In children, cataracts are responsible for more visual disability than any other form of treatable blindness. In the US, more than 200,000 children are blind from unoperated cataracts, complications of cataract surgery, or the general effects of cataracts (1). The socioeconomic and quality-of-life costs associated with a lifetime of blindness stemming from untreated visually significant cataracts are huge, and estimates put the cumulative risk of cataract during the growing years as high as 1 per 1,000 (2). Fortunately, not all childhood cataracts require removal.
The complexity of cataract surgery in children demands that the surgeon has a high degree of confidence and competence. Cataract surgeons who specialize in adult surgery often lack training in the techniques specific to pediatric intraocular surgery; therefore, cases should be done by ophthalmic surgeons who perform them on a weekly or biweekly basis to ensure competency. Whenever possible, children should be referred to regional centers with significant experience (3).
Challenges of the pediatric eye
Cataract surgery in children poses several specific challenges. Anatomically, a child's eye is smaller, softer, and more flexible compared with an adult eye. Performing cataract surgery in an adult is akin to working inside a hard box, because the sclera is firm and holds its shape. Surgery in a pediatric eye, on the other hand, is more like working inside a squashed grape. The surgeon must maneuver the instruments within a tight space and use copious amounts of fluid to ensure that the eye retains its shape.
Another challenge in pediatric eyes is maintaining adequate intraoperative mydriasis – partly because of the lack of development of the pupil dilator muscle. Stromal rigidity is also reduced, causing the iris to constrict in response to even mild amounts of trauma during the surgery. Such features are consistent with adult intraoperative floppy-iris syndrome. Preservative-free epinephrine may be used intraoperatively in the irrigating solution – a step that has been routine in children long before it was seen as a need in even the most unusual adult cases