Some surgeons advocate the use of preservative-free intracameral corticosteroids in congenital cataract surgery in order to reduce the risk of postoperative anterior membranes. Several studies have shown that intracameral triamcinolone used at the time of childhood cataract surgery reduces the incidence of anterior chamber inflammation, posterior synaechae, deposits on the IOL and visual axis re-opacification [8,9]. A prospective randomised study of children having cataract surgery at age less than 2 years compared an intracameral injection of 1.2 mg/0.03 ml of triamcinolone acetonide (31 eyes) or 1 mg/kg per day of oral prednisolone for 15 days postoperatively (29 eyes) and found no difference in the incidence of cell deposits and posterior synaechae [10], suggesting that intracameral corticosteroids are as effective as oral in controlling post-operative inflammation.

Intracameral triamcinolone may also be used to allow visualisation of the anterior vitreous, to ensure adequate vitreous removal from the anterior chamber [11].

Children are at significant risk of ocular hypertension and glaucoma related to corticosteroid use. However, in a case series of 24 eyes in which intracameral dexamethasone was used at the time of infantile cataract surgery, no cases of glaucoma were reported at follow-up ranging from 20 to 48 months [12].

Intraoperative intravitreal steroids may be used in paediatric cataract surgery in selected cases (for example children with uveitis and refractory macular oedema). However caution needs to be made with regard to the risk of postoperative ocular hypertension and secondary glaucoma.

Sub-conjunctival corticosteroids may reduce postoperative inflammation. A half dose of subconjunctival short-acting dexamethasone may be used in infants, increased to full adult dose in older children. Subconjunctival use of long acting corticosteroids such as triamcinolone and depomedrone may precipitate a corticosteroid-related IOP rise, which occasionally necessitates removal of the corticosteroid deposit. Conjunctival necrosis has also been reported following subconjunctival corticosteroid injection in a child [13].

Long acting corticosteroids (triamcinolone or depomedrone) can be given as an orbital floor injection at the end of surgery [14]. This is particularly helpful when there is a high risk of severe post-operative inflammation such as in infantile cataract surgery requiring iris hooks or in eyes with uveitis, or in situations when instillation of post-operative drops may be difficult (due to cooperation of the child, or parental compliance issues). There is a risk however of post-operative IOP rise.

Topical corticosteroids are routinely used following childhood and adult cataract surgery to reduce postoperative inflammation. There is evidence however that systemic absorption of topical corticosteroids may cause growth suppression [15] and suppression of endogenous adrenal function [16]. Synacthen testing of 26 children who had cataract surgery at less than 5 years of age followed by topical dexamethasone treatment found that seven children (27 %) had adrenal insufficiency, which was severe in five children [17]. Cushing syndrome may be manifest as facial fullness, growth suppression, thin skin with bruising, and striae. Adrenal insufficiency reduces the physiological response to fever, infection, trauma and general anaesthesia; although the effects are reversible, hydrocortisone supplementation may be necessary during intercurrent infection or during further anaesthesia.

A significant number of children using topical corticosteroids have an ocular hypertensive response, and secondary glaucoma due to topical corticosteroids may occur even in infancy after a short course of topical corticosteroids [18].

High strength hourly topical corticosteroids can be used when the risk of severe inflammation is high (such as infantile cataract surgery with iris hooks, in cases with pre-operative uveitis) but risks systemic side effects in an infant. Topical corticosteroids are frequently used in a combined drop with antibiotics; six times a day maxitrol (dexamethasone, neomycin sulphate and polymixin B; Alcon UK) is usually sufficient following routine surgery, tapered over a 4–6 week period (combined with maxitrol ointment at night for the first few weeks) [19].

Oral corticosteroids have been advocated by some surgeons [10] in the postoperative period. Intracameral triamcinolone has been shown to be as effective as oral corticosteroids in children having cataract surgery at less than 2 years of age in prevention of IOL deposits and posterior synechiae [10]. However, the use of careful operative technique, periocular corticosteroid and postoperative corticosteroid drops has meant that oral corticosteroids and their associated side effects can be avoided in most cases. Intravenous corticosteroids are reserved for children with active uveitis prior to the cataract surgery.

Topical cycloplegics are usually given for 2 weeks following uncomplicated paediatric cataract surgery (for example cyclopentolate 0.5 or 1 % three times a day, topical phenylephrine 2.5 % two times a day).

Pre-operative periocular skin disinfection (with 10 % povidone-iodine or polyvinyl alcohol-iodine) or conjunctival disinfection (with 5 % PI) significantly reduces the risk of endophthalmitis [21].

Cataract surgery is facilitated by optimal pupillary dilation. Pre-operative preparation of the patient involves the use of topical mydriatics, but some infants and children may be sub-optimally dilated, or whilst undertaking surgery, the pupil may become constricted, making surgery more hazardous. The use of intracameral mydriatics (phenylephrine 0.5 %, epinephrine 0.5 cc/500 cc BSS, has been adopted for adult cataract surgery, particularly in the context of intra-operative floppy iris syndrome (IFIS). Concerns regarding the safety of intracameral phenylephrine in adult cataract surgery, particularly to the corneal endothelium, toxic anterior segment syndrome, and endophthalmitis, have been allayed by 6 year follow up demonstrating no significant difference in endothelial cell loss, IOP control, and PCO rates compared with controls only receiving topical mydriatics [27]. Systemic adverse effects are rare, although a small rise in mean arterial pressure has been described in adults [28]. A combination of intracameral phenylephrine and ketorolac (Omeros) has been shown to maintain mydriasis and reduce post-operative pain in adult cataract surgery [29]; a randomised controlled trial is underway to study its use in paediatric cataract surgery. Until data is available on the safety and efficacy of intracameral mydriatics in the paediatric population, they should be used with caution.