Uniocular Cataract Management Strategy in a Child of 3 years
Denis Stark
 updated 23/09/2014

This page first prepared in 2001remains appropriate today. Since that time experience in managing surgery and intraocular lenses has advanced exponentially. Today the surgery is relatively routine. Aftercare still involves management of Amblyopia as the principal problem. Our team has had a great deal of experience in the surgery and postoperative management.


Possible Management Regimes
Today Cataract extraction and insertion of an Intraocular lens is the procedure of choice in this age group. The eye has developed almost to adult size at this stage thus this is most likely to result in improved vision.

An alternative approach of surgery and contact lens prescription is extremely unlikely to be as effective. As a long-term procedure it will introduce other restricting factors. Today this management has become much less favoured.

Spectacle wear to rehabilitate vision is not possible if a cataractous lens is removed from one eye only.
 

Cataract

A cataract is an opacity in the crystalline lens of the eye. Cataracts may be present at birth -Congenital Cataract or may develop in early childhood -Juvenile Cataract. Causes include hereditary, trauma, prenatal infection (Rubella), genetic, unknown.

Click on the  image to view a Congenital cataract

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Current Recommended Management

Extraction of Cataract and Insertion of an Intraocular lens + a regime of Occlusion of the normal eye + (probably)Spectacles for a period to overcome expected Amblyopia (Appendix 1 Amblyopia).
This cataract surgery should use the latest small incision techniques, capsulorrhexis, the most modern lens aspiration system, posterior capsulotomy (when not suitable for posoperative posterior capsulotomy). Careful calculation of the power of the intraocular lens is mandatory.

Effectivity of Current Therapy:
Even with this ideal management there are a number of concerns. 

If the cataract has been present for some years. It is extremely unlikely that the amblyopia will be able to be overcome.
Smaller eye. This suggests the cataract may be congenital. (i.e Present from birth.) Hence decreases chance of improved vision.
But if no surgery is performed there is no chance of improvement in the future!

Advantages of Recommended therapy:
A closer simulation of ‘normal refraction’- therefore more likely to be able to overcome Amblyopia and to allow maximal improvement of vision.

There is extensive experience in this surgery at the age of 5 years. Normal adult techniques are applicable making the procedure much safer. (Sinskey, O’Keefe, Lambert, Cheng,Vasavada)
 

Advantages when compared with Removal of Cataract and Contact Lens Use:

Better chance of recovery of some vision because of better stimulation by better focus.

But there is still a reduced chance of visual recovery - dependent on age at onset of cataract.
 

Disadvantages:
Still poor chance of visual recovery- because of Amblyopia
Will require patching and probably glasses.

Possible Complications of the Surgery:
The Worst: loss of the eye less than 1/1000
Short term problems -infection 1/1000
Long term due other problems eg Corneal complications, glaucoma, retinal detachment.

There is a possible need for further operations in the future to correct the problems related to the above complications.

Future Possible Additional Procedures:
It is also possible if visual improvement does occur that the following procedures may be of benefit in the future.

Exchange of IOL
Addition of IOL
Laser to clear the visual pathway

Who Should Perform This Surgery


With a very experienced Cataract Surgeon , in spite of the risks, cataract extraction and simultaneous lens insertion probably gives a child the best chance of obtaining the best visual result and minimises the risks of complications.
Experienced Cataract Surgeons perform between 500- 1000 catarct operations per year. They are therefore very familiar with the sophisticated equipment required. Cataract occurence in childhood is rare therefore Paediatric Ophthalmologists perform a relatively limited number of cataract operations. I consider that this surgery is best performed by a cataract surgeon who performs many similar procedures per week.

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Appendix:
The vision of a young infant or child is still developing. Anything, which interferes with this development, can result in permanent failure of vision- AMBLYOPIA.

The factors which can be involved:

1 Poor focus - the need for corrective lens.
2.An opacity in the line of vision- (Cataract)
3. Poor aim- a turned eye.

Congenital cataract (from birth) results in an opacity in the line of vision this causes deep Amblyopia.

If this cataract is removed the focus of the eye is then extremely poor unless a lens is placed in the system so Amblyopia may still occur.

A cataract developing slightly later (e.g. in the first few years of life) may not affect vision so seriously. In this case the visual brain has functioned at some stage and is more likely to recover vision with treatment (patching).

Thus we have 2 factors adding to the effect of visual failure after cataract extraction.

Time: The first months of life are critical. The failure to stimulate the visual brain in this period has a very severe effect on visual development making it ALMOST IMPOSSIBLE TO DEVELOP VISION LATER.

Focus: The more efficiently light is focused on the retina the better the chance of achieving better vision and therefore decreasing the risk of amblyopia. An intraocular lens will give the most natural visual stimulation, a contact lens is not so good but again is more efficient than spectacle correction.

After a cataract is removed from a young child amblyopia therapy is always required to achieve the best possible level of vision by overcoming amblyopia.
 

For further information regarding this page please contact:   Denis Stark < This email address is being protected from spambots. You need JavaScript enabled to view it. >