Long-term Effect of Intraocular Lens vs Contact Lens Correction on Visual Acuity After Cataract Surgery During Infancy

Abstract

IMPORTANCEAlthough intraocular lenses (IOLs) are often implanted in children, little is known whether primary IOL implantation or aphakia and contact lens correction results in better long-term visual outcomes after unilateral cataract surgery during infancy.OBJECTIVE To compare long-term visual outcomes with contact lens vs IOL correction following unilateral cataract surgery during infancy. DESIGN, SETTING, AND PARTICIPANTSThis multicenter randomized clinical trial enrolled 114 infants with a unilateral congenital cataract who underwent cataract surgery with or without primary IOL implantation between 1 and 6 months of age. Data on long-term visual outcomes were collected when the children were age 10.5 years (July 14, 2015, to July 12, 2019 and analyzed from March 30 through August 6, 2019. INTERVENTIONS Intraocular lens implantation at the time of cataract surgery.MAIN OUTCOMES AND MEASURES Best-corrected visual acuity using the electronic Early Treatment Diabetic Retinopathy Study (E-ETDRS) testing protocol. Analysis was performed on an intention-to-treat basis.RESULTS Best-corrected visual acuity was measured at age 10.5 years for 110 of the 114 patients (96%) enrolled as infants. The participants included 58 girls (53%) and 52 boys (47%). Overall, 27 of the children (25%) had good (logMAR 0.30 [Snellen equivalent, 20/40] or better) visual acuity in the treated eye (12 [22%] in the IOL group and 15 [27%] in the aphakia group), but 50 children (44%) had a visual acuity of logMAR 1.00 (Snellen equivalent, 20/200) or worse (25 [44%] in the IOL group and 25 [44%] in the aphakia group). The median logMAR acuity in the treated eye was similar in children randomized to receive an IOL at the time of cataract extraction (0.89; interquartile range [IQR], 0.33-1.43 [Snellen equivalent, 20/159]) and those who remained aphakic (0.86; IQR, 20/145]) (IQR, 0.30-1.46; P = .82). Although the overall difference in median visual acuity between the 2 groups was small, the estimate was imprecise (99% CI for the difference in medians was −0.54 to 0.47). CONCLUSIONS AND RELEVANCEAs in previous phases of the study, 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. Implanting an IOL at the time of cataract extraction was neither beneficial nor detrimental to the visual outcome.

Advisability of primary intraocular lens implantation for infants under 2: A systematic review and meta‐analysis

“…Vasavada et al reported that in their study, more infants in primary IOL group had documentable VA compared with aphakia group during early postoperative follow‐up, and this trend continued until age 5, namely the visual rehabilitation would be faster in primary IOL group, especially in early postoperative follow‐up 22 . However, in the IATS study, the VA was similar in the IOL group and the contact lens group at 1‐year, 6 4.5‐year 11 and 10.5‐year follow‐ups, 32 which could be explained by better compliance with wearing of contact lenses, spectacles and patches in the aphakia group. The IATS offered free contact lenses, spectacles and patches for the enrolled subjects thus, there were fewer financial barriers to adhering to the postoperative follow‐up protocol 41,42 .…”

“…The IATS reported the randomisation process and intervention deviation, and had no selective reporting and outcome data missing 11,30‐32 . The study of Qian 38 did not describe the approach of random sequence generation and potential intervention deviation.…”

“…Eleven studies were included. Among them, four studies reported data from the same RCT, The Infant Aphakia Treatment Study (IATS), 11,[30][31][32] from different aspect, five were retrospective studies [33][34][35][36][37] and another two were both RCTs. 22,38 Table 1 describes the characteristics of the 11 included studies that were published during 2001-2018.…”

Recent developments in the management of congenital cataract

“…Common complications of childhood cataract surgery include PCO (more precisely, Elschnig pearls proliferation and secondary membranes), despite posterior capsulorhexis (Figure 1E), aphakic or pseudophakic glaucoma, uveitis, pupil displacement and IOL decentration (5). Long-term visual outcome at 10 years and complication rates at 5 years seems similar after cataract extraction with or without primary IOL implantation (27,28).…”

Should intracameral triamcinolone acetonide become a mainstay in infantile cataract surgery?

“…Congenital cataracts are the leading cause of preventable blindness in children [1]. Well-timed surgical intervention may prevent deprivation amblyopia and result in good visual prognosis [2]. Despite advancements in the estimation of refractive outcome, surgical management, and the postoperative control of myopic shift and rehabilitation [3,4], late adverse events may jeopardize the result of the initial treatment [5,6].…”