A Rare Case Of Cataract Surgery During Pregnancy: Ophthalmic, Obstetric And Ethical Considerations

Cataract surgery during pregnancy and the post-partum period is rare, and evidence guiding surgical timing, refractive predictability, and peri-operative management remains limited. Pregnancy-related physiological ocular changes may influence biometry and refractive outcomes. Available data to inform consent for cataract surgery during pregnancy are of the lowest level of evidence.  We present a rare case of a patient presenting with significant visual impairment from cataracts who elected for surgery during pregnancy. We discuss pre- and post- partum refractive, biometric and topographical data as well as surgical and ethical considerations.

A 38-year-old woman presented at 6 weeks’ gestation with reduced vision. The patient reported significant functional impairment affecting childcare and ability to work. Her best corrected visual acuity was 6/36 (right) and 6/24 (left). Medical history included gestational diabetes in two prior pregnancies. Ocular history was unremarkable with previous normal visual acuity. Examination demonstrated visually significant bilateral posterior subcapsular cataracts. Diabetes mellitus was excluded.

Multidisciplinary consultation with the obstetrics team identified no specific foetal contraindications, and additional post-operative obstetric ultrasound monitoring was offered. The risks of surgery versus continued visual disability were discussed with the patient.

The patient elected to proceed with unilateral antenatal cataract surgery. Surgery was scheduled at 25 weeks’ gestation, accounting for potential preterm foetal viability and patient positioning considerations. Uncomplicated right phacoemulsification was performed under topical anaesthesia, with posturing of the lower body to one side. An emmetropic monofocal intraocular lens was implanted with a predicted spherical equivalent of −0.30 D. 

At 6 weeks, refraction measured +0.50 D, and unaided distance visual acuity improved to 6/9. Post-partum, biometry and corneal topography were repeated ahead of a plan for second eye surgery, showing no significant changes. The patient delivered her baby at term without complication.

Pregnancy-associated changes, including increased corneal thickness, may reduce refractive predictability despite standard biometry and uncomplicated surgery. Surgical decision-making requires consideration of anaesthesia, systemic exposure, medication safety, and maternal functional needs. To minimise foetal exposure to postoperative drops, punctal occlusion or dropless cataract surgery may be considered. Respect for the patient’s autonomy remains paramount in pregnancy.

Visually significant cataracts during pregnancy present unique clinical, refractive and ethical considerations. Careful counselling regarding refractive expectations, available evidence and multidisciplinary management are essential. Further studies are required to better characterise outcomes and optimise peri-operative strategies in this population. Whilst cataract surgery may be considered an elective intervention to be avoided in pregnancy,  in select cases where visual impairment is causing challenges and risk in a pregnant patient’s daily life, cataract surgery may safely be offered during pregnancy in the appropriately counselled patient.