Immediate versus delayed sequential bilateral cataract surgery for paediatric congenital cataracts in a teaching institute: A comparative study

INTRODUCTION

Cataract remains one of the leading causes of treatable childhood blindness worldwide, with timely surgical intervention being critical to prevent amblyopia and optimise visual outcomes. Bilateral congenital cataract patients usually come at an early age for management. Most of the patients have associated systemic conditions which can pose difficulty for their anaesthetic fitness. Congenital cataracts need urgent surgical management.

Conventionally, bilateral cataracts are managed through delayed sequential bilateral cataract surgery (DSBCS), in which each eye is operated on separately, typically spaced days to weeks apart. In contrast, immediate sequential bilateral cataract surgery (ISBCS) involves operating on both eyes during the same surgical session under a single administration of anaesthesia. While ISBCS has gained acceptance in adult populations for its efficiency and convenience, its application in paediatric cases remains limited and somewhat controversial, particularly due to concerns over bilateral complications and refractive unpredictability.^[1–3] ISBCS was done whenever the child had a grave anaesthetic risk and socioeconomic considerations.

However, potential benefits of ISBCS, such as reduced hospital visits, minimised exposure to multiple general anaesthetics, faster visual rehabilitation and decreased risk of loss to follow-up, make it an attractive option, especially in resource-constrained settings.^[4–6]

Despite its growing relevance, evidence regarding ISBCS in children, particularly from low- and middle-income countries, is scarce and warrants further investigations.

The present study was undertaken to assess some of these issues in Indian children with bilateral developmental cataract.

MATERIALS AND METHODS

Children who underwent bilateral cataract surgery for congenital lens opacity were identified through the operative logs of a single surgeon Dr. Vaishali Lalit Une (VLU). All paediatric cataracts were taken up as early as possible after anaesthetic fitness for surgery. A retrospective review of medical records was conducted for patients who met the inclusion criteria: Diagnosis of bilateral congenital cataracts and having undergone surgery on both eyes at 5 years of age or younger, between the years 2019 and 2025. All consecutive cases were included in the said period. No case was postponed due to intraoperative and anaesthetic complications in the ISBCS.

Clinical data were extracted using a structured data collection form, which included variables such as (1) age at the time of diagnosis, (2) age at which surgery was performed, (3) type of refractive correction initially used postoperatively, (4) time interval between surgery and initiation of optical correction for each eye, (5) any intraoperative or postoperative adverse events and (6) best-recorded visual acuity (Snellen) closest to the child’s fifth birthday. To enable statistical analysis, all Snellen acuities were converted to logMAR values.

Routine post-operative follow-up was carried out on day 1, at 1 week and at 1 month, followed by visits every 3 months until the child reached the age of five. Based on the surgical timing, patients were categorised into two cohorts: Those who had simultaneous surgery and those who underwent sequential procedures. Caregivers were presented with both options following a comprehensive explanation of their respective advantages and risks, including the theoretical risk of bilateral endophthalmitis associated with immediate sequential surgery.

Following a comprehensive systemic and ocular assessment, including B-scan ultrasonography, eligible children whose parents provided informed consent were randomly allocated to either the ISBCS group or the DSBCS group. Randomisation was conducted using a computer-generated list of random numbers. Children presenting with other ocular pathologies such as microphthalmia, retinal detachment, intraocular inflammation, eyelid infections or surface disorders were excluded from the study. All surgeries were performed by a single experienced ophthalmic surgeon.

The study assessed various clinical and logistical outcomes, including the number of hospital visits, total hospital stay, operating room (OR) time, anaesthesia-related adverse events (categorised as minor or major), significant post-operative inflammation or endophthalmitis and refractive outcome at 6 weeks postoperatively. For bilateral procedures, values such as cost (including admission, surgical supplies or usage and anaesthesia charges), duration in the OR (measured from entry to exit) and hospitalisation were recorded as combined totals. Minor anaesthesia events were defined as those requiring additional medication or intervention, whereas major events included permanent morbidity or mortality. In the DSBCS group, data were also collected on the interval between surgeries and any cases of failure to return for the second procedure. Refractive error was measured by cycloplegic retinoscopy at 6 weeks, and spherical equivalent was calculated for analysis.

Both groups followed a standardised surgical and postoperative protocol. Intraocular lens (IOL) power was calculated using the Sanders-Retzlaff-Kraff (SRK) II formula, as it has shown reasonable accuracy in paediatric eyes. A 10% reduction in calculated IOL power was applied in children younger than 2 years to account for future myopic shift, while older children received the full calculated value, based on the rationale that maintaining near-emmetropia during the developmental years is more beneficial than precise adult emmetropia, especially given unpredictable refractive changes and limited follow-up adherence in low-resource settings. Strict surgical guidelines in compliance with international society of bilateral cataract surgeons(ISBS) guidelines were followed and the second eye was considered as a new case with a new set of operative instruments and consumables, with rescrubbing of the nurse and surgeon between both cases.

Pre-operative preparation included topical antibiotics before surgery. A standard sclerocorneal tunnel was used, with anterior capsulorhexis under sodium hyaluronate 1.4%, followed by hydrodissection and lens aspiration. In children under 6 years of age, a posterior capsulotomy with anterior vitrectomy was performed. IOL implantation was performed in children older than 6 months (using Rajendra Prasad Centre (RPC) AIIMS, New Delhi criteria for IOL implantation), aiming for in-the-bag placement; sulcus fixation was used when capsular support was inadequate. Subconjunctival injections of dexamethasone (0.25 mL of 0.4%) and gentamicin (0.25 mL of 4%) were administered postoperatively.

Figures 1-4 depict the preoperative, intraoperative and postoperative pictures of the representative cases. The postoperative medication regimen included topical tobramycin 0.3% and loteprednol etabonate ophthalmic suspension 0.5% 6 times daily for 6 weeks with tapering, cyclopentolate eye drops 2% twice daily. Systemic therapy included oral amoxicillin-clavulanic acid (40 mg/kg/day and 10 mg/kg/day, respectively) beginning 1 day before surgery and continuing for 4 days after.

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Figure 1: (a) White to white distance measurement done intraoperatively in a 9-month-old child. (b) Pre-operative profile photo of 9-month old-child presenting with bilateral congenital cataract. (c) Post-operative profile picture of child 1 showing pseudophakic reflex.

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Figure 2: (a) White to white distance measurement done intra- operatively in a 6-month-old child. (b) Profile photo of a 6-month-old child depicting aphakia. (c) White to white distance measurement done intraoperatively following surgical capsulotomy after 8 weeks post-operation.

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Figure 3: (a) White to white distance measurement done intraoperatively in a 4-year old child. (b) Examination under anaesthesia (EUA) being performed in a 4-year old child. (c) Post operative profile photo of 4-year old child showing pseudophakic reflex.

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Figure 4: (a) 2^nd day post operative picture of child showing pseudophakic reflex. (b) Profile photo of child post operatively. (c) Pre operative profile photo of child showing cataract.

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In ISBCS cases, strict measures were followed to prevent cross-contamination: Separate sterile surgical sets, viscoelastic agents and irrigation fluids were used for each eye and the surgical team rescrubbed and changed gowns between eyes.

Patients were admitted 24 h before surgery. Postoperatively, the hospital stay ranged from 3 to 4 days for DSBCS patients and 4–5 days for those in the ISBCS group. Follow-up evaluations were conducted daily for the first 3 days and subsequently at 2 and 6 weeks. Refractive outcomes were assessed at 6 weeks. For DSBCS patients, a follow-up appointment was scheduled 4 weeks after the first surgery to perform the second-eye procedure.

Continuous variables were summarised using means and standard deviations.

RESULTS

A total of 50 paediatric patients diagnosed with bilateral congenital cataract were enrolled in this study, with 25 patients undergoing ISBCS and 25 undergoing DSBCS. The baseline demographics [Table 1], including age at surgery (mean 31 ± 2 months in ISBCS vs. 31 ± 2 months in DSBCS (youngest being of 8 weeks and oldest of 5 years), gender distribution and pre-operative axial length and keratometry values, were comparable between the groups (p > 0.05).

DISCUSSION

This study aimed to compare the outcomes of ISBCS and DSBCS in paediatric patients with bilateral congenital cataracts. Our findings suggest that ISBCS offers significant logistical, economic and clinical advantages without increasing the risk of major post-operative complications when performed under strict aseptic protocols.

A major benefit observed with ISBCS was the reduction in the number of hospital admissions, cumulative hospital stay and overall procedural cost. These findings are consistent with previous reports in both adult and paediatric populations, where ISBCS has been associated with decreased healthcare utilisation and improved cost-effectiveness, particularly in government hospitals and resource-limited settings.^[1–3] For families, ISBCS can alleviate the burden of repeated hospital visits, reduce parental work absenteeism and accelerate the child’s return to visual rehabilitation and developmental milestones.

From a clinical perspective, ISBCS potentially shortens the time to binocular vision development and avoids the inter-surgical period of anisometropia, which has been shown to negatively impact visual outcomes and neurodevelopment in young children.^[4,5] In our cohort, refractive outcomes at 6 weeks postoperatively did not significantly differ between groups, which aligns with previous research demonstrating that refractive stability and accuracy are not compromised by performing both surgeries in a single sitting.^[8]

One of the primary concerns with ISBCS has historically been the risk of bilateral endophthalmitis – a rare but devastating complication. However, this risk can be effectively minimised through rigorous surgical protocols, including the use of separate instrument trays, viscoelastic materials and repeat scrubbing between eyes, as adopted in our study.^[2,9] No cases of endophthalmitis or severe bilateral inflammation were observed, supporting the growing consensus that the procedure is safe when conducted under controlled conditions.

Another significant concern is the refractive predictability in paediatric eyes, which are more prone to myopic shift due to ocular growth. While some studies have questioned the long-term refractive outcomes in ISBCS due to the lack of an opportunity to adjust IOL power based on the first eye’s result, our use of the SRK II formula with age-appropriate modifications and conservative IOL power selection helped mitigate this issue.^[10] The refractive accuracy was comparable between groups, echoing findings from prior paediatric cataract studies.^[11]

Importantly, in the DSBCS group, a small proportion of children failed to return for second-eye surgery or experienced delays of several weeks. This is a well-documented limitation of the delayed approach and is particularly concerning in populations with socioeconomic barriers to consistent follow-up, as such delays can increase the risk of amblyopia in the untreated eye.^[12]

Despite these promising findings, our study has several limitations. As a single-centre retrospective analysis, it may be subject to selection bias and limited generalisability. Long-term visual and refractive outcomes were not assessed as parents were not compliant with follow-up visits, possibly due to economic constraints.

CONCLUSION

ISBCS appears to be a safe and efficient alternative to DSBCS in appropriately selected paediatric patients when performed under stringent aseptic conditions. Given its potential to improve access to timely care and reduce healthcare burdens, ISBCS may be particularly advantageous in developing countries and public health systems with limited resources. Further multicentre, randomised controlled trials are warranted to validate these findings and inform standardised guidelines for paediatric cataract surgery.