Importance The efficacy and safety of primary intraocular lens (IOL) implantation during early infancy is unknown. Objective To compare the visual outcomes of patients optically corrected with contact lenses vs IOLs following unilateral cataract surgery during early infancy. Design, Setting, and Participants The Infant Aphakia Treatment Study is a randomized clinical trial with 5 years of follow-up that involved 114 infants with unilateral congenital cataracts at 12 sites. A traveling examiner assessed visual acuity at age 4.5 years. Interventions Cataract surgery with or without primary IOL implantation. Contact lenses were used to correct aphakia in patients who did not receive IOLs. Treatment was determined through random assignment. Main Outcomes and Measures HOTV optotype visual acuity at 4.5 years of age. Results The median logMAR visual acuity was not significantly different between the treated eyes in the 2 treatment groups (both, 0.90 [20/159]; P  = .54). About 50% of treated eyes in both groups had visual acuity less than or equal to 20/200. Significantly more patients in the IOL group had at least 1 adverse event after cataract surgery (contact lens, 56%; IOL, 81%; P  = .02). The most common adverse events in the IOL group were lens reproliferation into the visual axis, pupillary membranes, and corectopia. Glaucoma/glaucoma suspect occurred in 35% of treated eyes in the contact lens group vs 28% of eyes in the IOL group ( P  = .55). Since the initial cataract surgery, significantly more patients in the IOL group have had at least 1 additional intraocular surgery (contact lens, 21%; IOL, 72%; P Conclusions and Relevance There was no significant difference between the median visual acuity of operated eyes in children who underwent primary IOL implantation and those left aphakic. However, there were significantly more adverse events and additional intraoperative procedures in the IOL group. When operating on an infant younger than 7 months of age with a unilateral cataract, we recommend leaving the eye aphakic and focusing the eye with a contact lens. Primary IOL implantation should be reserved for those infants where, in the opinion of the surgeon, the cost and handling of a contact lens would be so burdensome as to result in significant periods of uncorrected aphakia. Trial Registration clinicaltrials.gov Identifier:NCT00212134

https://jamanetwork.com/journals/jamaophthalmology/articlepdf/1838344/eoi140024.pdf

Comparison of contact lens and intraocular lens correction of monocular aphakia during infancy: a randomized clinical trial of HOTV optotype acuity at age 4.5 years and clinical findings at age 5 years.

Complications in the First 5 Years Following Cataract Surgery in Infants With and Without Intraocular Lens Implantation in the Infant Aphakia Treatment Study

Congenital and infantile cataracts produce deprivation amblyopia and can thus cause lifelong visual impairment. Successful management is dependent on early diagnosis and referral for surgery when indicated. Accurate optical rehabilitation and postoperative supervision are essential. The timing of surgery and its relationship to the duration of deprivation is important. Unilateral congenital cataract surgery within 6 weeks of birth produces the best outcomes. The equivalent ‘latent’ period for bilateral visual deprivation may be longer at around 10 weeks. Visual deprivation has a significant impact on the development of fixation stability. Major form deprivation, even after early surgery, leads to nystagmus. This is mostly manifest latent nystagmus (MLN). The latent period for fixation stability may be as short as 3 weeks. Preoperative congenital nystagmus (CN) can convert to more benign MLN after surgery. Infantile IOL implantation is becoming increasingly accepted. A satisfactory long-term refractive result requires that allowance be made for childhood axial growth and myopic shift. In a series of 25 infants (33 eyes) implanted before 12 months of age, the mean myopic shift at 12 months was 4.83 D. This increased to 5.3 D in infants implanted before 10 weeks. The initial desired refractive outcome following IOL implantation is thus hypermetropia, with the degree dependent on the age of the child. Glaucoma or ocular hypertension is a common complication following paediatric cataract surgery. Microphthalmia and surgery in early infancy are risk factors. Tonometry results may be influenced by the increased corneal thickness seen in aphakic and pseudophakic children. The long-term prognosis of eyes with aphakic glaucoma is not necessarily poor but intraocular pressure control may require three or more medications. Surgical intervention appears to be necessary in over a quarter of eyes. Posterior capsule opacification (PCO) is common in infants undergoing primary lens implantation. Primary capsulotomy and anterior vitrectomy reduce the risk of PCO. In the absence of anterior vitrectomy, primary posterior capsulotomy does not prevent visual axis opacification. Further developments will continue to be driven by clinical research. The prevention of capsule opacification and cellular proliferation may in future be achieved by the use of devices to specifically target epithelial cells at surgery.

/pdf/advances-in-the-management-of-congenital-and-infantile-5fufurhcpv.pdf

Advances in the management of congenital and infantile cataract.

Purpose: The optimal role of intraocular lenses (IOLs) in infants remains a controversial topic. Some ophthalmologists advocate correction with a contact lens (CL), whereas others r

Visual Results after Primary Intraocular Lens Implantation or Contact Lens Correction for Aphakia in the First Year of Age

Importance Infantile cataract surgery bears a significant risk for postoperative glaucoma, and no consensus exists on factors that may reduce this risk. Objective To assess the effect of primary intraocular lens implantation and timing of surgery on the incidence of postoperative glaucoma. Data Sources We searched multiple databases to July 14, 2013, to identify studies with eligible patients, including PubMed, MEDLINE, EMBASE, ISI Web of Science, Scopus, Central, Google Scholar, Intute, and Tripdata. We also searched abstracts of ophthalmology society meetings. Study Selection We included studies reporting on postoperative glaucoma in infants undergoing cataract surgery with regular follow-up for at least 1 year. Infants with concurrent ocular anomalies were excluded. Data Extraction and Synthesis Authors of eligible studies were invited to contribute individual patient data on infants who met the inclusion criteria. We also performed an aggregate data meta-analysis of published studies that did not contribute to the individual patient data. Data were pooled using a random-effects model. Main Outcomes and Measures Time to glaucoma with the effect of primary implantation, additional postoperative intraocular procedures, and age at surgery. Results Seven centers contributed individual patient data on 470 infants with a median age at surgery of 3.0 months and median follow-up of 6.0 years. Eighty patients (17.0%) developed glaucoma at a median follow-up of 4.3 years. Only 2 of these patients had a pseudophakic eye. The risk for postoperative glaucoma appeared to be lower after primary implantation (hazard ratio [HR], 0.10 [95% CI, 0.01-0.70]; P  = .02; I 2  = 34%), higher after surgery at 4 weeks or younger (HR, 2.10 [95% CI, 1.14-3.84]; P  = .02; I 2  = 0%), and higher after additional procedures (HR, 2.52 [95% CI, 1.11-5.72]; P  = .03; I 2  = 32%). In multivariable analysis, additional procedures independently increased the risk for glaucoma (HR, 2.25 [95% CI, 1.20-4.21]; P  = .01), and primary implantation independently reduced it (HR, 0.10 [95% CI, 0.01-0.76]; P  = .03). Results were similar in the aggregate data meta-analysis that included data from 10 published articles. Conclusions and Relevance Although confounding factors such as size of the eye and surgeon experience are not accounted for in this meta-analysis, the risk for postoperative glaucoma after infantile cataract surgery appears to be influenced by the timing of surgery, primary implantation, and additional intraocular surgery.

https://jamanetwork.com/journals/jamaophthalmology/articlepdf/1879761/eoi140038.pdf

Postoperative glaucoma following infantile cataract surgery: an individual patient data meta-analysis.

Purpose: The optimal role of intraocular lenses (IOLs) in infants remains a controversial topic for many reasons, including concerns about significant complications occurring in young rapidly developing eyes. Methods: To assess the number and type of significant complications requiring further intervention occurring in the first postoperative year, we reviewed the records of 15 eyes of 13 infants undergoing lensectomy with posterior chamber IOL and pars plana vitrectomy (PPV)/capsulectomy under 6 months (group A) of age as part of an ongoing prospective study of IOL use in infants. This group was compared with a group of 16 children age 10 months to 5 years undergoing an identical procedure (group B) and a group of 33 infants less than 6 months of age undergoing lensectomy/vitrectomy without IOL (group C). Results: Thirteen of 15 eyes in group A required additional surgery in the first postoperative year. Twelve of the 15 eyes (80%) developed secondary opacification across the visual axis posterior to the IOL requiring a second PPV and one eye developed pseudophakic glaucoma. Two patients required a third PPV to keep the visual axis clear. In group B, 0 of 16 ( P P Conclusions: Intraocular lens implants in infants may be associated with a higher complication rate requiring further surgery during the first postoperative year than is lensectomy/vitrectomy surgery without IOL implant in infants or lensectomy/IOL/vitrectomy surgery in children older than 6 months of age. (J AAPOS 2002;6:9-14)

Complications in the first year following cataract surgery with and without IOL in infants and older children

had more severe disease and development of psoriatic nail disease (Fig. 1a). He was commenced on calcipotriol ointment (Dovonex ; LEO Laboratories) and acitretin, which brought about marked improvement in his skin. He completed 3 months of acitretin with good results, at which point the drug was discontinued. Accelerated elimination of teriflunomide was not required due to the good response to treatment. In postmarketing surveillance of teriflunomide, which was licensed in the European Union in 2013, there was evidence for a potential causal role of teriflunomide in new onset and worsening of psoriasis in patients. The prodrug of teriflunomide, leflunomide, is also known to be associated with the development of psoriasis. Compared with the other published case reports of teriflunomideinduced pustular psoriasis, our patient developed pustular psoriasis within days rather than weeks, but otherwise the cases were similar, in that they all occurred in patients in their fifties without any personal or family history of psoriasis. This case contributes a further example of this uncommon AE of teriflunomide. As it can take 2 years for this drug to be fully eliminated from the body, it is important to be aware of psoriasis in this patient population and recognize the availability of accelerated elimination schedules to limit patient exposure to the drug if their disease is proving difficult to treat.

https://academic.oup.com/ced/article-pdf/47/6/1186/49328358/ced1186.pdf

Evaluating the safety and efficacy of COVID‐19 vaccination in patients with hidradenitis suppurativa

Dermatology residents have 3 years to master core competencies related to the delivery of patient care, preservation of medical professionalism, and responsible use of health care; however, it is crucial for residents to recognize other things outside of their formal curriculum that are equally vital to their training. Over the years, we have observed residents and now offer our own perspectives. We have collectively observed five extracurricular aspects commonly overlooked by dermatology residents that are important to their education and future practice. (SKINmed. 2022;20:123-125).

Five Extracurricular Things Commonly Overlooked by Dermatology Residents.

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Complications in the first year following cataract surgery with and without IOL in infants and older children

Evaluating the safety and efficacy of COVID‐19 vaccination in patients with hidradenitis suppurativa

Five Extracurricular Things Commonly Overlooked by Dermatology Residents.