Preoperative Considerations
Derek Bitner, MD
PREOPERATIVE EVALUATION OF PEDIATRIC CATARACT
Perform a complete examination of both eyes to assess ocular health, vision, and cataract etiology.
All Cataracts
Obtain vision in most reliable and age-appropriate way as possible (optotype > preferential looking > fixation).
Assess pupils for presence of an afferent pupillary defect suggesting a more significant ocular abnormality.
Assess ocular alignment and motility.
Strabismus can be evidence that the opacity is visually significant, and strabismus and amblyopia may need further treatment after cataract extraction.
Nystagmus is frequently seen in neonates with bilateral cataracts.
Anterior segment evaluation should be performed undilated and dilated.
Cataracts may be more visually significant in the undilated state, depending on their size and location.
Central cataracts ≥ 3 mm in diameter and posterior opacities are more likely to be visually significant than anterior opacities.
Evaluation of the retinoscopic reflex (ie size of opacity, clarity around opacity in undilated state, any distortion of the retinoscopic streak) and assessment of the view to the posterior pole may help to determine if a cataract is visually significant in a preverbal child.
Determine the type of cataract.
Anterior polar: Small isolated plaque on anterior surface of lens. Can be genetic and associated with refractive error. Often not visually significant and usually not progressive.
Pyramidal: Usually larger than anterior polar with extension into the anterior cortex. Usually fibrotic, may progress, and can be difficult to remove (Fig. 2.1).
Anterior lenticonus: Thinning of anterior capsule with lens protrusion and risk of spontaneous rupture. Associated with Alport syndrome.
Lamellar: Perinuclear opacity that is often hereditary and can progress (Fig. 2.2).
FIGURE 2.1. Anterior pyramidal cataract. This was bilateral, progressive, fibrotic, and very difficult to cut with vitrector. (Courtesy of Laura B. Enyedi, MD.)
FIGURE 2.2. Lamellar cataract. Cataracts were bilateral, asymmetric, and progressive. (Courtesy of Laura B. Enyedi, MD.)
Nuclear: Usually dense central opacity that is present at birth and can be associated with microphthalmia.
Posterior polar: Small central capsular opacity. Usually hereditary.
Posterior lenticonus: Weakness of posterior capsule with central protrusion. Although these lenses may rupture and lead to total cataracts, they are most frequently associated with irregular refraction that may not respond to spectacle or contact lens correction. The posterior capsule is prone to rupture with surgery.
Posterior subcapsular: Can be congenital, traumatic, related to diabetes or chronic corticosteroid use.
Persistent fetal vasculature (PFV): Usually unilateral, often with associated retrolental plaques. The eye is often smaller, and the plaque may be vascularized (Fig. 2.3). There may be a persistent vascular or non-vascular stalk between the optic nerve and posterior capsule (Fig. 2.4). Ciliary processes may be dragged forward and centrally, and the anterior chamber may be shallow.
Total cataract: Nonspecific, can be associated with rupture of lens or with other forms of cataract.
Assess anterior segment for signs of other ocular abnormalities that can affect the treatment options and prognosis including anterior segment dysgenesis (corectopia, iris atrophy, posterior embryotoxon), uveitis (posterior synechiae, keratic precipitates, cell/flare), trauma (corneal scarring, iridodonesis, phacodonesis), glaucoma (corneal enlargement, Haab’s striae, elevated IOP), or PFV (small corneal diameter, elongated ciliary processes, fibrovascular stalk, atypical vessels around the lens/iris).
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