April 18, 2022
3 minute read
Disclosures: Fortunato does not report any relevant financial information. Wilson claims to be a consultant for Alcon and Kala Pharmaceuticals.
Click here to read the cover story, “US Surgeons Benefit from Early Adoption of High-End IOLs by European Colleagues.”
Positive experience with multifocal technologies
I have a long experience of pseudoaccommodating IOLs in pediatric patients.
Since the first 3M diffractive implants in 1989, I have used them in over 2,100 children and I always welcome new innovations such as trifocal and extended depth of field (EDOF) lenses. So far, I’ve only implanted a small number (27 and 12 respectively), and my follow-up is limited, but I’ve been favorably impressed, especially with the trifocals. EDOF IOLs, at this stage of development, are insufficient for good reading vision, which is critically important for children.
Initially, when multifocal technologies first debuted, I was skeptical of their use in pediatric patients, and as I do with every new lens, I tried them first in adults. When I finally decided to implant them in children, I was surprised at how quickly and well they adapted. While adults must reset and retrain the visual brain through a slow and not always successful process, the neural plasticity of children’s brains allows them to learn to see through these lenses easily and naturally, without photic phenomena and loss of sensitivity. in contrast. , as shown by a study we carried out on 270 cases. After implantation of diffractive IOLs, they develop excellent vision at all distances, including intermediates, which has never been seen in adults. Importantly, the lens power is under-corrected to account for myopic shift, similar to how we would with monofocal IOLs.
When we operate on cataracts in children, we make them as far-sighted as at 65 at a time when the development of near visual function is crucial. Multifocal IOLs are the only option that preserves accommodation and therefore full visual function in a young eye. My long follow-up of many patients until adulthood has shown that good vision is maintained over time. Only in a few cases have I swapped IOLs with a similar lens from a later generation. These were patients with a family history of myopia who developed high myopia in adolescence.
My top choice so far has been the diffractive multifocal IOLs with a near +4 add, leading to an approximate +3.25 add at the plane of the glasses. In case of unilateral cataract, implantation must be performed early, within the first 12 months of life. With bilateral cataracts, one can wait longer, assess the individual case and discuss it with the parents because compliance with postoperative visual rehabilitation is crucial.
Michele Fortunato, MD, is an ophthalmologist at the Bambino Gesù Pediatric Hospital in Rome.
Axial Growth May Affect Long-Term Outcomes
In children, monofocal IOLs are the implant of choice due to their superior image quality and minimal visual aberrations.
Next-generation trifocal and extended depth-of-field (EDOF) lenses are remarkable, but their performance is sensitive to residual refractive error. In children, initial IOL calculations are often less accurate and continued axial growth of the eye ensures that any accuracy initially achieved will not remain unchanged over time. Myopic change is most pronounced in the first decade of life, but even in the second decade a variable amount of significant ocular growth and myopic change occurs. We studied 98 pseudophakic eyes with serial axial length measurements over the ages of 10 to 20 years. These real data from pseudophakic patients predicted a median axial growth of 23.11 mm at 10 years to 24.41 mm at 20 years, a 4 D change in IOL power needed for emmetropia.
Toric IOLs are a good option for children over 5 years old because keratometry becomes stable at this age. However, trifocals and EDOF should be used with caution in children who are still growing. The extra cost is not a good investment for the family because the independence of glasses is often short-lived. Also, monofocal IOLs work well in children. Young patients are often happy even when they develop mild to moderate myopia over time. Ironically, the child with a trifocal or EDOF IOL may become more dependent on glasses when myopia develops invariably than the myopic child with a monofocal IOL that functions well even without glasses. Refractive surgery or IOL exchange to treat myopia is often not offered until growth is complete.
The new “plus” monofocal lenses such as the Tecnis Eyhance (Johnson & Johnson Vision) or the enVista (Bausch + Lomb) are much more suitable for children. They have an improved intermediate focusing range and they still work well when the child becomes myopic over time due to axial eye growth. Also, there is no supplement for these IOLs. Because we can’t promise the child no glasses, many young families are understandably reluctant to pay extra for a glass that produces multiple images simultaneously and reduces contrast sensitivity.
- Wilson ME, et al. Trans Am Ophthalmol Soc. 2009;107:120-124.
Mr. Edward Wilson, MD, is a board member of OSN Pediatrics/Strabismus.