Pediatric Traumatic Cataract
Dinah Chen, MD
Fatema Ghasia, MD
PREOPERATIVE CONSIDERATIONS
Examination
Have a high suspicion for nonaccidental trauma. Look for other associated ocular or periocular injuries, and ensure the child has had a complete physical examination to evaluate for other signs of trauma.
Assess child’s visual acuity using age-appropriate methods.
Assess the red reflex in the undilated state to determine whether the opacity is visually significant in infants and toddlers.
Absence of view of the fundus or a dull retinoscopic reflex preventing refraction suggests a visually significant cataract.
Assess ocular motility and look for the presence of strabismus or nystagmus.
If either are present, this could suggest cataract is long standing, causing dense deprivation amblyopia.
Assess for other signs of ocular trauma, including corneal scar, iridodonesis, or phacodonesis.
Assess for lens dislocation and depth of anterior chamber.
Assess the morphology and location of cataracts.
More central and posterior location is more visually significant than more peripheral and anterior.
Bilateral posterior subcapsular cataracts and/or lens dislocation can be seen in nonaccidental trauma.
Assess anterior and posterior capsule integrity.
Note the extent of pupillary dilation.
If there is a history of hyphema, assess for angle recession, and monitor intraocular pressure.
Perform B-scan ultrasonography to evaluate for vitreous hemorrhage or retinal detachment if the view to the fundus is not clear.
Assess the cooperation of the child at slit lamp.
If the child is able to sit for a YAG capsulotomy, the posterior capsule may be left intact.
Obtain intraocular lens implant calculations in the outpatient setting if possible.
If the child cannot cooperate with awake lens calculations, perform lens calculation under anesthesia (see Chapter 4).
Discuss postoperative care and considerations.
Refractive correction including aphakic contact lenses and the need for spectacles with bifocals for all children (see Chapter 4).
Importance of compliance with follow-up and post-op medications.
Importance of amblyopia treatment.
Risk of visual axis opacification after surgery.
Risk of glaucoma and retinal detachment.
Timing of Surgery
Visually significant cataracts acquired in a child <6 years old should be removed within weeks. In children >6 years, it is acceptable to wait for inflammation to resolve prior to surgery.1
In children with penetrating trauma and subsequent cataract, primary repair of the anterior segment wound is generally performed initially (see Chapter 25). Cataract surgery with IOL can be performed 1-4 weeks following.
When to Consider IOL Implantation (see Chapter 4)
Most children <6 months are left aphakic.
IOL implantation in children between 6 months and 2 years is controversial, and the pros and cons should be considered for each patient individually.
In children >2 years of age, an IOL may be implanted in the capsular bag. If compromised, consider capsular tension ring, sulcus IOL, or leaving patient aphakic.
The IOL target is usually mild to moderate hyperopia in children <6 years and emmetropia at 7 years or older.
If IOL calculations cannot be performed awake, ultrasound biometry and IOL calculations can be obtained under anesthesia.
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