Traumatic cataract types and surgical manegement

1. Traumatic Cataract

2. Epidemiology
▪ Up to one-fifth of adults will experience ocular trauma at some point in their
lives.
▪ Depending on the report, 27-65% of ocular traumas lead to cataracts
▪ Trauma is the most common cause of unilateral cataract in young individuals.
▪ The majority of traumatic cataracts are visually significant and require surgery.

3. Pathophysiology
▪ Traumatic cataract is a clouding of the lens that may occur after
either blunt or penetrating ocular trauma that disrupts the lens
fibers.
▪ Cataracts may form immediately after trauma or months to
years later.
▪ Rapid cataract formation is typically a result of lens capsule
rupture with seepage of aqueous humor into lens fibers
▪ If there is no capsule rupture, it is suspected that the traumatic
forces damage lens fibers, resulting in cataract formation.

5. Types according to morphology
Based on lenticular opacity, the cataracts
were classified as
▪ total
▪ membranous, in which both capsules
fused with scant or no cortical material
▪ white soft
▪ rosette types

6. Causes
1) Penetrating
2) Blunt Sunflower-shaped opacity
3) Electric shock (Rare)
multiple snowflake-like opacities
stellate subcapsular distribution

7. Causes
4) Infrared radiation
Glassblower cataract
True exfoliation of ant.capsule
5) Ionizing radiation
posterior subcapsular opacities
6) Chemical burn

8. Diagnosis and Surgical Planning
▪Patient History
 Age of patient
Pediatric patients are at risk for developing amblyopia
not be reliable historians

9. Mechanism of injury
▪ Blunt or penetrating?
Significantly low intraocular pressure (IOP) should always raise the
suspicion of an open globe
If penetrating trauma is present, the use of topical medication or
devices that touch the eye should be avoided
They are reported to occur in 11% of eyes with closed globe
injuries. The concept of ‘coup' and ‘contrecoup' forces
If Blunt trauma, ultrasound A and B may be used to further assess
ocular status.

10.  Patient’s systemic health
▪ Poorly controlled diabetes or systemic hypertension, for example, are associated
with higher risk of perioperative and postoperative complications, including
expulsive hemorrhage
▪ diabetes is also associated with a higher risk of infection.
▪ Patients’ medication history including use of tamsulosin
▪ be aware of any prior intraocular surgeries for surgical planning of cataract
extraction

11. Exam Signs

12. 1) Birmingham Eye Trauma Terminology (BETT):
The BETT system was developed as a standardized method for documenting ocular trauma
2) Visual acuity:
Pre-operative visual acuity helps predict best corrected visual acuity after removal of the traumatic cataract.
3) Intraocular pressure (IOP):
LOW -> open globe injury or a cyclodialysis cleft
Elevated -> lens-associated glaucoma (phacomorphic, lens particle, or phaco-antigenic), hyphema,
angle recession glaucoma (in the chronic post-traumatic setting).

13. Cornea
Severe corneal damage and haze may limit pre-operative
assessment of cataract
A sealed anterior chamber is necessary to avoid fluid
leakage during cataract surgery
Anterior lens subluxation may also lead to corneal
decompensation as a result of lens-endothelial touch
.

14. Anterior chamber:
Flattening  rupture or a self-sealed laceration.
Assess the anterior chamber for hyphema, lens material, inflammatory reaction, or
vitreous prolapse.
Pupils:
RAPD can occur with traumatic optic neuropathy or optic nerve avulsion
Importantly, a cataract alone does not cause an RAPD.
Iridocorneal angle:
Evaluate for narrowing or occlusion of the iridocorneal angle secondary to lens
swelling or displacement.

15. Iris:
Transillumination defects may indicate intraocular foreign body or iris disinsertion.
Iris injury often occurs concomitantly with traumatic cataract.
A Vossius ring can occur if the insult caused the posterior iris pigment epithelium to imprint on the lens capsule.

16. Lens:
▪ Although there is no standardized system for documenting
traumatic cataract features
▪ location of the lens opacity (central vs. peripheral)
▪ severity
▪ morphology of the cataract (membranous, rosette, soft
fluffy, or total).
▪ lens position ( sublaxation , dislocation)
▪ presence of phacodonesis
▪ anterior capsule rupture.
▪ These features help confirm whether there is zonular
injury and determine the urgency of performing cataract
extraction.

17. Anterior dislocation of lens
▪ requires urgent lens removal, especially in cases of rising intraocular pressure where
lens-induced acute angle closure glaucoma occurs due to pupillary block.
▪ Other indications include persistent uveitis and lens-corneal decompensation.
▪ Temporizing measures to reduce intraocular pressure such as acetazolamide or
peripheral iridotomy can be used prior to lens removal.
▪ Zonular status needs to be well established to determine optimal intraocular lens
placement.

18. Posterior dislocation of the lens
▪ in some cases may be well-tolerated and managed conservatively with an
aphakic contact lens.
▪ If the patient is still symptomatic or develops complications such as persistent
uveitis or glaucoma, lens removal is indicated.

19. Posterior segment:
▪ If the view of the posterior segment is obscured-> obtain
gentle B-scan ultrasonography to confirm a normal globe
contour and assess for intraocular foreign bodies, vitreous
opacities, retinal detachments, or choroidal ruptures.
▪In unpublished data from the United States Eye Injury
Registry, 48% of eyes with traumatic cataract were also
found to have injury to the posterior segment
▪A CT scan may help rule out an intraocular or intraorbital
foreign body and abnormal globe contour.

20. Management

21. “primary” procedure -> performed immediately following open globe trauma
“secondary” procedure -> deferred weeks to months after the trauma
 Removal of the traumatic cataract should be performed urgently :
 capsule rupture
 lens material in the anterior chamber
 phacomorphic glaucoma
 any other conditions placing the patient at high risk for developing inflammation
and increased intraocular pressure.
Benefits of primary extraction  lower cost and time of a single surgery or
hospital admission, minimizing risk of developing elevated IOP and synechia, and
decreasing visual rehabilitation time and risk of amblyopia
Benefits of secondary extraction  the potential for more accurate intraocular
lens calculation, improved visualization during surgery, and operating in a “quiet”
eye.

22. Integrity of the anterior capsule:
▪Using trypan blue intraoperatively helps identify tears in
the anterior capsule.
▪There should be high suspicion for capsule rupture if the
lens opacified minutes to hours after the trauma
▪If the anterior capsule is intact  a standard continuous
curvilinear capsulorrhexis (CCC), 5 to 6 mm in diameter,
can be performed
▪If Ruptured anterior capsule  cut any bridge with
Vannas scissors to avoid pulling it with the
phacoemulsification handpiece or irrigation and aspiration
(I&A) tip.

23. Zonular weakness/dialysis
▪ the surgeon can place iris or
capsular bag hooks to secure the
bag for the cataract extraction.
▪ CTRs are indicated if zonular
dialysis is present (30-90 degrees
of zonular fibers).

24. Iris management
▪ Synechiae are fibrinous adhesions
 can scar the iris down to adjacent
structures and impair dilation
▪ these synechiae may need to be
lysed (i.e. synechiolysis) at the time
of cataract surgery
▪ Iris hooks or a Malyugin ring can be
used intraoperatively to dilate the iris
after synechiae are lysed

25. Iris management
▪ there is iridodialysis, the iris itself
may require repair.

27. Methods of removal of a dislocated crystalline lens
The approach is typically dictated by severity of lens subluxation due to zonular disruption:
▪ phacoemulsification with aid of a capsular tension device
▪ intracapsular cataract extraction
▪ pars plana lensectomy.
With minimal lens instability, an anterior approach with phacoemulsification with a capsular
tension device may be used.
If unsafe, extracapsular or intracapsular extraction is also another method of anterior
approach.
 In severe cases of lens subluxation and greater than 180 degrees of zonular disruption or
complete dislocation, a posterior approach with simultaneous pars plana lensectomy and
vitrectomy is used.

28. Cataract morphology:
Cataract morphology and the extent of damage of other ocular tissues help
determine surgical planning and technique:
Cataracts with a hard nucleus: typically use phacoemulsification.
White soft or rosette cataracts: typically use unimanual or bimanual
aspiration.

29. Cataract Extraction
▪ Low parameters :
using a low bottle height - low aspiration rate- low vacuum
Ultrasound power varies depending on the hardness of the cataract.
 Intracameral antibiotic:
At the end of the surgery, we inject 0.3 mL of cefuroxime solution (concentration of 1.0
mg/0.1 mL) into the anterior chamber as a prophylactic antibiotic.
 Hemostasis:
To control bleeding during cataract extraction, dispersive viscoelastic may be used for
tamponade, or intracameral epinephrine may be injected to cause vasoconstriction.

30. Complication
▪ Vitreous prolapse:
it must be removed by means of a second instrument through a lateral incision, and
anterior vitrectomy should be performed
Complications such as retinal detachment may occur if the vitreous is heated or
pulled with the phaco handpiece.
Vitreous should not be pulled out through the wound with a sponge.

31. Complications
▪ Hyphema:
If blood is present in the anterior chamber, it should be washed out and removed as
soon as possible because of risk of hematocornea (corneal blood staining).
To help control bleeding, dispersive viscoelastic may be used for tamponade, or
intracameral epinephrine may be injected to cause vasoconstriction.

32. IOL Placement
▪ The type and optimum placement of the IOL depend on the clinical context. If
visualization is poor, consider placing the IOL in a later secondary procedure.
▪ If the capsular bag is complete, a 1-piece acrylic IOL is usually placed in the
bag.
▪ if the capsule is ruptured with good support, a 3-piece acrylic IOL should be
placed in either the capsular bag or ciliary sulcus. The latter placement is
preferable if enough of the anterior capsule remains to support it.
▪ If no capsular support  AC-IOL , Iris fixation IOL, scleral fixated IOL (Yamane
technique IOL fixation)

33. IOL Placement

34. Prognosis
▪ Several factors have been identified to predict visual outcome in patients with
traumatic cataracts.
▪ A prognostication tool, the Ocular Trauma Score (OTS), was developed in the
early 2000s to predict visual outcomes after ocular trauma.
▪ It includes the following factors to make predictions about visual acuity: initial
vision, presence of rupture, endophthalmitis, perforating injury, retinal
detachment, and afferent pupillary defect.

35. the Ocular Trauma Score (OTS)

36. THANK YOU