Cataract Surgery with or without Intraocular Lens Implantation in Pediatric Uveitis: A Systematic Review with Meta-Analyses

Author: Schmidt DC, Al-Bakri M, Rasul A, Bangsgaard R, Subhi Y, Bach-Holm D, Kessel L.

Geographical coverage: USA, Europe, India, and Israel

Sector: Cataract surgery

Sub-sector: Intraocular lens

Equity focus: Not reported

Study population: Patients with paediatric uveitis

Review type: Effectiveness review

Quantitative synthesis method: Meta-analysis

Qualitative synthesis method: Not applicable

Background

Paediatric uveitis is a rare but serious condition, often asymptomatic and underreported due to children’s limited ability to communicate symptoms. This can result in complications such as cataracts, glaucoma, amblyopia, cystoid macular oedema, and other inflammatory sequelae that significantly impair vision. Cataracts develop in up to two-thirds of children with uveitis, typically due to chronic inflammation or prolonged corticosteroid use. Cataract surgery in this population is complicated by high rates of comorbidities and structural abnormalities. While IOL implantation was historically avoided due to poor outcomes, advancements in surgical techniques and inflammation control have reopened debate on its appropriateness.

Objective

To systematically review and compare outcomes of cataract surgery with and without intraocular lens (IOL) implantation in paediatric patients with uveitis, and to conduct meta-analyses of key outcomes.

Main findings

The review included 10 non-randomised comparative studies encompassing 202 patients from the USA (n=4), Europe (n=4), India (n=1), and Israel (n=1). Nine studies involving 256 eyes were included in the meta-analysis: 153 eyes received IOLs (pseudophakia), and 103 remained aphakic.

Pseudophakic eyes achieved significantly better best-corrected visual acuity (BCVA) than aphakic eyes at 1 year (−0.23 logMAR; 95% CI: −0.43 to −0.03; P=0.027) and 5 years (−0.35 logMAR; 95% CI: −0.51 to −0.18; P=0.000036). Preoperative BCVA analysis revealed heterogeneity, with one outlier study skewing results; its exclusion showed better preoperative BCVA in the IOL group (−0.36 logMAR; 95% CI: −0.52 to −0.20; P=0.000014).

Secondary outcomes showed pseudophakia increased risk of visual axis opacification (OR: 6.76; 95% CI: 2.73 to 16.8; P=0.000037) but decreased hypotony risk (OR: 0.19; 95% CI: 0.04 to 0.95; P=0.044). No significant differences were observed for cystoid macular oedema, glaucoma, retinal detachment, or posterior synechiae.

Methodology

Databases searched included PubMed/Medline, Embase, Cochrane Central, Web of Science, BIOSIS, CINAHL, and ClinicalTrials.gov. Studies were included if they compared IOL implantation with aphakia in children undergoing cataract surgery and were published in English between 2000 and November 2020. Two reviewers independently screened articles, extracted data, and assessed study quality using the ROBINS-I tool. A random-effects meta-analysis was conducted, with heterogeneity assessed via Cochrane’s Q test and I² statistics. Sensitivity analysis was also performed.

Findings are moderately generalisable. While the meta-analysis supports IOL implantation in selected cases with controlled inflammation, results may not extend to all subtypes of paediatric uveitis or settings. Limitations include the predominance of retrospective designs, possible selection bias, and variability in inflammation management.

Geographic focus

USA, Europe, India, and Israel

Summary of quality assessment

Medium confidence in conclusions. The search strategy was thorough, and inclusion/exclusion criteria were clear. Screening and data extraction were conducted independently by two reviewers. While study quality was assessed, no list of excluded studies was provided, author contact was not reported, and findings were not stratified by risk of bias. Language restrictions may also limit comprehensiveness.