New Research Changes the Recommendation for Congenital Cataract Care in Infants

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For decades, parents of children born with congenital cataracts (a cloudiness of the lens that reduces vision from birth) were faced with a difficult choice.  If they did not have the cataract removed early on, the result was permanently reduced vision in the eye even if cataract surgery was performed at an older age because the eye was functionally occluded during it's prime years of visual development. However if they did remove the cataract, there was significant risk of complications with using intraocular lens implants (IOLs) at such a young age, and parents were often left with having to use high powered glasses in the affected eye until the child was older and could have a less risky IOL surgery implantation.  Both choices had major drawbacks -- a risky surgery or a child needing to wear bulky glasses with a high prescription in the affected eye that is left without a lens for several years.  Luckily research has provided us with new options, and the current recommendations from a 2014 study by the American Medical Association point towards contact lens use as being a great alternative in the pediatric aphakic patient until an IOL can be safely implanted.

Congenital cataract via
The research published in the Journal of American Medical Association Ophthalmology compared the visual outcome of infants with unilateral congenital cataracts treated with implantation of an intraocular lens immediately after removal of the cataract, or treatment with contact lenses until a child could more safely have an intraocular lens implanted.  The Infant Aphakia Treatment Study followed 114 infants with congenital cataracts in one eye removed surgically between age 1 and 6 months.  Study participants were enrolled randomly between 2 groups: 57 having immediate IOL implantation, and 57 using contact lenses for vision correction while aphakic (without a lens).

The Results:

At 12 months old, infants in both treatment groups had no statistically significant difference in visual acuity (measured with grating acuity).  The IOL group had more intra- and post-operative complications, higher cost of treatment (by 38%), and higher stress reported by parents or caregivers 3 months after surgery.

At 4.5-5 years old, children were again assessed.

Vision: The average visual acuity between both treatment groups had no statistically significant difference.  50% of children in both groups had "poor visual acuity" out of the treated eye (vision was equal to worse than 20/200 in that eye).  Twice as many children had "good visual acuity" (greater than or equal to 20/32) in the contact lens group compared to the IOL group; 23% of the contact lens group had good acuity versus only 11% of the IOL group.

Ocular Alignment: A high number of patients in both treatment groups had issues with strabismus (an eye turn) in the treated eye.  37% of children in the contact lens group and 43% in the IOL group had strabismus surgery by age 5.

Adverse Effects:  There was a significantly higher complication rate in the IOL group compared to the contact lens wearing group.  56% of contact lens wearing group had had at least 1 adverse event as compared to 81% of children in the IOL group with adverse events.  Glaucoma developed in statistically similar rates between each group.  Contact lens adverse events included corneal abrasion, ulceration, and infections, but none of these events resulted in corneal scars that were considered to impact visual acuity.  Three patients in the contact lens group had IOL implantation before age 5 due to issues with "the day to day contact lens changing and maintenance."

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Additional Surgeries:  At age 5 only 21% of the contact lens wearing group had to have additional intraocular surgery compared with 72% of the IOL group.  The most common surgical procedures were clearing the visual axis of opacity (lens reproliferation, hemorrhage), followed by glaucoma surgery.

Conclusions:
This study did not demonstrate any visual benefit of recommending IOL implantation at the time of infant cataract extraction as compared to leaving the child aphakic and correcting vision with a contact lens.  Due to the significantly higher risk involved with IOL implantation at such a young age, it should only be considered if there is a reason that parents or the child will have extreme difficulty with contact lens insertion, removal, or wear.

This quote from study author Dr. Scott R Lambert, MD sums it up nicely:
"We think that for most infants with unilateral cataract, contact lenses are a better option than an IOL," Dr. Lambert said. "However, in some cases, the parents and their physician may decide that contact lens wear proves to be too challenging, and ultimately not in the child's best interests."


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On a personal, today's post was inspired by a friend of the blog's recent battle with congenital cataracts in her newborn son.  Christina was featured back in 2013 as part of our local blogger sunglasses initiative, and her son, Thomas, has recently had successful bilateral congenital cataract removal.  Just like this study suggests, her doctor has recommended leaving Thomas aphakic and they are about to start with contact lens wear in the coming weeks.  If you want to follow along with Christina and Thomas, just check their blog for regular updates at Carolina Charm. We are wishing them the best in the next step of their journey!

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