Cataract surgery is a complex procedure in children, with all aspects of
the surgical process requiring care and attention.
“Practically every step poses extra challenges,” Dominique
Brémond-Gignac, MD, PhD, OSN Europe Edition Editorial Board
Preoperative evaluation is crucial to decide what the best approach is
based on age, type of cataract, delay between onset and diagnosis, systemic and
ocular signs such as microphthalmia, and potential association with mental
“We have to work on a developing eye. As the eye grows front to
back, the lens changes shape to offset the axial growth of the eye. When we do
cataract surgery, we are interrupting that growth and ultimately changing the
refraction, so we have to plan on that, and it can be very difficult to
predict,” M. Edward Wilson, MD, OSN U.S. Edition
Pediatrics/Strabismus Board Member, said.
Dr. Brémond-Gignac, head of pediatric ophthalmology at Amiens
University Hospital, France, said that children younger than 1 year require a
completely different approach from those who are older. In children 2 years of
age and older, cataract management is closer to the procedure an adult would
OSN Editorial Board
Member Dominique Brémond-Gignac, MD, said that parents’ compliance
in their children’s pediatric cataract management is crucial.
In case of congenital cataract, early intervention is mandatory,
according to Michele Fortunato, MD, of Bambin Gesù pediatric eye
hospital in Rome. In his opinion, the ideal time range is between 3 weeks and 6
weeks at the latest, because waiting longer might have a devastating effect on
the child’s visual development.
“Then we can discuss when we should implant the intraocular lens.
We normally wait until 3 to 4 months, but no longer than that, particularly in
case of monolateral cataract,” he said.
With bilateral cataract, particularly in eyes with microphthalmia,
waiting up to 1 year or 2 years gives the eye time to develop a useful axial
length for IOL implantation, according to Dr. Brémond-Gignac.
In the meantime, refractive correction can be done with spectacles or
contact lenses. With short delays, such as 3 months, her advice is to use
spectacles. But with longer delays, contact lenses are the best option, she
IOLs can be implanted safely by 6 months of age, but the ideal age is 6
months to 12 months, according to Dimple Prakash, MBBS, MS, of Dr.
Agarwal’s Eye Hospital in Chennai, India.
“By the age of 12 months, all children should have a lens in cases
in which it is possible,” she said.
Infant Aphakia Treatment Study
Dr. Wilson is one of the investigators of the Infant Aphakia Treatment
Study. The aim of the study is to answer questions about visual outcomes in 114
infants between 1 month and 6 months of age who have a unilateral congenital
cataract and are treated with primary IOL implantation vs. contact lens.
Researchers evaluated visual acuity and adverse events; contact lenses were
used to correct aphakia in those who did not receive IOLs.
Early results of 1-year primary outcome data, presented at Kiawah Eye
2010, showed no statistically significant difference in visual acuity in the
contact lens group vs. the IOL group at 1 year, according to Dr. Wilson.
However, complications were higher in the IOL group, with patients returning
for a second operation more frequently after primary implantation (63% vs. 12%;
P < .001). Most of these additional operations were to clear lens
reproliferation and pupillary membranes, according to the study published in
the July 2010 issue of Archives of Ophthalmology.
Based on these preliminary results, Dr. Wilson said to be “cautious
when using IOLs in patients in the first 6 months of life until this study is
followed for a longer time. Every child with cataracts will need an IOL, but
the question is, when should that happen?”
Lower prevalence, earlier diagnosis
An estimated 1.4 million children are blind worldwide, with 1 million
living in Asia and 300,000 in Africa. Congenital cataracts are responsible for
about 10% of all vision loss in children. Overall cumulative risk for cataract
is one in 1,000 children, according to Dr. Wilson.
M. Edward Wilson
In industrialized countries, the estimated prevalence of bilateral
cataract is one to three per 10,000 children, according to a study by Foster
and colleagues. Studies conducted in individual European countries confirm that
data: In the U.K. and Sweden, the prevalence of congenital cataract is reported
to be three and 3.6 per 10,000 births, respectively. According to the same
study by Foster, the prevalence of child blindness from cataracts is one to
four per 10,000 in developing countries and less than one per 10,000 in the
However, although it is no longer a blinding disease in which
specialized health care services are available, unilateral congenital cataract
is still an important cause of amblyopia and strabismus.
In India, the incidence of blindness due to late diagnosis of congenital
and infantile cataract is declining, but the low number of physicians per
capita is still a major problem, although the situation is improving, Dr.
Prakash said. The high poverty and illiteracy rate in rural areas corresponds
with a high number of undiagnosed and untreated cataracts.
“We are setting up outreach programs in these areas. The large eye
hospitals — about 30, distributed in the eight metropolitan cities of
India — have satellite centers, eye camps and mobile screening units run
by ophthalmologists, optometrists and nurses who visit small towns and rural
areas, do screenings for cataract and refer the people who need surgery to
hospitals,” Dr. Prakash said.
Approximately 50 centers in India have specialized pediatric
ophthalmology units that are fully equipped in all surgical management aspects.
However, thanks to outreach programs and the better ability of pediatricians in
recognizing the signs of cataract in children, blindness from cataract is rare,
and most children are diagnosed early enough to have useful vision for
regularly attending school and college.
In Western countries, a closer cooperation with pediatricians has been
implemented in recent years, leading to better and earlier diagnosis.
“Very often, however, the first diagnosis is done by parents or
even grandparents. They notice some anomalous white reflex in the eye and seek
help,” Dr. Fortunato said.
Cases of relatively late diagnosis are rare nowadays, but advances in
surgical and rehabilitation means and techniques have considerably improved the
prognosis of delayed intervention.
“Until a few years ago, there were children whom we considered not
worth operating. Now we can tell the parents that some functional results can
still be achieved. Improvement is quite extraordinary compared to what we were
able to obtain 20, even 10 years ago,” he said.
At all times, parents play a crucial role in the management of pediatric
“The patient’s outcome is far better if you have involved,
committed and educated parents. The more engaged, the better the
outcomes,” Dr. Wilson said.
“Psychologically accompanying parents are very important,” Dr.
Brémond-Gignac said. “We must explain to them that it is not like
adult cataract and that successful surgery is only a first, short step toward
the final outcome. They have to do the rest, and it will be a long journey.
Parents’ compliance is crucial.”
With preschoolers and older children, teachers should also be involved,
Dr. Fortunato said.
“I always write an accompanying letter for the teachers. I explain
what patching is, how important it is and how they can do it. I also give
instructions on how to do drop instillation in those children who use
mydriatics instead of patching. Teachers normally appreciate being informed and
involved,” he said.
The follow-up is a crucial and demanding time for the surgeon or
referring physician as well.
“We must regularly monitor progress and changes in refraction as
well as corneal clarity and size. We must be vigilant about amblyopia and
continuously reassess the rehabilitation schedule with patching and refractive
correction. Also, we must keep our eyes open for potential complications like
glaucoma,” Dr. Brémond-Gignac said. “On the whole, we must be
there, for the child and for the parents. It is a long journey for us
Challenges of surgery
Typically, surgery is more difficult in a child because the capsule is
more elastic and the anterior chamber is smaller and has a high vitreous
pressure. Microsurgical techniques have made surgery easier and safer, but
Dr. Fortunato uses a Buratto double barrel irrigation and aspiration
cannula. The lens is always soft and easy to manage with just aspiration. He
does not use ultrasound phacoemulsification.
Dr. Prakash utilizes a different approach.
“We use low-energy ultrasound in some cases of harder cataract
types, setting a low pulse mode. However, with most cases of soft nuclei, we
just use irrigation and aspiration,” she said.
Dr. Prakash uses a pars plana approach to perform lensectomy, followed
by anterior vitrectomy in small children not undergoing primary IOL
implantation. Glued IOL implantation is performed in children older than 6
months who have been left aphakic. A near limbal clear corneal phaco approach
with in-the-bag implantation is used in older children.
“Today’s phaco and vitrectomy tools are so small that we no
longer need specific pediatric adaptations. I use 23- and 25-gauge cannulas and
needles,” she said.
Agarwal’s glued IOL technique is used at her hospital to fixate the
IOL to the sclera. Two sclerotomies are performed under two scleral flaps at 3
o’clock and 9 o’clock, 1-mm to 1.5-mm from the limbus. A foldable
lens is injected, and the two haptics are externalized through the sclerotomies
and tucked into two scleral tunnels made at the edge of the scleral flaps. The
scleral flap is then glued down on the scleral bed, using fibrin glue.
Good pupil dilation is often difficult to obtain in children.
Phenylephrine is not recommended, and mechanical dilators have to be used in
some cases. Particularly in very young children, capsulorrhexis can be
challenging, Dr. Fortunato said. Capsulotomy is a safer and easier
Anterior vitrectomy and posterior capsulorrhexis/capsulotomy should
always be performed to avoid inflammation and capsule opacification, according
to Dr. Brémond-Gignac.
Recently, Dr. Fortunato has changed his approach and prefers to leave
the posterior capsule untouched for better in-the-bag IOL stability and for
avoiding vitreous remnants accessing the anterior chamber.
“If secondary opacification occurs, as it does in most cases, I
treat it later, as I would do in adults. I don’t use the YAG laser, but a
23-gauge or 25-gauge vitreous cutter, which allows me to perform a very precise
capsulorrhexis/capsulotomy,” he said.
A delay of no more than 2 weeks is advisable when operating on bilateral
cataract in two separate sessions. Dr. Brémond-Gignac and Dr. Fortunato
do not perform simultaneous surgery, except in cases with anesthesiology
problems. Dr. Prakash does consecutive surgery with a short interval of 4 days
to 5 days between eyes.
Foldable hydrophobic acrylic IOLs are the current gold standard for
implantation in young eyes. They have replaced PMMA IOLs, which were once
Multifocal IOLs have advocates and opponents.
“Visual development needs a clear and stable retinal image, and
this is not possible with multifocal IOLs. Eyeball axial length is not
predictable, so multifocal IOL power cannot be calculated precisely. In
addition, at this time there is no study proving that multifocality is useful
in young children,” Dr. Brémond-Gignac said.
“Multifocal IOLs are first choice in our department,” Dr.
Fortunato said. “They recreate a condition that is nearer to natural
vision, and we have the best functional recovery and management of amblyopia.
We should consider that young children’s activities are mostly at
Diffractive multifocal lenses are the best option because they are not
pupil-dependent, and a +4 add is ideal for children, he explained.
“We implanted the first multifocal lens in a child in 1989, and
since then we have used them in more than 1,000 cases, constantly updating to
new models. I believe this is the largest series worldwide,” he said.
Dr. Fortunato said that adaptation to multifocality is natural and easy
in eyes that are still developing, and none of the problems experienced by
adults have been reported in his young patients.
“We have used multifocal IOLs in some cases, but they were older
children, around 10 years of age, who needed to study and read and had
monolateral cataract. They can be a good choice in these cases to balance the
other eye. But I don’t believe all younger children need them,” Dr.
In an article in Transactions of the American Ophthalmological
Society, Dr. Wilson reported the results of a survey of American
Association for Pediatric Ophthalmology and Strabismus members who were asked
if they would consider implanting a multifocal IOL in children. Responses were
distributed almost equally between yes, no and not sure. Many respondents
commented on their concern about the use of multifocal IOLs in children.
Dr. Wilson said he was in favor of the implantation of multifocal IOLs
in the second decade of life.
“Multifocal IOLs also have appeal for older children [because] they
have the potential to provide simultaneous distance and near focus. More than
one teenager has remarked to us about how embarrassing it is to reach for
reading glasses (‘granny glasses’) while on a date at a restaurant.
Children and teenagers are also very adaptable and may not be bothered by glare
and halos as much as some adults are. Our experience has borne this out,”
Postoperative management of pediatric cataract requires higher doses of
steroids because of the stronger immune response. Corticosteroid therapy should
be started 3 days to 4 days before surgery and continued for at least 1 month
postoperatively, six to eight times a day, Dr. Brémond-Gignac said.
“I also put all my patients on long-term IOP-lowering medications,
usually beta-blockers or acetazolamide, to prevent the risk of secondary
glaucoma,” Dr. Fortunato said.
Dr. Brémond-Gignac works in a large ophthalmology unit where more
than 4,000 surgical procedures are performed every year. About 400 are in
children, 80% less than 4 years of age. Congenital cataracts are approximately
60 cases per year.
In the Bambin Gesù hospital in Rome, 80 to 90 congenital
cataracts are treated per year. Considering other types of pediatric cataract,
mainly post-traumatic, the number grows to approximately 140 per year.
“If we consider that these operations generate a series of
secondary procedures for posterior capsulotomy and, more rarely, other
complications, the number at least doubles,” Dr. Fortunato said.
Dr. Agarwal’s Eye Hospital serves a large area, and approximately
15,600 cataract procedures are performed each year. Of these, about 80 are
pediatric cataracts. – by Michela Cimberle and Tara Grassia
Considering the high risk of secondary glaucoma after pediatric
cataract surgery, do you adopt surgical or medical preventive measures?
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Network of Study and Research in Eye Development. Visual development in
infants: physiological and pathological mechanisms. Curr Opin
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- Foster A, Gilbert C, Rahi J. Epidemiology of cataract in childhood:
a global perspective. J Cataract Refract Surg. 1997;23 Suppl
- Gogate P, Khandekar R, Shrishrimal M, et al. Delayed presentation
of cataracts in children: are they worth operating upon? Ophthalmic
- Infant Aphakia Treatment Study Group, Lambert SR, Buckley EG,
Drews-Botsch C, et al. 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.
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cataracts: are the cost savings worth the risk? Arch Ophthalmol.
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intraocular lens implantation. Curr Opin Ophthalmol.
- Mickler C, Boden J, Trivedi RH, Wilson ME. Pediatric cataract.
Pediatr Ann. 2011;40(2):83-87.
- Rahi JS, Dezateux C; British Congenital Cataract Interest Group.
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lessons from a national study of congenital cataract in the UK. Invest
Ophthalmol Vis Sci. 2001;42(7):1444-1448.
- Rychwalski PJ. Multifocal IOL implantation in children: is the
future clear? J Cataract Refract Surg. 2010;36(12):2019-2021.
- Wilson ME, Trivedi RH. Multicenter randomized controlled clinical
trial in pediatric cataract surgery: efficacy and effectiveness. Am J
- Wilson ME, Trivedi RH, Burger BM. Eye growth in the second decade
of life: implications for the implantation of a multifocal intraocular lens.
Trans Am Ophthalmol Soc. 2009;107:120-124.
- Zetterström C, Lundvall A, Kugelberg M. Cataracts in children.
J Cataract Refract Surg. 2005;31(4):824-840.
- Dominique Brémond-Gignac, MD, PhD, can be reached at
Ophthalmology Department, Saint Victor Centre, Amiens University Hospital, 354
Boulevard Beauvillé, 80054 Amiens, France; +33-3-22-82-41-08; fax:
+33-3-22-82-40-61; email: firstname.lastname@example.org.
- Michele Fortunato, MD, can be reached at Via Polibio 4, 00136 Rome,
Italy; +39-06-39742614; email: email@example.com.
- Dimple Prakash, MBBS, MS, can be reached at Dr. Agarwal’s Eye
Hospital, 19 Cathedral Road, 600 086 Chennai, India; email:
- M. Edward Wilson, MD, can be reached at Albert Florens Storm Eye
Institute at the Medical University of South Carolina, 167 Ashley Ave.,
Charleston, SC 29425, U.S.A.; +1-843-792-7622; fax: +1-843-792-1166; email:
- Disclosures: Drs. Brémond-Gignac, Fortunato and Prakash have
no relevant financial disclosures. Dr. Wilson is a consultant for Bausch + Lomb
and Alcon. He receives book royalties from Springer.