Evolving Strategies in Pediatric Cataract Surgery: A 7-Year Analysis of Ocular Biometry and IOL Localization

Objectives: To evaluate temporal trends in ocular biometrics, patient demographics and surgical strategies for intraocular lens (IOL) localization in pediatric cataracts. Methods: This retrospective study included 291 eyes of 148 pediatric patients operated at a tertiary referral center between 2019 and 2025, comprising 219 operated eyes and 72 unaffected fellow eyes serving as intra-individual controls. Eyes were stratified into three chronological cohorts (2019-2020, 2021-2022, 2023-2025). Axial length (AL), white-to-white (WTW) diameter and central corneal thickness were analyzed in relation to the anatomical IOL placement. A generalized linear mixed model with a random intercept per patient accounted for the within-patient correlation between fellow eyes. Results: Mean AL increased from 18.91 ± 2.83 mm to 20.32 ± 3.19 mm (p = 0.004), whereas the increase in WTW diameter was not significant (p = 0.450). The age at surgery increased significantly across the periods (median 1.08, 1.33 and 3.13 years; p < 0.001), a general temporal effect that was not modified by the site of implantation (p = 0.32). Underlying etiology strongly influenced the approach: all eyes with Marfan syndrome received an iris-fixated IOL, whereas 90% of uveitic eyes remained aphakic. Femtosecond laser-assisted cataract surgery (FLACS) was used in 13 eyes and confined to the most recent period. Conclusions: Pediatric cataract surgery shows a progressive increase in the age at surgery that is not specific to any IOL localization, while the surgical approach is frequently determined by the underlying etiology. The increasing use of FLACS represents an institutional trend; the small number of cases and absence of outcome data preclude conclusions regarding its safety or feasibility.