Table 1: Demographics and Laterality of Pediatric Cataract.

Demographics/ Laterality	Types of Pediatric Cataract				Total N (%)	p-value
Demographics/ Laterality	Traumatic n (%)	Congenital n (%)	Developmental n (%)	Complicated n (%)	Total N (%)	p-value
Age Group
0 – 3	2 (3.5)	63 (80.8)	17 (27.4)	3 (23.0)	85 (40.5)	0.00*
4 – 6	11 (19.3)	9 (11.5)	17 (27.4)	2 (15.4)	39 (18.6)	0.97
7 – 9	19 (33.3)	4 (5.1)	13 (21.0)	4 (30.8)	40 (19.0)	0.002*
10 – 12	16 (28.1)	2 (2.6)	7 (11.3)	4 (30.8)	29 (13.8)	0.001*
13 – 15	9 (15.8)	0 (0.0)	8 (12.9)	0 (0.0)	17 (8.1)	0.03*
Total	57 (100.0)	78 (100.0)	62 (100.0)	13 (100.0)	210 (100.0)
Gender
Female	21 (36.8)	32 (41.0)	18 (29.0)	7 (53.8)	78 (37.1)	0.92
Male	36 (63.2)	46 (59.0)	44 (71.0)	6 (45.2)	132 (62.9)
Total	57 (100.0)	78 (100.0)	62 (100.0)	13 (100.0)	210 (100.0)
Laterality
Bilateral	0 (0.0)	54 (69.2)	45 (72.6)	4 (30.8)	103 (49.1)	0.00*
Unilateral left eye	26 (45.6)	9 (11.6)	11 (17.7)	3 (23.1)	49 (23.3)
Unilateral right eye	31 (54.4)	15 (19.2)	6 (9.7)	6 (46.1)	58 (27.6)
Total	57 (100.0)	78 (100.0)	62 (100.0)	13 (100.0)	210 (100.0)

*Statistically significant

Table 2: Duration before Presentation of Pediatric Cataract.

Duration before Presentation	Types of Pediatric Cataract				Total n (%)	p-value
Duration before Presentation	Traumatic n (%)	Congenital n (%)	Developmental n (%)	Complicated n (%)	Total n (%)	p-value
Within a month	15 (26.3)	17 (21.8)	5 (8.1)	1 (7.7)	38 (18.1)	0.09
> 1 month -3 months	14 (24.5)	16 (20.5)	7 (11.3)	4 (30.8)	41 (19.5)	0.35
> 3 months - 6 months	9 (15.8)	9 (11.5)	4 (6.4)	1 (7.7)	23 (11.0)	0.26
> 6 months - 9 months	3 (5.3)	3 (3.9)	1 (1.6)	0 (0.0)	7 (3.3)	0.39^†
> 9 months - 1 year	7 (12.3)	7 (9.0)	13 (21.0)	2 (15.4)	29 (13.8)	0.87
> 1 year	9 (15.8)	26 (33.3)	32 (51.6)	5 (38.4)	72 (34.3)	0.001^*
Total	57 (100.0)	78 (100.0)	62 (100.0)	13 (100.0)	210 (100.0)

* Statistically significant, † = Fisher’s exact

Table 3: Association between Gender, Laterality and duration before Presentation.

	Duration before Presentation		Total (210)	p - value
	Within Six Months (n = 101)	After Six Months (n = 109)	Total (210)	p - value
Gender
Female	35 (44.9%)	43 (55.1%)	78 (100%)	0.47
Male	66 (50.0%)	66 (50.0%)	132 (100%)

Laterality
Bilateral	36 (35.0%)	67 (65.0%)	103 (100%)
Unilateral	65 (60.7%)	42 (39.3%)	107 (100%)	0.00

Out of the 313 eyes with pediatric cataract, 222 (70.9%) eyes had visual acuity worse than 6/60 while another 30 (9.6%) eyes and 15 (4.8%) eyes had their visual acuity documented as less than 6/24 and at least 6/24 respectively (using hundreds and thousands). 15 (4.8%) eyes had a visual acuity of 6/6 to 6/18 while the remaining 31 (9.9%) eyes had a visual acuity of 6/24 to 6/60. Twelve (7.8%) out of the 153 children with non-traumatic cataract had a positive family history of childhood cataract. Five (41.7%) out of these 12 had congenital cataract while the remaining seven (58.3%) had developmental cataract. Still on non-traumatic cataracts, 33 (21.6%) affected children had a positive history of maternal febrile illness in pregnancy. Twenty-five (75.8%) out of these were congenital cataract while the remaining eight (24.2%) were developmental cataracts. Similarly, 9 (5.9%) and one (0.7%) children with non-traumatic cataracts had a positive history of maternal rashes and use of abortifacients respectively in pregnancy. All of them had congenital cataracts. Seven (77.8%) out of the nine children with maternal rashes in pregnancy equally had a positive history of maternal febrile illness in pregnancy. Furthermore, eight (5.2%) children with non-traumatic cataracts had a positive history of maternal ingestion of herbal concoctions in pregnancy. Seven (87.5%) out of these had congenital cataracts while the remaining one (12.5%) had developmental cataract. Ninety-two (35.9%) out of the 256 eyes with non-traumatic cataracts had ocular co-morbidities with nystagmus, strabismus and microphthalmos/nanophthalmos observed in 34 (40.0%), 22 (23.1%) and 18 (19.6%) children respectively (some eyes had multiple ocular co-morbidities) as shown in Table 4. Twenty-six (17.0%) out of the 153 children with non-traumatic cataracts had systemic co-morbidities. The most common systemic co-morbidity was cardiac diseases documented in 10 (38.5%) children, followed by delayed developmental milestones and deafness in 7 (26.9%) and 5 (19.2%) children respectively as shown in Table 4. Out of the 10 children with cardiac diseases, patent ductus arteriosus (PDA) was documented in 6 (60.0%) children being the most common, followed by ventricular septal defect (VSD) and atrial septal defect (ASD) in 3 (30.0%) and 2 (20.0%) children respectively (some children had multiple cardiac diseases). Seventy-five (49.0%) out of the 153 non-traumatic cataracts neither had family history, ocular nor systemic co-morbidities.

The mean age at presentation for congenital cataract was 2.0 ± 2.5 years with a median age of 1.0 year. The youngest was a week old baby while the oldest was 11 years at presentation. Fifty-four (69.2%) out of the 78 congenital cataracts were bilateral. Forty (51.3%) children presented at age one and below. Only 17 (21.8%) out of the 78 congenital cataract presented within a month of noticing the main presenting complaint while 36 (46.2%) presented after six months (Table 2). Out of the 132 eyes of 78 children with congenital cataract, 83 (62.9%) eyes had total cataract being the most common. This is followed by nuclear, lamellar, anterior polar and membranous cataracts observed in 23 (17.4%), 9 (6.8%), 7 (5.3%) and 5 (3.8%) children respectively. Out of the 40 children with congenital cataract who presented at age one and below, 12 did the TORCH screening test. Out of these 12, 7 (58.3%) were positive for rubella IgG antibodies but only 2 (16.7%) were positive for rubella IgM antibodies. Similarly, 4 (33.3%) children were positive for cytomegalovirus IgG but only one (8.3%) child was positive for the IgM antibodies. Furthermore, five (41.7%) and one (8.3%) children had a positive IgG for herpes and toxoplasmosis respectively but none of them had positive IgM.

There were 107 eyes of 62 patients with developmental cataract. The mean age was 6.6 ± 4.1 years and 45 (72.6%) had bilateral cataract. The most common morphological type of cataract was lamellar observed in 61 (57.0%) eyes followed by total and cortical cataract documented in 39 (36.4%) and three (2.8%) eyes respectively. Two (1.9%) eyes each with developmental cataract had membranous and posterior sub-capsular cataract respectively. Seventeen eyes of 13 children had complicated cataract with a mean age of 7.4 ± 3.7 years. Nine (69.2%) out of the 13 children had unilateral cataract. Total, posterior sub-capsular and cortical cataracts were seen in 14 (82.4%), two (11.7%) and one (5.9%) eyes respectively. Seven (41.2%) eyes with complicated cataract had co-existing retinal detachment while the remaining 10 (58.8%) were post-uveitic with seclusion pupillae. Only three (23.1%) children out of the 13 with complicated cataract had systemic comorbidities. The systemic comorbidities were deafness, delayed developmental milestone and human immunodeficiency virus (HIV) infection.

There were 57 children with traumatic cataract. All (100.0%) of them had unilateral cataract (P < 0.01) as shown in Table 1 and the mean age at presentation was 9.1 ± 3.8 years. The youngest was a year old child who was inadvertently hit by a belt in the eye while the parents had a fight. The most common morphological type of cataract was total documented in 42 (72.4%) eyes. This was followed by cortical, posterior sub-capsular and anterior capsular cataract in seven (12.1%), six (10.3%) and two (3.4%) eyes respectively. Forty-five (78.9%) cases were associated with closed globe injuries while 52 (91.2%) children sustained ocular injury at home or school as shown in Table 5. The trauma circumstances were during playing or flogging in 45 (78.9%) children while wood, stick, broom, cane or belt were the most common agents of injury documented in 29 (50.9%) children. Overall, forty-five (78.9%) out of the 57 children with traumatic cataract sustained ocular injury while playing or being flogged either at home or school.

Table 4: Ocular and Systemic Co-morbidities in Non-traumatic Cataract Patients.

Ocular and Systemic Co-Morbidities	Frequency	Percentage
Ocular Co-morbidities in 92 eyes
Nystagmus	34	40.0
Strabismus	22	23.9
Microphthalmos/ Nanophthalmos	18	19.6
Seclusiopupillae	15	16.3
Retinal detachment	7	7.6
Corneal opacity	5	5.4
High myopia	5	5.4
Persistent fetal vasculature	2	2.2
Aniridia	2	2.2
Others	2	2.2
Systemic Co-morbidities in 26 Children
Cardiac diseases	10	38.5
Delayed developmental milestone	7	26.9
Deafness	5	19.2
Seizure disorders	2	7.7
HIV infection	2	7.7
Down syndrome	1	3.8
Others	2	5.0

*Some eyes and children had multiple ocular and systemic co-morbidities respectively.

Table 5: Characteristics of Traumatic Cataract.

Ocular co-Morbidities	Frequency	Percentage
Trauma Type
Closed globe injury	45	78.9
Open globe injury	12	21.1
Total	57	100.0
Trauma Environment
Home	33	57.9
School	19	33.3
Farm	1	1.8
Not recorded	4	7.0
Total	57	100.0
Trauma Circumstances
Playing	34	59.6
Flogging	11	19.3
Others	7	12.3
Not recorded	5	8.8
Total	57	100.0

DISCUSSION

This study recorded a mean age of 5.6 years for pediatric cataract. This was within the range of 5.1 years and 7.1 years documented in previous studies from Nigeria, Ethiopia and India^8-11. However, a higher mean age at presentation of 11.1 years was reported in Bosnia and Herzegovina¹². This has been attributed to unavailability of cataract surgical services during the war period, lack of information and poor socio-economic background. The preponderance of non-traumatic cataracts (NTC) over traumatic cataracts compares favorably with the observations of Halilbasic et al¹², Johar et al¹³ and Randrianotahina et al¹⁴. Late presentation was rampant in this study with over 60% presenting after three months of the onset of symptoms, more so that over 90% of the cataracts were visually significant. In fact, this study recorded a child with bilateral congenital cataract with nystagmus presenting at the age of 11. Similar experiences of late presentation were documented in previous studies from Nigeria^9,15, Bosnia-Herzegovina¹² and Tanzania¹⁶. Late presentation could lead to the development of stimulus deprivation amblyopia with attendant effect on visual outcome after surgical intervention. Furthermore, late presentation suggests barriers to early presentation. Mwendeet al¹⁶ attributed the late presentation in their study to awareness of the problem (and surgical intervention), access to surgical services or acceptance of surgical services. Unfortunately, barriers to early presentation could not be analyzed in this study because they were not documented in most patients’ record. To this end, there is a need for a prospective study to unravel these barriers to early presentation with a view to plan a result-oriented awareness and health education campaign. In spite of the rampant late presentation, children with unilateral cataract significantly presented earlier than those with bilateral cataract. This was contrary to the observation of Mwende et al¹⁶ who found no association between laterality of cataract and duration before presentation. This is surprising as one would have expected the bilateral cataract to present earlier. However, this could be explained by the difference in study design because Mwende et al¹⁶ only analyzed NTC and the cut-off for late presentation was 12 months compared to six months in this study. Furthermore, the unilateral nature of all the traumatic cataracts in this study could have influenced a relatively early presentation as trauma could be associated with inflammatory eye symptoms like redness, photophobia and pain which could be scary for the parents and caregivers. However, gender did not influence the duration before presentation as reported by Mwendeet al¹⁶.

Overall, there were more males with pediatric cataracts compared to females similar to observations in previous studies^8-19. This study recorded more unilateral cataracts in children. This compares favorably with the observations of Randrianotahina et al¹⁴, Lim et al¹⁸ and Khandehar et al¹⁹. Haargaard et al¹⁷ and Wirth et al²⁰ however, documented more bilateral cases. This disparity could be explained by the inclusion/exclusion criteria as the studies which included traumatic cataracts while those with more bilateral cataracts excluded traumatic cataract. Trauma has been known to be a significant cause of monocular cataracts. In fact, if traumatic cataracts were excluded from this study, there would have been more bilateral cataracts as nearly 70% of congenital cataracts and over 70% of developmental cataracts in this study were bilateral. The preponderance of bilateral involvement in congenital cataract in this study was similar to the findings of Rana et a²¹, Naz et al²² and Nadeem et al²³.

In this study, 7.8% of the NTC had a positive family history of childhood cataract. However, the pattern of inheritance could not be ascertained because of the lack of pedigree charts in the files of the patients. There were one and two cases of laboratory confirmed (IgM positive) cytomegalovirus and rubella respectively although more chilren tested positive for their corresponding IgG including Herpes Simplex and toxoplasmosis. Intuitively, these proportions could have been more if all the 40 children with congenital cataracts seen at age one and below had done the TORCH screening. Rubella is particularly relevant for being a preventable cause of congenital cataract since the vaccine is available in Nigeria but not part of the national immunization coverage for school aged girls and women of child bearing age. To this end, the determination of the seroprevalence of rubella in children with congenital cataracts could be an important advocacy tool for the clamour for inclusion of rubella vaccination in the Nigerian national vaccination program.

The most common systemic co-morbidity in this study was cardiac diseases while the most common cardiac disease was patent ductus arteriosus. This finding compares favorably with the findings of Duke et al⁸. Congenital heart diseases as well as mental retardation, deafness and seizure disorders are common features of the disease entities that form the acronym “TORCH” infection.

Traumatic cataract was more common in boys compared to girls. This agrees with findings in previous studies by Tomkins et al¹⁰, Johar et al¹³ and Gogate et al²⁴. This is not surprising because boys are known to engage in rough play and activities that could attract punishment from parents or other care-givers. All the 57 cases of traumatic cataracts in this study were unilateral. This was similar to the observation of Xu et al²⁵. However, Gogate et al²⁴ reported a case of bilateral traumatic cataract in a ten-year old girl following a fall from a height. Furthermore, closed globe injury was more associated with traumatic cataract in this study similar to the observations of Johar et al¹³ and Gogate et al²⁴ although Xu et al²⁵ documented more open globe injury related pediatric traumatic cataracts. Nearly 80% of the children with traumatic cataract sustained the ocular injuries while playing or being flogged either at home or in the school. These were inadvertent ocular injuries sustained while engaging in rough and unsupervised rough play as well as while being punished for perceived misbehaviour by the parents, teachers and other care givers. This calls for a better supervision of children while playing as well as the need to devise other punitive measures apart from corporal punishment when a child is deemed to have misbehaved. Johar¹³ et al also reported that 80% and 20% of the pediatric traumatic cataracts in their study were play and work-related respectively.

CONCLUSION

In conclusion, trauma and rubella were the main preventable causes of pediatric cataract identified in this study. Late presentation was the case in the majority of the patients. This preventable attitude could affect the visual outcome after intervention.

Conflicts of Interest: There are no conflicts of interest.

Author’s Affiliation

Dr. Musa Kareem Olatunbosun

M.B.B.S, FWACS, FMCOphth, FICO, ICO Fellow In Pediatric Ophthalmology

Cunsultant Ophthalmic Surgeon And Pediatric Ophthalmologist/Lecturer 1

Department of Ophthalmology (Guinness Eye Centre), Lagos University Teaching Hospital/College of Medicine, University of Lagos, Lagos, Nigeria.

Dr. Aribaba Olufisayo Temitayo

M.B.B.S, MSc (London), FWACS, FMCOphth, FICS.

Cunsultant Ophthalmologist/Senior Lecturer.

Department of Ophthalmology (Guinness Eye Centre), Lagos University Teaching Hospital/College of Medicine, University of Lagos, Lagos, Nigeria.

Dr. Rotimi-Samuel Adekunle

M.B.B.S, FWACS, FMCOphth

Cunsultant Ophthalmologist/Lecturer 1

Department of Ophthalmology (Guinness Eye Centre), Lagos University Teaching Hospital/College of Medicine, University of Lagos, Lagos, Nigeria.

Dr. Ikuomenisan Segan Joseph

M.B.Ch.B, FMCOphth, FICO

Cunsultant Ophthalmologist

Ancilla Catholic Hospital Eye Centre, Agege, Lagos.

Dr. Oluwoyeye Abimbola Olayinka

M.B.B.S., Senior Registrar

Department of Ophthalmology (Guinness Eye Centre), Lagos University Teaching Hospital, Lagos, Nigeria.

Prof. Onakoya Adeola Olukorede

M.B.B.S, FWACS, FMCOphth

Professor Of Ophthalmology/Consultant Ophthalmologist

Department of Ophthalmology (Guinness Eye Centre), Lagos University Teaching Hospital/College of Medicine, University of Lagos, Lagos, Nigeria.

Role of Authors

Dr. Musa Kareem Olatunbosun

Concept and design of study; acquisition of data; analysis and interpretation of data; drafting the article; revising the manuscript critically for important intellectual content and final approval of the version to be published.

Dr. Aribaba Olufisayo Temitayo

Concept and design of study; interpretation of data; revising the manuscript critically for important intellectual content and final approval of the version to be published.

Dr. Rotimi-Samuel Adekunle

Concept and design of study; revising it critically for important intellectual content and final approval of the version to be published.

Dr. Ikuomenisan Segan Joseph

Concept and design of study; revising it critically for important intellectual content and final approval of the version to be published.

Dr. Oluwoyeye Abimbola Olayinka

Concept and design of study; revising it critically for important intellectual content and final approval of the version to be published.

Prof. Onakoya Adeola Olukorede

Concept and design of study; revising it critically for important intellectual content and final approval of the version to be published.

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