Retinal Microvascular and RNFL Changes After Bilateral Congenital Cataract Surgery: Preliminary Results from an Exploratory OCT/OCTA Analysis

Background Early visual deprivation and subsequent surgical rehabilitation in congenital cataracts may induce long-term structural retinal changes. This study aimed to investigate retinal microvascular and retinal nerve fiber layer (RNFL) alterations in children after bilateral congenital cataract extraction followed by secondary intraocular lens (IOL) implantation, using optical coherence tomography angiography (OCTA) combined with an OCTAVA-based quantitative analysis. Methods This retrospective, cross-sectional exploratory study included children who underwent bilateral congenital cataract extraction before one year of age with subsequent secondary IOL implantation. Age-matched healthy children served as controls. All participants underwent standardized ophthalmic examinations, spectral-domain OCT, and 6×6 mm macular and peripapillary OCTA imaging. Quantitative vascular metrics included mean vessel diameter, branchpoint density, and tortuosity. RNFL thickness was assessed in all quadrants. To account for significant baseline differences, imaging metrics were corrected for magnification effects, and between-group comparisons were adjusted for age, axial length (AL), and spherical equivalent (SE) using generalized estimating equations (GEE). Results Eighteen pseudophakic patients (36 eyes; median age 8 years) and 17 controls (34 eyes; median age 9 years) were included. Pseudophakic eyes were significantly more myopic and had longer AL than controls (p < 0.05). In GEE-adjusted models, OCTA demonstrated increased mean vessel diameter (p = 0.001), higher tortuosity (p < 0.001), and reduced branchpoint density (p = 0.004) in the study group. No significant group differences were observed for choroidal thickness, choroidal vascularity index, or foveal avascular zone. Adjusted RNFL thickness was significantly greater in the temporal (p = 0.006) and inferotemporal (p = 0.023) sectors of the study group, while global RNFL thickness did not differ. Conclusions Children undergoing bilateral congenital cataract surgery with secondary IOL implantation exhibit persistent microvascular remodeling—characterized by dilated, more tortuous vessels with reduced branching—and localized temporal RNFL thickening despite visual rehabilitation. These findings provide preliminary evidence of distinct structural alterations that warrant confirmation in larger longitudinal studies.