Cataracts in Children

What is a cataract?

The eye works similar to a camera.  There is a lens that helps to focus the visual image.  This lens, normally crystal clear, brings objects into focus on the lining inside the eye called the retina.  The retina acts like the film in a camera.

When the lens becomes cloudy and interferes with vision, it is called a cataract.  When a cataract occurs in a child, it may interfere with visual development.  If the cataract is present in just one eye, the child will usually prefer the normal eye and ignore the eye with a cataract, leading to the development of amblyopia (lazy eye) and strabismus (wandering eye).

What causes cataracts in children?

Some cataracts are present at birth, and others develop during the first few months or years of life.  Some cataracts will be inherited, and others will be related to metabolic or systemic abnormalities.  In many cases, the cause is unknown.  In the older child, cataracts are often related to injuries or ocular inflammation related to juvenile rheumatoid arthritis.  When a visually significant cataract occurs in a child, prompt surgery and rehabilitation are required to maximize visual development.  The visual outcome for children with cataracts is much more optimistic now than it was a few years ago.  However, some eyes will have associated abnormalities, which limit the visual potential that can be obtained, despite early surgery and adequate visual rehabilitation.

How are cataracts in children treated?

There are three important parts in the management of the child with a cataract:  Preoperative evaluation, surgery, and visual rehabilitation.

Preoperative evaluation:  A complete preoperative evaluation of both eyes is required.  Some cataracts are unilateral and the health of the apparently normal eye requires careful evaluation as well.  An eye with a cataract may have other associated abnormalities, for example:  inflammation, abnormal tissue behind the lens of the eye, and glaucoma, which require assessment preoperatively in order to provide the most reasonable expectation for visual outcome.  An ultrasound (sound waves), used to image the inside structure of the eyes, is needed in some cases.

Surgery:  Unlike adults, cataract surgery in children requires general anesthesia.  This is usually very well tolerated even in the youngest babies.  Microsurgical techniques are used to remove the cataract with a small instrument.  This allows almost complete removal of the cataract that decreases the chance of it recurring.  Following surgery, infants less than 12 weeks of age are kept in the hospital overnight for observation.  Older children are usually allowed to return home the day of surgery, after recovery from anesthesia.  You may notice slight redness of the eye for a few days or weeks as the incision heals.  Your baby's surgeon will ask you to administer several different types of drops to help the eye heal.  Children should not swim for a couple of weeks following surgery and rubbing the eye should be avoided.  A protective shield, worn over the operated eye, will be required for several days or weeks.

Visual rehabilitation:  There are two essential components to visual rehabilitation:  1.  Replacing the lens, and 2.  Restoring the vision.  Usually, a “new” lens is required to help focus the visual image once the lens with the cataract has been removed.  This may be accomplished with glasses, contact lenses, or an intraocular lens implant (IOL) placed inside the eye at the time of the cataract surgery.  Your doctor will discuss with you which option(s) are best for your child as the decision is influenced by the type of cataract present and by your child's age.  If contact lens or glasses are selected, these are fitted within several days or weeks following surgery, and should be worn on a full-time basis.  Parents are taught how to carefully insert and remove contact lenses.  Even when an IOL is implanted, glasses and, occasionally, contact lenses may still be required.

Frequently, patching therapy is needed to encourage the development of vision in the operated eye and to prevent amblyopia (poor vision that occurs as a consequence of not using the eye).  This is particularly true in the child who has a cataract in only one eye.  Sometimes an opaque contact lens or atropine drops (which blur the vision) are used in the good eye if patching is not working or if the child is intolerant of the patch.

Some children who have had cataract surgery when they were younger, but who did not receive an IOL implant, may benefit from lens implant surgery at a later date.  This option is not always possible, and depends, to some extent, on how the original surgery was performed, and on the visual potential of the eye.

What post-operative issues should we be aware of?

Despite adequate optical rehabilitation (a new lens) and patching therapy, misalignment of the eyes (strabismus) often develops.  This may require eye muscle surgery to improve the alignment.  Periodic evaluations are required to detect any other post-operative complications (for example, secondary cataract, inflammation, glaucoma, retinal detachment).  A child who has undergone cataract surgery requires close monitoring of visual development and will need changes in glasses or contact lenses as the eye matures.  The parents must accept the responsibility for the optical rehabilitation, patching therapy, and continued follow-up care that is required to maximize the visual development in the operated eye.  Without the participation of parents, optimal vision will not be realized.

If you have additional questions regarding cataracts in children, feel free to contact one of the University’s pediatric ophthalmologists at (612) 625-4400 or (800) 937-4393.