Premium Intraocular Lenses in Children

Author: Asif MI, Raj N, Kalra N, Yadav MA, Bafna RK, Sinha R.

Geographical coverage: Not reported

Sector: Pediatric cataract surgery

Sub-sector: Intraocular lens

Equity focus: Not reported

Study population: Pediatric patients with cataract

Review type: Effectiveness review

Quantitative synthesis method: Narrative synthesis

Qualitative synthesis method: Not applicable

Background: Premium intraocular lenses (IOLs), including toric, multifocal, and accommodative types, have substantially improved visual outcomes in adult cataract surgery by reducing dependence on spectacles. However, their use in children is still limited due to anatomical and physiological differences, such as ocular growth, higher rates of posterior capsular opacification, and the complexity of paediatric cataract management. As children require optimal visual rehabilitation to support visual development, postoperative refractive outcomes become particularly critical. Premium IOLs offer several benefits (like improved uncorrected vision and enhanced depth of focus), making them increasingly considered for paediatric use. However, several barriers, including concerns about long-term outcomes, limited clinical data, and potential complication risks, hinder widespread adoption.

Objective: To study the role of multifocal and toric IOLs following paediatric cataract surgery.

Main findings:

The review included 17 studies (10 case series/interventional studies and 7 case reports). Studies reported significant gains in corrected distance visual acuity (CDVA) and near vision, with 70-80% spectacle independence for near tasks in bilateral implants. However, unilateral cases showed less consistent results. While some studies reported improved stereopsis, concerns persisted about dysphotic phenomena (e.g., glare/haloes) and the brain’s ability to adapt to multifocal images in young children.

Toric IOLs effectively addressed astigmatism (>1.5D) in children aged 5-15 years, with significant reduction in residual astigmatism and better uncorrected visual acuity (UCVA) compared to monofocal IOLs. Alignment remained stable (<5° rotation), and reintervention rates were minimal. Optic capture techniques further reduced postoperative rotation and were particularly beneficial in older children with stabilised corneal curvature.

The findings also revealed improved stereoacuity in most children, especially with bilateral implants. Newer IOL designs showed fewer complications, such as visual axis opacification and IOL decentration, than earlier models. Some studies also reported behavioural and quality-of-life improvements following bilateral multifocal IOL implantation, such as increased participation in outdoor activities.

Methodology:

The searches were conducted in PubMed, Embase, Web of Science, and Scopus to identify relevant peer-reviewed studies published until 31st January 2022. The studies were included if they were conducted on children with cataracts aged 2 to 19 years. In addition, articles in languages other than English were included if the abstract was available in English or if a translated version of the article was available. Reference lists of included studies were also scanned to identify additional relevant publications. Identified articles were screened, and relevant data were extracted. The findings were synthesised narratively.

Applicability/external validity:

The review did not explicitly discuss the external validity or generalisability of its findings. However, it acknowledged key limitations that impact applicability, including the small number of studies, predominance of case series and case reports, short follow-up durations (1-4 years), and heterogeneity in patient age, IOL types, and surgical techniques. The review authors emphasised that while results are promising, further randomised controlled trials with longer follow-up are needed before recommending routine use of premium IOLs in paediatric cataract surgery.

Geographic focus:

The review did not apply any geographical limits. However, it did not report the geographical distribution of the included studies.

Summary of quality assessment: Overall, there is medium confidence in the review’s conclusion. The searches were comprehensive. Inclusion and exclusion criteria were clearly defined. The reference lists of included studies were also scanned to identify additional relevant publications. A list of included studies was provided. Characteristics of the included studies were presented. The findings were synthesised narratively. However, a list of excluded studies was not provided. Additionally, the review did not specify the number of reviewers involved in the screening or data extraction, and did not mention assessing the risk of bias.