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Implantation of a Multifocal IOL in a 4-year-old Boy with Unilateral Cataract

1Tandogan T., 2Drodofsky C. M.,
1Augenklinik Tausendfensterhaus (Duisburg)
2 (Duisburg)

Purpose: A 4 year old boy has been referred for cataract-surgery because of posterior lenticonus. Occlusion therapy had already been performed for 13 months. On initial examination refraction was +1.75 D in the healthy right eye and +9.5/-4.75@123° in the left eye. Keratometry revealed r1=8.30@155°, r2=8.17@65° right and r1=8.41@152°, r2=8.29@62° left. Best corrected visual acuity was 1.0 right and 0.25 left. With the Titmus-test no stereoscopic vision was detectable. Fundusexamination showed no pathologic findings.
Method: An optical (IOL-Master, Zeiss) and an ultrasonic biometry (Compuscan, Storz) have been done preoperatively. For the IOL-calculation the SRK/T formula has been used. Uneventful cataract surgery has been performed in general anaesthesia with a 3 mm temporal clear cornea incision (CCI), anterior and posterior continuos curvilinear capsulorhexis (CCC) and an anterior vitrectomy. A capsular tension ring and a zonal-progressive MIOL (Array, Allergan) have been implanted into the bag. The MIOL has been chosen to support the management of amblyopia. The corneal incision and the paracentesesses have been stabilized with a 10-0 nylon (Ethilon) stich each. For treating amblyopia the right eye has been occluded postoperatively.
Results: After surgery only minimal inflammation has been seen (cells+ and flare+), especially no fibrin exsudation. 1 month postop visual acuity in the left eye was 0.4 with -1.5. 18 months postop uncorrected visual acuity was still 1.0 in his right eye and 0.8 in his left eye for distance and 0.9 in reading distance. He recognized fhe fly and rings 1 to 6 in the Titmus-test. He had no halos and no glare. The IOL is stable in the bag and there are no capsular fibrosis, no changes of the anterior or posterior capsular opening and the visual axis is free.
Discussion: These results with the reasonable good stereoscopic vision indicate that the implantation of a multifocal IOL as a substitute for the lost accomodation is an option for treating children with unilateral cataract, especially if the child does not tolerate wearing glasses very well. The general disadvantages of a multifocal IOL, like less contrast sensitivity, glare or halos seem not to be clinically important for this patient. As published before stabilization of the corneal incision and the paracenteses with stiches helps reducing postoperative inflammation and a posterior capsulorhexis and an anterior vitrectomy help keeping the visual axis clear. Since children are at higher risk of a severe inflammatory or capsular reaction and because of the risk of a retinal detachment due to pseudophakia it would be fine to have an acrylic multifocal IOL with sharp edges.