What aphakia means for a child
Aphakia means the eye has no natural lens. In children, this is usually because a cataract (a clouded lens) was removed, either one present from birth or one that developed later, sometimes after an injury.[1] The natural lens does a large share of the eye’s focusing, so an aphakic eye is strongly farsighted and can’t see clearly without correction.
Timing is everything in young children. The first weeks and months of life are a critical period for visual development. A dense cataract, or an uncorrected eye after surgery, deprives the brain of a clear image and causes amblyopia (often called lazy eye). When only one eye is affected, the large difference in focus between the two eyes adds to that risk and can lead to strabismus, an eye turn.[1]
That’s why specialists aim to provide optical correction as soon as possible after surgery, combined with patching of the stronger eye and regular follow-up as the eye grows.[1]
The usual ways to correct aphakia in children
Contact lenses are central in infancy and early childhood, up to about age 2.[1] Several kinds are used:
- Silicone elastomer lenses are often the first choice for infants. Their very high oxygen permeability allows them to stay in the eye for days at a time, even up to a month, so the lens doesn’t need to go in and out of a baby’s eye every day.[1]
- Rigid gas-permeable corneal lenses can be made in a wide range of powers and correct corneal astigmatism well. They are especially useful after injuries that leave the cornea irregular.[1]
- Soft hydrogel and silicone hydrogel lenses are also used, usually removed daily.[1]
In the US Infant Aphakia Treatment Study, a randomized trial of 114 infants with a cataract in one eye, children in the contact lens group mostly wore silicone elastomer lenses, rigid lenses, or both at different times.[3]
Glasses can work when both eyes are aphakic, but the thick, high-power lenses distort the image and narrow the field of view. When only one eye is aphakic, the difference in image size between the two eyes makes glasses hard to tolerate.[7]
A lens implant (intraocular lens) can be placed during cataract surgery or later. In infants, the trial evidence favors waiting, as explained below.
Where scleral lenses fit
A scleral lens is a large rigid gas-permeable lens that rests on the sclera (the white of the eye) and arches over the whole cornea without touching it. It is filled with sterile saline before insertion. It can be made in the high plus powers an aphakic eye needs, and the saline layer smooths out an irregular or scarred cornea optically.
A 2024 review of contact lenses in pediatric aphakia notes that two separate studies have reported mini-scleral and scleral lenses as safe and effective options in aphakic children.[1] They are most likely to be considered when:
- the cornea is irregular or scarred, for example after an eye injury, so other lenses can’t give clear vision;
- other lens types don’t fit, keep falling out, or aren’t tolerated;
- the child is old enough that daily insertion and removal is manageable.
What the research shows
The evidence comes from small, single-center studies. There are no trials comparing scleral lenses with other lenses in aphakic children.
An Israeli study of aphakic children. Researchers reviewed children who had their lens removed for cataract or a dislocated lens between 2004 and 2018 and then wore scleral lenses. Seventeen eyes (34%) reached a best-corrected vision of 20/40 or better. The amblyopia rate was 50%, and 56% of the children developed strabismus; those with strabismus had poorer vision. No corneal infections were recorded. The main surface side effect was superficial punctate keratopathy (tiny surface spots), reported 16 times. By parent report, compliance was good in 48 children (96%).[4]
A US pediatric clinic. In a review of 18 children under 15 (24 eyes) fitted with scleral lenses, aphakia was one of the reasons for fitting, alongside keratoconus, scarring after injury, and corneal transplants. Ages ranged from 16 months to 14 years. Fifteen of the 18 children (83%) continued wearing the lenses over a mean follow-up of 9.2 months. Complications included one corneal graft rejection and one corneal scratch from insertion.[5]
A long-running US program. In a 21-year review of 209 children’s eyes fitted with scleral lenses, only 6% of the eyes fitted for irregular corneas or refractive needs were fitted for aphakia or after cataract surgery.[6] Aphakia is an uncommon reason for pediatric scleral fitting.
Aphakia after injury. In an Iranian series of 8 people aged 11 to 59 with aphakia and a badly damaged cornea after eye injuries, who couldn’t be corrected with standard rigid lenses, mini-scleral lenses improved average vision to about 20/22 (0.05 logMAR). Average comfortable wear was 11.6 hours a day, and two patients had mild redness and irritation.[7] Most were not young children.
Why infants are often left without an implant
The Infant Aphakia Treatment Study randomly assigned 114 infants with a cataract in one eye to a lens implant at surgery or to contact lens correction. At age 4.5, vision in the treated eye was no different between the groups: in both, about half of treated eyes saw 20/200 or worse. But more children in the implant group had at least one adverse event (81% vs 56%) and more needed additional eye surgery (72% vs 21%). Glaucoma or suspected glaucoma occurred in 35% of the contact lens group and 28% of the implant group. The authors recommended leaving infants younger than 7 months without an implant and using a contact lens, unless the cost and handling of a lens would leave the eye uncorrected for long periods.[2]
That trial used silicone elastomer and rigid corneal lenses, not scleral lenses.[3]
Other options, compared
| Option | What it does | Typically suited to |
|---|---|---|
| Silicone elastomer contact lens | High-power lens that can stay in for days or weeks | Infants and young children; often first choice |
| Rigid corneal (RGP) lens | Corrects power and corneal astigmatism; removed daily | Children of all ages, including irregular corneas after injury |
| Soft hydrogel or silicone hydrogel lens | Comfortable daily-wear correction | Older infants and children |
| Glasses | High-power spectacle correction | Both eyes aphakic; backup to contact lenses |
| Scleral lens | Vaults the cornea; corrects power and an irregular cornea | Older children, irregular or scarred corneas, other lenses not working |
| Intraocular lens implant | Replaces the focusing lens inside the eye | Older children, or when contact lens care isn’t feasible |
Questions to ask a scleral lens fitter
- How many aphakic children have you fitted with scleral lenses, and at what ages?
- Why do you suggest a scleral lens rather than a silicone elastomer or rigid corneal lens for my child?
- How will you teach us to put the lens in and take it out, and what if my child resists?
- How often will you check the fit and power as my child grows?
- How will you work with the surgeon and the eye doctor managing patching and glaucoma checks?
- What should we have at home if a lens is lost or breaks, so my child isn’t left uncorrected?
- What signs should make us remove the lens and call right away?
Common questions
Is a scleral lens the usual first lens for a baby after cataract surgery?
Usually not. For infants, silicone elastomer lenses are often preferred because their very high oxygen permeability lets them stay in for days or weeks at a time, which avoids daily insertion and removal in a baby. Scleral lenses are taken out daily and are more often considered for older children or for eyes with an irregular cornea.
Why does my child need a lens so soon after surgery?
The first weeks and months of life are a critical period for vision. If the eye doesn't get a clear image, the brain may not learn to see well with it, a condition called amblyopia. Fast, full-time optical correction and patching give the best chance.
Can my child have a lens implant instead?
Sometimes, but in a US trial of infants with a cataract in one eye, implants led to more complications and more repeat surgery without better vision at age 4.5. The trial's authors recommended leaving the eye without an implant in infants under 7 months and using a contact lens. Older children and other situations can be different, so ask your surgeon.
Will the scleral lens fix my child's lazy eye?
Not on its own. The lens gives the eye a focused image. Patching the stronger eye, as your child's eye doctor prescribes, is usually needed to help the weaker eye catch up, and keeping to it is one of the biggest factors in how well vision develops.
Who puts the lens in and takes it out?
A parent or caregiver, at first and often for years. Your fitter should teach you hands-on and check you can do it before you go home. As children grow, many learn to handle their own lenses.