When Glasses Beat The Scalpel: Functional Vision In Pediatric Nanophthalmos

To report a case of pediatric nanophthalmos with progressive bilateral posterior subcapsular cataracts in which functional, selective refractive optimization allowed postponement of high-risk cataract surgery.

Department of Ophthalmology, 20 Août 1953 Hospital, Ibn Rochd University Hospital Center, Casablanca, Morocco.

A 10-year-old girl with a history of amblyopia was referred for progressive visual decline. She had bilateral posterior subcapsular cataracts and moderate nanophthalmos (OD 19.9 mm, OS 20.9 mm) with shallow anterior chambers. Best-corrected visual acuity had decreased to 8/20 in both eyes.

Surgery in such eyes is high-risk due to short axial length and crowded anterior segments, with potential complications including uveal effusion and malignant glaucoma.

Comprehensive refraction revealed a new prescription of +13.5 D in the right eye and +12 D in the left eye, compared to her previous glasses (+11 D and +10 D). When we trialed the new prescription, the right eye developed diplopia, likely due to prismatic effects and sensory imbalance. Using the previous spherical values while only optimizing astigmatism (−2 / −1 D → −3 / −2.5 D) restored comfortable binocular vision.

This approach improved BCVA to 12/20 and allowed safe deferral of cataract surgery.

In pediatric nanophthalmos, a cataract does not automatically necessitate immediate surgical intervention. Careful functional refractive optimization can provide meaningful visual improvement and maintain binocular stability, allowing for a safe postponement of high-risk cataract extraction. Given the elevated risk of intraoperative and postoperative complications in these anatomically complex eyes, management should be individualized, with thorough risk–benefit assessment guiding the timing of surgery.