Note the benefits of fitting and steps for success

The early 1980s brought one of the most significant technological advances in contact lenses (CLs): silicone polymers. This meant manufacturers could design both soft and rigid CLs of high-plus powers capable of delivering adequate oxygen to the cornea. Among the many resulting clinical benefits: the CL management of pediatric aphakia.

Here, I discuss a study that supports the use of these CLs on pediatric aphakia patients, and the three steps needed to manage such patients successfully.

Supporting study

The Infant Aphakia Treatment Study (IATS) followed 114 children between 2004 and 2020 who had unilateral cataract. They were randomized to IOL implantation or contact lens (CLs) correction (both RGP and silicone elastomer CLs). The primary outcomes measured were VA at 12 months, 4.5 years, and 10.5 years.¹

The secondary outcomes measured were surgical complications, surgical adverse events, parent stress, and adherence to occlusion therapy.

The results of the IATS showed equal visual outcomes measured with optotypes and stereopsis in the two groups, with the surgical complications lens reproliferation into the visual axis, pupillary membranes and corectopia the concerning outcomes.

The investigators’ conclusion: CL fitting should be the first choice in managing unilateral congenital cataract extraction on an infant <7 months old, and IOLs should be used when it is the opinion of the surgeon that the cost and handling of CLs will be “so burdensome as to result in significant periods of uncorrected aphakia.”¹

Three steps to success

The three key steps to a successful pediatric aphakic CL practice:

1. Establish and maintain effective communication with surgeons. Start by gathering general information regarding the surgeon’s clinical approach, such as timing of post-operative CL fitting, refractive target, preferred CL modality (if not left up to the optometrist), and post-operative and ongoing follow-up schedule. The case-specific information I request is preoperative history and refractive data, intraoperative measurements, such as keratometry and axial length, and the surgeon’s preferred type of CL (if expressed).
2. Understand the clinical considerations in CL selection. The two CL modalities commonly used for managing pediatric aphakia are silicone elastomer and RGP CLs. Each have pros and cons (see Table 1, p.37.) The optometrist should base their selection on variables, such as the surgeon’s preference, parental capability, and willingness to be involved in CL insertion and removal, and the anatomical and refractive profile of the child. For example, I prefer RGPs in children who have high degrees of corneal astigmatism (greater than 1.5 D against the rule, greater than 2.0 D with the rule) to ensure best-corrected vision. For caregivers who prefer a more hands off approach, weekly cleaning and disinfection of an extended-wear silicone elastomer CL might be best.
    

   Table 1. CONTACT LENS OPTIONS FOR APHAKIA IN KIDS

   SOFT/ELASTOMER	RGB
   High Dk/Can be worn overnight	High Dk/Not approved for EW*
   Easier to fit	More difficult to fit
   Fewer power options	Unlimited power options
   More costly	Less costly
   Less lens loss	More lens loss
   Potentially more comfortable	Potentially less comfortable
   Potentially lower VA	Potentially better VA
   Source: Susan A. Resnick, OD, FAAO, FSLS.

    
3. Develop a dedicated staff. Pediatric fittings require a considerable amount of devoted time and patience. I typically spend about one hour at the first appointment for initial clinical evaluation and selection of CL modality and parental discussion. The dispensing visit also takes about one hour to train the parents in insertion, removal, and CL care. We are always prepared to spread this process out over multiple visits to avoid parental frustration and patient fatigue. Having confident, highly proficient CL technicians allows the optometrist to integrate infant and toddler care without major disruption to normal patient flow, spend the necessary time communicating with parents, and conduct a methodical CL fitting.

To limit chair time, all diagnostic CLs are applied by an experienced technician in a quiet, dedicated space. Whenever possible, my practice schedules new patients prior to normal patient hours, given the dedicated time needed for them. Our technicians are trained in a variety of methods, such as having the infant lie on the floor for CL insertion, and techs understanding that they need to be able to pivot quickly if the original approach is not effective. Several online images and videos can help with both training staff and instructing parents on these fits. ODs can simply search “inserting contact lenses in infants/babies,” or “silicone lens insertion and removal in infants.”

Advantages

Restoring vision to our youngest patients is personally rewarding and, with some advanced preparation, can be a great asset to a CL practice. Why not give fits for pediatric aphakia a go? OM

Reference

1. Cromelin CH, Drews-Botsch C, Russell B, Lambert SR, for the Infant Aphakia Treatment Study Group. Association of Contact Lens Adherence With Visual Outcome in the Infant Aphakia Treatment Study: A Secondary Analysis of a Randomized Clinical Trial. JAMA Ophthalmol. 2018;136(3):279–285. doi:10.1001/jamaophthalmol.2017.6691.

DR. RESNICK is president and managing partner at Drs. Farkas, Kassalow, Resnick, and Associates, a contact lens and anterior segment specialty practice in New York. She is a diplomate in the Cornea, Contact Lens, and Refractive Technology section of the AAO, a diplomate of the ABO, and a fellow of the Scleral Lens Education Society.