March 2019


Presentation spotlight
Pediatric IOLs: 10 years on

by Stefanie Petrou Binder, MD, EyeWorld Contributing Writer

The study evaluated the long-term outcomes of in-the-bag single piece hydrophobic acrylic IOL implantation following congenital and developmental cataract surgery.
Source: Shail Vasavada, DO


Follow-up data reveal single piece in-the-bag IOL implantation in pediatric patients is safe, effective

Study outcomes on pediatric patients with implanted single piece IOLs are now available to help physicians understand the risks and benefits of IOL implantation in very young eyes.
According to the 10-year outcomes, in-the-bag implantation of a single piece hydrophobic acrylic AcrySof IOL (Alcon, Fort Worth, Texas) is safe and effective in the long term, with good uveal and capsular biocompatibility. Shail Vasavada, DO, Ahmedabad, India, one of the study’s co-investigators who presented the work at the 36th Congress of the European Society of Cataract and Refractive Surgeons (ESCRS), reported that visual axis opacification (VAO) in pediatric patients will usually become evident within 3 years of surgery and that glaucoma was more likely to develop in patients operated at a younger age, especially under the age of 1.

Long-term pediatric study

The study evaluated the long-term outcomes of in-the-bag single piece hydrophobic acrylic IOL implantation following congenital and developmental cataract surgery. The retrospective, observational case series of 71 eyes (37 patients) undergoing cataract surgery included cases with at least 10 years of postoperative follow up. It excluded eyes with microcornea, microphthalmos, and any co-existing ocular morbidity. The single surgeon implemented a standardized surgical technique involving manual anterior capsulorhexis, bimanual irrigation/aspiration, manual posterior capsulorhexis, limbal anterior vitrectomy, and the implantation of the in-the-bag single piece AcrySof IOL SA60AT.
Dr. Vasavada assessed outcomes over 10 years. At the final follow-up visit, postoperative complications were divided into: glaucoma, visual axis obscuration, secondary surgical interventions, and retinal detachment. Visual outcome was noted by the best spectacle corrected visual acuity.
The mean preoperative axial length was 21.1 ± 2.75 mm in the study eyes, the mean IOP was 13 ± 2.41 mm Hg, and the horizontal corneal diameter was 11.1 ± 0.94 mm, which were all within the normal range, he said. Additional patient information included:
• Mean patient age at surgery: 33 ± 30 months (range 2–111 months or 12 years)
• Mean follow-up duration: 126.7 ± 19.7 months (roughly 10 years)
• Median follow-up duration: 121 months (10 years)
• Children younger than 1 year of age at time of surgery: 32 eyes of 17 patients (45%)
• Children 6 months old or younger when operated: 20 eyes of 10
• Patients with unilateral cataract: 3
• Patients with bilateral cataract: 34
• Female patients: 14
• Male patients: 23
Cataracts among the study population varied morphologically.
• Lamellar cataracts: 40%
• Mixed morphology: 31%
• Membranous cataracts: 16%
• White cataracts: 12%
• Posterior polar/posterior subcapsular cataracts: 1%
Dr. Vasavada reported that almost 50% of the eyes had squint preoperatively, observed in 34 eyes out of the total of 71 eyes and absent in 37 eyes. Nystagmus was present in 16 eyes and absent in 55 eyes.

Intra- and postop complications

None of the eyes demonstrated major intraoperative complications. Posterior capsule plaque was noted in 3 eyes (4.2%) and preexisting posterior capsule defect was seen in 8 (11.2%). Vitrectomy was performed in 42 of the eyes (59.1%). The criteria for vitrectomy was patient age under 3 years, inadvertent vitreous face disruption, or the inability to perform laser capsulotomy in a child more than 3 years of age.
Despite vitrectomy, visual axis obscuration was seen, with significant VAO noted in 32 eyes (45%) and none in 39 eyes (55%). The patients underwent secondary membranectomy and Nd:YAG laser capsulotomy was done in 31 eyes (43.6%), while in 40 eyes (56.4%) it was not required. The mean duration from surgery to the secondary procedure was 22.31 ± 11.26 months; the median duration to the secondary procedure was 21 months. Six eyes (8.45%) needing a secondary procedure were younger than 1 year of age. Dr. Vasavada explained that the younger the eye, the greater the threat of visual obscuration.
In a different study that Dr. Vasavada performed involving VAO after cataract surgery and hydrophobic IOL implantation in pediatric patients less than 1 year of age, nearly 25% of the operated eyes of infants required a secondary surgical procedure for VOA. He found the rate was higher in female infants’ eyes but did not differ between IOLs. The data indicated that surgery for VAO was required later in eyes with SN60WF IOLs (Alcon) than in eyes in which other AcrySof IOLs were used.1
Regarding glaucoma development in this study group, 4 eyes of 3 patients developed glaucoma during the entire length of the follow-up period. The mean age at surgery for eyes developing glaucoma was 6.76 months. The glaucoma was well controlled with medications until the time of the last follow up, and none of the patients required any surgery.
None of the eyes in this series developed retinal detachment by the time of the 10-year follow up, and there was no incidence of IOL dislocation.
Retinal detachment was estimated at 5.5% within the first 10 years after cataract surgery in children with no known ocular and systemic anomalies, according to a recent retrospective consecutive interventional case series of 481 eyes of 295 children aged below 16 years who underwent lensectomy, posterior capsulorhexis, and anterior vitrectomy combined with IOL implantation with a median follow up of 66 months. The risk of retinal detachment significantly increases in male patients, myopic patients, and intellectually disabled children, the authors of the study maintained.2
In the current study, all of the eyes showed significant visual improvement from baseline. The visual acuity outcomes demonstrated a mean BSCVA of 0.44 ± 0.22 logMAR. The mean spherical equivalent of refraction was –0.62 ± 1.59 (range: 0 to –6.25 D), which meant a reasonably good prediction of the IOL power.
Axial length measurements showed the expected change of growing pediatric eyes. The preoperative axial length was 21.1 ± 2.75 mm, and postoperatively it was 23.7 ± 2.62 mm.


1. Trivedi RH, et al. Visual axis opacification after cataract surgery and hydrophobic acrylic intraocular lens implantation in the first year of life. J Cataract Refract Surg. 2011;37:83–7.
2. Agarkar S, et al. Incidence, risk factors, and outcomes of retinal detachment after pediatric cataract surgery. Ophthalmology. 2018;125:36–42.

Editors’ note: Dr. Vasavada has no financial interests related to his comments.

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