Continuing Education Activity

The formation of traumatic cataracts is common after blunt or penetrating ocular trauma. Up to 65% of eye traumas lead to cataract formation, resulting in significant short- and long-term vision loss. Most cases of ocular trauma result in some degree of lenticular swelling. The severity of the trauma and the integrity of the capsular bag determine the type of cataract developed and the clinical course. Traumatic cataracts may occur acutely or develop slowly over time, as in the case of a concussion cataract.

Surgery for traumatic cataracts is often more complex than standard age-related cataracts due to associated damage to the lens capsule and zonules, synechiae, and reduced media clarity. A thorough preoperative assessment and planning are crucial to achieve successful outcomes and optimal vision.[

This activity reviews the etiology, epidemiology, evaluation, management, procedural techniques, complications, deterrence, and age-related specifics of traumatic cataracts while highlighting the role of the interprofessional team in improving outcomes for patients after ocular trauma.

Objectives:

• Identify patients at risk for developing traumatic cataracts based on their clinical history.
• Assess patients with ocular trauma for globe injury and traumatic cataracts.
• Apply best practices when treating traumatic cataracts to reduce the risk of complications and facilitate optimal visual acuity.
• Develop and implement effective interprofessional team strategies to improve outcomes for patients with traumatic cataracts.

Introduction

Ocular trauma is a significant cause of vision loss, and as many as 1.6 million people lose sight yearly due to traumatic cataracts.[1] Eye injuries occur in approximately one-fifth of adults, with men and young people being the most commonly affected.[2] There are an estimated 55 million eye injuries annually, with developed countries experiencing a high incidence of one-sided blindness.[3] Thorough assessment and management of oculofacial trauma are crucial, and guidelines are available to determine the visual prognosis.[4] Factors such as initial visual acuity, pupillary reflex response, and the severity of the trauma are essential in this assessment.[5] This activity provides a comprehensive guide to managing lens injuries, particularly traumatic cataracts, including aseptic and antiseptic procedures before surgery and surgical indications and timing. Patients can receive the appropriate treatment and care with this approach, leading to better visual outcomes after ocular trauma.

Etiology

Ocular trauma can occur via many mechanisms, affecting the crystalline lens in various ways, including perforating or blunt trauma, electric shock, ultraviolet and ionizing radiation, and chemical injuries.[6][7] 

In penetrating trauma, where an object with a sharp edge, such as glass, wood, or metal, pierces the eye, a traumatic cataract may develop immediately if the object reaches the lens after passing through the cornea.[4][8] The lens may also be damaged or completely ruptured, leading to partial or complete cataracts and blindness (see Image. Traumatic Cataract Secondary to Penetrating Ocular Injury). Chemical trauma may occur when a foreign substance enters the eye and alters the composition of the lens fibers, leading to traumatic cataracts.[7][9] Radiation exposure can also damage and rupture the lens, resulting in traumatic cataracts over time.[10] Radiation-induced ocular trauma is often seen in children.[11] 

Opacification of the lens may occur immediately after an injury or years later; the type of cataract formed will depend on the nature and extent of the ocular trauma.[11] Penetrating trauma may result in a cataract proportional to the size of the opening in the lens capsule. No morphologic grouping exists for cataracts due to penetrating trauma.[12][4][13] 

In contrast, cataracts secondary to blunt trauma often exhibit a distinctive rosette- or flower-shaped appearance.[14] Larger capsular openings can cause the entire lens to become cataractous, while smaller openings may produce only a focal opacity.[8] Additionally, blunt trauma can cause cataract formation without a loss of capsular integrity due to the forces of the original trauma or subsequent inflammation.[15] Ocular trauma may also lead to subcapsular cataracts.[16] Electric shock can cause diffuse milky-white opacification or multiple snowflake-like opacities. Ultraviolet radiation can induce true exfoliation of the anterior lens capsule with subsequent cataract development. The ionizing radiation used to treat ocular tumors or during cardiac interventions may cause posterior subcapsular opacities. Finally, chemical injuries to the lens can result from various sources, including naphthalene, thallium, lactose, and galactose.[17]

Epidemiology

The prevalence of cataract formation after ocular trauma is approximately 65%.[2] Traumatic cataract formation contributes significantly to short-term and long-term vision impairment on a global scale.[18] Eye injuries occur in approximately one-fifth of adults, with men and young people being the most commonly affected.[19][20] There are an estimated 55 million eye injuries annually, with up to 1.6 million people losing sight yearly due to traumatic cataracts.[21] 

The incidence of traumatic cataract formation varies globally, influenced by age, gender, environment, and socioeconomic factors.[22] While males are more prone to ocular injuries from outdoor activities, gender does not significantly affect visual outcomes.[22] Younger individuals are more susceptible to ocular injuries but respond well to treatment.[21][22] The incidence of ocular injuries is higher in rural areas, but the visual outcome does not differ significantly from urban counterparts. The etiology of the traumatic incident varies with geography and socioeconomic status, but the results do not differ significantly. 

Pathophysiology

Disruption of the lens fibers after blunt or penetrating ocular trauma commonly leads to a traumatic cataract.[23][24][25] The traumatic mechanism and the integrity of the capsular bag dictate the morphology of the cataract and the clinical course.[26] Trauma disrupts and injures the lens fibers, leading to lens swelling.[23][27] Worldwide, traumatic cataract formation is observed in 24% of patients with globe contusions. Concussion cataracts, another type of traumatic cataract, occur due to blunt trauma. Although the lens capsule is not extensively damaged, it becomes progressively opaque over time. The pathophysiology of traumatic cataracts occurs through direct rupture and distortion of the capsule or coup and equatorial expansion due to various forces transferring the traumatic energy to the other side of the eye.[28] Traumatic cataracts typically present as rosette or stellate subtypes.[9][29] 

The lens comprises the cortex and the nucleus, and the lens capsule is an uninterrupted basement membrane of modified epithelial cells. Denaturation and coagulation of lens proteins can lead to cataract formation through loss of transparency due to degenerative processes.[28][30] Various disturbances can cause these degenerative processes. Disturbances during lens growth and formation lead to congenital cataracts. Fibrous changes in the lens epithelium result in subcapsular cataracts, cortical hydration between lens fibers induces cortical cataracts, and the deposition of pigments such as urochrome leads to nuclear cataracts.[30] Trauma can also cause partial (subluxated) or complete (luxated) displacement of the lens, leading to ocular disorders such as phacomorphic glaucoma, in which the lens diameter swells and occludes the iridocorneal angle. (see Image. Posttraumatic Crystalline Lens Subluxation) Trauma may also induce lens-particle glaucoma, where lens proteins clog the trabecular meshwork, or an inflammatory response within the anterior chamber leading to the development of phacoantigenic glaucoma.[7][28][30][31][32][33]

Histopathology

Traumatic cataracts lack a standardized morphologic classification system. Cataract morphology is dictated by the type of injury and the time interval between injury and intervention.[13][34] Cataracts are categorized by lenticular opacity and are total, white soft, or membranous. A total cataract is characterized by a lack of visible lens matter between the capsule and nucleus. The fusion of both capsules is characteristic of a membranous cataract with minimal cortical material. White soft cataracts have loose cortical material in the anterior chamber with a ruptured lens capsule. Additionally, a lens with a rosette opacity pattern indicates a traumatic cataract caused by blunt trauma.[14]

Ultrastructural findings of traumatic white cataracts suggest that dysfunction of the lens epithelium can lead to edema of superficial cortical lens fibers, resulting in degeneration and localized vacuolization.[23][28][35] Gap junctions and desmosomes interconnect lens epithelial cells and contain scattered microfilaments.[36] A break in the capsule can cause a change in tension on the underlying epithelium, which may be transmitted along the points of strong attachment from cell to cell. Capsulorhexis may be turned to the periphery at a site where these changes are most pronounced, especially if the inner pressure in the lens is high.[37] These findings may increase the rate of capsular breaks during surgery, indicating a potential correlation between histopathology, morphology, and clinical behavior of the anterior lens capsule in traumatic white cataracts.

History and Physical

The first step in evaluating ocular trauma is determining if an acute ocular emergency is present. The second step is determining if the injury is due to blunt or penetrating trauma.[38][5][39][38] If the intraocular pressure is significantly low, there may be an open globe injury, which requires caution when using topical medication or eye devices. Pediatric patients may be unable to recount their ocular trauma accurately, and an increased level of suspicion of an open globe injury or intraocular foreign body is imperative.

A comprehensive medical history should be obtained, as specific comorbidities, such as poorly controlled diabetes or hypertension, can increase the risk of complications, particularly expulsive hemorrhage or infection.[40] Particular attention should be paid to the ocular history to estimate vision potential accurately. A prior history of intraocular surgery may affect the planning of cataract extraction. The date of the most recent tetanus vaccination should be ascertained.

The physical evaluation of a traumatic cataract aims to determine if surgery is necessary and, if so, which procedure will be safest and most effective.[20][41][42] When assessing acute ocular trauma, a thorough evaluation is essential to determine the severity of the eye injury.[2][20] The physical examination should carefully evaluate visual acuity, pupillary function, and intraocular pressure. Slit lamp biomicroscopy and a dilated fundus examination should be performed. Identifying signs of zonular damage, such as phacodonesis, focal iridodonesis, vitreous prolapse, and lens subluxation, is crucial though these signs may not always be present (see Image. Traumatic Cataract).[20][43] Subtle signs of lens injury include seeing the lens equator during eccentric gaze, a decentered nucleus in the primary position, an iridolenticular gap, or changes in the lens periphery contour. The formation of a cataract within minutes to hours after ocular trauma may indicate a violation of the anterior lens capsule.[44]

Evaluation

Surgery for traumatic cataracts is a complex procedure that requires careful consideration.[5][19][45][19][46] The lens capsule and zonules are often damaged, increasing intraoperative risks, such as intraoperative lens dislocation, capsular rupture, and vitreous loss.[45][47]

Preoperative assessment and planning are essential for successful surgical outcomes. In cases where corneal or other media opacities obscure visualization, computed tomography (CT) imaging may facilitate the identification of a traumatic cataract.[48] Capsular tears can occur simultaneously or separately, and traditional B-scan ocular ultrasonography can detect ocular pathology but lacks resolution for posterior capsule or zonular structures.[49][50] Instead, ocular echography with a 20-MHz frequency is an effective imaging method for detecting occult posterior lens capsular rupture.[51][52][53]

Ultrasound biomicroscopy is also an effective method for identifying occult zonular damage in patients with anterior segment trauma.[51][54][55] Ocular CT of the anterior segment and Scheimpflug imaging have utility in determining the presence and extent of posterior capsular rupture and zonular integrity.[55][56] Accurate intraocular lens (IOL) calculations may not be possible in the acute setting. However, options include using data from the traumatized or fellow eye or deferring IOL placement to a secondary procedure.[43] Studies indicate that acceptable IOL calculations can be obtained from the fellow eye in most cases.[57][58]

Treatment / Management

The anesthesia choice should be tailored to the individual based on age, overall health, and estimated procedure duration.[59] General anesthesia is frequently used for open globe injuries, uncooperative patients, complex procedures, and pediatric patients.[60] 

Aseptic and antiseptic procedures should be performed with care to prevent eye damage or the introduction of bacteria. Preoperative cleansing with diluted povidone-iodine 5% in the conjunctival sac is the most effective method for reducing the risk of endophthalmitis.

Initial Management Considerations

Surgery to remove traumatic cataracts is typically not recommended in the acute setting. The standard approach is first to perform primary globe closure for penetrating or perforating injuries, followed by a secondary procedure to remove the cataract and place an intraocular lens.[18][61][62] This approach offers the benefit of a thorough assessment of associated injuries to adjacent ocular structures, which is crucial for preoperative planning. Additionally, cataracts may not be severe enough to affect vision immediately following the injury. Poor intraoperative visualization and limited ability to assess retinal or optic nerve damage during primary procedures can make cataract surgery more challenging in the acute setting. Nevertheless, some studies have demonstrated that earlier surgical intervention can enhance visual outcomes, and immediate cataract removal can alleviate inflammation and pressure elevation.[62][4] While deciding to place an IOL during primary surgery is debatable, small case series have reported favorable outcomes.[63][64] Primary extraction is imperative for patients with lens vitreous admixture to avoid further complications.[63]

Considerations in the Pediatric Population

Eye injuries in children are severe in about one-third of cases. In cases of acquired cataracts in children with vague trauma histories, it is essential to consider possible child abuse. To prevent stimulus deprivation amblyopia in children aged 5 years or younger, the timing of clearing the visual axis must be considered.[63][39] Cataract surgery should be performed within 1 year of ocular trauma; delay can increase amblyopia risk. Prompt cataract extraction is necessary to prevent phacomorphic glaucoma in pediatric eyes caused by a swollen cataractous lens causing the pupillary block.[65] Primary posterior capsulectomy and vitrectomy should be considered for children with traumatic cataracts to slow the opacification of the posterior capsule.[66][67]

Epilenticular IOL implantation is an option that may avoid common complications such as intraoperative high positive pressure and postoperative fibrinous uveitis, resulting in clear visual pathways and improved visual acuity. However, using contact lenses for unilateral aphakia is not feasible for many children worldwide due to cost, inadequate sanitation, and lack of availability. A study in sub-Saharan Africa supports using posterior chamber IOLs as the standard of care for children older than 2 years, as it produces the best visual acuity results. IOLs placed in the capsular bag are much less likely to require future capsulotomy, reducing amblyopia risk from developing posterior capsule opacification.[5] In cases from India where the posterior segment was not involved, extracapsular cataract extraction with posterior chamber IOL implantation resulted in better visual acuity in children following blunt trauma than penetrating trauma.

Concurrent Injury to the Cornea or Anterior Capsule

In cases where a traumatic corneal injury has occurred, there may be laceration or loss of corneal tissue. The anterior chamber must be sealed to prevent fluid leakage during cataract surgery. Corneal wounds may be closed using 10-0 nylon sutures during the same surgical session as the cataract extraction. Sutures should be placed perpendicularly when closing an irregular wound, starting from the wound edges.[68][69] The elasticity of the cornea decreases with age. Wound closure under higher tension to prevent leakage of the aqueous solution during and after the cataract extraction procedure is preferred in pediatric patients. Obtaining an accurate keratometry measurement may be challenging when the cornea is lacerated or traumatized, severely compromising the IOL calculation.[57][70][71] IOL calculation may be based on the uninjured fellow eye or an average keratometry value of 44 D.

A capsular dye such as trypan blue can be used to assess the condition of the anterior capsule. A standard continuous curvilinear capsulorhexis (CCC) may be performed if the anterior capsule is intact. If the anterior capsule is ruptured, bridges should be incised with Vannas scissors to avoid pulling with the phacoemulsification handpiece or irrigation-and-aspiration tip. In the presence of zonular weakness or dialysis, the bag for the cataract extraction may be secured by placing iris or capsular bag hooks. Capsular tension rings are indicated if zonular dialysis is present but contraindicated without a CCC or if posterior capsule rupture is suspected.[72][73][74]

Traumatic Cataract with Preexisting Ocular Comorbidities

Numerous factors must be considered when choosing a surgical approach to a traumatic cataract. Surgical expertise and preference play a role, as does the condition of the capsular bag, the quality of zonular support, and the presence of synechiae or vitreous prolapse.[73][75] In a study of 120 patients with traumatic cataracts, the inclusion of posterior capsulectomy and anterior vitrectomy during the primary procedure led to better visual outcomes. A pars plana lensectomy may be utilized in posterior segment injuries to remove the cataract while concurrently addressing the posterior pathology.[74] However, this technique has been associated with a higher risk of complications, such as macular pucker, cystoid macular edema, and secondary glaucoma.

Preexisting tears in the anterior capsule can be easily identified with trypan blue staining. Capsulorhexis may be performed in routine cataract surgery; a complete circular capsulorhexis is preferred to a can-opener opening. If a thick fibrotic capsule is present, Vannas scissors may be required. It is imperative to avoid damaging the zonules; using flexible iris retractors to anchor the capsule or placing a fixated capsular tension ring is helpful. In some traumatic settings, femtosecond laser-assisted capsulorhexis has been used successfully, achieving a more predictable capsulorhexis and reducing zonular stress.

Managing preexisting posterior tears requires a tailored approach dictated by the type and size of the tear.[76] Type 1 tears have fibrosed margins less likely to extend during irrigation. Type 2 tears have thin, transparent margins that can enlarge during irrigation-aspiration. The use of IOLs is not supported for tears larger than 6 mm. Both anterior and posterior approaches to posterior tears have reported successful outcomes; exercising precautionary measures when using an anterior approach is crucial to prevent further complications. The literature thoroughly explains these measures, including preventing lens matter from mixing with the vitreous, establishing a semi-closed system, using dry aspiration techniques, meticulously controlling infusion, and performing anterior vitrectomy.

Phacoemulsification requires the use of low flow rates and ultrasound settings. Triamcinolone staining can identify and remove the prolapsed vitreous in the anterior chamber.[77] Cases of compromised zonular support may be inadequate for an in-the-bag IOL. However, capsular tension rings (CTR) can be used during surgery as a support tool or long-term implant device for IOL fixation (Image. Traumatic Cataract Repair).[74] Traumatic subluxation can be addressed by preserving the capsular bag using fixated CTR.[75] The key surgical steps of capsulorhexis and cortical removal can worsen preexisting zonular compromise. Nonetheless, the use of CTR can effectively address this issue.

When there is a small tear in the posterior capsule, placing a foldable IOL in the capsular bag is a viable solution if there is enough support.[76] A three-piece IOL can also be placed in the ciliary sulcus with sufficient capsular support.[78] However, studies have demonstrated that visual acuity is superior when the IOL is placed in the capsular bag rather than the ciliary sulcus due to decreased inflammation. Other alternatives, such as an anterior chamber IOL and iris and scleral suture fixated IOLs, can be considered if there is inadequate support.[78][79] Furthermore, newer techniques for glued sutureless scleral-fixated IOLs are promising. Light-adjustable IOLs may also improve refractive outcomes in difficult cases of ocular trauma.

Procedural Considerations

Either a Venturi or peristaltic pump may be employed during phacoemulsification surgery. Keeping the parameters low is recommended, and the divide-and-conquer technique is preferred. If the nucleus is visible, the stop-and-chop method can be employed using an Akahoshi pre-chopper after sculpting a central groove. Pushing down the nucleus during chopping should be avoided. The irrigation and aspiration tip can easily aspirate the lens nucleus. Beginning with the nucleus and finishing with the cortex is the best approach to prevent damaging the posterior capsule.

During phacoemulsification surgery, it is recommended to utilize conservative settings.[73][80] A low bottle height of 60 to 75 cm, a low aspiration rate of 18 to 20 mL/min, and a low vacuum pressure of 180 to 200 mm Hg can be used initially and adjusted based on the specific device and clinical situation. The amount of ultrasound power utilized will depend on the hardness of the cataract.[81] 

A Simcoe cannula is another option to aspirate a soft cataract and can be inserted through a small incision measuring 2.8 to 3.0 mm. If both lens components are present, the hardness of the cataract should be assessed before surgery. Hydrodissection can separate the nucleus from the cortex, protecting the posterior capsule during phacoemulsification.

The selection and placement of the IOL are entirely dependent on the clinical situation, with consideration given to visibility.[63] Occasionally, placing the IOL in a later secondary procedure may be recommended.[63] It is not advised to use an anterior chamber lens for young patients or those with a lacerated cornea. After the surgery, cefuroxime is injected into the anterior chamber for antibiotic prophylaxis. Tamponade with dispersive viscoelastic or intracameral epinephrine injection for vasoconstriction may be utilized to control bleeding during cataract extraction.

Differential Diagnosis

Traumatic cataract always occurs in the setting of acute or remote ocular trauma. However, the following conditions must be excluded:

• Acute angle-closure glaucoma
• Angle-recession glaucoma 
• Choroidal rupture
• Retinal detachment
• Laceration of the corneoscleral complex
• Iridodialysis
• Iridocyclitis
• Ectopia Lentis (subluxation and luxation)
• Hyphema 
• Vitreous Hemorrhage 
• Age-related or senile cataract
• Sudden vision loss

Prognosis

Blindness caused by injury poses a significant burden on society and individuals. There remains a pressing need for standardized classification, investigations, and treatment guidelines to enhance outcomes.[4][13][40] The Birmingham Eye Trauma Terminology (BETT) was established in 1996 to standardize ocular trauma documentation. The BETT facilitates the investigation of visual outcomes following traumatic cataract surgery.[4][13] However, many issues and controversies surrounding the management of traumatic cataracts remain. Although a controlled, prospective clinical trial is not feasible, studies have been conducted to forecast visual outcomes in cases of traumatic cataracts. Predicting visual outcomes is complicated by multiple factors beyond just the lens.[82] 

Predicting visual outcomes in patients with traumatic cataracts is a complex process requiring consideration of various factors.[2][4][19][83] The Ocular Trauma Score (OTS), developed in the early 2000s, is a validated tool for predicting visual acuity after ocular trauma.[4][20][84] The variables used in the OTS are initial vision, rupture, endophthalmitis, perforating injury, retinal detachment, and afferent pupillary defect. A retrospective study of over 300 children has demonstrated the effectiveness of OTS in predicting visual outcomes in pediatric patients with traumatic cataracts. However, further research is needed to improve the accuracy of OTS in children. Two recent studies evaluating the value of the OTS in 2-year-old pediatric patients reached conflicting conclusions, leading to some controversy.[85][86][87] A new pediatric OTS has been developed to enhance accuracy in children with uncertain initial vision.[83][87] 

The morphology of cataracts plays a significant role in determining the surgical technique and visual outcome.[4][88][89] However, there is no consensus on whether primary or secondary cataract extraction is optimal.

Infection and endophthalmitis following an open globe injury are common.[90] Infection is also common with a retained intraocular foreign body.[91] Using plants with antimicrobial and antifungal properties may effectively prevent infection following penetrating injuries caused by a wooden object.[90][92] According to a study of patients with open or closed globe injuries with similar characteristics, a satisfactory grade of vision after managing traumatic cataracts was significantly better in the eyes with open injuries.[40] 

Complications

The complications of traumatic cataracts include phacoanaphylactic uveitis, retinal detachment, choroidal rupture, hyphema, retrobulbar hemorrhage, traumatic optic neuropathy, globe rupture, and phacolytic, phacomorphic, pupillary block, or angle-recession glaucoma.[2][62][93][94][32][95][96][97][98][99][100][101][102] 

Preventing retinal detachment requires removing the prolapsed vitreous in the anterior chamber through a lateral incision and performing an anterior vitrectomy using a second instrument.[103] Using the phacoemulsification handpiece to pull or heat the vitreous or removing it through the wound with a sponge must be avoided. If bleeding occurs in the anterior chamber, prompt removal and irrigation are essential to prevent hematocornea. During cataract extraction, dispersive viscoelastic or intracameral epinephrine can be utilized to control spontaneous bleeding.

Postoperative and Rehabilitation Care

Progress after cataract surgery is monitored during examinations performed 1 day, 1 week, and 1 month after the procedure.[5][104] Patients are prescribed ophthalmic antibiotics and anti-inflammatory medications. If complications occur, ophthalmic steroids or IOP-lowering medications may be prescribed.

Each postoperative examination should include a slit-lamp examination and an assessment of visual acuity.[105]

Pediatric patients at risk for postoperative amblyopia may benefit from patching the good eye during postoperative visual rehabilitation. Pediatric patients risk developing posterior capsular opacification that can lead to amblyopia if left untreated.[106][107] Inflammatory responses in young patients may cause fibrinous uveitis, which can be managed with aggressive perioperative steroid regimens.[108]

Deterrence and Patient Education

Educating patients about the risks of developing traumatic cataracts and their sequelae is crucial.[109][110]. Patients should be advised to seek immediate care following any ocular trauma. Additionally, patients should be educated on the benefits of wearing sunglasses to shield their eyes from harmful ultraviolet rays and the proper use of eye protection during high-risk activities. 

Enhancing Healthcare Team Outcomes

Managing traumatic cataracts requires an interprofessional team of healthcare professionals, including nurses, laboratory technologists, pharmacists, and clinicians of various specialties.[5][111] Without proper management, traumatic cataracts can lead to devastating outcomes, blindness, and poor quality of life.[38][112] Risk factors, including smoking, excessive alcohol consumption, extended exposure to sunlight without protective sunglasses, diabetes, severe eye or head injuries, other eye conditions, prolonged use of systemic steroids, and radiation treatment for cancer or other diseases, can contribute to traumatic cataracts.[113] Taking proper precautions to prevent eye trauma, such as using protective eyewear like glasses and eye shields, limiting time spent in hazardous situations, and avoiding exposure to infrared or ultraviolet rays, is something every patient should be educated about.[114]

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Disclosure: Godwin Okoye declares no relevant financial relationships with ineligible companies.

Disclosure: Bharat Gurnani declares no relevant financial relationships with ineligible companies.