European Journal of Cardiovascular Medicine

Ocular trauma is one of the most important causes of avoidable blindness. Trauma can result in various injuries ranging from minor abrasion to blinding injuries like rupture of globe and optic nerve injuries. One of the common manifestations of trauma is traumatic cataract which can result following blunt or penetrating injuries. Traumatic cataract grossly differs from other forms of senile and acquired cataract not only in morphology but also in the visual outcome that can be achieved. Concurrent injuries to other ocular structures can have a significant bearing on the final visual acuity of the eye. ^[1]

Birmingham Eye Trauma Terminology system was introduced by Kuhn F, Morris R. It was a significant step in standardizing the ocular trauma nomenclature, classification and prognosting the visual outcome. The Ocular Trauma Classification Group has developed a classification system Ocular Trauma Score. ^[2]

It was based on BETTS and features of globe injury at initial examination. The Ocular Trauma Score carries significance for both patient and doctor. It categorizes trauma by four parameters - type of trauma, grade, afferent pupillary defect and extent of injury. Although there is no standard classification for morphology of traumatic cataract but it does play a role in final visual outcome. ^[3] Various treatment modalities are available for the management of traumatic cataract. Cataractous lens can be removed as primary procedure or secondary procedure. Each procedure has its own advantages and disadvantages. ^[4]

Similarly, IOL can be implanted as primary procedure or secondary procedure. In case of severe corneal edema secondary implantation to be a better option as compared to primary implantation as it is associated with early visual rehabilitation and less post operative complications. ^[5] 

Primary removal with implantation is recommended if there is severe inflammatory reaction with cortical matter in anterior chamber. ^[6]

The study was conducted with the aims and objectives to study the demographic profile, etiological factors, prognostic factors and suggesting the preventing measures.Awareness regarding these factors will guide ophthalmologist to maximize the visual outcome.

This is a prospective study was conducted in the Department of Ophthalmology, Mahavir Institute of Medical Sciences and Research Centre in patients who was presented with unilateral traumatic cataract, underwent surgical intervention and completed at least 6 months.

Patients of both genders and all age groups with unilateral traumatic cataract were included in the study. Patient's data including demographic details, causative agents, initial visual acuity, intraocular pressure, slit lamp examination findings, B-scan findings, treatment / surgery, early and late complications and final outcome were obtained from patient's chart in the hospital record. Removal of cataract was performed as a second and separate procedure in patients of perforating ocular injury, intraocular lens (IOL) implantation was performed only in patients with adequate capsular support. Patients without any capsular support were kept aphakic. Anterior vitrectomy was performed in patients with posterior capsular tear and vitreous prolapse.

Patients were subsequently followed-up on 1 day, 1 week, 6 weeks, 3 months and 6 months postoperatively. At each follow-up visit patient's visual acuity was recorded. Final best corrected visual acuity (BCVA) was recorded on the 5th postoperative visit that is at 6 months.

Statistical Analysis:  The data processing was carried out on Statistical Package for Social Science (SPSS) version 25.0 software and expressed as frequencies, percentages, mean and standard deviation.

In the current study majority of the cases were seen in 5-15 years with a male preponderance.

Table 1: Age Distribution

Table 2: Sex Distribution

Table 3: Type of injury

In table 3, 60% were penetrating trauma and 40% were blunt trauma. Wooden stick was the most common object causing trauma.

Table 4: Objects causing trauma

Table 5: Associated Ocular Damage

Associated ocular injuries Associated ocular injuries go long way in determining the ultimate visual prognosis in cases of traumatic cataract. Corneal and iris injuries were the most common associated injury.

Table 6: Type of Surgery

Type of surgery 

Depending on the condition of the eye, the type of surgery done were SICS with Aldol and lens extraction with anterior vitrectomy

On comparing final visual outcome among adult and pediatric group, there was no significant difference statistically with a p value of 0.658.

Effect of time interval between injury and cataract surgery 

The time interval between injury and intervention had no significant effect on final visual outcome.

Adenoviral keratoconjunctivitis was first described by Fuchs in 188913 in 1955, Jawetzetal14 identified adenovirus as the cause of the disease. Other authors isolated adenovirus types 8,19 and 37 as the most frequent causative adenovirus sub types. EKC is commonly associated with serotypes 8,19 and 37 and is considered to be the more critical form because of its adverse consequences on visual acuity. ^[7]

EKC is an ocular surface disease with a marked inflammatory reaction and symptoms of redness, irritation, watering, blurred vision, and aversion to light (photophobia). The clinical signs include painful swollen lids (eye lid oedema) follicular conjunctivitis, conjunctival chemosis, hyperemia, punctuate epithelial keratitis, (PEK), sub epithelial opacities (SEI), anterior stromal infiltrates and pre auricular lymph- adenropthy. ^[8]

The corneal involvement results in reduced visual acuity causing blurry vision and photophobia. The punctuate epithelial keratitis (PEK) resolves in 1-2 weeks however the sub epithelial infiltrates (SEI) which is the hall mark of the more chronic phase of EKC and distinguishes it from other adenoviral infections may take longer. (weeks to months even 1-2 years) to resolve.5,6 Pseudo- membranes may form and punctual occlusion may occur. Laboratory diagnostic methods to identify adenoviral injections include serologic methods of antigen detection and Polymerase chain reaction (PCR). The traditional gold standard for diagnosis of EKC has been cell culture in combination with immune flourescence staining (CC-IFA), however this is time consuming and not cost effective. Therefore, the clinical diagnosis of an adenovirus infection is typically made based on the history and presenting signs and symptoms. Sabursky et al have reported the introduction of the Rapid pathogen screening (RPS) adeno detector with a sensitivity of 88% and specificity of 91% in comparison to CC-IFA with immediate and easy to read results. It may prove useful in diagnosing patients who may be suffering from some other type of conjunctivitis. The onset of EKC may seem to be rapid but actually there is an incubation period of about one week before the clinical symptoms present.

The second eye is often affected days later to a much lesser degree. The adenovirus is shed up to 14 days after the onset of disease and can remain viable on nonporous surfaces. No gender predilection exists. The infection is more common in adults but all age groups can be affected by transmission of the virus, occurs by direct contact with ocular secretions or through respiratory droplet infections, Or by indirect contact with contaminated instruments such as tonometer heads and inanimate vectors such as door handles.

To avoid spreading epidemic keratoconjunctivitis, prevention is the best strategy. Patients should be advised to avoid touching their eyes and wash their hands frequently with soap and water as long as the eye is red, not to touch others, and not to share tissues towels, soap and handkerchiefs, cover their mouth and nose while coughing and sneezing. ^[9] They should stay off work / school for at least 14 days, while infected. They should be told the disease is contagious and other family members should be warned about the contagious nature of the disease.

Due to its highly contagious nature, EKC in an eye OPD can have a snowball effect, quickly spreading, from one patient to the next. The ophthalmologist concerned should also wash his / her hands before and after examining these patients. Any things the patients might have touched (especially the slit lamp examination and chair) tonometer head etc should be disinfected after the patient leaves the room with 3% hydrogen peroxide or sodium hypochlorite Solution. ^[10] The adenovirus is resistant to 70% isopropyl alcohol. Single use disposable devices like disposable tonometer prism, gloves, droppers, shields, cotton tipped applicators should be used for examination of these patients and then discarded immediately. ^[11]

EKC is highly contagious and occurs in epidemics. Outbreaks have been reported worldwide. However, it is a self-limiting disease and resolves in 1-3 weeks without significant complications. To reduce patients’ discomfort and the associated inflammation, various treatment regimens have been tried. There is ongoing research for topical agents that have antiviral activity. Cidofovir has been shown to reduce the viral replication cycle and also to be effective as prophylactic agent but it was abandoned due to its toxic effects. Ganciclovir gel. ^[12] May prove to be the most useful topical antiviral agent in the treatment and prophylaxis of epidemic keratoconjunctivitis (EKC). Supportive Management of (EKC) includes.

• Lubricants / artificial tears
• Topical corticosteroids or
• Other topical immunomdulatory drugs like cyclosporine (0.05%)
• Topical cycloplegic agents for severe photophobia and
• Povidone–Iodine Solution. solution to reduce the duration of conjunctivitis.

Topical corticosteroids are often used to reduce inflammation and for severe membranous conjunctivitis or a marked reduction in visual acuity from late subepithelial opacities. Any patient on topical steroids should be observed routinely to monitor for adverse effects, like elevation of intraocular pressure or formation of lens opacities. ^[13] Topical cyclosporine (0.05%) is an immunohematology drug. It is very effective in suppressing the activation and proliferation of B & T lymphocytes and formation of inflammatory mediators like cytokines especially interlukin. It has no ocular penetration and complications like elevation of the intraocular pressure and formation of cataract. Various studies have shown this to be a safe and effective drug for ocular surface disorders like dry eyes., moorens’s ulcer scleritis, cicatricial conjunctivitis and vernal keratoconjunctivitis. Its use in VKC results in resolution of punctuate epithelial erosions and opacities in corneal stroma. Recent research shows that treatment with topical corticosteroids for the relief of symptoms of EKC enhances adenovirus replication, and delays cell shedding from the ocular surface which delays adenovirus elimination. The current management of EKC largely revolves around accurate clinical diagnosis and implementation of disinfection protocol to prevent its spread.

Various studies indicate the role of topical cyclosporine as a immunohematology drug for symptomatic relief and improvement of symptoms in patients of EKC. Cyclosporine does not penetrate the ocular surface and it also does not have the adverse side effects of topical corticosteroids (like IOP elevation and formation of cataract) Romanowski et al. found that treatment with cyclosporine 0.05% significantly reduced the formation of SEI. However, use of topical cyclosporine increased the adenoviral replication. Similar to the result reported with topical corticosteroids. The effects of non-steroidal anti-inflammatory drugs (NSAIDS) have demonstrated no better relief in patients symptoms from viral conjunctivitis than artificial tears. There is ongoing research to find an appropriate antiviral drug. It has been suggested that topical ganciclovir 0.15% ophthalmic gel is safe and effective treatment for adenoviral conjunctivitis. Other studies have shown promising results in the treatment of adenoviral conductivities, with povidoniodine (PVP-I) or with a combination of topical dexamethasone 0.1% with. Povidone-iodine 0.4% (FST100) in reducing clinical symptoms and infections of viral titers in adenoviral conjunctivitis.

In this study we compared the efficacy and safety of topical cyclosporine with flouromethalone in combination with artificial tears in treating patients with epidemic kerato conjunctivitis. Our results show that patients treated with topical cyclosporine 0.5% showed a more rapid resolution of symptoms and signs with less incidence of sub-epithelial infiltrates SEI compared with patients treated with flouromethalone.

The management of EKC continues to present a clinical (dilemma). Epidemic kerato conjunctivitis is a self-limiting disease with a natural course. Treatment is mostly supportive and for symptomatic relief. Subepithelial infiltrates usually resolve spontaneously without scarring the cornea. Until an effective antiviral drug becomes available, eye care providers and clinicians must be cautious in prescribing corticosteroids for symptomatic relief of EKC, considering the risks involved and its potential to prolong the infection. The extended period of adenovirus shedding associated with the use of corticosteroids could also enhance the spread of EKC and lead to increased epidemics. Use of an alternative anti-inflammatory agent with minimal side effects such as topical cyclosporine is suggested which causes more rapid resolution of patient’s symptoms. (redness, pain, lid swelling, photo phobia and watering). Accurate diagnosis and prevention of transmission, advising frequent hand washing shortens the course of the disease, decreases the occurrence of sub-epithelial opacities and blurry vision. Avoiding close contact with others and use of communal objects should be stressed as first line of defense to stop the spreading of EKC epidemics. Educate patients that the symptoms will get worse in the first week before getting better and that it may take a month or longer for complete resolution.

1. Epidemic Keratoconjunctivities Treatment & management Author: Ahmed Bawazeer, MBChB, FRCSC; Chief editor : hamptonn Roy, Sr MD Updated April 03,2015.
2. Jin X., Ishiko H., Ha N.T. Molecular epidemiology of adenoviral conjunctivitis in Hanoi, Vietnam. Am J Ophthalmol. 2006;142:1064–1066. [PubMed].
3. Kinchington P.R., Romanowski E.G., Gordon Y.J. Prospects for adenoviral antivirals. J Antimicrob Chemother. 2005;55:424–429. [PubMed].
4. Butt A.L., Chodosh J. Adenoviral keratoconjunctivitis in a tertiary care eye clinic. Cornea. 2006;25:199–202. [PubMed].
5. Lenaerts L., De Clercq E., Naesens L. Clinical features and treatment of adenovirus infections. Rev Med Virol. 2008;18:357– 374. [PubMed].
6. Rajaiya J., Chodosh J. New paradigms in infectious eye disease: adenoviral keratoconjunctivitis. Arch Soc Esp Oftalmol. 2006;81:493–498. [PubMed].
7. Cheung D., Bremner J., Chan J.T.K. Epidemic keratoconjunctivitis – do outbreaks have to be epidemic? Eye. 2003;17:356–363. [PubMed].
8. Melendez C.P., Florentino M.M., Martinez I.L. Outbreak of Epidemic keratoconjunctivitis caused by adenovirus in medical students. Mol Vis. 2009;15:557–562. [PubMed].
9. Gottsch J.D. Surveillance and control of epidemic keratoconjunctivitis. Trans Am Ophthalmol Soc.1996;XCIV:539–587. [PubMed].
10. Sambursky R., Tauber S., Schirra F. The RPS Adeno Detector for diagnosing adenoviral conjunctivitis.Ophthalmology. 2006;113:1758–1764. [PubMed].
11. Ford E., Nelson K.E., Warren D. Epidemiology of epidemic keratoconjunctivitis. Epidemiol Rev.1987;9:244–261. [PubMed].
12. Kaufman H.E. Adenovirus advances: new diagnostic and therapeutic options. Curr Opin Ophthalmol.2011;22:290–293. [PubMed].
13. Luchs E Keratitis punctata superficialis. Wien klin wochenschr. 1889;44837-842.