Category: 3. Business

Introduction

Pediatric cataracts are considered a leading cause of preventable, severe visual impairment in children. Optimal visual outcomes are determined by the timing of the intervention, the surgical procedure, and optical correction options.^1–3

Cataract extraction paired with intraocular lens (IOL) implantation has become the gold standard for children age two years or older.^4–6 However, the application of this approach in younger infants remains controversial. The Infant Aphakia Treatment Study (IATS) recommended that infants younger than 6 months of age undergo cataract extraction followed by aphakia correction with contact lenses and secondary IOL implantation at a later age.

Primary IOL implantation was reserved for exceptional cases in which, according to the surgeon’s judgment, contact lens management would likely result in significant periods of uncorrected aphakia.^7–15 Nonetheless, some studies have suggested that primary IOL implantation in this age group results in visual outcomes and complications comparable to those achieved with secondary IOL implantation (Supplemental Table 1).^16–21

Soroka University Medical Center (SUMC), located in the Negev desert, provides care to a diverse population, including a substantial proportion from socioeconomically disadvantaged communities living in remote and underserved areas. In particular, the local Bedouin population often faces barriers to obtaining consistent medical care, including limited access to utilities, transportation challenges, and reduced adherence to long-term follow-up.²² In light of these unique circumstances, and recognizing the critical need to minimize the risk of prolonged uncorrected aphakia, over the past two decades, SUMC has adopted a clinical approach favoring primary IOL implantation for infants younger than 6 months of age.

Considering the unique circumstances and the choice to perform primary IOL implantation at all pediatric ages, this study provides an opportunity to evaluate the outcomes of this approach within this specific clinical setting. The study evaluates the long-term outcomes of primary IOL implantation in pediatric cataract patients, stratified into three age groups: younger than 6 months, 6 to 12 months, and 1–18 years at the time of surgery.

Materials and Methods

Study Design and Patient Selection

A retrospective review of medical records from 2000 to 2020 was conducted. The study was approved by the Soroka University Medical Center (SUMC) Ethics Committee (IOL-2000-2020). Children who underwent cataract extraction surgery with primary IOL implantation at the SUMC Ophthalmology Department within this timeframe were included. Subjects were stratified into three groups based on age at the time of surgery: under 6 months, 6–12 months, and 1–18 years,²³ to enable comprehensive analysis of outcomes across the full pediatric age range.

Inclusion and Exclusion Criteria

The inclusion criteria encompassed children under the age of 18 years who underwent cataract extraction surgery with IOL implantation. Exclusion criteria were patients without available postoperative follow-up data and patients with severe systemic comorbidities that could independently affect visual outcomes.

Data Collection

Electronic medical records were comprehensively reviewed, encompassing demographic information (age, sex, ethnicity), detailed ophthalmic medical history, surgical records, complication reports, and postoperative follow-up data. Biometric measurements were obtained using an Echoscan US-400 (NIDEK, Inc., San Jose, CA) for axial length and a Righton Retinomax K plus 3 Autorefractor Keratometer (Right Mfg. Co., Ltd. Tokyo, Japan) for keratometry. Surgical reports were meticulously examined, and patient follow-up data were thoroughly analyzed to assess postoperative outcomes and complications.

Surgical Methods

Two surgical methods were employed in this study: (1) lensectomy with posterior chamber IOL implantation – in the bag- with anterior vitrectomy (the anterior vitrectomy technique), (2) lensectomy with posterior chamber IOL implantation – in the bag- and posterior capsulorhexis, with posterior optic capture (the optic capture technique). The SRK/T formula was primarily used to calculate IOL power. Either 3-piece or 1-piece AcrySof IOLs were used across the study groups. The selection of IOL type was based on the surgical technique used; only three 3-piece IOLs were used in the optic capture technique. Whereas in the anterior vitrectomy technique, the IOL choice was based on the surgeon’s preference.

When implanting IOLs in infants under 6 months of age, the refractive target was set to achieve postoperative hyperopia of +6.0 to +8.0 diopters, adjusted according to the infant’s age at the time of surgery, to account for anticipated axial elongation and ocular growth.²⁴

Throughout the study period (2000–2020), all surgeries were performed by two experienced pediatric cataract surgeons using a consistent manual lens washout technique. An AcrySof IOL was implanted in all patients.

Follow-up and Complications

For unilateral cataract cases, postoperative amblyopia therapy was prescribed according to the severity-based guidelines established by the Pediatric Eye Disease Investigator Group (PEDIG). Amblyopia severity was categorized as mild (visual acuity better than 6/12), moderate (6/12–6/24), or severe (worse than 6/24). All visual acuity assessments which were conducted using age-appropriate tools, were converted to Snellen-equivalent values. Patients with mild or moderate amblyopia underwent patching therapy of the fellow eye for two hours daily, while those with severe amblyopia received 6 hours of daily patching. Regular follow-up visits were conducted with a pediatric ophthalmologist and orthoptist to assess visual development and adjust the treatment as necessary.^25,26

Surgical complications were defined as intraoperative, early postoperative (toxic anterior segment syndrome (TASS) or ophthalmic diseases such as IOL decentration, wound leakage, or corneal edema) and late-onset complications (yttrium-aluminum-garnet (YAG)/membranectomy indicating visual axis opacification, retinal detachment, or glaucoma). Metrics indicative of glaucoma, such as maximum intraocular pressure (IOP) and cup-to-disc ratio, were collected. Additionally, any medications prescribed and previous glaucoma surgeries performed were examined.

Best corrected visual acuity (BCVA) measurements were converted to logMAR for statistical analysis. Visual acuity was assessed according to the child’s age and developmental stage at the time of follow-up. Pre-verbal children were evaluated using age-appropriate methods such as Teller Acuity Cards or Cardiff Cards, while verbal and cooperative children were tested with HOTV matching tests or the Snellen chart.

Statistical Analysis

Categorical covariates are presented as frequencies and percentages, while parametric variables are represented as means ± standard deviations (SD). Data analysis employed various statistical methods depending on the type of variable. ANOVA was applied for normal variable distribution, Kruskal–Wallis for quantitative variables that were not normally distributed, and chi-square for categorical variables. In cases with bilateral cataracts, the patient was defined as a cluster to account for repeated measures. Statistical analyses were performed using R Studio software, version 2021.09.2 Build 382. Results were considered significant at p-values < 0.05.

Results

Patient Characteristics

The study included 169 eyes of 119 pediatric patients diagnosed with cataracts. Three patients were excluded from the analysis: two with a unilateral cataracts who lacked postoperative follow-up data, and one bilateral case due to severe neurodevelopmental delay and severe systemic comorbidities. All excluded patients were in the >12 months age group. No patients were excluded due to IOL explantation secondary to severe complications.

The study population consisted of 134 (79.3%) patients of Arab descent (Table 1). A familial incidence of pediatric cataracts was observed in approximately one-third of the patients. Parental consanguinity was noted in 37.8% of cases, with a notable prevalence in the 6–12-month age group (66.7%, p = 0.022). Concurrent systemic diseases accompanied cataract diagnoses in 13 patients, particularly prominent in the 6–12-month age group (33.3%, p = 0.012).

Table 1 Patient Characteristics

As detailed in Table 2, bilateral cataracts were present in 138 (81.7%) cases, including all patients in the 6–12-month group. Strabismus was the most common pre-surgery ocular comorbidity, present in 19 (11.2%) cases, with 2 (8.0%) in the 0–6 month group, 2 (9.1%) in the 6–12 month group, and 15 (12.3%) in the >12 month group (p=0.778).

Table 2 Eye Characteristics

Operative Details and Complications

The mean age at surgery was 2.7 (±1.7), 8.3 (±1.8), and 69.5 (±53.8) months for the 0–6, 6–12, and > 12-month groups, respectively (p<0.001) (Table 3). The median (IQR) time from diagnosis to surgery was 15.0 (5.0, 35.0) months with the longest period of 24 (13.0, 48.0) months in children older than 12 months (p = 0.001).

Table 3 Operative Details and Complications

Lens types, either 3p AcrySof and 1p AcrySof, were used. Regarding operative method, vitrectomy rates were 56.0%, 68.2%, and 63.1% for the 0–6, 6–12, and > 12-month groups, respectively, with no significant difference between groups (p = 0.17). Intraoperative complications between age groups were also not statistically different groups. Primarily subluxation occurred in 12.0%, 4.5%, and 5.7% of cases in the 0–6, 6–12, and >12 month groups, respectively (p=0.352). No significant differences were observed in other surgical parameters and complications across age groups (p>0.5 for all comparisons).

Post-Operative Follow-up

The median (IQR) follow-up period was 77 (31, 144) months: 85 (58, 202) for the 0–6 month group, 76 (44.50, 152.75) for the 6–12 month group, and 69.5 18.25, 133) months for the > 12-month group (p = 0.181). The mean ± SD BCVA score as presented by logMAR was 0.56 ± 0.55 in the 0-6-month group, 0.28 ± 0.16 in the 6–12-month group, and 0.41 ± 0.58 in the >12 months group (p = 0.344) (Table 4).

Table 4 Post-Operative Follow-up and Outcomes

Additional ocular parameters, including maximum IOP and cup-to-disc ratio, were uniform across the age groups. The outcome of objective refraction testing revealed consistent mean values across age groups: −0.70 ± 4.82 D for the sphere and −1.66 ± 1.44 D for the cylinder. Furthermore, the average axis measurement was 108 ± 56.35 mm, with no notable differences across age groups.

Axial length measurements were performed preoperatively and at the end of follow-up. Before surgery, the mean axial length was 20.67 ± 1.94 mm. It increased significantly with age (p = 0.001). Despite these preoperative differences, post-follow-up axial length measurements averaged 22.57 ± 2.00 mm and displayed no significant differences among age groups (p = 0.12). However, when considering the change in axial length, the degree of alteration decreased significantly with increasing age (p = 0.001).

Potential secondary outcomes were monitored during the follow-up period. Glaucoma was diagnosed in only one case, accounting for 0.6% of the study population. This patient was in the 6–12-month age group. Two other individuals in the same group were suspected of having glaucoma.

One patient from each of the three age groups had retinal detachment (1.8%). The rates were 4% for the 0–6-month-old age group, 4.5% for the 6–12-month-old group, and 0.8% for ages 12 and above (p = 0.244). TASS was identified in 19 patients (11.3%); 3 (12.0%) from the 0-6-month age group, 2 (9.5%) from the 6–12-month group, and 14 (11.5%) in the >12 months group (p = 0.960).

The incidence of YAG/membranectomy varied significantly among the age groups. As shown in Table 4, 9 cases (36%) were observed in the infant group, 5 cases (22%) in the 6–12-month group, and 16 (13%) in the 1-year or older group (p = 0.020).

Stratification of Outcomes by Laterality

Given the known differences in visual outcomes, amblyopia risk, and surgical prognosis between unilateral and bilateral cataracts, outcomes were analyzed separately for these cases (Table 5).

Table 5 Long-Term Postoperative Outcomes Stratified by Laterality and Age at Surgery

Among unilateral cases, 28 patients (90.3%) were observed in the >12 months group, while only 3 (9.7%) were in the <6 months age group. Visual outcomes, as measured by mean logMAR ± SD, were 1.60 ± 0.37 in the <6 months group and 0.65 ± 0.74 in the >12 months group, with no significant difference (p = 0.253). All three patients in the <6 months group underwent YAG/membranectomy (100%), compared to 17.9% in the >12 months group (p = 0.012). No cases of glaucoma, suspected glaucoma, or retinal detachment were observed in the unilateral cataract cohort.

Among bilateral cases, 22 (15.9%) were observed in the <6 months of age, 22 (15.9%) in the 6–12 months group, and 94 patients (68.2%) in the >12 months group. Visual outcomes were 0.26 ± 0.41 in the <6 months group, 0.27 ± 0.30 in the 6–12 months group, and 0.16 ± 0.18 in the >12 months group, with no significant difference between groups (p = 0.496). Suspected glaucoma was observed in two patients (9.0%) in the 6–12 months group, and confirmed glaucoma was diagnosed in one patient (4.5%) in the same group (p = 0.003). Retinal detachment occurred in 1 patient (4.5%) in the <6 months group, 1 (4.5%) in the 6–12 months group, and 1 (1.1%) in the >12 months group (p = 0.390).

YAG/membranectomy was performed in 6 eyes (27.3%) in the <6 months group, 5 (22.7%) in the 6–12 months group, and 11 (11.7%) in the >12 months group, with no significant difference between age groups (p = 0.127).

In contrast to the unilateral cohort, no significant association was found between age at surgery and the need for YAG/membranectomy in bilateral cases.

Discussion

The present study explored the use of primary IOL implantation for pediatric cataract management across various age groups, incorporating a population of mixed ethnicities in the southern region of Israel. Given the limited adherence to postoperative care and the clinical concern for prolonged periods of uncorrected aphakia, primary IOL implantation was selected for all patients, including those younger than 6 months of age. This allowed for evaluation of this approach and its outcomes across different age groups. The results indicated no significant differences between age groups in visual acuity or intraoperative and postoperative complications, such as glaucoma, TASS, or retinal detachment, except for an increased rate of YAG/membranectomy in younger patients, predominantly unilateral cases, necessitating further surgical intervention.

In our study, the median follow-up period was 77 months (6.4 years), providing a long-term assessment of outcomes. The primary outcome, BCVA measured in logMAR units, did not differ significantly across age groups (<6 months, 6–12 months, >12 months), with mean logMAR ± SD values of 0.56 ± 0.55, 0.28 ± 0.16, and 0.41 ± 0.58, respectively (p = 0.344). The relatively better BCVA observed in the 6–12-month group may, in part, reflect that this group included only bilateral cases. Those findings are similar to previous research, including the IATS, which reported comparable visual acuity outcomes between different age groups. Studies by Poole et al, Tadros et al, and Negalur et al similarly demonstrated that early primary IOL implantation in infancy can achieve visual outcomes comparable to those achieved with alternative approaches.^{7,8,10,15,17–20} In addition, The Toddler Aphakia and Pseudophakia Treatment Study Registry, evaluating patients ages 1 to 7 months with bilateral cataracts, reported a median logMAR of 0.35 in both aphakic and pseudophakic children.¹³ This underscores the broad consistency of visual acuity outcomes, regardless of the treatment modality or age group.

In the current study, objective refraction, as denoted by sphere values, revealed a median value of −0.70 D ± 4.82 D across the study population. Upon closer examination of the 0–6 month age group, the median was slightly higher at −1.75 ± 7.96 D. Despite this, the variation was not statistically significant, indicating a general uniformity in objective refraction across the age groups in our study. In our surgical protocol, the refractive target for infants under 6 months was set at +6.0 to +8.0 diopters of hyperopia, adjusted according to the infant’s age at surgery to account for expected axial elongation. Thus, the mild myopic shift observed at long-term follow-up among the youngest age group likely reflects anticipated refractive changes associated with ocular growth.²⁴

Previous reports from the IATS described an overall intraoperative complication rate of 28% during the first postoperative year following primary IOL implantation. Additionally, adverse events were reported in 77% of patients in the IOL group compared to 25% in the contact lens group (p<0.0001), and additional intraocular surgeries were required in 63% of the IOL group versus 12% in the contact lens group during the same period (p<0.0001).⁹ During the longer-term follow-up of 5 years, the incidence of adverse events increased slightly in the contact lens group but decreased in the IOL group.¹¹ The IATS reported a 16% incidence of glaucoma or suspected glaucoma in the IOL group and 9% in the contact lens group at one year postoperatively, increasing to 28% and 35%, respectively, after five years of follow-up.^10,27 In addition, high rates of visual axis opacification were also observed: 81% in the IOL group and 56% in the contact lens group at 5 years, with YAG/membranectomy required in 72% and 16% of these groups, respectively.⁹

In our cohort of patients who underwent primary IOL implantation, postoperative complications such as TASS, retinal detachment and glaucoma were not statistically different across the different age groups; consistent with findings from previous studies.^{17–20,28,29} These complications remained non-significant even when analyzed separately for unilateral and bilateral cases. However, the increased incidence of YAG/membranectomy observed in the <6 months age group is primarily attributable to unilateral cases (p=0.012), as bilateral cases were not significantly different for this complication (p=0.127). This supports findings from the IATS, which included only unilateral cases and similarly reported higher rates of visual axis opacification requiring YAG or membranectomy interventions among infants operated on before 6 months of age.⁹ Nevertheless, within the <6 months group 64% of patients in our cohort who underwent primary IOL implantation without any complications did not require any further surgical interventions. Thus, for these infants, the cataract was effectively managed through a single surgical procedure.

Some studies have highlighted the cost and burden associated with contact lens use and secondary IOL implantation, suggesting that socioeconomic factors and parental involvement are important in determining treatment in pediatric cataracts.^30,31 In line with these observations, and consistent with the findings of the IATS, we believe that primary IOL implantation could be considered a valid strategy for selected children younger than 6 months of age, particularly in populations characterized by low socioeconomic status, high birth rates, and limited compliance with contact lens management. In such settings, primary IOL implantation may help reduce the risk of prolonged uncorrected aphakia, and infections related to improper contact lens use, while providing visual outcomes comparable to those achieved with secondary IOL implantation, with a similar overall complication rate. The only notable difference observed was a higher incidence of YAG/Membranectomy among unilateral cases operated before 6 months of age. In these unilateral cases, surgeons should carefully weigh the risk-benefit ratio, specifically evaluating the potential risk of requiring additional interventions due to postoperative complications against the risk of poor optical correction.

This study was limited by its retrospective nature. In addition, the absence of a control group limited direct comparison between treatments, particularly with prospective studies such as the IATS, which included a larger sample size and a standardized study protocol. The study sample was primarily composed of Arab and Bedouin children, which could limit the applicability of the results to a broader, more diverse population. In addition, the relatively small sample size in the <6 months age group may limit the robustness of statistical comparisons. Most of the cases in our cohort were bilateral, which may further influence the generalizability of the findings, particularly in comparison to studies involving mostly unilateral cases. Furthermore, the absence of a control group limited direct comparison between treatments. Although substantial, the follow-up duration may not capture the full spectrum of long-term complications or the impact of primary IOL implantation on visual outcomes as patients age.

In conclusion, our findings suggest that primary IOL implantation for pediatric cataracts resulted in comparable visual acuity and overall complication rates across all age groups. However, we observed a higher incidence of YAG/membranectomy in the 0–6-month age group, mainly in unilateral cases. It is important to note that 64% of patients in this group still avoided additional surgery. We suggest that IOL implantation could be considered in children under 6 months of age, especially those with low compliance with contact lens use or when caregivers prefer alternatives to contact lens management.

Summary

This study revealed that primary intraocular lens implantation effectively treated pediatric cataracts across various age groups, with consistent outcomes; although, children <6 months had elevated YAG/membranectomy rates.

Data Sharing Statement

The datasets used and/or analyzed during the current retrospective study are available from the corresponding author upon reasonable request.

Ethics Statement

This retrospective study was conducted in accordance with the ethical standards of the Soroka University Medical Center Ethics Committee (IOL-2000-2020) and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards. Given the retrospective nature of the study, formal consent was not required. All patient data were anonymized and handled in accordance with institutional and national guidelines to ensure confidentiality.

Funding

The study was not funded.

Disclosure

The authors declare that there is no conflict of interest in this work.

References

1. Gilbert C, Foster A. Childhood blindness in the context of VISION 2020-the right to sight.

2. Khatib N, Tsumi E, Baidousi A, et al. Infantile cataract: comparison of two surgical approaches. Can J Ophthalmol. 2017;52(5):527–532. doi:10.1016/j.jcjo.2017.02.023

3. Singh R, Barker L, Chen SI, et al. Surgical interventions for bilateral congenital cataract in children aged two years and under. Cochrane Database Syst Rev. 2022;9(9). doi:10.1002/14651858.CD003171.pub3

4. Self JE, Taylor R, Solebo AL, et al. Cataract management in children: a review of the literature and current practice across five large UK centres. Eye. 2020;34:2197–2218. doi:10.1038/s41433-020-1115-6

5. Mohammadpour M, Shaabani A, Sahraian A, et al. Updates on managements of pediatric cataract. J Curr Ophthalmol. 2019;31(2):118–126. doi:10.1016/j.joco.2018.11.005

6. McAnena L, McCreery K, Brosnahan D. Migration to aphakia and contact lens treatment is the trend in the management of unilateral congenital cataract in Britain and Ireland. Ir J Med Sci. 2019;188(3):1021–1024. doi:10.1007/s11845-018-1908-9

7. Lambert SR, Cotsonis G, DuBois L, et al. Long-term effect of intraocular lens vs contact lens correction on visual acuity after cataract surgery during Infancy: a randomized clinical trial. JAMA Ophthalmol. 2020;138(4):365–372. doi:10.1001/jamaophthalmol.2020.0006

8. Lambert SR. A randomized clinical trial comparing contact lens with intraocular lens correction of monocular aphakia during infancy: grating acuity and adverse events at age 1 year. Arch Ophthalmol. 2010;128:810–818.

9. Plager DA, Lynn MJ, Buckley EG, Wilson ME, Lambert SR. Complications, adverse events, and additional intraocular surgery 1 year after cataract surgery in the infant Aphakia treatment study. Ophthalmology. 2011;118(12):2330–2334. doi:10.1016/j.ophtha.2011.06.017

10. Lambert SR, Lynn MJ, Hartmann EE, et al. 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. JAMA Ophthalmol. 2014;132(6):676–682. doi:10.1001/jamaophthalmol.2014.531

11. Plager DA, Lynn MJ, Buckley EG, Wilson ME, Lambert SR. Complications in the first 5 years following cataract surgery in infants with and without intraocular lens implantation in the infant aphakia treatment study. Am J Ophthalmol. 2014;158(5):892–898.e2. doi:10.1016/j.ajo.2014.07.031

12. Bothun ED, Wilson ME, Traboulsi EI, et al. Outcomes of unilateral cataracts in infants and toddlers 7 to 24 months of age: toddler aphakia and pseudophakia study (TAPS). Ophthalmology. 2019;126(8):1189–1195. doi:10.1016/j.ophtha.2019.03.011

13. Bothun ED, Wilson ME, VanderVeen DK, et al. Outcomes of bilateral cataracts removed in infants 1 to 7 months of age using the toddler aphakia and pseudophakia treatment study registry. Ophthalmology. 2020;127(4):501–510.

14. Bothun ED, Wilson ME, Yen KG, et al. Outcomes of bilateral cataract surgery in infants 7 to 24 months of age using the toddler Aphakia and Pseudophakia treatment study registry. Ophthalmology. 2021;128(2):302–308. doi:10.1016/j.ophtha.2020.07.020

15. VanderVeen DK, Drews-Botsch CD, Nizam A, et al. Outcomes of secondary intraocular lens implantation in the infant aphakia treatment study. J Cataract Refract Surg. 2021;47(2):172–177. doi:10.1097/j.jcrs.0000000000000412

16. Poole ZB, Trivedi RH, Wilson ME. Primary IOL implantation in children: the effect of the Infant Aphakia treatment study on practice patterns. J AAPOS. 2019;23(4):228–230. doi:10.1016/j.jaapos.2018.12.013

17. Tadros D, Trivedi RH, Wilson ME. Primary versus secondary IOL implantation following removal of infantile unilateral congenital cataract: outcomes after at least 5 years. J AAPOS. 2016;20(1):25–29. doi:10.1016/j.jaapos.2015.10.010

18. Louison S, Blanc J, Pallot C, et al. Visual outcomes and complications of congenital cataract surgery. J Fr Ophtalmol. 2019;42(4):368–374. doi:10.1016/j.jfo.2018.10.007

19. Chattannavar G, Badakere A, Mohamed A, Kekunnaya R. Visual outcomes and complications in infantile cataract surgery: a real – world scenario. BMJ Open Ophthalmol. 2022;7(1):e000744. doi:10.1136/bmjophth-2021-000744

20. Negalur M, Sachdeva V, Neriyanuri S, Ali MH, Kekunnaya R. Long-term outcomes following primary intraocular lens implantation in infants younger than 6 months. Indian J Ophthalmol. 2018;66(8):1088–1093. doi:10.4103/ijo.IJO_182_18

21. Bothun ED, Cleveland J, Lynn MJ, et al. One-year strabismus outcomes in the infant aphakia treatment study. Ophthalmology. 2013;120(6):1227–1231. doi:10.1016/j.ophtha.2012.11.039

22. Rudnitzky A, Abu Ras T. The Bedouin Population in the Negev. Vol. 124. 2012.

23. Vera L, Lambert N, Sommet J, et al. Visual outcomes and complications of cataract surgery with primary implantation in infants. J Fr Ophtalmol. 2017;40(5):386–393. doi:10.1016/j.jfo.2016.12.010

24. Trivedi RH, E WM. Selecting intraocular lens power in children. EyeNet Magazine (2006).

25. Repka MX, et al. A randomized trial of patching regimens for treatment of moderate amblyopia in children. Arch Ophthalmol. 2003;121:603–611. doi:10.1001/archopht.121.5.603

26. Holmes JM, Kraker RT, Beck RW, et al. A randomized trial of prescribed patching regimens for treatment of severe amblyopia in children. Ophthalmology. 2003;110(11):2075–2087. doi:10.1016/j.ophtha.2003.08.001

27. Beck AD, Freedman SF, Lynn MJ, et al. Glaucoma-related adverse events in the infant aphakia treatment study: 1-year results. Arch Ophthalmol. 2012;130(3):300–305. doi:10.1001/archophthalmol.2011.347

28. Freedman SF, Beck AD, Nizam A, et al. Glaucoma-related adverse events at 10 years in the infant aphakia treatment study: a secondary analysis of a randomized clinical trial. JAMA Ophthalmol. 2021;139(2):165–173. doi:10.1001/jamaophthalmol.2020.5664

29. Zhang S, Wang J, Li Y, et al. The role of primary intraocular lens implantation in the risk of secondary glaucoma following congenital cataract surgery: a systematic review and meta-analysis. PLoS One. 2019;14.

30. Kruger SJ, DuBois L, Becker ER, et al. Cost of intraocular lens versus contact lens treatment after unilateral congenital cataract surgery in the infant aphakia treatment study at age 5 years. Ophthalmol. 2015;122(2):288–292. doi:10.1016/j.ophtha.2014.08.037

31. Carrigan AK, Dubois LG, Becker ER, Lambert SR. Cost of intraocular lens versus contact lens treatment after unilateral congenital cataract surgery: retrospective analysis at age 1 year. Ophthalmology. 2013;120(1):14–19. doi:10.1016/j.ophtha.2012.07.049

From increasing catastrophic risk exposures, to operational challenges, to cybersecurity threats, real estate and hospitality companies are navigating an increasingly complex risk landscape that demands tailored strategies and agile risk management.

While both real estate and hospitality companies own significant physical assets, their risk exposures diverge in meaningful ways, creating unique challenges. These differences require tailored strategies that address the nuanced operational and environmental factors unique to each sector.

In this episode of Risk in Context, Duncan Ellis, Marsh’s US and Canada Real Estate and Hospitality Practice leader, speaks with Brian Taliaferro, Entertainment and Gaming Industry Practice leader for Marsh. They discuss the evolving and distinct risk landscapes faced by real estate and hospitality companies and share several risk mitigation strategies that hospitality and real estate companies should consider to remain resilient to current and emerging risks.

Foreign consultancies in Saudi Arabia are reining in a years-long boom in hiring, recruiters and analysts say, as the kingdom reviews its priorities and slows parts of its economic transformation plan.

Consulting firms have piled into the Middle East’s largest economy since 2016 when it embarked on several transformational “gigaprojects”, including futuristic economic area Neom with its 170km linear city, The Line. 

But low oil prices that are cutting into government budgets and doubts about the feasibility of some projects have slowed activity this year, as Saudi officials weigh up where to direct spending.

“There’s a bit of a panic, at least within KPMG,” said one former partner at the Big Four firm. “Understandable, considering 60-70 per cent of [advisory] revenue was public sector.”

KPMG said businesses worldwide were “navigating an uncertain economic environment”, and that “many professional services organisations” had been affected. The firm said its Middle East business continued to “align its services to current client demand”.

Dane Albertelli, senior research analyst at consultancy-focused advisory firm Source Global Research, said “there’s definitely been a realignment in the year but it’s becoming even more acute I think in the last two or three months”. He expects “a marked decrease” in the Saudi consulting market’s growth from 25 per cent in 2024 to about 11 or 12 per cent this year.  

Consultants are at a “crossroads because the Saudis are realigning what projects are top of the agenda, and obviously contracts are going to be awarded in different ways because of that”, Albertelli added, saying there would be “losers” as well as winners. 

Jason Grundy, Middle East and Africa managing director at executive recruitment firm Robert Walters, said that with many of the kingdom’s gigaprojects having moved from planning to delivery phase, less consulting was required. “Strategy consultancy firms don’t mix cement,” he added.

Bashar Kilani, United Arab Emirates managing partner at recruitment firm Boyden and a former managing director at Accenture in Dubai, said that what was once rapid-fire hiring by the consulting firms “is slowing and in some cases there are cutbacks”.

“It’s driven by two forces,” he added. “One is the actual reduction in spend [by clients] but the other one is technology,” with artificial intelligence forcing firms to show greater efficiencies.  

An Accenture consultant working in the kingdom added some firms were getting “majorly hit” by staffing cuts as a result of the new environment, while “AI is actually doing many tasks better than humans at analyst level”.

Kilani estimated that in consulting teams focused on banking and finance there had been a “15-20 per cent reduction” in middle management jobs, while in teams focused on construction the decrease was “much higher”.

But curbs on employee numbers come after an “unprecedented” increase in staffing levels for consulting firms in Saudi Arabia since the pandemic, Kilani added. According to researcher Albertelli, “this is a pause rather than a decline”.

The workforce boom had been driven by government entities looking for help from consultancies in accelerating the ambitious projects in Crown Prince Mohammed bin Salman’s “Vision 2030” plan, with outsiders assisting in everything from drawing up strategies to attract tourists to setting up entirely new ministries.

Consulting in Saudi Arabia “is softening back to a real market”, said one retired PwC partner. “It’s been an extraordinary market for the last five years”.

The FT has previously reported downward pressure on fees for consulting services, which some in the sector say have fallen as much as 40 per cent this year. 

Industry insiders report increasing scepticism from government clients about the role of consultancies, as value for money becomes paramount. Officials are concerned about consultants “overpromising on mega-projects, over-optimism”, said the retired PwC partner, as well as “the talent churn inside firms, and . . . conflicts of interest”. 

Companies under the umbrella of Saudi Arabia’s sovereign Public Investment Fund, which is driving the kingdom’s economic diversification efforts, are also coming under increasing pressure to deliver results. Management teams are facing more scrutiny from their boards, many of them populated by government ministers, to meet targets and tighten their spending, including their outlay on consultants.

It was taking longer for government entities to approve consulting contracts because the agreements were being more closely scrutinised, said Omer Zakaria, Robert Walters’ Saudi Arabia country head. 

“If someone wants to use a Bain or a BCG or a Big Four, they have to go through a process of getting it approved by the main government . . . it’s taking a while to do that,” he added, estimating a four-to-six-month lag. “The Big Four can’t wait and they were already heavily staffed based on the old model.”

However, some consultants say approval processes were already lengthy.

A former local PwC consultant said some government agencies had also become more restrictive about hiring foreign consultants at sensitive ministries over security concerns, limiting work on certain projects to Saudi nationals.

Grundy and Zakaria said there had been a “significant” decline this year in the number of placements Robert Walters makes for senior roles in professional services firms in Saudi Arabia, even as demand has risen in sectors such as healthcare, tourism and law.

The former KPMG partner said he was receiving messages from recruiters “several times per day offering me very senior talent based in Saudi Arabia”. 

Others in the industry said consulting firms were still taking on new staff but that the pace had slowed. While hiring continues because of constant attrition, one strategy consultant said, overall headcount growth was lower than in the past as firms adjusted after a period in which they “overhired”.

While many say they expect the consulting market in Saudi Arabia to weather the slowdown, others are more pessimistic.

“The glory days are over,” said one executive. “Now it’s a hard slog with more people in the room.” 

MIT engineers have developed a printable aluminum alloy that can withstand high temperatures and is five times stronger than traditionally manufactured aluminum.

The new printable metal is made from a mix of aluminum and other elements that the team identified using a combination of simulations and machine learning, which significantly pruned the number of possible combinations of materials to search through. While traditional methods would require simulating over 1 million possible combinations of materials, the team’s new machine learning-based approach needed only to evaluate 40 possible compositions before identifying an ideal mix for a high-strength, printable aluminum alloy.

When they printed the alloy and tested the resulting material, the team confirmed that, as predicted, the aluminum alloy was as strong as the strongest aluminum alloys that are manufactured today using traditional casting methods.

The researchers envision that the new printable aluminum could be made into stronger, more lightweight and temperature-resistant products, such as fan blades in jet engines. Fan blades are traditionally cast from titanium — a material that is more than 50 percent heavier and up to 10 times costlier than aluminum — or made from advanced composites.

“If we can use lighter, high-strength material, this would save a considerable amount of energy for the transportation industry,” says Mohadeseh Taheri-Mousavi, who led the work as a postdoc at MIT and is now an assistant professor at Carnegie Mellon University.

“Because 3D printing can produce complex geometries, save material, and enable unique designs, we see this printable alloy as something that could also be used in advanced vacuum pumps, high-end automobiles, and cooling devices for data centers,” adds John Hart, the Class of 1922 Professor and head of the Department of Mechanical Engineering at MIT.

Hart and Taheri-Mousavi provide details on the new printable aluminum design in a paper published in the journal Advanced Materials. The paper’s MIT co-authors include Michael Xu, Clay Houser, Shaolou Wei, James LeBeau, and Greg Olson, along with Florian Hengsbach and Mirko Schaper of Paderborn University in Germany, and Zhaoxuan Ge and Benjamin Glaser of Carnegie Mellon University.

Micro-sizing

The new work grew out of an MIT class that Taheri-Mousavi took in 2020, which was taught by Greg Olson, professor of the practice in the Department of Materials Science and Engineering. As part of the class, students learned to use computational simulations to design high-performance alloys. Alloys are materials that are made from a mix of different elements, the combination of which imparts exceptional strength and other unique properties to the material as a whole.

Olson challenged the class to design an aluminum alloy that would be stronger than the strongest printable aluminum alloy designed to date. As with most materials, the strength of aluminum depends in large part on its microstructure: The smaller and more densely packed its microscopic constituents, or “precipitates,” the stronger the alloy would be.

With this in mind, the class used computer simulations to methodically combine aluminum with various types and concentrations of elements, to simulate and predict the resulting alloy’s strength. However, the exercise failed to produce a stronger result. At the end of the class, Taheri-Mousavi wondered: Could machine learning do better?

“At some point, there are a lot of things that contribute nonlinearly to a material’s properties, and you are lost,” Taheri-Mousavi says. “With machine-learning tools, they can point you to where you need to focus, and tell you for example, these two elements are controlling this feature. It lets you explore the design space more efficiently.”

Layer by layer

In the new study, Taheri-Mousavi continued where Olson’s class left off, this time looking to identify a stronger recipe for aluminum alloy. This time, she used machine-learning techniques designed to efficiently comb through data such as the properties of elements, to identify key connections and correlations that should lead to a more desirable outcome or product.

She found that, using just 40 compositions mixing aluminum with different elements, their machine-learning approach quickly homed in on a recipe for an aluminum alloy with higher volume fraction of small precipitates, and therefore higher strength, than what the previous studies identified. The alloy’s strength was even higher than what they could identify after simulating over 1 million possibilities without using machine learning.

To physically produce this new strong, small-precipitate alloy, the team realized 3D printing would be the way to go instead of traditional metal casting, in which molten liquid aluminum is poured into a mold and is left to cool and harden. The longer this cooling time is, the more likely the individual precipitate is to grow.

The researchers showed that 3D printing, broadly also known as additive manufacturing, can be a faster way to cool and solidify the aluminum alloy. Specifically, they considered laser bed powder fusion (LBPF) — a technique by which a powder is deposited, layer by layer, on a surface in a desired pattern and then quickly melted by a laser that traces over the pattern. The melted pattern is thin enough that it solidfies quickly before another layer is deposited and similarly “printed.” The team found that LBPF’s inherently rapid cooling and solidification enabled the small-precipitate, high-strength aluminum alloy that their machine learning method predicted.

“Sometimes we have to think about how to get a material to be compatible with 3D printing,” says study co-author John Hart. “Here, 3D printing opens a new door because of the unique characteristics of the process — particularly, the fast cooling rate. Very rapid freezing of the alloy after it’s melted by the laser creates this special set of properties.”

Putting their idea into practice, the researchers ordered a formulation of printable powder, based on their new aluminum alloy recipe. They sent the powder — a mix of aluminum and five other elements — to collaborators in Germany, who printed small samples of the alloy using their in-house LPBF system. The samples were then sent to MIT where the team ran multiple tests to measure the alloy’s strength and image the samples’ microstructure.

Their results confirmed the predictions made by their initial machine learning search: The printed alloy was five times stronger than a casted counterpart and 50 percent stronger than alloys designed using conventional simulations without machine learning. The new alloy’s microstructure also consisted of a higher volume fraction of small precipitates, and was stable at high temperatures of up to 400 degrees Celsius — a very high temperature for aluminum alloys.

The researchers are applying similar machine-learning techniques to further optimize other properties of the alloy.

“Our methodology opens new doors for anyone who wants to do 3D printing alloy design,” Taheri-Mousavi says. “My dream is that one day, passengers looking out their airplane window will see fan blades of engines made from our aluminum alloys.”

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Elon Musk has appointed former Morgan Stanley banker Anthony Armstrong as the new chief financial officer of his artificial intelligence group xAI, marking the latest shake-up to his executive ranks. 

The financier, who advised on the Twitter takeover, has emerged as a key lieutenant to Musk in recent years, including during the billionaire’s time in Washington at the so-called Department of Government Efficiency (Doge).

He will head up the finance function for both xAI and social media platform X, according to several people familiar with the matter. Musk merged X and xAI in March, valuing the combined group at $113bn.

The change of CFO at xAI comes as Musk contends with a spate of senior departures across his businesses. Linda Yaccarino, chief executive of X, resigned in July. xAI’s general counsel Robert Keele and its previous CFO Mike Liberatore also left over the summer.

Armstrong has been working with xAI for several weeks and was formally appointed chief financial officer of the company in recent days, one of the people said.

His X account now carries an xAI logo by his name signifying that he is an employee of the company.

Armstrong and xAI did not respond to requests for comment.

Musk has doubled down on his bet on AI, racing to build sophisticated models to compete with the likes of OpenAI and Google’s DeepMind, while pouring investment into costly infrastructure to support those ambitions.

xAI has recently been discussing a new funding round that would value the company at around $200bn, according to investors in the group, who added that the round had not yet closed.

Armstrong will also be tasked with returning the social media business to financial health following an exodus of advertisers, after Musk relaxed its content moderation standards and told marketers who disagreed with his approach to “go fuck” themselves.

As head of global technology mergers and acquisitions at Morgan Stanley, Armstrong was part of the team hired by Musk to facilitate the $44bn acquisition of X, then Twitter. Armstrong and Musk grew close as the deal, for which Morgan Stanley provided financing, was hashed out, the people said.

More recently, Armstrong worked for the Trump administration as a senior adviser to the Office to Personnel Management as Musk enacted his Doge cost-cutting efforts before falling out with President Donald Trump. Armstrong left the administration over the summer.

Armstrong will replace Liberatore as CFO, who defected to OpenAI after three months in the role. Liberatore left after clashing with some of Musk’s inner circle over corporate structure and tough financial targets, people with knowledge of the matter said.

Armstrong will also take up the duties of X’s chief financial officer Mahmoud Reza Banki, who is leaving after less than a year into the role, according to three people familiar with the matter. Banki did not respond to a request for comment.

Additional reporting by George Hammond in San Francisco

7 October 2025

The letter of indemnity would be a familiar instrument to those involved in the shipping and commodities trade. These are typically used to procure the discharge and delivery of cargo from a vessel when the bills of lading are unavailable for presentation at the discharge port. Through the letter of indemnity, the risks of a claim for misdelivery are transferred from the carrier to the party issuing the letter of indemnity (typically the shipper/charterer), provided the letter of indemnity is properly worded and valid. Such letters of indemnity are often referred to as discharge letters of indemnity.

A less familiar use of the letter of indemnity would be in commodity finance where the letter of indemnity is issued by a beneficiary of a letter of credit (“LOC”) and tendered in lieu of original bills of lading in order to draw on the LOC. Such letters of indemnity, known as payment letters of indemnity (“Payment LOIs”), are not a recent innovation. They are commonplace in the oil trade and were mentioned in the UK Law Commission Report on Rights of Suit in Respect of Carriage of Goods by Sea issued in 1991.

However, it is only in recent years that Payment LOIs have received attention from the Singapore courts. This has come about in cases brought by trade financiers to recover their loans following the insolvencies of major oil traders. The judgment by the Singapore Court of Appeal in The Maersk Katalin [2025] SGCA 42 is the most recent of these cases.

This article discusses the High Court and Court of Appeal decisions in The Maersk Katalin – decisions which go a long way towards restoring faith in the bill of lading and the presentation rule in Singapore.

Allen & Gledhill Partners Corina Song and Daniel Liang represented the successful bank in The Maersk Katalin.

To read the article, please click here.

Chinese car making giant BYD says the UK has become its biggest market outside China, after its sales there surged by 880% in September compared to a year earlier.

The company says it sold 11,271 cars in the UK last month, with the plug-in hybrid version of its Seal U sports utility vehicle (SUV) accounting for the majority of those sales.

It comes after figures from the car industry body the Society of Motor Manufacturers and Traders (SMMT) showed that sales of electric vehicles (EVs) jumped to a record high in September.

The UK is particularly attractive to firms like BYD as the country has not imposed tariffs on Chinese EVs, unlike other major markets such as the European Union and the US.

BYD, which offers cheaper models than many of its Western rivals, said its share of the UK market jumped to 3.6% in September.

The company will launch more new hybrid and electric cars in the months ahead, said the BYD’s UK manager Bono Ge. He added that the brand’s future in Britain looks “hugely exciting”, having just opened its 100th retail outlet.

UK EV sales hit a record high last month, with sales of pure battery electric vehicles rising to almost 73,000, according to the SMMT.

Sales of plug-in hybrid cars grew even faster, it said.

The Kia Sportage, Ford Puma and Nissan Qashqai were the best-selling cars in September. Chinese models – the Jaecoo 7 and BYD Seal U – were also in the top 10.

But despite the surge in overall EV sales in the UK, petrol and diesel vehicles still made up more than half of new car sales last month, according to the SMMT.

In October last year, the EU announced it would hit imports of Chinese EVs with levies of up to 45%.

The measure is aimed to protect European car makers from being undermined by what the EU believes are unfair Chinese-state subsidies.

Chinese car makers like BYD have been effectively shut out of the US by high tariffs, which were backed by both President Donald Trump and his predecessor Joe Biden.

WATCH TIME: 3 minutes | Captions are auto-generated and may contain errors.

“We know dopamine works really well, but beyond that, we don’t really fully understand how Parkinson works. There are many, what I call ‘pathway abnormalities’—things that are different in cells of somebody with Parkinson from somebody who doesn’t have Parkinson. Those pathway abnormalities may be things that you can target [with disease-modifying therapies].”

At the 2025 International Congress of Parkinson’s Disease and Movement Disorders (MDS), held October 5-9, in Honolulu, Hawaii, interim data were presented by Jonas Hannestad, MD, PhD, which detail the open-label, phase 1b findings to-date of a small trial of 21 participants with Parkinson disease (PD) in Australia. The study’s primary goal is to determine the therapy’s safety and tolerability, but secondarily, it is seeking to assess results from mechanistic biomarker readings to confirm target engagement and efficacy signals.

The therapy, GT-02287, is an investigational small-molecule designed to attempt to act as a disease-modifier for PD. All told, it is showing promising early safety and tolerability results in the ongoing phase 1b trial. Although Hannestad, who is the the chief medical officer at Gain, expressed that the results must be taken with “a grain of salt” as they are early phase and the trial is not powered for efficacy, the positive signals on the MDS Unified Parkinson’s Disease Rating Scale Parts I and II do offer some momentum for the treatment’s future development.

While on-site at the congress, NeurologyLive spoke with Hannestad further to discuss the results, but also to glean his perspective on the state of therapuetic availability for patients with PD. He offered his thoughts on the current model of therapy, often beginning with dopeminergic targeting treatments—such as the gold standard in PD, levodopa—which offers great symptomatic relief to patients, particularly early on. However, long-term, these approaches have some limitations, with patients experiencing wearing off effects and lessened efficacy. Additionally, he noted, these treatments do not offer disease-modifying effects—simply put, they do not slow disease progression. Many therapies in the pipeline are being evaluated for their ability to potentially do this, and Hannestad provided some context on the targets that GT-02287 acts on in its attempt to modify disease progression in PD.

Click here to read more from MDS 2025.

REFERENCES
1. Pozzi R, Ignoni T, Bosetti M, et al. GT-02287 in Parkinson’s Disease: Interim Data from a Phase 1b Study. Presented at: International Congress of Parkinson’s Disease and Movement Disorders; October 5-9, 2025; Honolulu, HI.