in Review News commentary and perspectives Contacts vs. IOLs for Congenital Cataract he verdict is in on the issue of optical correction in children who undergo unilateral cataract surgery before age 7 months: Aphakia, corrected with a contact lens, is a better option than an T CONTACT LENS PATIENT. Dr. Lambert examines a 6-year-old intraocular lens (IOL) for 55 others who received an aphakic girl in the IATS trial. This child was prescribed a most of these babies. IOL implant (median VA in contact lens in one eye at 1 month of age and could insert “Primary IOL implan- both groups, 0.90 logMAR her own contact lens by the age 4 years. tation should be reserved [20/159]). for those infants where, in More complications. pillary membranes occurred one normal eye. But the the opinion of the surgeon, However, a significantly 10 times more often in the thing about children is that the cost and handling of greater number of the pseu- pseudophakic eyes. they’re going to live for a a contact lens would be so dophakic eyes required one Scott R. Lambert, MD, very long time, and it is burdensome as to result in or more additional intra- a professor of ophthalmol- important for them to have significant periods of uncor- operative procedures over ogy at Emory University in the best possible visual acu- rected aphakia,” stated the the course of the study (41 Atlanta and the lead inves- ity in their problem eye,” investigators in the Infant patients compared with tigator in the trial, credited he said, particularly in case Aphakia Treatment Study.1 12 in the aphakic group; advocacy by the pediatric anything should happen to Comparable VA. This p < .001), the researchers ophthalmology community their other eye. multicenter randomized found. At least one adverse for the National Eye Insti- About half of the chil- clinical trial determined event had occurred in a tute (NEI) decision nearly dren in both groups had that, at age 4.5 years, visual significantly greater num- a decade ago to support the visual acuity at age 4.5 years outcomes were equivalent ber of IOL eyes (46 patients study, despite the rarity of of 20/200 or worse. But the between 57 aphakic children compared with 31 in the congenital cataract. study also demonstrated whose cataract was removed aphakic group; p < .02). Long-term outlook. the potential for excellent emory eye center eye center emory at age 1 to 6 months and Lens proliferation and pu- “These children may have visual outcomes, he added. eyenet 17 News in Review “The very best child in our wise be available.” ogists might be called on to their eyes are doing well.” study ended up with 20/12 Dr. Lambert said the in- treat in the future. —Linda Roach vision in both eyes and vestigators now are examin- “We know that an IOL normal depth perception,” ing their data to determine puts them at increased risk 1 The Infant Aphakia Treatment Dr. Lambert noted. “I really which children with IOLs of having glaucoma if they Study Group. JAMA Ophthal- think that this child’s life is are most likely to develop had cataract surgery when mol. 2014 March 6. [Epub ahead going to be different than if complications later in life, they were young,” he said. of print]. he were blind in one eye. It such as glaucoma or retinal “So these patients will need creates a lot of opportunities detachment—problems that ongoing eye care the rest of Dr. Lambert reports no related in life that would not other- comprehensive ophthalmol- their lives, to be sure that financial interests. Cornea Caveats which are not available in all practices or centers, exacer- bating diagnostic delay.” Dangers of Steroids in Further impacting the outcomes—even after ac- curate diagnosis is finally Misdiagnosed Keratitis made—the treatment of AK requires compounded anti-amoebic drugs that are he first cohort study in a binary (yes/no) clas- AK SIGN. The presence of not immediately available in optimized to ex- sification, they found that it radial perineuritis can aid smaller centers. Tamine the impact increased the risk of a sub- in the diagnosis of Acan- “Comprehensivists of topical corticosteroids optimal visual outcome by thamoeba keratitis. confronted with indolent on visual outcomes from almost fourfold after adjust- keratitis should consider re- Acanthamoeba keratitis ment for confounding vari- contact lens wearers, were ferring the patient to a cor- (AK) reported that steroid ables. Second, they classified initially misdiagnosed with nea specialist, who has the use before diagnosis of AK patients into three catego- HSV keratitis,” she said. resources and expertise in is not only widespread but ries by duration of steroid The early clinical signs managing unusual microbi- also highly detrimental to use (1-13 days, 14-30 days, of AK are highly variable al keratitis that’s unrespon- patients with this relatively and more than 30 days). and often appear very simi- sive to standard treatment,” uncommon disease.1 Given the small sample size lar to HSV keratitis, with Dr. Robaei advised. Study details. A chart in each category, the authors epithelial irregularity and Key takeaways. “Our review identified 196 pa- chose not to publish those dendritiform lesions. Pain study highlights the critical tients diagnosed with AK results in the article, ac- often—but not always—ac- importance of 1) having a at Moorfields Eye Hospital, cording to first author Dana companies early AK, and high index of suspicion for London, between January Robaei, MBBS, MPH, PhD, a lack of pain can mislead AK in contact lens wearers, 1991 and April 2012. Of FRANZCO, at the Univer- clinicians toward an HSV particularly before making these, 22 were excluded for sity of Sydney in Australia. diagnosis. Moreover, long- a diagnosis of HSV keratitis, missing data, leaving 174 pa- But, she said, more than 30 term contact lens wear is and in non–contact lens tients available for analysis. days of use was associated associated with reduced cor- users who have a persistent Half of the patients (87) had with an almost eightfold neal sensation, which also keratitis; and 2) the need for used topical steroids before increased risk of a poor may be incorrectly ascribed judicious use of topical cor- the diagnosis of AK. visual outcome, compared to HSV. Finally, photopho- ticosteroids when the pos- The primary outcome with 1-13 days (odds ratio, bia is associated with both sibility of AK has not been measure was a suboptimal 7.92; confidence interval, HSV keratitis and AK. definitively ruled out,” said visual outcome, defined as 2.0-32.1). “AK is an unusual cause Dr. Robaei. a final best-available visual Widespread misdiag- of microbial keratitis, and —Gabrielle Weiner acuity of 20/80 or worse nosis. This harmful use of general ophthalmologists (recorded after completion steroids is largely due to ini- seldom encounter it,” said 1 Robaei D et al. Ophthalmology. of therapy for AK), corneal tial misdiagnosis of AK as Dr. Robaei. “Diagnosis 2014 March 17. [Epub ahead of perforation, or need for herpes simplex virus (HSV) often relies on ancillary print]. keratoplasty. keratitis. “In our study, techniques, such as confocal Researchers studied ste- 52.3 percent of all patients, microscopy and PCR [poly- Dr. Robaei reports no related fi- roid use in two ways. First, the majority of whom were merase chain reaction], nancial interests. dana robaei, mbbs, mph, phd, franzco 18 june 2014 News in Review Uveitis Therapy thrombocytopenia are also worrisome and, unfortu- nately, not rare. Chloram- Chlorambucil & Remission bucil also carries the risk of sterility, which is important to discuss with younger pa- In Sympathetic Ophthalmia tients.” However, she noted, the drug is well tolerated subjectively, with little or hort-term, high-dose 441 months). Chlorambucil no fatigue, nausea, or other chlorambucil prolongs controlled inflammation SYMPATHETIC OPHTHAL- bothersome symptoms. Sdrug-free remissions in all patients, 13 of whom MIA. Peripapillary and mul- “We know that in sym- for patients with sympa- (81.3 percent) maintained tifocal choroiditis with exu- pathetic ophthalmia, as thetic ophthalmia, accord- vision of 20/40 or better in dative retinal detachment. in other forms of uveitis, ing to a study conducted the sympathizing eye. outcomes are better with in Chicago and Buenos After stopping systemic true disease remission that earlier diagnosis and aggres- Aires.1 Lead author Debra A. therapy, four patients re- persists when all therapy has sive therapy,” Dr. Goldstein Goldstein, MD, director of lapsed at a median of 83 been discontinued.” added. “It is always discour- Northwestern University’s months (mean, 131 months). The advantages of chlo- aging to see a patient with uveitis service, further re- Topical treatment alone rambucil must be weighed potentially blinding posteri- ported that no systemic ma- controlled 75 percent of against the risks. “Certainly, or segment disease who has lignancies occurred among these relapses, which con- the risk of malignancy is the been managed for months the 16 patients treated with sisted of only mild anterior most worrisome, although or years with topical therapy the drug, although one pa- chamber inflammation. its occurrence is rare,” she only. Early consultation tient developed conjunctival “Long-term, drug-free said, adding that although with a specialist may help to Kaposi sarcoma. remission of sympathetic this study did not find an improve outcomes.” The patients were given ophthalmia has not been increased risk of malig- —Marianne Doran chlorambucil for a median reported with corticosteroid nancy with the high-dose, of 14 weeks (mean, 14.5 therapy or other nonalkyl- short-term protocol, the 1 Patel SS et al. Ophthalmology. weeks; range, 12-19 weeks), ator-based treatments,” Dr.