Childhood cataracts are caused by malnutrition, low birth weight, neonatal complications such as hypoglycemia and hypophosphatemia, intrauterine infections such as rubella, and genetic variations. If one looks closely, all of these entities are common in the Indian scenario. A child’s average birth weight in India is around 2.8 kg, compared to 3.5 kg in the developed world. Low-birth-weight babies are more likely to develop complications in the early neonatal period. This can result in cataract formation. “Similarly, in children, recurrent episodes of diarrhoea or other systemic illness can lead to developmental cataract. Although maternal infections during pregnancy are becoming less common, they remain a significant cause of cataract in children. Genetic causes of cataract are also common in India due to the presence of consanguinity and local breeding among several populations,” says Dr Shailja Tibrewal, Senior Consultant, Department of Pediatric Ophthalmology, Strabismus, and Ocular Genetics, Dr Shroff’s Charity Eye Hospital, New Delhi.

Causes of cataract in children

Dr Tibrewal notes shares the causes of a child’s cataract:

• Genetic variations (mutations) in the genes involved in lens formation, resulting in defective proteins and subsequent lens opacification.
• Infections in the mother during pregnancy, particularly in the first three months. The TORCH group of infections is among these (toxoplasma, rubella, cytomegalovirus and herpes). During pregnancy, they manifest as fever with or without rashes.
• Injury to the lens of the eye caused by blunt or penetrating trauma is also very common in children and, in the majority of cases, results in traumatic cataract.
• Down’s syndrome, Lowe’s syndrome, galactosemia, hypocalcemia, juvenile rheumatoid arthritis, and diabetes are all linked to childhood cataracts.
• Childhood cataract may be seen in conjunction with other eye development abnormalities such as persistent foetal vasculature, aniridia, and anterior segment dysgenesis, where it is part of a larger developmental anomaly.
• Long-term indiscriminate use of some eye drops (steroids) can lead to cataract.
• Low birth weight is also associated with an increased risk of childhood cataract.

Some symptoms parents should watch out for?

A childhood cataract can occur at birth or develop at any time during childhood. When a child is very young and unable to communicate his or her vision problems, detection of the problem is frequently delayed. “Cataracts that are extremely dense can be seen as a whitish reflex in the centre of the eye (pupil). When a dense cataract is present from birth, the eyes may be unable to remain stable and begin shaking, resulting in an abnormal movement of the eyes. An attentive mother will notice that the child is unable to make eye contact or smile while looking at the mother’s face, which is normal after 2-3 months of age,” adds Dr Tibrewal.

Reduced vision in an older child may cause difficulty walking, getting close to watch television, and bringing objects closer to the face to see. Children are frequently unable to express their visual issues. Some children may withdraw from social activities, avoid playing with friends, and become scared or uncomfortable in unfamiliar surroundings as a result of poor vision. Cataracts may be detected in school-aged children during eye health screening activities. Older children may inform their parents about their reduced vision or difficulties with schoolwork, which should not be ignored, and immediate professional assistance should be sought.

How is cataract detected in children?

A cataract can be detected by an eye doctor or eye care professional using a variety of tests. The Arclight or direct ophthalmoscope is a simple screening tool that can detect any obstruction to light entering the eye. “A reduction in the red glow produced by the normal retina indicates such an obstruction (back of the eye). To confirm the presence of a cataract, the doctor dilates the pupil with eye drops and examines the patient carefully with a slit lamp biomicroscope,” says Dr Tibrewal.

How is childhood cataract different from adult cataract?

Childhood cataract differs from adult cataract in terms of aetiology, impact on patients’ lives, consequences of not treating, and management strategies. As previously stated, events during the child’s birth and development are closely related to cataract formation. Better maternal and child nutrition and health may reduce the prevalence of childhood cataracts overall. Dr Tibrewal feels childhood cataract may be associated with other systemic problems that require referral and treatment as well. The majority of cataracts in adults are caused by the ageing process. When compared to adult cataracts, childhood cataracts add many disability years. If the child is not treated, the disease will follow him or her throughout his or her life.

Blindness and untreated visual impairment have a negative impact on a child’s overall motor and social development. It also has an impact on their education, occupation, and productivity, resulting in a larger socioeconomic impact. “Long-term untreated paediatric cataract can result in amblyopia (lazy eye). When the developing retina and brain are deprived of high-quality images, the eye-brain connection fails to develop properly. This results in amblyopia, or lazy eye. Once this occurs, no amount of cataract surgery will be able to completely restore vision,” says Dr Tibrewal. Amblyopia can be reversed in children as young as 10 years old with the right therapy. However, as people get older, their response to treatment diminishes. As a result, it is critical to treat paediatric cataract as soon as possible.

In terms of management, paediatric cataract surgery necessitates additional steps to avoid recurrence (after-cataract or visual axis opacification). If these extra steps are not taken by trained surgeons, visual axis opacification will occur in 100% of the cases. Unlike adults, children will always need glasses after surgery. This is because the child’s growing eye will change in size as he or she grows older. As a result, despite the insertion of an intraocular lens, the child may require small glasses to achieve the clearest vision possible. As previously stated, amblyopia may require treatment following surgery. Thus, repeated check-ups and evaluations are required for years after surgery to maintain good vision quality.

How is cataract in children treated?

Currently, the only treatment option for childhood cataract is surgery. To remove the cataractous lens, microincision surgery is used. To replace the cataract, an intraocular lens is implanted. Despite microincision cataract surgery, sutures may be required for safety. To avoid complications, the intraocular lens is sometimes not implanted in the eye when the eyeball is small. In such cases, the child will require high-powered glasses following surgery. When the eye reaches the appropriate size, the intraocular lens can be implanted. Regular follow-up is required to ensure the best possible outcome.

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