Incidence, Risk Factors, and Outcomes of

Retinal Detachment after Pediatric Cataract

Surgery
Sumita Agarkar, MS, DNB,1 Varada Vinay Gokhale, DNB,1 Rajiv Raman, MS, DNB,2 Muna Bhende, MS,2
Gayathri Swaminathan, MSc,2 Mukesh Jain, MS2

Purpose: To report the incidence of, and to estimate the long-term risk and predisposing factors and the
surgical outcomes for, retinal detachment (RD) after pediatric cataract surgery.
Design: Retrospective consecutive interventional case series.
Participants: During the study period 1996 to 2007 at a tertiary eye care institute, 481 eyes of 295 children
aged below 16 years with no other ocular and systemic anomalies who underwent lensectomy, posterior cap-
sulorrhexis, and anterior vitrectomy combined with primary intraocular lens implantation were included. The
median follow-up was 66 months.
Methods: KaplaneMeier estimates and Cox proportional hazard regression model were used for estimating
cumulative risk and hazard ratio (HR), respectively. Difference between measured preoperative axial length and
age-matched mean axial length (prior studies) was calculated, and was defined as age-adjusted axial length
difference (ALD) (minus and plus denotes myopia and hypermetropia, respectively).
Main Outcome Measures: Cumulative risk and potential risk factors for RD.
Results: Of the total, 12 eyes of 9 children developed RD after cataract surgery, with a median time of 70
months. The overall risk of RD was 5.5% at 10 years after cataract surgery. All 9 children were male. The multi-
adjusted HR associated with increased risk of RD was 12.42 (95% confidence interval [CI], 2.91e53.01;
P ¼ 0.001) for eyes of children with intellectual disability and 21.93 (95% CI, 2.95e162.80; P ¼ 0.003) for eyes of
children with age-adjusted ALD < 1 mm (myopic). Retinal break associated with induction of posterior vitreous
detachment was the most common (8 eyes) cause of RD. No surgical intervention was done in 2 eyes. Scleral
buckle and vitrectomy combined with belt buckle were performed in 4 and 6 eyes, respectively. At final follow-up,
5 and 9 eyes had a visual acuity better than or equal to 6/18 and 6/60, respectively.
Conclusions: A 5.5% risk for RD is estimated for the first 10 years after cataract surgery in children with no
known ocular and systemic anomalies. The risk significantly increases in a male, myopic, and intellectual disabled
child. We emphasize the need for regular and long-term follow-up after pediatric cataract
surgery. Ophthalmology 2017;-:1e7 ª 2017 by the American Academy of Ophthalmology

Childhood cataract is a common treatable cause of child-
hood blindness with a reported prevalence of 1.2 to 13.6
cases in 10 000 children.1 Progressive ocular anatomic and
physiological changes make the management of pediatric
cataract challenging, as compared with that of adults.
Recent advances in surgical techniques, availability of
better viscoelastic materials, and improved design of
intraocular lenses have contributed significantly to the
improved outcomes in these challenging situations. The
current standard of care for managing pediatric cataract
includes lens aspiration, primary posterior capsulorrhexis,
and anterior vitrectomy combined with primary intraocular
lens implantation. However, complications that are
inherent owing to the age group continue to pose problems.2
Retinal detachment (RD) after pediatric cataract surgery
is a vision-threatening complication that requires surgical
intervention. Most of the early studies of cataract surgery in
children reported an incidence of RD ranging from 0.57% to
5%.3e9 However, these studies had a smaller sample size
and limited follow-up. Besides, the technique of cataract
surgery used in these studies has changed over the years.
Most of these studies were based on aphakic eyes and many
of them had not excluded other ocular abnormalities that are
independent risk factors for RD.
Two recent well-designed studies, conducted by Rabiah
et al10 and Haargaard et al,11 adequately addressed many of
these shortcomings. However, the relationship of axial
length with RD after cataract surgery in children has not
been elucidated in these studies. Likewise, in the modern
era of vitreoretinal surgeries, there is limited literature on
the outcome after retinal reattachment surgery in children
with RD after cataract surgery.
The aim of this study was to report the incidence and risk
factors for RD after cataract surgery in a cohort of children
below 16 years of age with no known ocular and systemic
anomalies, undergoing lens aspiration, primary posterior

ª 2017 by the American Academy of Ophthalmology http://dx.doi.org/10.1016/j.ophtha.2017.07.003 1

Published by Elsevier Inc. ISSN 0161-6420/17
 Ophthalmology Volume -, Number -, Month 2017
capsulorrhexis, and anterior vitrectomy combined with
primary intraocular lens implantation. We also report the
clinical presentation, surgical intervention, and post-
operative outcomes in eyes that had RD after cataract
surgery.
Methods
Electronic medical records of 517 eyes of 326 children aged below
16 years undergoing cataract surgery during 1996 to 2007 at a
tertiary eye care hospital were retrospectively reviewed. We
excluded eyes with traumatic cataract (n ¼ 2), systemic anomalies
(n ¼ 2) (Marfan syndrome, n ¼ 1; EhlerseDanlos syndrome, n ¼
1), and ocular anomalies (n ¼ 30) (retinopathy of prematurity, n ¼
4; persistent hyperplastic primary vitreous, n ¼ 9; coloboma, n ¼
4; disc anomalies, n ¼ 3; uveitis, n ¼ 4; AxenfeldeRieger
anomalies, n ¼ 3; and pre-existing glaucoma, n ¼ 3), which are
known to be independent risk factors for RD. We further excluded
children with pre-existing RD (n ¼ 2). Thus, after exclusions, a
total of 481 eyes of 295 children who underwent lens aspiration,
primary posterior capsulorrhexis, and anterior vitrectomy com-
bined with primary intraocular lens implantation were included in
this study. Ultrasound B-scan was performed in children in whom
the retinal view was obscured by lenticular opacity to exclude any
posterior segment pathology. The study was approved by the
institutional review board of the Vision Research Foundation,
Sankara Nethralaya, Chennai, Tamil Nadu, India, and adhered to
the tenets of the Declaration of Helsinki.
All patients included in the study underwent a lens aspiration
through a scleral tunnel approach. Primary posterior capsulorrhexis
was performed using the Utrata forceps, followed by automated
anterior vitrectomy. Subsequently, an intraocular lens was
implanted in the bag for all children. All the surgeries were per-
formed by experienced pediatric cataract surgeons. Topical corti-
costeroids were used for 6 weeks in tapering doses after the
surgery. The presence or absence of RD after pediatric cataract
surgery was analyzed at the follow-up. We identified 12 eyes of 9
children who developed RD after cataract surgery, with no history
of trauma.
The data obtained from the records included age at cataract sur-
gery, gender, laterality, cataract morphology, axial length
(obtained using A-scan contact probe method, Alcon OcuScan,
Alcon, Chennai, India), and any other systemic condition, such as
intellectual disability. For each child, the difference between age-
matched expected mean axial length (noted from prior studies) and
the measured preoperative axial length was calculated and was
defined as age-adjusted axial length difference (ALD).12 By
convention, a minus and a plus value indicate a more myopic
(greater axial length) and hypermetropic (smaller axial length)
refractive state, respectively, as compared with age-matched chil-
dren. For those who developed RD during their follow-up period,
additional data (including duration between cataract surgery and RD,
detailed retinal examination findings, primary vitreoretinal surgery,
any additional surgery, and the final visual outcome) were collected.
All statistical analyses were based on eyes as the unit. For
further analysis, continuous variables, age at cataract surgery, and
age-adjusted ALD (3 groups: ALD > 0 mm, hypermetropia; ALD
< 0 mm but > 1 mm, low myopia; ALD < 1 mm, high
myopia) were categorized into various groups. KaplaneMeier es-
timate was used to calculate the cumulative risk of RD by years
after cataract surgery. Hazard ratios (HRs) with 95% confidence
intervals (95% CIs) of RD after pediatric cataract surgery for po-
tential predictors were estimated using a Cox proportional hazard
regression model since surgery as the underlying time scale.
2
Because the outcome of 2 eyes of an individual may not neces-
sarily be considered independent, the traditional standard errors
were therefore substituted by more robust standard errors that allow
for such a clustered data structure as described by Lin and Wei.13
Statistical analysis was performed using Stata 14 statistical
software (StataCorp), and a P value of less than 0.05 was
considered to be statistically significant.
Results
The 5-year incidence of RD after pediatric cataract surgery was
2.5% (95% CI, 1.4%e4.3%). The median follow-up time since
cataract surgery was 66 months (25th quartile, 24 months; 75th
quartile, 100 months; range, 3 months to 16 years). Of the total 481
eyes, 12 eyes of 9 children developed RD after cataract surgery.
The median time between cataract surgery and development of RD
was 70 months (25th quartile, 32 months; 75th quartile, 88
months).
Table 1 shows the Cox proportional HRs with the respective CI
of developing RD for possible risk factors. Increased risk of RD
was not associated with young age at cataract surgery, bilateral
involvement, or morphology of cataract (P > 0.05). Risk of RD
was significantly higher in eyes of children with intellectual
disability (HR, 10.26; 95% CI, 3.08e34.22; P < 0.001).
Similarly, the risk was significantly greater for eyes of children
with high myopia (age-adjusted ALD < 1 mm) as compared
with eyes of children with hypermetropia (age-adjusted ALD >
0 mm) (HR, 8.88; 95% CI, 1.12e70.20; P ¼ 0.039).
A multifactorial analysis for the Cox regression HR model was
done. An increased risk of RD in eyes of children with intellectual
disability (HR, 12.42; 95% CI, 2.91e53.01; P ¼ 0.001) was
estimated. The risk for RD increased progressively with increasing
myopia (age-adjusted ALD < 0 mm) and was significantly higher
for eyes of children with high myopia (age-adjusted ALD < 1
mm) as compared with eyes of children with hypermetropia (age-
adjusted ALD > 0 mm) (HR, 21.93; 95% CI, 2.95e162.80; P ¼
0.003). All 9 children were male, implying gender to be an
important risk factor (no statistical analysis was feasible).
Figure 1A shows the KaplaneMeier estimates of the risk of RD
since cataract surgery by years in the overall group. A cumulative
risk of RD after cataract surgery at 10 years was found to be 5.5%
in children with no ocular and systemic anomalies. Figure 1B
shows the KaplaneMeier estimates of the risk of RD since
cataract surgery by years in the group with intellectual disability.
A cumulative risk of RD at 10 years was found to be 37.5% in
eyes of children with intellectual disability as compared with
3.2% in eyes of children with no intellectual disability.
Figure 1C shows the KaplaneMeier estimates of the risk of RD
by years since cataract surgery by age-adjusted ALD. A cumula-
tive risk of RD at 10 years was found to be 8.8% in eyes of children
with high myopia (age-adjusted ALD < 1 mm) as compared with
2.1% in eyes of children with hypermetropia (age-adjusted ALD >
0 mm).
Table 2 shows the baseline characteristics, retinal findings at
presentation, type of vitreoretinal surgery performed, and
outcomes for 12 eyes of 9 children. The mean age at the time of
RD was 12 years (range, 8e16 years). Two children (numbers 2
and 3 in our series) presented with bilateral simultaneous RD.
Another child (number 4 in our series) had sequential bilateral
RD, with left eye followed by right eye. In 10 eyes where the
fundus was visualized, the findings noted, in decreasing order of
frequency, were as follows: posterior vitreous detachment
(PVD)-induced breaks, 5 (50%) eyes; combined PVD-induced
break and lattice with holes, 3 (30%) eyes; and only lattice with
holes, 2 (20%) eyes.
 Agarkar et al 
Retinal Detachment after Pediatric Cataract Surgery

Table 1. Cox Proportional Hazard Ratios of Developing Retinal Detachment for Possible Risk Factors in the Study Groups

Cox Hazard Ratio Univariate Cox Hazard Ratio Bivariate

Developed Did Not
Variables Total RD Develop RD Hazard Ratio CI P Value Hazard Ratio CI P Value
Age at cataract surgery
>10 years 65 1 164 1 - - 1 - -
5e10 years 162 4 158 1.94 0.22e17.40 0.553 0.42 0.04e4.49 0.477
<5 years 254 7 247 1.64 0.20e13.36 0.643 0.17 0.15e1.89 0.148
Gender
Male 298 12 286 - - - - - -
Female 183 0 183 - - - - - -
Laterality
Unilateral 102 1 101 1 1 - -
Bilateral 379 11 368 1.96 0.25e15.23 0.521 5.7 0.75e43.43 0.093
Eye involved
OD 240 5 235 1 - - 1 - -
OS 240 7 233 1.58 0.50e4.97 0.437 1.25 0.42e3.74 0.693
Intellectual disability
No 456 8 448 1 - - 1 - -
Yes 25 4 21 10.26 3.08e34.22 <0.0001* 12.42 2.91e53.01 0.001*
Axial length difference
>0.00 156 1 155 1 - - 1 - -
1.00 to 0 134 2 132 2.99 0.27e32.99 0.371 8.33 0.95e72.74 0.055
<1.00 191 9 182 8.88 1.12e70.20 0.039* 21.93 2.95e162.80 0.003*
Type of cataract
Lamellar 259 10 249 1 - - 1 - -
PSC 16 1 15 2.02 0.25e16.06 0.505 4.63 0.75e28.53 0.098
Total 22 1 21 0.67 0.08e5.77 0.719 1.55 0.19e12.33 0.68
Others 184 0 184 - - -

CI ¼ confidence interval; OD ¼ right eye; OS ¼ left eye; PSC ¼ posterior subcapsular cataract; RD ¼ retinal detachment.
Asterisk (*) indicates statistically significant P value.

Two eyes had inoperable total RD with proliferative vitreor-
etinopathy (PVR) changes. Of the remaining 10 eyes, 4 and 6 eyes
underwent, respectively, a scleral buckle and a combined vitrec-
tomy with belt buckle surgery. At follow-up, 2 eyes presented with
retinal redetachment (secondary to PVR changes) and required a
second vitrectomy. Mean number of vitreoretinal surgeries per-
formed was 1.2 surgeries per eye.
The mean follow-up period after vitreoretinal surgery was
45.5 months (range, 3e144 months). At final follow-up, 5
(41.7%) and 9 (75.0%) eyes had visual acuity better than 6/18
and 6/60, respectively. Three (25%) eyes had a visual acuity less
than 3/60, secondary to advanced PVR (2 eyes) and amblyopia
(1 eye).
Of the total 481 eyes, 2 eyes with no pre-existing glaucoma at
the time of cataract surgery required trabeculectomy surgery during
follow-up. Similarly, significant posterior capsular opacification
was noted in 21 eyes, all of which underwent neodymium-doped
yttriumealuminumegarnet capsulotomy. Additionally, 1 eye

Figure 1. KaplaneMeier estimates of the risk of retinal detachment since cataract surgery by years. A, In overall group. B, In the group with intellectual
disability. C, Age-adjusted axial length (AL) difference.

3
4
Table 2. Details of 12 Eyes of 9 Children who Developed Retinal Detachment PosteCataract Surgery

Follow-up
after RD
Surgery
Presentation at Congenital/Developmental Cataract Surgery Presentation at Retinal Detachment (months) At Final Follow-up
Cataract
UL/ Development Type of Retinal Sx to RD Partial/ Macula Grade Primary Second
SN Sex/Age BL Milestones OD/OS Cataract AL (mm) Findings (months) Total On/Off of PVR Break Characteristics Sx Sx V/A/Status of Eye Other Eye
1 M/7 UL Normal OD PSC 28.39 Tesselated 12 Total Off 4 Not visualized* Nil - - PL neg; Normal
chronic retinal
detachment
2 M/9 BL Delayed OD Lamellar 22.65 Normal 70 Total Off 0 Lattice with holes SB - 3 CF @ 1MT; -

Ophthalmology Volume -, Number -, Month 2017

retina on; amblyopia
OS Lamellar 22.57 Normal 70 Total Off 4 Not visualized* Nil - - PL neg; chronic
retinal detachment
3 M/5 BL Normal OD Lamellar 24.01 Normal 88 Partial On 0 HST (PVD induced)þ SB - 16 6/12; -
Lattice with holes retina on
OS Lamellar 23.32 Normal 88 Partial Off 0 HST (PVD induced)þ SB - 16 6/12;
Lattice with holes retina on
4 M/5 BL Normal OD Lamellar 24.9 Normal 130 Total Off 0 Multiple breaks (PVD VþBB Re-VIT 144 6/60; -
induced) retina on;
pale disc
OS Lamellar 25.29 Normal 70 Total Off 0 Multiple breaks (PVD VþBB Re-VIT 67 6/60;
induced) retina on;
pale disc
5 M/3 BL Normal OS Lamellar 25.6 Tesselated 85 Total Off 0 GRT >180 (PVD VþBB - 37 6/12; Had lattice (treated
induced) retina on with ILO); Stable
6 M/12 BL Normal OS Cortical 29.01 Lattice 23 Partial Off 0 DialysisþHST (PVD VþBB - 124 6/18; Cataract surgery
induced) retina on outside (details
not available);
developed retinal
detachment
7 M/5 BL Delayed OS Lamellar 25.73 Normal 62 Total Off 0 HST (PVD induced) VþBB - 52 6/18; Had lattice (treated
retina on with ILO); Stable
8 M/8 BL Normal OD Lamellar 24.57 Lattice 4 Total On 0 Lattice with holes SB - 14 6/60; Cataract surgery
retina on; amblyopia outside (only
and RPE alterations lensectomy done);
developed retinal
detachment
9 M/5 BL Delayed OS Total 21.13 Normal 98 Total Off 2 HST (PVD induced)þ VITþBB - 12 6/60; Had lattice (nil
Lattice intervention);
retina on; amblyopia Stable
and RPE alterations

AL ¼ axial length; BB ¼ belt buckle; BL ¼ bilateral; CF ¼ count fingers; GRT ¼ giant retinal tear; HST ¼ horse-shoe tear; ILO ¼ indirect laser ophthalmoscopy; MT¼ meters; OD ¼ right eye; OS ¼ left
eye; PL ¼ perception of light; PSC ¼ posterior subcapsular cataract; PVD ¼ posterior vitreous detachment; RD ¼ retinal detachment; Re-VIT ¼ repeat vitrectomy; RPE ¼ retinal pigment epithelium;
SB ¼ scleral buckle; SN ¼ serial number; Sx ¼ surgery; UL ¼ unilateral; VA ¼ visual acuity; V ¼ vitrectomy.
Patient nos. 2, 3, and 4 had bilateral retinal detachment post cataract surgery.
*Posterior vitreous detachment not documented.
 Agarkar et al 
Retinal Detachment after Pediatric Cataract Surgery
required a membranectomy despite laser capsulotomy. In none of
these eyes did RD develop at follow-up.
Discussion
RD after pediatric cataract surgery is a late surgical vision-
threatening complication.14e17 We report the 5-year inci-
dence of RD after cataract surgery to be 2.5% in our cohort.
We estimated a 5.5% cumulative risk of RD after cataract
surgery at 10 years in eyes with no ocular and systemic
anomalies. However, the risk was found to be 3.2% in eyes
of children with no intellectual disability and 2.1% in eyes
of those with hypermetropia (age-adjusted ALD > 0 mm) as
compared with age-matched children.
Rabiah et al10 reported a 3.2% (33 of 1017 eyes)
incidence of RD in Asian children with no ocular and
systemic anomalies after lensectomy and anterior
vitrectomy without primary intraocular lens implantation,
with a mean follow-up of 6.84.4 years. Interestingly,
Haargaard et al11 estimated a 0.74% (6 of 807 eyes)
incidence of RD after cataract surgery in a cohort of
Danish children with no ocular and systemic anomalies,
with a median follow-up of 6.8 years.
We attribute these differences in the incidence rates
among studies primarily to the significant difference in the
prevalence of myopia among ethnic populations. Kleinstein
et al18 reported 18.5%, 13.2%, 4.4%, and 6.6% prevalence
of myopia in Asians, Hispanics, whites, and African-
American children, respectively. Similarly, Wen et al19
reported significant differences in the prevalence of
myopia among ethnic groups, with the highest among
Asian children. Saxena et al20 reported a 13.1%
prevalence of myopia in Indian children. Wang et al21
showed myopia to be a significant predisposing risk factor
for RD in Asian children, reaffirming the ethnic difference
observed in previous studies. Association of myopia with
PVD, lattice degenerations, peripheral retinal breaks, and
other unknown factors may explain the increased risk.
Similar to the observation by Rabiah et al,10 a
significantly larger proportion (67.6%, 325 of 481) of eyes
were found to be myopic in our study. Hence, as
expected, our incidence rates are comparatively higher.
Moreover, in the later study, children underwent different
surgical techniques and approaches, with few children
undergoing primary intraocular lens implantation. In
contrast, a single surgical technique with primary
intraocular lens implantation was performed in all children
in our study, thereby limiting the value of the direct
comparison of the 2 incidence rates.
Erie et al22 reported cumulative probability of RD after
adult cataract surgery to increase from 0.27% at 1 year to
1.79% at 20 years. The higher risk of RD after pediatric
cataract surgery as compared with adult cataract surgery
justifies frequent, long-term follow-up after pediatric cata-
ract surgery.
Male gender has been found to be a significant risk factor
for RD in both adults and children after cataract surgery, and
in those without previous cataract surgery.10,21e24 In accor-
dance, we observed that all children who developed RD were
male, affirming previous observations. However, this male
preponderance could also be due to chance, because of the
smaller number of children in the group who had RD. We
found a 12.42 times higher risk (95% CI, 3.14e49.08; P <
0.001) of developing RD in eyes of children with intellectual
disability as compared with eyes of children with no intel-
lectual disability. Our findings corroborate those of Haar-
gaard et al,11 who reported a 9.59 times risk of RD in eyes of
children with intellectual disability as compared with eyes of
normal children. The possible reason could be that the
operated eye is at risk owing to excessive rubbing and
inadvertent trauma. More importantly, given that these
children are uncooperative for examination, adequate
visualization of the fundus is not possible, resulting in late
diagnosis. Therefore, a frequent examination of children
with intellectual disability under sedation or anesthesia is
necessary for accurate assessment, early diagnosis, and
appropriate treatment.
Previous studies showed conflicting results regarding age
at cataract surgery and risk of RD. Young age at cataract
surgery has been associated with increased risk of RD.25
However, similar to Haargaard et al,11 we did not find any
correlation of age at surgery with risk of RD. Olsen
et al,26 Bhagwandien et al,27 and Tuft et al28 have all
shown increased axial length to be associated with higher
risk of RD after adult cataract surgery. Recently, Daien
et al23 estimated a 6.12 HR for RD after adult cataract
surgery in those with high myopia. However, in pediatric
cataract surgery similar relationship between axial length
and RD had not been studied.
We found that the risk for RD increased progressively
with increasing myopia (age-adjusted ALD < 0 mm). As
compared with eyes of children with hypermetropia (age-
adjusted ALD > 0 mm), significantly higher risk was esti-
mated in eyes of children with high myopia (age-adjusted
ALD < 1 mm) (HR, 21.93; 95% CI, 2.95e162.80; P ¼
0.003). The cumulative risk of RD at 10 years was found to
be 2.1% in eyes of children with hypermetropia (age-
adjusted ALD > 0 mm), which increased to 8.8% in eyes of
children with high myopia (age-adjusted ALD < 1 mm).
Considering postoperative aphakic refractive error as a
substitute for axial length, Rabiah et al10 showed that
aphakic refractive error more myopic than the age-
adjusted aphakic norm was significantly associated with
risk of RD after pediatric cataract surgery. However,
aphakic refraction as a proxy for axial length has inherent
limitations, especially in eyes with myopia and eyes with
abnormally steep or flat keratometry.29 Therefore, our
estimates of HR using the axial length seem more
appropriate.
Haargaard et al11 reported the median time between
cataract surgery and development of RD to be 9.1 years
(25th quartile, 5.2 years; 75th quartile, 16.9 years). Rabiah
et al10 reported the mean time between cataract surgery
and development of RD to be 6.44.4 years (range,
0.4e14.8 years). In accordance, we found that the median
time between cataract surgery and development of RD
was 70 months (25th quartile, 32 months; 75th quartile,
88 months). This re-emphasizes the need for frequent and
long-term follow-up after pediatric cataract surgery.
5
 Ophthalmology Volume -, Number -, Month 2017
In our study we found that RD occurred secondary to
either PVD-induced retinal break or holes complicating
lattice degeneration. Ripandelli et al30 showed that after
cataract surgery, PVD occurred in 77.6% and 87.2% of
emmetropic eyes without preoperative lattice degeneration
and with lattice degeneration, respectively. Although PVD
after cataract surgery itself is associated with increased
risk of RD, the risk increases multiple folds in eyes
having lattice degenerations, a very common finding
among those with myopia. PVD-induced retinal break was
the most common cause of RD. The symptoms of PVD must
be explained to the child and his or her parents to facilitate
early medical attention.
Hajari et al31 showed that patients with rhegmatogenous
RD in the first eye have a 100 times higher risk of
developing rhegmatogenous RD in the fellow eye, with the
risk increasing if lens surgery is performed. This finding is
exemplified in our series, with 5 of 9 patients (including
patient numbers 6 and 8, in whom the other eye was
operated outside) developing bilateral RD and holes
complicating lattice degeneration as the second important
cause for RD. To lower the incidence of RD after adult
cataract surgery in myopic patients, Fan et al32
recommended preoperative, intraoperative, and postoperative
comprehensive fundus evaluation and laser treatments for
suspicious lesions. Therefore, we recommend a similar
approach, but with equal emphasis to both the eyes of a child.
Yokoyama et al33 reported retinal reattachment in 90% of
eyes that underwent the initial scleral buckling procedure. In
our series, scleral buckling was found to be highly
successful (100%) for pediatric rhegmatogenous RD, with
more complex cases being managed effectively with
vitrectomy. We had 3 (25%) eyes with a visual acuity of
less than 3/60; this was in part due to chronic detachment
with high grades of RD and amblyopia in 2 eyes and 1
eye, respectively. We had 9 (75.0%) eyes with a visual
acuity better than 6/60 at final visit, which is relatively
higher than that reported previously by Yorston et al16
and Haargaard et al.11
The smaller number of patients in the RD group and
inherent limitations of a retrospective study should be noted
as limitations of our study. In future, similar studies from
different centers with longer follow-up are required to
validate our observations and reveal the true ethnic differ-
ences in risks of RD after pediatric congenital cataract
surgery using modern surgical techniques. In our study,
intellectual disability was diagnosed clinically by a qualified
treating internist. Although no obvious clinical syndromic
associations were noted in these children, it is possible that
some of them had subclinical milder forms that may have
gone unnoticed, contributing to some extent to the increased
risk of RD in these children with intellectual disability with
low IQ.
Our study has several strengths. The rigorous inclusion
and exclusion criteria ensured a homogenous cohort that
was followed postoperatively for a considerable time. For
the first time, the use of the time-tested robust Cox
regression hazard model helped to identify myopia as a
significant risk factor for RD after pediatric cataract
surgery.
6
To conclude, we report a 5.5% risk estimate for the first
10 years for RD after cataract surgery in children with no
known ocular or systemic anomalies. The risk significantly
increases in a child fulfilling the following 3 conditions:
male, with myopia, and with intellectual disability. The
result can be used as a reference when discussing the po-
tential risk with parents of patients with congenital cataract,
and to emphasize the need for regular and long-term follow-
up, especially when a child is at risk. Prophylactic treatment
of suspicious retinal lesions can reduce the risk of RD
considerably.
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Footnotes and Financial Disclosures
Originally received: March 14, 2017.
Final revision: June 18, 2017.
Accepted: July 5, 2017.
Available online: ---. Manuscript no. 2017-601.
1 Manuscript preparation: Raman, Jain
Department of Pediatric Ophthalmology, Sankara Nethralaya, Chennai,
Tamil Nadu, India.
2 ALD ¼ axial length difference; CI ¼ confidence interval; HR ¼ hazard
Shri Bhagwan Mahavir Vitreoretinal Services, Sankara Nethralaya,
Chennai, Tamil Nadu, India.
Financial Disclosure(s):
The authors have no proprietary or commercial interest in any materials
discussed in this article.
Author Contributions:
Conception and design: Agarkar, Bhende
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Data collection: Agarkar, Gokhale, Raman, Bhende, Swaminathan, Jain
Analysis and interpretation: Agarkar, Gokhale, Raman, Swaminathan, Jain
Obtained funding: Not applicable
Abbreviations and Acronyms:
ratio; PVD ¼ posterior vitreous detachment; PVR ¼ proliferative vitreor-
etinopathy; RD ¼ retinal detachment.
Correspondence:
Sumita Agarkar, MS, DNB, Department of Pediatric Ophthalmology,
Sankara Nethralaya, Chennai, Tamil Nadu, India. E-mail: drsar@snmail.
org.