Intraocular lens implantation in infants and toddlers in 2020

ABSTRACT

Introduction

Intraocular lens (IOL) implantation in an infant has been extensively debated with Infant Aphakia Treatment Study (IATS) (unilateral cataract; operated ≤7 months of age) and IOLunder2 trial (unilateral and bilateral cataracts; operated ≤2 years) strongly discouraging IOL implantation in infants and toddlers due to higher adverse events over 5 years.

Areas covered

Newer studies from developing countries demonstrated a lower incidence of complications, doubting the extrapolation of the results of a randomized controlled trial in developed countries to that of developing countries that face various multidimensional challenges including social, economic and attitudinal characteristics of caregivers. We studied the evidence supporting and against IOL implantation in infants and toddlers and conclude that implantation of IOL in these patients is a viable option, especially in developing countries due to lower rates of complications in carefully selected cases.

Expert opinion

This review suggests that an arbitrary age of six months is inadequate to decide whether to implant an IOL and requires a more comprehensive approach. New guidelines for patient selection for primary IOL implantation in infants and toddlers have been proposed, which include ocular factors such as biometry, coexisting ocular comorbidities, intraoperative risk factors, surgeon’s experience, and socio-economic considerations.

KEYWORDS:

• Infantile and toddler cataract
• intraocular lens implantation
• aphakia
• contact lens
• guidelines
• developing countries
• cost
• complications
• socioeconomic conditions

Acknowledgement

Hyderabad Research Eye Foundation (HERF)

Article highlights

• Implantation of IOL in infants and toddlers is a viable option, since recent studies from developing countries reported a lower rate of complications compared to randomized trials from developed countries which strongly discourage it.

• Age at surgery, patient selection criteria, setting of the study (randomized control study versus real world data), place of study (developed or developing country) or postoperative care could be potential reasons for the different outcomes of these studies.

• Optical correction of aphakia using glasses or contact lenses pose a peculiar challenge in developing countries due to their significant cost and lack of hygiene practices. The unique socioeconomic characteristics of developing countries further justify the need for a permanent remedy for visual rehabilitation in the form of IOL implantation to prevent risks of blindness or visual impairment in case of noncompliance to postoperative follow-up and treatment.

• An arbitrary cut-off age of six months at the time of surgery is inadequate to decide whether to implant an IOL and requires a more comprehensive approach

• A new set of guidelines based on the eligibility of the eye, surgeon’s experience and parental or family factors has been proposed for primary IOL implantation in infants and toddlers which consists of three set of criteria for IOL implantation, namely, (i) preoperative factors including biometry or any evidence of anterior segment dysgenesis; (ii) intraoperative factors including capsular support and intraocular hemorrhage and (iii) socioeconomic considerations such as poor economic condition with no insurance coverage, poor education and higher risk of being lost to follow-up.

Declaration of interest

The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.

Reviewer disclosures

Peer reviewers on this manuscript have no relevant financial or other relationships to disclose

Additional information

Funding

This paper was not funded.