A cataract is a clouding of the lens in the middle of the eye. Infant cataracts are usually caused by a malformation of the lens during early intra-uterine life, and are hereditary in about 20% of cases. Cataracts in older children can occur as the result of a less severe malformation or following eye trauma. Vision will range from slightly to severely impaired. Severe cataracts occurring near the time of birth must be removed within weeks or vision can fail to develop normally and the eye will become legally blind (the medical term is “amblyopia”).
Less severe cataracts may initially be treated with patching therapy, dilating eye drops and/or glasses. Your Pediatric ophthalmologist, Dr. Packwood, Hunt or Norman, will carefully consider these other methods and will only recommend cataract surgery if necessary.
Serious complications due to surgery are rare. These include serious anesthetic reactions, a detached retina, or infection or hemorrhage serious enough to cause blindness. In rare cases, despite cataract removal, a membrane can grow back in the middle of the eye, but can be removed by a repeat operation.
With modern instrumentation and techniques, cataract surgery performed by a pediatric ophthalmologist is considered safe and effective.
Problems Related to Cataracts
Pediatric cataracts can also cause eye wiggling (nystagmus) or amblyopia (lazy vision). Amblyopia may persist despite cataract removal if the amblyopia doesn’t respond to patching after surgery. In many children, this can also lead to eye crossing (strabismus) before or after cataract surgery. The crossing can usually be fully or partially corrected by eye muscle surgery.
Glaucoma (high eye pressure) may develop months or years after cataract removal. This is not caused by the cataract surgery, but by a malformation of the drainage channels in that eye. About one in five children who have cataract surgery will later require treatment for glaucoma. Eye pressure should be checked periodically throughout life.
Vision Correction After Cataract Removal
The lens inside the eye normally focuses light rays to a sharp point on the retina (in the back of the eye). After this lens is removed, the focus power will need to be replaced with either a lens implant (inside the eye), a contact lens (outside the eye) or eyeglasses. Dr. Packwood, Norman, or Hunt will help decide which method is best for your child.
Recommended for toddlers and older children, implants are designed to remain in the eye permanently. Implants avoid the magnification of cataract glasses and the need to insert, remove and replace contact lenses. Pediatric implant surgery is more complex because of the special characteristics of young eyes; the power of the implant depends on the size of your child’s eye at the time of surgery and estimates of future eye growth, and will be chosen to focus at either near or distant targets. Normal thickness bifocal glasses may be prescribed later to fine-tune your child’s vision.
Contact lenses are the preferred method for infants who have had cataracts removed from only one eye. Contacts make it easier to use both eyes together because they produce less image magnification than glasses. They are also aesthetically more appealing than glasses. However, contact lenses for infants are expensive (the total expense for the first year may be over $500). The lenses can be lost or torn, and a fast-growing baby needs frequent lens power changes. You’ll need to learn how to insert, remove and clean your child’s contact lenses. Fitting is usually done within one to three weeks after surgery, and initial instruction normally requires one or two office visits.
Glasses are sometimes recommended when cataracts have been removed from both eyes. However, cataract glasses are very thick and magnify the appearance of the eyes. They need to be fitted by an optician at an optical shop specializing in pediatric glasses (we recommend SpecialEyes Optical). When your child is older, we’ll prescribe bifocal cataract glasses to provide focusing at both near and far distances. Later on, the glasses can be replaced with contact lenses or implanted lenses.
What to Expect
The night before surgery, don’t give your child food or milk after midnight. Medicines may be taken with sips of water. Only apple juice and water may be taken up to three hours before the admission time. See the Hospital Pre-Op page.
If your child is acutely ill (has a fever, deep cough or vomiting) in the days before surgery, please call us at (817) 529-9949.
The time of day you’ve been given for the operation is tentative and may need to be changed on the day of surgery. In general, patients are taken by age, with the youngest going first.
The anesthesia doctor may order a preoperative oral sedative. A young child will be put to sleep within seconds by breathing gas from a mask held near his or her face. An intravenous (IV) line and a breathing tube (endotracheal tube) are placed only after the child is asleep and the breathing tube is removed before he or she is fully awake. Children age 13 or older who are not unduly frightened may be given an IV line of sedatives beforehand. Depending on the special needs or medical condition of a patient, the anesthesiologist may slightly alter the routine.
Using a microscope for a magnified view, the pediatric ophthalmologist makes a tiny incision in the wall of the eye. An instrument no thicker than a toothpick is inserted through the opening. This instrument, used to remove the cataract, is a combined vacuum and cutter. The doctor then makes a second incision and inserts a small tube to allow fresh fluid to be flushed into the eye. The cloudy lens is cut into pieces and vacuumed away. Depending on the age of your child, the doctor may need to remove some of the thick gel (vitreous) that fills the middle of the eye. This reduces the chance of scarring, which would cloud the vision. The space left in the eye after removal of the cataract will be filled with a special clear fluid.
Cataract surgery and the measurements of the eye under anesthesia are usually completed within 90 minutes, although this may vary from 45 minutes to two hours depending on the complexity of the case. After the surgery, Dr. Packwood, Norman, or Hunt will find you to discuss the results.
There may be mild discomfort from the surgery, and mild nausea is common. The nurses will treat any discomfort with appropriate medication and possibly Tylenol. Before you leave, we’ll schedule a postoperative exam for the next day, and provide a patch and shield to protect the eye until then. We discharge most patients within two to three hours after surgery.
The nurse may give you eye drops or ointment to help healing and prevent infection in the first 4-6 weeks after surgery. When giving the medicines, do not apply pressure on the eyeball itself.
Your child can resume limited activities the day after surgery. Younger children often play within hours after surgery, though some children may be tired, grouchy or nauseated for a day or two. We discourage rough play for the first week after surgery. Your child should avoid submerging his or her eyes in a bath or swimming pool for 7 to 10 days after surgery. Bathing, showering and washing of the hair with the eye gently closed (with care not to splash water directly in the eye) won’t interfere with healing. Redness of the eye usually disappears in a few weeks. Your child can return to day care or to school within days after surgery.
Eye shield and eyeglasses
In the first weeks after cataract removal, your child’s eye will need protection from possible injury. An eye shield will provide this at night and naptime for about two weeks. Eyeglasses, if prescribed, will protect the eye during waking hours. We may provide glasses with a more precise prescription a few months later.
If your child has lazy vision (amblyopia), we will start him or her on patching therapy. This involves covering the normal eye with a patch for part of the day to help develop better vision in the operated eye.
On Follow-Up Exams
We’ll need to see your child multiple times in the following months, including a short check-up the day after surgery, when we may provide additional prescriptions for eye drops.
We may need to arrange a brief examination under anesthesia in the weeks after cataract surgery. This allows us to make precise measurements and to ensure the healing process is continuing normally.