In the years to come, pediatric cataract surgery will evolve along its own unique path. Surgeons who operate on children are, by their very nature, more conservative since they know that children will endure the consequences of their treatments over a long life. However, innovation still occurs, often in response to the unique difficulties a surgeon faces when operating on a growing eye attached to a less than fully cooperative and energetic child. Pediatric surgeons strive to get the best results with the least surgical trauma and the fewest trips to the operating room. This continues to be a challenge. A more vigorous inflammatory response combined with variable postoperative medication compliance will continue to push us into the more frequent use of intracameral agents at the time of surgery. In the future, we will move as close as we can to eliminating the need for postoperative medications. Intracameral antibiotics will become routine for every intraocular case, and the use of intracameral dexamethasone or triamcinolone will be commonplace. Povidone-iodine will continue to be placed on the eye before and after every surgery but in a much more diluted form than commonly used today. Evidence is mounting that the effectiveness of povidone-iodine is not diminished when it is dilated down to 2.5% or even lower but the risk of chemical conjunctivitis as a complication is reduced markedly.

When vitrectomy and posterior capsulectomy were developed in the 1970s, it rapidly became a standard for infantile cataract surgery. Surgeons feared that cystoid macular edema and retinal detachment rates would soar, but outcomes without posterior capsulectomy and vitrectomy were so poor that taking those risks was warranted. This was a uniquely pediatric problem, and it was met with a uniquely pediatric innovation. Today, the advances in vitreoretinal surgery have also benefited the pediatric cataract surgeon. Venturi pump technology has made vitrectorhexis and pediatric lens aspiration easier. Highspeed cutters have made vitrectomy safer with less risk of traction on the retina. We will all move to >1,000 cuts per minute and smaller gauge handpieces. These smaller handpieces are already improved over the initial models and are now more capable of the unusual tasks we ask of these instruments (membrane and plaque removal, etc.). While manual posterior capsulorhexis without vitrectomy will gain in popularity for children above age 4, vitrectomy and posterior capsulectomy will remain the standard for babies and toddlers. In the future, more surgeons will adopt the pars plana/plicata approach when a vitrectomy is chosen and an intraocular lens (IOL) is being placed.

For babies operated in the first 6 months of life, the least traumatic surgery to clear the visual axis will continue to be a bimanual, closed chamber, microsurgical approach that includes a primary posterior capsulectomy and anterior vitrectomy and no IOL. The Infant Aphakia Treatment Study’s 5-year results will be available soon, and we expect that these reports will echo what the 1-year outcomes found for visual acuity. We predict that the contact lens and IOL treatment groups will continue to show no significant differences in best-corrected visual acuity. However, in these 5-year results, we will see very clearly how poor we are at predicting the growth rate and refractive change in these eyes when they are implanted primarily. There will be many IOL exchange

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