and early human studies.

Lens implantation in children requires a compromise that accounts for the age of the child and the target refraction at the time of surgery. There are 2 approaches to this situation. Some surgeons implant IOLs with powers that are expected to be required in adulthood, allowing the child to grow into the selected lens power. Thus, the child is undercorrected and requires hyperopic spectacles or contact lenses of decreasing powers until the teenaged years. Other surgeons aim for emmetropia at the time of lens implantation, especially in unilateral cases, believing that this approach may reduce the risk of amblyopia and facilitate development of binocular function by decreasing anisometropia in the early childhood years. These children can be expected to become progressively more myopic with time, and they may eventually require a secondary procedure in order to eliminate the increasing anisometropia.

Postoperative Care

Medical therapy

If all cortical material is adequately removed, postoperative inflammation in children without a lens implant is usually mild. Postoperative topical antibiotics, corticosteroids, and cycloplegics are commonly applied for a few weeks. Topical steroids should be used more aggressively in children who have undergone IOL implantation. Some surgeons administer intracameral steroids postoperatively, and others use oral steroids, especially in very young children and children with heavily pigmented irides. Some surgeons administer intracameral antibiotics in addition to topical antibiotics.

Amblyopia management

Amblyopia therapy should begin as soon as possible after surgery. For aphakic patients, corrective lenses—in general, contact lenses for unilateral or bilateral aphakia, spectacles for bilateral aphakia —should be dispensed within 1 week of surgery.

For infants with bilateral aphakia, spectacles are the safest and simplest method of correction. They can be easily changed to accommodate the refractive shifts that occur with growth of the eye. Until the child can use a bifocal lens properly, the power selected should make the eye myopic, because most of an infant’s visual activity occurs at near. Contact lenses may also be used in bilaterally aphakic patients, but they require more effort on the part of both the caregiver and the physician than do spectacles.

For infants with unilateral aphakia, contact lenses are the most popular method of correction. Advantages of contact lenses include relatively easy power changes and the potential for extended wear with certain lenses. Disadvantages include easy displacement by eye rubbing, the expense of replacement, and the risk of microbial keratitis. Aphakic spectacles are occasionally used in infants with unilateral aphakia who are unable to tolerate contact lenses, but these spectacles are suboptimal owing to the amblyogenic effect of aniseikonia and the difficulty of wearing glasses that are much heavier on one side.

After optical correction of aphakia, patching of the better eye is almost always necessary in patients with unilateral cataract and in some patients with bilateral cataracts if the visual acuity is asymmetric. The amount of patching is titrated based on the degree of amblyopia and the age of the child. Parttime occlusion in the neonatal period may allow stimulation of binocular vision and may help prevent associated strabismus.

Complications