Children’s eyes have unique anatomical and physiological characteristics, and different surgical approaches should be used for different age groups and different forms of children’s cataracts. Some surgical approaches are changed at any time according to the intraoperative conditions of children’s eyes, which requires surgeons to not only have skillful cataract surgery skills, but also understand the anatomical and functional parameters of children’s eyes and implement different surgical plans during surgery in order to pursue the maximum recovery of visual function after surgery for children. 1. Whether to choose scleral or corneal tunnel for pediatric cataract surgery incision Glaucoma may occur in any pediatric eye performing cataract surgery. The scleral incision requires cutting the conjunctiva and promotes the proliferation of conjunctival fibroblasts and inflammatory cells, which can lead to trabeculectomy failure, thus more cataract surgeons choose the corneal tunnel incision. However, recent studies have shown that only 37.8% of ASCRS members and 26.9% of AAPOS members choose the corneal tunnel incision for pediatric cataract surgery. To reduce the incidence of postoperative endophthalmitis in children with cataract, foreign surgeons choose a scleral tunnel incision and suture the incision at the end of surgery. Because of the tendency of young corneal tissue to cloud at the tunnel, we usually choose a scleral tunnel incision for surgery in infants and children. In older children, a corneal tunnel incision is used when a folding IOL is implanted. 2. How to complete a complete continuous circumferential capsule tear (CCC) in children’s eyes A high molecular weight viscoelastic is used to flatten the anterior capsule membrane, deepen the anterior chamber, and relax the anterior capsule membrane to resist vitreous protrusion caused by scleral collapse. During the capsular tearing process, the size, shape and direction of the capsular opening are frequently and continuously adjusted starting from the center of the pupil, repeatedly grasping the root of the successive capsular tears and adjusting the direction to tear in accordance with the planned course. Due to the extension of the capsule, the final completed capsule opening is larger than the beginning. Often, part of the lens material protrudes into the anterior chamber due to the intraocular pressure generated by the vitreous anterior protrusion during the capsule tearing process, at which time the lens material can be aspirated before completing CCC. 3. Thorough removal of lens material Childhood cataracts are soft lens material that can be easily aspirated, however, the purpose is not only to thoroughly aspirate the lens material, but also However, the purpose is not only to completely remove the lens material, but also the residual fibers or filaments, which contain a large number of mitotic active cells that can gradually proliferate and migrate to the visual axis, causing visual axis clouding, especially in infant eyes, where the cortex looks like a gum-like gum with close adhesion to the capsule membrane. 4. Role of posterior capsule tearing and anterior vitrectomy in preventing visual axis clouding It is well known that the posterior capsule membrane and anterior vitreous surface can serve as a scaffold for cell proliferation. After surgery, lens epithelial cells, chemotactic pigment epithelial cells, exudates and cells from the disrupted blood-atrial water barrier adhere to them, causing visual axis clouding. Therefore, many surgeons use posterior capsule continuous circumferential capsule tear (PCCC) combined with anterior vitrectomy (AV) as a routine procedure for cataract in children. However, there is an ongoing academic debate about the posterior capsule membrane as a biological barrier between the anterior and posterior segments of the eye, which theoretically should not be removed. Significant visual axis clouding occurs in most cases where the posterior capsule is preserved intact, most commonly at 18 months-2 years postoperatively, so we believe that continuous circumferential tearing of the posterior capsule combined with anterior vitrectomy is necessary for cataract management in infants and children, while in older children, the posterior capsule can be preserved if it can be combined with the Nd:YAG laser at about 2 years. Our experience is that anterior vitrectomy is performed in children <5 years old; to prevent the formation of a mass clouding on the anterior surface of the vitreous. The choice of whether to perform anterior vitrectomy at the age of 5-8 years should be made according to the specific situation of the child; for those >8 years old, the complete posterior capsule should be preserved. 5. Timing of treatment of posterior capsule Most physicians prefer to treat the posterior capsule and perform anterior vitrectomy at the same time of cataract surgery. The incidence of macular cystoid edema and retinal detachment after surgery in pediatric eyes is lower than expected, depending on the state of vitreous formation in pediatric eyes, high-quality vitrectomy technique, and sharp, high-speed cutting speed. the Nd:YAG laser is usually used for second-stage posterior capsulotomy, which has a 28% recurrence rate because the laser cannot resolve secondary clouding from lens fiber growth provided by the anterior vitreous surface. Posterior capsular membrane opening can be accomplished by manual capsular tearing or by using a vitrectomy head. Posterior capsulotomy combined with vitrectomy can be performed before/after IOL implantation, and each of its modalities has its own advantages. 6. The ultimate goal and extent of anterior vitrectomy Most surgeons believe that adequate central vitrectomy allows for the loss of hyperplastic lens epithelial cells and chemotactic cells that produce visual axis clouding with the vitreous as a scaffold. We have learned from years of surgical experience that any vitreous protruding from the posterior capsulotomy plane should be removed, and that the depth of removal is only as deep as can be seen with an operating microscope without placing a posterior segment vitrectomy visualization system. In conclusion, in view of the anatomical and physiological peculiarities of children’s eyes, different surgical approaches are used to obtain reconstruction of visual function after cataract surgery in children and to reduce the chances of postoperative complications and reoperation. The different surgical approaches we choose for each child depend on a combination of factors of the child and the surgeon’s surgical habits.