Contact lenses for infant aphakia.

Abstract

We prospectively studied for three years the optical correction by contact lenses of 83 aphakic infants (141 eyes) who generally also had systemic and other ocular anomalies: 85% of the patients tolerated the lens wear for the whole study period. Complications occurred in 46 eyes and led to cessation of lens wear in two cases. Ten patients abandoned the lenses for other reasons. Thirty-four eyes needed subsequent intraocular surgery, mostly minor, and nine patients had strabismus surgery. Contact lenses are a versatile, safe, successful, and cost effective treatment for aphakia in infancy against which, before their widespread introduction for primary optical correction of infant aphakia, other methods of aphakic treatment need to be compared.

Full text

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British JournalofOphthalmology, 1990,74, 150-154
Contact lenses for infant aphakia
Luis G Amaya, Lynne Speedwell, David Taylor
Abstract
We prospectively studied for three years the
optical correction by contact lenses of 83
aphakic infants (141 eyes) who generally also
had systemic and other ocular anomalies: 85%
of the patients tolerated the lens wear for the
whole studyperiod. Complications occurred in
46 eyes and led to cessation oflens wear in two
cases. Ten patients abandoned the lenses for
other reasons. Thirty-four eyes needed subse-
quent intraocular surgery, mostly minor, and
nine patients had strabismus surgery. Contact
lenses are a versatile, safe, successful, and
cost effective treatment for aphakia in infancy
against which, before their widespread intro-
duction forprimary optical correction ofinfant
aphakia, other methods of aphakic treatment
need to be compared.
Hospitals for Sick
Children, Great Ormond
Street, London
WC1N 3JH
L G Amaya
L Speedwell
D Taylor
Correspondence to: Mr D
Taylor.
Accepted for publication
16 September 1989
In 1959 Sato and Saito' presented two children
fitted with hard contact lenses, and other early
reports using hard lensesA described difficulties
but good visual results. Soft contact lenses were
used initially for adult aphakia,5 but complica-
tions occurred, such as the 'tight-fit syndrome',
corneal vascularisation, lens deposits, bacterial
conjunctivitis,
hypersensitivity,
oedema, all partly due to fitting techniques or to
the thickness oflenses. Preservatives were intro-
duced to reduce the incidence of conjunctivitis,
but hypersensitivity occurred to these agents.67
Hard contact lenses for the correction ofinfantile
aphakia have also been advocated,8 including the
use ofsilicone rubber lenses.9
Although spectacles are inexpensive, easily
changed, and generally
inappropriate for infants, as they are heavy, ugly
and they create a prismatic effect, visual field
constriction, and in monocular aphakes they are
usually impracticable.'0
Intraocular lenses have been used since the
early 1970s,"' but the difficulty in obtaining
adequate parameters for infants, the subsequent
growth of the eye after implantation, and the
number ofcomplications'2 make them unaccept-
able in view of the life-long nature of the
treatment and the uncertainty ofthe lenses' long-
term performance. There is little evidence to
support the safety of even the newest generation
of intraocular lenses in infants in the long term,
and the rapid growth of the eye during the first
year of life makes a permanent unchangeable
power inappropriate.'3
Epikeratophakia is a promising solution,'45
though the undercorrection of the refraction in
infants and other problems, including the rapid
change in refractive power of the eye in the first
year oflife,'6 suggest that it should be reserved as
an alternative in some older patients who are
intolerant to contact lenses.
Infantile aphakia needs an adaptable method
and
corneal
safe, they may be
of optical correction that allows the parameters
to be easily changed, that has a low complication
rate, and a high quality ofoptical correction. The
method must also be practical and inexpensive to
families and to the providers ofmedical care.
We present a review ofour experience with the
use of soft contact lenses, the incidence of
complications,
tolerance,
patients and parents, and the costs engendered.
co-operation from
Subjects and methods
From 31 December 1984 we have provided a
contact lens service for aphakic infants. Included
in our prospective study are all infants made
aphakic within the first year of life, until
1 January 1988. Cases where anatomical or
functional defects precluded useful vision were
not optically corrected postoperatively.
The patients with bilateral cataracts usually
had the operations donewithin three days ofeach
other, with the first eye beingpatched in between
to prevent the second eye from developing
amblyopia. Two uniocular cases were traumatic,
and one patient with Marfan's syndrome had
a dislocated lens; the rest were congenital
cataracts. The majority of patients came from
outside London; nine patients lived abroad
(Table I).
The lenses were fitted during the week follow-
ing surgery; in bilateral cases both lenses were
fitted at the same time. They were re-examined
the next week, one month later, and then every
three months, unless more frequent visits were
required because ofcomplications or lens handl-
ing difficulties. Parents were instructed to insert,
remove, and clean the lenses daily from the
beginning, with special emphasis on vigilance for
complications and side effects. Lenses of high
water content were used at first, and when the
child no longer slept during the day they were
changed to lenses ofa lower water content.
Initially the lenses were cleaned daily with a
surfactant cleaner and then sterilised by boiling
in preservative-free saline. Once the parents
were more used to the lenses a chlorine-based
cleaning regimen (Softab) preceded by sur-
factant cleaning was used. Protein removal
TABLE I
London
Patient's travelling distance in milesfrom central
Numberofmiles
Number ofpatients
Peripheral London (0-15)
16-30
31-50
51-80
81-120
121-160
161-200
More than 200
From abroad
No information
Total
16
15
10
6
7
3
7
5
9
5
83
Note: I mile= 1-6 km.
150
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Contact lensesforinfantaphakia
tablets were rarely used, as the lenses tended
to become lost or broken before this became
necessary.
After retinoscopy an overcorrection ofaround
2-3 dioptres was prescribed. The back optic
radius (BOR) was selected on a trial basis
according to the age ofthe patient on the known
average corneal radius, which in neonates was
7 1 mm, and changes were made as needed. The
diameter of the lenses and their fit was deter-
mined empirically from the corneal diameter and
careful observation on the stability ofthe lens on
the eye, with the size varying between micro-
phthalmic and normal corneas. At each visit an
ophthalmic examination was performed, includ-
ing funduscopy and retinoscopy and, when
possible, slit-lamp examination. The child was
examined by an orthoptist when signs ofa squint
were apparent. Spectacles were prescribed as an
alternative to contact lenses in case the contact
lenses caused problems, and parents were given
spare lenses, and extra lenses were mailed when
necessary. A detailed verbal description of the
risks and difficulties was given to the parents at
the outset; more recently they have been given a
booklet detailing the treatment.
Results
The surgical technique in 121 eyes was lensec-
tomy with anterior vitrectomy. A lens aspiration
without vitrectomy was performed in 19 cases.
One eye had an intraocular lens implant, in a
patient who lived far from London, andhad a life
span likely to be limited to three years.
The known age of onset of the visual depriva-
tion from the cataracts was at birth in 109 of the
eyes (77 3%). In six eyes the age of onset was
unknown (Table II). 12-2% ofthe bilateral cases
were operated on by 2 months and by 4 months
of age, and 53-8% of the unilateral cases had
surgery by 2 months and 85% by 4 months.
Twenty-six had associated systemic abnor-
malities (Table III), and 39 patients had other
eye anomalies apart from the cataracts (Table
IV). As regards postoperative complications, 11
eyes required pupilloplasties (Table V), mainly
to maintain a clear visual axis when this became
TABLE II
Age ofonset ofvisual deprivationfrom cataract
Onset (months)
BilateralUnilateral
0
1-5
2
3
5
6
8
9 or more
Unknown
4813
1
2
1
-
1
2
-
3
1
2
2
1
6
TABLE III
Systemic abnormalities (83 patients)
a.
b.
c.
d.
e.
f.
h.
i.
j-
Without other abnormalities
With other abnormalities
Down's syndrome
Congenital rubella
Marfan's syndrome
Cerebro-oculo-facial-skeletal syndrome (Pena Shokeir)
Cardiomyopathy; lactic acidosis
Severe neonatal asphyxia
Cerebral palsy
Persistent fetal circulation; sepsis
Ectopic anus
Hearing problems
57
26
7
7
21
2
1
2
2
inadequate. Six eyes developed glaucoma, of
which two improved on medical therapy. Four
eyes required anterior vitrectomy, three ofthem
to reduce increased intraocular pressure second-
ary to pupil block. Two of these improved with
surgery;
the otherdeveloped
glaucoma with a blind, buphthalmic eye. One
eye developed glaucoma of unknown cause,
controlled with a trabeculectomy. The eyes
with non-pupil-block glaucoma had anomalies
additional to the cataracts.
Removal ofresidual lens matter with posterior
capsulotomy was required in both eyes of one
patient. Of the 19 patients who had lens aspira-
tion without vitrectomy 14 required posterior
capsulotomy. Nine patients underwent squint
surgery. Five patients needed removal ofsutures
under general anaesthetic, and nine patients had
examinations under general anaesthetic
various reasons. 141 eyes of 83 patients were
fitted with soft contact lenses. Of these patients
67 were under 1 year of age, 58 were binocular
aphakes, and 25 were uniocular.
Forty-three eyes had complications due to
the use of contact lenses (Table VI). Twelve
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
loose sutures the eyes settled within a few days
once the lenses were removed. In bilateral cases
if one lens was removed the other was also, to
equate the optical state ofthe two eyes. Eighteen
patients hadbacterial
always improved with antibiotic treatment.
Three patients had recurrent infections, prob-
ably due to improper cleaning of the lenses.
Three patients who had hypoxic ulceration due
to improper handling and inadequate removal of
the lenses improved after regular and daily
removal oflenses, but two ofthese were changed
to spectacle wear.
Three patients developed intolerance, with
red eye, discomfort, and watery discharge when
the lenses were in, but they were completely
asymptomatic when the lenses were out. None of
these were related to giant papillary conjunc-
tivitis, but when changed to HEMA (38% water
content) soft contact lenses or silicone rubber
uncontrolled
for
conjunctivitis which
TABLE IV
Other ocular abnormalities (83 eyes)
Persistent hyperplastic primary vitreous
Posterior lenticonus
Microphthalmos
Ant segment dysgenesis
Ectropion uveae
Dislocated lenses
Rubella retinopathy
Heterochromia
Blepharospasm
Iridopupillary membrane
4 eyes
4 eyes
'2 eyes
21 eyes
2 eyes
2 eyes
1 patient
1 patient
1 patient
1 patient
TABLE V
Postoperative surgical complications (n=141 eyes)
Pupilloplasty
Anterior vitrectomy
Glaucoma
(a) Improved medically
(b) Anterior vitrectomy
(c) Trabeculectomy
Residual lens matter extraction
Posterior capsulotomies
Squint surgery
Removal ofsutures underGA
Examination under anaesthetic for other reasons
Total
11
4
6
2
3
1
2
14
9
5
9
60
151
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Amaya, Speedwell, Taylor
Figure 1: Total number of
lenses per month per eye.
TABLE VII
discontinued (n=83)
Number ofpatients in whom contact lenses were
Hypoxic ulceration
High turnover
Parent's difficulties in handling contact lens
Others (preferred glasses)
Total
2
3
4
3
12
lenses they were symptom-free. Two patients
had
removal of the contact lenses and change of
parameters.
developed in three patients. Two of them were
changed to Polycon gas-permeable hard lenses,
with reduction in the pannus; the other was
changed to spectacle wear. Punctate keratitis
necessitating temporary lens removal was diag-
nosed in two patients, and three patients had
such a high incidence ofloss or renewal oflenses
(turnover) that their use was abandoned.
Twelve (14 5%) ofthe patients abandoned the
lens wear (Table VII), two with hypoxic ulcera-
tion, three with a high lens turnover, and four
with visually handicapped parents; three older
children had no major problems but preferred to
use spectacles. Five other patients stopped the
use of contact lenses for more than one month
but started them again.
81-1% of the eyes in the bilateral aphakes and
66-8% of the unilaterals had less than one lens
replaced per month (Figs 1, 2). In the first six
months oftreatment there was a higher incidence
than in later months of lens replacement either
for changes in parameters or because the lenses
were lost, broken, or rubbed out (Fig 3). 76-6%
ofthe bilateral cases and 80-76% ofthe unilateral
required less than one change oflens for reasons
of change in parameters.
excluded from this figure because they had been
treated for less than three months.
corneal oedema which subsided
after
1 mm or more of corneal pannus
Seven
eyes were
All patients treated
20
No. of
.16
eyes
14-
12
10
fl0~
Bilateral
Unilateral
8-
Lenses / month
Patients treated > 6 months
No. of
eyes
Figure 2: Number oflenses
per month per eye in patients
treatedfor more than six
months.
Bilateral
E2
Unilateral
Lenses / month
Patients treated < 6 months
No. of
eyes
20
18-
16
14
12
10 -
8-
6-
4-
2-
n1UL
f
_
2.0
_ _
2.5
_
| Bilateral
| Unilateral
0.51.0
1.5
3.0
Lenses / month
Figure 3: Number oflenses per month per eye in patients
treatedfor less than six months. There is a higher turnover in
thefirstsix months.
Power
of lens
( + D )
36 -
33-
30-
27 -
24 -
21 -
18 -
15 -
12 J
6
12 18
Months
24
3036
Figure 4: Powerofthe contact lenses compared with the age of
the patients. As the age increases there is a steady decrease in
thepowerofthe contact lenses.
Figure 4 shows the average power ofthe lenses
up to 3 years ofage (the dioptric value range from
12 to 34 dioptres), clearly demonstrating how the
required power of the lenses decreased as the
infants grew. Microphthalmic eyes remained
small, requiring high power lenses, even with
age.
The number of lenses issued during this
period was 1483. At a cost of £18 per lens, this
totalled £26 694. The total cost of solutions was
£3978. On average, the cost of lenses per month
per patient was £28.50. In addition to this
the costs of running the clinic must be taken
into account, including the services of an
optometrist, an ophthalmologist, an orthoptist,
and nurses.
Discussion
Microsurgical
improved the outcome of infantile cataract
surgery, and our results show that the number of
reoperations is small, the majority ofthem being
pupilloplasties, often to recentre the pupil when
it has been decentred, usually by vitreous
strands. Nine patients at risk for glaucoma
required repeated examinations under anaes-
thetic, but the incidence of glaucoma was low,
unless the eye was otherwise anomalous or
microphthalmic.3 We do not routinely remove
the corneal sutures, but when these are loose,
especially when contact lenses are used, they can
cause irritation until removed.
With our contact-lens fitting protocol there is a
techniques
have
considerably
TABLE VI
with contact lens induced
complications (n= 141)
Number ofeyes
Redeye
Infection
Hypoxic ulceration
Fine vascularisation
Intolerance
Oedema
Punctate keratitis
Total
12
18
3
3
3
2
2
43
152
P.
n L
HP
W H
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Contact lensesfor infant aphakia
low incidence of side effects attributable to the
use ofthe lenses. We have seen no cases ofgiant
papillary conjunctivitis.'7
bacterial conjunctivitis, hypoxic ulceration, and
corneal oedema is probably due to the daily lens
removal and sterilisation regimen.
Although it may be thought that daily handl-
ing of the lenses increases the risks of infection,
our experience suggests the opposite, and this
may be due to the careful handling by well
trained and dedicated parents. Electron micro-
scopyN' has shown that bacteria attach to the
surface of soft contact lenses and 'proliferate'
unless the lenses are removed, cleaned, and
sterilised frequently.2' Solutions with preserva-
tives such as thiomersal or chlorhexidine may
cause allergic reactions, butourhandling scheme
avoids thisproblem. The lens deposits associated
with this method were usually avoided because
ofthe high lens turnover.
The daily removal oflenses may appear daunt-
ing for parents, but most of them were willing
and co-operative and learned within the first
weeks. Four families could not get used to
handling the lenses: in two cases, the mothers
were blind, and in another the patient had very
microphthalmic, sunken eyes.
The parents were impressed with the need to
remove the lenses if there were any signs of
infection, red eye, or discomfort. General practi-
tioners cannot be expected to be experienced
with the use of lenses and cannot usually advise
on handling them or on the treatment ofcompli-
cations, so removal by the parents, especially if
they live far from ophthalmological care, is
especially important as a first step. When the
child was older, or where corneal damage was
evident, they were changed to more durable low-
water-content lenses.
Three patients, two of whom had worn soft
lenses for three years, developed superficial
corneal vessels of less than 1 mm. The low
incidence in this study was presumably due to
the short period of follow up and the daily wear
regimen.
Only 12 (14-5%) of the 83 patients discon-
tinued use oftheir contact lenses. Three ofthese
did not have a clinical reason to do so. They
found itmore convenient to use the spectacles, or
they had an excessively high turnover rate. This
rate
reported failure rate ofLevin etal,2' and there are
sufficient other reports ofsuccessful contact lens
wear in aphakic infants22 25 to suggest that it is a
technique that can be adopted by many depart-
ments already experienced with adult contact
lenses provided some differences in management
are used. Most parents were reluctant to change
their child to spectacle wear even if the wearing
oflenses had been difficult.
The loss ofcontact lenses in adults is relatively
low.26 Lens loss in infants is necessarily higher
owing to the frequent change in parameters, the
high rate of loss and breakage of lenses, and the
ocular complications. Because of the necessary
changes in contact lens parameters it is not
practical to fit many children in the United
Kingdom with silicone rubber lenses, which are
slow and expensive to obtain and which have
inherent surface problems. This material was
The low incidence of
is remarkably similar to the recently
therefore only occasionally used. Figures 4 and 5
show the change in power during the first year of
life, and the frequent need to change parameter.
This is in contrast to the study by Pratt-Johnson
and Tillson,' who did not change hard lens
parameters during the first five years of life.
81 1% of the eyes required fewer than one lens
per month; many of these lenses can be reused
once
sterilised.
The
infantile aphakia during the first three years of
life costs £440 in contact lenses and £112 in
solutions (aerosol saline and cleaning solution),
making a total of £562. These costs do not
include the services ofan ophthalmologist and an
optometrist, nor the considerable travel costs for
parents (Table I).
The optical correction of infantile aphakia
with daily wear soft contact lenses is an effective
and economical method. It has the adaptability
to respond to changes in the parameters, and the
parents can easily insertandremove the lenses. It
gives a high quality optical correction with a low
incidence of complications. It is cost effective,
though there are many hidden costs for the
parents. With a contact lens tolerance rate of
85 5% it is difficult to see a need for alternative,
relatively untried optical correction, such as
intraocular lenses, for the primary correction of
infantile aphakia.
optical
correction
of
This project has been supported by the Iris Fund for the
Prevention ofBlindness, and the Help a Child to See Fund.
1 Sato T, Saito N. Contact lenses for babies and children.
Contacto 1959; 3: 419-24.
2 Girard L. Corneal contact lenses. Highlights Ophthalmol 1961;
4:228-41.
3 Cassady J. Contact lenses for an infant. AmJ Ophthalmol 1963;
56: 305-6.
4 Gould HL. Visual rehabilitation of aphakic infants with
contact lenses. J Pediatr Ophthalmol Strabismus 1969; 6:
203-6.
5 Stark WJ, Kracher GP, Cowan CL, et al. Extended wear
contact lenses and intraocular lenses for aphakic correction.
AmJ Ophthalmol 1979; 88: 535-42.
6 Wright P, Mackie I. Preservative-related problems in soft
contact lens wearers. Trans Ophthalmol Soc UK 1982; 102:
3-7.
7 Mondino BJ, Salamon SM, Zaidman GW. Allergic and toxic
reactions in soft contact lens wearers. Surv Ophthalmol 1982;
26: 337-44.
8 Pratt-Johnson JA, Tillson G. Hard contact lenses in the
management of congenital cataracts. J7 Pediatr Ophthalmol
Strabismus 1985; 22: 94-7.
9 Nelson LB, Cutler SI, Calhoun JH, Wilson TW, Harley RD.
Silsoft extended wear contact lenses in pediatric aphakia.
Ophthalmology 1985; 92: 1529-32.
10 Levinson A, Ticho U. The useofcontact lenses in children and
infants. AmJ7 Optom Physiol Opt 1972; 49: 59-64.
11 Binkhorst CD, Gobin MH, Leonard PAM. Post-traumatic
artificial lens implants (pseudofakoi) in children. Br J
Ophthalmol 1969; 53: 518-29.
12 Hiles DA. Intraocular lens implantation in children with
monocular cataracts: 1974- 1983. Ophthalmology 1984; 91:
1231-8.
13 Taylor D. The integrated management ofcongenital cataract.
In: Ginsberg SP, ed. Cataract and intraocular lens surgery.
Birmingham, Alabama: Aesculapius, 1984: 527-35.
14 Arffa RC, Maveille TL, Morgan KS. Long term follow up of
refractive and keratometric results of pediatric epikerato-
phakia. Arch Ophthalmol 1986; 104: 668-70.
15 Kelley CG, Keates RH, Lembach RG. Epikeratophakia for
pediatric aphakia. Arch Ophthalmol 1986; 104: 680-2.
16 Hoyt C. The optical correction of pediatric aphakia. Arch
Ophthalmol 1986; 104: 651-2.
17 Fowler SA, Greiner JV, Mathea R, Allansmith MR. Soft
contact lenses from patients with giant papillary conjunc-
tivitis. AmJ Ophthalmol 1979; 88: 1056-61.
18 Korb DR, Greener J, Finniemore VM, Allansmith MR.
Biomicroscopy of papillae associated with wearing of soft
contact lenses. BrJ Ophthalmol 1983; 67: 733-6.
19 Mackie IA, Wright P. Giant papillary conjunctivitis in associa-
tion with contact lens wear. Trans OphthalmolSoc UK 1978;
98: 3-9.
20 Fowler SA, Greiner JV, Allansmith MR. Attachment of
bacteria to soft contact lenses. Arch Ophthalmol 1979; 97:
659-60.
153
group.bmj.com on July 11, 2011 - Published by bjo.bmj.com Downloaded from

Page 5

Amaya, Speedwell, Taylor
21 Levin AV, Edmonds SA, Nelson LB, Calhoun JH, Harley
RD. Extended wear contact lenses for the treatment of
pediatric aphakia. Ophthalmology 1988; 95: 1107-13.
22 Cutler SH, Nelson L, CalhounJ. Extended wear contact lenses
inpediatric aphakia.J7 PediatrOphthalmolStrabismus1985;
22: 86-92.
23 Davis H. Use of contact lenses in infants and children. BrJ
Phvsiol Optics 1971; 26: 15-9.
24 Davies PD, Tarbuck DTH. Management of cataracts in
infancy and childhood. Trans Ophthalmol Soct UK 1977; 97:
148-52.
25 Epstein RJ, Fernandez A, Gammon JA. The correction of
aphakia in infants with hydrogen. Ophthalmology 1988; 95:
1102-6.
26 Howde WL, Rubin M. Extended wear lenses, an update. Surv
Ophthalmol 1981; 26: 103-4.
154
group.bmj.com on July 11, 2011 - Published by bjo.bmj.comDownloaded from