A 3-week-old male infant is brought to the pediatrician for a routine check-up. The mother mentions that she noticed a white spot in her son's right eye yesterday while he was sitting in his car seat. The infant was born at term via uncomplicated vaginal delivery, and the mother's prenatal screenings were all negative. On physical examination, the infant appears well-developed and is tracking objects with his left eye. Examination of the right eye reveals an absent red reflex and a visible white opacity behind the pupil. Slit-lamp examination confirms a dense central opacification of the crystalline lens. The red reflex is normal in the left eye.
Which of the following is the most appropriate next step in the management of this patient’s right eye?
The correct answer is:
A) Immediate surgical lens extraction
This infant has a congenital cataract, a condition that results in an opacification of the lens present at birth or shortly thereafter. The hallmark clinical sign is an absent or abnormal red reflex (leukocoria). Congenital cataracts are a leading cause of preventable blindness in children. The most critical management priority is the prevention of deprivation amblyopia, which occurs when the brain fails to develop the visual pathways for an eye because it is not receiving clear visual input. To minimize this risk, a dense central cataract must be surgically removed as soon as possible, ideally within the first 6 to 8 weeks of life. Following surgery, the infant will require optical correction, such as glasses, and potentially patching of the other eye to treat any residual amblyopia.
Answer choice B: Observation and re-evaluation in 6 months, is incorrect. Delaying treatment for a dense congenital cataract will inevitably lead to irreversible deprivation amblyopia. The critical period for visual development is in early infancy, and obstruction of the visual axis during this time results in permanent cortical blindness in the affected eye.
Answer choice C: Patching of the left eye, is incorrect. Occlusion therapy (patching the unaffected eye) is used to treat amblyopia by forcing the brain to use the weaker eye. However, patching is ineffective if the visual axis remains physically obstructed by a cataract. The cataract must be surgically removed first to allow light to reach the retina before patching can be of any benefit.
Answer choice D: Topical prednisolone drops, is incorrect. Corticosteroids are used to treat inflammatory conditions like uveitis. While uveitis can occasionally cause secondary cataracts in children, primary congenital cataracts are structural lens malformations (often idiopathic, genetic, or related to metabolic/infectious causes like Rubella) and do not respond to anti-inflammatory medication.
Answer choice E: Vitamin A supplementation, is incorrect. Vitamin A deficiency causes xerophthalmia, which can lead to night blindness, Bitot spots, and corneal scarring. It does not cause congenital cataracts, and supplementation would not resolve a formed lens opacity.
Key Learning Point
Congenital cataracts present as an absent red reflex (leukocoria) and require prompt surgical lens extraction, typically within the first 2 months of life, to prevent permanent vision loss due to deprivation amblyopia.
