Toric IOLs Outperform Non-Toric in Pediatric Congenital Cataracts and Corneal Astigmatism

Toric intraocular lens (IOL) implantation in patients aged 3-8 years with congenital cataracts and corneal astigmatism ≥2.0 D provided superior long-term visual outcomes and reduced amblyopia rates versus non-toric monofocal IOL implantation.¹

Monofocal IOLs are typically implanted only to correct spherical refractive errors; corneal astigmatism, meanwhile, is managed through spectacle correction. The efficacy of toric IOLs in correcting these astigmatisms in adults has long been established; however, despite toric IOL implantation demonstrating favorable safety and efficacy in children with congenital cataracts, there is limited evidence regarding their application in this subgroup.²

“The comparative long-term visual function and influence of amblyopia between non-toric and toric IOL implantations in congenital cataract surgery remains unclear,” Lei Cai, PhD, from the department of ophthalmology, Eye, Ear, Nose, and Throat Hospital of Fudan University, Shanghai, and colleagues wrote. “Accordingly, we aimed to evaluate and compare the visual prognosis in children aged 3-8 years with congenital cataract and ≥2.0 D corneal astigmatism between these two types of IOL implantation.”¹

Cai and colleagues conducted a nonrandomized concurrent controlled clinical trial at a single tertiary ophthalmology center in Shanghai, running from October 2017 to October 2024. Patients were eligible if they were aged 3-8 years with confirmed congenital cataracts and ≥2.0 D regular corneal astigmatism. Patients were excluded if they had a history of ocular comorbidities, ocular trauma, or surgical interventions, or concurrent severe systemic diseases, among other criteria.¹

A total of 236 eyes of 236 children were included in the trial and were allocated to either the non-toric or toric group based on parental preference following an informed discussion. Children with bilateral cataracts who underwent bilateral surgery sequentially only had the eye that was operated on first included in the study. All patients underwent comprehensive preoperative ophthalmic assessments, including uncorrected and corrected distance visual acuity (DVA), slit-lamp biomicroscopy, corneal topography, biometric measurements, and so on.¹

Follow-ups were performed 1 day, 1 week, 2 weeks, 1 month, 3 months, 6 months, 1 year, 2 years, and 3 years after the surgery was conducted. A mobile phone text service was used to improve follow-up adherence. Follow-up parameters included UDVA and CDVA, as well as intraocular pressure (IOP), axial length (AL), corneal curvature, residual astigmatism, stereopsis, and the IOL axis.¹

Initially, there were 131 eyes in the non-toric arm and 105 in the toric arm. Of these, 9 were excluded (6 eyes from non-toric, 3 from toric) due to intra- or postoperative complications. An additional 19 and 14 patients in the non-toric and toric groups, respectively, were lost to follow-up. Ultimately, a total of 106 and 88 participants were included in the final analysis.¹

Both arms saw significant improvements in UDVA and CDVA (P <.001) at the endpoint, with no significant differences between groups at 1 week (P = .987) or 2 weeks (P = 8336). However, beginning at 1 month postoperatively, the toric arm saw superior UDVA outcomes. At the 3-year follow-up, the toric group also showed substantially better CDVA (P = .003). By the end of follow-up, the proportion of eyes meeting non-amblyopic criteria was 86.4% and 69.8% for the toric and non-toric group, respectively (P = .0093).¹

In a subgroup analysis, patients with preoperative corneal astigmatism >3.0 D achieved significantly better CDVA among the toric group versus the non-toric group from 3 months to 3 years postoperatively (P <.001). Among patients with astigmatism, no significant difference was found in CDVA between groups. The toric group did, however, demonstrate substantially lower postoperative refractive astigmatism than the non-toric group during follow-up (P <.05).¹

Ultimately, investigators determined that these data support the toric IOL’s consideration as the preferred surgical approach for optimizing visual rehabilitation among children aged 3-8 years.¹

“This beneficial effect is particularly pronounced in patients with >3.0 D corneal astigmatism, where toric IOLs outperformed their non-toric counterparts, a finding that warrants further validation in future prospective, randomized controlled trials,” Cai and colleagues wrote. “For pediatric patients with congenital cataracts and preoperative moderate-to-high corneal astigmatism, toric IOL implantation represents a preferable therapeutic strategy – with particular adaptability in cases of high corneal astigmatism – to optimize the efficacy of amblyopia management and facilitate long-term visual rehabilitation.”¹

References

1. Cai L, Shi R, Lin X, et al. Three-year outcomes of Toric vs non-toric monofocal intraocular lens implantation in children aged 3–8 years with congenital cataract. American Journal of Ophthalmology. Published online February 3, 2026. doi:10.1016/j.ajo.2026.01.041

2. Zhong Y, Chen S, Wang H, et al. Femtosecond laser arcuate keratotomy vs Toric intraocular lens implantation in cataract surgery. JAMA Ophthalmology. 2025;143(3):199. doi:10.1001/jamaophthalmol.2024.5887