Intraocular lenses for infants?

IOLs have become the standard optical treatment following cataract surgery in children 12 months of age and older.

Their use during the first year of life remains controversial, however. Currently, implanting IOLs in infants is an off-label use of these lenses.

In a point-counterpoint debate on implantation of IOLs in neonates, Scott R. Lambert, MD, professor of ophthalmology, Emory University, Atlanta, said that a growing body of literature is reporting favorable visual outcomes after IOL implantation in young children and that there are many other advantages as well.

Dr. Lambert began the debate by noting that there are a number of reasons why IOLs might be better than contact lenses for treating young children.

"The first is that you're assured that there is a partial optical correction at all times for these children," Dr. Lambert said. "If a child is left aphakic and [doesn't] wear [the] contact lens, [there is no correction], and this can result in very severe amblyopia.

"The second reason is that IOLs more closely approximate the optics of the crystalline lens," he continued. "This is particularly true for children who have unilateral aphakia. If you have a very high-powered contact lens of +25 to 35 D, it can induce up to 12° to 17° of angular magnification, and this induced aniseikonia may interfere with the development of binocularity in these children."

Another advantage of IOL use in infants is in-the-bag capsular fixation. IOLs implanted into the capsular bag at the time of cataract surgery are less likely to become decentered or erode into the uveal tissue, Dr. Lambert said. Although it is possible to implant secondary IOLs when children are older, it is more difficult to place them in the capsular bag, and in most cases they will have to be placed in the sulcus, where decentration is more likely.

Pseudophakia also saves time, Dr. Lambert said, adding that some parents have recounted spending up to an hour a day trying to place aphakic contact lenses in their children's eyes, and that removal can also require significant time. He said he also knows of a few parents who have resorted to bringing their children to the doctor's office once a week to have the lenses removed, cleaned, and reinserted. IOLs, in contrast, do not require ongoing care by parents.

Yet another important argument in favor of IOL implantation in infants is the likelihood of superior visual outcomes, a finding observed in several small, nonrandomized studies. The results of an ongoing clinical trial, the Infant Aphakia Treatment Study (IATS), should determine which treatment has the better visual outcome, Dr. Lambert said. IATS was sponsored by the National Institutes of Health to investigate the advantages and disadvantages of implanting an IOL in an infant's eye after unilateral cataract surgery.