Controversial issues in paediatric cataract management

Indications for cataract surgery in children

Congenital cataracts can cause visual impairment in children[1]. It is the cause of approximately 10% of cases of childhood blindness worldwide.[2]. In particular, a significant proportion of cases occur in developing countries[3,4].
Due to the rapid development of vision in the first 4 months of life (development of the fixation reflex), a lack or limitation of visual sensations due to an opaque lens leads in most cases to amblyopia, strabismus, nystagmus or even a secondary decrease of neurons in the lateral geniculate bodies and visual cortex (VDS - Visual Deprivation Syndrome).
The causes of congenital cataracts are innumerable; of particular note are genetic factors, intrauterine infections, the use of drugs during pregnancy and metabolic disorders in children[1]. Clinical management depends primarily on the nature and severity of the cataract. Amblyopia, intra- and post-operative difficulties, and frequent medical check-ups make the treatment of congenital cataracts a major challenge.
All these issues make cataract surgery in children technically more complex than in adults.

Indications for cataract surgery in children
The main indication for cataract removal is opacification of the crystalline lens, which prevents normal visual development.

When to operate on cataracts in children?
It is generally agreed that the greatest decrease in visual acuity occurs in the first few weeks of life. Up to 14 weeks of age, every three-week delay causes a decrease in visual acuity of one line in the Snellen tables. Between 14 and 31 weeks of age there is a further slight decrease in visual acuity. Cataract surgery performed by 4 weeks of age reduces the incidence of strabismus and nystagmus[5].
It is considered that unilateral cataracts should be operated before the sixth to eighth week, and bilateral cataracts before the tenth week of age[6,7]. Because of the risk of amblyopia, surgical treatment should be performed as early as possible. However, an increased incidence of secondary glaucoma is reported in the literature if surgical treatment is performed too early.[5,7,8].

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Dr. Carmelo Chines
Direttore responsabile

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