Eye Movements, Strabismus, Amblyopia, and Neuro-Ophthalmology
Axial Elongation following Cataract Surgery during the
First Year of Life in the Infant Aphakia Treatment Study
Scott R. Lambert,1Michael J. Lynn,2Lindreth G. DuBois,1George A. Cotsonis,2
E. Eugenie Hartmann,3and M. Edward Wilson,4for the Infant Aphakia Treatment Study Groups5
PURPOSE. To compare ocular axial elongation in infants after
unilateral cataract surgery corrected with a contact lens (CL) or
primary intraocular lens (IOL) implantation.
METHODS. Baseline axial length (AL) was measured at the time
of cataract surgery (1–6 months) and at age 1 year. AL at
baseline and age 1 year and the change in length/mo were
analyzed in relation to treatment modality, cataractous versus
fellow eye, and age at surgery using linear mixed models.
RESULTS. Mean baseline AL did not differ between the CL and
IOL groups for either cataractous or fellow eyes. Eyes with
cataracts were shorter than fellow eyes by an average of 0.6
mm (95% confidence interval [CI], 0.4–0.8 mm; P < 0.0001).
For the operated eyes, the mean change in AL/mo was smaller
in the CL group (0.17 mm/mo) than in the IOL group (0.24
mm/mo) (P ¼ 0.0006) and was independent of age at surgery
(P ¼ 0.19). In contrast, the change in AL/mo for fellow eyes
decreased with older age at surgery (P < 0.0001). At age 1 year,
operated eyes treated with a CL were 0.6 mm shorter on
average than operated eyes treated with an IOL (P ¼ 0.009).
CONCLUSIONS. At baseline, eyes with cataracts were shorter than
fellow eyes. The change in AL/mo was smaller in operated eyes
treated with a CL than in operated eyes treated with an IOL, but
was not significantly related to age at surgery. (ClinicalTrials.
gov number, NCT00212134.) (Invest Ophthalmol Vis Sci. 2012;
the eye so that the desired refractive error can be achieved
when the eye is fully grown. The infant eye elongates rapidly
during the first year of life.1,2Both visual deprivation and
optical defocus can alter ocular growth.3,4In addition,
glaucoma during early childhood can cause excessive axial
ne of the most challenging facets of implanting intraocular
lenses (IOLs) during infancy is predicting the growth of
elongation.5Postoperative refractive errors are usually correct-
ed by spectacles or contact lenses. However, if the eye grows
more than expected after IOL implantation, a large myopic
refractive error may develop that in extreme cases may
necessitate an IOL exchange.
The effect of removing the crystalline lens on axial
elongation during early childhood is poorly understood.6–12
In a newborn rabbit model, a unilateral lensectomy has been
shown to significantly decrease axial elongation.13A similar
effect has also been observed using a nonhuman primate
model.14,15The effect is age dependent, with the greatest
effect occurring in neonates.16While some series have
reported a reduction of axial elongation following cataract
surgery and IOL implantation in children, others have reported
increased axial elongation.6,17,18Furthermore, unilateral cata-
ract surgery during infancy has been reported to be associated
with more axial elongation in the operated eye than bilateral
cataract surgery.19,20These effects have important clinical
implications in determining the optimal IOL power to implant
in a child to achieve the desired refractive correction later in
The Infant Aphakia Treatment Study (IATS) is a randomized
clinical trial comparing the effect of primary IOL implantation
versus aphakia corrected with a contact lens (CL) in infants 1
to 6 months of age following unilateral cataract surgery. We
previously reported that visual acuity was not significantly
different between the operated eyes of the two treatment
groups at age 12 months.21,22We now report the longitudinal
changes in axial length (AL) from the time of cataract surgery
until an examination under anesthesia (EUA) was performed
between the ages of 11 and 12 months.
The study design, surgical technique, follow-up schedules, patching
and optical correction regimens, evaluation methods, definitions used
for glaucoma and glaucoma suspect, and patient characteristics at
baseline have been reported in detail previously and are only
summarized in this report.21,23The study followed the tenets of the
Declaration of Helsinki, was approved by the institutional review
boards of the participating institutions, and was in compliance with the
Health Insurance Portability and Accountability Act. The off-label
research use of the AcrySof SN60AT and MA60AC IOLs (Alcon
Laboratories, Fort Worth, TX) was covered by US Food and Drug
Administration investigational device exemption No. G020021.
The main inclusion criteria were a visually significant congenital
cataract (‡3 mm central opacity) in one eye, a normal fellow eye, and
an age of 28 days to <210 days at the time of cataract surgery. The main
exclusion criteriawere an acquired cataract, persistent fetal vasculature
(PFV) causing stretching of the ciliary processes, a corneal diameter <9
From the Departments of1Ophthalmology and2Biostatistics
and Bioinformatics, Emory University, Atlanta, Georgia; the3Depart-
ment of Optometry, University of Alabama at Birmingham, Birming-
ham, Alabama; and the
4Medical University of South Carolina,
Charleston, South Carolina.
5See Appendix for a list of the members of the Infant Aphakia
Treatment Study Group.
Supported by National Institutes of Health Grants U10 EY13272
and U10 EY013287 and in part by NIH Departmental Core Grant
EY06360 and Research to Prevent Blindness, Inc., New York, New
Submitted for publication May 29, 2012; revised September 3
and October 2, 2012; accepted October 11, 2012.
Disclosure: S.R. Lambert, None; M.J. Lynn, None; L.G.
DuBois, None; G.A. Cotsonis, None; E.E. Hartmann, None;
M.E. Wilson, None
Corresponding author: Scott R. Lambert, Emory Eye Center,
1365-B Clifton Road, Atlanta, GA 30322; firstname.lastname@example.org.
Investigative Ophthalmology & Visual Science, November 2012, Vol. 53, No. 12
Copyright 2012 The Association for Research in Vision and Ophthalmology, Inc.
mm, a medical condition that might interfere with recognition visual
acuity testing at age 4.5 years, an intraocular pressure (IOP) ‡25 mm
Hg, and prematurity (<36 gestational weeks). Patients were random-
ized either to have an IOL placed at the time of the initial surgery or to
be left aphakic and optically corrected with a CL.
Axial Length Measurements
Baseline AL measurements on both eyes of all patients were obtained
during an EUA performed prior to cataract surgery. A second EUA was
performed 2 to 4 weeks prior to the grating acuity assessment at age 1
year. Thirty minutes prior to the EUA, both eyes were dilated with 1%
cyclopentolate and 2.5% Neo-Synephrine. A-scan biometry was
performed using immersion or applanation. Most A-scans were
performed with an Eye Cubed (Innovative Imaging, Sacramento, CA;
now owned by Ellex, Eden Prairie, MN) ultrasound unit, which has a
clinical accuracy of 60.1 mm. The A-scan with the best waveforms
(e.g., the highest five spikes with a perpendicular retinal spike) was
recorded on a case report form, and the tracing was printed. A-scan
tracings were then submitted to the Data Coordinating Center.
A-scan tracings were graded by a masked certified echographer and
graded as being valid, invalid, or unreadable. A-scans were judged as
valid if the gates, mode, and eye type (phakic, aphakic, or
pseudophakic acrylic) were set correctly; if corneal, lens (baseline
and pseudophakic eyes only), and retinal spikes were visible and of
sufficient gain to be measurable; and if the leading edge of the retinal
spike was perpendicular to the baseline. If an error was detected that
could cause the AL measurement to be inaccurate by >0.2 mm (e.g.,
inappropriate mode, improper gate or caliper placement, or poor spike
quality), then the scan was classified as invalid. A-scans were judged to
be unreadable if the quality of the printout was degraded so that the
scan could not be adequately assessed. Measurements from invalid,
unreadable, and missing A-scans were not included in the analyses. A-
scans from patients with glaucoma or glaucoma suspect were also
excluded from the analysis because of the excessive axial elongation
that occurs in infantile eyes with glaucoma.5,24
Infants randomized to the CL group underwent a lensectomy and
anterior vitrectomy. Infants randomized to the IOL group had their lens
aspirated followed by the implantation of an AcrySof SN60AT (Alcon
Laboratories) IOL into the capsular bag. In the event that both haptics
could not be implanted into the capsular bag, an AcrySof MA60AC IOL
was implanted into the ciliary sulcus. The IOL power was calculated
based on the Holladay 1 formula targeting an 8-diopter (D) under-
correction for infants 4 to 6 weeks of age and a 6 D undercorrection for
infants older than 6 weeks. Following IOL placement, a posterior
capsulectomy and an anterior vitrectomy were performed through the
Within a week after cataract surgery, patients randomized to the CL
group were fit with a Silsoft (Bausch and Lomb, Rochester, NY) or a
rigid gas-permeable contact lens with a 2.0 D overcorrection to provide
a near point focus. For patients randomized to the IOL group,
spectacles were prescribed prior to the 1-month postoperative visit
with an overcorrection of 2.0 D. The prescribed optical correction was
to be worn at all times while the patient was awake. Spectacle, CL, and
patching adherence was monitored by a 7-day diary completed 2
months after surgery and 48-hour recall interviews conducted 3 and 6
months after surgery.25
Mean age at baseline was compared between treatment groups using
an independent groups t-test. To assess whether there was a difference
in age according to whether or not patients were included in the
analyses, a one-way analysis of variance was used to compare mean age
among three groups of patients: patients included in the analysis;
patients excluded because of glaucoma; and patients excluded because
of missing, unreadable, or invalid A-scans.
Mean AL at baseline was compared between treatment groups and
eyes (cataractous versus fellow) accounting for age at surgery with a
linear mixed model assuming compound symmetry that included
treatment as a between-subjects factor, eye as a within-subject factor,
age as a covariate, and all interactions. Adjusted (least squares) means
and 95% confidence intervals for baseline AL were calculated from the
model. Baseline AL in the cataractous eye was related to age with linear
Since there were only two time points at which AL was measured,
and since the age at which the first measurement was made varied
among the patients while the second measurement was done at
relatively similar ages, the longitudinal change in AL was quantified as
the change in AL/mo. The calculation was made by subtracting the first
measurement of AL from the second measurement and dividing by the
time difference in months between the measurements. If either of the
two measurements was missing for an eye, that eye was not included in
the analysis. The change in AL (mm/mo) was related to treatment (IOL
versus CL), eye (cataractous versus fellow eye), and age at surgery
using a linear mixed model assuming compound symmetry with
treatment as a between-subjects factor, eye as a within-subject factor,
age at surgery as a covariate, and all interactions. Adjusted (least
squares) means and 95% confidence intervals for the change in AL/mo
were calculated from the model according to treatment, eye, and
selected ages. Separate models were also run for the cataractous and
Mean AL at 1 year of age was evaluated using the same linear mixed
model as for AL at baseline. For all analyses, a P value < 0.05 was
deemed statistically significant. All statistical analyses were done with
SAS 9.2 (SAS Institute Inc., Cary, NC).
Of the 114 patients enrolled (57 per treatment), 10 patients
were subsequently diagnosed with glaucoma (CL¼3, IOL¼7)
in their operated eye, and 4 were considered to be glaucoma
suspects (CL ¼ 2, IOL ¼ 2) by the age 1 year EUA.26Because
elevation of intraocular pressure during infancy is known to
cause ocular enlargement, these patients were excluded from
the analyses (Table 1). We also excluded an eye from the
analyses if either the baseline or age 1 year AL was not available
because the A-scan tracing was missing, invalid, or unreadable.
Of the 100 patients without glaucoma or glaucoma suspect, 21
(CL ¼ 7, IOL ¼ 14) were excluded because both eyes had
certain AL data that were unavailable, leaving 79 patients (CL¼
45, IOL ¼ 34). Several of these 79 patients had either the
operated or the fellow eye excluded because certain AL data
were unavailable for that eye. Among the 79 patients, for 62
(CL¼37, IOL¼25), both eyes were included; for 9 (CL¼3, IOL
¼6), only the operated eye was included; and for 8 (CL¼5, IOL
¼ 3), only the fellow eye was included. The total number of
eyes included in the analyses was 141 (operated¼71, fellow¼
70). Of these 141 eyes, AL was measured by immersion at both
exams for 95 (67%), by contact at both exams for 26 (18%), by
immersion at one exam and contact at the other for 11 (8%),
and by immersion at one exam and an unspecified technique at
the other for 9 (6%).
The mean (6 standard deviation) age at surgery among the 79
patients included in the analysis was 2.6 6 1.6 months (range,
7540Lambert et al.
IOVS, November 2012, Vol. 53, No. 12
0.9–6.8); 45 (57%) were female and 68 (86%) were white. The
mean patient age was not significantly different between
treatment groups (CL, 2.5 6 1.7 months; IOL, 2.6 6 1.7
months; P ¼ 0.81). The mean age among the 14 patients
excluded for glaucoma or glaucoma suspect was 1.7 months
versus 2.6 months for both the 21 patients excluded because of
missing, unreadable, or invalid A-scans and the 79 patients
included in the analyses (P ¼ 0.17).
P values for the linear mixed model analysis of baseline AL
are shown in Table 2. As expected because of randomization,
baseline AL was not significantly related to treatment (P ¼
0.62). This was demonstrated in an analysis of least squares
means, which showed that mean AL adjusted for age was not
significantly different between the treatment groups for either
the cataractous eyes (CL, 18.1 mm; IOL, 17.9 mm; P¼0.46) or
the fellow eyes (CL, 18.5 mm; IOL, 18.7 mm; P ¼ 0.23). The
treatment groups were compared for cataractous and fellow
eyes separately since the linear mixed model analysis showed
that baseline AL differed according to the type of eye (P <
0.0001, Table 2). Mean AL adjusted for age for fellow eyes (18.6
mm) was significantly greater than for cataractous eyes (18.0
mm) (mean difference, 0.6 mm; 95% confidence interval [CI],
0.4–0.8 mm; P < 0.0001).
Baseline AL was strongly associated with age at surgery (P <
0.0001, Table 2). We examined this relationship in detail for
the cataractous eyes. Since baseline AL was not related to
treatment, we combined the cataractous eyes from the two
treatment groups. Figure 1 demonstrates the strong association
between baseline AL and age (n¼75, r¼0.69; P < 0.0001). On
average, the AL increases 0.5 mm (95% CI, 0.4–0.6 mm) per
month among patients in the age range studied (1–7 months of
age). The estimated mean AL at 1 month of age was 17.2 mm
(95% CI, 16.9–17.5) and increased to 19.9 mm at age 6 months
(95% CI, 19.4–20.4).
Change in Axial Length
Longitudinal changes in AL for the operated and fellow eyes are
shown in Figure 2. Age at the time of the first measurement
varied among patients but was relatively similar for the second
measurement. Table 2 shows the P values associated with the
various terms in the linear mixed model. Figure 3 shows the
mean change in AL/mo estimated from the model versus age at
surgery according to treatment group (CL versus IOL) and eye
(operated versus fellow). The notable results are the significant
two-way interactions. One of these was eye 3 age (0.0072),
indicating that the change in AL/mo decreased significantly
with increasing age at surgery in the fellow eyes but not in the
operated eyes. This is demonstrated in Figure 3, where the
slopes of the lines are greater for the fellow eyes than for the
operated eyes. The second significant two-way interaction was
treatment 3 eye (0.042), suggesting that the difference
Number of Patients Included in the Analyses
No. of Patients
No. of Patients
No. of Patients
Axial length available
Operated eye only
Fellow eye only
P Values for Linear Mixed Model Analyses
P Values for Axial Length Analyses
Baseline AL*Change in AL per Month Age 1 Year AL
Treatment (CL vs. IOL)
Eye (cataractous vs. fellow)
Age at surgery
Interaction: treatment 3 eye
Interaction: treatment 3 age
Interaction: eye 3 age
Interaction: treatment 3 eye 3 age
* AL, axial length.
Axial length versus age at surgery for the cataractous eyes.
IOVS, November 2012, Vol. 53, No. 12
Axial Elongation after Cataract Surgery in the IATS7541
between operated and fellow eyes was not the same for the
two treatment groups. This can be seen in Figure 3, as the
operated and fellow eyes are more similar in the IOL group
than in the CL group.
Separate models were fit for the operated and fellow eyes
that included treatment, age at surgery, and the interaction of
treatment and age. The interaction was not significant for
either (operated: P ¼ 0.47; fellow: P ¼ 0.71). For the no-
interaction model for operated eyes, age was not significant (P
¼ 0.19), but the mean change in AL/mo was significantly
different between treatments (estimated means: CL, 0.17 mm/
mo; IOL, 0.24 mm/mo; P ¼ 0.0006). For the no-interaction
model for fellow eyes, treatment was not significant (P¼0.13),
but age was significant (P < 0.0001). In a linear regression
model with age as the only variable, the estimated mean
change in AL/mo was 0.28 mm/mo at 1 month of age (95% CI,
0.26–0.30) and 0.14 mm/mo at 6 months of age (95% CI, 0.11–
Axial Length at 1 Year of Age
In the linear mixed model for AL at 1 year of age, there was a
significant interaction for eye and age at surgery (Table 2),
indicating that the effect of age at surgery on the AL at 1 year of
age differed between operated eyes and fellow eyes (P ¼
0.0012). Separate models were fit for the operated and fellow
eyes that included treatment, age at surgery, and the
interaction of treatment and age.
For the operated eyes, the interaction was not significant (P
¼ 0.54). For the model without interaction, age at surgery was
significant (P < 0.0002) with a trend for significance with
treatment (P¼0.1). Therefore, we report the mean AL at 1 year
of age estimated from the model for different values of age at
surgery for the two treatment groups. The mean AL was 19.0
mm for aphakic and 19.5 mm for pseudophakic eyes having
surgery at 1 month of age and 20.6 mm for aphakic and 21.1
mm for pseudophakic eyes having surgery at 6 months of age
For fellow eyes, neither treatment (P¼0.63), age at surgery
(P ¼ 0.46), nor the interaction (P ¼ 0.89) was statistically
significant. Since none of these factors were significant, we
Longitudinal changes in axial length for the aphakic and pseudophakic eyes and fellow eyes in the CL and IOL groups.
surgery according to treatment group (contact lens versus intraocular
lens) and eye (operated versus fellow).
Mean change in axial length per month versus age at
7542 Lambert et al.
IOVS, November 2012, Vol. 53, No. 12
report the overall mean AL at 1 year of age for fellow eyes: 20.7
6 0.6 mm (95% CI for mean, 20.5–20.8 mm).
Prior to cataract surgery, the mean AL was similar for the
cataractous eyes in the two treatment groups. However, at 1
year of age, the mean AL of the pseudophakic eyes was 0.6 mm
longer than the mean AL of the aphakic eyes. This difference is
the result of a reduced rate of axial elongation in aphakic eyes
compared to pseudophakic eyes, which was independent of
the age of the infant at the time of cataract surgery. In contrast,
the fellow eyes had nearly the same axial elongation in the two
treatment groups, resulting in comparable ALs at age 12
A number of retrospective case series have evaluated the
effect of pediatric cataract surgery on axial elongation.
Differing results have been reported, ranging from reduced12,27
to greater axial elongation in pseudophakic eyes or no
effect.6,20,28However, unlike the IATS, all of these studies
were retrospective, with a wide range of inclusion criteria. In
addition, most used applanation biometry whereas we
primarily used immersion biometry.29Finally, we analyzed
only the data from patients with valid A-scan tracings as judged
by a masked echographer. None of the publications on these
other studies mentioned evaluation of the quality of the A-
scans used in the analyses.
Studies using a nonhuman primate model have also
reported a retardation of axial elongation following a
lensectomy during infancy. Lambert et al.15simulated a
unilateral congenital cataract by placing a translucent contact
lens on the right eye of a cohort of infant Rhesus monkeys.
When the monkeys were 11 to 16 days of age, a lensectomy
was performed on their right eyes. Some of the eyes had an IOL
implanted while others were left aphakic and corrected with a
contact lens. At 5 weeks of age, both the aphakic and the
pseudophakic eyes were significantly shorter than their fellow
eyes. At 12 months of age, the mean ALs of the pseudophakic
eyes were 2.0 6 0.2 mm shorter than their fellow eyes
whereas the aphakic eyes were 2.3 6 0.2 mm shorter than
their fellow eyes. The retardation of axial elongation that
occurs following a lensectomy has been shown to be age
dependent. While a large reduction in axial elongation was
noted in monkeys undergoing a lensectomy at 4 days and 2
weeks of age, only a small effect was noted after a lensectomy
at 7.5 months and 1 year of age.16We did not find the
retardation of AL to be age dependent in our study. However,
we studied only infants 1 to 6 months of age. Bradley and
coworkers30have also reported that axial elongation in the
untreated eye can be affected by the treatment of the fellow
eye in a nonhuman primate model. In our study, we did not
find that the type of treatment of the operated eyes had an
effect on axial elongation of the untreated fellow eyes.
It is uncertain why aphakic eyes in our study experienced
less ocular growth than pseudophakic eyes. One possibility is
that the pseudophakic eyes had an increased number of
additional intraocular surgeries, which we have reported
previously.21,22Most of these surgeries were performed to
clear visual axis opacities. These additional intraocular
surgeries may have elevated the level of chemical mediators
in these eyes, such as prostaglandins, which may have altered
ocular growth.31,32A second possibility is that axial elongation
was altered for optical reasons. Defocusing with plus and
minus lenses has been shown to alter axial elongation in a
nonhuman primate model.4,33However, this seems unlikely
since the operated eye in both treatment groups was focused
to a near point and since compliance with contact lens and
spectacle use was quite good.21Finally, there may have been a
difference in the IOP between the operated eyes in the two
treatment groups. However, this is unlikely since all eyes that
were judged to have glaucoma or glaucoma suspect were
excluded from the analysis.
As expected, we found that the mean change in AL/mo was
greater in the fellow eyes of patients enrolled at a younger age.
Others have reported a deceleration of axial elongation during
the first year of life in normal eyes.1,2Therefore an infant
enrolled in the study at 1 month of age would be expected to
have a greater mean change in AL/mo than an infant enrolled in
the study at 6 months of age. A novel finding in our study was
that the mean change in AL/mo for the operated eyes was not
correlated with the age at cataract surgery.
This study has a number of limitations. First, the follow-up
was variable, ranging from 6 to 11 months depending on the
age of the child at the time of cataract surgery. In addition, the
follow-up was only until approximately age 1 year; therefore
our estimates of change per month apply only up to that age.
We plan to repeat biometry on all of these patients when they
are 5 years of age, which will allow us to assess axial elongation
after these patients have completed the period of rapid axial
elongation in the first 2 years of life.1,2Second, the quality of
the A-scans varied between clinical centers. While two-thirds
of patients had biometry performed in both eyes using
immersion, the other one-third had biometry performed in
both eyes using applanation or in one eye using applanation
and in one eye using immersion. A recent prospective study
comparing AL measurements obtained by immersion and
contact biometry found that AL measurements obtained using
applanation were on average 0.27 mm shorter, presumably
secondary to corneal compression during applanation.29Third,
of the 114 patients enrolled in the study, 35 (31%) were not
included in the analyses. Fourteen patients were excluded
because they developed glaucoma.34In addition, 21 patients
were not included because of missing or invalid A-scans.
However, this group was similar in age to the patients who
were included, which suggests that factors related to age, such
as greater difficulty in measuring AL in younger patients, did
not systematically eliminate patients from analysis. Finally,
more of the patients in the CL (n¼45) versus the IOL group (n
¼ 34) were included in the analysis. This was partially due to
the increased number of eyes in the IOL group that had
glaucoma or were glaucoma suspects (IOL, n ¼ 9; CL, n ¼ 5)
and possibly the increased difficulty of obtaining a valid A-scan
in a pseudophakic eye.
pseudophakic eyes as a function of age at the time of cataract surgery.
Mean axial length at 1 year of age for aphakic and
IOVS, November 2012, Vol. 53, No. 12
Axial Elongation after Cataract Surgery in the IATS7543
Our findings are clinically important because they suggest
that cataract surgery coupled with IOL implantation is
associated with increased axial elongation compared to
cataract surgery without IOL implantation during infancy. In
our study, we targeted an undercorrection in the operated eye
for infants undergoing IOL implantation of 8 D for infants 6
weeks or younger and 6 D for infants older than 6 weeks,
which was based on data from a pilot study.35After these
patients have been followed over a longer time period, we will
be able to evaluate the long-term accuracy of our targeted
Cynthia Kendall graded the A-scan tracings and provided training
to the IATS investigators on how to perform biometry.
1. Gordon RA, Donzis PB. Refractive development of the human
eye. Arch Ophthalmol. 1985;103:785–789.
2. Manzitti E, Gamio S, Damel A, Benozzi J. Eye length in
congenital cataracts. In: Cotlier E, Lambert S, Tayor D, eds.
Congenital Cataracts. Austin, TX: R.G. Landes Company;
3. Wiesel TN, Raviola E. Myopia and eye enlargement after
neonatal lid fusion in monkeys. Nature. 1977;266:66–68.
4. Hung LF, Crawford ML, Smith EL. Spectacle lenses alter eye
growth and the refractive status of young monkeys. Nat Med.
5. Sampaolesi R, Caruso R. Ocular echometry in the diagnosis of
congenital glaucoma. Arch Ophthalmol. 1982;100:574–577.
6. Hutchinson AK, Wilson ME, Saunders RA. Outcomes and
ocular growth rates after intraocular lens implantation in the
first 2 years of life. J Cataract Refract Surg. 1998;24:846–852.
7. Flitcroft DI, Knight-Nanan D, Bowell R, Lanigan B, O’Keefe M.
Intraocular lenses in children: changes in axial length, corneal
curvature, and refraction. Br J Ophthalmol. 1999;83:265–269.
8. Inatomi M, Kora Y, Kinohira Y, Yaguchi S. Long-term follow-up
of eye growth in pediatric patients after unilateral cataract
surgery with intraocular lens implantation. J AAPOS. 2004;8:
9. Lal G, Trivedi RH, Wilson ME Jr, Scarlett LC, Peterseim MM.
Interocular axial length difference in eyes with pediatric
cataracts. J AAPOS. 2005;9:358–362.
10. Trivedi RH, Wilson ME Jr. Changes in interocular axial length
after pediatric cataract surgery. J AAPOS. 2007;11:225–229.
11. McClatchey SK, Dahan E, Maselli E, et al. A comparison of the
rate of refractive growth in pediatric aphakic and pseudo-
phakic eyes. Ophthalmology. 2000;107:118–122.
12. Sminia ML, de Faber JT, Doelwijt DJ, Wubbels RJ, Tjon-Fo-Sang
M. Axial eye length growth and final refractive outcome after
unilateral paediatric cataract surgery. Br J Ophthalmol. 2010;
13. Kugelberg U, Zetterstrom C, Lundgren B, Syren-Nordqvist S.
Eye growth in the aphakic newborn rabbit. J Cataract Refract
14. Lambert SR, Fernandes A, Grossniklaus H, Drews-Botsch C,
Eggers H, Boothe RG. Neonatal lensectomy and intraocular
lens implantation: effects in rhesus monkeys. Invest Ophthal-
mol Vis Sci. 1995;36:300–310.
15. Lambert SR, Fernandes A, Drews-Botsch C, Tigges M.
Pseudophakia retards axial elongation in neonatal monkey
eyes. Invest Ophthalmol Vis Sci. 1996;37:451–458.
16. Lambert SR. The effect of age on the retardation of axial
elongation following a lensectomy in infant monkeys. Arch
17. Griener ED, Dahan E, Lambert SR. Effect of age at time of
cataract surgery on subsequent axial length growth in infant
eyes. J Cataract Refract Surg. 1999;25:1209–1213.
18. Kora Y, Shimizu K, Inatomi M, Fukado Y, Ozawa T. Eye growth
after cataract extraction and intraocular lens implantation in
children. Ophthalmic Surg. 1993;24:467–475.
19. Lorenz B, Worle J, Friedl N, Hasenfratz G. Ocular growth in
infant aphakia. Bilateral versus unilateral congenital cataracts.
Ophthalmic Paediatr Genet. 1993;14:177–188.
20. Vasavada AR, Raj SM, Nihalani B. Rate of axial growth after
congenital cataract surgery. Am J Ophthalmol. 2004;138:915–
21. Lambert SR, Buckley EG, Drews-Botsch C, et al. A randomized
clinical trial comparing contact lens with intraocular lens
correction of monocular aphakia during infancy: grating acuity
and adverse events at age 1 year. Arch Ophthalmol. 2010;128:
22. Plager DA, Lynn MJ, Buckley EG, Wilson ME, Lambert SR.
Complications, adverse events, and additional intraocular
surgery 1 year after cataract surgery in the infant aphakia
treatment study. Ophthalmology. 2011;118:2330–2334.
23. Lambert SR, Buckley EG, Drews-Botsch C, et al. The infant
aphakia treatment study: design and clinical measures at
enrollment. Arch Ophthalmol. 2010;128:21–27.
24. Kiskis AA, Markowitz SN, Morin JD. Corneal diameter and axial
length in congenital glaucoma. Can J Ophthalmol. 1985;20:
25. Drews-Botsch CD, Celano M, Kruger S, Hartmann EE.
Adherence to occlusion therapy in the first six months of
follow-up and visual acuity among participants in the Infant
Aphakia Treatment Study (IATS). Invest Ophthalmol Vis Sci.
26. Beck AD, Freedman SF, Lynn MJ, Bothun E, Neely DE, Lambert
SR. Glaucoma-related adverse events in the Infant Aphakia
Treatment Study: 1-year results. Arch Ophthalmol. 2012;130:
27. Griener E, Lambert SR. Successful treatment of tractional
corectopia using 2 mJ of energy with an Nd:YAG laser. J
28. Hussin HM, Markham R. Changes in axial length growth after
congenital cataract surgery and intraocular lens implantation
in children younger than 5 years. J Cataract Refract Surg.
29. Trivedi RH, Wilson ME. Axial length measurements by contact
and immersion techniques in pediatric eyes with cataract.
30. Bradley DV, Fernandes A, Boothe RG. The refractive develop-
ment of untreated eyes of rhesus monkeys varies according to
the treatment received by their fellow eyes. Vision Res. 1999;
31. Lenart TD, Drack AV, Tarnuzzer RW, Fernandes A, Lambert SR.
Heterochromia after pediatric cataract surgery. JAAPOS. 2000;
32. Tarnuzzer RW, Fernandes A, Iuvone PM, Lambert SR. Neonatal
aphakia retards ocular growth and alters scleral gene
expression in rhesus monkeys. Mol Vis. 2005;11:36–49.
33. Smith EL III, Hung LF. The role of optical defocus in regulating
refractive development in infant monkeys. Vision Res. 1999;
34. Beck AD, Freedman SF, Lynn MJ, Bothun E, Neely D, Lambert
SR; Infant Aphakia Treatment Study Group. Glaucoma-related
adverse events in the Infant Aphakia Treatment Study (IATS):
1-year results. Arch Ophthalmol. 2012;130:300–305.
35. Lambert SR, Buckley EG, Plager DA, Medow NB, Wilson ME.
Unilateral intraocular lens implantation during the first six
months of life. J AAPOS. 1999;3:344–349.
7544Lambert et al.
IOVS, November 2012, Vol. 53, No. 12
APPENDIX Download full-text
The Infant Aphakia Treatment Study Group
Administrative Units and Participating Clinical
Centers: Clinical Coordinating Center (Emory University):
Scott R. Lambert, MD (Study Chair); Lindreth DuBois, MEd,
MMSc (National Coordinator).
Data Coordinating Center (Emory University): Michael
Lynn, MS (Director), Betsy Bridgman, BS; Marianne Celano,
PhD; Julia Cleveland, MSPH; George Cotsonis, MS; Carey
Drews-Botsch, PhD; Nana Freret, MSN; Lu Lu, MS; Seegar
Swanson; Thandeka Tutu-Gxashe, MPH.
Visual Acuity Testing Center (University of Alabama,
Birmingham): E. Eugenie Hartmann, PhD (Director); Clara
Edwards; Claudio Busettini, PhD; Samuel Hayley, BS.
Steering Committee: Scott R. Lambert, MD; Edward G.
Buckley, MD; David A. Plager, MD; M. Edward Wilson, MD;
Michael Lynn, MS; Lindreth DuBois, MEd, MMSc; Carolyn
Drews-Botsch, PhD; E. Eugenie Hartmann, PhD; Donald F.
Contact Lens Committee: Buddy Russell, COMT; Michael
Participating Clinical Centers (in order by the
number of patients enrolled): Medical University of South
Carolina; Charleston, South Carolina (14): M. Edward Wilson,
MD; Margaret Bozic, CCRC, COA.
Harvard University; Boston, Massachusetts (14): Deborah K.
Vanderveen, MD; Theresa A. Mansfield, RN; Kathryn Bisceglia
University of Minnesota; Minneapolis, Minnesota (13):
Stephen P. Christiansen, MD; Erick D. Bothun, MD; Ann
Holleschau, BA; Jason Jedlicka, OD; Patricia Winters, OD; Jacob
Cleveland Clinic; Cleveland, Ohio (10): Elias I. Traboulsi,
MD; Susan Crowe, BS, COT; Heather Hasley Cimino, OD.
Baylor College of Medicine; Houston, Texas (10): Kimberly
G. Yen, MD; Maria Castanes, MPH; Alma Sanchez, COA; Shirley
Oregon Health and Science University; Portland, Oregon
(9): David T Wheeler, MD; Ann U. Stout, MD; Paula Rauch, OT,
CRC; Kimberly Beaudet, CO, COMT; Pam Berg, CO, COMT.
Emory University; Atlanta, Georgia (9): Scott R. Lambert,
MD; Amy K. Hutchinson, MD; Lindreth DuBois, MEd, MMSc;
Rachel Robb, MMSc; Marla J. Shainberg, CO.
Duke University; Durham, North Carolina (8): Edward G.
Buckley, MD; Sharon F. Freedman, MD; Lois Duncan, BS; B.W.
Phillips, FCLSA; John T. Petrowski, OD.
Vanderbilt University; Nashville, Tennessee (8): David
Morrison, MD; Sandy Owings, COA, CCRP; Ron Biernacki,
CO, COMT; Christine Franklin, COT.
Indiana University (7): David A. Plager, MD; Daniel E. Neely,
MD; Michele Whitaker, COT; Donna Bates, COA; Dana
Miami Children’s Hospital (6): Stacey Kruger, MD; Charlotte
Tibi, CO; Susan Vega.
University of Texas Southwestern; Dallas, Texas (6): David
R. Weakley, MD; David R. Stager Jr, MD; Joost Felius, PhD; Clare
Dias, CO; Debra L. Sager; Todd Brantley, OD.
Data and Safety Monitoring Committee: Robert Hardy, PhD
(Chair); Eileen Birch, PhD; Ken Cheng, MD; Richard Hertle,
MD; Craig Kollman, PhD; Marshalyn Yeargin-Allsopp, MD
(resigned); Cyd McDowell; Donald F. Everett, MA.
Medical Safety Monitor: Allen Beck, MD.
IOVS, November 2012, Vol. 53, No. 12
Axial Elongation after Cataract Surgery in the IATS 7545