First Reported Pediatric Congenital Cataract Case Managed With Early Aphakia And Secondary Dual Intraocular Lens Implantation: Monofocal Iol Combined With Supplementary Addon Technology For Reversible Multifocality

The optimal timing and strategy for intraocular lens (IOL) implantation in congenital cataract remain debated. Evidence suggests that maintaining aphakia during infancy may reduce complications such as secondary glaucoma, visual axis opacification, and refractive unpredictability, while allowing physiological ocular growth. Preservation of capsular integrity may further enhance future surgical flexibility. We describe a staged pediatric rehabilitation strategy combining early aphakia, delayed secondary IOL implantation, and supplementary AddOn technology to enable reversible multifocality.

Female patient who underwent bilateral congenital cataract extraction at 3 months of age (2019) at a tertiary referral centre affiliated with the Benetti Institute of Ophthalmology (Itatiba, São Paulo, Brazil). Secondary dual intraocular lens implantation was performed at age 6 years (2025) at the same institution. Surgery was conducted under general anaesthesia.

A female patient underwent bilateral congenital cataract extraction at 3 months of age (2019). Posterior capsulotomy was intentionally deferred to preserve capsular integrity for long-term planning. In accordance with evidence, including the Infant Aphakia Treatment Study, the patient was maintained aphakic to minimise risks associated with primary infantile IOL implantation and to permit physiological ocular development. Structured visual rehabilitation continued until age 6.

Preoperative assessment included optical biometry and comprehensive ocular evaluation. Macular OCT demonstrated preserved retinal architecture, and specular microscopy confirmed adequate endothelial cell density. Suitability for secondary and supplementary IOL implantation was established based on favourable pupil dynamics, regular corneal astigmatism, and stable capsular–zonular support.

Surgical rehabilitation involved implantation of a monofocal IOL within the capsular bag, followed by placement of a supplementary AddOn multifocal IOL in the ciliary sulcus, enabling a reversible multifocal strategy. Postoperative binocular visual acuity reached 20/40 for distance and J2 for near. No neuroadaptation difficulties have been observed, and intraocular pressure remains normal. To the best of our knowledge, this represents the first reported pediatric case combining a capsular-bag monofocal IOL and a sulcus-based AddOn multifocal IOL to achieve reversible multifocality.

A staged rehabilitation strategy integrating early aphakia, preservation of capsular integrity, sustained visual development, and delayed dual IOL implantation may represent a flexible pathway for selected pediatric patients. Supplementary AddOn technology introduces a reversible optical component, permitting future adjustment or explantation if neuroadaptation challenges or ocular comorbidities arise while maintaining long-term optical stability. This concept may expand contemporary approaches to pediatric cataract rehabilitation.