February 2011




Infants' eye view: Contact lenses versus IOLs for aphakia

by Maxine Lipner Senior EyeWorld Contributing Editor



Study shows fewer complications with contacts

For aphakic infants, contact lenses may provide equally good acuity with fewer complications, according to Scott R. Lambert, M.D., professor of ophthalmology and pediatrics, 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 infants who received IOLs.

These days, use of IOLs in children has become commonplace. "Over the years there have been more children treated with intraocular lenses even though that's not approved by the FDA," Dr. Lambert said. "I think that nearly all ophthalmologists now treat children who are 2 years and older with intraocular lenses." It is not this toddler age group that is so much in question, however. "The controversy has always been in the really young children 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 complications and reoperations."

Considering an IOL trend

Investigators were spurred by this trend of using IOLs in younger children. "There was interest in surgeons 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 removal of a unilateral congenital cataract. Infants who did not undergo primary IOL implantation received 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 statistically the same in the contact lens and the intraocular lens patients," Dr. Lambert said. "However, the children who had intraocular lenses had more complications intraoperatively and required more additional surgeries after the original procedure." At the 1-year mark, results showed that 16% of IOL recipients experienced one or more intraoperative 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 compared 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 contact lens group. The most common complications were lens reproliferation, development 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 intraocular operations compared with only 12% of contact lens recipients.

Clinical considerations

Dr. Lambert sees the clinical implications here as fairly clear-cut. "I think that surgeons should be very careful putting intraocular lenses in babies because there are additional risks involved," he said. "Certainly, inexperienced surgeons should not be doing this." He acknowledged that these results are preliminary, however. "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 before performing the surgery," Dr. Lambert said.

He hopes that others come away from the study with the understanding that for infants with aphakia, contact lenses are a very viable option. "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 insurance 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 happens 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 children until they are 5 years old, so one group might end up doing a lot better or worse over time."

Editors' note: Dr. Lambert has financial interests with Bausch & Lomb (Rochester, N.Y.).

Contact information

Lambert: 404-778-3709, slamber@emory.edu

Contact lenses versus IOLs for aphakia Contact lenses versus IOLs for aphakia
Ophthalmology News - EyeWorld Magazine
283 110
216 143
True, 2