March 17, 2014

Options After Infant Cataract Surgery

A child's eye. A child wearing a contact lens. A green dye is used to evaluate the fit of hard lenses.Dr. Scott Lambert, Emory

For most infants, the use of contact lenses for several years after cataract surgery may be a better approach than immediately implanting an artificial lens, according to new results.

A cataract is a clouding of the eye’s lens. Although cataracts are often tied to aging, each year an estimated 1,200-1,600 infants nationwide are diagnosed with congenital cataracts (present from birth). This condition can affect both eyes, but it often affects just one, known as a unilateral cataract.

Cataracts can be removed through a safe, quick surgical procedure. After removal, most adults and children receive a permanent artificial lens, called an intraocular lens (IOL). This is an option for infants, too. IOLs can spare babies—and their parents—the discomfort of daily contact lens changes. They also reduce the risk of introducing germs into the eye.

But the use of IOLs in infants has some drawbacks. Because infancy is a time of rapid eye growth, surgeons may have difficulty judging the right focusing power of the lens. And while IOLs are typically safe and complication-free for adults, they’re more likely to cause postoperative problems for infants.

Funded in part by NIH’s National Eye Institute (NEI), researches began a large study in 2004 to compare the use of IOLs and contact lenses to treat congenital unilateral cataract in infants. Parents visiting 12 participating clinical centers were informed about the study, and about the potential benefits and risks of cataract surgery with and without an IOL. The team enrolled 114 infants who were between 1 to 6 months old at the time of surgery. About half the infants were randomly assigned to receive an IOL, while the other half received contact lenses. The most recent data were published online in JAMA Ophthalmology on March 6, 2014.

The researchers found no significant differences in visual acuity between the 2 groups at age 1 or 4 1/2. However, there were more post-surgical complications and corrective surgeries in the IOL group. Complications led to additional eye surgeries among 41 (72%) of the infants in the IOL group, compared to 12 (21%) in the contact lens group. The most frequent complication was lens reproliferation, which is when lens cells left behind after cataract surgery migrate into the pupil and interfere with vision. By age 5, lens reproliferation occurred in 23 (40%) of infants in the IOL group, compared to only 2 infants (4%) in the contact lens group.

By age 5, nine children in the contact lens group developed minor eye infections that cleared up with antibiotic drops. In one child, a contact lens broke during wear. None of these issues had permanent effects on vision. Three infants in the contact lens group had IOLs implanted before age 5 because their families had difficulty with day-to-day contact lens changing and maintenance.

“When we began this study, the prevailing theory was that IOLs would be the better option for cataract in infants because they correct vision constantly, while contact lenses can be removed or dislodged from the eye. But our data suggest that if the family can manage it, contact lenses are the better option until the child gets older,” says lead investigator Dr. Scott Lambert of Emory University in Atlanta.

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References: Comparison of Contact Lens and Intraocular Lens Correction of Monocular Aphakia During Infancy: A Randomized Clinical Trial of HOTV Optotype Acuity at Age 4.5 Years and Clinical Findings at Age 5 Years. The Infant Aphakia Treatment Study Group, Lambert SR, Lynn MJ, Hartmann EE, Dubois L, Drews-Botsch C, Freedman SF, Plager DA, Buckley EG, Wilson ME. JAMA Ophthalmol. 2014 Mar 6. doi: 10.1001/jamaophthalmol.2014.531. [Epub ahead of print.]. PMID: 24604348.

Funding: NIH’s National Eye Institute (NEI) and Research to Prevent Blindness.