International Journal of Current Medical And Applied Sciences, vol.5. Issue 1, December: 2014. PP: 11-13.

Management of Pediatric Cataract:

A Challenge
Jyoti Bhuyan*
* Professor, Department of Ophthalmology, RIO, Gauhati Medical College, Guwahati, Asam
INDIA.
Corresponding E-mail ID: bishnujyotidas@gmail.com
Subject: Ophthalmology
Review Article
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pediatric cataract has become technically more
Abstract: sound and the results more predictable [3].

Pediatric cataract is an important cause Current Surgical Techniques:

of visual morbidity in early childhood and ranks
as third major cause of childhood blindness.
Management of pediatric cataract is still a
challenge because facilities for management of
pediatric cataract are inadequate in India. The
aim of surgery is to provide long term visual axis
by preventing Posterior capsular opacification
(PCO). Surgery for pediatric cataract is
aspiration by using two way irrigation-
aspiration (IA) canula or automated IA.
Membranous cataract needs
phacoemulsification. IOL implantation is
recommended after 2 years of age. Primary
posterior capsulotomy with or without anterior
vitractomy is considered to prevent PCO.
Key words: cataract, Irrigation Aspiration [ IA],
IOL, posterior capsulotomy, visual
rehabilitation.
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Introduction:
Pediatric cataract is one of the major
causes of childhood blindness and it ranks third
after refractive errors and amblyopia.
Prevalence of childhood cataract has been
reported as 1 to 15 cases 10,000 children. It is
estimated that globally, there are 200,000
children blind from bilateral cataract [1]. It is
said that ‘treating childhood blindness is like
treating 10 blind adults.’ There are still
inadequate facilities for management of
pediatric cataract in India [2]. With the advances
in surgical techniques like maintaining closed
chamber during surgery, viscoelastic agents,
vitrectomy techniques, methods of calculating
IOL calculation and type of IOLs, management of
.
The aim of the surgical technique is to
provide a long term clear visual axis by
preventing PCO or secondary membrane. The
best current technique is “Phacoaspiration with
primary posterior capsulotomy with or without
anterior vitrectomy and capsular bag
implantation/optic capture of intraocular
lens”[4].
Preoperative Evaluation:
A thorough history is useful to diagnose
whether the cataract is congenital,
developmental or traumatic in origin.
Leucocoria is usually noticed in congenital
cataract, so other causes of leucocoria should be
excluded. Maternal history of drug use, infection
or exposure must be ascertained. Family history
of cataract and families with inherited cataracts
should receive genetic counselling. Each child
should be examined by a paediatrician for
thorough systemic work up to rule out systemic
associations, anomalies or congenital rubella.
Assessment of visual function: it
includes History of behavioural change like
bringing objects close to eye, frequent fall or
hitting the wall etc. Ruling out
nystagmus/nystagmoid movements, squint and
noting for central, steady and maintained
fixation.Slit lamp examination to evaluate
various types of cataract. Congenital cataracts
are more amblyogenic than developmental
cataracts.
Evaluation of fundus and B-Scan
ultrasound whenever required. Examination to
rule out congenital abnormalities like
microphthalmos, coloboma and persistent
hyperplastic primary vitreous.

Copyright @ 2014 Logic Publications, IJCMAAS,E-ISSN:2321-9335,P-ISSN:2321-9327, Page I 11

 Jyoti Bhuyan
Figure 1: Ant. Polar cataract
Figure 3: Lamellar cataract Figure 4: Nuclear cataract
Preoperative Investigations:
Serology for intrauterine infections (TORCH
infection): Urine analysis for- reducing
substance after milk feeding for Galactosemia,
amino acids for Lowe syndrome, copper for
Wilson’s disease, protein for All port
syndrome.Blood glucose level for diabetes
mellitus.VDRL for syphilis.Serum calcium for
Hyper or Hypothyroidism.
IOL Power Calculation:
The type of biometric formula for IOL
power calculation is not defined and different
theories have been proposed by different
surgeons. Most reports have recommended
under-correction anticipating the myopic shift
following IOL implantation. The axial length and
keratometry readings should be measured for
power calculation. The most preferred approach
is the one put forwarded by Dahan et al. [5] thus;
children between 2-3 years are under corrected
by 30%, 3-5 years by 20% and 5-8 years by 10%.
After 8 years, the IOL power is targeted for
emmetropia.
Indications For Pediatric Cataract Surgery:
Cataract which occupy visual axis and occupy
3mm or more of the pupil.Unilateral partial or
complete cataract to prevent amblyopia. Cataract
with squint,nystagmus / unsteady fixation.Poor
retinoscopy reflex: if during retinoscopy reflix is
poor due to cataract.
Timing of Surgery:
Once indicated child may be operated as
early as 2 weeks of age. Unilateral cataract needs
Copyright @ 2014 Logic Publications, IJCMAAS,E-ISSN:2321-9335,P-ISSN:2321-9327, Page I 12.
Figure 2: Sutural cataract
early surgery and in bilateral cataract, after
operating first eye, second eye may be operated
within a week or two to prevent amblyopia. In
general optimum age for surgery for unilateral
cataract is 6 weeks and bilateral cataract is 8
weeks.
Preoperative Counselling:
Preoperative counselling is most
important. Parents must understand that surgery
is the first step of management. The following
points to be stressed. Follow up for a long period
for repeated correction and occlusion therapy.
Possibility of postoperative complications and
need of secondary intervention must be
emphasized.
Anaesthesia:
Surgery is performed under general anaesthesia.
Cataract Removal In < 18 Months:
Two side ports are created at the limbus
and with a guillotine type vitrectomy probe an
opening is made in the anterior capsule. Lens
material is aspirated and a posterior continuous
curvilinear capsulorhexis ( PCCC) and anterior
vitrectomy is done. For secondary IOL after 2
years of age, a capsular rim is left. The small side
port entry may have to be sutured if required.
Nowadays this surgery can be done with 25
gauge vitrectomy instruments also [6].
Pediatric Cataract Surgery with IOL
Implantation:
A scleral tunnel incision is preferred due
to better wound apposition [7]. But with the
availability of soft foldable lens which require
 Logic Publications @2014, IJCMAAS, E-ISSN: 2321-9335,P-ISSN:2321-9327.
incision of 3 mm or less some surgeons are
shifting to clear corneal incision with good
results. Two paracentesis incisions are made in
the clear cornea.
A Continuous curvilinear capsulotomy
(CCC) is challenging as the anterior capsule is
more elastic. Rhexis should be aimed as small as
possible. The desirable size is 5.0 to 5.5 mm in
diameter. It is preferable to use a cohesive
vicoelastic agent. Maximum removal of cortex
and lens epithelial cells from the equatorial
region is essential. Cortical material is aspirated
using two port irrigation-aspiration (IA).
As Posterior capsular opacification
(PCO) is the most frequent complication after a
successful surgery in children, primary posterior
capsulotomy with anterior vitractomy needs to
be done [8,9].
An ideal PCCC should be around 3-4 mm
circular ring and should be performed under the
age of 6 years. Most surgeons prefer doing
anterior vitrectomy to decrease the PCO, stabilise
the IOL and vitreous prolapsed in the anterior
chamber. The vitrectomy may be performed
using limbal or pars plana route.
Capsular bag implantation is the best
choice. Hydrophobic acrylic, foldable lens are
preferred now a days [10,11]. Some surgeons
prefer optic capture, whereby haptics are placed
in the bag and optic is pushed through the PCCC.
The principle behind the optic capture is to avoid
the need for vitrectomy and better IOL
centration.
All incisions should be closed with a
suture because of lower scleral rigidity with
higher risk of fish mouthing of the incision.
For secondary IOL in paediatric aphakia,
the IOL is can be implanted in the sulcus, and
very rarely into the capsular bag. PMMA lenses
are preferred over acrylic IOLs for lesser chances
of decentration [12].
Post-Operative Management:
Pediatric eye tends to show more tissue
reaction and chances of fibrinous reactions are
significantly high. Hence post-operative
management include frequent instillation of high
potent topical steroid like prednisolone acetate
and a cycloplegic agent. If required systemic
steroid have to be administered.
Visual Rehabilitation:
Visual rehabilitation is as important as
surgery itself. Amblyopic therapy should be
instituted meticulously. Children <2 years
retinoscopy is done on the table after surgery
and prescribe glass immediately. Occlusion
International Journal of Current Medical And Applied Sciences [IJCMAAS] volume 5, Issue 1.
therapy for unilateral cataract after surgery
should be instituted early as these children are at
a higher risk of developing amblyopia. Children
after cataract surgery need to undergo refraction
routinely due to the frequent refractive changes.
Conclusion:
Management of paediatric cataract is
challenging, if not treated early, may be
associated with dismal results. However early
surgery combined with appropriate refractive
correction and aggressive amblyopic therapy
usually provide encouraging results. The role of
parents is as important as the paediatric
ophthalmologist for optimum visual outcome.
References:
1. Jagat Ram, Crrent Surgical Techniques for Pediatric
Cataract Surgery, Ready Reckoner in
Ophthalmology 2010, p 179-182.
2 . GVS Murthy, N Jhon, SK Gupta, P Vashist, GV Rao;
Status of pediatric Eye care in India; Indian Journal
of Ophthalmology 2008: Vol 56, Issue 6 ,pp 481-88
3. Rishikesh Mayee , Pediatric Cataract- Management
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4 . Ram J, Brar GS. Textbook of Pediatric Cataract
Surgery , Jaypee Brothers, New Delhi, 2006.
5. Dahan E. Intraocular Lens implantation in children.
Curr Opin Ophthalmol. 2000 Feb; 11(1): 51-5.
6. Chee KY, Lam GC. Management of congenital cataract
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Completion rate of primary posterior continuous
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9. Hardwig PW, Erie JC, Buettner H. Preventing
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10. Nihalani BR, Vasvada AR. Single-piece AcrySof
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11. Aasuri MK, Fernandes M, Pathan PP. Comparison of
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