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141]

Original Article
Evaluation of visual outcomes after pediatric cataract surgery in a Tertiary Eye
Care Hospital in Western Maharashtra
Rishikeshi Nikhil, Tripathi Shubhi, KaduskarAney Anushree, Taras Sudhir, Deshpande Madan
Background: A review of pediatric cataract cases operated between January 2007 and May 2008 in a Tertiary Eye
Care Hospital in Western Maharashtra was done. Aim: To evaluate postoperative visual status for distance and near
after pediatric cataract surgery. Settings and Design: Retrospective and prospective medical record retrieval type of
cohort study. Materials and Methods: The demographic data, preoperative, intraoperative, and postoperative details
were noted. The surgical procedure included cataract extraction with intraocular lens implantation with primary
posterior capsulorrhexis and anterior vitrectomy in most of the cases. The visual status of eyes was evaluated before
and 6 weeks after surgery. Statistical Analysis: Univariate and multivariate type of statistical analysis using SPSS
software. Results: Three hundred and sixteen eyes of 250 children were included in the study. Sixtysix children had
bilateral, and 184 children had unilateral cataract. Most common were congenital cataracts seen in 124 eyes (39.2%).
Distant vision following surgery was more than 6/60 in 86 eyes (49.1%). Aided near vision of N12 and above was seen
in 75 eyes (68%). The common causes for noncompliance with spectacles were heavyweight, repeated breakage, and
peer pressure. Conclusion: Early detection and management of cataract in children is the key to good visual outcomes.
Postoperative care should include a special emphasis on near vision. Improved coordination is needed between parents,
school teachers, and the pediatric eye care center to improve the compliance with spectacles.

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DOI:
10.4103/2320-3897.174345
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Key words: Near vision, pediatric cataract, spectacles, visual outcomes

Childhood blindness is one of the priority eye diseases

within the diseasecontrol strategy of the VISION 2020
initiative.[1] In developing countries such as India, 7.415.3%
of childhood blindness is due to cataract.[24] The prevalence
of cataract in children has been estimated between 1 and
15/10,000 children.[5,6] Visual impairment at an early age has far
reaching implications on a childs life. It can hinder education,
hamper personality development, and deprive the individual of
career opportunities, thus increasing the socioeconomic burden
on the family and the community.[7] Pediatric cataract surgery
is often the first step of a long, complex visual rehabilitation
program. Previously, an established mindset took into account
only distance vision improvement after surgery, but a new wave
of insight has swept the pediatric ophthalmologists, who now
give equal importance to near work since the world of a child
is more focused on his immediate surroundings, and if he/she
is of schoolgoing age, then his/her scholarly requirements
have to be taken into consideration. This has implications on
visual recovery as well as on their performance. A number
of studies have been carried out on visual outcomes[810] and
complications[8,11] following cataract surgeries in children. The
outcome of pediatric cataract surgery in many developing
countries remains poor as a result of late detection, inadequate
surgical facilities for children, lack of pediatric anesthesia, and
inadequate followup. Scant literature is available regarding
Department of Pediatric Ophthalmology and Strabismus, PBMAS H.V.
Desai Eye Hospital, Pune, Maharashtra, India
Address for correspondence: Dr. KaduskarAney Anushree, PBMAS
H.V. Desai Eye Hospital, Survey Number 93, Mohammadwadi,
Tarawde Vasti, Hadapsar, Pune 411 060, Maharashtra, India.
Email: sndrakr@gmail.com
Manuscript received: 05.06.2015; Revision accepted: 09.10.2015

assessment of spectacle compliance in schoolgoing children

as a part of refractive error screening programs,[12,13] but no
literature is available regarding spectacle compliance following
pediatric cataract surgery to the best of our knowledge. The
aim of this study was to assess the visual outcome both for
distance and near, complications and evaluation of compliance
for spectacles after pediatric cataract surgery.

Materials and Methods

A part retrospective and part prospective medical record
retrieval type of study was performed at a Tertiary Eye Care
Hospital in Western Maharashtra from January 2007 to May
2008. All walkin patients presenting to the Pediatric Unit
of the hospital, along with the children screened at various
screening camps organized under the Sarva Shiksha Abhiyaan
(SSA)Education for all scheme were included. Children
<16 years of age with cataract (irrespective of etiology) were
the study population. The Ethical Committee members of the
hospital were briefed about the rationale of the study, nature of
the procedures, and the benefits that could be availed. There
being neither any ethical considerations nor conflicts of
interest the ethical committee clearance was obtained.
This is an open access article distributed under the terms of the Creative
Commons AttributionNonCommercialShareAlike 3.0 License, which allows
others to remix, tweak, and build upon the work noncommercially, as long as the
author is credited and the new creations are licensed under the identical terms.
For reprints contact: reprints@medknow.com

Cite this article as: Nikhil R, Shubhi T, Anushree KA, Sudhir T, Madan D.
Evaluation of visual outcomes after pediatric cataract surgery in a Tertiary Eye
Care Hospital in Western Maharashtra. J Clin Ophthalmol Res 2016;4:13-8.

2016 Journal of Clinical Ophthalmology and Research | Published by Wolters Kluwer -Medknow

13

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Nikhil, et al.: Pediatric cataract visual outcomes

Vision of each eye was assessed with the help of various

visual acuity charts depending on the childs age and the
level of intelligence; Snellen charts for schoolgoing children,
Cambridge cards for preschool children (35 years), Cardiff
cards for toddlers (12 years), and lea symbols for infants. If
a child was unable to recognize the symbol in the top line of
the Snellen chart kept at 6 metre distance, we asked him/her
to count the number of fingers of the examiner at 3, 2 and
1 metre distances. The perception and projection of light were
tested in all the four quadrants. The presented vision was
recorded. Refraction was tried wherever possible to check
improvement in vision. Both unaided and aided visual acuities
were recorded. Complete anterior segment examination was
done with the aid of slit lamp, and a handheld slit lamp was
used for infants. Ocular alignment was recorded in terms of
Hirschberg corneal reflex test. The cornea was examined for
the presence of congenital abnormalities such as microcornea,
any corneal opacity and its relation to visual axis, presence
of any lamellar laceration/fullthickness corneal tear and
wound of entry in cases of trauma. The type and density of
opacification of the lens were noted, along with presence of
any subluxation, dislocation or zonular dehiscence. Posterior
segment examination was done either using a +90D lens
in conjunction with the slitlamp or indirect panretinal
ophthalmoscope and a +20D lens. Ultrasound Bscan was
done in all cases where posterior segment visualization was
not possible by either of the above techniques and in all cases
of traumatic cataract. In cooperative children, keratometric
readings were obtained, and intraocular lens (IOL) power was
calculated. In small and uncooperative children, biometry
was performed under anesthesia. The standard pediatric
cataract surgery done in the institute was cataract extraction/
aspiration with posterior chamber IOLs (PCIOLs) implantation.
Primary posterior capsulorrhexis with anterior vitrectomy
(PPC + AV) was done in all children <6 years of age and in
children who were considered uncooperative for subsequent
laser capsulotomy.
IOL implantation was not done in children <2 years of
age, in those cases only cataract extraction/aspiration with
PPC + AV was done. In cases with traumatic etiology, cataract
extraction was combined with synechiolysis and iridectomy
was performed if needed. In cases with coexisting corneal
tear, the repair was done in the same sitting.
All the children who underwent surgery were examined the
next day on slitlamp. Visual acuity was assessed appropriately
and recorded. In select cases (those with excessive iris tissue
handling, traumatic etiology, cases where vitrectomy was
done), oral steroids (1 mg/kg body weight) were started on the
day of surgery as a single morning dose after breakfast. Oral
antibiotics and oral antiinflammatory drugs were given in all
cases for a period of 5 days from the day of surgery. The topical
regimen consisted of steroidantibiotic combination eye drops 1
hourly (1% prednisolone acetate with 0.3% ofloxacin) along with
mydriatic agent twice or thrice daily (either 2% homatropine
eye drops or eye ointment atropine 1%). The stronger mydriatic
14

agent was routinely used in infants and in cases with traumatic

etiology. Oral steroids were tapered over the 2week duration.
Tapering of topical steroids was done over a period of 6 weeks.
Mydriatic agents were stopped after 1 week. The followup was
scheduled on day 1, day 3, 1 week and 6 weeks postsurgery. In
all followup visits, uncorrected visual acuity was noted, and a
thorough slitlamp examination was carried out. Complications,
if any, were noted and appropriately managed. At 6 weeks,
refraction was carried out, and bestcorrected visual acuity
(BCVA) both for distance and near was determined. Spectacle
prescription was given with appropriate near addition.
Postoperative amblyopia treatment, wherever applicable, was
given in the form of 6 hours of compulsory patching at home.
Near tasks were given to the child during that time span for
at least an hour. Spectacle compliance was noted at 6 months
postoperatively, with the reason for noncompliance being noted
if spectacles were not used.
We used univariate and multivariate types of statistical
analysis to find out factors that influenced visual outcome
after pediatric cataract surgery. SPSS software (SPSS Statistics
for Windows, Version 17.0.Chicago: SPSS Inc.) was used for
this purpose.

Results
This study included 250 children and 316 eyes with cataract.
The mean age of the study population at the time of surgery
was 7.6 years, with a standard deviation of 4.2 years. The
youngest child to undergo surgery was 2 months of age,
and the oldest child was 16 years of age [Table 1]. This study
included 174 eyes of 138 male children and 142 eyes of 112
female children, thereby pointing toward a small gender bias
in presentation of pediatric cataract. 105 children (42%) were
direct walkin patients presenting to the pediatric outpatient
department, whose parents paid the entire cost of surgery.
145 children (58%) were recruited from pediatric screening
camps who were operated free of cost. 184 children (73.6%)
had unilateral cataract while 66 children (26.4%) had bilateral
cataract.
Congenital cataract was the most common type of pediatric
cataract observed [Table 2]. Of the 124 eyes with congenital
cataract, 8 eyes had coloboma including one child who had
persistent fetal vasculature; 10 eyes had microcornea, 3 eyes
had the subluxated lens, and microspherophakia was seen in
1 case; 1 child each was diagnosed as having Down syndrome
and galactosemia.
Table1: Agewise distribution of patients
Age group(years)

Number(%)

<3

46(14.5)

3-6

78(24.7)

7-10

83(26.3)

>10

109(34.5)

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Nikhil, et al.: Pediatric cataract visual outcomes

The greatest proportion of cases, nearly 79%, had a

preoperative visual acuity between <3/60 and perception
of light. In seven eyes of five children with age from 2 to 6
years, preoperative visual acuity could not be recorded, as the
children were irritable [Figure 1].

pediatric screening camps and were inhabitants of remote areas.

They were brought to the tertiary center only for the surgery and
were operated free of cost. The majority of them did not revert
back to the center for followups due to financial constraints.
Those completing followups were mostly walkin patients.

Nine eyes underwent only cataract extraction and

were left aphakic, the indication of surgery being either
cataract associated with other congenital anomalies such as
microphthalmos/microcornea or subluxated lens. Thirtytwo
eyes underwent cataract extraction along with primary
posterior capsulorrhexis and anterior vitrectomy [Figure 2].
Except in four cases, all 28 cases were of children <2 years of
age. The other four children who were left aphakic wereone
child aged 3 years with traumatic cataract with adherent
leukoma, a 7yearold child with microcornea, coloboma,
and microspherophakia; two children aged 10 and 12 years
had subluxated cataract and were managed with cataract
extraction and vitrectomy. Ninetyseven eyes underwent
cataract extraction with IOL implantation with primary
posterior capsulorrhexis and anterior vitrectomy. In one case
of traumatic cataract with adherent leukoma with repaired
corneal tear, synechiolysis and pupilloplasty were combined
with routine cataract extraction. One case of complicated
cataract was managed by pupilloplasty. Adherent leukoma
was managed by iridectomy in two cases of traumatic
cataract. In two cases, there was preexistent posterior capsular
dehiscence including a case with posterior lenticonus, which
was managed by anterior vitrectomy and a bigger optic
diameter IOL was implanted in the bag. In three cases of
traumatic etiology, iridectomy was performed. In a case of
congenital cataract, posterior capsular rent occurred, which
had dislocated IOL in the vitreous cavity as a sequel, managed
by pars plana vitrectomy and IOL explantation on the first
postoperative day. This same child had a vitreous hemorrhage
at 6 weeks postoperatively. Two cases of traumatic etiology had
a primary corneal tear repair with cataract extraction and IOL
implantation done in the same sitting. In one case of traumatic
absorbed cataract, scleralfixated PCIOL implantation was
done. Three cases underwent cataract extraction with PCIOL
implantation and squint correction in the same sitting.

The postoperative vision of 175 eyes was analyzed

[Figure 3]. 48 eyes (27%) had vision 6/18. In 38 eyes (22%), the
vision was between 6/60 and 6/18. 23 eyes (13%) had visual
acuity between 6/60 and 3/60. In 54 eyes (31%), the vision was
<3/60. In seven eyes of five children, all aged <4 years, visual

Two cases were subjected to cataract extraction with PCIOL

implantation and trabeculectomy done simultaneously, out
of which one case was preoperatively diagnosed as having
Peters anomaly, and the other case had a traumatic etiology.
175 eyes (55.4%) completed the 6week followup. As
mentioned previously, 145 children in this study were from the

79%

250
200
150
100
50

10%

2%

6/6-6/18

Preop vision

7%

6/24-6/60
31

2%

<6/603/60
21

<3/60-PL

uncooper
ative
7

251

Figure 1: Preoperative vision

53%

31%

10%
3%

3%

Cat ext

Cat
Cat ext+IOL
ext+PPC +PPC+AV

32

Cat
ext+IOL

Others

168

10

97

Figure 2: Types of surgical procedures performed

31%

60
27%
50

22%

40
13%

30
20

Table2: Causes of pediatric cataract

Type of cataract

300

Number of eyes

Percentage

10
0

Congenital

124

39.2

Developmental

117

37

Traumatic

71

22.5

Others

1.3

Journal of Clinical Ophthalmology and Research - Jan-Apr 2016 - Volume 4 - Issue 1

6weeks distant
vision

7%

6/6-6/18

6/24-6/60

48

38

<6/60-3/60
23

<3/60-PL

uncooper
ative

54

12

Figure 3: Postoperative vision

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Nikhil, et al.: Pediatric cataract visual outcomes

acuity could not be assessed as they were uncooperative at

the time of examination.
Out of the 175 eyes which had completed the 6week
followup, in 55 eyes (31%) near add was not applicable, since
either a majority of these children were <2 years of age or in
whom near vision could not be assessed. Near vision could
not be assessed even in nine children who were older as they
were uncooperative for assessment. Of the remaining 111
eyes, 24 eyes (22%) had a near vision of N6, 30 eyes (27%)
had a near vision of N8, and 13 eyes (12%) had a near vision
of N10. Eight eyes (7%) had a near vision of N12, two eyes
(2%) had a near vision of N18, and six eyes (5%) had a near
vision of N36.
In 66 eyes (39%), the postoperative course was uneventful.
Eightyfive eyes (48.6%) had posterior capsular opacification (PCO).
In 46 eyes (26.2%), optic capture was seen at 6 weeks. Figure 4
represents the outcomes after cataract surgery at a glance and
Table 3 represents the visual outcomes after pediatric cataract
surgery as per the etiology of cataract.

Discussion
Pediatric cataract surgery differs from adult cataract surgery
in many waysthere may be a delay in presentation associated
with amblyopia, the sclera is less rigid, the axial length
and refractive status of the eye keep on changing, chances
of postoperative inflammation and PCO are higher. Hence,
visual results of pediatric cataract surgery are less spectacular
than adult cataract surgery. Nonetheless, the intervention
is very much needed, as a childs vision restored is a great
achievement in terms of blind personyears saved.

attended the 2week followup and 42.9% attended 10week

followup[14] and the Nepalese study in which followup
was 94% at 1 month and 63% at the end of 3 months.[9] In
another Tanzanian study, a multivariate analysis revealed
that sex (being a boy), close proximity to a hospital, and
minimal delay in presentation for surgery all independently
predicted good followup at 2 weeks; only distance from a
hospital and preoperative vision (not blind in the operative
eye) predicted good 10week followup.[14]
In a study conducted in Miraj (Maharashtra) to study the
barriers to followup in pediatric cataract surgery,[18] the
authors reported a poor followup of only 20.6%. Lack of
affordability was a major cause for poor followup. In this
study, out of the 132 eyes (42%) of the direct walkin patients,
only 33 eyes (25%) were lost to followup whereas 108 eyes
(58.7%) lost to followup were of children who were recruited
from the various pediatric screening camps organized under
the aegis of SSA Education for all scheme and were operated
free of cost. They followed up at their respective health centers.
These patients were from screening camps conducted at
different geographical locations and from remote areas, so
they could not be traced if they did not revert back to the
tertiary center. Hence, no postoperative data is available for
these patients.
In this study, near addition was not required in 55 eyes.
Infants who underwent only cataract extraction and were
left aphakic were given aphakic glasses incorporating the
near addition rather than prescribing bifocals as their area of

As many patients were recruited through camps of SSA and

followed up in their respective districts, the followup at the
base hospital was 85% at 1 week and 55.4% at 6 weeks. This
was comparable with the Tanzanian study in which 66.9%

No change line

Congenital cataract was also reported as the commonest

cause of pediatric cataract by a study conducted in Spain[15]
whereas a study from central India[8] reports trauma as the
leading cause of pediatric cataract [Table 4]. The postoperative
visual acuity results of 27% of patients having BCVA 6/18
compare favorably with reports from Central India, [8]
Tanzania,[14] and Nepal[9] [Table 5]. In a study reporting the
outcomes of traumatic cataracts from rural India, 43% patients
had BCVA 6/18.[16] A study from south India reports 39.5%
patients having BCVA 6/18.[17]

Deterioration
11

51

22

29

10

28

PREOPERAT

5
1

4
3
2
2

1
0

Improvement
0

3
4
POSTOPERATIVE

Figure 4: Scatter diagram at a glance showing the improvement,

deterioration, and no change in the visual acuity following cataract
surgery

Table3: Visual outcome as per etiological types

Type of
cataract

6/66/18(%)

6/246/60(%)

<6/603/60(%)

<3/60PL(%)

Uncooperative (%)

Pre

Post

Pre

Post

Pre

Post

Pre

Post

Pre

Post

Congenital

1(1)

17(25)

17(13)

17(25)

10(8)

12(18)

95(77)

15(22)

1(1)

7(10)

Traumatic

17(35)

1(1)

8(17)

4(6)

7(15)

65(92)

15(31)

1(1)

1(2)

5(4)

14(24)

13(11)

12(21)

7(6)

4(7)

87(75)

24(41)

5(4)

4(7)

2(100)

4(100)

Developmental
Others

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Nikhil, et al.: Pediatric cataract visual outcomes

visual demand differed from older children. Their visual area of

interest is restricted to maximum 3 metre. Hence, bifocals were
not prescribed. Excluding these cases, aided near vision of N12
and above was seen in 68%, but a point worth mentioning here
is that near add was not given in 25%, thus greater awareness
has to be inculcated even in the ophthalmologist fraternity
that near vision is equally important in the life of a child for his
social and academic improvement and that greater functional
success could be achieved by proper implementation of this
measure.
Due to poor cooperation, visual acuity both for distance and
near could not be recorded in 7% and 9% cases. In other studies
also, inability to record visual status has been mentioned, and
even alternative methods such as observing a childs behavior
and assessing visual functions have been suggested.[19,20]
Analysis of complications in the present study revealed PCO
in 48.6% of eyes, as in nearly 41% cases anterior vitrectomy
with primary posterior capsulotomy was performed, thereby
rendering the central visual axis clear. This explains the low
rate of PCO as compared to the R P center study (87.2%)[20]
Table4: Comparison of etiological diagnosis with various
studies
Etiology(%)
Congenital
Developmental

Present study

Central India[8]

Spain[15]

39.2

17.5

74.3

37

25.5

Traumatic

22.5

33.9

21.5

Others

1.3

5.2

Table 5: Comparison of postoperative visual acuity of this

study versus other studies
Present
study
Number of eyes

Central
India[8]

Mexican
study[10]

175

575

574

6 weeks

6-8 weeks

3 months

6/18 or above (%)

27

19

27.6

6/18-6/60 (%)

22

14.6

19.4

6/60-3/60 (%)

13

31

16.6

Duration

<3/60 (%)
No PL (%)

22

1 eye (0.57) 2 eyes (0.35)

Could not be assessed (%)

44.5

31

PL: Perception of light

Present study

In a study conducted at Postgraduate Institute Chandigarh

[Table 6], postoperatively 25 eyes with an intact capsule and
5 eyes that had PPC + AV developed PCO regardless of the
material of IOL implanted, the difference being statistically
significant (P < 0.05).[22]
Whereas, in our study, PCO was seen in 21% of eyes with
PPC +AV whereas 33% of eyes developed PCO without PPC
+ AV.

Conclusions
Our study revealed that the majority of pediatric cataracts
are developmental in origin. Cataract extraction with IOLs
implantation with PPC + AV is the procedure of choice for
management of pediatric cataract.
Ophthalmic assistants at primary health centers had
followed and refracted the children operated in our study.
This data was not shared with the hospital and was not
included in the present study. This was a major limitation
of the study.
Cataracts associated with anterior segment abnormalities
have a poor postoperative outcome.
Early diagnosis and prompt surgical intervention are
extremely important in the management of pediatric cataract,
as also adequate visual rehabilitation in the form of spectacles
with both distance and near correction.
PCO is the most common postoperative complication after
pediatric cataract surgery.
The parents need to be counseled about the importance of
postoperative care, followup, refraction and compliance of
spectacle wear. A mechanism should be set up to improve
coordination between parents, school teachers, ophthalmic
assistants, and the pediatric eye care center to reexamine
and manage the operated children.
Acknowledgment

Table6: Comparison with study conducted at PGI

Type of
surgery

where all the children recruited were referred for management

of complications following surgery performed elsewhere.
In a study from Maharashtra, 63.2% (163 eyes out of 258)
children who had not undergone posterior capsulorrhexis
developed PCO.[21] In this study, only 12.40% (32 eyes out of 258)
underwent posterior capsulorrhexis with anterior vitrectomy.
The high rate of PCO in the study can be attributed to this
factor. PCO was managed by Nd: YAG capsulotomy in 11%
cases and surgical membranectomy in 3.5% cases.

PGI study[22]

Number
of eyes

PCO(%)

Number
of eyes

PCO

With PPC + AV

129

27(21)

32

Without

177

58(33)

32

25

PPC + AV: Primary posterior capsulorrhexis with anterior vitrectomy,

PCO:Posterior capsular opacification, PGI: Postgraduate Institute

Journal of Clinical Ophthalmology and Research - Jan-Apr 2016 - Volume 4 - Issue 1

Dr. Gadkari Salil (M. S. Senior Consultant, Department of Vitreo

Retina, Director Medical Research, PBMAS H. V. Desai Eye
Hospital, Pune, Maharashtra, India).
Financial support and sponsorship

Nil.
Conflicts of interest

There are no conflicts of interest.

17

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Nikhil, et al.: Pediatric cataract visual outcomes

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Journal of Clinical Ophthalmology and Research - Jan-Apr 2016 - Volume 4 - Issue 1