Volume 7, Issue 6, June – 2022 International Journal of Innovative Science and Research Technology

ISSN No:-2456-2165

Childhood Cataract: A Socio-Clinical Study

at a Public Sector Tertiary Eye Care Centre in India
Deepak Jugran
Ph.D. Scholar Panjab University,
Chandigarh, India-160012

Abstract:- detection, diagnosis and management. The childhood

Purpose: To study the demographic, sociological and cataract is an emerging and major cause of preventable
clinical profile of the children presented for childhood and avoidable childhood blindness, especially in low and
cataract at a public sector tertiary eye care centre in middle-income countries. In the formative years, the
India. children require a sound physical, mental and emotional
state and in the absence of either one of them, it can
Methodology: The design of the study is retrospective severely dent their future growth. The recent estimate
and hospital-based. Data available with the Central suggests that India could suffer an economic loss of
Registration Department of the PGIMER, Chandigarh US$12 billion (Rs. 88,000 Crores) due to blindness and
was used. The majority of the childhood cataract cases almost 35% of cases of blindness are preventable and
are being reported in this hospital, yet not each and avoidable if detected at an early age. Besides reporting
every case of childhood cataract approaches PGI, these results to the policy makers, synchronized efforts
Chandigarh. Nevertheless, this study is going to be are also needed for early detection and management of
pioneering research in India covering five-year data of avoidable causes of childhood blindness such as
the childhood cataract patients who visited the Advanced childhood cataract.
Eye Centre, PGIMER, Chandigarh from 1.1.2015 to
31.12.2019. The SPSS version 23 was used for all Keywords:- childhood cataract, WHO, blindness, NPCB,
statistical calculations. Ayushman Bharat.

Results: 354 children were presented for childhood I. INTRODUCTION

cataract screening and treatment from 1.1.2015 to
31.12.2019. Of 354 children, 248 (70%) were male, and The visual system is one of the most important sensory
106 (30%) were female. Further, out of these 354 organs of the human body.1 As per the estimates; almost 1.4
children registered in the special clinics, 42 were million children are blind in the world, with a majority
incorrectly registered for childhood cataract. Therefore, living with socio-economic deprivation and inaccessibility
the final number children registered in 5 yearswas 312. to proper nutritional and medical care. As a result, they are
Despite two flagship programmes by the Govt. of India, more likely to have infectious diseases and malnutrition,
namely the National Programme for Control of leading to delayed cognitive development, frequent
Blindness (NPCB) and Aayushman Bharat (PM-JAY), hospitalization and death within the first year of their birth.2
for eradicating cataract-related blindness, only nine Nearly 20% of the childhood blindness is caused by
children received financial assistance from the Govt of childhood cataract, with almost 60% of blind children dying
India and only 1 from Ayushman Bharat (PM-JAY). Out within the first year of their birth and the rest of them live a
of 312 patients, 99 children (31.73%) reached late at the miserable 40 years without vision.3,4 Cataract is one of the
hospital, and 39 children did not continue their major causes of childhood blindness and causes more
treatment, mainly due to poverty and transport-related disability in children, compared to any other form of
issues. A whopping 99% of these children belong to low- preventable blindness. Blindness in children can have
income families. Out of 39 children who discontinued devastating effects on their quality of life and on the socio-
their treatment, 24 were male, and 15 were female. In economic condition of the family and society. Childhood
most of these families, the mothers were housewives and cataract, if left untreated, can result in severe visual
did not work anywhere. We intend to convey these impairment, including blindness.5
results to the Govt. of India to evolve a suitable
mechanism to address pertinent issues hindering the World Health Organization (WHO) has prioritized
treatment of children suffering from childhood cataract. childhood blindness from cataract as a priority area and has
Further, the disproportionate ratio of male and female urged all the countries to develop institutionalized
mechanisms to tackle this menace threatening the sight of
children in this study is an area of concern as it is
difficult to assess whether the prevalence of childhood the children, especially in the low and middle-income
cataract is lower in female children or they are not being countries.6 In developed countries, institutional mechanisms
presented on time in the hospital by the families. are in place for infantile screening for the detection of
congenital diseases that include childhood cataract and
Conclusion: The World Health Organization (WHO) has retinopathy of prematurity (ROP). All over the world,
categorized Childhood blindness resulting from cataract midwives, primary health care workers and pediatricians
as a priority area and urged all member countries to remain the first contact with the child, but due to limited
develop institutionalized mechanisms for its early number of ophthalmologists in developing countries, the

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Volume 7, Issue 6, June – 2022 International Journal of Innovative Science and Research Technology
ISSN No:-2456-2165
reporting and presentation of childhood cataract often gets II. CLASSIFICATION OF CHILDHOOD CATARACTS
delayed. Since the detection and surgical management of
childhood cataract is difficult and requires specialization, The lens in the human eye has unique properties as the
therefore, there is an urgent need to develop artificial addition of new cells is continuous throughout the life-time
intelligence-based systems for paramedical staff, primary of an individual. The growth of the human lens takes place
health care physicians and midwives to look for childhood in two phases; the asymptotic phase and linear growth
cataract in their routine screening of children after birth. It phase. The asymptotic growth starts during the gestational
is, therefore, important for us to sensitize parents, primary period and lasts up to 3 months after birth and the linear
care physicians, community health care workers, growth phase starts soon after. Due to this biphasic lens
anesthesiologists, ophthalmic technicians and low vision growth, two different and distinct compartments are formed
rehabilitation technicians to closely coordinate with all within the lens. The lens nucleus is formed during the
stakeholders to minimize the extent of childhood blindness prenatal period followed by an ever-expanding cortex with
leading from pediatric cataracts. unique physical and biochemical properties during the linear
growth phase.5

The classification and pattern of childhood cataract can

provide better insights for management and surgical plan. It
is, therefore, desirable to describe the location, layer, density
and pattern of the lens opacities. Once the morphology is
decided, then ophthalmologists can describe its etiology and
associations. Broadly, the childhood cataract can be
classified using three categories; based on age, etiology and
morphology (Table 1).6

Classification of childhood cataracts

Age of onset Etiology Morphology
Congenital Cataract Genetic/hereditary Diffuse/Total Cataract
Secondary cataract Secondary Nuclear Cataract
- Inflammation/
Uveitis
- Traumatic
- Intrauterine
- Iatrogenic
Polar Cataract
- Anterior polar cataract
- Posterior polar cataract
Lamellar Cataract
Nuclear Combined with cortical
- Coral like
- Dust like
- Blue dot
Cortical Cataract
Y-suture Cataract
Table 1: Classification of childhood cataract based on Age of Onset, Etiology and Morphology

A. Age of Onset its etiology and systemic associations may prove

As per the definition, a cataract present at birth, or beneficial before the cataract extraction. Anterior
developing after birth but before 16 years of age is termed as polar, persistent hyperplastic primary vitreous
a childhood cataract.5 The lens in the human eye is (PHPV), central nuclear and posterior polar cataract
composed of avascular transplant tissue with unique protein suggest a congenital onset.7
composition and cellular structure. The function of this
lens, in combination with the cornea, is to focus the image b) Developmental cataract
on the retina. Its ability to change the shape and These cataracts are mostly acquired after birth. All
transparency are the key factors in the production of a clear cataracts with onset in childhood, after infancy,
and focused image on the retina. It can further be divided irrespective of their underlying etiology can be
into two categories based on age. classified as ‘developmental cataract’. 8

a) Congenital cataract
The presence of lens opacity at the time of birth
indicates its congenital onset. However, its diagnosis
even at a later stage does not rule out its congenital
onset. The detailed examination of the lens opacity,

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Volume 7, Issue 6, June – 2022 International Journal of Innovative Science and Research Technology
ISSN No:-2456-2165
B. Etiology d) Traumatic Cataract
The transparent fibres in the lens are known as crystallin Traumatic cataract remains a major challenge in low
and the nucleus of the lens is layered with fibres, resembling and middle-income countries (Figure 1). The
the layers around the onion. As a result of continuous traumatic cataracts are not uncommon in boys due to
expansion during the lifetime of an individual, the lens their exposure to hazardous working condition,
becomes rigid and loses its innate ability to change shape, unhygienic living conditions, playing unconventional
causing visual problems. games, cracker burning and fights with fellow
friends.
a) Genetic/hereditary
In the majority of the cases, etiology of the cataract is e) Intrauterine infections
not known and is classified as “idiopathic”.5 Among many reasons, intrauterine infections such as
However, congenital cataract has also been linked to toxoplasmosis, rubella, cytomegalovirus and herpes
mutation in genes linked with lens development. (TORCH) is some of the major causes in low and
While most of these genes are dominantly inherited, middle-income countries due to their high prevalence
but cases with autosomal recessive or x-linked and require strict vaccination programmes for mother
inheritance have also been reported.7 With recent and child.10
advancements such as next-generation sequencing,
researchers are trying to find out the exact cause of f) Iatrogenic
congenital cataracts, but it is still in its preliminary In the last few years, we have seen an increased
stages and will require more time and validation prevalence of cataract after laser treatment of ROP
before it can be used for diagnostic purposes. and other intraocular diseases requiring prolonged
use of steroid therapy.3
b) Secondary
The opacity in different parts of the lens depends on C. Morphology
the etiology of the cataract and compared to The lens opacities in childhood cataract can have
congenital cataracts, the etiology of secondary multiple phenotypes and it is perhaps the most challenging
cataracts are mostly known, including: task for ophthalmologists to list the precise morphology of
the childhood cataract. Diagnosis of cataract can be made by
c) Inflammation or Uveitis an ophthalmologist under torch light examination or slit-
Due to persistent inflammation and steroids used in lamp examination (Figure 2). The morphology can guide
the treatment of uveitis, children may develop the ophthalmologists to link its etiology, systemic
cataract, most commonly posterior sub-capsular association, and surgical plan. Based on morphology,
cataract. Hence, ruling out active inflammation is childhood cataract can be classified based on the opacity of
essential before surgical intervention in these lens structure (Table 2).7,8,11
children. Many patients may also develop a
pupillary membrane, making the surgery
challenging. Juvenile idiopathic arthritis is one of
the major causes of uveitis with cataract in
children. In recent years, the use of systemic
antimetabolites has helped to control the
inflammation in these.8.9

Whole lens Total Congenital Morganian Membranous Partially

Central Lamellar Zonular Nuclear Central Sutural Cortical

Anterior Anterior polar Anterior Anterior

Dot like subcapsular lenticonus
Plaque like
Anterior
pyramidal
Posterior Posterior polar Posterior Posterior
subcapsular lenticonous
Misc. Linear opacities Wedge-shaped/ Coralliform Dandelion Reduplicated Barbed fence-
Crystalline /Floriform like/Starry sky cataract/ like/
cataract/Stud Nodular stem Oil droplet
button of cactus
Table 2: Childhood cataract classification based on morphology

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Volume 7, Issue 6, June – 2022 International Journal of Innovative Science and Research Technology
ISSN No:-2456-2165
III. MATERNAL MALNUTRITION AND In general, ophthalmologists look for the following features
INTRAUTERINE INFECTIONS to confirm the presence of cataract:
 White reflex in the eye (Leukocoria)
The role of micronutrients for a pregnant mother is  Misaligned eyes.
essential for balanced fetal growth and ample studies have  Rhythmic and uncontrolled movements of the eye
established the link between maternal malnutrition and (nystagmus).
intrauterine growth retardation, increased perinatal
 Cloudy or blurry vision.
morbidity and even mortality.5
 Glare in the eye on the application of light (photophobia).
A. Maternal malnutrition
Besides, the diagnosis of childhood cataract is also
The incidence of idiopathic cataract is highest in low-
done using a visual acuity test. In a visual acuity test,
and middle-income countries suggesting the role of low
ophthalmologists check the vision of the child from different
birth weight, malnutrition and infectious causes in the
distances whereas the pupil is dilated to get a closer view of
development of idiopathic cataract. Also, the low birth
the lens, retina and optic nerve.
weight indicates poor fetal growth and maternal malnutrition
can be one of the factors causing altered physiology of the B. Treatment for Childhood Cataract
fetal lens. A possible link has been suggested between The treatment of childhood cataract depends on the
maternal malnutrition, low birth weight and the development density of the cataract. Generally, if the lens opacity is
of childhood cataract.11 While exploring the existing central and more than 3 mm in diameter, it should be
literature on pathways delivering nutrients to the adult lens, removed. The ideal time to perform surgery is as early as
authors presented a cellular mechanism by which oxidative possible, after the first 4 weeks of life. Primary intraocular
stress caused due to maternal malnutrition can impact the lens implantation is favoured by most ophthalmologists in
development of antioxidant defence pathways in the childhood cataract in developing countries, as aphakia
embryonic lens, thus accelerating the onset of nuclear required the use of glasses and contact lens for visual
cataract in childhood.5 rehabilitation, which becomes difficult in low and middle-
income countries. The childhood cataract without the risk of
B. Intrauterine infections
amblyopia is generally avoided for surgery. However,
In the developing world, intrauterine infections are major
ophthalmologists may continue to prescribe spectacles or
causes of childhood blindness.8 The mnemonic TORCH
contact lens. But, there are certain categories of cataracts
symbolizes the most common congenital intrauterine
such as dense and total cataracts, which require immediate
infections which include; Toxoplasma gondii, others,
surgical intervention to avoid visual impairment. Posterior
rubella, cytomegalovirus and herpes. The "others" include
capsular opacification (PCO) is the most common
varicella-zoster, treponema pallidum, Epstein-Barr, HIV,
complication in childhood cataract surgery. 8
lymphocytic choriomeningitis and West Nile virus. Though
they manifest relatively mild symptoms and illness in the V. PREVALENCE AND EPIDEMIOLOGY OF
mother, they can severely impact the fetus growth. The CHILDHOOD CATARACT
more virulent forms of these viruses may also result in
abortion, stillbirth and can have direct toxic effects on the Despite significant improvements in health services
fetus. In cases, the fetus is unable to eliminate these viruses; over the last century, health inequalities persist among
it can lead to chronic infections and elevated levels of IgM various population groups. The socio-economically
and IgA. In 1941, Sir, Norman Mcalister Gregg, an disadvantaged areas of the world experience higher
ophthalmologist from Australia described the association of morbidity, mortality and disability rates. In addition, even
rubella with congenital cataract, congenital heart disease and within the developed and developing countries, inequalities
deafness. It was the first-ever demonstration of exist based on the socio-economic status of the population.
teratogenicity secondary to a virus.10 Rubella is still a major The definition of “Health inequalities” refers to the health
cause of congenital cataracts and blindness across status of how worse off is the disadvantaged group from the
developing countries. privileged group. India, China and Africa share almost 75%
of the global burden of blindness. The data also indicate a
IV. SYMPTOMS, DIAGNOSIS AND TREATMENT disproportionate burden of blindness in developing countries
compared to developed countries.13,14
A. Symptoms & Diagnosis
The ultimate goal of diagnosis and treatment of The epidemiology of childhood blindness due to
childhood cataractis successful visual rehabilitation. At cataract corresponds to socio-economic development,
present, ophthalmologists use a slit lamp examination to demographic change, public health intervention for child-
diagnose childhood cataract. The decision to operate care, accessibility and the availability of eye care services
depends upon the density of lens opacity, evaluated with the within a geographical area. Though there is a decline in the
help of a red-reflex test, retinoscopy and EUA (Examination absolute number of blind children from 1.4 million in the
under anaesthesia). Decreased vision, leukocoria, and 1990s to 1.14 million in 2014, it attributes primarily due to
strabismus are the most common symptoms seen in pediatric the improved performance of the developed countries. In
cataract.7,8,12 the past two decades, blindness due to corneal scarring has
also reduced in low-income countries and cataract has
emerged as the most common cause of avoidable blindness.

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ISSN No:-2456-2165
In a major systematic review, the ratio of girls accessing Control of Blindness (NPCB) and Aayushman Bharat (PM-
bilateral cataract surgery was found lower especially in the JAY), for eradicating cataract-related blindness, only nine
Asian countries. The possible reason for this may be a children received financial assistance from the Govt of
gender difference in birth rates reported from China and India. Out of 312 patients, 99 children (31.73%) reached late
India. In 2015, the United Nations Population Division at the hospital, and 39 children did not continue their
reported 12.1 and 13.4 million fewer girls than boys (0-9 treatment, mainly due to poverty and transport-related
years) in China and India respectively.15 The gender bias issues. A whopping 99% of these children belong to low-
was reported in almost all categories of child health care income families. Out of 39 children who discontinued their
including rates of immunization and nutritional values. treatment, 24 were male, and 15 were female. In most of
these families, the mothers were housewives and did not
The studies further suggest huge variations in the work anywhere. We intend to convey these results to the
causes of vision loss across different parts of the world. Govt. of India to evolve a suitable mechanism to address
While low-income countries still face a shortage of health pertinent issues hindering the treatment of children suffering
care infrastructure, malnourishment and infectious diseases from childhood cataract. Further, the disproportionate ratio
(rubella, measles), the causes in middle-income countries of male and female children in this study is an area of
include congenital cataract and retinopathy of prematurity concern as it is difficult to assess whether the prevalence of
(ROP) as major causes of childhood blindness. However, in childhood cataract is lower in female children or they are not
developed countries, hereditary or genetic causes are the being presented on time in the hospital by the families.
primary causes of childhood blindness.16 Almost 75% of the
world’s blind children live in Asia and Africa. In these VII. DISCUSSION
countries, a majority of them live in extreme poverty and
childhood cataracts and corneal diseases are the major A. Social factors affecting health-seeking behaviour:
causes of childhood blindness. The cultural, economical and social conditions of the
individual and family can have a substantial influence on the
However, in one of the major systemic review health-seeking behaviour of the individual and family; and
published in 2016, the findings did not agree with the earlier remain the most significant determinants of the health-
reported results and suggested higher prevalence even in seeking behaviour in low and middle-income countries.15
high-income countries. Overall, there is a substantial gap in Besides, lower educational level of mother and gender
the epidemiological knowledge of childhood cataract and disparities were also reported as major reasons in accessing
the yearly figure and is reflected in the yearly figure for new health care services. In low- and middle-income countries,
childhood cataract cases which varies from 1,91,000 cases to girls from families with higher socioeconomic status are
3,14,000.16 The prevalence of childhood cataract was also more likely to undergo treatment than girls from lower
reported with a wide range from 1-15/10000. One possible socioeconomic status. There is a fear of surgeries in parents
reason for this huge variation is different methodologies, age from lower socio-economic.In the studies conducted in Asia
group and case definitions being used by the researchers in and Africa, the parents of a girl child from a lower socio-
the past. In one of the studies, reports suggest that with a economic background are more likely to delay the
2% birth in developed countries, the prevalence of bilateral presentation of their ailing girl child to hospitals, as they
cataract could be 4 children/million, however, the same may believe that it would be detrimental to her marriage
increase to 10 children/million in developing countries due prospects. Besides, the lack of understanding of medical
to higher birth rate.17 treatment and surgery and fear of visiting urban cities for
treatment was also reported as one of the major reasons for
VI. RESULTS delayed presentation.15

The design of the study was retrospective and hospital- B. Economic Burden of Childhood blindness
based. Data available with the Central Registration As per global estimates, childhood blindness contributes
Department of the PGIMER, Chandigarh was used. The to an enormous loss in earning capacity of US$ 6000-27000
majority of the childhood cataract cases are being reported million. With extrapolation, if we assume a 3% growth rate
in this hospital, yet not each and every case of childhood in the global population, the economic loss over a period of
cataract approaches PGI, Chandigarh. Nevertheless, this 10 years resulting from childhood cataract varies from US$
study is going to be pioneering research in India covering 1000-6000 million. The Indian estimates suggest, a loss of
five-year data of the childhood cataract patients who visited US$ 3500 million in earning capacity, considering an
the Advanced Eye Centre, PGIMER, Chandigarh from average of 33 years of blind years due to cataract. 18,19 The
1.1.2015 to 31.12.2019. latest estimates from Orbis India show that India can incur
an economic loss of Rs. 88,000 crore in 2020 with almost
354 children were presented for childhood cataract 35% of cases of blindness are preventable and curable. It
screening and treatment from 1.1.2015 to 31.12.2019. Of has been reported that with this trend, the country can incur
354 children, 248 (70%) were male, and 106 (30%) were a loss of Rs. 3,31,000 crore in national GDP considering 40
female. Further, out of these 354 children registered in the lost working years.19
special clinics, 42 were wrongly registered for childhood
cataract. Therefore, the final number was 312 children
registered in 5 years. Despite two flagship programmes by
the Govt. of India, namely the National Programme for

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Volume 7, Issue 6, June – 2022 International Journal of Innovative Science and Research Technology
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C. Psychosocial Impact on children & family: Over the years, the history of science has reflected the
Unlike the cataract in adults, where the results are highly tremendous progress achieved by medical sciences and
encouraging after surgery, cataracts in children can have rehabilitation, including advances in the field of optics and
detrimental effects on their overall psychology and their technology. Over the past century, rapid strides were made
families.20 In childhood cataract, parents play a crucial role in untraded areas of preventable and avoidable blindness.
in the care of the child and it has been reported in two These advances not only minimized the impact of childhood
inductive studies that uncertainty can become a major blindness but also gave newer insights for research to look
barrier in self-efficacy. However, to balance the ability or into the emerging causes of avoidable and preventable
inability of a child, parents generally use a process blindness. With change in time and environment,
comprising of four main categories; mastering, demographic centric strategies are required to maximize the
collaborating, facilitating and adapting. 20 Their painful efforts for sensitization of pregnant mothers to adopt a
journey starts from birth and continues for years with healthier lifestyle, with emphasis on the role of nutrition and
frequent visits to the eye clinics. The parents are also intrauterine infections like rubella and measles. In addition,
expected to be vigilant in reporting the complications. It has synchronized efforts are needed for early detection and
been seen that strict compliance during the treatment such as management of avoidable causes of childhood blindness
administering eye drops, handling contact lens, patching and such as childhood cataract.
motivating the child for treatment and visiting the hospital
can be extremely challenging.21 Fatigue, physical and REFERENCES
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