Secondary IOLs in children remain controversial

March 15, 2005

New Orleans—The condition of the anterior segment will determine the outcome of secondary IOL implantation in children, according to Edward G. Buckley, MD, chief, divisions of pediatrics and neuro-ophthalmology, Duke University Eye Center, Durham, NC.

He delivered the 6th annual Marshall M. Parks lecture at the annual meeting of the American Academy of Ophthalmology in New Orleans.

"The relationship between the remnant of the capsule and the iris is the big concern in trying to put an IOL in secondarily in children," said Dr. Buckley. "If the anterior segment is in good shape, the surgery is likely to have a good result. However, if it is complicated with a lot of membranes and iris problems, beware that there is an increased likelihood for a poor outcome."

Dr. Buckley said the indications for secondary IOLs in children are fairly straightforward. They include:

Discussing sulcus versus capsule placement, Dr. Buckley noted the technique for secondary IOL implantation in the sulcus is relatively straightforward. He recommended against vitrectomy unless there is extensive vitreous in the anterior segment. He noted his preference for an acrylic foldable three-piece IOL, which has the advantage in this situation of being supported better than a one-piece injectable IOL.

"The technique for sulcus implantation seems relatively simple and any anterior segment surgeon can pull it off without trouble, and actually the results are pretty good," Dr. Buckley said.

Review of his personal series showed a tendency for improving visual acuity with very few cases of loss, and acute postoperative complications occurred at a reasonably low rate that could be easily managed to result in a good visual outcome.

The rate of long-term complications was similar, but the types of events that occurred point to the importance of good patient selection.

Placement of the secondary IOL into the capsule can be done in selected cases, but does require more manipulation and surgical skill. There must be a Soemmering's ring and enough remaining capsule to allow opening of the ring, and the posterior capsule must be relatively stiff.

"If those criteria are met, there are advantages to placement in the capsule, but the sulcus is preferred otherwise, and sulcus placement is always an option whenever there is any doubt," Dr. Buckley said.

In deciding whether it is better to place a lens primarily in the bag in a child <6 months old or to remove the lens and put an IOL in the sulcus secondarily requires weighing the potential for improved visual acuity versus the many complications that occur with primary IOL placement at a very young age. Knowing exactly where primary and secondary IOL implantation fall out in relation to each other on those issues is difficult due to a paucity of data.

Primary versus secondary surgery Based on his analysis, Dr. Buckley concluded visual outcomes of primary IOL implantation appear to be about equal to what can be expected with secondary surgery or perhaps a little better. Complications may be a little higher after primary IOL surgery. However, with secondary IOL surgery, there are some complications after cataract removal, complications of the secondary IOL surgery, and the unknown complications of having an implant in the sulcus for many decades.