Could new generation lenses be considered for children with congenital cataracts? – Tips & Results

April 18, 2022

3 min read


Disclosure: Fortunato does not report any relevant financial disclosures. Wilson reports on consulting for Alcon and Kala Pharmaceuticals.

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Positive experience with multifocal technologies

I have many years of experience with pseudoaccommodating IOLs in pediatric patients.

Michele Fortunato, MD
Michel Fortunato

I have used them on more than 2,100 children since 3M first introduced diffractive implants in 1989, and I am always excited to see new innovations such as trifocals and extended depth of field (EDOF) lenses. I’ve only implanted a small number of them to date (27 and 12 respectively) and my follow-up is limited, but I’m positively impressed, especially with trifocals. EDOF IOLs are not sufficient at this stage of development to achieve good reading vision, which is crucial for children.

When multifocal technologies made their debut, I was initially skeptical about using them in pediatric patients, and as I do with any new lens, I tried them on adults first. When I finally decided to implant them in children, I was surprised to see how quickly and well they adapted. While adults have to reset and retrain the visual brain through a slow and not always successful process, the neural plasticity of the brain allows children to learn how to see through these lenses easily and naturally, without photic phenomena and without loss of contrast sensitivity, as shown by a study we conducted on 270 cases. After implantation of diffractive IOLs, they develop excellent vision at all distances, including intermediate distances, something we have never seen in adults. Importantly, the lens power is undercorrected to account for the myopia shift, just as we would with monofocal IOLs.

When we perform cataract surgery on children, we do it at a time when the development of near vision is crucial, as presbyopic as a 65-year-old. Multifocal IOLs are the only way to preserve the accommodation and thus the full visual function of a young eye. My long follow-up of many patients into adulthood has shown that good vision is maintained over time. Only in a few cases have I performed an IOL change with a similar later generation lens. These were patients with a family history of myopia who developed high myopia in their teens.

My first choice so far has been diffractive multifocal IOLs with a near add of +4, resulting in an add of about +3.25 at the glasses level. In the case of unilateral cataract, the implantation should take place early, within the first 12 months of life. In the case of bilateral cataracts, we can wait longer, evaluate the individual case and discuss with the parents, since compliance with postoperative visual rehabilitation is crucial.

Michele Fortunato, MD, is an ophthalmologist at the Bambino Gesù children’s hospital in Rome.


Axial growth can affect long-term results

In children, monofocal IOLs are the implant of choice because of their superior image quality and minimal visual aberrations.

M. Edward Wilson, MD
M. Edward Wilson

The new generation trifocal and EDOF lenses are remarkable, but their performance is sensitive to residual refractive errors. In children, the initial IOL calculations are often less accurate and the ongoing axial growth of the eye ensures that the precision achieved initially does not remain unchanged over time. The myopia shift is most pronounced in the first decade of life, but even in the second decade of life there is a variable amount of significant eye growth and myopia shift. We studied 98 pseudophakic eyes with serial axis length measurements aged 10 to 20 years. These true pseudophakic patient data predicted mean axial growth from 23.11 mm at age 10 to 24.41 mm at age 20, a 4-D change in IOL power required for emmetropia.

Toric IOLs are a good option for children over the age of 5 as keratometry becomes stable at this age. However, trifocal and EDOF lenses should be used with caution in children who are still growing. The extra expense is not a good investment for the family, as eyewear independence is often short-lived. Additionally, monofocal IOLs work well in children. Young patients are often even lucky if they develop mild to moderate myopia over time. Ironically, if myopia invariably develops, the child with a trifocal or EDOF IOL may become more glasses dependent than the myopic child with a monofocal IOL, who works well without glasses. Refractive surgery or IOL replacement to treat myopia is often not offered until growth is complete.

The newer “plus” monofocals like the Tecnis Eyhance (Johnson & Johnson Vision) or the enVista (Bausch + Lomb) are much better suited for children. They have an extended central focus range and still work well if the child becomes myopic over time due to axial eye growth. In addition, there is no extra charge for these IOLs. Since we cannot promise the child glasses addiction, many young families are understandably reluctant to pay a premium for a lens that produces multiple simultaneous images and reduces contrast sensitivity.

M. Edward Wilson, MD, is a board member of OSN Pediatrics/Strabismus.

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