Contact Lenses for Infant Aphakia Br J Ophthalmol: First Published As 10.1136/Bjo.74.3.150 on 1 March 1990

150 British JournalofOphthalmology, 1990,74, 150-154

Contact lenses for infant aphakia Br J Ophthalmol: first published as 10.1136/bjo.74.3.150 on 1 March 1990. Downloaded from

Luis G Amaya, Lynne Speedwell, David Taylor

Abstract of optical correction that allows the parameters We prospectively studied for three years the to be easily changed, that has a low complication optical correction by contact lenses of 83 rate, and a high quality ofoptical correction. The aphakic infants (141 eyes) who generally also method must also be practical and inexpensive to had systemic and other ocular anomalies: 85% families and to the providers of medical care. of the patients tolerated the lens wear for the We present a review ofour experience with the whole study period. Complications occurred in use of soft contact lenses, the incidence of 46 eyes and led to cessation oflens wear in two complications, tolerance, co-operation from cases. Ten patients abandoned the lenses for patients and parents, and the costs engendered. other reasons. Thirty-four eyes needed subsequent intraocular surgery, mostly minor, and nine patients had strabismus surgery. Contact Subjects and methods lenses are a versatile, safe, successful, and From 31 December 1984 we have provided a cost effective treatment for aphakia in infancy contact lens service for aphakic infants. Included against which, before their widespread intro- in our prospective study are all infants made duction for primary optical correction of infant aphakic within the first year of life, until aphakia, other methods of aphakic treatment 1 January 1988. Cases where anatomical or need to be compared. functional defects precluded useful vision were not optically corrected postoperatively. The patients with bilateral cataracts usually In 1959 Sato and Saito' presented two children had the operations done within three days ofeach fitted with hard contact lenses, and other early other, with the first eye being patched in between reports using hard lensesA described difficulties to prevent the second eye from developing but good visual results. Soft contact lenses were amblyopia. Two uniocular cases were traumatic, used initially for adult aphakia,5 but complica- and one patient with Marfan's syndrome had tions occurred, such as the 'tight-fit syndrome', a dislocated lens; the rest were congenital corneal vascularisation, lens deposits, bacterial cataracts. The majority of patients came from conjunctivitis, hypersensitivity, and corneal outside London; nine patients lived abroad

oedema, all partly due to fitting techniques or to (Table I). http://bjo.bmj.com/ the thickness of lenses. Preservatives were intro- The lenses were fitted during the week follow- duced to reduce the incidence of conjunctivitis, ing surgery; in bilateral cases both lenses were but hypersensitivity occurred to these agents.67 fitted at the same time. They were re-examined Hard contact lenses for the correction ofinfantile the next week, one month later, and then every aphakia have also been advocated,8 including the three months, unless more frequent visits were use of silicone rubber lenses.9 required because ofcomplications or lens handl-

Although spectacles are inexpensive, easily ing difficulties. Parents were instructed to insert, on September 29, 2021 by guest. Protected copyright. changed, and generally safe, they may be remove, and clean the lenses daily from the inappropriate for infants, as they are heavy, ugly beginning, with special emphasis on vigilance for and they create a prismatic effect, visual field complications and side effects. Lenses of high constriction, and in monocular aphakes they are water content were used at first, and when the usually impracticable.'0 child no longer slept during the day they were Intraocular lenses have been used since the changed to lenses of a lower water content. early 1970s,"' but the difficulty in obtaining Initially the lenses were cleaned daily with a adequate parameters for infants, the subsequent surfactant cleaner and then sterilised by boiling growth of the eye after implantation, and the in preservative-free saline. Once the parents number of complications'2 make them unaccept- were more used to the lenses a chlorine-based able in view of the life-long nature of the cleaning regimen (Softab) preceded by sur- treatment and the uncertainty ofthe lenses' long- factant cleaning was used. Protein removal term performance. There is little evidence to support the safety of even the newest generation TABLE I Patient's travelling distance in milesfrom central of intraocular lenses in infants in the long term, London and the rapid growth of the eye during the first Number ofmiles Number ofpatients year of life makes a permanent unchangeable for Sick power inappropriate.'3 Peripheral London (0-15) 16 Hospitals 16-30 15 Children, Great Ormond Epikeratophakia is a promising solution,'4 5 31-50 10 Street, London though the undercorrection of the refraction in 51-80 6 WC1N 3JH 81-120 7 L G Amaya infants and other problems, including the rapid 121-160 3 L Speedwell change in refractive power of the eye in the first 161-200 7 D Taylor More than 200 5 year oflife,'6 suggest that it should be reserved as From abroad 9 to: Mr D Correspondence an alternative in some older patients who are No information 5 Taylor. Total 83 Accepted for publication intolerant to contact lenses. 16 September 1989 Infantile aphakia needs an adaptable method Note: I mile= 1-6 km. Contact lensesforinfantaphakia 151

tablets were rarely used, as the lenses tended inadequate. Six eyes developed glaucoma, of to become lost or broken before this became which two improved on medical therapy. Four Br J Ophthalmol: first published as 10.1136/bjo.74.3.150 on 1 March 1990. Downloaded from necessary. eyes required anterior vitrectomy, three of them After retinoscopy an overcorrection of around to reduce increased intraocular pressure second- 2-3 dioptres was prescribed. The back optic ary to pupil block. Two of these improved with radius (BOR) was selected on a trial basis surgery; the other developed uncontrolled according to the age of the patient on the known glaucoma with a blind, buphthalmic eye. One average corneal radius, which in neonates was eye developed glaucoma of unknown cause, 7 1 mm, and changes were made as needed. The controlled with a trabeculectomy. The eyes diameter of the lenses and their fit was deter- with non-pupil-block glaucoma had anomalies mined empirically from the corneal diameter and additional to the cataracts. careful observation on the stability of the lens on Removal ofresidual lens matter with posterior the eye, with the size varying between micro- capsulotomy was required in both eyes of one phthalmic and normal corneas. At each visit an patient. Of the 19 patients who had lens aspira- ophthalmic examination was performed, includ- tion without vitrectomy 14 required posterior ing funduscopy and retinoscopy and, when capsulotomy. Nine patients underwent squint possible, slit-lamp examination. The child was surgery. Five patients needed removal ofsutures examined by an orthoptist when signs ofa squint under general anaesthetic, and nine patients had were apparent. Spectacles were prescribed as an examinations under general anaesthetic for alternative to contact lenses in case the contact various reasons. 141 eyes of 83 patients were lenses caused problems, and parents were given fitted with soft contact lenses. Of these patients spare lenses, and extra lenses were mailed when 67 were under 1 year of age, 58 were binocular necessary. A detailed verbal description of the aphakes, and 25 were uniocular. risks and difficulties was given to the parents at Forty-three eyes had complications due to the outset; more recently they have been given a the use of contact lenses (Table VI). Twelve booklet detailing the treatment. developed red eye, with no evidence of bacterial or viral infection; loose sutures were responsible for this in five cases. In those cases not due to Results loose sutures the eyes settled within a few days The surgical technique in 121 eyes was lensec- once the lenses were removed. In bilateral cases tomy with anterior vitrectomy. A lens aspiration if one lens was removed the other was also, to without vitrectomy was performed in 19 cases. equate the optical state ofthe two eyes. Eighteen One eye had an intraocular lens implant, in a patients had bacterial conjunctivitis which patient who lived far from London, and had a life always improved with antibiotic treatment. span likely to be limited to three years. Three patients had recurrent infections, prob-

The known age of onset of the visual depriva- ably due to improper cleaning of the lenses. http://bjo.bmj.com/ tion from the cataracts was at birth in 109 of the Three patients who had hypoxic ulceration due eyes (77 3%). In six eyes the age of onset was to improper handling and inadequate removal of unknown (Table II). 12-2% ofthe bilateral cases the lenses improved after regular and daily were operated on by 2 months and by 4 months removal oflenses, but two ofthese were changed of age, and 53-8% of the unilateral cases had to spectacle wear. surgery by 2 months and 85% by 4 months. Three patients developed intolerance, with

Twenty-six had associated systemic abnor- red eye, discomfort, and watery discharge when on September 29, 2021 by guest. Protected copyright. malities (Table III), and 39 patients had other the lenses were in, but they were completely eye anomalies apart from the cataracts (Table asymptomatic when the lenses were out. None of IV). As regards postoperative complications, 11 these were related to giant papillary conjunc- eyes required pupilloplasties (Table V), mainly tivitis, but when changed to HEMA (38% water to maintain a clear visual axis when this became content) soft contact lenses or silicone rubber

TABLE II Age ofonset ofvisual deprivationfrom cataract TABLE IV Other ocular abnormalities (83 eyes) Onset (months) Bilateral Unilateral Persistent hyperplastic primary vitreous 4 eyes 0 48 13 Posterior lenticonus 4 eyes 1-5 1 1 Microphthalmos '2 eyes 2 2 Ant segment dysgenesis 21 eyes 3 1 Ectropion uveae 2 eyes 5 - 2 Dislocated lenses 2 eyes 6 1 2 Rubella retinopathy 1 patient 8 2 1 Heterochromia 1 patient 9 or more - 6 Blepharospasm 1 patient Unknown 3 Iridopupillary membrane 1 patient

TABLE III Systemic abnormalities (83 patients) TABLE V Postoperative surgical complications (n= 141 eyes) Without other abnormalities 57 Pupilloplasty 11 With other abnormalities 26 Anterior vitrectomy 4 a. Down's syndrome 7 Glaucoma 6 b. Congenital rubella 7 (a) Improved medically 2 c. Marfan's syndrome (b) Anterior vitrectomy 3 d. Cerebro-oculo-facial-skeletal syndrome (Pena Shokeir) 21 (c) Trabeculectomy 1 e. Cardiomyopathy; lactic acidosis Residual lens matter extraction 2 f. Severe neonatal asphyxia 2 Posterior capsulotomies 14 Cerebral palsy Squint surgery 9 h. Persistent fetal circulation; sepsis 1 Removal of sutures under GA 5 i. Ectopic anus 2 Examination under anaesthetic for other reasons 9 j- Hearing problems 2 Total 60 152 Amaya, Speedwell, Taylor

TABLE VI Number ofeyes TABLE VII Number ofpatients in whom contact lenses were Patients treated < 6 months 20 with contact lens induced discontinued (n=83) Br J Ophthalmol: first published as 10.1136/bjo.74.3.150 on 1 March 1990. Downloaded from complications (n= 141) 18- Hypoxic ulceration 2 16 Redeye 12 High turnover 3 No. of Infection 18 eyes 14 Hypoxic ulceration 3 Parent's difficulties in handling contact lens 4 Fine vascularisation 3 Others (preferred glasses) 3 12 Total 12 | Bilateral Intolerance 3 10 - Oedema 2 | Unilateral Punctate keratitis 2 8- Total 43 6- lenses they were symptom-free. Two patients 4- had corneal oedema which subsided after 2- removal of the contact lenses and change of ULn1 P. n Lf HP _W H __ _ 0.5 1.0 1.5 2.0 2.5 3.0 parameters. 1 mm or more of corneal pannus Lenses / month developed in three Two of them were patients. Figure 3: Number oflenses per month per eye in patients changed to Polycon gas-permeable hard lenses, treatedfor less than six months. There is a higher turnover in with reduction in the pannus; the other was the first six months. changed to spectacle wear. Punctate keratitis 36 - necessitating temporary lens removal was diag- nosed in two patients, and three patients had Power 33 - such a high incidence of loss or renewal of lenses of lens 30 - (turnover) that their use was abandoned. ( + D ) Twelve (14 5%) of the patients abandoned the 27 - lens wear (Table VII), two with hypoxic ulceration, three with a high lens turnover, and four 24 -

with visually handicapped parents; three older 21 - children had no major problems but preferred to use spectacles. Five other patients stopped the 18 -

use of contact lenses for more than one month 15 - but started them again. 81-1% of the eyes in the bilateral aphakes and 12 J 66-8% of the unilaterals had less than one lens 6 12 18 24 30 36 replaced per month (Figs 1, 2). In the first six Months months oftreatment there was a higher incidence Figure 4: Power ofthe contact lenses compared with the age of than in later months of lens either the patients. As the age increases there is a steady decrease in replacement the power ofthe contact lenses. for changes in parameters or because the lenses were lost, broken, or rubbed out (Fig 3). 76-6% ofthe bilateral cases and 80-76% of the unilateral Figure 4 shows the average power ofthe lenses http://bjo.bmj.com/ required less than one change of lens for reasons up to 3 years ofage (the dioptric value range from of change in parameters. Seven eyes were 12 to 34 dioptres), clearly demonstrating how the excluded from this figure because they had been required power of the lenses decreased as the treated for less than three months. infants grew. Microphthalmic eyes remained small, requiring high power lenses, even with age. All patients treated The number of 20 lenses issued during this on September 29, 2021 by guest. Protected copyright. period was 1483. At a cost of £18 per lens, this totalled £26 694. The total cost of solutions was No. of .16 £3978. On average, the cost of lenses per month eyes 14- per patient was £28.50. In addition to this 12 the costs of running the clinic must be taken

10 fl0~ Bilateral into account, including the services of an 8- Unilateral optometrist, an ophthalmologist, an orthoptist, and nurses.

Figure 1: Total number of Discussion lenses per month per eye. Lenses / month Microsurgical techniques have considerably improved the outcome of infantile cataract Patients treated > 6 months surgery, and our results show that the number of reoperations is small, the majority of them being pupilloplasties, often to recentre the pupil when No. of it has been decentred, usually by vitreous eyes strands. Nine patients at risk for glaucoma required repeated examinations under anaes- Bilateral thetic, but the incidence of glaucoma was low, E2 Unilateral unless the eye was otherwise anomalous or microphthalmic.3 We do not routinely remove the corneal sutures, but when these are loose, Figure 2: Number oflenses especially when contact lenses are per month per eye in patients used, they can treatedfor more than six cause irritation until removed. months. Lenses / month With our contact-lens fitting protocol there is a Contact lensesfor infant aphakia 153

low incidence of side effects attributable to the therefore only occasionally used. Figures 4 and 5 use of the lenses. We have seen no cases of giant show the change in power during the first year of Br J Ophthalmol: first published as 10.1136/bjo.74.3.150 on 1 March 1990. Downloaded from papillary conjunctivitis.'7 The low incidence of life, and the frequent need to change parameter. bacterial conjunctivitis, hypoxic ulceration, and This is in contrast to the study by Pratt-Johnson corneal oedema is probably due to the daily lens and Tillson,' who did not change hard lens removal and sterilisation regimen. parameters during the first five years of life. Although it may be thought that daily handl- 81 1% of the eyes required fewer than one lens ing of the lenses increases the risks of infection, per month; many of these lenses can be reused our experience suggests the opposite, and this once sterilised. The optical correction of may be due to the careful handling by well infantile aphakia during the first three years of trained and dedicated parents. Electron micro- life costs £440 in contact lenses and £112 in scopyN' has shown that bacteria attach to the solutions (aerosol saline and cleaning solution), surface of soft contact lenses and 'proliferate' making a total of £562. These costs do not unless the lenses are removed, cleaned, and include the services ofan ophthalmologist and an sterilised frequently.2' Solutions with preserva- optometrist, nor the considerable travel costs for tives such as thiomersal or chlorhexidine may parents (Table I). cause allergic reactions, but our handling scheme The optical correction of infantile aphakia avoids this problem. The lens deposits associated with daily wear soft contact lenses is an effective with this method were usually avoided because and economical method. It has the adaptability ofthe high lens turnover. to respond to changes in the parameters, and the The daily removal oflenses may appear daunt- parents can easily insert and remove the lenses. It ing for parents, but most of them were willing gives a high quality optical correction with a low and co-operative and learned within the first incidence of complications. It is cost effective, weeks. Four families could not get used to though there are many hidden costs for the handling the lenses: in two cases, the mothers parents. With a contact lens tolerance rate of were blind, and in another the patient had very 85 5% it is difficult to see a need for alternative, microphthalmic, sunken eyes. relatively untried optical correction, such as The parents were impressed with the need to intraocular lenses, for the primary correction of remove the lenses if there were any signs of infantile aphakia. infection, red eye, or discomfort. General practi- tioners cannot be expected to be experienced This project has been supported by the Iris Fund for the with the use of lenses and cannot usually advise Prevention ofBlindness, and the Help a Child to See Fund. on handling them or on the treatment of complications, so removal by the parents, especially if 1 Sato T, Saito N. Contact lenses for babies and children. they live far from ophthalmological care, is Contacto 1959; 3: 419-24.

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