A 5-year-old boy who had congenital cataract surgery (lensectomy with anterior vitrectomy) at six weeks of age is brought for routine follow-up. His mother reports the right eye has looked ‘a bit bigger’ lately and he rubs it in bright light. Vision with his contact lens is 6/24 right, 6/12 left.
Examination Findings
Right cornea enlarged compared with the left, with mild haze; axial length longer on the right; pressure 30 mmHg right, 16 mmHg left on Perkins tonometry. Optic disc right: cup 0.7 with a healthy rim so far. The left eye is normal. No rubeosis, angles open on gonioscopy under anaesthesia later.
Investigations
Examination under anaesthesia with accurate tonometry, corneal diameters, axial lengths and disc assessment. The measurements are plotted against previous visits — change over time is the diagnosis in paediatric glaucoma.
Questions to Think About
- Why does glaucoma appear years after the cataract surgery?
- Which measurements diagnose it in a child who cannot do fields?
- Why is the left eye relevant?
Diagnosis
Aphakic glaucoma of the right eye following congenital cataract surgery in infancy.
Reasoning
Reasoning: Removing the infant lens alters the angle’s development and aqueous dynamics; in a proportion of children the drain fails months to years later — aphakic (or pseudophakic) glaucoma, one of the commonest late complications of congenital cataract surgery. Children cannot perform visual fields reliably, so the diagnosis rests on the objective triad: rising pressure, enlarging corneal diameter and increasing axial length, with progressive cupping. The operated left eye had the same surgery and carries the same lifetime risk. Diagnosis: secondary glaucoma following congenital cataract surgery (aphakic glaucoma), right eye. Management: typical management includes pressure-lowering drops as the first step, but paediatric post-cataract glaucoma often needs surgery — angle surgery or drainage implants per local expertise — and amblyopia therapy continues in parallel because the visual system is still developing. The parents learn that cataract surgery was the beginning of lifelong eye care, not the end: both eyes need pressure surveillance indefinitely.
Differential Diagnosis
- Primary congenital glaucoma — ruled out: the glaucoma follows cataract surgery; the mechanism is secondary.
- Steroid-induced ocular hypertension — ruled out: no recent steroids; the structural post-surgical cause fits.
- Corneal decompensation alone — ruled out: pressure, axial length and cupping confirm glaucoma.
Management
Typical management includes topical pressure-lowering therapy, with early surgical referral (goniotomy/trabeculotomy or drainage implant depending on anatomy and local expertise) when drops are insufficient — medical control alone often fails in these eyes. Lifelong surveillance of pressure, corneal diameter, axial length and discs in both operated eyes continues, alongside amblyopia management and refractive correction.
Key Learning Points
- Aphakic glaucoma can surface years after infant cataract surgery — surveillance never ends.
- In children, glaucoma is diagnosed by pressure, corneal diameter, axial length and cupping — not fields.
- Both operated eyes carry the risk, even if only one declares itself.
- Amblyopia therapy and glaucoma care run together in these children.
Red Flags
- An enlarging eye after infant cataract surgery — measure the pressure; do not wait.
- Stopping follow-up after ‘successful’ cataract surgery — the commonest route to missed aphakic glaucoma.
- Photophobia and tearing in an operated eye — corneal oedema from raised pressure.
Educational content only — not medical advice. Clinical decisions must be made by a qualified professional for the individual patient.