We read with great interest the article published by Plager and associates. They have addressed issues of concern over a long period in infants <7 months undergoing cataract surgery. The most important difference between the contact lens group and the primary intraocular lens (IOL) group was the need for significantly more surgical procedures to clear the visual axis in the latter. However, their data show that this was significant in the first year of life and was comparable after that. This points to the fact that more stringent control over parameters in the immediate postoperative period is required.

We would like to highlight that they have used topical steroids just 4 times a day in infants less than 7 months of age who underwent IOL implantation. This low frequency of steroids postoperatively could have been a cause of more inflammatory membranes, obscuration of the visual axis, and corectopia. We would like to know the type of IOL (3-piece or single piece) used in each of these patients and the site of placement (sulcus/bag), and also whether this complication was seen more in those with persistent fetal vasculature. Ram and associates used subconjunctival dexamethasone 2 mg and topical prednisolone once hourly in children <2 years who were operated for congenital cataract. Fibrinous uveitis, which was observed in 8.9% of cases, completely disappeared with topical steroids. Visual axis opacification was observed in 4 of 17 eyes of children less than 1 year old. Watts and associates observed secondary membranes in 17% of cases in children <12 weeks of age (cataract with no fetal vasculature) who were left aphakic, although they have not mentioned the postoperative steroid regimen used. This is much higher compared to the aphakic group in the present study. Plager and associates have implanted IOL in the bag or sulcus. Koch and Kohnen showed no evidence of posterior capsule opacification (PCO) when an anterior vitrectomy was combined with optic capture of IOL in children 18–24 months of age. This shows that the site of IOL implantation also affects the incidence of visual axis opacification. There is no doubt that all surgeries were done by experts in their field, but data on vitrectomy have been collected from videos in this infant aphakia treatment study and in most of the pseudophakic patients anterior vitrectomy was done after IOL placement. It is difficult to judge from videos the adequacy of anterior vitrectomy after IOL placement and the appropriate size of primary posterior capsulotomy, which could partly be a cause of higher incidence of visual axis opacification in the IOL group. Alexandrakis and associates have shown that inadequately performed vitrectomy could lead to reopacification of the visual axis.

It is well known that intraocular surgery in children with congenital cataract is associated with a more severe inflammatory reaction, which is age dependent and is compounded by IOL implantation, as in this article. The authors have shown that IOL-related adverse events were at a maximum in the first year and decreased thereafter, whereas it was the opposite in the contact lens group. This emphasizes the need for aggressive control of inflammation with a much more frequent steroid regimen in the immediate postoperative period.

A significant observation in the present study is the incidence of glaucoma in the contact lens group, which is more than double that in the IOL group at 5 years (16 vs 7). This shows that IOL implantation protects against glaucoma and could go a long way toward decreasing the financial burden (glaucoma medications) and improving the quality of life.

Modifying the placement of IOL (bag-vitreous capture) and comparing it to endocapsular implantation, along with increasing the dosage of steroids, could be a viable option to reduce the incidence of complications in infants <7 months. This would avoid significant complications requiring additional surgery and also decrease the incidence of glaucoma, thus improving visual prognosis.

Currently it may not be right to conclude against IOL implantation in this age group. Until more options are explored, the decision to implant an IOL or not is still debatable.