[Downloaded free from http://www.meajo.org on Wednesday, July 29, 2015, IP: 36.76.176.

63]

Original Article
Pediatric Cataract Surgery in National Eye Centre
Kaduna, Nigeria: Outcome and Challenges
Murtala M. Umar, Ahmed Abubakar1, Ibrahim Achi, Mahmoud B. Alhassan2, Amina Hassan

Access this article online

ABSTRACT
Purpose: To assess the outcomes of congenital/developmental cataract from a tertiary eye
care hospital in Northwest Nigeria.
Materials and Methods: Aretrospective chart review was performed of all patients
diagnosed with congenital or developmental cataract who underwent surgery from January
2008 to December 2009. Data were collected on patient demographics, preoperative
characteristics, intraoperative complications, and postoperative outcomes as well as
complications.
Results: Atotal of 181 eyes of 102patients underwent surgery. There were 95(52.5%) right
eyes. There were 64(62.7%) males. The mean age of the patients was 6.887.97years.
Fiftyfour(51.3%) patients were below 3years old. Most(62%) patients had congenital cataract
with a history of onset within the first year of life[39(62.9%) patients]. Amblyopia, nystagmus,
and strabismus were the most frequent ocular comorbidities accounting for 50.3%, 36.5%, and
35.4% of eyes respectively. The majority(84.3%) of the patients had surgery within 6months
of presentation. All patients underwent manual small incision cataract surgery(MSICS).
Seventynine(77.5%) patients underwent simultaneous bilateral surgery. Intraocular lens
implantation was performed in 83.4% eyes. The most common early and late postoperative
complication was, posterior capsular opacity which occurred in 65 eyes of 43 children. In
these cases, moderate visual acuity was predominant visual outcome.
Conclusion: Treatment of pediatric cataract in our setting is complicated by demographic
factors which results in late presentation and consequently, late treatment of children.
Shortterm visual outcome is fair. Data on long term postoperative outcomes could not be
acquired due to poor follow-up.

Website:
www.meajo.org
DOI:
10.4103/0974-9233.148356
Quick Response Code:

Key words: Cataract, Congenital Cataracts, Nigeria, Pediatric

INTRODUCTION

he goal of vision 2020 the Right to sight, is the worldwide

reduction of childhood blindness from the current level
of 0.75/1000 to 0.4/1000 children.1,2 Blindness in children
remains the second leading cause of blind person years
worldwide.2 The prevalence of childhood blindness in Africa is
approximately 10times higher than in industrialized nations.3
Of the 1.4 million children suffering from blindness worldwide,4
congenital cataract remains a major cause especially in middle
and low income countries.2,5

The purpose of this 2year retrospective study is to review

the visual outcomes, postoperative complications and other
challenges of pediatric cataract surgery at a tertiary eye hospital
in Northwestern Nigeria.

MATERIALS AND METHODS

A retrospective chart review was performed for all patients
who underwent surgery for congenital or developmental
cataract. The research ethics committee of National Eye Centre,
Kaduna approved this study. We defined congenital cataract

Departments of Pediatric, 1Research and Statistc Unit, and 2Department of Vitreoretina, National Eye Centre, Kaduna, Nigeria
Corresponding Author: Dr. Murtala M. Umar, Senior Resident Ophthalmologist, Pediatric department, National Eye Centre, PMB 2267,
Kaduna, Nigeria. E-mail: murtalau@gmail.com

92

Middle East African Journal of Ophthalmology, Volume 22, Number 1, January - March 2015

[Downloaded free from http://www.meajo.org on Wednesday, July 29, 2015, IP: 36.76.176.63]

Umar, etal.: Pediatric Cataract Surgery, Outcome and Challenges

as cataract that developed within the first year of life or the

signs of poor fixation signifying early onset. Developmental
cataract was defined as a cataract that develops after the first
year of life.1,2 Data were collected on patient demographics,
preoperative characteristics, intraoperative complications, and
postoperative outcomes. All patients underwent manual small
incision cataract surgery(MSICS). Patients below 5years of
age underwent primary capsulotomy with or without anterior
vitrectomy(Vitron 2020BF Geuder, Germany). MSICS was
performed in the following manner; first a 3-7mm scleral
tunnel[depending on the need for an intraocular lens(IOL)]
was lifted; cortical matter was washed out/or nuclear material
was extracted(older children) and at least one alternate stitch
using 10.0 nonabsorbable nylon suture was applied for all
patients below 18-years-old. The sutures were only removed
in some cases, mainly in older children due to irritation. The
IOL power was calculated using the SRKII or HofferQ formulas
and 20% and 10% of the calculated power was deducted
in patients 2-4-years-old and 5-7-years-old, respectively.
Polymethylmethacylate(PMMA) IOLs were implanted in
children 2years and older and in some patients below 2years.
Most patients underwent surgery under general anesthesia(GA).
Surgeries were performed by the same pediatric ophthalmologist.
Postoperatively, all patients were placed on topical steroid and
chloramphenicol for at least 2months, and 5days course of
5-10mg of oral prednisone. Uncorrected visual acuity(UCVA)
was assessed with age appropriate acuity testing techniques, such
as ability to fix and follow lights/objects hundred and thousand
sweet test, Kay picture, and the Snellen chart. Children who did
not receive an IOL were provided aphakic glasses and occlusion
therapy for amblyopia was initiated where indicated. In cases of
monocluar surgery, aphakic glasses was also provided with an
eye patch on the seeing eye for variable duration(depending on
the age of the patient) during waking hours. Posterior capsular
opacity was managed by YAG laser capsulotomy for patients older
than 4years and manual posterior capsulectomy for patients
below 4-years-old. Results were analyzed with SPSS version16
(IBM Corp., NewYork, NY, USA). APvalue less than 0.05 was
considered statistically significant.

RESULTS
A total of 181 eyes of 102patients under went surger y,
95 surgeries were performed on the right eye. There were
64(62.7%) males in the study sample. Table 1 shows the detail
of the age and sex distribution of patients. The mean age of all
the patients was 6.88 7.97 years (range, 0-13 years). The
differences in the gender proportions of the was independent
age-group (P > 0.05). Seventytwo percent of the patients
were from northwestern Nigeria, where the hospital is located.
Seventyeight percent of the eyes were blind at presentation [UCVA
of light perception(LP) to<3/60, Figure1]. Preoperatively, UCVA

Table1: Age and Sex distribution

Sex (%)
Age(years)
0-1
>1-3
>3-8
>8
Total

Total

Male

Female

13
20.3%
12
18.8%
23
35.9%
16
25.0%
64
100.0%

10
26.3%
7
18.4%
12
31.6%
9
23.7%
38
100.0%

23
22.5%
19
18.6%
35
34.3%
25
24.5%
102
100.0%

ranged from 6/18 to LP. Statistically significantly younger patients

presented with congenital cataracts compared to developmental
cataracts(P=0.00). Twentytwo percent of the congenital
cataracts were diagnosed at birth. Thirtyseven percent of the
congenital cataracts were identified after the first birthday, and
66% of the developmental cataracts were noticed between the
first and the eighth birthdays[Table2]. The resulting delay in
diagnosis affects the postoperative visual outcome.
Amblyopia, nystagmus and strabismus were the most frequent
ocular comorbidities accounting for 50.3%, 36.5%, and 35.4%
of patients, respectively[Figure2]. These were signs of severe
vision deprivation early in life. There were 7 children with
systemic associations. The associated systemic abnormalities
included, hearing loss(1 child); mental retardation(1 child)
and delayed developmental milestones(5 children).
Simultaneous bilateral intraocular surgery(SBIS; bilateral
surgery in one session) was performed in 77.5% of patients.
These where cases with bilateral congenital cataracts. IOL was
implanted in 83.4% eyes[Figure3].
Intraoperative complications recorded include: Miosis in five
eyes, posterior capsule rupture with vitreous loss in two eyes
and hyphema in one eye[Table3].
Approximately 87.3% of the eyes presented for postoperative
evaluation at one week, 71.2% at 4weeks postoperatively and
27.1% at 12weeks postoperatively. Patients were more likely to
present at 1week postoperatively(P=0.000). The follow-up
rate was low which limited the ablity to refract patients and to
treat patients with amblyopia or low vision.
One hundred and forty three eyes(78.8%) were blind
preoperatively. At 1week postoperatively 9/73(12.3%) eyes
remained blind and 6/65(9.2%) remained blind at 4weeks.
About 76.7%, 81.5%. and 71.2% of the eyes had moderate
vision i.e.between<6/18 and 6/60, one week, 4weeks and
12weeks postoperatively, respectively The proportion of eyes
with this vision preoperatively was 11.8%.[Table4].

Middle East African Journal of Ophthalmology, Volume 22, Number 1, January - March 2015

93

[Downloaded free from http://www.meajo.org on Wednesday, July 29, 2015, IP: 36.76.176.63]

Umar, etal.: Pediatric Cataract Surgery, Outcome and Challenges

35(6(17,1*9$(<(6

Table2: Age at which cataract was noticed by pateints/care givers



Type of cataract

6HULHV

Age at which cataract

was first recognize
At birth









1-12 months


3/

13-36 months

Figure 1: Pre-operataive VA of operated patients

>3-8years
>8years
Total

Total

Congenital

Developmental

14
22.6
26
40.3
8
12.9
11
17.7
4
6.5
63
100.0

0
0.0
3
7.7
13
33.3
13
33.3
10
25.6
39
100.0

14
13.7
29
28.4
21
20.6
24
23.5
14
13.7
102
100.0

Table3: Intra operative complications

No of eyes, n=181(%)

Complication
Small pupil<5 mm
Vitreous loss
Hyphema

5(2.76)
2(1.10)
1(0.55)

Table4: Postoperative(available) visual acuity

Figure 2: Showing ocular co-morbidities in eyes

V.A
category
(6/6-6/18)
<6/18-6/60
6/60-3/60
<3/60-PL
Total

No of eyes(%)
Preop

1st week

4th week

12th week

17(9.40)
4(2.4)
17(9.4)
143(78.8)
181(100)

8(10.96)
29(39.72)
27(36.99)
9(12. 33)
73(100)

06(9.23)
32(49.23)
21(32.31)
06(9.23)
65(100)

08(16.54)
24(48.98)
11(22.24)
06(12.24)
49(100)

78.8% of the eyes were blind before surgery up check one week after surgery
(P =0.000)

Table5: Postop complications

Complication

No of eyes (%)
1st week
4th week
n=158
n=129

12th week
n=46

34(18.78)
02(1.10)
07(3.87)
01(0.55)
20(11.05)

01(0.63)
49(31.01)

62(48.06)

27(58.69)

1(0.55)

01(0.63)
04(2.53)
01(0.63)
01(0.63)
02(1.27)
01(0.63)
01(0.63)

01(0.77)

01(2.17)

01(2.17)

1st day
n=181

Figure 3: IOL implantation in operated eyes

Corneal edema was the most common complication on

the first postoperative day(34 eyes). Other complications
included posterior capsule opacification(20 eyes), fibrinoid
reaction in the anterior chamber(7 eyes) and shallow anterior
chamber(2 eyes)[Table5].
Complications at 1week postoperatively included, posterior
capsular opacification(49 eyes), conjunctivitis(4 eyes),
and uveitis(2 eyes). Four and 12weeks postoperatively,
posterior capsular opacification accounted for the majority
complications[Table5]. Opacification at the visual axis
was more common in younger patients and in patients who
underwent SBIS[Tables6 and 7]. Opacification at the visual
axis occured in 65 eyes of 43patients at various followup
visits.
94

Cornea edema
Shallow AC
Fibrin
Cortical matter
Posterior capsular
opacity
Hyphema
Conjunctivitis
Exotropia
Maculopathy
Uveitis
Posterior synaechia
Glaucoma
Pupil capture
Occlusio pupilae
AC: Anterior chamber

DISCUSSION
Pediatric cataract is the most common cause of childhood
blindness worldwide. 2,6 A review by Tablin etal., reported

Middle East African Journal of Ophthalmology, Volume 22, Number 1, January - March 2015

[Downloaded free from http://www.meajo.org on Wednesday, July 29, 2015, IP: 36.76.176.63]

Umar, etal.: Pediatric Cataract Surgery, Outcome and Challenges

Table6: Age distribution of patients with PCO after SBIS
Age
(years)
0-2
25
5
Total

No of eyes examined (%) (postop)

1st Day
n=158

1week
n=136

4weeks
n=114

12weeks
n=40

5(3.2)
4(2.5)
7(4.4)
16(10.1)

11(8.0)
17(12.6)
9(6.6)
37(27.2)

23(20.2)
8(7.0)
22(19.3)
53(46.5)

7(17.5)
5(12.5)
14(35.0)
26(65.0)

SBIS: Simultaneous bilateral intraocular surgery; PCO: Posterior capsular opacity

Table7: Age distribution of patients with PCO after unilateral

cataract surgery
Age
(years)
0-2
>2-5
>5
Total

1st Day
n=23(%)
1(4.3)
0(0.0)
3(13.0)
4(17.3)

No of eyes examined (postop)

1week
4weeks
n=22
n=15
1(4.5)
1(6.7)
2(9.0)
1(6.7)
9(41.0)
7(46.6)
12(54.5)
9(60.0)

12weeks
n=6
0(0.0)
1(16.7)
0(0.0)
1(16.7)

that up to 75% of childhood blindness is due to cataracts in

developing countries. 7 In children with cataract, sight can
only be restored by surgery. Agood childhood cataract surgery
service demands a multidisciplinary approach. We performed
a retrospective review of cataract surgery in children in our
hospital over a 2year period. We found that the uptake of
surgery was higher in male children. This may due to the fact
that male children are valued more than the female children
across African communities.6
The average age of our patients at the time of surgery was 7years.
At this age, amblyopia is a significant complication depending on
the laterality and morphology of the cataract. Late presentation
is an important factor in the management of pediatric cataract
in developing countries. Yortson etals study from east Africa,
reported a mean age at surgery of 3.5years.3 In Nepal the average
age at the time of surgery was approximately 6-years-old which
is similar to our study.8 In Tanzania health treatment seeking
behavior, poverty, gender, local health beliefs, and the ability of
the health care team to provide the needed care determined
when children are brought to hospital.6,9
Due to late presentation, the majority of the eyes(79%) were
blind at presentation(>3/60 to LP). In east Africa and India,
a similar proportion of the eyes were blind at presentation.3,10
Children with developmental cataract are brought to a hospital
relatively late in time frame for the development of the visual
system.10 This explains the high number of eyes with amblyopia,
nystagmus and strabismus.
Only seven of our patients had associated systemic abnormalities
such as deafness, mental retardation, and delayed developmental
milestones. These factors could negatively impact on the
postoperative visual outcome. The children with other severe

systemic associations might have died or not been brought to

the hospital for cultural reasons.
Bilateral simultaneous surgery was performed on 77% of the
patients in this study. The main reason for bilateral surgery was
to reduce cost, reduce the risk of anesthesia and to increase
the uptake of surgery for the second eye. Previous studies have
reported that bilateral simultaneous cataract surgery in children
is safe.1118
Longterm assessment of visual outcome is limited by very
poor follow-up. Only a quarter of the patients were seen
at 3months postoperatively. However, follow out 1week
postoperatively was good. In Tanzania, 67% and 43% of
children who underwent cataract surgery were seen at two
and ten weeks postoperatively respectively.19 Comprehensive
long term postoperative care of these children is precluded
with this early and high rate of attrition. This care includes
refraction, spectacle prescription, treatment of amblyopia and
monitoring for long term complications such as glaucoma and
corneal decompensation. Sex(being a male), close proximity
to hospital and short delay in presentation were significantly
associated with presenting for the two weeks follow up in a
study from Tanzania.20 The 10weeks postoperative visit was
related to the distance from hospital and good preoperative
vision in the operated eye.20 High quality counseling to parents
and good tracking of patients/parents improved the follow-up
after surgery at the Kilimanjaro Christian Medical Centre in
Tanzania.19
Visual outcome was generally fair, with about three quarters of
the eyes regaining useful vision in the operated eye. Yortson etal.,
reported a visual acuity of better than 6/60 in about 91% of their
patients.3,21 In Kuwait, a mean best corrected visual acuity of 6/60
and 6/12 was achieved after surgery for unilateral and bilateral
cataracts in children respectively.22 Postoperative refraction needs
to be enforced in our centre in order to achieve the best vision for
these children. This will ensure optimal treatment of amblyopia.
Cornea edema and fibrinoid reaction were the most common
immediate postoperative complications in our study. These were
managed with topical and shortterm systemic steroids. The
most important postoperative challenge was posterior capsule
opacification. The loss of the clarity of visual axis needs to be
urgently treated in order achieve the aim of cataract surgery in
children. Numerous surgical techniques have been described
to either prevent or manage visual axis opacification, none of
which are ideal. 23 Techinues for treating visual axis opacification
includes removing the posterior capsule(intraoperative or
postoperative), removing the anterior vitreous body and
membranectomy. These surgical maneuvers can increase the
risk of posterior segment complication. We manage posterior
capsule opacification by YAG capsulotomy or rarely manually if
very thick. Very few patients underwent these procedures and

Middle East African Journal of Ophthalmology, Volume 22, Number 1, January - March 2015

95

[Downloaded free from http://www.meajo.org on Wednesday, July 29, 2015, IP: 36.76.176.63]

Umar, etal.: Pediatric Cataract Surgery, Outcome and Challenges

low follow up was low likely due to financial constraint. Hence,

the UCVA was not analyzed.
One of the major limitations was lack of data on best corrected
visual acuity. The refraction is easier to perform once the wound
is stable as about 10-12weeks postoperatively. Refraction
outcome is useful in determining need for amblyopia treatment
and referral to the low vision service. Decentralization of follow
up as suggested by cataract experts at the Kilimanjaro Centre
for Community Ophthalmology (KCCO)7 may significantly
enhance postoperative checkups. Follow up can be improved
by telephone follow up and home visits as appropriate.

8.

9.

10.

11.

12.

CONCLUSION

13.

Treatment of pediatric cataract in our environment is

complicated by sociodemographic factors. This results into
late presentation of children for care. Shortterm visual outcome
is fair. Longterm monitoring of treatment is not possible due
to poor follow up. The current standard of care is inclusive care
that is good preoperative counseling, varying surgical techniques,
good postoperative visual rehabilitation including treatment of
amblyopia, low vision services and inclusive education for the
children.

14.

15.
16.
17.

18.

ACKNOWLEDGEMENTS

19.

We thank Helen Keller International who supported the training

of the Pediatric Surgeon and SightSavers for provision of surgical
consumables.

20.

REFERENCES

21.

1.
2.

3.
4.
5.
6.
7.

96

YorstonD. The global initiative vision 2020: The right to sight

childhood blindness. Community Eye Health 1999;12:445.
GilbertC, FosterA. Childhood blindness in the context of
VISION 2020The right to Sight. Bull World Health Organ
2001;79:22732.
YorstonD, WoodM, FosterA. Results of cataract surgery in
young children in east Africa. Br J Ophthalmol 2001;85:26771.
BrownRJ. How should blindness in children be managed?
Eye(Lond) 2005;19:103743.
TabinG, ChenM, EspandarL. Cataract surgery for the
developing world. Curr Opin Ophthalmol 2008;19:559.
FosterA, GilbertC. Epidemiology of childhood blindness.
Eye(Lond) 1992;6:1736.
BronsardA, GeneauR, ShirimaS, CourtrightP, MwendeJ.
Why are children brought late for cataract surgery? Qualitative
findings from Tanzania. Ophthalmic Epidemiol 2008;15:3838.

22.

23.

ThakurJ, ReddyH, Wilson ME Jr, PaudyalG, GurungR,

ThapaS, etal. Pediatric cataract surgery in Nepal. JCataract
Refract Surg 2004;30:162935.
MwendeJ, BronsardA, MoshaM, BowmanR, GeneauR,
CourtrightP. Delay in presentation to hospital for surgery
for congenital and developmental cataract in Tanzania. Br J
Ophthalmol 2005;89:147882.
GogateP, KhandekarR, ShrishrimalM, DoleK, TarasS,
KulkarniS, etal. Delayed presentation of cataracts in children:
Are they worth operating upon? Ophthalmic Epidemiol
2010;17:2533.
Totan Y, Bayramlar H, eki O, Aydin E, Erten A, Daliolu
MC. Bilateral cataract surgery in adult and pediatric patients in
a single session. JCataract Refract Surg 2000;26:100811.
TotanY, BayramlarH, YilmazH. Bilateral paediatric cataract
surgery in the same session. Eye(Lond) 2008;23:1199205.
SmithGT, LiuCS. Is it time for a new attitude to simultaneous
bilateral cataract surgery? Br J Ophthalmol 2001;85:148996.
RamsayAL, DiaperCJ, SabaSN, BeiroutyZA, FawziHH.
Simultaneous bilateral cataract extraction. JCataract Refract
Surg 1999;25:75362.
SharmaTK, WorstmannT. Simultaneous bilateral cataract
extraction. JCataract Refract Surg 2001;27:7414.
ArshinoffSA, StrubeYN, YagevR. Simultaneous bilateral
cataract surgery. JCataract Refract Surg 2003;29:128191.
SarikkolaAU, KontkanenM, Kivel T, LaatikainenL.
Simultaneous bilateral cataract surgery: Aretrospective survey.
JCataract Refract Surg 2004;30:133541.
NallasamyS, DavidsonSL, KuhnI, MillsMD, ForbesBJ,
StrickerPA, etal. Simultaneous bilateral intraocular surgery
in children. JAAPOS 2010;14:159.
KishikiE, ShirimaS, LewallenS, CourtrightP. Improving
postoperative followup of children receiving surgery for
congenital or developmental cataracts in Africa. JAAPOS
2009;13:2802.
EriksenJR, BronsardA, MoshaM, CarmichaelD, HallA,
CourtrightP, etal. Predictors of poor followup in children that
had cataract surgery. Ophthalmic Epidemiol 2006;13:23743.
Wilson ME Jr, BartholomewLR, TrivediRH. Pediatric cataract
surgery and intraocular lens implantation: Practice styles and
preferences of the 2001 ASCRS and AAPOS memberships.
JCataract Refract Surg 2003;29:181120.
AbdelmoatySM, BehbehaniAH. The outcome of congenital
cataract surgery in Kuwait. Saudi J Ophthalmol[Internet].
2011;25:2956. Available from: http://linkinghub.elsevier.com/
retrieve/pii/S1319453411000038.
WilsonME, PandeySK, ThakurJ. Paediatric cataract
blindness in the developing world: Surgical techniques and
intraocular lenses in the new millennium. Br J Ophthalmol
2003;87:149.

Cite this article as: Umar MM, Abubakar A, Achi I, Alhassan MB, Hassan A.
Pediatric cataract surgery in national eye centre Kaduna, Nigeria: Outcome
and challenges. Middle East Afr J Ophthalmol 2015;22:92-6.
Source of Support: Nil, Conflict of Interest: None declared.

Middle East African Journal of Ophthalmology, Volume 22, Number 1, January - March 2015