Congenital or Acquired Cataracts in Children

A cataract is a medical condition of the eye, which results in a cloudy, painless area in the lens of the eye. The cloudy patch blocks the passage of light to the retina causing problems with the vision. Cataracts commonly occur in adults and rarely in babies and children. However, a child can be born with a cataract due to genetics, low birth weight or infection during pregnancy. This condition is known as congenital cataract. Around 5% to 20% of blindness in children all over the world occurs due to congenital cataracts. Cataracts in children can be congenital, i.e. present at birth or can later on develop in a child’s life (acquired cataract). Cataracts can affect one eye (unilateral) or both the eyes (bilateral).

The sooner the cataracts are diagnosed and treated, the greater the chances of preservation of the sight and its normal development. The vision of the baby develops very fast in the first few months of its life. If a child has cataract, then it blocks the light from reaching the eye and fails to stimulate the retina; and because of this, the region of the brain which is used for sight does not develop properly leading to amblyopia (lazy eye). If surgery is not done in the initial few months of the child’s life, then the child will not be able to see well with that eye ever, even if he/she gets a surgery done later in life.

Treatment comprises of surgery, eye drops, glasses and contact lenses.

• If the cataract is mild, then the child can be asymptomatic and the condition can go undiagnosed for years.
• The child does not react to light and may have photophobia to bright lights.
• A child may not respond or directly look at faces, large and colorful objects.
• An infant with cataract may not be able to find small objects on the floor when crawling.
• The child with cataract tends to excessively squint, scowl or shield the eyes when in bright sunlight.
• The child can develop strabismus, i.e. the eyes can be misaligned and do not focus on the same point at the same time.
• In photographs, the child with cataract may have white reflex instead of a red reflex, such as one eye can appear white, whereas the other eyes will have the normal “red eye” look.
• There may also be nystagmus in the affected eye of the child, that is, the eye will have repetitively wandering movements. This is commonly a later sign of cataracts and tends to develop when the infant is many months old. At this point, the chances of correcting the vision loss after removing the cataract are very less.
• Unilateral cataracts in a child often go undetected by parents.
• A child with cataract may also have other eye problems, such as megalocornea, microcornea, aniridia, coloboma of the iris and zonular dehiscence.
• An older child with cataract will complain of cloudy, blurry, decreased or double vision.
• The child with cataract is not able to see colors of objects properly and they appear dull or faded.
• The child is not able to tolerate bright lights and they appear even brighter with halos or glares due to cataract.
• Children should have regular eye exams by an ophthalmologist and screening for detection of cataracts.
• Contact your pediatrician immediately if your child has one eye with red reflex and one eye with white reflex, as the one with white reflex may have a cataract.
• Contact your pediatrician immediately if the baby does not respond readily or look directly at faces and large, colorful objects by the time he/she is 3 to 4 months old.
• Contact your pediatrician immediately if the child excessively squints, scowls, or shields his/her eyes in bright sunlight.
• Contact your pediatrician immediately if light hurts or causes photophobia in your child.

Cataracts cause opacity or clouding of the natural lens of the eye. This condition commonly occurs as a natural aging process. However, cataract developing in newborn babies is known as congenital cataract and this happens for a lot of reasons, such as it can be genetic, due to infection in pregnancy, diabetes, metabolic problems, trauma, reaction to certain medications and inflammation.

• If the mother during pregnancy develops infection and is treated with tetracycline antibiotics, then it can cause cataracts in newborn babies.
• If the mother during pregnancy develops infections, such as rubella, measles, cytomegalovirus, chicken pox, herpes zoster, herpes simplex, influenza, poliomyelitis, syphilis, Epstein-Barr virus, and toxoplasmosis, then it can cause congenital cataract in a new born child. These same reasons can cause acquired cataracts in older babies and children too.
• Any trauma or injury to the eye is the commonest underlying cause in about half of the older children developing cataracts (acquired).
• Congenital cataracts can be caused by improper formation of the lens. This occurs as a result of abnormalities in the interaction of the protein formation, which is essential for maintaining transparency and formation of lens. This results in formation of clumping and specks which create the opaque cloudy areas in the eye.
• In around 35% cases of pediatric cataracts, the children were actually born with congenital cataracts which were overlooked or left undiagnosed for a long time.
• Eye trauma, poisoning and steroid use can also cause acquired cataracts in a child.
• Childhood diseases, such as rheumatoid arthritis can cause acquired cataract in children.
• Radiation therapy after cancer can also cause cataracts in children (acquired).
• Metabolic diseases can also cause cataracts in children.

• Anterior polar cataracts are situated in the front part of the eye’s lens and they are well defined cataracts. These types of cataracts are commonly related to inherited features. These are very small cataracts and surgical intervention is not usually required.
• Posterior polar cataracts are located in the back portion of the eye’s lens and they also are well defined.
• Cerulean cataracts appear as small and bluish dots on the lens. They are commonly present in both eyes of infants. Usually, cerulean cataracts do not cause any vision problems. Cerulean cataracts also tend to be associated with inherited traits.
• Nuclear cataracts are a very common type of congenital cataracts and they are located in the central part of the eye lens.

If treatment is not done immediately, then congenital cataracts can cause amblyopia (lazy eye). This condition can then further lead to other eye problems, such as strabismus, nystagmus which causes inability to focus on one point. These problems can affect a child’s personality, his/hers learning ability and appearance. The complete life of a child is affected due to these problems; so, because of these reasons, it is important to get your child’s eyes regularly examined and immediately after the baby is born.

Congenital cataracts are often detected at birth or during well-baby checkups. If the child has other medical problems, which increase the risk of an acquired cataract, such as diabetes or rheumatoid arthritis, then frequent eye exams are needed for such a child for early detection and treatment of cataracts.

There are different treatment options for cataracts in children. If the child is visually affected, then surgery is the only option left. Replacing the natural lens of the eye with an artificial lens may sound scary, but it is a very routine and safe procedure and a child can recover easily from it.

If detected and treated early, children with congenital cataracts are able to live a normal life. Depending on the severity of the cataract and the age of the child, options for treating cataracts include:

• Surgery is done to remove the opaque or cloudy lens and it is replaced with an artificial lens.
• Patient can wear glasses or contact lenses.
• A combination of the above treatments can also be used.
• If the congenital cataract is very dense, then it is advisable to remove the cataract within 2 months and should not exceed more than 4 months. The sooner the cataract is removed, the better is the prognosis for good long-term vision.
• Like mentioned before, children who are having problems with vision due to cataracts need to have surgery in order to prevent permanent vision loss and to ensure that they will continue to have development of normal vision.
• Eye drops can be used for some children as a temporary measurement. These eye drops will dilate the pupil thus increasing the amount of light entering into the eye and retina. These eye drops also help in preventing loss of vision in infants and young children who are required to wait for surgery.

There are some types of cataracts in children which need treatment and surgery immediately and these are:

• Unilateral congenital cataracts, which are large and dense and are located in the middle of the lens and are more likely to cause vision loss, which is permanent. It is very important that these types of cataracts are diagnosed and treated early to prevent lasting vision loss and they will need to be removed immediately.
• Unilateral smaller cataracts, which do not cause significant loss of vision, can be treated by patching the good eye. This will strengthen the vision in the affected eye with the cataract.
• As mentioned before, eye drops which dilate the pupil can also be used to increase the amount of light entering the eye. This will help in preventing vision loss until the surgery is done or in case the surgery needs to be delayed in infants or young children.
• Bilateral congenital cataracts, which cover only a part of the lens, are least likely to cause vision loss or blindness. These cataracts need regular exams by an ophthalmologist to check whether they are increasing in size.
• Other coexisting eye problems, such as nystagmus, amblyopia, will persist even after removing the cataract and they need to be treated as well.

The prognosis of children with congenital cataracts is good if treated early, i.e. within the first two months of the child’s life. The prognosis becomes very poor if the cataract is left untreated and the chances of permanent vision loss are more. Children with acquired cataracts, i.e. cataracts which develop after a few months of birth or later in life, have a better prognosis as there is already some visual development occurred. Certain types of cataracts need immediate surgery with lens implantation. This is a routine and almost painless type of surgery. Long-term patching is needed restore the vision completely.