Traumatic Cataract

• 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

• Penetrating trauma may result in a cataract proportional to the size of the opening in the lens capsule

• Cataracts secondary to blunt trauma often exhibit a distinctive rosette- or flower-shaped appearance

PATHOPHYSIOLOGY:

• Trauma disrupts and injures the lens fibers, leading to lens swelling

• 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.

• Traumatic cataracts typically present as rosette or stellate subtypes

HISTORY:

• Determine if it an acute ocular emergency

• If the intraocular pressure is significantly low, there may be an open globe injury

• 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

EXAMINATION:

• Identify signs of zonular damage, such as phacodonesis, focal iridodonesis, vitreous prolapse, and lens subluxation, if present

• 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

EVALUATION:

• CT scan - in case IOFB is suspected

• Capsular tears can occur simultaneously or separately, and B-scan can detect ocular pathology but lacks resolution for posterior capsule or zonular structures

• IOL calculation

MANAGEMENT:

• General anesthesia is frequently used for open globe injuries, uncooperative patients, complex procedures, and pediatric patients

• In case of open globe injury - first perform primary globe closure, followed by a secondary procedure to remove the cataract and place an intraocular lens

• Primary extraction is imperative for patients with lens vitreous admixture to avoid further complications

• In children - cataract surgery should be performed within 1 year of ocular trauma; delay can increase amblyopia risk

• Earlier surgical intervention can enhance visual outcomes, and immediate cataract removal can alleviate inflammation and pressure elevation

• Phacoemulsification requires the use of low flow rates and ultrasound settings

• Triamcinolone staining can identify and remove the prolapsed vitreous in the anterior chamber

• In suspicion of vitreous prolapse - keep a vitrectomy machine ready or the back up of a VR surgeon

• 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

  COMPLICATIONS:

• Phacoanaphylactic uveitis

• Retinal detachment

• Choroidal rupture

• Hyphema

• Retrobulbar hemorrhage

• Traumatic optic neuropathy

• Globe rupture

• Phacolytic, phacomorphic, pupillary block, or angle-recession glaucoma

  Image from Rajan Eye Care Hospital

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