Faculty Bibliography

PURPOSE/OBJECTIVE:To compare rates and severity of complications between infants undergoing cataract surgery with and without intraocular lens (IOL) implantation. DESIGN/METHODS:Prospective, randomized clinical trial. PARTICIPANTS/METHODS:The Infant Aphakia Treatment Study (IATS) is a randomized, multicenter (n = 12) clinical trial comparing treatment of aphakia with a primary IOL or contact lens in 114 infants with unilateral congenital cataract. INTERVENTION/METHODS:Infants underwent cataract surgery with or without placement of an IOL. MAIN OUTCOME MEASURES/METHODS:The rate, character, and severity of intraoperative complications (ICs), adverse events (AEs), and additional intraocular surgeries (AISs) during the first postoperative year in the 2 groups were analyzed. RESULTS:There were more patients with ICs (28% vs. 11%; P = 0.031), AEs (77% vs. 25%; P<0.0001), and AISs (63% vs. 12%; P<0.0001) in the IOL group than the contact lens group. Iris prolapse was the most common IC. The most common AE was visual axis opacification, and the most common additional intraocular reoperation was a clearing of visual axis opacification. CONCLUSIONS:The rates of ICs, AEs, and AISs 1 year after surgery were numerically higher in the IOL group, but their functional impact does not clearly favor either treatment group. FINANCIAL DISCLOSURE(S)/BACKGROUND:The author(s) have no proprietary or commercial interest in any materials discussed in this article.

BACKGROUND:The Infant Aphakia Treatment Study is a randomized trial that compares the treatment of unilateral congenital cataract with primary intraocular lens (IOL) implantation versus aphakic contact lens (CLs). The purpose of this study was to compare the outcomes for infants with lens opacity associated with persistent fetal vasculature (PFV) to those without. METHODS:Retrospective subgroup analysis of grating visual acuity at 1 year of age and adverse events up to 1 year after surgery in eyes identified intraoperatively as having evidence of mild PFV from the IATS. RESULTS:Of 83 infants, 18 (22%: 11 CL, 7 IOL) had PFV. Median logMAR visual acuity was 0.88 for patients with PFV and 0.80 for patients without PFV (P = 0.46). One or more adverse events up to 1 year after surgery occurred in 12 infants (67%) with PFV and 30 infants (46%) without PFV (P = 0.18). The incidence of adverse events was significantly greater in patients with PFV compared with patients without PFV in the CL group (55% vs 20%, P = 0.049) but not in the IOL group (86% vs 71%, P = 0.65), possibly because all children receiving IOLs had greater rates of adverse events when compared with aphakic children (73% vs 29%, P < 0.001). CONCLUSIONS:Aphakic infants with mild PFV treated with CL had a greater incidence of adverse events after lensectomy compared with children with other forms of unilateral congenital cataract; nevertheless, similar visual outcomes at 1 year after surgery were obtained.

OBJECTIVE:To compare the visual outcomes and adverse events of contact lens with primary intraocular lens (IOL) correction of monocular aphakia during infancy. METHODS:In a randomized, multicenter (12 sites) clinical trial, 114 infants with a unilateral congenital cataract were assigned to undergo cataract surgery between 1 to 6 months of age either with or without primary IOL implantation. Contact lenses were used to correct aphakia in patients who did not receive IOLs. Grating visual acuity was tested at 1 year of age by a masked traveling examiner. MAIN OUTCOME MEASURE/METHODS:Grating visual acuity at 1 year of age. RESULTS:The median logMAR visual acuity was not significantly different between the treated eyes in the 2 groups (contact lens group, 0.80; IOL group, 0.97; P = .19). More patients in the IOL group underwent 1 or more additional intraocular operations than patients in the contact lens group (63% vs 12%; P < .001). Most of these additional operations were performed to clear lens reproliferation and pupillary membranes from the visual axis. CONCLUSIONS:There was no statistically significant difference in grating visual acuity at age 1 year between the IOL and contact lens groups; however, additional intraocular operations were performed more frequently in the IOL group. APPLICATION TO CLINICAL PRACTICE/CONCLUSIONS:Until longer-term follow-up data are available, caution should be exercised when performing IOL implantation in children aged 6 months or younger given the higher incidence of adverse events and the absence of an improved short-term visual outcome compared with contact lens use.

OBJECTIVE:To compare the use of contact lenses and intraocular lenses (IOLs) for the optical correction of unilateral aphakia during infancy. METHODS:In a randomized, multicenter (12 sites) clinical trial, 114 infants with unilateral congenital cataracts were assigned to undergo cataract surgery with or without IOL implantation. Children randomized to IOL treatment had their residual refractive error corrected with spectacles. Children randomized to no IOL treatment had their aphakia treated with a contact lens. MAIN OUTCOME MEASURES/METHODS:Grating acuity at 12 months of age and HOTV visual acuity at 4 1/2 years of age. APPLICATION TO CLINICAL PRACTICE/CONCLUSIONS:This study should determine whether either treatment for an infant with a visually significant unilateral congenital cataract results in a better visual outcome. RESULTS:Enrollment began December 23, 2004, and was completed January 16, 2009. The median age at the time of cataract surgery was 1.8 months. Fifty patients were 4 to 6 weeks of age at the time of enrollment; 32, 7 weeks to 3 months of age; and the remaining 32, more than 3 to less than 7 months of age. Fifty-seven children were randomized to each treatment group. Eyes with cataracts had shorter axial lengths and steeper corneas on average than the fellow eyes. CONCLUSIONS:The optimal optical treatment of aphakia in infants is unknown. However, the Infant Aphakia Treatment Study was designed to provide empirical evidence of whether optical treatment with an IOL or a contact lens after unilateral cataract surgery during infancy is associated with a better visual outcome.

OBJECTIVE:To report the effect of weakening the superior rectus and inferior oblique (IO) muscles on ocular rotations. DESIGN/METHODS:Observational case series. We reviewed a 10-year period of medical records of consecutive patients who underwent bilateral 5- to 11-mm (mean, 8.0 mm; SD, 1.1 mm) superior rectus muscle recessions combined with an IO muscle recession, myectomy, or anterior transposition. The effects on ocular rotations and eyelid position were recorded for the 37 patients (69 eyes) who were followed up for at least 6 months postoperatively. Nonparametric 1-way analysis of variance was used to compare results across the 3 procedures. The setting was a subspecialty practice at an academic institution. RESULTS:Supraduction deficiency was significantly associated with transposition of the IO muscle anterior to the inferior rectus muscle insertion compared with the standard IO muscle recession (P = .001), and IO muscle myectomy (P = .009). Y-pattern exotropia occurred more frequently after transposition of the IO muscle anterior to the inferior rectus muscle insertion than other weakening procedures (P<.001). CONCLUSION/CONCLUSIONS:Transposition of the IO muscle anterior to the inferior rectus muscle insertion, combined with ipsilateral superior rectus muscle recession, results in more supraduction deficiency and more frequent Y-pattern exotropia compared with standard IO muscle recession.

PURPOSE/OBJECTIVE:To report 14 cases (28 eyes) of cataract associated with type-1 diabetes mellitus in young children and adolescents. METHODS:Retrospective review of the medical records of 14 patients from seven institutions. All patients under the age of 18 years who met the inclusion criteria of type-1 diabetes mellitus and cataract were included. RESULTS:Mean age at the time of diabetes diagnosis was 9.8 years (range, 0.5-14 years), and mean age at cataract diagnosis was 11.7 years (range, 5-16 years). Two patients presented with cataracts one month before the diagnosis of diabetes; seven after the diagnosis of diabetes; and in five patients the cataract was found at the time the diabetes was diagnosed by the pediatrician. Nineteen out of 23 operated eyes had a best corrected post operative visual acuity of 20/40 or better. Two patients (4 eyes) developed diabetic retinopathy postoperatively. CONCLUSIONS:Although cataract formation in type-1 diabetes is rare, it is treatable and potentially sight-saving in young children and adolescents.

BACKGROUND:Oculocerebrorenal syndrome is an X-linked recessive hereditary oculocerebrorenal disorder characterized by congenital cataract, mental retardation, and Fanconi syndrome of the proximal renal tubules. Other ocular findings include glaucoma, corneal opacity (keloid), enophthalmos, and hypotonia. OBJECTIVE:To describe the treatment of 7 patients (14 eyes) with bilateral cataracts associated with oculocerebrorenal syndrome. Method Retrospective review. RESULTS:Seven patients with oculocerebrorenal syndrome had visually significant bilateral cataracts detected on their first full ophthalmic examination. All underwent bilateral cataract surgery. The mean age (of 14 eyes) at cataract extraction was 1.25 (median, 1.1) months. Glaucoma diagnosis and treatment were more variable. The mean age (of 11 eyes) at glaucoma diagnosis was 24.1 (range, 0.2-70.0) months: the mean age was 0.2 month (of 4 eyes) when glaucoma was diagnosed before cataract extraction, and the mean age was 37.7 months (of 7 eyes) when glaucoma was diagnosed after cataract extraction. All eyes were followed up for a mean of 100.8 (range, 38-190) months. Main Outcome Measure Treatment of 7 patients (14 eyes) with bilateral cataracts associated with oculocerebrorenal syndrome. CONCLUSIONS:Early identification and surgical removal of cataracts is recommended in patients with oculocerebrorenal syndrome. Despite this, visual acuity results will only rarely be better than 20/70, and nystagmus is likely. Patients should be monitored closely and regularly for changes in intraocular pressure, optic nerve cupping, and refractive error to rule out the development of glaucoma.