Treating pediatric cataracts
Early-age surgery presents challenges, benefits

David Hunter, MD, PhD

Brennan Hughes-Shiverick was diagnosed with pediatric cataracts at 1 year old. He needed surgical removal of the cataracts, but with traditional methods, even after the procedure his parents would have needed to fit his tiny eyes with contact lenses for his vision to develop correctly.

Although mild cataracts in older children can sometimes be treated by patching the eye, using dilating eyedrops or prescription glasses, most pediatric cataracts require removal by surgery. Pediatric cataracts are uniquely challenging to ophthalmologists and are not like the cataracts that occur in adults. The eyes are too small for some of the standard cataract instruments. The lens itself can be extremely soft, rock hard or membrane-like, with increased risk of bleeding. The inflammatory response of the eye can be tremendous, requiring removal of the vitreous and intense steroid therapy after surgery. And after surgery, the child must be treated with amblyopia therapy, or the vision will not recover despite a good technical result.

Brennan's problem was not the removal of the cataracts, but retraining his eyes to focus after the procedure. The options available to children his age are problematic. Contact lenses and prescription eyeglasses are an option, but pose serious compliance issues, especially in younger children. If a child fails to wear lenses regularly after the procedure, long-term outcomes will be affected.

The alternative is surgical implantation of intraocular lenses, but this has traditionally been avoided in children under 6 years because of their intense inflammatory response and high rate of implant rejection. However, under the leadership of David Hunter, MD, PhD, chair of Ophthalmology at Children's Hospital Boston, intraocular lenses are successfully being placed in younger and younger patients. “Dr. Deborah VanderVeen [assistant in Ophthalmology] and I have been successfully doing this procedure on children from 1 to 5 years old for long enough that it is now fairly routine for us, although it is never easy,” says Dr. Hunter. “In some cases the procedure is appropriate for children as young as 6 months.”

Surgical implantation of an intraocular lens. The folded lens is inserted through a 3 mm incision and unfolded to its full 13 mm size.

When Dr. Hunter met Brennan, he was certain surgery would be appropriate. He not only performed the procedure, but invited the child's ophthalmologist to participate. Dr. Hunter used a 3-mm knife to enter the anterior chamber of the eye. He aspirated the cloudy lens, then injected an acrylic lens into the existing lens capsule, where it unfolded to its full, 13-mm size. He removed the posterior capsule behind the implant to prevent clouding, as well as part of the vitreous to prevent formation of cloudy scar tissue. He closed the tiny incisions with ultra-fine, absorbable sutures.

“Choosing the lens power is a very complex process, since the eye is still growing,” says Dr. Hunter. “We use special software in the operating room to predict the patients' eye growth in future years so that we can choose the best possible lens. Ideally, we will never have to replace the implant even though we know that the eye will grow.”

The success of cases such as Brennan's owes both to the technology employed and the experience of Children's doctors, who see relatively high volume for a disease that affects just one in 2,000 children.

Department of
Ophthalmology
Phone:
617.355.6401 (Boston)
781.672.2100 (Lexington)
978.538.3600 (Peabody)

Related event:

On April 18, Dr. Hunter will speak about pediatric vision screening at Caritas Good Samaritan Medical Center. For more information, call (508) 427-3547.