Seminars in Ophthalmology, 2014; 29(5–6): 414–420

! Informa Healthcare USA, Inc.

ISSN: 0882-0538 print / 1744-5205 online
DOI: 10.3109/08820538.2014.959192

REVIEW

Complications of Pediatric Cataract Surgery

Mary C. Whitman and Deborah K. Vanderveen

Department of Ophthalmology, Boston Children’s Hospital, Harvard Medical School, Boston,

Massachusetts, USA
Semin Ophthalmol Downloaded from informahealthcare.com by Selcuk Universitesi on 01/30/15

ABSTRACT
Purpose: Cataract surgery in young children poses different challenges and potential complications compared
to those encountered in adult populations. We performed a literature review of the complications of
pediatric cataract surgery. Methods: Literature review of complications of pediatric cataract surgery. Results:
Complications in children vary based on the age of the patient at surgery and the cause of the cataract. Common
events discussed include increased inflammatory response, opacification of the posterior capsule, lens
reproliferation, pupillary membrane, and amblyopia; less common events include infections, significant
bleeding, and retinal detachment. Conclusion: Complications after cataract surgery in children are often
associated with a robust inflammatory reaction or secondary opacity and, in infants, glaucoma. Late
complications can occur decades later, so that long-term follow-up is required. Though surgery carries
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significant risks, the consequences of no surgery and irreversible deprivation amblyopia in very young children
should be considered.
Keywords: Aphakia, aphakic glaucoma, complications, congenital cataract, pediatric cataract

INTRODUCTION or due to trauma (penetrating or blunt, possibly with

There are many potential causes of pediatric cataract,
and the timing of onset and the cause of the cataract
can affect the risk of surgical complications. Children
may have congenital cataract, present at birth or
shortly thereafter, which may be unilateral or bilat-
eral. These may be caused by associated diagnoses
such as genetic disorders, prenatal infections, persist-
ent fetal vasculature (PFV), or may be idiopathic. In
infants, visually significant congenital cataracts need
to be removed promptly to prevent irreversible
deprivation amblyopia. Many of the eyes with con-
genital cataract, however, also have other abnormal-
ities that increase the risk of complications.
Developmental cataracts, not present at birth but
developing during early childhood, may also occur.
Surgery for these cataracts can sometimes be delayed
if vision is developing normally, though lamellar or
posterior cataracts may progress quickly and require
intervention. Some cataracts are acquired in associ-
ation with other ocular diagnoses such as uveitis,
injury to other parts of the eye), or be a result of
treatments such as radiation or corticosteroid therapy.
Some children with cataracts have syndromes such as
trisomy 21 or have developmental delays, which
make management during the postoperative period
and visual rehabilitation phase challenging.
When consenting families for pediatric cataract
surgery, we review the risks for cataract surgery that
include immediate events, such as bleeding, inflam-
mation, or risk of infection in the eye, and also discuss
the risks of long-term potential complications, includ-
ing opacity of the posterior capsule, secondary mem-
branes, reproliferation of lens material, glaucoma,
dislocation of the intraocular lens (if placed), retinal
detachment, loss of vision or the eye, and need for
further treatment or surgery for any of these compli-
cations. We also emphasize that while some of these
events may occur early, some occur many years in the
future. In addition, children must undergo general
anesthesia for each surgical procedure. Finally, the
importance of compliance with the visual

Received 18 May 2014; revised 19 June 2014; accepted 29 June 2014; published online 24 September 2014
Correspondence: Mary Whitman, Department of Ophthalmology, Boston Children’s Hospital, Fegan 4, 300 Longwood Ave., Boston, MA 02115,
USA. E-mail: Mary.whitman@childrens.harvard.edu

414

rehabilitation program is discussed, since amblyopia
in young children can result despite successful
surgery, and certainly will occur without surgery.
In this review, we will discuss management of the
expected consequences of cataract surgery as well as
the postoperative complications, and the intraopera-
tive problems that can make postoperative complica-
tions more likely.
INFANTILE CATARACTS
Infant Aphakia Treatment Study
The Infant Aphakia Treatment Study (IATS) was a
randomized, controlled, multicenter trial of infants
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with unilateral congenital cataract, and age57 months
at surgery, comparing primary intraocular lens (IOL)
implantation to aphakia and contact lens use.1–3
At both one and five years, there were no signifi-
cant differences in visual acuity outcomes between
the groups.4,5 Data on complications were collected
meticulously, and all participating surgeons were
experienced pediatric cataract surgeons. Intraopera-
tive complications tabulated in IATS included iris
prolapse, iris damage, hyphema, retained cortex,
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corneal clouding, lens fragment in vitreous, and
posterior capsule rupture. These complications were
more common in cases in which an IOL was
implanted and mostly occurred during placement of
the IOL.2 Within the first year of the study, the adverse
events reported included reproliferation of lens
material, pupillary membrane, corectopia, retinal
detachment, wound dehiscence, IOL exchange, vitre-
ous wick, and glaucoma. By five years, at least one
adverse event had occurred in 56% of contact lens
patients and 81% of IOL patients, the most common
being lens reproliferation into the visual axis, pupil-
lary membranes, and corectopia in the IOL group, and
diagnosis of glaucoma or glaucoma suspect in the
contact lens group.5
Though a common cause of unilateral cataract in
infancy is persistent fetal vasculature (PFV; also
known as persistent hyperplastic primary vitreous,
PHPV), eyes were excluded from enrollment in IATS
if the corneal diameter was59 mm or for PFV with in-
pulling of the ciliary processes. Even so, the rate
of complications for eyes with milder forms of
PFV enrolled in IATS was higher than for eyes
without PFV.2
Aphakic Glaucoma and Pseudophakic
Glaucoma
Glaucoma is one of the most common complications
after cataract surgery in infants. The typical reported
incidence of aphakic glaucoma ranges from 15–45%,
! 2014 Informa Healthcare USA, Inc.
Pediatric Cataract Complications 415
depending on the population studied. Over one-third
of cases are diagnosed within a year of cataract
removal,6 but glaucoma can also develop years or
decades later.7,8
The cause(s) of aphakic glaucoma are unknown,
but several possible mechanisms have been sug-
gested, including chronic trabeculitis from inflamma-
tion, blockade of the angle from retained lens
material,9 changes in the trabecular meshwork due
to exposure to lens epithelial cells,10 chemical factors
from the vitreous, and an abnormal anterior segment,
leading to both the cataract and maldevelopment of
the angle.
There are several risk factors for aphakic glaucoma,
several of which are correlated with each other,
including congenital onset of cataract, microcornea,
and younger age (3 months) at cataract sur-
gery.7,11–13 A poorly dilating pupil and congenital
rubella are also risk factors. Though some have
suggested that placement of an IOL at initial surgery
is protective from glaucoma, usually the cohorts are
biased with IOL placement only performed for older
children.14,15 In the IATS trial, there was no significant
difference at one year or at five years in the rate of
glaucoma or diagnosis of glaucoma suspect.16
Aphakic glaucoma is usually first treated with
medications: topical beta-blockers and prostaglandin
inhibitors, and/or systemic carbonic anhydrase
inhibitors (alphagan should not be used in infants or
young children due to the risks of central nervous
system depression). If the pressure cannot be normal-
ized with medications, then glaucoma surgery should
be performed. Angle surgery, such as goniotomy or
trabeculotomy, as would be used for congenital
glaucoma, is effective in some cases.17 Some patients
will require a trabeculectomy (with mitomycin c) or
tube shunt, and some may continue to require
medications after surgery. If it is recognized and
managed appropriately, children with aphakic glau-
coma can have good visual acuity.18,19 The major
cause of vision loss in young children with unilateral
cataract or glaucoma is amblyopia.
Children are also susceptible to steroid-induced
ocular hypertension, which must be monitored in the
perioperative period.20 The rise in intraocular pres-
sure occurs earlier and in more dramatic fashion than
in the adult population, and should be treated until
steroids can be discontinued.
Posterior Capsular Opacity,
Lens Re-proliferation, and Pupillary
Membranes
Posterior Capsular Opacity (PCO) is caused by pro-
liferation of residual lens epithelial cells on the
posterior capsule. In children under five years of
age, posterior capsulotomy and anterior vitrectomy
 416 M. C. Whitman and D. K. Vanderveen
are routinely performed as part of the initial cataract
extraction to lower the incidence of PCO (which is
virtually 100% without posterior capsulotomy).
Additionally, reproliferation of lens material occurs
in virtually all pediatric patients to some degree. In
young children who are left aphakic, this results in
development of the Sommering’s ring behind the iris,
or Elschnig pearl formation may occur outside of the
capsular leaflets. Even with IOL implantation, lens
material will fill in within the capsular bag and may
migrate centrally on the posterior capsule or on the
anterior vitreous face. Pupillary membranes are
inflammatory membranes across the pupil. All of
these cause a secondary opacification of the visual
axis that needs to be cleared if decreased visual
responses are noted.
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Older children who have simple PCO may undergo
office laser capsulotomy with Nd:YAG laser, and
those who cannot cooperate for this can have laser
capsulotomy performed under general anesthesia.
Children with both PCO and reproliferation of cortical
lens material or with pupillary membranes will
require a second intraocular surgery (and general
anesthesthetic).
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Bleeding
Bleeding after cataract surgery ranges from simple
subconjunctival hemorrhage, to significant intraocular
hemorrhages. Vitreous hemorrhage is not uncommon
in eyes with PFV, with up to 10% incidence.12
Hyphema can be caused by damage to the iris with
vitrector, instruments, or during corneal suturing.
Swan syndrome, resulting from abnormal vessels at
the cataract wound, can later cause spontaneous
hyphema, which can be recurrent.21
Inflammation
Inflammation is expected after cataract surgery, and
children have a more robust inflammatory reaction
than adults. Significant postoperative inflammation
can lead to complications that include secondary
membranes that block vision and posterior synechiae,
and necessitate a second surgery. Intracameral pre-
servative-free triamcinolone22,23 or dexamethasone24
decreases inflammation in children and is especially
helpful for those undergoing IOL implantation.
Dexamethasone has routinely been administered
subconjunctivally at the end of pediatric cases.
Adding low-molecular-weight heparin to the irrigat-
ing solution has been tried as a way to decrease
inflammation, but is not very effective.25 Intraocular
cefuroxime does not decrease fibrin formation,
indicating fibrin formation is not due to bacterial
contamination.26
Inflammation is especially worrisome in children
with uveitic cataracts. The surgery is often difficult
due to posterior synechiae and pupillary membranes.
The surgeon (and rheumatologist) needs to aggres-
sively manage inflammation before surgery, often
with systemic medications. As with adults, inflam-
mation should be controlled for at least three months
before surgery. In young children, however, when
amblyopia is a concern, there is pressure to operate as
soon as possible. These children should be aggres-
sively managed to get the eye quiet as soon as
possible so that surgery can be scheduled. IOLs can be
used successfully, if inflammation is controlled.27
Children are also at risk for TASS (Toxic Anterior
Segment syndrome), an acute, severe intraocular
inflammation with diffuse corneal edema, presenting
12–24 hours after cataract surgery.28 It represents a
sterile endophthalmitis, and is thought to be a
reaction to contamination or pH imbalance of solu-
tions, viscoelastics, intraocular medications, or other
items that enter the eye. In pediatric cases, TASS has
been associated with ethyline-oxide sterilized vitrec-
tomy packs.29
Infection
In children, the incidence of infectious endophthalmi-
tis is low (51:1000). Staph and strep are the most
common organisms identified. Cases of pediatric
endophthalmitis are associated with nasolacrimal
duct obstruction or upper respiratory infection at
the time of cataract extraction. The outcome of
endophthalmitis is often poor, with over half of the
patients having LP or NLP vision.30,31
Retinal Detachment
In children, as in adults, cataract extraction increases
the risk of future retinal detachment. Rabiah et al.32
reviewed a series of 1,017 eyes of 579 patients with
cataract extraction without IOL implantation at age
516 yrs. With a mean follow-up of 6.8 years (range
2–18.3 years), they found an incidence of retinal
detachment of 3.2% (33/1017). The mean time from
surgery to detachment was 6.8 years (range 0.4 to 14.8
years). The risk factors they found associated with
retinal detachment were more myopic (less hyper-
opic) aphakic refraction and wound dehiscence.
Posterior capsulotomy and anterior vitrectomy were
not found to be risk factors. More recently, in
Denmark, in a series of 1,043 eyes of patients aged
0–17 at the time of surgery, 25 developed retinal
detachment a mean of 9.1 years after surgery. They
calculated the 20–year risk as 7% overall, but only 3%
among patients with isolated cataract. Retinal detach-
ment was more common in patients with intellectual
Seminars in Ophthalmology

disabilities and those with other ocular or systemic
anomalies.33
Loss of Vision
Although loss of vision can be caused by posterior
capsular opacity or pupillary membranes (‘‘secondary
cataract’’) that can be treated, or be the end result of
other complications such as endophthalmitis or ret-
inal detachment that result in poor outcomes despite
treatment, the leading cause of vision loss and poor
outcomes in young children and infants with cataract
is amblyopia. Amblyopia is particularly challenging
in unilateral cases, since the phakic eye will naturally
be the preferred eye. Amblyopia therapy needs to be
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started promptly after surgery. The IATS protocol
called for patching one hour per day per month of life
(i.e., five hours per day in a five-month-old) until
eight months, then half of waking hours, through at
least age five.1 Compliance with correction of residual
refractive error and patching, if indicated, is required.
Even children who have an IOL implanted have
significant refractive error in childhood, since the
growth of the pediatric eye will result in a myopic
shift, requiring over-correction regardless of the initial
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postoperative refraction. Because of the difficulties of
maintaining amblyopia therapy in unilateral cases,
better VA outcomes are usually found in bilateral
cataract cases compared to unilateral cases.34,35
While amblyopia is not a complication of cataract
surgery, lack of amblyopia treatment will result in a
poor visual outcome despite successful surgery, and
its importance should be recognized. On the other
hand, avoidance of surgery will also result in (depriv-
ation) amblyopia. Amblyopia remains a major barrier
to good outcomes after cataract surgery in young
children (58 years of age).
Need for Further Surgery in Children
after Primary Cataract Surgery
The most common reason for additional surgery is
posterior capsule opacification. In children who did
not have primary posterior capsulotomy, over 60% of
one- to six-year-olds require intervention within two
years from surgery.36,37 Among children 6-13 years of
age at the time of surgery, only 19% require YAG
capsulotomy within two years.37 Other additional
surgeries include glaucoma surgery, secondary IOL
for eyes left aphakic initially, and strabismus surgery.
In the IATS study, 63% of patients in the IOL
group required additional intraocular surgery within
the first year vs. 12% in the contact lens group, most
commonly for clearing the visual axis (60% IOL group,
11% CL group). Additionally, 18% of the contact lens
group and 10% of the IOL group had strabismus
! 2014 Informa Healthcare USA, Inc.
Pediatric Cataract Complications 417
surgery within the first year.2,38 By five years, 37%
percent of contact lens patients and 43% of IOL patients
had strabismus surgery.5 Other studies, including a
greater variety of cataract patients, also report strabis-
mus in 24–34% of cataract patients.39,40
OTHER RISKS AND COMPLICATIONS
Corneal Decompensation
Children undergoing cataract surgery are also subject
to other risks and complications seen in adults, such as
damage to the corneal endothelium. Children with a
history of cataract extraction had decreased number of
endothelial cells with polymegathism and pleomorph-
ism, unrelated to the presence of IOL.41 On long-term
follow-up, a 9.2% loss of endothelial cells was noted
over 12 years.42 No studies have assessed the corneas
of adults who had cataract surgery as children to
determine if they progress to corneal decompensation.
Loss of Accommodation
In both adults and children, cataract extraction elim-
inates the ability to accommodate. This is a more
profound loss for children, however, since most adults
undergoing cataract surgery have already been pres-
byopic for years. Surprisingly, many children have
better pseudoaccommodation than might be expected.
One series of children with monofocal IOLs implanted
at age 5 or older, and with low residual refractive
error, showed that 50% of eyes and 75% of patients
had 20/40 or better vision uncorrected at both
distance and near, perhaps due to astigmatism.43
There are a few reports of using multifocal IOLs in
children, but there have been no randomized con-
trolled trials.44,45
Associated Ocular Abnormalities
and Diagnoses
The patient with a congenital cataract has an error in
eye development, and even in cases of unilateral
cataract, there can be abnormalities of the other eye. In
patients treated for unilateral cataract, 41% had at
least one abnormality of the phakic eye, including
decreased vision (20%), nystagmus (19%), cataract
(15%), iris heterochromia (9%), myopia (6%), micro-
phthalmos (6%), pupillary miosis (2%), congenital
glaucoma (2%), optic nerve abnormality (2%), aniridia
(1%), and corneal opacity (1%). These abnormalities
were often not apparent at the time of initial treat-
ment, underscoring the importance of prompt treat-
ment for the cataractous eye, as the phakic eye may
have other abnormalities.46
 418 M. C. Whitman and D. K. Vanderveen
Traumatic Cataracts
Another cause of cataracts in children is ocular
trauma. These cases present a higher risk of compli-
cations due to the initial trauma and damage to other
ocular structures. The surgeon must worry about
zonular instability, capsular holes, and vitreous loss.
Complications (especially corneal scarring, posterior
synechiae, posterior capsular tear, and iris distortion)
are more common with open globe injury than blunt
trauma.47,48 Many trauma patients need scleral-fix-
ation of an IOL, if an IOL can be placed.49 About half
of the cases have a good visual acuity outcome, but
development of amblyopia is common. Common
modes of trauma in the US are paintballs, BBs, and
pens and pencils.50 In contrast, in rural India, bow and
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arrow injuries are common.47 Perhaps unsurprisingly,
the majority of these injuries occur in boys.
Bilateral vs Unilateral Surgery
In children with bilateral cataracts, there is some
controversy about performing surgery on both eyes
under the same anesthesia, or scheduling surgery
on two separate days.51 Usually, bilateral cases are
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done on two separate days to prevent the small
chance of bilateral endophthalmitis (or bilateral TASS)
if the solutions or equipment are contaminated.
Others argue, however, that the small risk of bilateral
endophthalmitis needs to be weighed against the
risk of two general anesthesia events in a very
young child, and the risk of deprivation amblyopia
if the second surgery is delayed for any reason. In
a developing country, the incidence of early
endophthalmitis (O.16%) was found to be similar to
the risk of anesthetic related death (0.11%).52 If
bilateral cases are performed on the same day, a
fully new set-up should be used, including re-scrub
and gowning of surgeons and assistants between
eyes. The total cost is estimated to be 20% lower for
simultaneous surgery.53
General Anesthesia Risks
There has been concern recently about the risks of
general anesthesia on cognitive development in
young children.54 Animals subjected to prolonged
periods of high-dose inhalational anesthestics at very
young ages have neuronal apoptosis. Some retro-
spective studies show higher risks of developmental
or learning disabilities in children exposed to anes-
thesia.55,56 The SmartTots consortium is dedicated to
further research on safe anesthetics, and has issued a
consensus statement that the research results are
mixed and, in the absence of conclusive evidence, it
would be unethical to withhold anesthesia or sedation
for necessary surgical procedures. In each case, the
risks of not treating the underlying condition need to
be weighed against the potential risks of anesthesia.57
CONCLUSION
Cataract surgery in children poses different risks
and complications than in adults. In adults, cataract
surgery can be performed with topical or local
anesthesia, is quick, usually uncomplicated, and
allows early restoration of vision without extensive
follow-up. In children, however, general anesthesia is
required, ocular anatomy and cataract morphology
require alternative techniques and management, need
for secondary surgery is common, and visual rehabili-
tation after cataract surgery is a long process that
requires parental dedication. Despite these challenges,
good outcomes for all ages are possible, and the
consequence of not operating is usually much greater.
DECLARATION OF INTEREST
The authors report no conflicts of interest. The authors
alone are responsible for the content and writing of
the paper.
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