Eyes of Tomorrow– Innovative Therapies to Preserve Vision in Children Takes Center Stage at WCPOS V 2024

Take a look into the fascinating technologies and treatments that are shaping and improving eye health and vision for future generations, presented on Day 3 of the 5th World Congress of Paediatric Ophthalmology & Strabismus (WCPOS V 2024) in Kuala Lumpur, Malaysia.

Bag-in-the-lens implantation in pediatric cataracts

Pediatric cataracts can be challenging to treat due to the fact that children’s eyes are smaller and more delicate, hence requiring precise surgical techniques. Bag-in-the-lens (BIL) implantation is a specialized approach in pediatric cataract surgery aimed at optimizing visual outcomes and minimizing complications. 

Leading the session with his talk, Dr. Matthieu Robert (France) highlighted that the advantages obtained from the BIL technique are due to the complete confinement of epithelial cells. Because of this, “you do not have any cytokines after the surgery, therefore there’s no possibility of any secondary cataract if you fit the lens in properly. Also, you won’t have any postoperative inflammation, which is a really striking point of the surgery,” he said. Additionally, there is excellent visualization of the posterior pole and there will be no iris synechiae. 

Nevertheless, this technique is technically complex and usually takes longer to perform especially in young infants. Postoperative complications that may occur include posterior luxation of IOL and iris capture. Specific infantile difficulties include rhexis calibration in young infants and dissection of the Berger space, noted Dr. Robert.

The BIL technique is most suitable for uveitic, congenital and infantile cataracts but is contraindicated in cases of adhesive capsules with flat involute cataracts, adhesive capsules in uveitic cataracts with iris synechiae and insufficient dilation.

“This is a difficult technique, yet it seems very interesting in infants. Probably about 50% of all infantile cataracts could benefit from this technique,” Dr. Robert concluded. 

Corneal neurotization to treat pediatric neurotrophic keratopathy

Pediatric neurotrophic keratopathy (PNK) is a condition characterized by diminished corneal sensation due to damage or dysfunction of the trigeminal nerve’s ophthalmic branch, essential for corneal innervation. This loss of sensory input can result in corneal anesthesia, where the cornea becomes insensitive to touch and pain stimuli, leading to poor healing, infections and stroll lysis. “The outcomes in children are very poor, vision worsened in almost all eyes over a 3-year follow-up in a study¹ that I did,” said Dr. Asmin Ali (Canada). 

Dr. Ali shared that reinnervation of the cornea proves to be an effective therapy for PNK. By surgically transplanting nerves to restore corneal sensation, this treatment aims to improve healing, reduce epithelial defects and prevent complications like ulcers or scarring.

“Vision does improve with corneal neurotization alone. You can usually see 2-3 lines without surgery or contact lens,”explained Dr. Ali. “This could be due to improvement in ocular surface, and reduction in scarring and amblyopia. Importantly, it allows us to do corneal transplantation in children without significant scarring,” he added.

“In summary, corneal neurotization improves corneal sensation, ocular health and vision. It treats both congenital and acquired causes. Nevertheless, we are still trying to determine whether multiple techniques and modifications are better. The role of nerve growth factor (NGF) is unclear and its timing and place in therapy for neurotrophic keratopathy needs to be identified,” concluded Dr. Ali.

The neurotrophic factor hypothesis for strabismus treatment

Despite strabismus being a common and serious condition, surgical treatments can yield unpredictable outcomes and failure rates, noted Dr. Jolene Rudell (USA). 

“The reason for unpredictable surgical results may be due to an inherent plasticity in the visual oculomotor system that drives eye alignment back to its pre-surgical state after strabismus surgery, as shown by some studies,” she said.  

Dr. Rudell further shared that a potentially more effective treatment could involve disrupting the compensatory mechanisms by modifying the communication between motor neurons and extraocular muscles.

“Neurotrophic factors are a group of proteins that facilitate communication between neurons and muscles through antero- or retro-grade transport,”she said. “Local treatment with neurotrophic factors has the potential to modify both extraocular muscle and neuronal characteristics in strabismus models. These properties could be utilized in the treatment of patients with strabismus. Long-term local neurotrophic factor treatment might mitigate the abrupt changes following surgery, potentially resulting in longer-lasting outcomes,” added Dr. Rudell.

Insulin and losartan as novel topical ocular agents

Persistent epithelial defects (PED), defined as corneal lesions that do not improve after two weeks of conventional treatment, present significant challenges in treatment. Fortunately, a new, non-invasive option has emerged: topical insulin, which is both affordable and readily accessible. 

Prof. Ken Nischal (UK/USA) highlighted that while the mechanism is not fully understood, insulin-like growth factors (IGF) play a crucial role in the growth, differentiation and proliferation of corneal epithelial cells. “Corneal keratocytes and epithelial cells express IGF-I, its receptors and insulin receptors,” he noted. “It’s plausible that cell proliferation may be the mechanism of normalization of the re-epithelization process,” he explained.

PED can also cause scarring. Enter Losartan, an angiotensin II receptor blocker with a potential role in reducing scarring, particularly in the context of fibrosis. 

“Corneal scars are dynamic. Precursor cells and mature myofibroblasts continually undergo mitosis and apoptosis. The ratio of mitosis to apoptosis determines whether myofibroblasts and fibrosis are increasing, persisting unchanged or decreasing in a particular fibrotic cornea,” he emphasized.

Prof. Nischal continued to explain that myofibroblasts that induce fibrosis require ongoing TGF-beta levels; without it, they undergo apoptosis. Losartan interferes with TGF-beta signaling, causing myofibroblast apoptosis and reducing fibrosis. He added that topical losartan 0.08% in balanced salt solution (BSS) is currently being used in this context.

Innovations in treatments and technologies represent hope and a brighter future for countless young lives. These advancements promise clearer vision and better eye health, allowing children to fully experience the world. By pushing the boundaries of what’s possible, we are transforming lives, one bright, clear-eyed smile at a time.

Reference

1. Lambley RG, Pereyra-Muñoz N, Parulekar M, Mireskandari K, Ali A. Structural and functional outcomes of anaesthetic cornea in children. Br J Ophthalmol. 2015;99(3):418-424.

Editor’s Note: Reporting for this article occurred at the 5th World Congress of Paediatric Ophthalmology & Strabismus (WCPOS V 2024) from 11-13 July in Kuala Lumpur, Malaysia.