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Pediatric Cataract: An Overview

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 INTERNATIONAL JOURNAL FOR RESEARCH & DEVELOPMENT IN Volume-14,Issue-6(Dec-20)
TECHNOLOGY ISSN (O) :- 2349-3585

Pediatric Cataract: An Overview

__________________________________________________________________________________________

Dr.VinitkumarKamble1, ArbindRay2, Sushma Chaudhary3, DeepshikhaBhusal4,Tirtha Kumar Singh5

1
Ophthalmologist, IGIMS Medical College, Patna (Bihar), RIO Ophthalmology
2,3,4,5
Optometrist,
2
R.P Centre AIIMS, New Delhi
2,3,4,5
SagarmathaChoudhary Eye Hospital (SCEH), Lahan
Regional Institute of Ophthalmology,
IGIMS Medical College, Patna, Bihar, India.

Abstract prevention.3 ORBIS worked with 24 eye care partners in

An extensive review in congenital cataract treatment
protocol can helppaediatric ophthalmologists in managing
such a strenuous ocular condition which remains a notable
cause of preventable pediatric or childhood blindness. Here
in this article we will pivot on cataract surgical management,
post-surgery complications, and intraocular lens (IOL)-
related disputes.
Keywords: American Academy of Pediatrics (AAP),
Cataract, Congenital, Pediatric, Surgery, Posterior capsular
opacification (PCO), Visual axis opacification (VAO)
Introduction:
According to VISION 2020 programmed a visually impaired
pediatric patient has inexistence of blindness in their future,
which significantly deteriorates their quality of life...1Different
studies all over the world shows that one-third to half of
1
blindness in children is preventable and treatable . Pediatric
cataract is the major manageable cause of blindness in
children.2The 8th General Assembly of the International
Agency for the Prevention of Blindness (IAPB) provided an
opportunity to be acquainted with recent research and
programmed development work in the prevention of childhood
3
blindness. Deepti Bajaj with the help of ORBIS started the
childhood blindness programme in India. The objective of the
programme is to carry the Indian government's goal to create
50 paediatric eye care centres by 2010. Master plan consists
creating a child-friendly environment in eye care facilities,
training paediatric eye care teams, supplying technology and
important equipment for paediatric eye care, allowing the local
communities in case detection and educating the parents
regarding children’s different eye diseases and their
between 2002 up to 2008.It helps to establish paediatric eye
care centres in India, which will have a long-term impact on
reducing avoidable blindness in children.3Childhood cataract
categorized as congenital and developmental cataract.
Developmental sub classified as infantile, juvenile and senile
cataract. In Asia more than one million children are blind due
to childhood cataract.4The incidence of blindness due to
pediatric cataract in India is 7.4 up to 15.3 %.5,6,7The
prevalence of cataract in children has been approximately 1-15
per 10,000 children.8
Etiology:
Metabolic disorders, ocular injury, genetic or hereditary
problem, systemic abnormalities and idiopathic conditions9 are
the main cause for childhood cataract in India. 10The source of
childhood cataract includes intrauterine septicemia, metabolic
inherited conditions and genetic disorders. Johar and
colleagues11 reported that 86% of unilateral and 68% of
bilateral cataract had no discernible cause. The study tells that
88.4% had non-traumatic cataract and 11.6% had traumatic
cataract out of 172 children. In cases with non-traumatic
cataract, 73.0% were undetermined, 15.1% were secondary
(uveitis, persistent hyperplastic primary vitreous, aniridia,
Down, Marfan and Lowe syndromes), 7.2% were hereditary,
and 4.6% were due to congenital rubella syndrome.Inherited
non syndromic cataract represents a significant proportion of
congenital cataract cases and many causative genetic
mutations have been identified. Genetic mutation is most
frequent aetiology for bilateral pediatric cataract, but the
proportion of cases with a genetic basis is still unclear. Rahi
and Dezateux12shows that 27% of child with bilateral isolated

12
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Paper Title: - Pediatric Cataract: An Overview
congenital cataract had a genetic cause compared with 2% of
unilateral cases as far as family history concerned. It is likely
that some children with congenital cataracts who don't have a
family history of cataract still have a genetic cause; they may
represent new autosomal dominant mutations or have
autosomal recessive or x linked form of cataract. All at-risk
family members should be subjected to slit lamp examinations
as some affected individuals may have minor lens opacities,
which do not cause a significant reduction in visual acuity.
Hereditary cataracts commonly present in between 8.3% and
25% of congenital cataract.13, 14, and 15.
Cataract may be
inherited as either autosomal dominant, autosomal recessive,
or X-linked recessive traits. Hereditary Mendelian cataracts
are most frequently autosomal dominant, but can also be
autosomal recessive or X-linked. Cross sectionallysimilar
childhood cataract can cause by mutations at different genetic
loci and it may have different inheritance patterns, while
phenotypic ally variable cataracts can be found in a single
16
large family. Merin classified pediatric cataract according to
anatomical location of lens opacity as total (mature or
complete), polar (anterior or posterior), zonular (nuclear,
17
lamellar, sutural.) and membranous cataract.
Role of Pediatrician in Early Diagnosis of Cataract: In
children, early detection of cataract is important to avoid
lifelong visual impairment. Paediatricians play a key role in
early detection of infantile cataract. Red fundal reflex
examination is mostly helpful for premature spotting of
cataract. The AAP recommends red fundal glow estimation as
a part of the ocular evaluation in the neonates and during all
routine follow up health supervision visits.18 The test should
be carrying out in a dark room which helpful for more dilation
of pupil. A distance direct ophthalmoscope should be
performed about 12 to 18 inches away from each eye, and red
fundal glow should be detected from both eyes. Eyes which
show diminished red reflex should be referred to an
ophthalmologist.
History, Examination and Investigation: Patients may
present with parents or caretaker complaining of a white spot
in the pupil, visual inattentiveness, nystagmus, strabismus,
asymmetry of one eye relative to the other like eye trauma,
micro cornea, microphthalmos, light insensitivity and because
13
of a referral from other physicians who have identified
possible lens opacity. At times, the evaluation of a family
history of childhood cataract, systemic conditions or
syndromes which associated with lens opacity should be ruled
out. Typical history should be taken in to consideration like
maternal TORCH infection, rash or febrile illness during
pregnancy which could be suggestive of intrauterine infection,
any other prenatal and perinatal history that may consist (
alcohol- tobacco intake , steroid drug use, ionizing radiation
during pregnancy), history of ocular trauma (unless cataract
appears to be purely non-traumatic), age at onset of visual
symptoms, ocular examinations can be helpful in assessing
visual prognosis after treatment. Posing a series of simple
questions can help in determining the surgical need, the timing
or urgency of surgery, and the visual prognosis after cataract
removal (e.g. Does your child appears to see well? Do your
child's eyes focus straight or do they seem to cross or drift or
seem lazy? How long have you noticed a change in your
child's visual function?). In cases of congenital cataract,
abnormalities such as poor visual behavior, nystagmus or
strabismus (in unilateral cases) are a late sign, and deprivation
amblyopic is already present.As compared to unilateral
cataract, laboratory investigations of bilateral cases are more
rewarding. Based on past history of the eye and observations
during the examination, customized laboratory investigations
can be advised. Since cataract can be the presenting sign of
diabetes, children with acquired cataract of unknown aetiology
should be questioned about symptoms of diabetes and
evaluation for hyperglycemia should be performed. Patient of
Lowe’s syndrome19have infantile glaucoma, weak muscle
tone, behavioral abnormality, mental handicap, seizures,
amino acid occurs in urine and an abnormal facial morphology
with frontal bossing and chunky swollen cheeks. In a child
with Lowe syndrome, the urine should be screened for amino
acids, and also salt, water, mineral to rule out Fanconi
syndrome.20
Cataract Surgery: The goal of paediatric cataract surgery is
to maintain a clear visual axis and clear retinal image. Cataract
surgery in children is mostly for road to visual rehabilitation.
Achieving better visual outcome is a team approach involving
the patient, the ophthalmologist, parents and other caregivers,
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Paper Title: - Pediatric Cataract: An Overview
while considering visual, economical, psychological, and
social issues. It is not just the surgical procedure that
determines a successful visual outcome; it also depends on the
surgeon's ability to maintain adequate aphakic correction and
follow through with amblyopia therapy. The following are
indications for cataract surgery: cataract obstructing the
examiner's view during fundus examination in non-dilated
pupils or a blackened retinoscopy reflex preventing refraction
of the eye. Deciding when to remove a partial cataract can be
difficult and challenging. The loss of accommodation after
cataract removal may negatively affect visual functioning far
more than the actual presence of partial cataract did deciding
on the appropriate time at which to perform surgery is very
critical during early infancy. In the case of unilateral dense
cataract diagnosed at birth, it is advisable to wait until the
patient is 4-6 weeks of age so as to decrease the possibility of
occurrence of anaesthesia-related complications and facilitate
the surgical procedure. Waiting afar this period, however,
badly affects the visual status. Patient with both eye cataract
which was diagnosed at birth, a good visual result is obtained
if a child is operated as early as possible before two to three
months of age. Surgery in the first eye can be performed when
the infant is 4-6 weeks of age; surgery in the second eye can
be performed after another 1-2 weeks. It is important to
minimize the time interval between the surgeries in the two
eyes. For older children, the timing of the surgery is not as
critical as it is in the case of infants. Children after amblyopic
age, surgery can often be marked based on benefit issues.
Paediatric cataract surgery remains a complex and challenging
proposition. The surgery is quite different from cataract
surgery in elderly patients. A propensity for increased
postoperative inflammation and capsular opacification, a
refractive state that is constantly changing due to the growth
of the eye, difficulty in documenting anatomic and refractive
changes due to poor compliance, and a tendency to develop
amblyopic are among the factors that make pediatric cataract
surgery different from that in adults. In addition, the lack of a
hard nucleus, vastly reduced scleral and corneal rigidity, and
enhanced posterior vitreous pressure in pediatric eyes demand
a surgical approach that differs in many ways from the adult
procedure. Ocular growth makes selection of an intraocular
14
lens (IOL) power difficult. Normal childhood behavior can
make compliance with postoperative instructions difficult, and
postoperative eye examinations are also often challenging.
Limoux et al. reported a 14-year case control study of 239
children (aged 11 days to 17 years), with single eye as well as
both eye cataract who did primary IOL implantation.21They
found approximately 75% achieved 20/40 vision or better and
with better outcomes in bilateral cases and in children who
were older than 1 year prior to IOL implantation.In contrast,
the advisability of IOL implantation during the first year of
life is still questionable. Intraocular lens implantation in
children has the advantage of decrease in dependency on
external optical devices like aphasic spectacles and contact
lenses. It also gives a partial optical correction. These are
important advantages in the visual rehabilitation of amblyopic-
prone eyes. However, concerns about primary IOL
implantation are the technical difficulties involved in
implanting an IOL in pediatric eyes, selecting an appropriate
IOL power, and the risk of visual axis or posterior capsule
pacification (VAO/ PCO) after implantation. The rate of PCO
is higher in pseudophakia infantile eyes as compared with
aphasic infantile eyes. On the other hand, although it is
possible for an eye with a unilateral infantile cataract 22 to
achieve good visual outcome following contact lens
correction, it has continued to be the exception rather than the
rule. Secondary IOL implantation is far more common in
children who have undergone early cataract surgery and who
are contact lens or aphasic spectacle wearers.
IOL Power Selection: It is well known that the majority of
the eye's axial growth occurs during the first two years of life.
For increasing axial length of eyeball in infants the selection
of an IOL power for was difficult. Selecting the best IOL
power to implant in a growing child presents unique
challenges22. While Gordon and Donzis23havedocumented the
axial growth pattern of normal eyes in children, the axial
growth of cataract us eyes is different. In the eyes of normal
phakic children, there are hardly any changes in refraction (0.9
dioptres from birth through adulthood on an average) because
the power of the natural lenses decreases dramatically as the
eyes grow axially. The limitation of an IOL placed in a
pediatric eye is that it has constant power which can’t change
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Paper Title: - Pediatric Cataract: An Overview
with increase in axial length of eyeball. An IOL picked out for
emmetropia in early pediatric age group is likely to result in
highly myopic shift in adulthood. When operating on children,
many surgeons prefer to select an IOL power that will leave
the eye hyperopic, so that hyperopic will decrease with
increasing age. Other authors have advocated aiming for
emmetropia especially when operating on children beyond 2
years of age. This approach avoids potentially amblyogenic
24
residual hyperopia but is likely to lead to the development of
significant myopia later in life.
Multi-focal and Accommodating IOL Implantation: These
IOLs have mostly used in adult cataract surgery. There is an
increased use of multifocal and accommodative IOLs during
cataract surgeries performed on patients in their teenage years
with predictable outcomes. However, demerits of these lenses
are that it may not be helpful in growing or amblyopic eyes.
With residual refractive error, especially the myopia that
develops after eye growth, multifocal IOLs may (ironically)
result in a higher level of spectacle dependence compared to
the use of monofocal IOLs with residual myopia.
Parental Commitment: A child operated for cataract requires
regular scheduled care during the first decade of life, and then
every 1-2 years throughout life. To obtain best follow up
visual results for the child, a long-term dedication from the
parents is must requirement. The changing refraction will
require frequent follow-up examinations. Glaucoma is known
to develop even years after cataract surgery. Parents need to
understand that their children may initially need serial
examinations under anesthesia till they are cooperative enough
to be examined in the office. Parents of children with lens
implants are also made aware that spectacles may still be
needed postoperatively even when an IOL is implanted. In
addition, changing refraction necessitates changing the power
of the spectacles frequently after surgery. Understanding eye
condition before surgery which helpsparents to understand the
treatment options will promote better compliance with
medication, glasses, contact lenses, and occlusion therapy.
Summary and Conclusion: Thepediatrician plays an
important role not only in early detection and referral for
cataract patients, but also in supporting the family through the
process of visual rehabilitation after the cataract is diagnosed
15
and treatment initiated. Pediatric cataract surgery is a
complex issue best left to surgeons that are familiar with its
long-term complications and lengthy follow-up. Cataract
surgery is the first important step in a life long journey of a
child to visual rehabilitation. An uneventful surgery is simply
the first step toward achieving the main goal. Maintaining a
clear visual axis while correcting the changing residual
refractive error requires careful observation, sound judgment
and diligent follow-up. Complications may grow in the
immediate postoperative period, or after many years, bring off
pivotalto survey these children regularly on a long-term basis
after cataract surgery. Management of residual refractive
error, amblyopic, and strabismus must be customized to each
child based on measurements that can be a challenge to obtain,
and which can change over time. Despite these uncertainties,
diligent teamwork involving the physician and the parents can
result in a gratifying visual outcome throughout the long life
of the child.Picture A show preoperative photo of nine year
old girl had bilateral developmental cataract with delayed
presentation and B shows operated both eye after one month
follow up. Similarly picture C shows a five year old male
child with left eye congenital cataract with stimulus
deprivation amblyopia. Picture D show first day post operative
presentation. Picture E shows examination of a child in our
pediatric ophthalmology department with synoptophore
exercise in a child. Picture F shows retinoscope in a child.
Picture A
ISSN:-2349-3585 |www.ijrdt.org
Paper Title: - Pediatric Cataract: An Overview

Picture B
Picture E

Picture F
Picture C

References
Picture D
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