Highlight
• In a 5-year prospective cohort of 75 children undergoing lensectomy for unilateral traumatic cataract, median best-corrected visual acuity (BCVA) at 5 years favored pseudophakic eyes (20/63) over aphakic eyes (20/258) among those with available data.
• Glaucoma prevalence at 5 years was low (9% in both pseudophakic and aphakic groups among those followed), but nearly half of pseudophakic eyes required surgery for visual axis opacification (VAO) by 5 years; VAO risk was dramatically lower when an anterior vitrectomy was performed.
Background
Traumatic cataract in childhood is a common cause of acquired monocular visual loss. Management usually requires lensectomy with decisions about primary intraocular lens (IOL) implantation versus leaving the eye aphakic, timing of surgery, and adjuncts such as anterior vitrectomy. Outcomes are influenced by age at injury and surgery, the severity and mechanism of ocular trauma, capsular and zonular integrity, and adherence to amblyopia therapy.
Long-term data after surgical management of traumatic pediatric cataract are limited compared with congenital cataract series, complicating counseling and surgical planning. The Pediatric Eye Disease Investigator Group (PEDIG) prospective multicenter cohort reported 5-year visual and complication outcomes after lensectomy for childhood traumatic cataract, providing important longitudinal evidence to inform practice and parental expectations.
Study design
This was a prospective cohort study conducted at 32 sites across the United States and Canada including 75 children aged from birth to less than 13 years who underwent lensectomy for unilateral traumatic cataract between August 2012 and February 2020. Annual medical record review was performed through 5 years postoperatively, and data analysis occurred 2022–2025.
Key features:
- Population: 75 children, median age at lensectomy 7.4 years (range 0.1–13 years), 37% female.
- Intervention: lensectomy; 60 children (80%) underwent primary IOL implantation (pseudophakic), 15 (20%) were left aphakic.
- Primary outcomes: best-corrected visual acuity (BCVA) at 5 years, period prevalence of strabismus and glaucoma (including pre-lensectomy diagnoses), occurrence of surgery for visual axis opacification (VAO), and cumulative incidence of ocular complications through 5 years.
- Follow-up completeness: 5-year BCVA available for 37 participants (49%).
Key findings
This report provides explicit clinical outcomes with effect estimates and confidence intervals where available. The most clinically relevant findings are summarized below.
Visual acuity at 5 years
Among the 37 participants with available 5-year BCVA:
- Pseudophakic eyes (n = 29): median BCVA 20/63 (interquartile range 20/35–20/159). Mean age at surgery was 7.2 years (SD 3.0).
- Aphakic eyes (n = 8): median BCVA 20/258 (IQR 20/56–<20/800). Mean age at surgery was 5.5 years (SD 4.3).
- Age-normal VA was achieved in 21% of pseudophakic eyes (6/29; 95% CI, 10%–38%) and 13% of aphakic eyes (1/8; 95% CI, 2%–47%).
Interpretation: among those assessed at 5 years, eyes that received an IOL had substantially better median acuity than those left aphakic. However, selection bias is likely: older children were more often implanted, and other injury characteristics influenced surgical decisions. Missing 5-year VA data for half the cohort further limits inference.
Visual axis opacification (VAO) and reoperation
- 5-year cumulative incidence of surgery for VAO was 47% in pseudophakic eyes (95% CI, 31%–60%) and 13% in aphakic eyes (95% CI, 0%–28%).
- Anterior vitrectomy during the primary procedure was strongly associated with reduced VAO requiring surgery. In eyes that did not undergo anterior vitrectomy, the 5-year cumulative incidence of VAO surgery was 84% (95% CI, 55%–94%) vs 15% (95% CI, 2%–26%) in eyes that did; age-adjusted hazard ratio 11.4 (95% CI, 4.6–33.1; P < .001).
Clinical implication: VAO is a frequent and clinically important complication after IOL implantation in this population. Anterior vitrectomy appears to markedly decrease the need for later VAO surgery and should be considered when planning primary IOL insertion, particularly for younger children and when posterior capsule integrity is compromised.
Glaucoma and strabismus
- The 5-year period prevalence of glaucoma was 9% in pseudophakic eyes (95% CI, 1%–16%) and 9% in aphakic eyes (95% CI, 0%–24%) among those with follow-up.
- Strabismus was reported but prevalence estimates were not emphasized in summary statistics provided here; amblyopia and ocular misalignment remain common comorbidities after pediatric ocular trauma and cataract surgery.
Interpretation: the observed glaucoma prevalence at 5 years is lower than seen in some congenital cataract cohorts but is non-negligible; glaucoma can present years after infant cataract surgery, so prolonged surveillance is warranted.
Other complications
The cohort experienced a range of expected post-lensectomy complications related to trauma and surgery; the highest actionable signal was the VAO rate in pseudophakic eyes without anterior vitrectomy. Detailed rates of other complications (eg, retinal detachment, endophthalmitis) were not prominent in the summary and likely low, but clinicians should maintain vigilance after trauma and intraocular surgery.
Expert commentary and context
This multicenter prospective cohort addresses an evidence gap about long-term outcomes after lensectomy for childhood traumatic cataract. Strengths include multicenter enrollment, prospective data collection, and clinically meaningful endpoints (BCVA, glaucoma, VAO surgery). Important caveats were acknowledged by the investigators and should guide interpretation.
- Follow-up completeness: only 49% of participants had a documented 5-year BCVA. Loss to follow-up could bias outcome estimates if children with worse or better vision were differentially lost. Clinicians should interpret the visual acuity distributions cautiously.
- Selection bias in surgical approach: patients receiving primary IOLs were on average older than those left aphakic, and surgical decisions were influenced by injury characteristics (capsular support, ocular surface, presence of uveitis), which confound comparisons between pseudophakia and aphakia.
- Generalizability: the cohort represents tertiary-care pediatric ophthalmology practices in North America and may not reflect outcomes in different health systems or resource settings where amblyopia therapy access, follow-up, and surgical techniques differ.
Biological plausibility: the higher VAO rate in pseudophakic eyes is consistent with retained lens epithelial cell proliferation and posterior capsule fibrosis being more visually consequential when an IOL is present. An anterior vitrectomy reduces posterior capsular plaque formation and improves vitreous–anterior capsule interactions, explaining the large effect size observed.
Clinical implications
For clinicians counseling families after traumatic pediatric cataract, key points are:
- Expect modest long-term visual gains on average; achieving age-normal acuity is possible but not common in this series (≈15–20% among eyes with 5-year data), and outcomes depend on age, injury severity, and adherence to amblyopia treatment.
- Primary IOL implantation was associated with better median BCVA among those followed, but this likely reflects selection of older, otherwise more favorable eyes for implantation. IOL vs aphakia remains an individualized decision.
- An anterior vitrectomy at the time of IOL implantation markedly reduced the risk of subsequent VAO surgery and should be strongly considered when implanting an IOL in a child, particularly in younger patients or when the posterior capsule is at risk.
- Glaucoma risk at 5 years was relatively low in this cohort but not negligible—lifelong monitoring is appropriate because glaucoma can appear years after pediatric cataract surgery.
- Robust postoperative follow-up and vigorous amblyopia therapy are essential determinants of ultimate visual outcome and must be emphasized to families.
Limitations and research gaps
Important limitations include incomplete 5-year visual data, potential selection confounding for the IOL vs aphakia comparison, and limited power to precisely estimate uncommon complications. Future studies should strive for higher retention, larger sample sizes to evaluate predictors of poor outcome, and ideally randomized designs for specific surgical techniques (for example, anterior vitrectomy vs none when feasible) to determine causality.
Longer-term follow-up beyond 5 years is also needed to capture late-onset glaucoma and other sequelae of ocular trauma and childhood lens surgery.
Conclusions
This PEDIG prospective cohort provides valuable real-world 5-year outcomes after lensectomy for childhood traumatic cataract. Among those with 5-year data, pseudophakic eyes had better median BCVA than aphakic eyes, but age and selection confounding limit causal inference. Glaucoma prevalence at 5 years was low, but nearly half of pseudophakic eyes required surgery for VAO, particularly when an anterior vitrectomy was not performed. These findings support careful surgical planning (including consideration of anterior vitrectomy) and prolonged surveillance for VAO and glaucoma, coupled with rigorous amblyopia management and counseling about guarded visual prognosis in many cases.
Funding and registration
See the original JAMA Ophthalmology publication for details on study funding and trial registration.
References
1. Stahl ED, Sutherland DR, Repka MX, et al; Pediatric Eye Disease Investigator Group (PEDIG). Visual Outcomes and Complications Over 5 Years Following Lensectomy for Childhood Traumatic Cataract. JAMA Ophthalmol. 2025 Nov 6:e254121. doi:10.1001/jamaophthalmol.2025.4121. PMID: 41196614; PMCID: PMC12593669.
2. American Academy of Ophthalmology. Pediatric Cataract. Preferred Practice Pattern. San Francisco, CA: American Academy of Ophthalmology; 2017. (Practice patterns and guidance for postoperative follow-up and amblyopia management.)
