Open Journal of Ophthalmology, 2013, 3, 122-126
Published Online November 2013 (
Open Access OJOph
Outcome of Strabismus in Children with Cataracts
Lingkun Kong, Bradley L. Shoss, Karen A. Alvarez, Kimberly G. Yen
Department of Ophthalmology, Cullen Eye Institute, Baylor College of Medicine, Houston, USA.
Received August 6th, 2013; revised September 6th, 2013; accepted October 6th, 2013
Copyright © 2013 Lingkun Kong et al. This is an open access article distributed under the Creative Commons Attribution License,
which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
We characterized the outcome of strabismus in 54 pediatric patients with cataracts. Patients were less than 18 years of
age at the time of undergoing cataract extraction with or without intraocular lens (IOL) implantation. Of 54 patients, 24
(44%) were male; 30 (56%) were female. 36 (67%) had congenital cataract; 18 (33%) had acquired cataract. Average
age at cataract surgery was 40.39 months (SD: 38.82; range: 2 - 156). All patients had strabismus at the time of diagno-
sis of the cataracts. One year after cataract surgery, 39 (72%) patients had resolution or improvement of strabismus
without surgery at an average of 3.8 months (SD: 3.6; range 0 to 12 months); 15 (28%) of patients required strabismus
surgery. No association was found between resolution of strabismus, gender, the presence of congenital or acquired
cataract, unilateral or bilateral cataract, duration of cataract, and the presence of IOL or aphakia. Strabismus was more
likely to resolve without surgical intervention if the child was older at the time of diagnosis of cataract. The predicted
value of resolution at 50 months of age is 70% and increases with age.
Keywords: Strabismus; Cataract; Aphakia
1. Introduction
Pediatric cataracts remain a significant contributor to
vision loss in children worldwide [1,2]. Strabismus has
been found to occur more frequently in patients with
developmental cataracts compared to that of the general
population. In the general population, the incidence of
strabismus is reported to be 2% to 5% [3,4]. In a study of
113 pediatric patients with developmental cataracts by
Magli et al. (2008) [5], however, strabismus was present
in 34% of the patients prior to cataract surgery.
There is little documented evidence in the literature
regarding the outcomes of strabismus after cataract sur-
gery. This paper aims to characterize the outcome of
strabismus in pediatric patients who present with cata-
racts and strabismus.
2. Patients and Method
This retrospective study was approved by the Institu-
tional Review Board. Medical records were reviewed of
all patients less than 18 years of age who underwent
cataract extraction with or without IOL implantation be-
tween January 2002 and December 2010. Patients were
excluded if they did not have reported strabismus or if
strabismus measurements were not performed before or
after the cataract surgery. Data collected included the
patient’s age at surgery, gender, nature of the strabismus
(intermittent versus (vs.) constant and esotropia vs.
exotropia), nature of the cataract(s) (congenital vs. ac-
quired and unilateral vs. bilateral), presence of amblyopia,
and resolution of the strabismus after surgery. This sam-
ple was then divided into 2 subgroups: those whose stra-
bismus resolved after cataract surgery and those whose
strabismus did not.
Strabismus was recorded as significant if it was greater
than 10 prism dioptor (PD) on physical exam using
Krimsky technique or prism alternate cover test at near.
All surgeries were performed by a single surgeon (KGY)
using the standard technique that has been described in
the literature [6]. The two subgroups were compared us-
ing a chi-squared test for significance. Data were ana-
lyzed in a logistic regression model which included the
following variables: gender, esotropia vs. exotropia, in-
termittent vs. constant deviation, amblyopia vs. no am-
blyopia, congenital vs. acquired, IOL vs. aphakic, and
bilateral vs. unilateral cataracts.
3. Results
3.1. Characteristics of Patients
After reviewing the selected charts, 54 patients with both
Outcome of Strabismus in Children with Cataracts 123
cataract and strabismus at the time of diagnosis of the
cataract(s) were included in this study. The characteris-
tics of the eyes are summarized in Table 1. Of 54 pa-
tients, 24 (44%) were male and 30 (56%) were female.
36 (67%) had congenital cataract and 18 (33%) had ac-
quired cataract. The average age at diagnosis of cataract
was 37.3 months (SD: 37.2; range 1 - 156) and average
age at cataract surgery was 40.39 months (SD: 38.82;
range: 2 - 156).
Thirty two (59%) patients had intermittent strabismus
and 22 (41%) had constant strabismus. Three (5%) had a
vertical form of strabismus (1 had DVD, 1 had hyper-
tropia, and 1 had both XT and hyperopia). Within one
year after cataract surgery, 34 (63%) patients had resolu-
tion of their strabismus without strabismus surgery at an
average time of 3.8 months after the cataract surgery (SD:
3.6; range 0 to 12 months). 5 (9%) patients had im-
provement of strabismus and did not require surgery be-
cause their angle was less than 10 PD. In 15 (28%) pa-
Table 1. Characteristics of patients with strabismus and
Variables No. %
Male 24 44
Female 30 56
Character of cataract
Congenital 36 67
Acquired 18 33
Eye(s) involved
Unilateral 40 74
Bilateral 14 26
Types of deviation
Intermittent 23 43
Constant 28 52
Yes 34 63
No 15 28
Improved 5 9
Yes 41 76
No 13 24
Types of strabismus
ET 23 44
XT 29 56
Intraocular lens implantation
Yes 41 76
No 13 24
ET: esotropia; XT: exotropia.
tients, the strabismus did not improve with cataract sur-
gery alone and the patients required strabismus surgery.
At their final visit, all of these patients had an angle of 10
PD or less after strabismus surgery.
3.2. Risk Factors for Amblyopia
Of the 54 patients, 17 (31%) were able to be evaluated
using HOTV testing; mean vision was 1.15 LogMar (SD,
0.35) before surgery and 0.67 LogMar (SD, 0.41) after
the surgery in these eyes. The 37 (69%) other patients
could not perform visual acuity due to either young age
or lack of cooperation and were assessed as no fix and
follow or blink to light, blink to light only, or fix and
follow. The patients were divided into three groups: 1)
improved vision (for example, an improvement in Log-
Mar acuity; improvement from blink to light only preop-
eratively to fix and follow postoperatively; or improve-
ment from no fix and follow to fix and follow after sur-
gery) 2) vision unchanged; and 3) vision decreased. Us-
ing these criteria, 41 (76%) patients had vision improve-
ment and 13 (24%) patients had no vision change. Logis-
tic regression test showed that the improvement of vision
has significant contribution to the resolution of strabis-
mus (p = 0.015).
The presence of amblyopia was correlated with age at
cataract diagnosis and surgery (r = 0.33, p = 0.0138), and
showed that patients without amblyopia were likely to be
older at the time of cataract diagnosis and surgery. The
presence of amblyopia was correlated with the presence
of a unilateral cataract (p = 0.002), but was not related to
the presence of IOL or aphakia (p = 0.6).
3.3. The Outcomes of Strabismus after Cataract
Using logistical regression analysis, we found that stra-
bismus was more likely to resolve without surgical in-
tervention if the child was older at the time of diagnosis
of cataract (p = 0.036) and at the time of cataract surgery
(p = 0.028), however there was no correlation of time to
resolution with the duration of cataract or the time from
diagnosis to cataract surgery. The average time between
date of diagnosis of cataract and time of cataract surgery
was 3.1 months (SD = 1.6). For every increase of 1
month of age at diagnosis of cataract, the odds of resolu-
tion of the strabismus increased by 2.0%. Logistic re-
gression analysis also showed that, in patients who had
resolved strabismus without strabismus surgery, 80% are
older than 14.5 months (95% CI 63% - 91%) and, of
those who required strabismus surgery, 65% are younger
than 14.5 months (95% CI 41% - 84%). Using 14.5
months of age as cut off therefore allows us to correctly
identify 80% of the patients whose strabismus would
resolve without surgery with a 20% false positive rate.
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Outcome of Strabismus in Children with Cataracts
Open Access OJOph
tients with cataracts are limited in the literature. Weis-
berg et al. [8] performed a retrospective study of 94 pa-
tients (age 18 years or younger) who underwent cataract
extraction/intraocular lens implantation (CE/IOL) sur-
gery. Weisberg, et al. found that patients with bilateral
cataracts were less likely to develop strabismus than
those with unilateral cataracts.
The predicted value of resolution of strabismus is 70% at
an average age of 50 months and increases with age
(Figure 1).
The presence of constant strabismus (versus intermit-
tent strabismus) was found to be marginally significant
with a p-value of 0.075 (OR = 0.314) suggesting that
intermittent strabismus is more likely to be resolved after
cataract surgery only. In this study, we did not find the
association between resolution of strabismus and pres-
ence of amblyopia or need for amblyopia treatment.
Magli et al. performed a retrospective study of 113 pa-
tients with developmental cataracts between the ages of
36 - 144 months in Naples, Italy from 1990 to 2005) [5].
Strabismus was seen in 34% of their patients before
cataract surgery and 41% after surgery. They found that
patients with unilateral cataracts were more likely to
have strabismus following cataract surgery (p = 0.002)
and that 40% of their patients had amblyopia.
We also assessed the association between resolutions
of strabismus and gender, the presence of congenital or
acquired cataract, unilateral or bilateral cataract, and du-
ration of cataract, presence of IOL or aphakia. None of
these variables showed significance (p < 0.05) or mar-
ginal significance (p < 0.10) in predicting resolution of
strabismus after cataract surgery (Table 2).
There have been a few studies that have looked at the
presence of strabismus in infants who had cataract sur-
gery. In a study by Autrata, et al., strabismus (either esot-
ropia or exotropia) was found in significantly fewer chil-
dren who received an IOL than those who were left
aphakic after cataract surgery; all the patients in this
study had surgery before 12 months of age [9]. However,
Lambert, et al., in 2001 [9] found that, in 25 infants who
had cataract surgery during the first 6 months of life,
there was a similar incidence of strabismus between
children treated primarily with an IOL and those left
aphakic and treated with a contact lens (CL) (75% vs.
92%, p = 0.24). In Lambert’s study, 17% in the IOL
group and 15% in CL group required strabismus surgery
to correct their strabismus. Our study did not find a cor-
relation between resolutions of strabismus with aphakia
or pseudophakia, however, the age range in our study is
wider as we included older patients. Age of onset of the
cataract likely plays a role in the presence and resolution
4. Discussion
Strabismus occurs frequently in children with pediatric
cataracts and has been described up to 83% of patients
with congenital cataracts [7]. Our study suggests that age
is the best predictor of whether the strabismus will re-
solve without strabismus surgery and that there was a
trend towards a higher chance of resolution if the patient
had intermittent strabismus. With every increase of 1
month of age at the diagnosis of cataract, the odds for
resolution of strabismus increased by 2.0% in our studied
population. Other factors such as amblyopia, type of ca-
taract, and IOl versus aphakia were not found to be sig-
nificant in predicting resolution of strabismus in our pa-
tient population.
Data on the resolution of strabismus in pediatric pa-
Figure 1. Predicted value for the resolution of strabismus in children with cataract. At age of 50 months old, the average pre-
diced value is 70% and increase with age. t
Outcome of Strabismus in Children with Cataracts 125
Table 2. Characteristics of patients with strabismus re-
solved versus non-resolved cases.
Va ri ab le s Resolved
N (%)
N (%)
Male 19 (56) 11(55)
Female 15 (44) 9 (45)
Character of cataract
Congenital 21 (58) 13 (72)
Acquired 15 (42) 5 (28)
Eye(s) involved
Unilateral 26 (76) 14 (70)
Bilateral 8 (24) 6 (30)
Types of deviation
Intermittent 13 (42) 10 (50)
Constant 18 (58) 10 (50)
Yes 25 (73) 16 (80)
No 9 (26) 4 (20)
Types of strabismus
ET 12 (38) 11 (55)
XT 20 (62) 9 (45)
Intraocular lens implantation
Yes 27 (77) 14 (70)
No 8 (23) 6 (39)
ET: esotropia; XT: exotropia.
of strabismus.
Amblyopia was present in 41 (76%) patients. Our re-
sults demonstrated that the presence of amblyopia was
significantly correlated with younger age and unilateral
cataract at surgery, regardless if the patient had pseudo-
phakia or aphakia. However, multiple logistic regression
analysis did not find correlation between the resolution
of strabismus and the presence of amblyopia (73% versus
80%). In Weisberg et al.’s paper, the highest risk of am-
blyopia was seen in the pseudophakic group with stra-
bismus (78% versus 51% in the pseudophakic non-stra-
bismus group). Weisberg et al. asserted that this might
point to an association with the potential for amblyopia
in unilateral pseudophakia increasing the possibility of
amblyopic strabismus [8].
Based on theories of a latent or “sub-cortical” period
in infants, it is estimated that unilateral cataracts which
are present beyond 6 weeks can have profound effects on
the maturation of the visual pathways with the next sen-
sitive period of cortical plasticity lasting approximately
for 7 - 8 years. For bilateral cataracts, Lambert et al. [6]
contended that there was no significant advantage for
performing cataract surgery before 10 weeks of age,
based on their retrospective study of 43 children. Birch et
al. [10] argued that there was a linear relationship be-
tween the delay in surgery and the long-term visual acu-
ity (VA) outcome for dense bilateral cataracts, with an
average loss of one line of VA for every 3 weeks of de-
lay. Accordingly, they contended that surgery during the
first four weeks of life was associated with a significantly
lower prevalence of strabismus and nystagmus than sur-
gery after 14 weeks.
One topic that we did not address is the change or de-
velopment of strabismus after extensive patching or am-
blyopia treatment. Many of pediatric cataract patients
undergo extensive occlusion therapy for years after cata-
ract surgery, especially if the cataract is unilateral. In a
1984 study by France and Frank [7], an increase in the
incidence of strabismus was found in patients with
aphakia after surgery for congenital cataracts with an
average follow-up of 4.9 years. This topic would cer-
tainly be of importance in future studies.
Our study is limited by the small sample size and ret-
rospective nature of the study. Furthermore, visual acuity
and sensory data were not available consistently due to
the age of the patients. Variability of strabismus meas-
urements in young children due to cooperation and atten-
tion span should also be taken into account. Due to small
sample size, we included all pediatric patients with cata-
racts; studies which assess larger groups of patients at
different age ranges and categorize the types and densi-
ties of cataracts the patients have would be enlightening.
In summary, we found that age is the best predictor for
the resolution of strabismus after cataract surgery and
that patients with intermittent strabismus have a trend
toward a higher chance of resolution without strabismus
surgery. Other factors such as gender, the presence of
congenital or acquired cataract, unilateral or bilateral
cataract, duration of cataract, and the presence of IOL or
aphakia were not found to affect the resolution of stra-
bismus. Future larger studies and randomized trials eva-
luating the nature and behavior of strabismus in pedi-
atric cataract patients are necessary.
[1] C. Gilbert and A. Foster, “Childhood Blindness in the
Context of VISION 2020—The Right to Sight,” World
Health Organization, Vol. 79, No. 3, 2001, pp. 227-232.
[2] A. Foster, C. Gilbert and J. Rahi, “Epidemiology of Cata-
ract in Childhood: A Global Perspective,” Journal of Ca-
taract & Refractive Surgery, Vol. 23, Suppl. 1, 1997, pp.
[3] U. M. Donnelly, N. M. Stewart and M. Hollinger, “Preva-
lence and Outcomes of Childhood Visual Disorders,”
Ophthalmic Epidemiology, Vol. 12, No. 4, 2005, pp. 243-
Open Access OJOph
Outcome of Strabismus in Children with Cataracts
[4] D. S. Friedman, M. X. Repka, J. Katz, L. Giordano, J.
Ibironke, P. Hawes, et al., “Prevalence of Decreased Vis-
ual Acuity among Preschool-Aged Children in an Ameri-
can Urban Population: The Baltimore Pediatric Eye Dis-
ease Study, Methods, and Results,” Ophthalmology, Vol.
115, No. 10, 2008, pp. 1786-1795.
[5] A. Magli, A. Iovine, D. Bruzzese, U. Giani and F. Fi-
miani, “Strabismus in Developmental Cataract,” Euro-
pean Journal of Ophthalmology, Vol. 18, No. 4, 2008, pp.
[6] S. R. Lambert, M. J. Lynn, R. Reeves, D. A. Plager, E. G.
Buckley and M. E. Wilson, “Is There a Latent Period for
the Surgical Treatment of Children with Dense Bilateral
Congenital Cataracts?” Journal of AAPOS, Vol. 10, No. 1,
2006, pp. 30-36.
[7] T. D. France and J. W. Frank, “The Association of Stra-
bismus and Aphakia in Children,” Journal of Pediatric
Ophthalmology and Strabismus, Vol. 21, No. 6, 1984, pp.
[8] O. L. Weisberg, D. T. Sprunger, D. A. Plager, D. E.
Neely and N. Sondhi, “Strabismus in Pediatric Pseudo-
phakia,” Ophthalmology, Vol. 112, No. 9, 2005, pp. 1625-
[9] S. R. Lambert, M. Lynn, C. Drews-Botsch, D. Loupe, D.
A. Plager, N. B. Medow, et al., “A Comparison of Grat-
ing Visual Acuity, Strabismus, and Reoperation Out-
comes among Children with Aphakia and Pseudophakia
after Unilateral Cataract Surgery during the First Six
Months of Life,” Journal of AAPOS, Vol. 5, No. 2, 2001,
pp. 70-75.
[10] E. E. Birch, C. Cheng, D. R. Stager Jr., D. R. Weakley Jr.
and D. R. Stager Sr., “The Critical Period for Surgical
Treatment of Dense Congenital Bilateral Cataracts,” Jour-
nal of AAPOS, Vol. 13, No. 1, 2009, pp. 67-71.
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