surgery, intraocular lens power, intraocular lens A-constant, initial postoperative refraction, final refraction, and final age. RESULTS Overall, pseudophakic eyes showed a lesser rate of refractive growth than aphakic eyes (-4.6 diopter vs. -5.7 diopter, P = 0.03). This trend was also present but less significant when the eyes were grouped into those less than 6 months of age at surgery (-3.3 diopter vs. -4.6 diopter, P = 0.09) and older patients (-5.0 diopter vs. -6.1 diopter, P = 0.07). However, the mean quantity of myopic shift was greater in pseudophakic eyes than in aphakic eyes (-5.26 diopter vs. -4.54 diopter), despite shorter follow-up times in the pseudophakic eyes. This is due to the optical effects of a constant intraocular lens power in a growing eye. CONCLUSIONS Pediatric pseudophakic eyes have a slightly lesser rate of refractive growth than aphakic eyes. The new rate values should be used for predicting future refractions in these eyes.

Large Recession of the Horizontal Recti for Treatment of Nystagmus

Ten patients had large recession of four horizontal recti at one procedure for treatment of nystagmus. Six patients had congenital motor nystagmus, two had oculocutaneous albinism, and two had optic nerve hypoplasia. Anomalous head posture with null point was also present in five patients. The rectus muscles were placed at or behind the equator in all but one case. Three patients with both esotropia and nystagmus had the medial recti placed 1 mm behind the equator and the lateral recti or at 1 mm anterior to the equator. Visual acuity improved an average of 1 line at distance and/or near in 8 patients who cooperated for testing. Although nystagmus was not eliminated in any patient, its its amplitude decreased in eight of ten patients, and anomalous head posture improved in three of five patients. In all patients, near vision was better than distance vision both preoperatively and postoperatively. Ductions were diminished minimally after the large recession and there were no other complications from surgery.

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.

A new classification of superior oblique palsy based on congenital variations in the tendon.

BACKGROUND Superior oblique palsy is the most frequent isolated cranial nerve palsy seen in strabismus practice. It is traditionally diagnosed according to etiology as acquired, congenital, or idiopathic, but surgical treatment is based on deviation not etiology. Observations at surgery led to speculation that the superior oblique tendon is different in congenital compared with acquired superior oblique palsy and that this difference should be considered in surgical treatment. METHODS The authors reviewed the charts of 82 patients (89 eyes) undergoing surgery on the superior oblique tendon for superior oblique palsy. In each case, the palsy had been diagnosed preoperatively as acquired, congenital, or idiopathic, and, at surgery, characteristics of the tendon anatomy were described. RESULTS Thirty-eight superior oblique tendons (36 patients), diagnosed as congenital superior oblique palsy, included 33 abnormal tendons and 5 normal tendons. Twenty-four tendons (21 patients), diagnosed as traumatic superior oblique palsy, included 22 normal and 2 abnormal tendons. Twenty-seven tendons (25 patients), diagnosed as idiopathic, included 19 normal and 8 abnormal tendons. Abnormal tendons were divided into 4 categories: (1) redundant, (2) misdirected, (3) inserted in posterior Tenons capsule, and (4) absent. CONCLUSIONS The authors conclude that congenital superior oblique palsy is usually associated with a structural abnormality of the superior oblique tendon (87%). Whereas acquired superior oblique palsy usually has a normal tendon (92%). Superior oblique underaction in acquired superior oblique palsy results from a neural deficit. Potential variance in anatomy of the superior oblique tendon should be considered when undertaking surgery for superior oblique palsy.

Capsular management and refractive error in pediatric intraocular lenses.

BACKGROUND Guidelines for intraocular lens (IOL) implantation in children regarding patient selection, age limitations, operative techniques, including management of the posterior capsule, and refractive goals are not universally agreed on. METHODS The authors placed posterior chamber IOLs in the capsular bag of 79 eyes in 57 children. Patient age ranged from 10 months to 17 years. Follow-up averaged 2 years. Patients were selected on the basis of age, cataract morphology, laterality, and lack of potential complicating factors. In general, postoperative refractions were intended to be mildly hyperopic with the magnitude dependent on patient age. RESULTS Seventy-nine percent of patients able to report a postoperative visual acuity showed 20/40 or better visual acuity. Vision was limited by amblyopia in the remaining patients. There were no significant complications. The posterior capsule opacified on average 2 years after surgery regardless of patient age. CONCLUSIONS Implantation of posterior chamber IOLs in carefully selected children appears to be effective and safe. Consideration should be given to primary posterior capsulectomy-anterior vitrectomy at the time of lens implant in children who are not expected to be candidates for yttrium aluminum garnet (YAG) capsulotomy within 18 months of surgery.

Recognition and Repair of the “Lost” Rectus Muscle: A Report of 25 Cases+

Twenty-five consecutive cases of lost muscle over a 10-year period are presented with regard to etiology, clinical presentation, operative findings, and treatment results. All patients showed a large-angle strabismus and all muscles had marked limitation of excursion in its field of action. This complication of ocular surgery or trauma, unlike the slipped muscle which has its empty capsule attached to the sclera, is characterized by the absence of any attachment of the muscle or its capsule to the sclera. Eleven of the 25 muscles were retrievable largely because of attachments through intermuscular septum to adjacent oblique muscles. The remaining 14 muscles were considered irretrievable, and these patients underwent a muscle transposition procedure. The clinical features and surgical repair of the lost muscle are described and compared with those of the slipped muscle.

Complications, adverse events, and additional intraocular surgery 1 year after cataract surgery in the infant Aphakia Treatment Study.

PURPOSE To compare rates and severity of complications between infants undergoing cataract surgery with and without intraocular lens (IOL) implantation. DESIGN Prospective, randomized clinical trial. PARTICIPANTS The Infant Aphakia Treatment Study (IATS) is a randomized, multicenter (n = 12) clinical trial comparing treatment of aphakia with a primary IOL or contact lens in 114 infants with unilateral congenital cataract. INTERVENTION Infants underwent cataract surgery with or without placement of an IOL. MAIN OUTCOME MEASURES The rate, character, and severity of intraoperative complications (ICs), adverse events (AEs), and additional intraocular surgeries (AISs) during the first postoperative year in the 2 groups were analyzed. RESULTS There were more patients with ICs (28% vs. 11%; P = 0.031), AEs (77% vs. 25%; P<0.0001), and AISs (63% vs. 12%; P<0.0001) in the IOL group than the contact lens group. Iris prolapse was the most common IC. The most common AE was visual axis opacification, and the most common additional intraocular reoperation was a clearing of visual axis opacification. CONCLUSIONS The rates of ICs, AEs, and AISs 1 year after surgery were numerically higher in the IOL group, but their functional impact does not clearly favor either treatment group. FINANCIAL DISCLOSURE(S) The author(s) have no proprietary or commercial interest in any materials discussed in this article.