What investigations are needed perioperatively for cataract surgery in a child?

Perioperative Investigations for Pediatric Cataract Surgery

For pediatric cataract surgery, essential perioperative investigations include optical biometry for IOL power calculation, comprehensive ocular examination with assessment of posterior segment pathology, evaluation for underlying systemic etiologies (particularly TORCH infections, genetic syndromes, and metabolic disorders), and assessment of the child's ability to cooperate with postoperative care and visual rehabilitation.

Preoperative Ocular Investigations

Biometry and IOL Calculations

• Optical biometry is the preferred method for IOL power calculation over ultrasound techniques 1
• Accurate axial length measurement is critical, as pediatric eyes undergo significant axial growth postoperatively, with myopic shifts of -2.9 D in aphakes and -4.53 D in pseudophakes over 1 year 2
• Predicting axial growth and refractive changes based on age at surgery is essential for long-term planning 3

Comprehensive Ocular Assessment

• Optical coherence tomography of the macula to rule out concurrent retinal pathology that may limit visual potential 4
• Corneal topography/tomography to assess for corneal irregularities affecting surgical planning 4
• Evaluation of the posterior segment when possible, as lens opacity may interfere with optimal diagnosis of posterior pathology 5
• Assessment for concurrent ocular abnormalities including glaucoma, microphthalmia, or persistent fetal vasculature 6, 2

Etiological Workup

Infectious and Systemic Causes

• TORCH (Toxoplasmosis, Rubella, Cytomegalovirus, Herpes) screening is mandatory, as these infections represent the most common etiology in both unilateral (47.6%) and bilateral (55.1%) pediatric cataracts 2
• Genetic and syndromic evaluation, particularly in bilateral cases with family history 2, 3
• Metabolic screening when indicated by clinical presentation 2

Preoperative Medical Assessment

General Health Evaluation

• Assessment of the child's mental and physical status, including ability to cooperate with surgery and postoperative positioning 5, 1
• Routine preoperative laboratory testing is not indicated for cataract surgery unless directed by specific medical comorbidities 1
• Evaluation by primary care physician only for children with significant systemic conditions (poorly controlled diabetes, cardiac conditions, pulmonary disease) 1

Anesthesia Planning

• Assessment for safe administration of general anesthesia, which is universally required in pediatric cases 5
• Review of any contraindications to anesthesia based on systemic health 5

Age-Specific Considerations

Timing and Risk Stratification

• Children undergoing surgery before 8 weeks of age have significantly higher complication rates (P < 0.025), requiring more intensive monitoring 6
• Infants under 6 months represent 76% of cases and require special attention to postoperative glaucoma surveillance 2
• Age at surgery directly correlates with axial growth rate and long-term refractive outcomes 3

Postoperative Planning Assessment

Visual Rehabilitation Capacity

• Evaluation of family's ability to provide optimal aftercare and refractive rehabilitation, particularly critical for aphakic management 2
• Assessment of barriers to communication with caregivers, including language or hearing impairment 1
• Planning for aggressive amblyopia treatment, especially in unilateral cases where visual outcomes are significantly worse (mean logMAR 1.00 vs 1.21, p=0.012) 2

Glaucoma Surveillance Protocol

• Baseline intraocular pressure measurement and anterior segment assessment, as glaucoma develops in 11% of cases postoperatively 6
• Children operated early in life require routine lifelong examination for postoperative glaucoma 6

Common Pitfalls to Avoid

• Failing to screen for TORCH infections, which are the predominant cause and may affect surgical planning and visual prognosis 2
• Inadequate counseling about the high risk of visual axis opacification (most common complication in pseudophakes) and glaucoma (most common in aphakes) 2
• Underestimating the myopic shift in IOL power calculations, particularly in younger children 2, 3
• Not establishing realistic expectations with parents, as functional outcomes remain unpredictable despite satisfactory technical outcomes 3