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Major Review Infantile : where are we now?

Praveen Kumar KV and Sumita Agarkar

Correspondence to: Introduction disorder but also helps in planning the manage- Dr. Sumita Agarkar, Pediatric cataract is one of the major causes of pre- ment. Based on morphology, pediatric – Deputy Director Pediatric ventable affecting approximately can be classified into cataracts involving the Department, 1 Sankara Nethralaya 200,000 children worldwide. In developing countries, entire , central cataracts, anterior cataracts, Medical Research Foundation the prevalence of blindness from cataractC is higher, posterior cataracts, punctate lens opacities, coral- 18, College Road, about one to four per 10,000 children. Early diag- line cataracts, sutural cataract, wedge shaped cata- Chennai - 600 006 nosis and treatment WWWis essential to prevent ract and cataracts associated with PFV. email: [email protected] the development of stimulus deprivation ambly- opia in these children. Cataract surgery in infants Preoperative evaluation poses greater challenges compared to young chil- History taking is an integral part in the evaluation dren. Primary implantation of an intraocular lens of an infant with . The history remains controversial for infants, and the selec- should include tion of an appropriate IOL power is difficult. The Family history of congenital or developmental management of infantile cataract has changed cataract, over the last decade. In this study, we present an 1. Antenatal history of maternal drug intake and overview of the changing concepts of cataracts in fever with rash. infants and its management. 2. Birth history should be specifically looked for Etiology of childhood cataract as bilateral congenital cataract is more The common causes of congenital cataract are common in preterm, low birthweight, small genetic, metabolic disorders, prematurity and intra- for gestational age children.5 uterine infections. Almost 60% of cases of congeni- 3. Developmental mile stones should be carefully tal cataract in developed countries are idiopathic.2 assessed. One-third of cases of congenital cataract are her- editary without any known associated systemic 4. History of visual interaction of the child with disease.3 The various causes of congenital cataract the family members should also be inquired are as it helps in determining the severity of visual dysfunction. 1. Heredity: These cataracts are usually auto- somal dominant but can be autosomal reces- 5. History of the onset of the opacities, progres- sive and x linked. sion and laterality is also important. Unilateral cataracts are isolated but are 2. Associated with genetic disorders: Seen in usually associated with other ocular abnor- downs and turners syndrome. malities like persistent fetal vasculature, lenti- 3. Metabolic disorders: Galactosemia, Hypocalcemia. conus, lentiglobus.6,7 4. Intrauterine infections: Toxoplasmosis, Rubella, Cytomegalovirus, Herpes, Varicella and Syphilis. Examination of the child Detailed ocular examination of the child can be 5. Associated Ocular conditions: , done either in an outpatient setting if the child is coloboma, lens coloboma, Lenticonus, cooperative or under general anesthesia when the Lentiglobus, Persistent fetal vasculature. child is being taken up for surgery. Quantification Next generation DNA sequencing shown prom- of visual acuity of the child as far as possible ising results in identifying mutations leading to should be done. In infants, fixation behavior, fix- metabolic abnormalities and cataracts. This new ation preference and resistance to occlusion gives technology has immense potential in identifying us a clue to the visual acuity. In young infants metabolic abnormalities and correct them with with poorly developed fixation, an undilated appropriate intervention. In future, this technology distant direct ophthalmoscopy can indicate whether is likely to become cheaper to allow testing in chil- the opacity is visually significant or not. Dense dren with non-syndromic bilateral cataracts with central opacities larger than 3 mm in diameter systemic manifestation and delayed development.4 usually need surgical removal.8 Examination of both the eyes has to be done to Morphology of pediatric cataract determine whether the cataract is unilateral or Morphology of pediatric cataract can not only bilateral. Unilateral cataract, even if mild can help in the diagnosis of specific associated cause irreversible deep if not treated.9

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Often the first symptom is a white or partially should be treated by appropriate glasses and patch- white reflex noted by the parents. and ing. Small opacities can be managed by prescribing should be specifically looked for in mydriatric agents to achieve a larger area of clear these children and sometimes these may be the visual axis. presenting signs. Strabismus is usually seen in children with unilateral cataracts and develops Timing of surgery when an irreparable visual loss has already Extraction of unilateral congenital cataracts by 4– occurred. The presence of manifest nystagmus at 6 weeks and bilateral cataracts within 6–8 weeks age of 2–3 months or elder generally indicates a of life can prevent the development of strabismus, very poor prognosis.10 The presence of either stra- nystagmus and amblyopia.14 bismus or nystagmus indicates that cataract is visually significant. How does an infant eye differ from the adult eye? Slit lamp biomciroscopy should be done to A child’s eye is unique and is different from an assess the size, location, density of the opacity. adult eye. The eyes are smaller in size at birth and Corneal diameters and intraocular pressure have have steeper . The normal new born eye has to be measured with a tonopen or Perkins hand a mean axial length of 16.6–17 mm.15 It reaches a held applanation tonometer. Indirect ophthalmos- mean adult value of 23.6 mm at 15 years age. More copy can reveal persistent fetal vasculature or other than half of this growth in axial length occurs posterior segment abnormalities that may affect the before 1 year age and most axial elongation occurs visual outcome. In cases where the media opacity during the first 2 years of life. The corneal curva- precludes examination of the fundus, a B scan ultra- ture reduces from 51.2 D in new borns to 43.5 D in sonography has to be performed to rule out other adults.16 The is thin and less rigid, the lens posterior segment pathologies that mimic congenital capsule is more elastic, and there is a risk of severe cataract. These conditions include retinoblastoma, postoperative inflammatory response. persistent hyperplastic primary vitreous, coats disease, ROP with retrolental fibroplasia, orgainzed Biometry in infants vitreous hemorrhage, congenital falciform fold, With advances in surgical techniques and instru- ocular toxocariasis and retinal hamartomas. mentation, several surgeons are implanting IOLs in Performing cataract surgery in these conditions is infants. Refractive growth after IOL implantation in disastrous and can lead one into medicolegal pro- infants cannot be predicted accurately and current blems. These children should be evaluated by a IOL formulae vary in their predictive outcomes. If r pediatrician to exclude systemic disorders or meta- target postoperative emmetropia, amblyopia treat- bolic causes causing cataract. ment is easier but this strategy results in high in later life. If we aim for hyperopia, ambly- Laboratory workup opia therapy and refractive correction in initial Most children with congenital cataract do not phase is difficult but thisstrategy has the advantage need systemic work up. Unilateral, familial, iso- of potentially achieving either emmetropia or low lated cataracts with no systemic association do myopia later in adulthood. The amount of hyper- not need any systemic investigations. Trauma opia will vary depending on the age of the child at should be ruled out in all cases of unilateral cata- the time of surgery. Most surgeons prefer to leave ract. A child with peculiar facies or systemic mal- infants with hyperopia as it’s easy to titrate as chil- formations like microcephaly, deafness, cardiac dren grow. IATS recommended an hyperopia abnormalities, developmental delayneed systemic ranging from +6 D to +8 D depending on the age of workup. The work up usually includes fasting infant at the time of surgery. It is important to blood sugar, urine for reducing substances for counsel parents regarding need for glasses post- galactosemia, aminoacids for Lowes syndrome. operatively as well as perhaps through the life. Plasma phosphorous, calcium levels, RBC transfer- Three important things to be considered when ase and galactokinase levels have to be assessed. determining the IOL power to be implanted in TORCH titers have to be done to rule out infec- infants are tious causes of cataract.11,12 1. Anticipated refractive shift. Management 2. Age of the patient. Indication for cataract surgery in infants depends 3. Target refraction in the immediate postoperative on the extent of its effect on the visual function. period. Mere presence of a lenticular opacity does not warrant surgical removal. Cataract which is incom- Children who are younger at the time of plete at birth, peripheral lens opacities, punctate surgery, have a significantly greater myopic shift opacities with intervening clear zones, opacities and greater variance in predictive refractive <3 mm in diameter can be kept under close follow change than older children. Crouch et al. in a up.13 Associated amblyopia in these children study of 52 eyes undergoing cataract surgery with

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IOL implantation found a mean myopic shift of result in greater posterior IOL displacement. 3.66 D in children operated on at 3–4 weeks age Implantation of high-power IOLs in these eyes, which reduced to 0.38 D in children operated on can increase the measurement and calculation at 15–18 years age.17 Most pseudophakic eyes errors as well as the errors induced by changes grow normally and so a significant shift after IOL in IOL position. Nihalani and Vanderveen in a implantation is expected in these children.18 retrospective study of 135 pediatric eyes that under- went cataract surgery and primary IOL implantation Postoperative refractive goal in infants found mean predictability of four formulae was In infants, implantation of IOL still remains con- comparable, with 57% of infants having a predic- troversial and several surgeons prefer to leave the tion error of more than 0.5 diopters.25 Greater pre- infants aphakic after cataract surgery.19 In the diction errors were seen in children <2 years, axial Infant Aphakia Treatment Study, the target length <22 mm and mean keratometry readings refractive error after IOL implantation was +8 for >43.5. The SRK II, SRK T and Holladay formulae infants 4–6 weeks of age and +6 for infants tended to overcorrect whereas Hoffer Q had an between 6 weeks to 6 months age.20 equal number of undercorrection and overcorrec- Keratometry and axial length measurements in tions. Kekunnaya et al. in their study on IOL children are usually less accurate compared to power calculation in children <2 years age found adults. These measurements are often obtained prediction errors were larger for all formulas but 26 under anesthesia in infants who do not cooperate SRK II had the least prediction error. In the for fixation. Mittelviefhaus et al. in their study Infant treatment study to determine the have shown that lack of fixation in children under predictability of IOL power calculation formulae in general anesthesia can result in inaccurate kerato- infants eyes, overall median absolute prediction metry measurements.21 However, the reliability error values appeared to be similar for the can be increased by averaging several readings per Holladay 1, Holladay 2 and SRK/T formulae (1.2 eye. D, 1.4 D and 1.3 D, respectively), and in paired Axial length is a more significant source of comparisons of SRK/T versus other formulae, the error in IOL power calculation. Inaccurate axial median paired differences in absolute prediction length measurement can account for 4–14 diop- error was more than zero, indicating greater accur- ters for each millimeter difference in IOL power.22 acy for the SRK/T formula. The study concluded Errors are often magnified because of shorter that Holladay I and SRK T formula gave good axial length. Immersion biometry is more predict- comparable results and have the best predictive able than contact method for IOL power calcula- value for infant eyes. The greatest prediction tion in infants.23 But the limitation of the errors in their study were seen in eyes with axial 27 immersion scan is that it cannot be used in small length of 18 mm or less. eyes and with shallow anterior chamber and other ocular anomalies as in infants. Partial Type of IOL to be implanted coherence interferometry can be used to measure There is a large debate regarding the type of IOL axial length in cooperative children with reliability to be implanted in infants. IOL implantation during 24 and accuracy. Advantages over conventional childhood may be associated with better visual ultrasound include high reproducibility, contact outcomes but in IOL implantation in infancy, free measurements, observer independence of the these potential advantages are offset by a higher measurements. The disadvantage is that it cannot incidence of intraoperative and postoperative be used in total cataracts which are more often adverse events. Additional intraocular surgeries encountered in children. are often required to treat these adverse events which are associated with risks, costs and parental IOL formula stress. Although it is agreed that cataract surgery Furthermore, no time tested formula exists for cal- during early infancy is associated with the best culation of IOL power in infants. The accuracy of visual outcomes, it remains undetermined whether each formula depends on optimized values and primary IOL implantation is advisable in this age measures of the formula components, including group. Ram et al. compared outcomes of hydro- factors such as actual anterior chamber depth, phobic acrylic and PMMA lenses in children <1 lens thickness, vertex distance, and use of a perso- year age and reported that complication rates were nalized surgeon factor or A-constant. The anterior comparable in both the groups. PMMA lenses may segment of an infant eye is significantly smaller, require early surgical intervention for PCO.28 The eyes with congenital cataract may have greater single piece acrylic hydrophobic IOL is a soft IOL anatomic variation in anterior segment structures and can be implanted in the smaller capsular bag and the anterior segment of an infant is propor- as in infants with relative ease. It also has the tionally larger to the posterior segment compared advantage of requiring a smaller incision thereby to an adult eye. The capsular bag of an infant eye allowing corneal incision leaving is smaller and will contract earlier, which may intact. However, single piece IOL cannot be placed

128 Sci J Med & Vis Res Foun October 2015 | volume XXXIII | number 3 | Major Review in sulcus. Silicon IOLs have also be implanted in socioeconomic factors and non-availability of young children, but are associated with more cap- contact lenses in smaller towns. So these infants sular contraction.29 will probably do better with IOL. Only rider is that lens be placed in the bag with appropriate capsu- Are IOLs good for infants? lar management and anterior vitrectomy to ensure This question has been debated by Pediatric clear visual axis. Other important factor is patient ophthalmologists for several years. There was little selection and we do recommend IOL in infants evidence to support the claim either way. The who have otherwise anatomically normal eye with infant aphakia study was designed to answer this no anterior segment dysgenesis or other anomal- question. This was a prospective randomized mul- ies. Bilateral cataracts in infants however aphakia ticentric trial comparing infants who underwent can be easily managed with aphakic glasses as cataract surgery for unilateral cataract with either well as contact lenses. Attending surgeon is best IOL implantation or were left aphakic and were placed to take that decision customising it accord- ’ fi fitted with a contact lens. The main outcome vari- ing to patient spro le and his/her skills. IATS has able was visual acuity at 1 year and 4 ½ years of certainly provided information for better informed age. The investigators also looked at complica- decisions. tions, resurgery rates and strabismus and stereop- sis and compliance to occlusion. IATS found that Complications following surgery there was no difference in visual acuity at either 1 Postoperative inflammatory response in children year of age or at 4 ½ years between the two can result in fibrinous and pigment deposits on groups. But alarmingly adverse events like mem- the IOL. Inflammatory response can be really brane proliferation into the visual axis, corectopia exaggerated in infants with Rubella syndrome. were almost 10 times more common in infants Posterior capsular opacification is the most with IOL implantation compared to aphakic common complication after pediatric cataract infants.30 In aphakic eyes, the margins of the surgery. Primary posterior capsulotomy with anter- anterior and posterior capsular bag usually fuse ior vitrectomy combined with hydrophobic acrylic together preventing lens material from migrating IOL in the bag, can prevent or delay the occurrence out of the Sommerring ring into the pupillary of VAO. PCO if develops can be treated by NdYag space. Whereas in pseudophakic eyes, lens epithe- laser capsulotomy or membraectomy depending on lial cells are able to migrate into the pupillary the child’s cooperation and the thickness of PCO. space because the IOL interfers with the fusion of Secondary is the most feared compli- the lens capsular remnanats. Hence, not surpris- cation of infantile cataract surgery. IATS showed ingly, the commonest indication for resurgery in that IOL implantation does not seem to protect 33 IOL group was to clear the visual axis. Additional against the development of glaucoma. Mataftsihave intraocular surgeries were 3 ½ times more in reported that glaucoma after pediatric cataract pseudophakic infants compared to aphakic surgery is associated with surgery with in first 1 infants.31 The risk of glaucoma was same in both month of life and additional surgical procedures the groups. The development of stereopsis did not but not with primary IOL implantation.32 Parents differ depending on the type of optical rehabilita- must be counselled regarding glaucoma and need tion. In conclusion, the study did not demonstrate for regular follow up. Rapid myopic shift and any visual benefit from implanting an IOL at the increased axial length points towards glaucoma time of unilateral cataract surgery in infants <7 and high index of suspicion should be maintained months of age and the children who had IOL in these children. implantation had more adverse events and is a rare late postoperative required more reoperations to clear visual axis complication of pediatric cataract surgery. opacities. The investigators concluded by saying “When operating on an infant younger than 7 Postoperative visual rehabilitation months of age with a unilateral cataract, we rec- Visual rehabilitation in children after surgery can ommend leaving the eye aphakic and focusing the be achieved by aphakic glasses, contact lenses, eye with a contact lens. Primary IOL implantation IOL implantation. Aphakic glasses are efficient should be reserved for those infants where, in the method of visual rehabilitation in infants espe- opinion of the surgeon, the cost and handling of a cially in bilateral cataracts. Contact lenses are par- contact lens would be some burdensome as to ticularly useful in unilateral cataract. Silcon soft result in significant periods of uncorrected lenses or rigid gas permeable lenses are commonly aphakia.”32 In the context of our country, used. Speegschatz et al. in their study of 157 however the IATS conclusions need to be inter- aphakic subjects found that initial rehabilitation preted in a slightly different light. Monocular cat- with aphakic glasses and secondary IOL implant- aracts in infants, where only way of visual ation at a later date has the advantage of predictable rehabilitation is contact lens, is often problematic postoperative refraction and fewer complications.34 in developing countries because of poor hygiene, Visual rehabilitation can be done in the immediate

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postoperative period by aphakic glasses in bilateral 2. Lim Z, Rubab S, Chan YH, Levin AV. Pediatric cataract: the cases and contact lenses in unilateral cases. When Toronto experience-etiology. Am J Ophthalmol 2010; 149: – fitting an infant with aphakia with contact lens the 887 892. 3. Merin S, Crawford JS. The etiology of congenital cataracts. A problem of appropriate power of the contact lens survey of 386 cases. Can J Ophthalmol 1971; 6: 178–182. arises. Silicon elastomer contact lens is the preferred 4. Gillespie RL, Sullivan J, Ashworth J, Bhaskar S, Williams S, contact lens for the treatment of aphakia in infants. Biswas S, Kehdi E, Ramsden SC, Clayton-Smith J, Black GC, It is easy to fit and can be used as an extended wear Lloyd IC. Personalized diagnosis and management of congenital contact lens. Rigid gas permeable lens is also an cataract by next-generation sequencing. Ophthalmology 2014; option given the advantage of cost and good oxy- 12: 2124–2137. genation for . The preoperative axial length 5. Haargaard B, Wohlfahrt J, Rosenberg T, Fledelius HC, Melbye M. Risk factors for idiopathic congenital/infantile can be used to determine the contact lens power to cataract. Invest Ophthalmol Vis Sci 2005; 46: 3067–3073. be used. Martin et al. in their study reported the 6. Amaya L, Taylor D, Russell-Eggitti , Nischal KK, Lengyel D. The power of the contact lens depending on the pre- morphology and natural history of childhood cataracts. Surv operative axial length as: 0–6months,+29D;7–17 Ophthalmol 2003; 48: 125–144. months, +26 D; 18–28 months, +23 D and 29–34 7. Haargaard B, Wohlfahrt J, Fledelius HC, Rosenberg T, months, +18 D.5 Moore noted that the mean spher- Melbye M. A nationwide Danish study of 1027 cases of congenital/infantile cataracts: etiological and clinical ical equivalent for these patients was classifications. Ophthalmology 2004; 111: 2292–2298. +28.5 D at 6 months, +26.5 D at 12 months, +23 D 8. Arkin M, Azar D, Fraioli A. Infantile cataracts. Int Ophthalmol 35 at 24 months and +21.5 D at 36 months. Trivedi Clin 1992; 32: 107–120. et al. recommends 32-D CL when the preoperative 9. Zetterström C, Lundvall A, Kugelberg M. Cataracts in children. AL is <17 mm, a 29-D Cl when the preoperative AL J Cataract Refract Surg 2005; 31: 824–840. is between 17 and 18.5 mm, a 26-D CL when the 10. Gelbart SS, Hoyt CS, Jastrebski EM. Long term visual results in preoperative AL is 18.5–19.5 D, a 23-D CL when the bilateral congenital cataracts. Am J Ophthalmol 1982; 93: 615–621. preoperative AL is between 19.5 and 20 mm (21 mm) 11. Raghu H, Subhan S, Jose RJ, Gangopadhyay N, Bhende J, – and a 20-D CL for an AL of 20 21 mm (20 D for Sharma S. Herpes simplex virus-1—associated congenital 36 >21 mm). Secondary IOL implantation can be cataract. Am J Ophthalmol 2004;138:313–314. reserved as an option for later visual rehabilitation 12. Vijayalakshmi P, Kakkar G, Samprathi A, Banushree R. Ocular in these children. Nihalani et al. in their study of sec- manifestations of congenital rubella syndrome in a developing ondary IOL implantation in children left aphakic country. Indian J Ophthalmol 2002; 50: 307–311. during initial cataract surgery found satisfactory 13. Choi J, Kim JH, Kim SJ, Yu YS. Clinical characteristics, course, and visual prognosis of partial cataracts that seem to be visually visual and refractory outcomes in children receiving insignificant in children. J AAPOS 2012; 16: 161–167. secondary IOL implantation. However, immediate 14. Birch EE, Cheng C, Stager Dr, Weakley Dr. The critical period postoperative inflammation and corneal edema was for surgical treatment of dense congenital bilateral cataracts. more in eyes with sulcus implanted IOL compared to J AAPOS 2009; 13:67–71. in the bag IOL.37 15. Swan KC, Wilkins JH. Extraocular muscle surgery in early — Last but not the least, several of these infants infancy anatomicalfactors. J Pediatr Ophthalmol Strabismus 1984; 21:44–49. will need continued monitoring for amblyopia 16. Eibschitz-Tsimhoni M, Archer SM, Del Monte MA. Intraocular and patching and strabismus. They will need lens power calculation in children. Surv Ophthalmol 2007; 52: appropriate refractive correction moving from a 474–482. single vision glass to a bifocal or progressive as 17. Crouch ER, Crouch ER Jr, Pressman SH. Prospective analysis of their visual needs change. It is important not to pediatricpseudophakia: myopic shift and postoperative miss these unglamorous factors in follow up visits outcomes. J AAPOS 2002; 6: 277–282. otherwise amblyopia can trump a beautifully done 18. Hutchinson AK, Drews-Botsch C, Lambert SR. Myopic shift after intraocular lens implantation during childhood. surgery in a matter of few months. Ophthalmology 1997; 104: 1752–1757. 19. Lambert SR, Lynn M, Drews-Botsch C, et al. Intraocularlens Conclusion implantation during infancy: perceptions of parents and the Cataract surgery in infants is a specially challen- American Association for Pediatric Ophthalmology and Strabismus members. J AAPOS 2003; 7: 400–405. ging subset among all cataract surgeries in chil- 20. Eibschitz-Tsimhoni M, Archer SM, Del Monte MA. Intraocular dren in terms of surgical technique, formula to be lens power calculation in children. Surv Ophthalmol 2007; 52: used, biometry and postoperative visual rehabilita- 474–482. tion. But it is rewarding, if we are able to rehabili- 21. Mittelviefhaus H, Gentner C. Errors in keratometry for tate them either with glasses or primary IOL intraocularlen simplantation in infants. Ophthalmology 2000; implantation or contact lenses. Surgeon has the 97: 186–188. onus of deciding on the best course looking ahead 22. Eibschitz-Tsimhoni M, Tsimhoni O, Archer SM, Delmonte MA. Effect of axial length and keratometry measurement error on not few years but few decades. intraocular lens implant power prediction formula in pediatric patients. J AAPOS 2008; 12: 173–176. References 23. Trivedi RH, Wilson ME. Prediction error after pediatric cataract 1. Holmes JM, Leske DA, Burke JP, Hodge DO. Birth prevalence of surgery with intraocular lens implantation: contact versus visually significant infantile cataract in a defined U.S. immersion A-scan biometry. J Cataract Refract Surg 2011; 37: – population. Ophthalmic Epidemiol 2003; 10:67–74. 501 505.

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24. Hussin HM, Spry PGD, Majid MA, et al. Reliability and surgery 1 year after cataract surgery in the Infant Aphakia validity of the partial coherence interferometry for Treatment Study. Ophthalmology 2011; 118: 2330–2334. measurement of ocular axial length in children. Eye 2005; 20: 31. Carrigan AK, DuBois LG, Becker ER, Lambert SR. Cost of 1021–1024. intraocular lens versus contact lens treatment after unilateral 25. Nihalani BR, VanderVeen DK. Comparison of intraocular lens congenital cataract surgery: retrospective analysis at age 1 year. power calculation formulae in pediatric eyes. Ophthalmology Ophthalmology 2013; 120:14–19. 2010; 117: 1493–1499. 32. Mataftsi A, Haidich AB, Kokkali S, et al. Postoperative 26. Kekunnaya R, Gupta A, Sachdeva V, Rao HL, Vaddavalli PK, glaucoma following infantile cataract surgery: an individual Om Prakash V. Accuracy of intraocular lens power calculation patient data meta-analysis. JAMA Ophthalmol 2014; 132: formulae in children less than two years. Am J Ophthalmol 1059–1067. 2012; 154:13–19. 33. Trivedi RH, Wilson ME Jr, Golub RL. Incidence and risk factors 27. VanderVeen DK, Nizam A, Lynn MJ, Bothun ED, for glaucoma after pediatric cataract surgery with and without McClatchey SK, Weakley DR, DuBois LG, Lambert SR; Infant intraocular lens implantation. J AAPOS 2006; 10: 117–123. Aphakia Treatment Study Group. Predictability of intraocular 34. Speeg-Schatz C, Flament J, Weissrock M. Congenital cataract lens calculation and early refractive status: the Infant extraction withprimary aphakia and secondary intraocular lens Aphakia Treatment Study. Arch Ophthalmol 2012; 130: implantation in the ciliarysulcus. J Cataract Refract Surg 2005; 293–299. 750–756. 28. Ram J, Jain VK, Agarwal A, Kumar J. Hydrophobic acrylic 35. Martin NF, Kracher GP, Stark WJ, Maumenee AE. versus polymethylmethacrylate intraocular lens implantation Extended-wear soft contact lenses for aphakic correction. Arch following cataract surgery in the first year of life. Graefes Arch Ophthalmol 1983; 101:39–41. Clin Exp Ophthalmol 2014; 252: 1443–1449. 36. Trivedi R, Wilson E. Selection of an initial contact lens power 29. Pavlovic S, Jacobi FK, Graef M, Jacobi KW. Silicone intraocular for infantile cataract surgery without primary intraocular lens lens implantation in children: preliminary results. J Cataract implantation. Ophthalmology 2013; 120: 1973–1976. Refract Surg 2000; 26:88–95. 37. Nihalani BR, Vanderveen DK. Secondary intraocular lens 30. Plager DA, Lynn MJ, Buckley EG, Wilson ME, Lambert SR. implantation after pediatric aphakia. J AAPOS 2011; 15: Complications, adverse events, and additional intraocular 435–440.

How to cite this article Praveen Kumar KV, Agarkar S. Infantile cataract: where are we now? Sci J Med & Vis Res Foun 2015;XXXIII:126–131.

Sci J Med & Vis Res Foun October 2015 | volume XXXIII | number 3 | 131