Clinical science
Br J Ophthalmol: first published as 10.1136/bjophthalmol-2017-311294 on 31 January 2018. Downloaded from http://bjo.bmj.com/ on January 4, 2020 at AAO/BJO. Protected by copyright.
1
Child Sight Institute, Jasti V
Ramanamma Children’s Eye
Care Centre, L V Prasad Eye
Institute, Hyderabad, Telangana,
India
2
Ophthalmic Biophysics, L V
Prasad Eye Institute, Hyderabad,
Telangana, India
Correspondence to
Dr Ramesh Kekunnaya, Head,
Child Sight Institute, Jasti V
Ramanamma Children’s Eye
Care Centre, L. V. Prasad Eye
Institute, Hyderabad, Telangana
500034, India; ​rameshak@​
lvpei.​org
Presented at the 4th World
Congress of Paediatric
Ophthalmology & Strabismus
(WCPOS) 2017, Hyderabad,
Indiaand APAO 2017,
Hongkong.
Received 7 September 2017
Revised 13 January 2018
Accepted 19 January 2018
Published Online First
31 January 2018
To cite: Chougule P, Murat S,
Mohamed A, et al.
Br J Ophthalmol
2018;102:1550–1555.
1550
Follow-up patterns and associated risk factors after
paediatric cataract surgery: observation over a
5-year period
Pratik Chougule,1 Shamsiya Murat,1 Ashik Mohamed,2 Ramesh Kekunnaya1
Abstract
Purpose  To study the pattern of compliance to follow-
up of children less than 5 years of age undergoing
surgery for congenital and developmental cataract over a
period of 5 years.
Methods  It is a retrospective study of children less
than 5 years of age undergoing cataract surgery
between January and December 2010 for congenital
or developmental cataract and followed up until 31
December 2015. Age, sex, distance from hospital
and urban or rural habitat, delay in presentation,
socioeconomic status, laterality, morphology and
type of cataract, implantation of intraocular lens and
interventions done were noted. Compliance to follow-up
at postoperative 1 week, 1 month, 3 months, 6 months,
1 year and then once a year until 5 years were recorded.
Results  169 patients were included in the study.
The median follow-up was 22 months. Median age at
surgery was 10 months and had a negative correlation
with total follow-up. Male-to-female ratio was 1.82.
Logarithmic curve of follow-up was noticed with 85%,
61%, 55%, 52%, 39% and 28% patients attending
1 month, 3 months, 6 months, 1 year, 3 years and 5 years
of follow-up, respectively. Low socioeconomic group had
poor follow-up compared with higher socioeconomic
group (P=0.009), but the curve of follow-up was similar
in both groups; multiple interventions group had better
follow-up (P<0.0001).
Conclusion  Curve of loss to follow-up is logarithmic in
children undergoing paediatric cataract surgery. Age at
surgery and low economic status are the most important
factors associated with poor follow-up.
Introduction
Cataract is now considered as one of the most
common causes of preventable childhood blindness
and is included among the priority eye diseases by
the World Health Organization (WHO).1 Preven-
tion of visual loss should be a continuous effort in
critical age period, when the visual system is imma-
ture. Early recognition and surgical removal of
cataract and supportive measures like postoperative
care, amblyopia therapy and refractive correction
are important.2–5 Patients with congenital cataracts
have higher chances of visual axis opacification,
development of glaucoma and other adverse events
after cataract surgery.6–10 Regular follow-up plays a
crucial role in early detection of complications and
its management.11
Follow-up of children undergoing cataract
surgery has been known to be poor, especially in
Chougule P, et al. Br J Ophthalmol 2018;102:1550–1555. doi:10.1136/bjophthalmol-2017-311294
the developing world.3 12 This is a matter of serious
concern, particularly in younger children who are at
greater risk of permanent visual loss. Several studies
from the developing world have focused on the
predictive factors for good follow-up in paediatric
cataract surgeries,13–15 and included children below
18 years of age who underwent cataract surgery,
including traumatic cataract. None of these studies
have discussed the predictive factors and pattern of
follow-up for children below 5 years of age.
The purpose of the present study is to evaluate
the pattern of compliance to follow-up of chil-
dren less than 5 years of age undergoing surgery
for congenital and developmental cataract and to
study the various demographic, clinical and surgical
factors that are associated with the follow-up.
Methods
This is a retrospective study conducted at L V
Prasad Eye Institute (LVPEI), Hyderabad, India.
The study was approved by the Institutional Ethics
Committee and adhered to the tenets of the Decla-
ration of Helsinki. All children below 5 years of age
who underwent cataract surgery between 1 January
2010 and 31 December 2010 were included. Their
postoperative follow-up visits until 31 December
2015 were studied. Patients with preoperative
ocular comorbidities like congenital glaucoma,
retinopathy of prematurity, corneal opacity, reti-
noblastoma and surgical indications like post-trau-
matic cataract or secondary cataract following an
intraocular surgery, which would change or require
additional follow-up visits, were excluded from the
study. The demographic data collected included age
at the time of surgery, gender and place of residence.
Patients were divided into ‘high’ and ‘low’ socio-
economic class based on their ability or inability to
pay for the hospital services, respectively. Based on
the address provided by the patient, the distance
from the place of residence to the base hospital was
calculated using Google maps (https://www.​google.​
co.​in/​maps).16 It was noted whether the patient
came from a rural or urban community.
Based on history, duration between the age
of child at which parents first noticed the ‘visual
complaint’ and the cataract surgery was calcu-
lated and was termed ‘time delay for surgery’. On
examination, visual acuity was measured using
age-appropriate measures. A detailed anterior and
posterior segment examination was performed
with appropriate investigations whenever needed.
The laterality and morphology of cataract was

noted. Patients were diagnosed clinically to have congenital or
developmental cataract based on the onset of symptoms and
the morphology of cataract. Systemic abnormalities if any were
noted. All patients underwent a standard surgical procedure
of lens aspiration, primary posterior capsulorhexis and ante-
rior vitrectomy with or without implantation of an intraocular
lens (IOL) as described in our earlier studies.17 The decision
to implant an IOL was made intraoperatively by the oper-
ating surgeon depending on the horizontal and vertical corneal
diameter (>10.50 mm), the adequacy of capsular support and
the absence of anterior segment dysgenesis. The postoperative
regimen followed for all patients was uniform with follow-up
visits at day 1, 1 week, 1 month, 3 months, 6 months, 1 year and
yearly thereafter until 5 years. In case of bilateral cataract, the
duration between the surgeries for each eye was 1 week and the
postoperative visits were scheduled after the second eye surgery.
If the patient underwent any surgical or laser intervention, then
the nature and the follow-up visit at which it was performed was
noted. Visual acuity at the last follow-up visit was recorded for
all the patients using Teller acuity charts, fixing and following
light or brightly coloured objects for non-verbal children and
matching Lea symbols, Kay pictures and LogMAR visual acuity
charts for verbal children.
Descriptive statistics included mean and standard deviation
(SD) and median and inter-quartile range (IQR) for continuous
variables. Spearman’s correlation was used to determine the
correlation between two continuous variables. Mann-Whitney
test was used to determine the difference between two groups
and Kruskal-Wallis test for more than two groups. A P value of
less than 0.05 was considered statistically significant. Statistical
analysis was performed using commercial software (Stata V.11.2;
StataCorp, College Station, Texas, USA).
Results
A total of 262 patients below 5 years of age underwent cataract
surgery during the study period out of which only 169 patients
were included. The median follow-up of patients was 22 months
(IQR 4–59 months) and the median age at the time of surgery
was 10 months (IQR 4–27 months). Male-to-female ratio was
1.8:1 (109 boys and 60 girls). There was no significant differ-
ence (P=0.49) in the total follow-up between boys (median 23
months, IQR 4–59 months) and girls (median 19 months, IQR
3–51  months). There was a significant correlation between
the age at surgery and the follow-up duration (rho=−0.32,
P<0.0001), and higher age at surgery was associated with poorer
follow-up (figure 1). A total of 137 patients presented with bilat-
eral cataract and 32 presented with unilateral cataract. Three
bilateral cases had one eye operated outside the study period and
one bilateral case was lost to follow-up after the first eye surgery
and did not undergo the other eye surgery; the other eye of these
four cases were excluded from the analysis. One hundred thirty
eyes had total cataract, 33 eyes had nuclear, 39 had lamellar, 19
had other miscellaneous types and in 81 eyes, the morphology of
cataract was not documented.
Fifteen per cent of patients were lost to follow-up at 1 month
and dropped rapidly to 61% at 3 months, but slowed there-
after to 55%, 52%, 39% and 28% attending 6 months, 1 year,
3 years and 5 years of follow-up, respectively (figure 2A).
The follow-up of patients belonging to higher socioeconomic
status (median 35 months, IQR 8–60 months) was significantly
longer (P=0.009) than those belonging to lower socioeconomic
status (median 14 months, IQR 2–54 months) (figure 2B). The
trend in the curve of drop-out for the two groups was similar
Chougule P, et al. Br J Ophthalmol 2018;102:1550–1555. doi:10.1136/bjophthalmol-2017-311294
Clinical science
Br J Ophthalmol: first published as 10.1136/bjophthalmol-2017-311294 on 31 January 2018. Downloaded from http://bjo.bmj.com/ on January 4, 2020 at AAO/BJO. Protected by copyright.
Figure 1  Follow-up patterns after paediatric cataract surgery: scatter
plot showing negative correlation between age at surgery with the total
follow-up in months. It shows that patients operated on at a younger
age had better follow-up compared with those operated late.
but was steeper in the low socioeconomic group (figure 2C).
There was no significant difference in the follow-up between
rural and urban habitat (P=0.71). There was no relation-
ship between distance from the patients’ residence to the base
hospital and the duration of follow-up (P=0.12). Clinical
features like congenital or developmental cataract (P=0.64),
unilateral or bilateral cataract (P=0.31) or cataract morphology
like partial or total cataract (P=0.42) did not show any rela-
tionship with the total follow-up duration. The median time
delay for surgery was 2.5 months (IQR 0.5–6 months). There
was no significant correlation between the duration of symp-
toms and the total follow-up duration (P=0.48). The implan-
tation of IOL at the time of primary surgery had no effet on
the duration of the final follow-up (P=0.37). In case of bilateral
cataracts, IOL was implanted either in both eyes or both eyes
were left aphakic. Patients who underwent secondary interven-
tion (median 59 months, IQR 37–64 months) had a significantly
longer follow-up than those who did not undergo any secondary
intervention (median 13 months, IQR 2–51 months) (P<0.0001)
(table 1).
We compared the follow-up between patients who underwent
cataract surgery with primary IOL implantation (median 13.5
months, IQR 2.75–41 months; excluding patients who under-
went additional intervention) with those who underwent
multiple interventions in the form of secondary IOL or any other
procedure (median follow-up 59 months, IQR 37–64 months)
and found that there was a significant difference between these
two groups (P<0.0001, Mann-Whitney U test). However, we
did not find any significant difference in follow-up in chil-
dren undergoing additional interventions between primary
IOL (median 60, IQR 42–64) and no IOL group (median 38,
IQR 32–56) (P=0.25, Mann-Whitney U test). Similarly, we
found that the follow-up was not significantly different in chil-
dren not undergoing any additional interventions between the
primary IOL implantation (median 13.5, IQR 2.75–41) and no
IOL group (median 12, IQR 2–55.5) (P=0.97, Mann-Whitney
U test).
Children who presented with congenital cataract were divided
into three subgroups based on their age at the time of surgery
into early (0 to 6 months), mid (7 to 24 months) and late
presenters (≥25 months). On further subgroup analysis, it was
found that the early presenters had a longer median follow-up
1551
 Clinical science
Figure 2  (A) Follow-up patterns after paediatric cataract surgery:
a line diagram showing the percentage of patients attending various
follow-ups. The line denotes the slope of the curve, which is similar to
that of an exponential decay (a logarithmic curve). (B) Box plot showing
significant difference in the final follow-up between high and low
socioeconomic groups. (C) Similar logarithmic curve of drop-outs (left)
from follow-up seen in both the high as well as low socioeconomic
group; however, the slope in the low socioeconomic group is steeper.
(median 58 months, IQR 12–64 months) compared with those of
mid (median 20 months, IQR 6–56 months) and late presenters
(median 8 months, IQR 1–22 months) (figure 3). There was a
significant difference between the follow-up of patients below 6
months of age and those more than 24 months of age (P=0.0007).
1552 Chougule P, et al. Br J Ophthalmol 2018;102:1550–1555. doi:10.1136/bjophthalmol-2017-311294
Br J Ophthalmol: first published as 10.1136/bjophthalmol-2017-311294 on 31 January 2018. Downloaded from http://bjo.bmj.com/ on January 4, 2020 at AAO/BJO. Protected by copyright.
There were no significant differences in the follow-up between
the early and mid or mid and late presenters group (figure 3).
Patients who underwent additional intervention were divided
into two subgroups: one with secondary IOL implantation
and the other group with any other procedures. There was no
significant difference in the follow-up between these two groups
(P=0.44). Patients undergoing  ≥2 secondary interventions did
not show any significant difference in the follow-up from those
undergoing single secondary intervention (P=0.12). The visual
outcomes at the final visit are shown in table 2.
Discussion
Follow-up in children after cataract surgery has been a major
concern in the developing world due to lack of awareness, means
of transport and poverty. The follow-up rates are variable in
different parts of the globe ranging from a mean follow-up of 3.5
months in Mexico13 to 98.3% of patients attending at least one
follow-up, 66.9% patients attending 2 weeks of follow-up and
42.9% attending 10 weeks of follow-up in Tanzania.14 Gogate et
al reported only 20.6% patients followed up regularly.15 These
studies included children up to late teens undergoing surgery
for all types of cataract including traumatic cataract whereas we
focused particularly on children less than 5 years of age operated
for either congenital or developmental cataract, which are more
prone to permanent visual loss.
We noted an exponential rate of drop-outs in the follow-up
with close to 40% being lost by 3 months and then slowing
down to 50% by 1 year and further down to 72% drop-outs
at the end of 5 years (figure 2A). It is known that the myopic
shift is greater in younger children and follows a logarithmic
curve,18 which implies that the maximum refractive changes
occur within the first year of surgery. Hence, a good follow-up
in the initial postoperative period is necessary for optimal refrac-
tive correction.
Figure 2A highlights two points; one being that the maximum
efforts to create awareness for a good follow-up needs to be done
in the perioperative period, as the parents are more receptive
then, and once again after 1 month, so that we can reach out to
the maximum number of patients before they drop out. Second,
if a patient is coming for follow-up until 1 year or more, then
he/she is likely to continue follow-up for a longer time. There
could be multiple explanations to this trend such as parents
assuming that their responsibility is completed once the surgery
gets over, or that once the child sees well, there is no necessity
for further visits, or that they were not aware about the need for
follow-up.15 These reasons can be easily tackled with the help of
a good counselling team in the perioperative period. Frequent
visits initially may be taxing to the parents considering the direct
and indirect financial burden with respect to travelling, accom-
modation and per-diem expenses. Many of the parents live on
daily wages, especially in the low socioeconomic group. Travel-
ling from long distance means additional expenditure on travel
and accommodation, and also loss of livelihood for a few days,
which may make a huge impact on the financial aspects of these
families. Frequent and regular visits in the initial period may be
a huge discouraging factor for them to continue the follow-up;
however, they should be informed about the prospects of fewer
postoperative visits later.
Gogate et al found that children less than 5 years of age had
better follow-up compared with older children.15 However, the
follow-up pattern of children less than 5 years has been poorly
understood. We found a significant correlation between age at
surgery and total follow-up. In patients with congenital cataract,
 Clinical science

Br J Ophthalmol: first published as 10.1136/bjophthalmol-2017-311294 on 31 January 2018. Downloaded from http://bjo.bmj.com/ on January 4, 2020 at AAO/BJO. Protected by copyright.
Table 1  Details of each factor and its association with follow-up of the patient
Factor Sample size Median follow-up in months IQR in months P value Test
Age 169 10 4–27 P=0.00003 Spearman’s correlation
rs=−0.32
Sex 0.49 Mann-Whitney U test
 Male 109 23 4–59
 Female 60 19 3–51
Community 0.71 Mann-Whitney U test
 Urban 36 25 4–60
 Rural 133 22 3–58
Distance 169 222 78–314 0.12 Spearman’s correlation
Socioeconomic status 0.009 Mann-Whitney U test
 High 82 35 8–60
 Low 87 14 2–54
Onset 0.64 Mann-Whitney U test
 Congenital 96 24 4–60
 Developmental 17 32 5–53
Time delay in surgery 169 2.5 0.5–6 0.48 Spearman’s correlation
Laterality* 0.31 Mann-Whitney U test
 Unilateral 36 36.5 4–62
 Bilateral 133 20 3–57
Morphology 0.42 Kruskal-Wallis test
 Partial B/L† 44 22.5 3–59
 Total U/L‡ 28 17.5 1–49
 Total B/L 51 12 2–53
IOL§ 0.37 Mann-Whitney U test
 Yes 107 20 4–56
 No 62 36.5 2–61
Secondary intervention¶ <0.0001 Mann-Whitney U test
 Yes 36 59 37–64
 No 133 13 2–51
Subgroup analysis
Congenital cataract presentation 0.0015 Kruskal-Wallis test
 Early 41 58 12–64 Early vs mid=0.07
 Mid 31 20 6–56 Early vs late=0.0007
Mann-Whitney U test and
 Late 24 8 1–22 Mid vs late=0.027 (not Bonferroni correction
significant using Bonferroni
correction)
Additional procedure 0.44 Mann-Whitney U test
 Secondary IOL 9 59 56–64
 Secondary intervention¶ 36 59 37–64
*The other eye of four bilateral cases were excluded from the analysis since they were operated on beyond the study period or did not undergo surgery for the other eye. These
four cases were considered as unilateral for analysis except for the analysis of visual acuity at last follow-up shown in table 2.
†B/L, both eyes have partial cataract.
‡U/L, at least one eye has total cataract.
§IOL, intraocular lens—number of patients. In case of bilateral cataracts, IOL was implanted either in both eyes or both eyes were left aphakic. Therefore, IOL implantation was
counted as number of patients rather than number of eyes.
¶Secondary intervention—all surgical or laser procedures done to improve the vision of the child (except secondary IOL) or for the management of any complication after the
primary surgery.

those operated before 6 months of age (early presenters) had
better follow-up compared with the late presenters. This could
be attributed to the fact that if the parents were not vigilant
enough to bring the child to the hospital early, they may not
be so sincere with the follow-up either. This finding has been
in consistence with the study by Eriksen et al.14 Nine patients
(21.95%) in the early presenter group (≤6 months at surgery) in
congenital cataract did not follow up for more than 1 year with
a median follow-up of 1 month.
We did not find any significant difference in the follow-up
between boys and girls. However, the number of girls seeking
Chougule P, et al. Br J Ophthalmol 2018;102:1550–1555. doi:10.1136/bjophthalmol-2017-311294
medical services was only half to that of boys. Other studies
have also found that the number of girls getting operated on and
following up regularly for visual rehabilitation is poor compared
with boys.13–15 This could be attributed to the male centric soci-
eties in these geographical areas. Many girls may still be deprived
of necessary medical care and efficient strategies need to be
designed to increase the number of girls being operated on and
followed up by creating awareness in the society. Pleasantly
though, we noted that if the parents of a girl are willing to visit a
hospital for surgical treatment, then they are likely to follow up
just as regularly as that of boys.
1553
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Br J Ophthalmol: first published as 10.1136/bjophthalmol-2017-311294 on 31 January 2018. Downloaded from http://bjo.bmj.com/ on January 4, 2020 at AAO/BJO. Protected by copyright.
community. Rural communities usually have poor means of trans-
port and infrastructure, which can be a hindrance to follow-up.
These observations were alarming, as we found that one-fifth
(19.11%) of patients having less than 1 year of follow-up came
from Hyderabad or Secunderabad, the twin cities in which the
study hospital is based.
Type and laterality of cataract or the time delay in cata-
ract surgery did not have any correlation with the follow-up.
Implantation of IOL at the time of surgery did not affect the
final follow-up duration. All patients who were left aphakic were
informed about the need for a second procedure for IOL implan-
tation later, but it did not encourage them to follow up regularly.
We found that the final follow-up was greater in patients under-
going secondary procedure. This could be because the parents
are more concerned with the second procedure or may be the
second procedure was an effect of better follow-up as patients
coming for review have a better chance of being diagnosed and
managed for any ocular adverse event. We found a significantly
Figure 3  Follow-up patterns after surgery in congenital cataract
lower follow-up in patients who underwent cataract surgery
subgroup: box plot shows comparison of total follow-up between
with primary IOL implantation (excluding patients who under-
early (0 to 6 months), mid (7 to 24 months) and late presenters (>24
went additional intervention) compared with those who under-
months) in children with congenital cataract. The total follow-up of
went multiple interventions in the form of secondary IOL or any
early presenters is better than mid and late presenters, but statistical
other procedure. So implanting an IOL in the primary surgery
significance was reached only between the follow-ups of early and late
could be one of the confounding factors for the poor follow-up.
presenters.
However, we did not find any significant difference in follow-up
in children undergoing additional interventions between primary
Financial constraints have been another major reason for IOL and no IOL group and in children not undergoing any addi-
poor follow-up in most parts of the world.13–15 We found that tional interventions between the two groups.
patients from the low socioeconomic group had a significantly Various strategies have been developed and implemented to
poor follow-up compared with the high socioeconomic group improve the total postoperative follow-up following paediatric
(figure 2B). Although the trend of drop-outs from follow-up was cataract. Various monetary support schemes like sponsored
similar in both groups, it was steeper in the low socioeconomic surgery, accommodation and even travelling allowances have
group (figure 2C). been advocated. Appointment of a patient follow-up coordi-
We did not find any significant relationship between the nator has shown improved compliance with follow-up,19–21 so
distance of the patient’s residence to the hospital and total did short message service reminders.22 At LVPEI, we have an
follow-up, which was surprising. Many studies have mentioned additional advantage of having developed a pyramidal model
that greater distance from the base hospital is associated with of eye care system comprising 158 vision centres, 16 secondary
poor compliance to follow-up.13–15 There was no difference in centres, 9 partner centres and 3 tertiary centres with 1 centre of
the follow-up pattern of patients coming from a rural or urban excellence extending over four states in India. About 73.52%
of patients who had a follow-up of less than 1 year belong to
districts in which LVPEI has its secondary or a partner centre
Table 2  Visual acuity at the final visit* situated. Other patients come from districts neighbouring these
No of eyes in No of eyes
centres. By decentralising the follow-up services to secondary
bilateral cataract in unilateral Total no of eyes centre, the cost of transport, accommodation and loss of pay at
Visual acuity cases (%) cataract cases (%) (%) work can be reduced significantly for the patient. This would
20/40 or better 39 (14.44) 1 (3.12) 40 (13.24)
be a great way of improving the follow-up without putting any
20/41 to 20/100 51 (18.89) 2 (6.25) 53 (17.55)
extra burden over the family.
There are a few limitations in this study. One of them is its
20/101 to 20/200 54 (20) 3 (9.37) 57 (18.87)
retrospective design. The delay in presentation and the onset
20/201 to 20/400 33 (12.22) 6 (18.75) 39 (12.91)
of cataract were determined on the basis of history given by
Worse than 20/400 28 (10.37) 1 (3.12) 29 (9.60)
parents and the clinical clues. We are not aware whether these
CFCF† to HM‡ 3 (1.11) 6 (18.75) 9 (2.98)
children followed up in their locality with an ophthalmologist.
PL§ 1 (0.37) 0 (0) 1 (0.33) However, this is highly unlikely as one-fifth of the children lost
Fixing and following 42 (15.56) 5 (15.625) 47 (15.56) to follow-up within 1 year were from the same city where the
light or brightly
hospital is located and majority of patients were from areas with
coloured objects
no tertiary eye care centres in their vicinity. The distribution of
Poor fixation or not 19 (7.04) 8 (25) 27 (8.94)
recordable
samples was not equivocal in multiple groups like urban and
rural, congenital and developmental cataract, intervention and
Total 270 32 302
no intervention group, and IOL and no IOL group.
*This table should be read with caution since it shows the visual acuity recorded The visual system is not mature in children less than 5 years
at the last follow-up ranging from 1 day to 6 years (study period January 2010 to
of age. If timely intervention is not done in these young kids,
December 2015). It does not show the final visual outcomes at 6 years.
†CFCF, counting fingers close to face. their vision can deteriorate with permanent vision loss. These
‡HM, perception of hand movement. interventions may be as simple as prescribing glasses or patching
§PL, perception of light. therapy. Our study particularly focused on the children in the
1554 Chougule P, et al. Br J Ophthalmol 2018;102:1550–1555. doi:10.1136/bjophthalmol-2017-311294

age group of less than 5 years. It showed that more than half of
the children are lost to the follow-up within 1 year when they
need maximum care. Age at surgery had a negative correlation
with the total follow-up, higher age being associated with poor
follow-up. Moreover, children from the low socioeconomic
group had a poorer follow-up compared with the high socio-
economic group. Therefore, strategies should be designed and
tested for earlier detection of paediatric cataract and reduce the
economic burden associated with frequent follow-up visits in
order to improve the follow-up. The time frame to implement
these strategies is from the perioperative period up to 1 month
postoperatively, in order to reach out to the maximum number
of patients.
Contributors  Design and conduct of the study: RK, PC, SM. Collection,
management, analysis and interpretation of the data: PC, RK, SM, AM. Preparation,
review or approval of the manuscript: PC, AM, RK.
Funding  This work was supported by Hyderabad Eye Research Foundation (HERF).
Competing interests  None declared.
Patient consent  Detail has been removed from this case description/these case
descriptions to ensure anonymity. The editors and reviewers have seen the detailed
information available and are satisfied that the information backs up the case the
authors are making.
Ethics approval  LVPEI Ethics Bureau.
Provenance and peer review  Not commissioned; externally peer reviewed.
© Article author(s) (or their employer(s) unless otherwise stated in the text of the
article) 2018. All rights reserved. No commercial use is permitted unless otherwise
expressly granted.
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Clinical science
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