Contact Lens Correction of Aphakia in Children: A Report by the American Academy of Ophthalmology.

PURPOSE: To review the published literature to assess the visual outcomes and adverse events associated with the 2 most commonly used contact lenses for treating aphakia in children: silicone elastomer (SE) and rigid gas permeable (RGP). METHODS: Literature searches were last conducted in January 2018 in the PubMed, Cochrane Library, and ClinicalTrials.gov databases with no date or language restrictions. These combined searches yielded 167 citations, 27 of which were reviewed in full text. Of these, 10 articles were deemed appropriate for inclusion in this assessment and subsequently assigned a level of evidence rating by the panel methodologist. RESULTS: The literature search identified 4 level II studies and 6 level III studies. There were insufficient data to compare visual outcomes for eyes treated using SE lenses versus RGP lenses. Silicone elastomer lenses have the advantage that they can be worn on an extended-wear basis, but they were associated with more adverse events than RGP lenses. These adverse events included microbial keratitis, corneal infiltrates, corneal edema, corneal scars, lenses adhering to the cornea, superficial punctate keratopathy, lid swelling, and conjunctival hyperemia. The lens replacement rate was approximately 50% higher for RGP lenses in the only study that directly compared SE and RGP lenses. CONCLUSIONS: Limited evidence was found in the literature on this topic. Silicone elastomer and RGP contact lenses were found to be effective for treating aphakia in children. Silicone elastomer lenses are easier to fit and may be worn on an extended-wear basis. Rigid gas permeable lenses must be removed every night and require a more customized fit, but they are associated with fewer adverse events. The choice of which lens a practitioner prescribes should be based on the particular needs of each patient.

Iris Clip Lens Implantation with Novel Approach for Aphakia After Previous Filtration Surgery.

Purpose To present a novel and simplified surgical technique of Artisan lens implantation for intraocular lens luxation and aphakia in glaucoma patients with previous superior filtration surgery. Methods Analysis of 12 patients with a history of previous superior filtration surgery for glaucoma, who underwent artisan lens implantation. To allow lens manipulation and implantation without alteration of the filtration bleb, the main sclerocorneal incision was performed laterally and the Artisan lens was held in place for enclavation of the iris stroma via a superior corneal incision without disturbing the filtration bleb. Results Mean pre-operative visual acuity was 0.54 ± 0.85 LogMAR, and intraocular pressure (IOP) was 15.8 ± 7.7 mmHg. At the end of follow-up (11.6 ± 8.1 months), visual acuity had improved to 0.32 ± 0.57 LogMAR and intraocular pressure was 14.7 ± 5.4 mmHg. No disturbance of the filtration bleb was observed. Conclusions Artisan lens implantation can be performed successfully via a combined lateral and superior approach despite the presence of a filtration bleb at the 12 o'clock position.

Contact lens management of irregular corneas after traumatic aphakia: A pediatric case series.

PURPOSE: Pediatric patients account for 35% of all cases that present after ocular trauma and 20.9% of those result in a ruptured globe. When repairing the globe, the removal of the natural lens results in a significant change in refractive error and loss of accommodation. In addition, the eye can have scarring, irregular astigmatism, and changes to the ocular surface. Treatment and vision rehabilitation should be aggressive and done quickly to prevent amblyopia. Advanced lens designs are often needed to treat both the irregular ocular surface and the aphakia. Treatment options are often confounded with the usual issues of contact lens compliance, intolerance, and complications. CASE REPORT: This case series follows three aphakic pediatric patients through the contact lens fitting process after sustaining a ruptured globe that left them aphakic with residual irregular astigmatism and corneal scarring. Patient 1 is a 3-year-old Hispanic male fit with a bitoric gas permeable contact lens with irregular astigmatism and an elevated central corneal scarring. Patient 2 is a 12-year-old Caucasian male with minimal residual astigmatism fit in a multifocal soft contact lens. Patient 3 is an 8-year-old African American male fit with a hybrid contact lens that was needed to vault the irregular astigmatism and central corneal scarring. CONCLUSIONS: Treating patients with irregular corneas or aphakia can be challenging in their own right, but in combination are some of the most advanced specialty contact lens fittings. This case series followed three pediatric patients through the fitting process and demonstrated the options and challenges when fitting this unique patient population.

Stereopsis results at 4.5 years of age in the infant aphakia treatment study.

PURPOSE: To determine whether stereopsis of infants treated for monocular cataracts varies with the type of optical correction used. DESIGN: Randomized prospective clinical trial. METHODS: The Infant Aphakia Treatment Study randomized 114 patients with unilateral cataracts at age 1-7 months to either primary intraocular lens (IOL) or contact lens correction. At 4.5 years of age a masked examiner assessed stereopsis on these patients using 3 different tests: (1) Frisby; (2) Randot Preschool; and (3) Titmus Fly. RESULTS: Twenty-eight patients (25%) had a positive response to at least 1 of the stereopsis tests. There was no statistically significant difference in stereopsis between the 2 treatment groups: Frisby (contact lens, 6 [11%]; IOL, 7 [13%]; P = .99), Randot (contact lens, 3 [6%]; IOL, 1 [2%]; P = .62), or Titmus (contact lens, 8 [15%]; IOL, 13 [23%]; P = .34). The median age at surgery for patients with stereopsis was younger than for those without stereopsis (1.2 vs 2.4 months; P = .002). The median visual acuity for patients with stereopsis was better than for those without stereopsis (20/40 vs 20/252; P = .0003). CONCLUSION: The type of optical correction did not influence stereopsis outcomes. However, 2 other factors did: age at surgery and visual acuity in the treated eye at age 4.5 years. Early surgery for unilateral congenital cataract and the presence of visual acuity better than or equal to 20/40 appear to be more important than the type of initial optical correction used for the development of stereopsis.

[Retroiridal implantation of a Verisyse™ iris claw lens: refractive outcome and individualized intraocular lens constants]. / Retroiridale Implantation einer Verisyse(TM) Irisklauenlinse : Refraktive Treffsicherheit und Anpassung der Kunstlinsenkonstanten.

BACKGROUND: Evaluation of refractive predictability with retroiridal implantation of a Verisyse(TM) iris-claw lens (AMO) and optimization of the IOL-constants recommended by the manufacturer. PATIENTS AND METHODS: A retrospective study after retroiridal iris-claw lens implantation in the years 2007-2012 including 52 eyes of 50 patients with a lack of capsular support was carried out. Follow-up data was recorded on average 5 weeks after surgery. Demographic data, indications, accompanying diseases, biometrical data and refractive outcome were analysed and an individualization of the intraocular lens constants for the SRK/T-, Holladay-1, Hoffer-Q and Haigis-formula was carried out. RESULT: Indications for retroiridal implantation of a Verisyse(TM) lens were IOL luxation (32.7 %), complicated primary cataract surgery (25.0 %), secondary IOL Implantation (19.2 %), lens exchange (19.2 %) and luxation of the crystalline lens (3.8 %). Accompanying diseases were pancreatic diabetes (21.2 %), rheumatic diseases (7.7 %), homocystinuria (1.9 %), pseudoexfoliation of lens capsule (23.1 %), traumata (23.1 %), secondary glaucoma (23.1 %), proliferative diabetic retinopathy (9.6 %) and age related macular degeneration (5.8 %). Optimized IOL constants were an A-constant of 116.8 for the SRK/T formula, a surgeon factor (Holladay1) of 0.8, a pACD (HofferQ) of 4,4 and an a0 constant of 0,49 for the Haigis formula. Postoperative deviation of target refraction was within ± 2 D in 84.6 % of the eyes. CONCLUSION: The retroiridal Verisyse(TM) intraocular lens shows a broad spectrum of indications and achieves a good visual outcome. The previously published IOL constants show optimization potential due to the small number of cases.

The importance of the relationship between the position of the correcting lens principal planes (H'1-H'2) and principal planes (H1-H2) of the optical eye system--aphakic correction.

In the clinical refraction of the eye, aniseikonia and anisometropia are inevitably used terms. Image formation and its retinal size is the function of the power of the dioptric eye system. However, the correcting lens in front of the eye and the eye optical system represent a unique optical afocal system, in which the distance between correcting lens and corneal vertex is of utmost importance, since it determines the size (together with appropriate correcting lens) of the retinal image. In the case of a monoculus, the size of the retinal image is not important. But, when correcting one eye while the other is emmetropic, it is important to correct it in the way that the image of the corrected eye does not produce considerable aniseikonia as a consequence of anisometropia. The authors hereby present mathematical calculation proving that if the principal point of the correcting lens P'2 is in the F1 of the emmetropic eye, meaning that? is equal to the front focal length of the emmetropic eye, there is no change in the refractive eye system, i.e. it becomes emmetropic and there is no change in the size of the retinal image. It means that an ideal position of the correcting lens in front of the eye guarantees no aniseikonia even in the extreme case of monocular aphakic spectacle correction.

Traumatic anterior dislocation of the crystalline lens and its surgical management.

This paper reports a case of a 57-year old female who had sustained a blunt ocular trauma resulting in anterior dislocation of the crystalline lens and acute painful visual loss in the left eye. The patient was managed with anterior chamber intracapsular phacoemulsification through a small anterior capsulotomy, pars plana vitrectomy, and surgical iridotomy. Aphakia was corrected by a contact lens. Two months after the surgery, the best corrected visual acuity was 0.9 in the left eye. The vision and retina remained stable in her follow-up examination 1 year later. Anterior dislocation of the crystalline lens can cause severe complications so that dislocated lens should be removed immediately.

Intralenticular bimanual irrigation: aspiration for subluxated lens in Marfan's syndrome.

We describe a new technique of aspiration of subluxated lens in young patients with Marfan's syndrome. Two small circular anterior capsulorhexis (1.5 mm to 2.0 mm) openings were created, and bimanual irrigation/aspiration was performed by introducing the irrigation cannula through 1 capsular opening and the aspiration cannula through the other. The irrigation cannula served the dual purpose of hydrating the lens matter and holding the lens in central position to ensure complete aspiration of the lens matter. The lens capsule was later removed and anterior vitrectomy performed by a vitrectomy cutter. This new technique of intralenticular irrigation/aspiration is effective and safe in performing lens aspiration in extensively dislocated crystalline lens in Marfan's syndrome.

[Secondary glaucoma in patients with lens subluxation or luxation]. / Jaskra wtórna u chorych z podwichnieciem lub zwichnieciem soczewki.

AIM: To estimate the frequency of secondary glaucoma appearance and the influence of surgical treatment on intraocular pressure (IOP) in patients with posterior lens dislocation. MATERIAL AND METHODS: The study concerned 152 patients (57 females and 95 males, age range: 19 to 91 years, mean--58 years). Secondary glaucoma was found in 62 patients (41%). Trauma was the cause of lens dislocation in 81% of these cases, while it was the cause in only 69% of cases in the whole material. Pars plana vitrectomy with limbal intracapsular lens extraction or lentectomy were performed in all cases. In 24 cases perfluorocarbon liquid was used. Scleral fixation PC IOLs were implanted in 85 eyes (group A), AC IOLs in 27 eyes (group B), and 40 eyes remained aphakic (group C). The follow-up time ranged from 6 months to 5 years, mean 22 months. RESULTS: Raised IOP was found preoperatively in 46 cases (30.3%). It was raised in 21 (24.7%) eyes in group A (24-60 mm Hg, mean 37.1 mm Hg), and it has normalized postoperatively in 14 eyes, while topical medication was necessary in 7 remaining cases. In group B raised IOP (26-60 mm Hg, mean 41.4 mm Hg) was found preoperatively in 8 (29.6%) eyes. It has normalized postoperatively in 5 eyes, while topical medication was necessary in 3 eyes. The respective values in group C were: 17 (42.5%), 24-80 mm Hg, mean 43.2 mm Hg. In 7 eyes IOP was normal after surgery, 10 patients required topical treatment, and in 3 of these cases trabeculectomy had to be performed. In 16 eyes with normal preoperative IOP it has raised postoperatively in different periods of time (from 1 week to 6 months). CONCLUSIONS: Secondary glaucoma is a frequent complication of the posterior lens dislocation, and it is more often related with traumatic cases. The dislocated lens removal with the use of vitrectomy causes IOP normalization in most of the cases. The periodical examination of IOP is necessary after the dislocated lens removal also in cases with normal preoperative IOP, because secondary glaucoma may appear in different time after surgery.

[Intraocular correction of aphakia after cataract extraction for uveitis in adolescents]. / Korekcja wewnatrzgalkowa afakii po usunieciu zacmy wiklajacej zapalenie blony naczyniowej u mlodziezy.

PURPOSE: To demonstrate 3 cases with pediatric pseudophakia after cataract extraction as a complication of unilateral uveitis. MATERIAL AND METHODS: The boys were at the age of 8, 11 and 15 years at the moment of surgery. Uveitis was monocular, the etiology unknown and clinically significant cataract was diagnosed after several months from the beginning of inflammation. The last recurrence of uveitis was observed 1 to 6 months before operation. There were intermediate uveitis (2 cases) and anterior uveitis (1 cases). In 2 eyes PMMA implant was placed in-the-bag and in one eye in the ciliary sulcus. During surgery we did not observe any complications except greater tendency to bleeding. Follow-up after operation ranged from 1.5 to 2.5 years. RESULTS: Visual acuity before cataract extraction was 0.01; 0.04 and 0.02 and during last visit after surgery it was 0.9, 0.6 and 0.4 respectively. Postoperative near distance visual acuity was 0.5, 0.75 and 1.25. We observed cystoid macular oedema in the latter case. Two months after PC-IOL implantation the symptoms of mild inflammation in the eye of 15-year-old boy with anterior uveitis occurred. Intraocular pressure before and after operation ranged from 12 to 17 mm Hg. Corneal central endothelial cell density was from 2850/mm2 to 3100/mm2 before and from 2469/mm2 to 2979/mm2 during last visit. CONCLUSION: Cases of posterior pseudophakia during uveitis in children showing good functional and anatomical state of eyes in the long term observation after IOL implantation recommend the intraocular correction in carefully selected uveitic pediatric patients.

Management of pediatric aphakia with silsoft contact lenses.

PURPOSE: To evaluate the performance of silicone elastomer lenses in pediatric eyes with aphakia. METHODS: We retrospectively studied pediatric aphakic eyes fit with Silsoft lenses (elastofilcon A, Bausch & Lomb) at the L.V. Prasad Eye Institute, India. RESULTS: Seventy-four children (106 eyes) with a median age of 9.0 months (range: 1 month to 12 years) were included in the study. Congenital cataract was the pre-existing pathology in 84 eyes. Lenses were fit between 1 week and 5 years following surgical intervention (median: 25 days). The most frequently used base curves were 7.5 mm (n=46 eyes) and 7.7 mm (n=39 eyes); lens diameter was 11.3 mm (n=103 eyes). Satisfactory fit was achieved in 86 eyes (81.1%). One-week extended wear was the most commonly recommended mode of wear (n=95 eyes). Lenses (n=118) were replaced for change of power, lens loss, and deposits or damage. Lenses were worn for > or =6 months in 68 eyes (64.2%). Twenty-three contact lens related adverse events occurred, all of which resolved uneventfully. On survival analysis, the probability of not having a lens related complication was 75.5% (95% CI; 61.5-89.5) at 24 months. CONCLUSIONS: In the management of pediatric aphakia, Silsoft lenses are safe, provide satisfactory optical correction, and are easy to handle. Limited availability and the financial costs associated with frequent lens replacement are limitations in our socioeconomic circumstances.

Contact lens correction of patients with Marfan syndrome.

BACKGROUND: Marfan syndrome, a genetic connective tissue disorder, manifests many problems: high myopia, astigmatism, crystalline lens subluxation, and cataracts. No published studies have described the contact lens corrections that can be used with Marfan syndrome patients. This report describes the variety of contact lens modalities used for a subpopulation of patients with Marfan syndrome. METHODS: The clinical records of eight patients with Marfan syndrome (16 eyes) from two hospital-based contact lens practices were retrospectively reviewed. Seven different contact lens modalities were used for this subpopulation. RESULTS: Mean unaided visual acuities were 20/296, while mean best-corrected optimal spectacle refraction visual acuities were 20/33. Contact lenses improved the mean visual acuity to 20/27. Patients wore the contact lenses for an average of 12 hours per day. Complications of contact lens wear occurred in approximately 70% of eyes and included neovascularization, giant papillary conjunctivitis, 3 and 9 o'clock staining, and central superficial punctate staining. Additionally, ocular non-contact lens-related complications occurred in 50% of patients. CONCLUSIONS: A variety of contact lens designs may be used during the care of patients with Marfan syndrome. However, patients may experience an increased rate of complications associated with contact lens wear or unrelated to lens wear, and thus they deserve more intensive follow-up care than non-Marfan syndrome patients.

Clinical assessment of Holo-Or trifocal diffractive contact lens.

PURPOSE: To evaluate the objective and subjective performance of the Holo-Or multifocal contact lens, a new rigid gas permeable (RGP) trifocal diffractive contact lens. METHODS: Eleven experienced and two non-experienced RGP contact lens wearers participated in the study. Eleven patients were presbyopic (age range: 40-57 years) and two were aphakic (ages: 12 and 14 years). Each patient was evaluated by comparing best spectacle correction to Holo-Or multifocal contact lens correction, using the following tests of visual function: visual acuity at 6 m, 80 cm, and 40 cm; contrast sensitivity at near and distance; and depth of focus. RESULTS: No significant differences were found between best spectacle correction and the Holo-Or contact lenses. When using the contact lenses, there was an improvement in depth of focus and a small reduction in contrast sensitivity compared with best spectacle correction. Overall satisfaction and comfort was good to excellent in ten of thirteen patients. CONCLUSIONS: Holo-Or trifocal diffractive contact lenses are a satisfactory means of optical correction for patients with presbyopia or accommodative problems.

A ray tracer for ophthalmological applications.

Ray tracing with a personal computer allows realistic simulation of optical properties of the human eye. Patterns of point sources are used as objects. The path of light rays is calculated between the point source and the retina for a Gullstrand eye model with improved parameters; the normal eye model has a resolution limit close to the natural resolution limit of the human eye. The image formed on the retina is projected back to a screen at the distance of the object so as to simulate image interpretation by the brain. Refractive errors are modeled by a change in eye parameters and corrected by eyeglasses or/and contact lenses or by an artificial intraocular lens. For optic correction the parameters of seeing aids can be fitted automatically by a least-squares routine. The effect of faulty eye correction on image quality is visualized by using a photograph of a realistic scene as an object.

Improvement in visual acuity in children with ectopia lentis.

The early development of vision in an eye with a dislocated lens is often poor, leading to disappointing postoperative results due to amblyopia. A retrospective review of the best corrected visual acuity of 49 eyes of 27 children with ectopia lentis, who were rendered aphakic either spontaneously or by lensectomy, showed a gradual improvement. Nineteen eyes achieved an early postoperative acuity of 6/12 or better. Of the remaining 30 eyes, 21 were followed up for 1 or more years. During this period, an improvement of two or more Snellen visual acuity lines was noted in all but one of the eyes.