Cataract surgery for infants and children

Erick D. Bothun, M.D., consultant in Pediatric Ophthalmology at Mayo Clinic Children's Center in Rochester, Minnesota, answers questions about pediatric cataracts.

When should pediatric cataracts be treated?

Pediatric eyes have a critical role in feeding the brain clear images of the world so that the brain can learn to process vision. Severe cataracts impede that development. Cataracts that are present in a newborn for only a few months before removal can profoundly impact future vision. Thus, cataracts should be evaluated and treated promptly.

After the first months of life, the development of vision slowly becomes less time sensitive. The ideal time frame for removing cataracts in a newborn is often urgent, whereas in a 1-year-old it is more routine, and very elective in a school-age kid.

What conditions are associated with pediatric cataracts?

Cataracts are often isolated and not associated with any other anomaly. However, they may be the presenting feature for an underlying metabolic, genetic or congenital condition. Those conditions might involve other eye anomalies such as retinal disease, craniofacial abnormalities or systemic findings such as cardiac disease, renal dysfunction, cognitive impairment or hearing loss.

How does the team approach of Mayo Clinic Children's Center benefit these patients?

Our comprehensive team approach is critical in delivering the best outcomes for children with pediatric cataracts. I often draw from my Mayo Clinic colleagues and resources to help diagnose ocular anomalies, curb systemic disease and rehabilitate vision in children. This may include pediatric rheumatologists, metabolism specialists or neurologists.

I have the utmost trust in our surgical team, including pediatric anesthetists who can manage even the smallest and most delicate patients. For children who have genetic conditions with effects beyond the eye, Mayo Clinic Children's Center has geneticists with vast experience in pediatric eye anomalies who can expedite prompt diagnosis.

What surgical expertise does Mayo Clinic Children's Center bring to these complex cases?

My experience with performing complex cataract procedures allows us to care for children with unique structural challenges. This may involve removing a cataract from extremely small eyes, after trauma, or from patients with associated glaucoma or systemic disease.

We have a robust Marfan syndrome care center within Mayo Clinic Children's Center. These children have very particular needs — often their eyes can't support the normal lenses that we implant in adults. We offer special surgical techniques and expertise for such patients, including researching new lens designs for children with Marfan syndrome.

Lastly, we are adept at providing multispecialty surgical approaches, including corneal transplantation services or vitreoretinal procedures.

What is Mayo Clinic Children's Center's approach to rehabilitative care?

Rehabilitating the eye and the brain after cataract surgery may be considered a marathon that extends over years. Some children will start wearing contact lenses in the first month of life. Some will be patched to occlude one eye at a time for asymmetric vision for years to maximize vision.

It's important to have a care team that understands the projected growth of the child's eye, the options in rehabilitation, and how to bond with and educate families. Our team includes orthoptists — specialists in vision and alignment testing — as well as contact lens experts and providers of child life services. We work to guide families to a rehab program that is impactful yet sustainable. We all strive to give children the best chances for optical success when they finish developing.

Families with capable ophthalmic care close to home can have some follow-up evaluations performed by local eye care providers. Yet families and children grow to appreciate the care and bonds we create and choose to make at least some trips back to Mayo Clinic Children's Center.

What outcomes do you see for these patients?

Bilateral cataract conditions caught at a reasonable age tend to have excellent outcomes. Provided complications such as glaucoma do not interrupt the progress, driving vision and even 20/20 vision in both eyes are not uncommon outcomes.

For unilateral cataracts, the outcomes can also be good. However, because of the severe optical asymmetry between the eyes, the development of vision in the cataract eye may continue to struggle. Outcomes vary but are maximized by ideal optical correction through contacts, intraocular implant and glasses, and the family's success with adhering to patching.

For one-eye cataracts, about one-third of kids will obtain driving vision in their poor-seeing eye, one-third will have more moderate "walking-around" vision and one-third never reach quality vision in the affected eye, largely due to complications and lack of compliance with patching.

What clinical studies are underway?

I was a surgeon and investigator in the Infant Aphakia Treatment Study, which compared treatment of aphakia with a primary intraocular lens or contact lens in infants with a unilateral congenital cataract. Because we found that young infants experience a higher rate of complications with intraocular lenses, we typically choose contact lenses for infants up to age 6 months.

At Mayo Clinic Children's Center, we are collaborating with various institutions to evaluate the use of intraocular lenses in children ages 7 months to 2 years. I believe that study may shape the role of intraocular lenses in toddlers and young children for years to come.

For more information

The Infant Aphakia Treatment Study Group. The Infant Aphakia Treatment Study: Design and clinical measures at enrollment. Archives of Ophthalmology. 2010;128:21.