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Ophthalmology (Eye Conditions)

Paediatric Cataract

Lens opacity present at birth (congenital) or developing during childhood. Requires prompt diagnosis and management to prevent irreversible vision loss (amblyopia).

Also known as: Congenital Cataract, Childhood Cataract

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Referral and warning signs

When to refer

IMMEDIATE URGENT REFERRAL to Paediatric Ophthalmologist/Tertiary Eye Centre (RR) for ANY infant or child suspected of having a cataract (e.g., leukocoria, poor vision).

Red flags

  • Leukocoria (white pupil).
  • Absent red reflex.
  • Nystagmus in an infant.
  • Persistent squint.
  • Obvious poor visual behaviour in an infant.

Signs and symptoms

  • Leukocoria (white pupil / white reflex in photos).
  • Poor visual behaviour / failure to fix and follow.
  • Nystagmus (dancing eyes).
  • Strabismus (squint / crossed eyes).
  • Photophobia.
  • Cloudy appearance of cornea/pupil (if dense cataract).

Risk factors

  • Hereditary / Genetic disorders (most common identifiable cause).
  • Intrauterine infections (TORCHES - Toxoplasmosis, Other(Syphilis, VZV, Parvo), Rubella, Cytomegalovirus, Herpes Simplex).
  • Metabolic disorders (e.g., Galactosemia).
  • Chromosomal abnormalities (e.g., Down Syndrome).
  • Prematurity.
  • Maternal drug use during pregnancy.
  • Trauma.
  • Idiopathic (unknown cause).

Diagnosis

Clinical assessment

Screening: Red Reflex test at birth and routine child checks (absence or abnormality suggests cataract/other pathology). Observation of visual behaviour, leukocoria, nystagmus, strabismus.

Investigations

  • Ophthalmic Examination (Paediatric Ophthalmologist):
  • - Red Reflex testing.
  • - Assessment of visual behaviour.
  • - Slit Lamp Examination (may require examination under anaesthesia - EUA).
  • - Dilated Fundus Examination (rule out other causes like retinoblastoma).
  • - Biometry (for IOL calculation if surgery planned).
  • Systemic Workup (to identify cause):
  • - TORCH screen.
  • - Metabolic screen (e.g., urine for reducing substances - Galactosemia).
  • - Genetic testing.

Diagnostic criteria

Presence of lens opacity on ophthalmic examination in a child.

Management

Non-pharmacological management

  • Urgent Referral to Paediatric Ophthalmologist.
  • Amblyopia Prevention/Treatment: Crucial if cataract is visually significant. May involve patching the better eye after surgery.
  • Low vision aids / Rehabilitation if vision permanently impaired.

Pharmacological treatment

  • No medical treatment for the cataract itself.
  • Post-operative eye drops (antibiotics, steroids).

Monitoring

Requires long-term follow-up with Paediatric Ophthalmologist for visual development monitoring, amblyopia management, refractive error correction, glaucoma screening (increased risk after surgery).

Complications

  • Amblyopia ('lazy eye') - irreversible vision loss if not treated early.
  • Nystagmus.
  • Strabismus.
  • Glaucoma (secondary, especially after surgery).
  • Retinal detachment.
  • Posterior capsule opacification.
  • Visual field defects.

Prevention

  • Maternal immunization (Rubella).
  • Genetic counseling for hereditary cases.
  • Avoidance of teratogenic drugs during pregnancy.
  • Good antenatal care.

Patient education

  • (To Parents/Caregivers):
  • Explanation of congenital/paediatric cataract.
  • Critical importance of early surgery for dense cataracts to prevent amblyopia.
  • Surgical procedure overview.
  • Need for optical correction (glasses/contacts/IOL).
  • Importance of long-term follow-up, patching therapy if needed.
  • Genetic counseling if indicated.
  • Support resources.

Uganda-specific notes

Congenital cataract is a significant cause of treatable childhood blindness. Early detection through red reflex screening is vital but may be inconsistent. Access to specialized paediatric ophthalmic surgery and post-operative care (contact lenses, amblyopia therapy) is very limited, primarily at tertiary centres.

Surgical Management

  • Cataract Surgery: Timing depends on laterality and density.
  • - Bilateral Dense Congenital Cataracts: Surgery usually within first 6-8 weeks of life.
  • - Unilateral Dense Congenital Cataract: Surgery often within first 4-6 weeks of life.
  • - Less dense/later onset cataracts: Surgery timing based on visual significance.
  • Optical Correction after Surgery:
  • - Intraocular Lens (IOL) implantation (often delayed in very young infants <6-12m).
  • - Aphakic glasses.
  • - Contact lenses (often preferred in infants).

References

  • Uganda Clinical Guidelines (UCG) 2023

    Chapter 20, Section 20.2.1.1

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