This document discusses surgery for pediatric cataracts. Indications for surgery include visually significant central cataracts over 3mm, dense nuclear cataracts, cataracts with strabismus, and cataracts obstructing fundus exams. For bilateral cataracts, the denser eye should be addressed first within 10 weeks to prevent amblyopia. For unilateral cataracts, urgent surgery is needed within 6 weeks followed by amblyopia therapy. Pediatric cataract surgery differs from adults due to smaller eye size, highly elastic capsules, and propensity for inflammation. The surgery involves manual capsulorhexis, lens aspiration, and primary IOL implantation in the bag or leaving the child a

1. Surgery For Pediatric
Cataracts
Dr Salman Sohail
FCPS Resident - I

2. Indications for Surgery
• Visually significant central cataracts ( central or post. opacities over 3
mm in diameter )
• Dense nuclear cataracts ( UNI or BI )
• Cataract aw strabismus
• Cataract obstructing examiners view of the fundus

3. Timing for Cataract Surgery
Bilateral cataract
1.Bilateral dense
• Early surgery – before 10 weeks of age
• To prevent simultaneous deprivation amblyopia.
• Denser eye should be addressed first
2. Bilateral partial
• Monitor lens opacity and visual function
• Intervene latter if vision deteriorates.

4. Timing
Unilateral cataract
1. Unilateral dense
• urgent surgery with in 6 wks.
• Followed by aggressive anti-amblyopia
therapy
2. Unilateral partial
• Can be observed or treated non-surgically
with pupillary dilatation and possibly part time
contra lateral occlusion to prevent amblyopia.

5. Biometry & IOL power
calculation
Usually left APHAKIC with Spectacles Correction and Rehab afterwards
At birth the human lens is more spherical than in
adults. It has a power of about 30D, decreases to
about 20-22D by the age of five i.e. Myopic
shift.
This means that an IOL which gives normal
vision to an infant at the time , will lead to significant myopia
in adulthood.
So Aim for hypermetropia / under correction …

6. Pediatric cataract surgery differs from adult:
• Small size of eyes
• Highly elastic anterior capsule
• Low scleral rigidity
• Dense vitreous
• Propensity for severe post-op inflammation
• Constantly changing refractive status
• Tendency to develop amblyopia
• Difficulty in Doing YAG Capsulotomy post op - in a child

7. Surgery Points
• Lensectomy + primary posterior capsulotomy & anterior vitrectomy
with/without primary IOL implantation.
• Primary IOL implantation in infants – controversial - high tissue
reactivity – as marked changes in Ax Length & Refractive status.
• In Aphkic , Safe & effective alternative are contact lens/spects. Aids
amblyopia treatment by eliminating period of uncorrected aphakia

8. Types
• Pars plana Lensectomy- if no IOL implantation is planned.
• Performed through pars plana incision with vitreous cutting
instrument/manual aspirating device.
• Disadvantage- capsular bag is not preserved, so in-the-bag IOL
implantation is not possible.
• Limbal lensectomy –
• Most preferred approach especially when primary or secondary IOL
implantation is planned.

9. STEPS OF SURGERY - pg1/6
• If IOL is being implanted- partial thickness scleral incision , 2-2.5 mm
from limbus or a clear corneal incision. Scleral tunnel- preffered-
maintains AC & prevents iris prolapse.
• Management of anterior capsule: Manual continuous curvilinear
capsulorhexis using Uttrata forceps. Anterior capsule is tough &
elastic

10. Pg 2/6
• It is facilated by using highly retentive viscoelastic e.g.Healon GV,
force lens posteriorly and reduce its anterior convexity-combat the
effect of vitreous upthrust.
• Anterior capsule-stained with Trypan blue.
• Capsular flap is frequently released to inspect size,shape &
direction of the tear.

11. Pg 3/6
• More pull is needed centripetally to avoid extension of CCC.
• 2 incision pull-push technique:
• 2 small incisions superior & inferior
• Grasp the centre of flap of superior incision & push towards centre-
semicircular tear.
• Grasp the centre of flap of inferior incision & pull towards centre-
semicircular tear

12. Pg 4/6
• Lens matter is aspirated by using vitreous cutter or a Simcoe cannula.
• Primary IOL is implanted in the bag for long term stability & safety.
• children < 2yrs :Downsize IOL to 10mm diameter.
• To prevent- capsular bag stretching- PC folds.
• Lens epithelial cells migrate towards the visual axis through folds-
PCO.

13. Pg 5/6
• Single piece acrylic IOL is best, less capsulorhexis ovaling & capsular
bag stretch.
• PMMA IOL can be used.
• Management of Posterior capsule: Child < 5 yrs Primary Posterior
capsulotomy+ anterior vitrectomy to prevent opacification.
• Manually or vitrector

14. Pg 6/6
• Children > 5yrs: PC left intact
• Nd:YAG laser posterior capsulotomy in early postop period.
• Intraop miotics-avoided-to prevent ant.segment inflammation.
• Use of LMW Heparin(5IU in 500ml) irrigating solution reduces
ant.segment inflammation.
• Low scleral rigidity-wound is not self sealing-fish mouthing. Suture
the wound at the end.

15. • Video time

16. Take Home Message
• For APHAKIC – Spectacles , Rehab regular fu
• < 5 yo Ant. plus post. capsulotomy with ant viterectomy done (with or
without iol)
• > 5 yo PC left intact with iol in bag with yag capsulotomy afterwards

17. ThankYou