Pediatric Cataract Surgery | PristynCare

Risk Factors

Risk factors for poor visual outcomes in pediatric cataracts include:

• Unilateral dense cataract present from birth (highest amblyopia risk)
• Delayed diagnosis beyond 6 to 8 weeks of age in dense cataracts
• Poor compliance with patching or contact lens wear
• Associated nystagmus suggesting long-standing visual deprivation
• Posterior capsular opacification (PCO) after surgery

Who Needs Surgery

All infants with a dense central cataract causing visual axis obstruction should have surgery as early as 4 to 6 weeks of age. Partial or peripheral cataracts not affecting vision may be monitored closely. Any cataract that is causing amblyopia, strabismus, or nystagmus should be treated urgently. The timing of surgery and optical rehabilitation is the most critical factor determining visual outcomes.

Diagnosis

Diagnosis of pediatric cataracts includes:

• Red reflex examination (Bruckner test) at every newborn and infant check-up
• Slit-lamp examination under general anesthesia (EUA) for young infants
• Retinoscopy and refraction to assess visual potential
• B-scan ultrasonography if the posterior segment is not visible
• Systemic evaluation including metabolic screen, urine amino acids, TORCH serology
• Genetic testing when a hereditary cause is suspected

Treatment Plan

Treatment involves surgical removal of the cataract followed by immediate optical rehabilitation. In infants under 2 years, contact lenses are preferred over intraocular lenses (IOL) due to the rapidly changing refraction. IOL implantation is generally considered from age 2 to 4 years depending on the axial length and predicted adult refraction. Patching of the fellow eye (occlusion therapy) for 4 to 6 hours daily is essential to treat amblyopia.

Pediatric Cataract Surgery Steps

Pediatric cataract surgery involves the following steps:

• General anesthesia administered by a pediatric anesthesiologist
• A small incision is made at the limbus (junction of cornea and sclera)
• The anterior capsule is opened using a vitrectorhexis or continuous curvilinear capsulorrhexis
• The lens material is aspirated using an irrigation-aspiration handpiece
• A posterior capsulotomy and anterior vitrectomy are performed routinely to prevent posterior capsule opacification (PCO)
• An IOL may be placed in the capsular bag if the child is old enough and the eye is of adequate size
• In infants, the eye is left aphakic and a contact lens is fitted post-operatively
• Antibiotic and steroid drops are started immediately

Post-Surgery Recovery

Post-operative care after pediatric cataract surgery includes:

• Contact lens or glasses fitting within 1 to 2 weeks of surgery
• Occlusion therapy (patching the good eye) started as soon as optical correction is in place
• Regular follow-up every 4 to 6 weeks to monitor refractive changes and amblyopia treatment
• Topical antibiotic and steroid drops for 4 to 6 weeks
• General anesthesia EUA may be needed for IOP checks and refraction in young infants
• Annual refraction updates as the eye grows

Risks and Complications of Pediatric Cataract Surgery

Complications of pediatric cataract surgery include:

• Posterior capsule opacification (PCO): Very common in young children; managed with posterior capsulotomy and anterior vitrectomy at the primary surgery
• Glaucoma: Aphakic glaucoma is a long-term complication requiring lifelong monitoring
• Amblyopia: Risk of developing or worsening amblyopia if optical correction or patching is delayed
• Strabismus: May develop or persist after surgery
• Endophthalmitis: Rare but serious intraocular infection
• IOL malposition: In small eyes, IOL can decentre as the eye grows