This editorial written in response to an article on secondary IOL implantation in aphakic children emphasizes the importance of amblyopia management when treating pediatric cataract, particularly in unilateral cases.
The author notes that several features of the pediatric eye make the challenges of cataract surgery unique. While smaller incisions, better wound construction, the use of ophthalmic viscosurgical devices, improved posterior capsular management and progress toward better IOL design have all reduced complications and led to improved surgical outcomes in pediatric cataract, the major barrier to excellent functional visual outcomes, especially in unilateral pediatric cataract, remains amblyopia management. He says that none of these modifications can take the place of early cataract detection and management followed by visual rehabilitation and aggressive amblyopia therapy.
He writes that IOL selection also remains a significant challenge in pediatric cataract management. Whether or not to place an IOL primarily versus visual rehabilitation with aphakic spectacles or contact lenses has been, and remains, a controversy. A further dilemma revolves around the timing and final refractive goal of IOL implantation.
Strategies to objectively predict final refraction after pediatric IOL placement range from complex nomograms to tables based solely on patient age at the time of IOL implantation. However, there remains the occasional ‘refractive surprise,’ typically a large myopic shift. These unpredicted refractions might exacerbate anisometropia and add to the amblyopic burden.
Close attention to biometric measurements, especially axial length, is crucial. Ongoing research on postoperative IOL power change and lens replacement materials and devices may lead to a more predictable and stable refractive outcome. Additionally, many cataracts in children are associated with other ocular, neurologic and systemic disorders that may significantly affect final visual outcome.
The author says it is clear from early analysis of the data from the Infant Aphakia Treatment Study that better prevention and management of posterior capsule opacification in pediatric cataract is needed. Attention to the complete removal of all lens material is especially important. Strategies include primary posterior capsulectomy with or without limited anterior vitrectomy before or after IOL placement.
Alternatively, the posterior capsule may be left in place at the time of IOL placement and managed later by YAG capsulotomy or pars plana capsulectomy and vitrectomy. The success of YAG laser capsulotomy in children is extremely variable due to patient cooperation and the composition of the residual lens material. It is ideal to manage the posterior capsule at the time of initial surgery unless the surgeon is certain of the capsule’s clarity at the completion of the operation.
The author concludes that pediatric IOLs of the future should address several concerns: (1) safety and biocompatibility, (2) rapid visual recovery, (3) reduction in lens reproliferation and posterior capsule opacification, (4) restoration of accommodative function and (5) adjustability to account for physiologic and surprise refractive shifts.
He adds that it will be just as important to complement future technologic advances in IOLs with investigations on understanding and improving amblyopia therapy.