Pediatric cataract requires prompt treatment, long-term follow-up

Eye injuries from sports, games and cultural festivals are the leading causes of unilateral pediatric traumatic cataract in India, a recent study found. Prevention of these injuries hinges on public education, adult supervision and the use of protective eyewear.

Tanuj Dada

Tanuj Dada, MD, of the Dr. Rajendra Prasad Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, New Delhi, and colleagues summarized injury rates and complications in a poster presentation at the European Society of Cataract and Refractive Surgeons meeting in Berlin.

In an interview with Ocular Surgery News, Dr. Dada pointed to the lack of facilities devoted to treating the children who present with eye injuries.

“In a country like ours, there are many pediatric injuries,” he said. “The eye care facilities for managing these injuries are very few. Few centers have the general anesthesia where these injuries can be tackled. Whenever these children get this sort of injury, there is often a delay in treatment, and they present with severe complications in the eye caused by the injury. That was the first thing we wanted to highlight.”

Leading cause of cataract

Trauma is one of the leading causes of pediatric cataract in India, other than congenital/developmental cataracts, Dr. Dada said.

According to another poster presented at the ESCRS meeting, which highlighted the demographics and epidemiology of pediatric cataract in Bihar, trauma was found to be the leading cause of acquired pediatric cataract and was more prevalent in children of low socioeconomic status.

Dr. Dada and colleagues conducted a retrospective review that included 101 cases of unilateral traumatic cataract in children younger than 15 years. The patient group included 83 boys and 18 girls with a mean age of 7.49 years. Ocular examination included best corrected visual acuity, slit lamp biomicroscopy, applanation tonometry and posterior segment ultrasonography, the authors reported.

The leading causes of ocular injury were wooden sticks (28%), sharp objects such as bows, arrows, knives, scissors and pencils (41%), blunt objects such as cricket balls and stones (20%), firecrackers (5%) and miscellaneous objects (6%). Open globe injuries were seen in 56% of eyes, closed globe injuries in 44%, the authors said.

Clinical findings related to trauma included elevated IOP (16%), ruptured anterior lens capsule (21%), subluxated lens (7%), retinal detachment (4%), endophthalmitis (2%) and trapped foreign bodies (2%).

Traumatic cataracts commonly appear in children older than 3 or 4 years who have entered school and participate in activities that cause eye injuries, Dr. Dada said.

“These games these children play are mostly not supervised by adults,” he said. “Whenever children are involved in these sorts of activities, particularly playing with bows and arrows or these wooden sticks, sharp instruments or firecrackers, they often lead to a serious injury in the eye.”

Education and prevention

There is a need for public awareness of risk factors and preventive measures, Dr. Dada said.

“Serious injury often leads to a sight-threatening complication in the eye,” he said. “That was the purpose of highlighting the presentation, that sharp instruments, firecrackers, wooden sticks and balls are the immediate cause for unilateral post-traumatic cataract. These children who present with cataract often have associated findings, like retinal detachment or a subluxated lens or a ruptured anterior capsule. Some of them unilaterally contain a foreign body that has to be tackled, in addition to the cataract.”

Most injuries occurred in children who did not use protective eye wear.

“There should be education of the patients and the teachers, to avoid children being involved in these sorts of dangerous activities,” Dr. Dada said.

An existing program is designed to educate children about the hazards of playing with sharp objects and firecrackers, he said. However, education about eye care and prevention is not widespread, particularly in rural areas.

“This sort of education program has not been created,” Dr. Dada said. “So we do need a lot of input for the parents and the schoolteachers to educate them and to have protective eyeglasses freely available.”

The other presentation that focused on epidemiology and demographic showed a lack of visual rehabilitation services for pediatric cataract in rural and suburban areas of Bihar. Public awareness and continuing medical education are critical, the authors said.

“Increasing public awareness toward the preventable aspects of pediatric cataract and concomitant continued medical education and training of ophthalmic clinicians toward management of such cases will ensure total visual and social rehabilitation of these kids,” the authors said.

Screening is essential to minimizing complications and facilitating treatment, Dr. Dada said.

“All children must go to preschool at the age of 3 years,” he said. “They must undergo some sort of vision screening and tests by an ophthalmologist to detect if there is any cataract.”

Complications and surgical challenges

A child presenting with a cataract should be referred for surgery immediately, Dr. Dada said, adding that surgery is merely the first of a long treatment regimen.

“Any child who undergoes pediatric cataract surgery is usually followed up for a long time to see the change in the refractive error, to give the child glasses or contact lenses and to see that the child is not developing amblyopia after cataract surgery,” he said.

Complications may arise, even after cataract surgery.

“Mainly, the problem is not the cataract itself,” Dr. Dada said. “The main problem is that even though they get operated, many of them require long-term amblyopia therapy and spectacle use. … The long-term follow-up requires use of contact lenses and amblyopia therapy. That is the major problem because many of them come from a poor socioeconomic status, and they don’t come for a regular follow-up. That is an issue.”

Many economically disadvantaged families cannot afford foldable acrylic IOLs. Instead, their children often receive PMMA lenses that have a high incidence of posterior capsule opacification, Dr. Dada said.

Amar Agarwal

Amar Agarwal, MS, FRCS, FRCOphth, director of Dr. Agarwal’s Eye Hospital in Chennai, outlined problematic surgical scenarios, particularly those in which in-the-bag IOL implantation is impossible.

“These are two nice studies which highlight the significance of trauma as a leading factor contributing to cataract in the pediatric age group,” Prof. Agarwal said. “An important factor in trauma is the nature of the cataract and associated complications such as zonular weakness, subluxation, vitreous prolapse and so on, all of which add to the difficulties experienced during surgery.”

A glued IOL technique shows efficacy for cases in which in-the-bag IOL implantation is not feasible because of a lack of capsular support or massive subluxation of the lens. The technique involves two partial-thickness scleral flaps 180· apart, followed by full-thickness sclerotomies under the flap. The haptics of a PMMA IOL are pulled through the sclerotomies, and the tips of the haptics are tucked into a scleral pocket at the edge of the flap to ensure stability. The flaps are sealed with fibrin glue, Prof. Agarwal said.

“We have operated on such cases with the glued IOL and have had extremely encouraging results with close to a year of follow-up,” he said. — by Matt Hasson

• Amar Agarwal, MS, FRCS, FRCOphth, can be reached at 19 Cathedral Road, Chennai 600 086, India; +91-44-281-16233; fax: +91-44-281-15871; e-mail: dragarwal@vsnl.com.
• Tanuj Dada, MD, can be reached at Rajendra Prasad Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, Ansari Nagar, New Delhi 110029, India; +91-98-733-36315; fax: +91-11-265-88919; e-mail: tanujdada@hotmail.com.