Management of Pediatric

Cataract
(Preoperative, Intra and Postoperative)

Feti Karfiati Memed, MD

Pediatric Ophthalmology and Strabismus Team
Cicendo Eye Hospital Bandung
Pediatric cataract is a
significant cause of
visual disability in the Preventable childhood
pediatric population blindness
worldwide

Early diagnosis and

treatment are crucial
to prevent the
development of
irreversible deprivation
amblyopia
 A child’s eye is unique

• Smaller in size at birth, changing axial length and

corneal curvature over a period of time
• Rapid growth of eyes in the first 18 months of life
• The process of emetropization

Management of Pediatric Cataract different from

Adult Cataract
 PEDIATRIC CATARACT CLASSIFICATION

1. Onset
• Congenital : cataracts may occur at birth
• Developmental : cataracts that occur within the first
year of life and within a period of visual development
2. Morphology
• Lamellar
• Nuclear
• Cortical
• Subcapsular
 3. Pediatric Cataract Etiology

• Bilateral:
- Idiopathic (50%)
- Hereditary (20%)  autosomal dominance
- Genetic
- Metabolic Disorder (down syndrome, galactosemia,
hipoglikemia, marfan syndrome)
- Intraunterine infection: TORCH
- Ocular anomaly (aniridia, anterior segment
dysgenesis)
- Toxic (steroid, radiation)
Unilateral:
- Traumatic
- Idiopathic
- Ocular Anomaly
Persistent Fetal Vasculature (PFV), anterior segment
dysgenesis
 Pediatric Cataract Symptoms

Decrease
Leucokoria Nystagmus
Visual Acuity

Strabismus Photophobia
 Pediatric Cataract

The management depend Some obstacles for

on: achieving good visual
• Age of onset outcomes after surgery:
• Increased postoperative
• Laterality inflammation
• Morphology of the • Axial length growth after
cataract cataract extraction
• Associated ocular and • IOL power calculation
systemic comorbidities • Secondary glaucoma
• Posterior capsule
opacification (PCO)
• Amblyopia management
 Preoperative Management

Complete Ocular
Systemic Evaluation
Examination

systemic work up to rule out

systemic associations with cataract • Visual acuity
or other anomalies (ex. Congenital • Anterior segment  slit lamp
rubella syndrome) /microscope
• Posterior segment 
funduscopy or B-scan/Ascan
USG
Surgery ?? • Keratometer
• Biometry
 Nonsurgical Management

Peripheral lens Punctate Opacities less

opacities opacities than 3 mm

• Observed closely
• Dilatation by mydriatic agent
• Treating amblyopia by glasses and patching
 Preoperative Management

IOL/Non IOL

• Appropriate IOL Contact Lens

power
Glasses
• Target Refraction
 Surgical Management

Timing of Surgery

• Unilateral congenital cataracts  4–6 weeks

• Bilateral congenital cataracts  6–8 weeks
• As soon as systemic condition tolerate to general anesthesia

Prevent development of deprivation

amblyopia, strabismus, and sensory
nystagmus
 Surgical Management

Surgical Technique

Wound
• Superior incisions are
commonly performed compared
to temporal approach
• Corneal approach or scleral
approach
• To prevent wound leakage 
suturing the wounds (10-0 or 9-
0 vicryl or nylon suture)
 Surgical Technique

Capsulotomy
• Continuous, smooth, and well centered anterior capsulotomy is a prerequisite
for safe lens implantation
• Manual CCC has been the gold standard

Tips:
Anterior capsulotomy
should be smaller than IOL
optic
(4–5 mm)
 Surgical Technique

Techniques for cataract extraction:

• Lens removal can be conducted through an anterior

approach by aspiration-irrigation
• Phacoemulsification unnecessary
• An anterior chamber maintaining by continuous
irrigation to prevent anterior chamber collapse during
surgery
 Posterior Capsule Management

• PPC with or without anterior

vitrectomy in infants and young
children (< 5 years) or in older
children who are poor
candidates for NdYAG laser
capsulotomy
• PPC diameter smaller than the
anterior capsulotomy
 Posterior Capsule Management

Maintenance clear Posterior capsule

visual axis is critical left intact 
for postoperative develop significant
visual outcome PCO (100%)

cooperative Membranectomy
children  NdYag for dense
Laser Capsulotomy membrane
post opr formation
 IOL IMPLANTATION

Type of IOL
Timing of IOL
implantation : Hydrophobic
Use foldable
acrylic IOLs have
design for smaller
Bilateral Cat gained popularity
incision size
over PMMA IOLs
Unilateral cat
One piece lenses Three pieces
for in the bag lenses for sulcus
fixation fixation
 Postoperative Management

Postoperative Medications

• Topical Steroid
Prednisolone acetate 1% or similar 6-8 times daily for 1-2
months
• Topical Antibiotic
Broad spectrum antibiotic 6 times daily for 1-2 weeks
• Cycloplegic agent
Atropine 1% or homartropine 2% 2-3 times daily for 4
weeks
• Oral Antibiotic and oral analgetic
 Postoperative Management

Postoperative Follow-Up

• Examination schedule
1 day, 1 week, 1 month, every 3 months after surgery
• Examination Elements
– Visual acuity
– Refractive state
– Intraocular pressure
– Anterior segment evaluation
(inflammation process, pupil size, IOL centration, PCO or
membrane formation)
– Red reflex or funduscopy
 Pediatric Cataract Visual Rehabilitation

Prompt optical correction and amblyopia management can

result in good visual outcome

Optical Corrections
• IOL Implantation
– Primary or secondary
• Glasses
– Aphakic glasses
– Near vision glasses
– Bifocal glasses
• Contact Lens
– For unilateral aphakic case

Never Delayed Optical Corrections and Amblyopia

management
Thank You