AIM: To compare the visual outcomes of children with small (≤3 mm) posterior polar cataracts (PPC) and posterior lenticonus who had cataract extraction surgery with the visual outcomes of those who were managed conservatively. METHODS: Children who initially had small PPC and posterior lenticonus who were followed up over 1-year period were retrospective reviewed in the study. Patients receiving surgery were compared with those receiving conservative therapy. The axial length, keratometry, refraction, best-corrected visual acuity (BCVA), and strabismus measurements were recorded. Lens morphology, i.e., the location, size, and depth of the cataract lesion, was measured with a Scheimpflug imaging system. To help control for baseline differences in the groups, patients were matched with controls by propensity score methodology. RESULTS: The study evaluated 60 patients (30 in the surgery group and 30 in the conservative therapy group) after matching by propensity score. Patients who underwent cataract surgery showed greater BCVA improvements (0.36±0.24 logMAR) than patients who were treated without surgery (0.22±0.26 logMAR; P=0.036). Surgery was effective in patients with a rear projection length (RPL) less than 1.0 mm and a pretreatment BCVA worse than 0.52 logMAR. CONCLUSION: Children with small PPC and posterior lenticonus who undergo cataract surgery experience greater BCVA improvements than those managed conservatively. Certain patients presenting with a RPL less than 1.0 mm and a pretreatment BCVA of 0.52 logMAR or worse may benefit from surgery.