KidsMD Health Topics

Cataracts

  • Overview

    "At Boston Children's Hospital, we have a high volume of pediatric cataract cases, which present unique challenges and are different from adult cataracts, so we have a lot of experience helping kids with cataracts."

    Deborah K. VanderVeen, MD, associate in Ophthalmology at Children?s Hospital Boston

    Most people think of cataracts as something that happens to our eyes as we age, and age-related cataracts are, in fact, the most common type. But cataracts can also affect newborns and children – and when they do, they can sometimes be accompanied by special urgency and challenges.


    click to enlarge

    A cataract is a cloudy area in the lens of the eye.  The lens should be clear, in order to focus images properly. If the cataract is large or dense enough, it can cause blurry vision or block vision. 

    • A cataract may be in one eye (unilateral) or both eyes (bilateral).
    • Children may be born with a cataract (congenital), or develop one later (acquired).
    • Cataracts aren’t always visible to the naked eye. When they are, they usually appear as a white or gray spot or reflection inside the pupil.  
    • If a cataract has been identified and is limiting vision, we recommend surgery to remove it.  

    A baby or young child with an untreated cataract could be slowly going blind. This is because when the cloudy lens blocks light from getting to the retina (the back of the eye), the retina can’t send visual information to the brain at a crucial time when eye and brain are working together to learn to see. If the cataract isn’t removed in time, it may be too late – the brain may never learn to see, even if the cataract is removed.


    How Children’s Hospital Boston approaches cataracts

    Babies and children with cataracts require highly specialized care. Our Pediatric Cataract Service offers the expertise, child-modified equipment and advanced technology to diagnose and treat cataracts in even our tiniest patients. Babies and children with cataracts are referred to us from all over the country. 

    Our pediatric ophthalmologists:

    • are very experienced in treating kids with cataracts, and have removed cataracts in newborn babies
    • have access to specialized tools and equipment, including an innovative laser that allows children to be cradled in a horizontal position after being anesthetized
    • can predict the growth of your child’s eye with customized software that lets us choose the best lens to serve her through adulthood
    • use the latest refined, delicate lens implantation techniques
    • have successfully implanted intraocular lenses in babies as young as one month old

    The Pediatric Cataract Service is part of Children’s Department of Ophthalmology, the largest group of full-time practicing pediatric ophthalmologists in the United States.

    Enabling Allie to see again

    During her first year of life, Allie DeFrancisco's vision seemed perfect. But by the time she was 15 months old, she developed cataracts, a clouding of the eyes' lenses that affects less than one percent of all children. Read more.

    Cataracts: Reviewed by Deborah K. VanderVeen, MD ©Children’s Hospital Boston, 2011

    »
    Boston Children's Hospital
    300 Longwood Avenue
    Boston MA 02115

     617-355-6401



  • In-Depth

    We understand that you may have a lot of questions when your child is diagnosed with a cataract:

    • What is it? 
    • What does it mean?
    • How will it affect my child?

    We’ve tried to provide some answers to questions about cataracts in children here, and when you meet with our experts, we can explain your child’s condition and options fully.

    Background: How we see

    The structure of our eyes is complex, but put simply: light enters the eye through the pupil and travel to the lens, which gathers and focuses the light on the tissue lining the back of the eye, called the retina. The retina converts the light into nerve impulses, which travel through the optic nerve up to the brain. Read more about the different parts of the eye.

    What is a cataract?

    A cataract is a cloudiness in the lens, similar to a smudged window or a window with a speck in it. Just as you can’t see through a window that’s sufficiently smudged, light can’t get through a cataract. But unlike a window, a cataract can’t be “cleaned” – the whole lens needs to be taken out and replaced, with a contact lens (for infants and very young children), or a clear plastic lens (for children who are older).

    A cataract can be partial (not involving the whole lens) or complete, but they’re usually partial. They can look like speckles, crystals, stripes or plaques.

    How common are cataracts in children?

    Around one in 5,000 children are born with a cataract. Taken together, congenital and acquired (developing later in life) cataracts occur in about .4 percent of children.

    Do all cataracts affect vision?

    No – sometimes a cataract may be so small that your child perceives no blurriness at all. But one thing to keep in mind is that unlike your circulatory or respiratory system, your experience of your visual system completely depends on how you use it. Here’s what we mean:

    Say you’re using a magnifying glass to read some small print, and it works perfectly. Now say someone gives you something else to read, in much smaller print. The magnifying glass hasn’t changed, but it might not work quite so well for this new task. A child’s vision can be like that. Her eyesight might be perfectly fine for playing with her friends, but when it comes time to learn to read, you may discover that she needs glasses. Physiologically, her vision hasn’t changed (in all likelihood), but as her “visual demands” change, how she experiences vision might change, too.

    Will my child’s cataract get worse?

    This is hard to predict – some cataracts progress, and some don’t. And sometimes a child’s vision might seem like it’s starting to worsen because her visual needs are changing, even if the cataract itself isn’t changing.  

    If my child is born with a cataract, when should it be removed?

    If your child is born with a dense cataract, we like to remove within first two months, and definitely by four months. Often, the sooner we take the cataract out, the better the vision your child will be able to develop afterwards.

    What are the complications of cataracts?

    Cataracts can cause poor vision, and that means that the eye is more likely to wander, too. If this happens, we perform surgery on the eye muscles, or sometimes use Botox injections. Kids with cataracts also have a higher risk of developing high pressure in the eye (glaucoma), sometimes years later. Glaucoma may be treated with surgery or, in some cases, medicine. 

    Can cataracts be prevented?

    Not really, although it’s important that kids wear eye protection when playing sports to lessen the chance of injury to the eye. Learn more about how to prevent eye injuries.

     

    Causes

    What causes a cataract?

    Congenital (present at birth) cataracts occur when the lens didn’t form properly. Acquired cataracts are caused by abnormal interactions among the proteins that make up the lens. Over time, these abnormal interactions cause clumping, specks, opacities and/or cloudy areas to form.

    About 25 percent of the time, congenital cataracts have a genetic cause, and may accompany a metabolic, hormonal or chromosomal abnormality (e.g., Down syndrome).  Another 25 percent of the time, cataracts are hereditary, which means that the child’s mom or dad also had a cataract in childhood.

    Some possible causes of acquired cataracts are:

    • idiopathic (unknown)
    • trauma to the eye
    • diabetes or another metabolic disease
    • steroid use
    • complications from other eye diseases, such as uveitis (inflammation in the eye)
    • complications from treatment of other childhood diseases, like rheumatoid arthritis
    • radiation therapy after cancer

    Often cataracts are idiopathic – meaning they occur for no identifiable reason.

     

    Symptoms

    What are the symptoms of cataracts?

    While each child may experience symptoms differently, some things that they may notice include:  

    • cloudy or blurry vision
    • decreased vision
    • double vision
    • lights appear too bright and/or present a glare or a surrounding halo
    • colors seem faded

    If your child is too young to complain about vision problems, you might notice a white pupil if you shine a flashlight into her eye. You may also be able to see a white or grayish area on her eye, but many cataracts can’t be seen with the naked eye because they’re too far back in the lens. 

    If many cataracts aren’t visible, what should I be watching for?

    Most babies are looking around and tracking things with their eyes nicely by the time they’re 3 or 4 months old. If you get the sense that your baby isn’t seeing and responding appropriately, that may be a tip off that something is wrong. Jiggling eye movements may also be a sign of a cataract or other eye problem.

    Strabismus, or misaligned eyes (eyes that are not looking in the same direction), usually aren’t a sign of cataracts – most often, they’re just the result of a newborn’s poor coordination. However, sometimes strabismus occurs if there is a cataract in just one eye.  Your child’s pediatrician can easily check for a cataract, and if the misalignment hasn’t gone away by 4 or so months, talk to your child’s pediatrician, who will be able to refer you to a specialist if need be.

     

    FAQ

    Q: What is a cataract?
    A:
    A cataract is a cloudiness of the lens of the eye, which is supposed to be crystal clear. Imagine if the clear lens of your camera just turned white. That's basically a cataract. Even if the lens just developed a white dot in the middle, it would still be a cataract.

    Q: How do I know if my child has a cataract? Can I see it?
    A:
    Parents occasionally notice a white pupil (or white dot in the pupil) in their baby's eye, but usually the primary care doctor notices it first. And doctors always check for cataracts in newborn babies, too.

    Q: Don't only old people get cataracts?
    A:
    It's certainly much more common for people to get cataracts as they age, but adults and children tend to have different types of cataracts. In kids, the lens clouds over because it didn’t form properly. In adults, a normal lens just gets old, hard and yellow and finally clouds over.

    Q: Why must my baby's cataract be treated right away?
    A:
    An eye with a cataract can’t provide visual information to the brain. If this occurs while the brain is “learning to see,” it may learn to ignore that eye. And since vision occurs when the brain and the eye work together, if this happens, your child may not be able to see with that eye, even if the cataract is eventually removed. That’s why babies with a cataract should be referred to our Pediatric Cataract Service for pediatric cataract surgery as soon as a cataract is discovered.

    Q: Do all cataracts have to be removed?
    A: No – in some cases, the cataract may be just a dot in the middle of the lens that doesn't have to be removed because there’s room for light to get around it. Sometimes figuring out whether a cataract needs to be removed requires lots of experience and expertise, so it’s crucial that your child be evaluated by an eye doctor who sees many babies and children with cataracts.

    Q: Will my child need to wear glasses?
    A:
    Likely so. We often leave the eye a little farsighted (difficulty seeing objects up close) to allow for it to grow, so most children will wear glasses for their absolute best vision (which they may not need all the time).

    Also, remember that the eye’s natural lenses can shift focus from distance to near, but implanted plastic lenses can only focus at one place. To compensate for this, we often put children in bifocals once they’re able to sit up. This helps them focus both up close and far away.  

    Q: Will my child require ultrasonography to break up her lens before it can be removed?
    A:
    Probably not. Ultrasounds are used in cataract surgery for adults to break up hard lenses that are usually caused by aging. Most children don’t need ultrasound because their lenses are soft. 

     

    Questions to ask your doctor

    After your child is diagnosed with a cataract, you may feel overwhelmed with information. It can be easy to lose track of the questions that occur to you. Lots of parents find it helpful to jot down questions as they arise – that way, when you talk to your child’s doctors, you can be sure that all of your concerns are addressed. If your child is old enough, you might suggest that she write down some questions to ask her doctor, too.  

    Here are some questions to get you started:

    • How did you reach the diagnosis?
    • What treatment do you recommend for my child now? Why?
    • How will you follow-up with my child?
    • What will I need to do when my child comes home?
    • What changes/accommodations will my child need at home or at school?
    • Will my child need surgery?
    • If so, what restrictions will be necessary after surgery?
    • What are our options after the surgery?
    • Will my child need to wear a patch? If so, for how long?
    • Is there anything in particular that I should watch out for, and what should I do if I see it?
    • Are there any other resources you can point me to for more information?
    Putting in and removing contacts in your infant or toddler

    Watch a video to learn how to put contacts in your infant or toddler.

  • Tests

    How are cataracts diagnosed?

    Even if you can’t see a cataract when you look at your child’s eyes, if one is present, our doctors will be able to detect it. We’ll start by compiling your child’s medical history, and examining her eye with special, kid-sized equipment. We may also:

    • perform a visual acuity test (the common eye chart test), which measures how well your child can see at various distances
    • dilate your child’s pupils with eye drops – this allows us examine the back of the eye  
    • perform an ultrasound to make sure there’s nothing unusual in the back of the eye
    • take measurements of your child’s eye to help choose a replacement lens if your child is a candidate for having an artificial lens implant

    After we complete all the necessary tests, we’ll meet with you and your family to discuss the results. If appropriate, we’ll talk about the pros and cons of lens implantation with you, and together we’ll decide whether it’s the right treatment for your child at this time.

  • Undoubtedly, you were distressed when you learned that your child has a cataract. The good news is that cataracts in kids are definitely treatable, and it's entirely possible to lead an active, normal life with good vision afterwards. And since the treatment process for cataracts extends into well after the surgery, parents are able to play a large role in their child's care.

    While our specialists develop customized treatment plans for each child, they most often begin with a surgeon completely removing the lens that has the cataract.  In some cases, we may recommend postponing the placement of an artificial lens inside the eye until the child is older, and using contact lenses in the meantime.

    Why postpone the placement of an artificial lens?   

    After surgery, the lens that developed a cataract has been removed, leaving the eye very much out of focus.  This focusing power needs to be replaced. This can be done with contact lenses, eyeglasses, or with an intraocular lens – a clear, plastic, permanent lens that the surgeon fits into the space where the old lens used to be. Since it's considered to be a permanent solution, many people prefer this kind of lens.

    But it can be hard to guess how strong this new permanent lens should be - a little like looking at a baby's feet and predicting her shoe size as an adult. The older your child is, the easier it is to predict the lens power she'll need, and the less likely it is that she'll need to have surgery later in life to get a new lens.

    When a child is born with a dense cataract, or develops one before her brain has learned to see, it's extremely important that the cataract is removed as soon as advisable.  

    When should my child have surgery?

    Each child and cataract is different, but a general rule is that the older the child, the less urgent it is that the surgery be done “soon.” This means that some cataracts can be managed without surgery for months or years.    

    My child's doctor recommended surgery, but why can't she just wear glasses or contact lenses instead?

    Glasses or contact lenses don't clear the cloudy area. A cataract is a different kind of eye problem than being farsighted or nearsighted. Of course, some children might have a cataract and also be farsighted or nearsighted glasses, and it's not uncommon for children to need to wear glasses at least some of the time after cataract surgery. 

    Can cataracts be treated medically?

    No, there is no medicine to treat cataracts. The lens has to be removed and replaced. 

    Surgery to remove the cataract

    Will my child need to be hospitalized overnight before or after the surgery?

    In most cases, no. But if your child is younger than 1 month, we usually have her stay overnight just so we can make sure there are no complications after general anesthesia.

    Will my child be asleep during the surgery?

    Yes, we use general anesthesia for the surgery. If you think it's helpful for your child, you're welcomed to come into the operating room and stay with her until she falls asleep.  After the surgery, you will be brought into the recovery room just as your child is waking up.

    What happens during cataract surgery?

    After your child goes to sleep with anesthesia, her eyelids are gently opened, and a small incision is made in the eye. The cloudy lens is removed with a special instrument. If the surgeon is going to replace the cloudy lens with a plastic intraocular lens, the lens is injected through the same tiny incision and unfolded to its full size, sort of like assembling a ship in a bottle. Then the surgeon will place some dissolvable sutures to close the incision, and finally place a patch and a shield over your child's eye.

    Most children who haven't had a lens implanted at this time are fitted with specialty contact lenses a few days later through our Contact Lens Service.

    How long does the surgery take?

    We usually plan to be in the operating room for one to two hours for cataract surgery – but please don't be concerned if we seem to be taking a long time; this may happen for a variety of routine reasons, such as getting started later than expected.

    What happens after surgery?

    After surgery, we put a patch and shield over your child's eye. Most children will sleep for several hours after the surgery, and most of the time, you and your child can go home within a few hours of the surgery.

    We'll send you home with a prescription for eye drops for your child, and make sure you know everything you need to know about how and when to give them.  Your child will wear a shield to protect her eye from accidental injury for days or weeks following the surgery. If your child wears glasses, they can be worn instead of the shield during the day. 

    Young children tend to recover quickly from surgery, usually behaving normally by the next day or so. Older children may be uncomfortable for a few days, which is often due to a scratching or itchy feeling in the eye. Some find that Tylenol or ibuprofen is helpful.

    Lenses – intraocular or contact

    It's important to remember that removing the cloudy lens is just the beginning of treatment.Without a lens to focus light, vision is blurrier than ever; so your child will most likely need either an intraocular lens (a permanent lens implant) or contact lenses. 

    1. Intraocular lenses

    When adults have cataract surgery, the cloudy lens is often replaced on the spot with a clear, plastic permanent lens. The benefit to an intraocular lens is that once it's in, the patient can usually just forget about it. But for children, this type of lens isn't always an option for a couple of reasons:

    • Since an eye that's still growing and developing is more sensitive to foreign invaders, lens implants in young children are much more likely to cause complications (e.g., inflammation).  
    • It can be hard to determine the best lens power to use in a young child's eye that will be useful to her both now and as an adult.

    Children's pediatric ophthalmology expertise comes in handy here. We use smaller incisions to ensure less trauma and disruption to the eye during surgery – we've successfully implanted intraocular lenses in babies as young as one month old. And we also use customized computer software to model the growth of the eye, and predict lens specifications that will work for your child now and into adulthood.

    Still, because of the potential complications mentioned above, not every child is a candidate for a lens implant. You and your child's doctor will work together to determine the best course for her care.

    Why is my child's doctor recommending both an intraocular lens and glasses?

    Most children need glasses after intraocular lens implants. There are a few reasons for this, including:

    • Reading glasses may be prescribed because we often have to leave the eye a little farsighted to allow for the eye to grow.
    • The formulas, while quite exact, can never predict the final power of the eye perfectly.
    • Natural lenses can shift focus from far to near, but intraocular lenses can only focus on one place. Once children are able to sit up, we often put them in bifocals to help them focus up close and far away.

    If your child has been prescribed reading glasses or bifocals, she might not need to wear them all the time – only when she needs her best vision.

    Are intraocular lenses noticeable?

    Most often, the implant is invisible. Some parents say that the eye with the implant seems to have a “sparkle” or “glint” if light catches it just right, but that certainly doesn't cause any problems for your child.

    2. Contact lenses

    Most babies and young children wear contact lenses post-surgery, and if you're like most parents, you may be daunted by the idea of putting in your child's contact lens. It's true that it's not always so easy in the beginning, but don't worry– as the process becomes part of everyday life, you'll get better at it, and most parents find that their kids become quite accustomed to it. These lenses usually last about six months.

    Infants in particular wear soft contact lenses. They're easier to put in and take out than you might expect, because they're pretty thick – not very floppy, like the ones most adults use. Our staff has helped lots of parents become comfortable with this process, and we'll help you, too. Watch a video about putting in and taking out contacts for your infant or toddler.

    In some cases, this is a temporary solution used until it's time for intraocular implants; other times, the lenses work great, everyone is happy and there's no need for more surgery.  

    Patching

    If your child has a cataract in one eye, the other eye will usually do most of the work. This means that vision in that eye gets stronger, and the eyes don't develop at the same rate. Patching the “good” eye forces the other eye to develop better vision, to compensate.

    When are patches used?

    1. Sometimes, if the cataract is only a tiny dot on the lens, the lens may not need to be removed. When that happens, we may recommend simply placing a patch over the unaffected eye, and maybe having your child wear glasses or contact lenses, too. We'll routinely monitor your child to make sure her vision isn't slipping.

    2. Patches are also commonly used after cataract surgery, to help the eye that had the cataract “catch up” to the other one.

    What does the patch look like?

    It's an adhesive covering that completely blocks the eye, and they're available in fun, kid-friendly designs.

    Will my child have to wear the patch all the time? 

    Most likely not. Your child's doctor will provide guidance, but typically the patch might be worn anywhere from one hour per day to fifty percent of waking hours. 

    How long will my child have to wear the patch?  

    This also varies:

    • If only one eye had a cataract, your child might wear the patch for several years on a part-time basis. This is to help develop vision in the eye that had the cataract, because there's a lot of competition from the normal eye.
    • If both eyes had cataracts, they're about the same, so there's isn't one stronger eye. If one eye is developing more quickly, we'll patch it to give the other one a chance to keep up.

    If only one of my child's eyes had a cataract, will it catch up to the other eye?

    A perfectly normal eye will always develop more normal vision than an eye that's had a cataract.

    Is there anything I can do to help my child at home?

    Help her with her contact lenses when needed, and encourage her to wear her patch (if prescribed). Other than that, your child just needs to be a child. Reading (especially books that encourage close looking, like Where's Waldo), coloring and playing with toys that draw on hand-eye coordination are all good ways to promote her vision development. We can suggest other activities too, and may be able to put you in touch with a family in a similar situation.

    Are there activities my child should avoid after surgery?

    Yes, for a little while. No heavy lifting, rough play, or high speed sports such as biking for several weeks, and we ask that your child stay out of swimming pools for two weeks. Showering, taking baths and washing hair are OK, but avoid getting water in the eye.

    How often will my child need follow-up appointments? 

    Post-surgery, your child's team will most likely want to see her after one day, one week, and typically after one month. After that, we usually see children under 4 about every three months, and older children every six months. Then once her vision is recovered, we usually schedule annual visits.

    One of our ophthalmologists is available to answer your questions and provide assistance 24 hours a day. If your child has any problems after you get home, please do call our office.
     

    Coping and support

    We understand that you may have a lot of questions if your child has a cataract. Will it affect my child long-term? What do we do next? We've tried to provide some answers to those questions here, but there are also a number of other resources to help you and your family through this difficult time.
     
    Patient education: From the first visit through follow-up care, our staff will be on hand to walk you through your child's treatment and help answer any questions you may have — How long will my child be in the hospital? How often will my child require follow-up? They will also reach out to you by phone, continuing the care and support you received while at Children's.
     
    Parent to parent: Want to talk with someone whose child has been treated for a cataract? We can put you in touch with other families who have been through the same experience that you and your child are facing, and share with you their experience at Children's.
     
    Faith-based support: If you need of spiritual support, we will help connect you with the Children's chaplaincy. Our program includes nearly a dozen clergy representing Episcopal, Jewish, Lutheran, Muslim, Roman Catholic, Unitarian and United Church of Christ traditions who will listen to you, pray with you and help you observe your own faith practices during your hospital experience.
     

    Social work and mental health professionals:We can offer counseling and assistance with issues such as coping with your child's diagnosis and dealing with financial difficulties.

    On our For Patients and Families site , you can learn all you need to know about:

    • getting to Children's
    • accommodations
    • navigating the hospital experience
    • resources that are available for your family

    Other online sources of support include:

    What to expect during cataract surgery
    Download information on what to expect during your child's surgery, including insurance information, preparation and post-surgery care.
  • Research & Innovation

    Boston Children's Hospital is extending the boundaries of cataract surgery in babies and children. Our Ophthalmology Department includes a mix of researchers and clinicians working side by side and training fellows from around the world. The result of this collaboration is improvement in the way cataracts and other eye conditions are treated in even the smallest eyes.

    A laser can be used to treat "after-cataracts," which develop after cataract surgery and must be removed to allow normal vision. Adults must undergo this procedure in a sitting position, but for children and babies, it would be impossible to hold still. A special laser used at Children's, called a supine YAG laser, allows children to be cradled in a horizontal position after being anesthetized. Learn more.

    We participate in the Infant Aphakia Treatment Study, which aims to determine whether contact lenses or intraocular lenses are the better way to focus a baby's eyes following cataract surgery. The study will follow infants between the ages of four weeks and seven months who were treated for cataracts for five years. Learn more.

    We’re also expanding our ability to treat children of progressively younger ages, in an effort to preserve as much sight as we can. Our doctors have successfully treated babies as young as a few days old with cataract extraction and as young as 6 months with lens implantation. And we’re part of a national multi-eye center study to determine whether these lenses can be safely implanted in infants younger than 6 months old.

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