AAPOS 2025: Study assesses outcomes and offers management recommendations for the treatment of cataracts in pediatric patients with developmental delays
The American Association for Pediatric Ophthalmology and Strabismus Annual Meeting recently took place in Salt Lake City, Utah. Yoav Glidai, MD, of Boston Children’s Hospital, spoke with Ophthalmology 360 about a study he presented at the meeting, titled “Challenges and Outcomes in Surgical Management of Cataract in Patients with Developmental Delays.”
Yoav Glidai, MD:
My name is Dr. Yoav Glidai. I’m originally Israeli, and I completed my training in ophthalmology in New York, at Northwell Eye Institute and Manhattan Eye and Ear Hospital. I’m a pediatric ophthalmology fellow at Boston Children’s Hospital in Boston.
Cataract is a haziness of the natural intraocular lens. When it happens in kids, it’s a significant problem because vision keeps developing through childhood. When we’re born, we don’t have good vision, and we only get to 20/20 vision when we’re about 5 years old. Vision continues to develop until we’re about 10 years old. For that to happen, the eye needs a clear visual axis. When there’s a cataract, it prevents the development of good vision.
In young kids, cataracts can be either congenital or acquired. When it’s congenital, it’s most commonly sporadic and happens in one eye because of a development failure in utero. When there’s a bilateral congenital cataract, there’s a higher chance of having a familial genetic predisposition, systemic condition, or an infection during the pregnancy that caused that. In older kids, cataracts are most commonly due to trauma, intraocular inflammation, or associated with a syndrome or systemic condition. That can also occur in both eyes together. The prevalence of congenital cataracts is about 0.01% of the whole population. The prevalence may be up to 0.5% in older kids in specific populations.
Our study, which delves into the outcomes of cataract surgery in children with developmental delays, is a unique and pioneering endeavor. It stands out due to its incorporation of 30 years of collective experience, a feat that hasn’t been achieved in previous studies. Managing intraocular surgery in children with developmental delays presents significant challenges, and our study aims to shed light on this underexplored area. While cataract surgery is generally safe, even with an experienced surgeon, there are always rare risks that can be devastating. These include intraocular infections and retinal complications that can cause vision loss. My study was mentored by Dr. Deborah Vanderveen of Boston Children’s, an outstanding surgeon who has gained much experience over her many years in practice.
Many surgeons may worry about performing cataract surgeries on individuals with developmental delays because of communication gaps with them or concerns about combative or self-injurious behavior. Over those 30 years of experience, we describe lessons learned and modifications made in our perioperative management of these patients. The study includes about 150 eyes, with an average age at the time of the surgery of about 10 years and an average follow-up of 5 years.
We found that the rate of adverse events was about 10% in that population. 4% had mild adverse events such as elevated intraocular pressure or a minor infection treated with drops that did not cause vision loss. The other 6% had severe adverse events that were vision-threatening or led to vision loss. These included retinal complications, retinal detachment, and uncontrolled inflammation leading to retinal detachment. This rate of adverse retinal events is comparable to previous studies on pediatric populations without developmental delays.
Our study also revealed encouraging results. We found that in verbal individuals with measurable visual acuity, there was a significant visual improvement in over 80% of patients. This is particularly significant for children with developmental delays, as it signifies a substantial enhancement in their quality of life and their ability to communicate and interact with the world. For those children who did not experience improved vision, it was often due to other ophthalmic issues that hindered their progress.
We did find that there’s a higher risk of complications in kids that are nonverbal or minimally verbal and patients that exhibited combative or self-injurious behavior. We also showed that kids with complete cataract, when their cataract is dense and white, have a higher risk of complications. One of the nicer things about our study is that we detailed modifications that help manage these patients. For example, surgical techniques such as scleral tunnel, which is reserved for younger kids, were also used for older patients, depending on their behavior.
In addition, we inject steroids intraoperatively because some of these patients are averse to the use of eye drops. Using those antibiotics and steroids inside the eye during the surgery likely protects our kids from developing infections or uncontrollable inflammation in the eye. We also started using combination drops, drops that have steroids and antibiotics in them, instead of using two different kinds of drops, which is helpful for both patients and parents.
We also found that having a behavioral plan in place is very helpful. It is important to make sure that the parents can accompany the kid into the operating room until they fall asleep, if possible, or that they are in the recovery room before they wake up. Also, having a child life specialist come to the bedside and help entertain and distract the kid is important. They have tablets, games, and coloring activities. They really are so helpful in managing these patients.
After cataract surgery, the kid needs to wear protective eyewear, an eye shield during the night, and protective eyewear during the day so they don’t rub the eyes or open the wounds. It is really difficult to communicate with some of these kids. Having the parents practice using eyewear before the surgery, with sport goggles or swimming goggles, can happen weeks in advance and really prepares the child. In some cases, we even used arm restraints for the kids, especially in the first 24-48 hours and up to a week, when the wound of the cataract surgery is still fresh, and it’s more dangerous to rub the eyes.
Our study underscores the importance of a tailored approach to patient care. Communicating with the parent, listening, and learning the child’s behavior in advance are crucial steps. Observing how the child behaves in the clinic can provide valuable insights, helping to anticipate potential challenges and devise an effective behavioral plan. Ultimately, a tailored plan for each patient is the key to preventing complications and ensuring successful outcomes from cataract surgery in this patient population.
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