The Unique Challenges of Pediatric Cataract

A look at the decision-making process and surgical procedure.

Recent data from Sightsavers indicate that congenital cataracts account for roughly 39 percent of all childhood blindness around the world, affecting approximately 200,000 children. Pediatric cataract touches not only the children, but also their families, and communities, for life.

Treatment for pediatric cataract requires specialized professional competency for both the surgical intervention and follow-up care. A detailed eye exam will determine if and when the cataract needs to be removed, and what the optimal course of action may be. Some children require surgery at a very early age, sometimes as young as just a few weeks old. However, the earlier in life the surgery is performed to remove the cataract, the higher the child's risk for perioperative complications and for the development of other long-term vision problems, such as glaucoma. If the cataract isn't affecting the child's vision significantly or hindering his or her visual development, the doctor may monitor the child's ocular health closely and postpone the need for surgical intervention for as long as possible.

Modifying Your Technique

Unlike adult cataract surgeries, in which local or topical anesthesia is almost always used, infants and children are administered general anesthesia. Typically in adults, clear corneal incisions are used, which rarely require post-surgical sutures. However, sutures are recommended when performing this incision on young children to reduce the risk of infection and the possibility for wound leak.

While most ophthalmologists opt for a traditional capsulorhexis for this procedure, some favor vitrectorhexis, which is well suited for use in children under the age of two due to their highly elastic anterior lens capsule. Hydrodissection is often used to loosen the adhesions of cortex to capsule. For children who have been diagnosed with posterior lenticonus or a PFV-type cataract in which the posterior capsule is already weak or abnormal, many surgeons will opt to eliminate or perform only delicate hydrodissection to protect the posterior capsule.

Using a phaco machine (typically with little or no phaco power), the nucleus of the cataract will be emulsified and removed from the child's eye. After phacoemulsification of the lens nucleus and epinuclear material is completed, an irrigation/aspiration apparatus is used to remove the remaining peripheral cortical material. In most procedures, the posterior capsule is initially left intact.

One of the major areas of discussion among pediatric ophthalmologists is whether or not to implant an intraocular lens when treating infantile congenital cataract. Recent data from the Infant Aphakia Treatment Study, spearheaded by Dr. Scott Lambert, indicate that the younger a child is when an IOL is implanted, the higher the rate of necessary short-term reoperation, risk of error in IOL calculation and unpredictable long-term results in refractive error. In an older child—those close to six months to over one year old—most pediatric ophthalmologists tend to prefer to use an IOL. Further data as this study progresses should elucidate the optimal choice for visual rehabilitation in these infantile cataract eyes.

The implantation and model of the IOL varies. I commonly use a foldable acrylic lens that is injected directly into the capsular bag. If performing a posterior capsulectomy, I will enter through the pars plana and perform the capsulectomy with a vitrector. Additionally, an anterior vitrectomy is performed, leaving the IOL in place. Some surgeons prefer to perform the posterior capsulectomy and anterior vitrectomy through the anterior incision, either before or after IOL placement. Some choose to capture the optic through the posterior capsular opening.

In most adult cataract surgeries, the posterior capsule will be left intact after the implantation of the intraocular lens. Many children, however, are best served if the surgeon removes the posterior capsule during the surgical procedure. The doctor's decision to remove the capsule is based largely on the age of the child (the younger the child, the more likely the capsule will opacify), in addition to the specifics of his or her condition and other medical history. If the child is older and more cooperative, the posterior capsule may be removed later on as necessary using a YAG laser.

Following IOL insertion, posterior capsulectomy, vitrectomy if necessary, and removal of viscoelastic, I close the incision with 10-0 vicryl sutures and inject subconjunctival antibiotic and steroid as well as intraocular steroid. Antibiotic/steroid ointment, a patch and a shield are then applied and secured, and the child is discharged from the hospital after postoperative recovery.

The following day, the patch and shield are removed in the office and medication and follow-up care begins. My postop regimen begins for most patients with a week-long course of oral steroids in conjunction with topical steroid, antibiotic and cycloplegic eye drops. Additional medications may be prescribed as needed. I typically see the child four to seven days later and then every one to two weeks, with visits tapering off as the eye heals.

Beyond Surgery

While each pediatric cataract case presents unique challenges, it is important to note that with proper diagnosis, early intervention and treatment, most cataract-related vision problems can be corrected and a child's sight can be saved. It is crucial to remember that treatment of pediatric cataract to optimize vision does not end with surgery. Glasses, contact lenses and amblyopia treatment are critical to ensure an optimal visual outcome as well as careful monitoring for short and long-term sight-threatening complications, such as glaucoma, infection and membrane formation. OM