Indications

In pediatric patients, the indications for the removal of the lens include:

1. A lens opacity or cataract that causes a loss of best corrected visual acuity.

2. Lens subluxation or dislocation causing an uncorrectable decrease in visual acuity.

Surgical Management in the Pediatric Patient

Following are general recommendations for the surgical approach to cataract surgery in the pediatric patient. Specific guidelines depend on multiple factors such as the surgeon’s experience with limbal versus pars plana surgery.

Age younger than 18–24 months:

Lensectomy

Primary posterior capsulotomy

Anterior vitrectomy

Age 2–6 years:

Phacoemulsification/irrigation and aspiration

Optional but recommended: Primary intraocular lens (IOL) implantation

Optional but recommended: Primary posterior capsulotomy and anterior vitrectomy

Age older than ~6 years (depending if the child is able to sit for a YAG capsulotomy):

Phacoemulsification

Primary IOL implantation

Irrigation/aspiration is the preferred method for cataract extraction in children younger than 2 years.

Children 18 months to 2 years may need phacoemulsification, depending on the density of the lens.

Advantages of Phacoemulsification over Standard Extracapsular Surgery

Smaller wound speeds recovery and minimizes astigmatism and wound-related postoperative complications.

Surgery accomplished within a relatively closed system.

Disadvantages of Phacoemulsification Compared with Extracapsular Surgery

Possible increased corneal endothelial damage.

Possible increased risk of iris damage with smaller pupils.

Recommended Surgical Incision in Pediatric Patient

A scleral tunnel incision may be preferable to a clear cornea incision, as self-sealing clear cornea wounds are unreliable in a child. Perform a limbal incision, slightly anterior, within the scleral tunnel to avoid iris prolapse.

Intraocular Lens Placement

1. IOL implantation is generally recommended for children 2 years or older. Surgeons have implanted lenses in younger patients, but the long-term safety is still being investigated.

2. Polymethyl methacrylate (PMMA) lenses are recommended because of their long-term safety. Foldable acrylic lenses are suitable lens material as many studies have shown them to be well tolerated. (Silicone lenses have not been well studied in children.)

3. Multifocal lenses have been used in pediatric patients. The safety of multifocal lenses in pediatric patients has not yet been established.

4. If no IOL is used during the surgery, a contact lens must be used to achieve the best corrected vision. A secondary sulcus fixated lens or sutured lens may be planned for the future. The safety of sutured IOLs has not yet been established.

1. A primary posterior capsulotomy and anterior vitrectomy should be performed in children younger than 4 years, as posterior capsular opacification will develop postoperatively. An anterior vitrectomy must be preformed along with a posterior capsulotomy because the anterior vitreous face can act as a scaffold for fibrous proliferation, which can occlude the visual axis.

2. Primary posterior capsulotomies may compromise capsule integrity.

3. After the age of 4, a YAG may be possible in compliant pediatric patients.

4. The surgical procedure is only part of the visual rehabilitation of the pediatric patient. Optical rehabilitation with contact lens fitting, patching, and further amblyopic care is essential.

a. Patching of the other eye should be started, in most cases the first day after surgery according to the schedule recommended by the surgeon.

b. If an IOL is not used, the appropriate contact lens or glasses prescriptions should be used as early as 1 week after surgery.

c. Follow-up evaluations of posterior capsular opacification, late-onset glaucoma, and retinal detachment are also required.

Preoperative Procedure

1. Maximum dilation may be difficult to achieve because of iris hypoplasia.

2. Recommendations for dilation in the pediatric patient include the following:

a. One drop of 2.5% neosynephrine, 1% tropicamide, and 1% cyclopentolate; alternatively use collyrium 3 and 38¼ ophthalmic solution (this contains cyclopentolate 1%, phenylephrine 2.5%, tropicamide 0.25%).

b. Repeat above once if necessary.

c. If refractory to adequate dilations, atropine 0.5% 1 per day for 1 week before surgery.

d. Intraoperatively, 0.5 ml of 1:10,000 nonpreserved epinephrine added to a 500 ml bottle of balanced salt solution (BSS) may be used if approved by anesthesiology.

e. Iris hooks (e.g., Grieshaber) may be needed intraoperatively in an otherwise unresponsive pupil.