How is cataract managed in children and what is its visual prognosis?

Pediatric cataracts can occur in one eye (unilateral) or both eyes (bilateral). They can be complete or partial and can be present at birth or occur sometime after birth. Cataracts can be partial at birth and later progress to become visually significant. In contrast to adults, cataracts in children present a special challenge, since early visual rehabilitation is critical to prevent irreversible amblyopia (lazy eyes). The earlier the onset, and the longer the duration of the cataract, the worse the prognosis. With new techniques and material in the treatment of congenital cataracts and improved surgical and clinical management, visual prognosis has improved. Now ophthalmologists operate as early as the first week of life and visually rehabilitate the child with either glasses or contact lenses.

Children born with cataracts are also at risk for developing glaucoma, strabismus, nystagmus, and poor stereopsis, further complicating successful outcomes. In most cases, it is the willpower and resolve of the parents or caregivers to follow post-operative management that determines visual success for the child. Patients with acquired progressive cataracts have less amblyopia and a much better visual prognosis than patients with cataracts that cover the visual axis since birth.

Unilateral infantile cataracts are rarely caused by a systemic disease, except in some cases of intrauterine infections such as rubella. Generally, monocular congenital cataracts have a relatively good prognosis if surgery and optical correction is provided by two months of age. Beyond this age, there is a possibility of having dense amblyopia in the operated eye.

Bilateral cataracts are often inherited. The work-up for bilateral congenital or infantile cataracts should include a careful pediatric examination and special tests. Dense bilateral congenital cataracts require urgent surgery and visual rehabilitation. In general, bilateral cataracts operated prior to two months of age have a good visual prognosis with approximately 80% achieving vision of 20/50 or better.

Cataract surgery in children is done under general anesthesia. It involves removal of the cataractous (opaque) crystalline lens. This is often accompanied by surgical measures (primary posterior capsulorrhexis /anterior vitrectomy) to ensure the clarity of the central visual axis in the postoperative period, which can otherwise get obscured by the ‘after cataract’ (collection of inflammatory cells and fibrous tissue) formation. We currently consider IOL implantation in patients who are one year or older, and IOL implantation is the procedure of choice in children 2 years and older. The use of aphakic glasses or contact lenses continues to be the treatment of choice for congenital cataracts in neonates, while an IOL is preferred for children over one year of age. Postoperatively, the child will still require glasses after the IOL implantation. The child may require occlusion therapy for the management of amblyopia.