Infant IOL Implants Do Not Improve, Worsen Visual Acuity, Study Finds

Implanting intraocular lenses (IOLs) after cataract surgery in infants is neither beneficial nor detrimental to long-term visual outcomes, according to a study published in JAMA Ophthalmology.

In this randomized clinical trial, researchers analyzed data from 110 patients between the ages of 1 and 6 months who underwent treatment for unilateral congenial cataracts. At an average age of 10.5 years, there was no statistically significant difference in visual acuity after surgery between those who did and did not receive IOLs.

Investigators determined best-corrected visual acuity using the electronic Early Treatment Diabetic Retinopathy Study (E-ETDRS) testing protocol. “Visual acuity outcomes were highly variable, with only 27 children (25%) achieving excellent visual acuity in their treated eye and 50 children (44%) having poor vision in the treated eye,” the authors said.

The researchers predicted visual acuity would be superior in the IOL group because these children would be wearing at least a partial correction for their treated eye at all times. Although IOLs are commonly used to help focus childrens’ eyes after cataract surgery, some ophthalmologists are reluctant to implant IOLs, concerned that the eyes may develop large refractive errors later in childhood. In addition, children have a greater risk of developing visual axis opacities after IOL implantation.

Of the 110 patients included in the study, 55 children made up the aphakia (lack of lens) group and the remaining 55 received IOL implants.

The researchers found “12 treated eyes (22%) randomized to receive an IOL and 15 eyes (27%) originally left aphakic had a visual acuity of 20/40 or better.” However, “25 eyes (44%) randomized to receive an IOL and 25 eyes (44%) eyes originally remaining aphakic had a visual acuity of logMAR 1.00 (Snellen equivalent 20/200) or worse (P = .97).”

Data also showed:

• Median logMAR acuity in the treated eye was similar in children randan IOomized to receive L (0.89; interquartile range [IQR], 0.33-1.43 [Snellen equivalent, 20/159]) and those who remained aphakic (0.86; IQR, 0.30-1.46 [Snellen equivalent, 20/145]) (IQR, 0.30-1.46; P = .82)
• Overall difference in median visual acuity between the 2 groups was small, but the estimate was imprecise (99% CI for the difference in medians was −0.54 to 0.47)

The researchers also found children in the aphakia group who continued to wear a contact lens to age 10.5 years had the best visual outcomes of the study group.

These findings, in addition to “the increased incidence of visual axis opacities developing in eyes with an IOL and the increased frequency of additional intraocular surgeries, led to our recommendation that IOLs not be routinely implanted in the eyes of children undergoing unilateral cataract surgery when aged 6 months or younger,” the researchers concluded.

Because children who continued to wear contact lenses were more likely to have private health insurance, the authors recommend future analyses to investigate the factors that influence contact lens wear.

“The extent to which these findings can be generalized to intervention by surgeons with less experience or children whose families cannot afford the costs associated with contact lens wear should be taken into consideration when deciding on a course of treatment for an infant with a unilateral congenital cataract,” they said.

Reference

Lambert SR, Cotsonis G, DuBois L, et al. Long-term effect of intraocular lens vs contact lens correction on visual acuity after cataract surgery during infancy [published online February 20, 2020]. JAMA Ophthalmol. doi: 10.1001/jamaophthalmol.2020.0006.