Study and management of pediatric cataracts
Authors: Costa Alejandro Alcaide 
Published: January 2025

Setting: Childhood cataract remains an important visual impairment cause, although its prevalence in developed countries is low. Age at which secondary IOL should be implanted is still a question of debate, as different postoperative sequelae have been described, which include visual axis secondary opacification, glaucoma, amblyopia, strabismus or remaining refractive error. Effective aphakia management is essential for optimal visual potential. Contact lenses are the main corrective method, but challenges like tolerance and adaptability must be carefully monitored to prevent treatment failure.

Purpose: To describe pediatric cataract management at our institution, differentiating between unilateral and bilateral cases. We evaluated visual correction methods applied in both groups between cataract extraction (CE) and secondary intraocular lens (IOL) implantation. Furthermore, we examined visual acuity improvement with these corrections and their refractive outcomes following IOL implantation.

Methods: Ninety‐eight medical records of 64 children with pediatric cataracts who underwent CE at < 1 year with further IOL implantation were revised. Patients with current aphakia, primary IOL implantation, or those with ≤ 1 follow‐up visit after CE were excluded. Fifty‐three eyes were finally included and classified as unilateral or bilateral for analysis. Postoperative aphakia management was evaluated in each group, comparing contact lenses alone (Silsoft™) vs contact lens plus glasses. Best‐corrected visual acuity (BCVA) was measured (decimal scale) and converted to logMAR scale for statistical analysis. Teller test was used in the youngest children and results were also converted to logMAR scale. Functional success was defined as BCVA greater than or equal to 0.05 (decimal scale) and was evaluated before and after IOL implantation.

Results: 26 cases were unilateral (5 primary IOL, 15 secondary IOL and 6 aphakic) and 65 bilateral (45 secondary IOL and 20 aphakic). Secondary IOL implantation was the most common practice with a mean time of 3.6 ± 2.9 years after cataract extraction. In the secondary IOL group, All unilateral cases were corrected with contact lenses, while in the bilateral group, this percentage was of 63% (n = 26). Fifteen bilateral cases (37%) were also treated with glasses (P = 0.012). Functional success in these aphakic eyes was of 36% in unilateral vs 55% in bilateral eyes. In the last follow‐up after IOL implantation (mean: 8.7 ± 4.6 years), this functional success improved in both groups, being 63% in unilateral eyes and 90% in bilateral. BCVA at the last follow‐up visit was 1.3 ± 0.21 logMAR (mean 0.05 decimal) in the unilateral group and 0.33 ± 0.22 logMAR (mean 0.49 decimal) in the bilateral group (p < 0.001).

Conclusions: Uncorrected refractive error in the early years can lead to amblyopia. In our institution, children with CE under 1 year of age are left aphakic usually four years due to their ocular growth. Contact lens adaptation is the preferred modality for their refractive management during this aphakic period but it can become a true challenge that can modify the predicted therapeutic approach and anticipate the age of IOL implantation. Therefore, BCVA, patching, and refractive correction must be carefully evaluated and optimized before IOL placement in order to achieve optimal visual development.