Volume 17 Number 6 / December 2013
Wilson, Johnson, and Trivedi
623
Primary multifocal intraocular lens implantation for teenage-onset bilateral cataracts: visual results a decade after surgery in 3 siblings M. Edward Wilson, MD, William J. Johnson, BS, and Rupal H. Trivedi, MD, MSCR
Three siblings developed bilateral, visually significant posterior subcapsular cataracts in their teenage years and were implanted with the SA40N Array Multifocal IOL. A recall examination was performed on the siblings at 12, 10, and 9 years, respectively, after implantation.
P
rimary intraocular lens (IOL) implantation at the time of cataract surgery has become the standard of care for children beyond infancy.1 The vast majority of these implants are monofocal implants, chosen, in part, because the eye is still undergoing axial growth. For cataracts that occur after visual maturity, eye growth is more predictable compared to cataracts that develop earlier in life. Teenage patients and their parents often ask about whether a multifocal IOL is appropriate and recommended for them. The literature contains few reports on children after multifocal IOLs, and long-term followup is particularly lacking.2-4
Case Series This study complied with the Health Insurance Portability and Accountability Act of 1996. Three sisters developed posterior subcapsular cataracts bilaterally and were implanted with multifocal IOLs (SA-40 Array, Abbott Medical Optics [formerly Alergan Medical Optics], Abbott Park, IL) at the time of cataract surgery between ages 16 and 19 years. The postoperative refractive aim in each patient was plano. Recently published evidence demonstrates a significant continued refractive shift up to and beyond age 20.5,6 These patients were recalled and examined to determine whether any myopic shift had
Author affiliations: Department of Ophthalmology, Miles Center for Pediatric Ophthalmology, Storm Eye Institute, Medical University of South Carolina, Charleston, South Carolina Supported in part by an unrestricted grant to MUSC-SEI from Research to Prevent Blindness, Inc, New York, NY. Submitted March 15, 2013. Revision accepted July 6, 2013. Correspondence: M. Edward Wilson, MD, MUSC—Storm Eye Institute, 167 Ashley Avenue, Charleston, SC 29425-5536 (email: [email protected]). J AAPOS 2013;17:623-625. Copyright Ó 2013 by the American Association for Pediatric Ophthalmology and Strabismus. 1091-8531/$36.00 http://dx.doi.org/10.1016/j.jaapos.2013.07.013
Journal of AAPOS
occurred and to document the long-term visual outcome from these implantations. One surgeon (MEW) performed all of the surgeries. Case 1 The first procedure was performed on a then 16-yearold girl. Her preoperative best-corrected visual acuity was 20/50 in the right eye and 20/40 in the left eye. Her visual acuity worsened with glare testing. She desired spectacle independence and, with parental consent, asked for a multifocal IOL. During her procedure, a multifocal IOL (18 D) was implanted within the capsular bag, with a postoperative goal of emmetropia. One week later, the left eye was operated on in a similar fashion using multifocal IOL (18.5 D). The posterior capsule in each eye was left intact. A recent recall examination was performed 12 years after implantation (Table 1). Her spherical equivalent distance refraction had decreased from 10.75 to 10.37 in the right eye and 10.37 to 10.12 in the left eye. She reported using reading glasses only for fine print and needing to occasionally adjust the light to optimize her uncorrected near vision. She reported no glare or halos, even with night driving. A subjective refraction for near visual acuity showed that a 11.50 D sphere was preferred but her stereopsis was 40 arcsec at near with no spectacles. All other components of the examination were normal and unremarkable.
Case 2 The second patient was 19 years old at the time of surgery. Her preoperative visual acuity was 20/100 in each eye. The procedure generally mirrored the procedure in case 1. However, because of posterior capsule plaque formation, a posterior capsulorhexis without vitrectomy was performed in each before inserting the multifocal IOL into the capsular bag. Array multifocal IOL was implanted in both eyes (18 D in the right eye and 18.5 D in the left eye). At her recall examination,11.5 years postoperatively (Table 1), she reported that she did not drive at night because of the glare she experienced. She also reported not using reading glasses but did notice the negative effect of dimmer light on her vision. Her distance refraction had changed over time from plano to
624
Wilson, Johnson, and Trivedi
Volume 17 Number 6 / December 2013
Table 1. Summary of postoperative visit
Case
OD/OS
1
OD OS OD OS OD OS
2 3
IOL power
Immediate post-op refraction
118.0 118.5 118.0 118.5 120.0 120.0
10.25 11.00 085 Plano 10.75 090 Plano sphere Plano sphere 10.50 sphere Plano sphere
Immediate post-op uncorrected distance VA
Immediate post-op uncorrected near VA
20/20 20/20 20/15 20/15 20/20 20/20
20/30 20/30 20/25 20/25 20/20 20/20
Latest refraction
Latest uncorrected distance VA
Latest uncorrected near VA
Post-op duration, years
10.25 10.25 095 Plano 10.25 105 0.75 0.75 Plano sphere Plano sphere
20/15 -2 20/15 20/20 20/30 20/20 20/20
20/30 20/30 20/30 20/30 20/30 20/20
12.0 12.0 11.0 11.5 9.0 9.0
OD, right eye; OS, left eye; IOL, intraocular lens; VA, visual acuity.
planted in both eyes. Her recall examination was at 9 years postoperatively (Table 1, Figure 1). She reported no glare and did not use glasses for any visual tasks at distance or near. Her distance refraction had changed over time from 10.5 D sphere in the right eye to plano. The left eye remained at plano throughout the 9 years since surgery. The remainder of her eye examination, including intraocular pressure, was normal.
Discussion
FIG 1. Nine-year follow-up after array multifocal IOL implantation (case 3).
0.75 D in each eye. Her uncorrected near stereoacuity was 60 arcsec. She stated that the glare at night was not bothersome enough for her to wear 0.75 D sphere glasses to drive and she would not consider an IOL exchange. Case 3 The third sister was operated on as a 16-year-old. Her preoperative visual acuity in each eye was 20/70. The surgeries were similar to that described for case 1, except for the posterior capsule management of the left eye. A manual posterior capsulorhexis was performed but was augmented by the vitrector to remove an area of plaque not easily torn with forceps. An anterior vitrectomy was also performed. Array multifocal IOL (20 D) was im-
Three siblings were examined 9-12 years after implantation of an early generation multifocal IOL. A small refractive shift of #0.5 D was noted in 4 of the 6 eyes (cases 1 and 3). In each of these, the final refraction was closer to emmetropia than the immediate postoperative refraction. Ironically, the patient who developed 0.75 D of myopia in each eye was the eldest (19 years old) at the time of surgery. She was also the only one with symptoms of glare. None of the patients reported using glasses for routine distance or near visual tasks. These data offer some very limited insight for surgeons considering the implantation of multifocal IOLs in children. The results from these three patients compare favorably with another published report2 in which none of the subjects reported using glasses throughout the day and only one reported glare. Since we do not have a control group with bilateral monofocal IOLs implanted at this age, questions remain about how much of the near and intermediate visual functioning is due to the multifocal IOL and how much would have been present even if monofocal IOLs had been implanted. Teenagers with monofocal IOLs, especially when mildly myopic, may function very well at distance and near without glasses. The Array multifocal IOL was an early-generation multifocal IOL. Newer designs offer greater efficacy in terms of patients functioning without glasses for both distance and near vision.4 These results suggest that even with an earlier lens design, good visual outcomes independent of external correction are possible.
Journal of AAPOS
Volume 17 Number 6 / December 2013 References 1. Wilson ME. Intraocular lens implantation: has it become the standard of care for children? Ophthalmology 1996;103:1719-20. 2. Jacobi PC, Dietlein TS, Konen W. Multifocal intraocular lens implantation in pediatric cataract surgery. Ophthalmology 2001;108: 1375-80. 3. Rychwalski PJ. Multifocal IOL implantation in children: is the future clear? J Cataract Refract Surg 2010;36:2019-21.
Cullen and Zaborowski
625
4. Cristobal JA, Remon L, Del Buey MA, Montes-Mico R. Multifocal intraocular lenses for unilateral cataract in children. J Cataract Refract Surg 2010;36:2035-40. 5. Trivedi RH, Wilson ME, Bandyopadhyay D. Refractive shift in pseudophakic eyes during the second decade of life. J Cataract Refract Surg 2012;38:102-7. 6. Wilson ME, Trivedi RH, Burger BM. Eye growth in the second decade of life: implications for the implantation of a multifocal intraocular lens. Trans Am Ophthalmol Soc 2009;107:120-24.
A case report of torpedo maculopathy in an African boy Claire Cullen, MB BCh, FCOphth (SA),a and Anthony G. Zaborowski, MB BCh, FCOphth (SA)b
We describe a case report of torpedo maculopathy in a young African boy. Ophthalmic examination revealed normal visual acuity and a characteristic unilateral retinal lesion with the typical appearance on ocular coherence tomographic imaging, fluorescein angiography, and visual fields testing.
T
orpedo maculopathy is a congenital abnormality of the retinal pigment epithelium (RPE), clinically manifesting as an asymptomatic, wellcircumscribed hypopigmented macular lesion temporal to the fovea with a torpedo-like tip directed toward the foveola.1 We describe a case of torpedo maculopathy in a 10-year-old black South African boy.
Case Report A 10-year-old black South African boy presented to the eye clinic at Edendale Hospital, South Africa, for routine ophthalmic assessment after experiencing difficulties with school work. He was asymptomatic and his ocular history was unremarkable. There were no perinatal problems and his development was normal. His medical history was significant for human immunodeficiency virus (HIV), for which he had been undergoing antiretroviral therapy for one year, and for successful treatment of pulmonary
Author affiliations: aDepartment of Ophthalmology, Edendale Hospital, University of Kwazulu-Natal; bDepartment of Ophthalmology, Nelson R. Mandela School of Medicine, University of Kwazulu-Natal, Pietermaritzburg, South Africa Submitted February 20, 2013. Revision accepted July 6, 2013. Published online November 7, 2013. Correspondence: Claire Cullen, MB BCh, FCOphth (SA), 8 Gemini road, Sunward Park, Boksburg 1459, South Africa (email: [email protected]). J AAPOS 2013;17:625-626. Copyright Ó 2013 by the American Association for Pediatric Ophthalmology and Strabismus. 1091-8531/$36.00 http://dx.doi.org/10.1016/j.jaapos.2013.07.009
Journal of AAPOS
FIG 1. A, Fundus photograph of the right eye of a 10-year-old boy diagnosed with torpedo maculopathy showing an oval, hypopigmented macular lesion with a tapered tip pointing towards the foveola. B, Optical coherence tomograph showing a retinal pigment epithelium cleft.
Wilson, Johnson, and Trivedi
623
Primary multifocal intraocular lens implantation for teenage-onset bilateral cataracts: visual results a decade after surgery in 3 siblings M. Edward Wilson, MD, William J. Johnson, BS, and Rupal H. Trivedi, MD, MSCR
Three siblings developed bilateral, visually significant posterior subcapsular cataracts in their teenage years and were implanted with the SA40N Array Multifocal IOL. A recall examination was performed on the siblings at 12, 10, and 9 years, respectively, after implantation.
P
rimary intraocular lens (IOL) implantation at the time of cataract surgery has become the standard of care for children beyond infancy.1 The vast majority of these implants are monofocal implants, chosen, in part, because the eye is still undergoing axial growth. For cataracts that occur after visual maturity, eye growth is more predictable compared to cataracts that develop earlier in life. Teenage patients and their parents often ask about whether a multifocal IOL is appropriate and recommended for them. The literature contains few reports on children after multifocal IOLs, and long-term followup is particularly lacking.2-4
Case Series This study complied with the Health Insurance Portability and Accountability Act of 1996. Three sisters developed posterior subcapsular cataracts bilaterally and were implanted with multifocal IOLs (SA-40 Array, Abbott Medical Optics [formerly Alergan Medical Optics], Abbott Park, IL) at the time of cataract surgery between ages 16 and 19 years. The postoperative refractive aim in each patient was plano. Recently published evidence demonstrates a significant continued refractive shift up to and beyond age 20.5,6 These patients were recalled and examined to determine whether any myopic shift had
Author affiliations: Department of Ophthalmology, Miles Center for Pediatric Ophthalmology, Storm Eye Institute, Medical University of South Carolina, Charleston, South Carolina Supported in part by an unrestricted grant to MUSC-SEI from Research to Prevent Blindness, Inc, New York, NY. Submitted March 15, 2013. Revision accepted July 6, 2013. Correspondence: M. Edward Wilson, MD, MUSC—Storm Eye Institute, 167 Ashley Avenue, Charleston, SC 29425-5536 (email: [email protected]). J AAPOS 2013;17:623-625. Copyright Ó 2013 by the American Association for Pediatric Ophthalmology and Strabismus. 1091-8531/$36.00 http://dx.doi.org/10.1016/j.jaapos.2013.07.013
Journal of AAPOS
occurred and to document the long-term visual outcome from these implantations. One surgeon (MEW) performed all of the surgeries. Case 1 The first procedure was performed on a then 16-yearold girl. Her preoperative best-corrected visual acuity was 20/50 in the right eye and 20/40 in the left eye. Her visual acuity worsened with glare testing. She desired spectacle independence and, with parental consent, asked for a multifocal IOL. During her procedure, a multifocal IOL (18 D) was implanted within the capsular bag, with a postoperative goal of emmetropia. One week later, the left eye was operated on in a similar fashion using multifocal IOL (18.5 D). The posterior capsule in each eye was left intact. A recent recall examination was performed 12 years after implantation (Table 1). Her spherical equivalent distance refraction had decreased from 10.75 to 10.37 in the right eye and 10.37 to 10.12 in the left eye. She reported using reading glasses only for fine print and needing to occasionally adjust the light to optimize her uncorrected near vision. She reported no glare or halos, even with night driving. A subjective refraction for near visual acuity showed that a 11.50 D sphere was preferred but her stereopsis was 40 arcsec at near with no spectacles. All other components of the examination were normal and unremarkable.
Case 2 The second patient was 19 years old at the time of surgery. Her preoperative visual acuity was 20/100 in each eye. The procedure generally mirrored the procedure in case 1. However, because of posterior capsule plaque formation, a posterior capsulorhexis without vitrectomy was performed in each before inserting the multifocal IOL into the capsular bag. Array multifocal IOL was implanted in both eyes (18 D in the right eye and 18.5 D in the left eye). At her recall examination,11.5 years postoperatively (Table 1), she reported that she did not drive at night because of the glare she experienced. She also reported not using reading glasses but did notice the negative effect of dimmer light on her vision. Her distance refraction had changed over time from plano to
624
Wilson, Johnson, and Trivedi
Volume 17 Number 6 / December 2013
Table 1. Summary of postoperative visit
Case
OD/OS
1
OD OS OD OS OD OS
2 3
IOL power
Immediate post-op refraction
118.0 118.5 118.0 118.5 120.0 120.0
10.25 11.00 085 Plano 10.75 090 Plano sphere Plano sphere 10.50 sphere Plano sphere
Immediate post-op uncorrected distance VA
Immediate post-op uncorrected near VA
20/20 20/20 20/15 20/15 20/20 20/20
20/30 20/30 20/25 20/25 20/20 20/20
Latest refraction
Latest uncorrected distance VA
Latest uncorrected near VA
Post-op duration, years
10.25 10.25 095 Plano 10.25 105 0.75 0.75 Plano sphere Plano sphere
20/15 -2 20/15 20/20 20/30 20/20 20/20
20/30 20/30 20/30 20/30 20/30 20/20
12.0 12.0 11.0 11.5 9.0 9.0
OD, right eye; OS, left eye; IOL, intraocular lens; VA, visual acuity.
planted in both eyes. Her recall examination was at 9 years postoperatively (Table 1, Figure 1). She reported no glare and did not use glasses for any visual tasks at distance or near. Her distance refraction had changed over time from 10.5 D sphere in the right eye to plano. The left eye remained at plano throughout the 9 years since surgery. The remainder of her eye examination, including intraocular pressure, was normal.
Discussion
FIG 1. Nine-year follow-up after array multifocal IOL implantation (case 3).
0.75 D in each eye. Her uncorrected near stereoacuity was 60 arcsec. She stated that the glare at night was not bothersome enough for her to wear 0.75 D sphere glasses to drive and she would not consider an IOL exchange. Case 3 The third sister was operated on as a 16-year-old. Her preoperative visual acuity in each eye was 20/70. The surgeries were similar to that described for case 1, except for the posterior capsule management of the left eye. A manual posterior capsulorhexis was performed but was augmented by the vitrector to remove an area of plaque not easily torn with forceps. An anterior vitrectomy was also performed. Array multifocal IOL (20 D) was im-
Three siblings were examined 9-12 years after implantation of an early generation multifocal IOL. A small refractive shift of #0.5 D was noted in 4 of the 6 eyes (cases 1 and 3). In each of these, the final refraction was closer to emmetropia than the immediate postoperative refraction. Ironically, the patient who developed 0.75 D of myopia in each eye was the eldest (19 years old) at the time of surgery. She was also the only one with symptoms of glare. None of the patients reported using glasses for routine distance or near visual tasks. These data offer some very limited insight for surgeons considering the implantation of multifocal IOLs in children. The results from these three patients compare favorably with another published report2 in which none of the subjects reported using glasses throughout the day and only one reported glare. Since we do not have a control group with bilateral monofocal IOLs implanted at this age, questions remain about how much of the near and intermediate visual functioning is due to the multifocal IOL and how much would have been present even if monofocal IOLs had been implanted. Teenagers with monofocal IOLs, especially when mildly myopic, may function very well at distance and near without glasses. The Array multifocal IOL was an early-generation multifocal IOL. Newer designs offer greater efficacy in terms of patients functioning without glasses for both distance and near vision.4 These results suggest that even with an earlier lens design, good visual outcomes independent of external correction are possible.
Journal of AAPOS
Volume 17 Number 6 / December 2013 References 1. Wilson ME. Intraocular lens implantation: has it become the standard of care for children? Ophthalmology 1996;103:1719-20. 2. Jacobi PC, Dietlein TS, Konen W. Multifocal intraocular lens implantation in pediatric cataract surgery. Ophthalmology 2001;108: 1375-80. 3. Rychwalski PJ. Multifocal IOL implantation in children: is the future clear? J Cataract Refract Surg 2010;36:2019-21.
Cullen and Zaborowski
625
4. Cristobal JA, Remon L, Del Buey MA, Montes-Mico R. Multifocal intraocular lenses for unilateral cataract in children. J Cataract Refract Surg 2010;36:2035-40. 5. Trivedi RH, Wilson ME, Bandyopadhyay D. Refractive shift in pseudophakic eyes during the second decade of life. J Cataract Refract Surg 2012;38:102-7. 6. Wilson ME, Trivedi RH, Burger BM. Eye growth in the second decade of life: implications for the implantation of a multifocal intraocular lens. Trans Am Ophthalmol Soc 2009;107:120-24.
A case report of torpedo maculopathy in an African boy Claire Cullen, MB BCh, FCOphth (SA),a and Anthony G. Zaborowski, MB BCh, FCOphth (SA)b
We describe a case report of torpedo maculopathy in a young African boy. Ophthalmic examination revealed normal visual acuity and a characteristic unilateral retinal lesion with the typical appearance on ocular coherence tomographic imaging, fluorescein angiography, and visual fields testing.
T
orpedo maculopathy is a congenital abnormality of the retinal pigment epithelium (RPE), clinically manifesting as an asymptomatic, wellcircumscribed hypopigmented macular lesion temporal to the fovea with a torpedo-like tip directed toward the foveola.1 We describe a case of torpedo maculopathy in a 10-year-old black South African boy.
Case Report A 10-year-old black South African boy presented to the eye clinic at Edendale Hospital, South Africa, for routine ophthalmic assessment after experiencing difficulties with school work. He was asymptomatic and his ocular history was unremarkable. There were no perinatal problems and his development was normal. His medical history was significant for human immunodeficiency virus (HIV), for which he had been undergoing antiretroviral therapy for one year, and for successful treatment of pulmonary
Author affiliations: aDepartment of Ophthalmology, Edendale Hospital, University of Kwazulu-Natal; bDepartment of Ophthalmology, Nelson R. Mandela School of Medicine, University of Kwazulu-Natal, Pietermaritzburg, South Africa Submitted February 20, 2013. Revision accepted July 6, 2013. Published online November 7, 2013. Correspondence: Claire Cullen, MB BCh, FCOphth (SA), 8 Gemini road, Sunward Park, Boksburg 1459, South Africa (email: [email protected]). J AAPOS 2013;17:625-626. Copyright Ó 2013 by the American Association for Pediatric Ophthalmology and Strabismus. 1091-8531/$36.00 http://dx.doi.org/10.1016/j.jaapos.2013.07.009
Journal of AAPOS
FIG 1. A, Fundus photograph of the right eye of a 10-year-old boy diagnosed with torpedo maculopathy showing an oval, hypopigmented macular lesion with a tapered tip pointing towards the foveola. B, Optical coherence tomograph showing a retinal pigment epithelium cleft.
