Journal of the College of Physicians and Surgeons Pakistan 2012, Vol. 22 (8): 497-500 497

INTRODUCTION

Ocular trauma is the leading cause of unilateralblindness all over the world.1 Traumatic cataract is acommon sequelae of ocular injuries in adults andchildren.2,3 The incidence of ocular injuries varies indifferent parts of the world. From India, the reportedincidence is 20.53%,4 and from Pakistan it is 12.9%.5Management of traumatic cataract that results fromeither blunt or penetrating ocular trauma needs specialconsideration because of associated injury to ocular andperiorbital structures.

Surgery of traumatic cataract can be primary orsecondary. Primary cataract removal is suggested if thelens is fragmentized, swollen causing a pupillary block orto examine the posterior segment otherwise blocked bylens opacity.6 Secondary cataract removal is morebeneficial because of improved visibility, properintraocular lens calculation, and less chances of post-operative inflammation.6

The aim of this study was to evaluate the final visualoutcome of a series of patients with secondary

extraction of traumatic cataract along with demographicfeatures and modes of trauma.

METHODOLOGY

Analysis of medical records of all patients who waspresented with unilateral traumatic cataract, underwentsurgical intervention and completed at least 6 monthsfollow-up during July 2007 to June 2010 at Departmentof Ophthalmology, Liaquat University Hospital,Hyderabad. Patients of both genders and all age groupswith unilateral traumatic cataract were included in thestudy. Patient's data including demographic details,causative agents, initial visual acuity, intraocularpressure, slit lamp examination findings, B-scanfindings, treatment / surgery, early and late complicationsand final outcome were obtained from patient's chart inthe hospital record. Removal of cataract was performedas a second and separate procedure in patients ofperforating ocular injury, intraocular lens (IOL)implantation was performed only in patients withadequate capsular support. Patients without anycapsular support were kept aphakic. Anterior vitrectomywas performed in patients with posterior capsular tearand vitreous prolapse. Patients were subsequentlyfollowed-up on 1 day, 1 week, 6 weeks, 3 months and 6months postoperatively. At each follow-up visit patient'svisual acuity was recorded. Final best corrected visualacuity (BCVA) was recorded on the 5th postoperativevisit i.e. at 6 months.

ORIGINAL ARTICLE

Visual Outcome of Unilateral Traumatic CataractMariya Nazish Memon, Ashok Kumar Narsani and Noor Bukht Nizamani

ABSTRACTObjective: To evaluate the visual outcome of a series of patients presenting with unilateral traumatic cataract.Study Design: Observational study.Place and Duration of Study: Ophthalmology Department, Liaquat University Hospital, Hyderabad, from July 2007 toJune 2010.Methodology: Analysis included data of 41 patients (31 males and 10 females) with unilateral traumatic cataract. Dataregarding demographics, causative agent, clinical course and outcome in terms of best corrected visual acuity (BCVA) wasretrieved from the patients’ files in hospital record. Data was expressed as frequencies, percentages, mean and standarddeviation.Results: There was a male predilection with a male to female ratio of 3.1:1. The age group more frequently affected was5 – 14 years (58.5%). Commonest causative agent was trauma with wooden stick in 13 eyes (31.7%) followed by thorn in9 eyes (22%) and stone in 7 eyes (17.1%). Pre-existing posterior capsular defects were observed intraoperatively in 6eyes. Posterior capsular opacification was evident in 10 eyes (24%). Best corrected visual acuity of 6/18 or more at 6months was achieved in 29 eyes (70.8%). Duration between injury and cataract surgery did not affect the final visualoutcome of traumatic cataract patients.Conclusion: Patients with traumatic cataract if managed appropriately can have best possible visual outcome. Youngmales are commonly affected. Taking protective measures in sports and work as well as patient education can avoid oculartrauma and traumatic cataract formation.

Key words: Traumatic cataract. Posterior capsular defects. Posterior capsular opacification. Ocular trauma.

Department of Ophthalmology, Liaquat University of Medicaland Health Sciences, Jamshoro.

Correspondence: Dr. Mariya Nazish Memon, Department ofOphthalmology, Liaquat University of Medical and HealthSciences (LUMHS), Jamshoro.E-mail: mariyamemon@hotmail.com

Received June 30, 2011; accepted May 30, 2012.

The data processing was carried out on StatisticalPackage for Social Science (SPSS) version 10.0software and expressed as frequencies, percentages,mean and standard deviation.

RESULTS

Over a period of 3 years i.e. from July 2007 to June2010, a total of 41 unilateral traumatic cataract patientswere managed at Liaquat University, Eye Hospital,Hyderabad. Out of a total 41 unilateral traumatic cataractpatients, there were 31 (75.6%) males and 10 (24.4%)females with a male to female ratio of 3.1: 1. The ageranged between 5 and 55 years (mean age: 18.5 ± 12years). The majority of the patients (58.5%) were agedbetween 5 and 14 years. Males were affected mostly.Details are shown in Table I.

Most of the injuries were caused by wooden stick(31.7%) followed by thorn (22%) and stone (17.1%,Table II).

The pre-operative visual acuity was perception of light in31 patients (75.6%), counting finger at 1 meter in 9patients (22%) and 6/24 in 1 patient (2.4%). Totalcataract was the most prevalent type with a percentage

of 90%. The other types (rosette, absorbed lens matter,calcified and posterior sub-capsular) were evenlydistributed comprising 2.4% cases each. Anteriorcapsular rupture and corneal scar were the commonassociated ophthalmic injuries found in 20 (44%) and 12(29.3%) patients respectively.

Lens aspiration was done in 36 cases (87.8%), lensaspiration and anterior vitrectomy in 4 cases (9.7%) andPhacoemulsification in 1 case (2.4%). Posteriorchamber intraocular lens was implanted in 39 patients(95%) while 2 (5%) were left aphakic due to inadequatecapsular support. Table III highlights the BCVA in termsof duration between the injury and cataract surgery.Majority of the cases had surgery in less than one month(17 cases) and between 1-6 months (16 cases).Duration between injury and cataract surgery was notmarkedly different among the patients.

The major postoperative complications encountered onfirst postoperative day were anterior uveitis in 20(48.8%) and corneal oedema in 10 (24%) patients whichresponded to medical therapy. Posterior capsularopacity was the only late complication seen in 10patients (24%) at 6 months postoperatively. In thesepatients visual acuity improved to 6/6 – 6/12 after NdYAG laser capsulotomy. The average time betweenlaser capsulotomy and surgery was 6 months. On firstpostoperative day, majority of the patients had visualacuity ranging between < 3/60 to 6/24, on sixth weekgreater part had between 6/36 to 6/6; at sixth month thebest corrected visual acuity of 20 patients (48.8%) was6/9 to 6/6 and 29 (70.8%) patients had visual acuity of6/18 or better. The main causes of no improvement invisual acuity were corneal opacity, high astigmatism,and macular scar.

DISCUSSION

This study included 41 cases of traumatic cataractmanaged at Department of Ophthalmology, LiaquatUniversity of Medical and Health Sciences, Hyderabad.Traumatic cataract is one of the most common outcomesof ocular injuries. There is a 1-15% incidence oftraumatic cataract in ocular injuries.7 Trauma is theleading cause of 90% of acquired paediatric cataracts.8

In this study, male preponderance was found with amale to female ratio of 3.1 : 1. It is due to involvement ofmales in sports and outdoor activities. Worldwide

Mariya Nazish Memon, Ashok Kumar Narsani and Noor Bukht Nizamani

498 Journal of the College of Physicians and Surgeons Pakistan 2012, Vol. 22 (8): 497-500

Table I: Baseline patient demographic characteristics (n = 41).

Age distribution n (%)

5 - 14 years 24 (58.5)

15 -24 years 7 (17.1)

25 -34 years 4 (9.8)

35 -44 years 3 (7.3)

> 45 years 3 (7.3)

Gender

Male 31 (75.6)

Female 10 (24.4)

Laterality

Right eye 16 (39)

Left eye 25 (61)

Type of Injury

Penetrating 28 (68.3)

Blunt 13 (31.7)

Table II: BCVA versus causative agents.

Causative Best corrected visual acuity

agents < 3/60 3/60 – 6/36 – 6/18 – 6/9 – Total %

6/60 6/24 6/12 6/6 (n)

Punch 1 0 0 0 0 1 2.4

Steel wire 0 0 0 1 0 1 2.4

Goat horn 0 0 0 0 1 1 2.4

Scissor 0 1 0 0 0 1 2.4

Plastic toy 0 0 0 0 1 1 2.4

Stone 2 0 2 2 1 7 17.1

Iron rod 0 0 1 0 2 3 7.3

Wooden stick 0 2 2 2 7 13 31.7

Sharp piece of wood 0 0 0 1 1 2 4.9

Thorn 0 1 0 3 5 9 22.0

Needle 0 0 0 0 2 2 4.9

Total 41 100%

Table III: BCVA versus duration between injury and cataract surgery.

Duration Best Corrected Visual Acuity

between injury < 3/60 3/60 - 6/36 - 6/18 - 6/9 - Total %

and surgery 6/60 6/24 6/12 6/6 (n)

< 1 month 1 3 1 4 8 17 41.5

1- 6 months 0 0 3 5 8 16 39.0

7-12 months 0 0 0 0 3 3 7.3

> 12 months 2 1 1 0 1 5 12.2

Total 41 100%

males are more commonly involved in traumatic cataractthan females.9-11

Zaman et al. stated that majority (50.64%) of thetraumatic cataract patients ranged between 5-15years,10 which is consistent with the present findings i.e.58.5% cases ranged between 5-14 years. Sports andwork-related eye injuries most commonly occur inchildren and young adults followed by injuries related toaccidents because of involvement of children in high risksports without supervision or without employingprotective measures.10 Thompson et al. observed that amajority of the ocular trauma in children occur at homedue to lack of adult supervision.14

Penetrating injuries are the most common cause ofocular injuries;12 the same was observed in this study.Twenty eight patients (68.3%) sustained penetratinginjury whereas 13 patients (31.7%) presented with bluntinjury. The leading cause of injury was wooden stick(31.7%) followed by thorn (22%) and stone (17.1%).Krishnamachari13 and Thompson et al.14 also found thatstick and stones were the most frequent cause of injury.There was no marked difference regarding causativeagents seen on BCVA postoperatively in this series.

In this series, over 90% of cataracts were total, similarobservations were made by Krishnamachari et al.13 andPanda et al.15 They stated that most of the traumaticcataracts were total in nature. The ophthalmic injuriesmost commonly associated with traumatic cataract wereanterior capsular rupture (48.7%) and corneal scar(29.2%). Ashvini and colleagues also concluded thatanterior capsule violation (56%) and corneal laceration(52%) were the most frequent associations withtraumatic cataract.11

Implantation of intra ocular lens (IOL) in traumatizedeyes after removal of traumatic cataract depends onavailability of capsular support. In capsular bag or sulcusfixation is preferred if there is sufficient capsular andZonular support. Patients with insufficient capsular orZonular support are the candidate for Artisan lenses,scleral fixation IOLS and anterior chamber IOLS.16-18

In this study, lens aspiration was done in 36 cases(87.8%), lens aspiration, posterior capsulotomy andanterior vitrectomy in 4 cases (9.7%) andPhacoemulsification in 1 case (2.4%). Posteriorchamber intraocular lens was implanted in 39 patientswhile two were left aphakic and planned for scleralfixated or anterior chamber intraocular lens. Majority ofthese patients were operated within 6 months aftertrauma. Duration between the injury and cataractsurgery was less than one month in 17 patients (41.5%),1-6 months in 16 patients (39%), 7-12 months in 3patients (7.3%) and more than 12 months in 5 patients(12.2%). Mehul and coworkers19 reported significanteffect of time interval between injury and cataractsurgery on final visual outcome (p=0.02),19 althoughthese patients did not show that.

The major postoperative complications encountered onfirst postoperative day were severe uveitis (48.8%)which responded to medical therapy. Cheema andcoworker reported that the fibrinous uveitis was the mostcommon postoperative complication (25%).20 It maymainly be due to surgical trauma in an alreadytraumatized eye and not related to type or location ofIOL inside the eye. The commonest late postoperativecomplication in these traumatic cataractous eyes wasposterior capsular opacification seen in 10 patients(24%) at 6 months postoperatively. Eckstein andcolleagues reported that posterior capsular opacity wasseen in almost 92%.21

This study revealed that satisfactory visual outcome inmajority of patients with traumatic cataract could besafely achieved after cataract removal and IOLimplantation. Best corrected visual acuity was 6/6 to 6/9in 20 patients (48.8%) and 6/18 or better in 29 patients(70.8%). Zaman et al.10 and Cheema et al.20 reportedvisual acuity of 6/18 or better in 68.7% of patients. Gainet al. concluded that postoperative visual acuity dependson complications.22 The main causes of no improvementin visual acuity in the presently reported patients werecorneal opacity, high astigmatism, and macular scar.

Blindness from ocular trauma can be avoided byemploying protective eye wears especially in high riskactivities. Patient education in schools, baby day carecentres and through media must be carried out toprevent ocular injuries in children. Once the injury hasoccurred, outcome depends on extent of injury to ocularand peri-orbital structures and immediate andprofessional approach must be taken to preventblindness.

Limitations of this study were a small sample size and afixed follow-up period. This study was conducted at atertiary care hospital where large number of complicatedcases were presented for management. It also affectedthe surgical success rates and outcome. A majority ofthe patients were from rural areas and seen by localdoctors postoperatively for their convenience whichlimited the follow-up period.

CONCLUSION

Patients with traumatic cataract can have an optional orbest possible visual outcome depending uponmanagement and complications. Young males arecommonly affected. Taking protective measures insports and work and patient education can avoid oculartrauma and traumatic cataract formation.

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