European Journal of Cardiovascular Medicine

Ocular trauma is one of the leading causes of visual morbidity all over the world.[1]Visual morbidity not only affects the individual, but also exerts a burden over the health care system of country[2,3]. Developing world faces the challenge of trauma as a significant contributor of monocular blindness.[4]

Ocular trauma can lead to traumatic cataracts which contribute to notable visual morbidity. Crystalline lens is vital for normal functioning of the eye. Thus traumatic cataract often deprives its victim of vision in the prime of his life. The knowledge of causes of ocular injury is very essential for designing the strategy to take preventive steps against it. This also helps to properly channelize the resources towards prevention of ocular injury. The burden of ocular injury on the victim as well as society is very large and potentially preventable.[5]

Traumatic cataracts occur secondary to blunt or penetrating ocular trauma. Infrared energy (glass-blower's cataract), electric shock, and ionizing radiation are other rare causes of traumatic cataracts.[6,7]

Worldwide, there are approximately 1.6 million people who are blind from ocular injuries, 2.3 million with bilateral visual impairment and 19.0 million with unilateral visual loss. Post Injury traumatic cataract is a major contributor.[8]

Pediatric traumatic cataract is one of the leading causes of monocular blindness in children, accounting for 29%-57% of pediatric cataract cases.[9]

Cataracts caused by blunt trauma classically form stellate- or rosette-shaped posterior axial opacities that may be stable or progressive. When the anterior surface of the eye is struck bluntly, there is a rapid anterior – posterior shortening accompanied by equatorial expansion. This equatorial expansion can disrupt the

lens capsule, zonules or both. Combination of coup, counter coup & equatorial expansion is responsible for formation of traumatic cataract.[10,11]Penetrating trauma with disruption of the lens capsule forms cortical changes that may remain focal if small or may progress rapidly to total cortical opacification. Occasionally, a small perforating injury of the lens capsule heals, resulting in a stationary focal cortical cataract [12,13]

Lens dislocation and subluxation are commonly found in conjunction with traumatic cataract. Other associated complications include phacolytic, phacomorphic, pupillary block, and angle-recession glaucoma; phacoanaphylactic uveitis; retinal detachment; choroidal rupture; hyphema; retrobulbar hemorrhage; traumatic optic neuropathy; and globe rupture.[14,15,16]

Traumatic cataract can present many medical and surgical challenges to the ophthalmologist. Careful examination and a management plan can simplify these difficult cases and provide the best possible outcome.[17,18] The methods used to evaluate the visual outcome in eyes managed for traumatic cataract & senile cataracts are similar. But the damage to the other tissue due to trauma may compromise the visual outcome of eyes operated for traumatic cataract. However, there is scarcity of literature on epidemiologic information about traumatic cataract.[1]

Aim & Objective

1. To study the demographic profile of traumatic cataract.
2. To study the visual outcome after traumatic cataract surgery.
3. To study post-operative complications in traumatic cataract.

This Prospective study was conducted on total 45 patients presenting with traumatic cataract to the outpatient department of Ophthalmology at AIMS & RC, Rajsamand Rajasthan between the time period of June 2023 and May 2024.

INCLUSION CRITERIA

1. Patients of all age groups presenting with cataract after trauma.
2. Patients who are ready to give consent for the study.

EXCLUSION CRITERIA

1. Pre-existing ocular disease such as retinal pathologies, corneal opacity, congenital optic atrophy or glaucoma.
2. History of ocular surgery.
3. Presence of systemic disease such as Down syndrome, Marfan syndrome and cerebral palsy.
4. Patients not giving reliable history of mode of injury.
5. Patients not willing to give consent for the study.

HISTORY & EXAMINATION:

Pre-operative assessment

1. Detailed history: Patient identification data (name, age, sex, and address- Nature of trauma and associated ocular damage. - Duration between trauma and presentation of patients - Diminution of vision and associated complaints like pain, redness, watering etc with duration
2. Ocular examination

• Visual acuity (unaided, BCVA) - Detailed anterior segment examination - Diffuse Illumination - Slit lamp examination - Intraocular pressure measurement - Posterior segment evolution by direct and indirect ophthalmoscopy. - B-scan ultrasonography - IOL power calculation.
• Pre-operative preparation 1. Informed consent for surgery was obtained from all patients. [2] Topical and systemic antibiotic eye drops started a day prior to surgery. (Moxifloxacin 0.5 % e/d qid, tab. Ciprofloxacin 500mg bd) 3. Pupil was maximally dilated with instillation of mydriatrics & cycloplegics. (Tropicamide 0.8% and phenylephrine 5%) 4. Patients to be taken under GA will be kept Nil by mouth at least 6 hrs prior to surgery.

Surgical procedure All the routine surgical steps for cataract extraction were followed, Capsular bag IOL implantation was preferably tried in favorable conditions. In cases where it was not possible sulcus fixation or sclera fixation or Iris claw was done.

Post operative examination Detailed examination of anterior and posterior segment was done as to find out.

- Discharge- present or not - Conjunctiva-congestion present or not - Cornea- To evaluate its clarity, presence or absence of striate keratopathy and oedema, state of sutures ( if applied). - Anterior chamber- to look for any signs of inflammation, presence of lens matter, hyphema by slit lamp examination. - Iris prolapse, iris capture, - Pupil - to evaluate its size , shape and reaction. - Lens - position of lens, - Visual acuity (unaided and pin hole) - Intraocular pressure - Fundus examination - direct or indirect ophthalmoscopy.

Post Operative medication:

All patients with injuries and without infection were treated with topical and systemic corticosteroid, antibiotics and cycloplegics. The duration of treatment depends on the degree of inflammation in the anterior and posterior segments of the operated eye. Tobramycin 0.3% + dexamethasone 0.1% e/drop 2hrly in operated eye. Systemic steroid (prednisolone 1.0mg/kg body wt). Cycloplegic e/drops (Atropine 1% or homoatropine 2%), and antiglaucoma drugs (Timolol 0.5% E/d,Tab. Acetazolamide 250 mg ) (if required)

Follow up:

All patients were followed up at 1st day, 5th day, 30th day. During their visits following examination was done:

• Visual acuity (snellen’s chart) ● Intraocular pressure (applanation tonometry) ● Anterior segment examination by slit lamp microscopy ● Posterior segment examination

The primary aim of the management of injured eye was to restore vision.

During the follow up period, any early or late complications of the injury or the treatment or surgery done was noted; improvement in visual acuity was mentioned.

STATISTICAL METHODS: Excel and SPSS software was used for data entry and analysis. Paired t- test and chi-square test was used for data analysis and to find out statistical significance.

The study group consists of 45 cases of traumatic cataract. In this study we were included the patient who had traumatic cataract due to closed globe injury. The study was based on age and sex distribution of traumatic cataract, etiological distribution, associated ocular injuries, associated complication, surgical management and final visual outcome were analyzed.

Gender Distribution:

Figure 1 Shows Gender Distribution Male &  Female

Gender distribution and age distribution of the patients in our study. Out of  the 45 patients 20 patients (44.44%) were female and 25 cases were & male (55.55%). 15 patients (33.33%) were aged between 1-20yrs and 15 patients (33.33%) were between the age of 21-40yrs. Only 3 cases (6.66 %) are above 60 years of age.

Geographic Distribution :

Out of total patients 31 (68.88%) patients belong to rural background

Figure 2 shows geographic distribution

Source Of Injury:

Wood injury came out to be most comman cause with 57.77 % in our study.

Figure 3 Shows source of injury

Type Of Injury

Total 38 patients (84.44 % ) found to have penetrating injury & rest 15.55 % had blunt injury as cause for traumatic cataract.

Figure 4 Shows type of Injury

Post operative vision

Figure 5 Shows Post operative visual outcome

post-operative vision and the type of trauma causing the injury i.e. penetrating or blunt injury. Our study shows that out of 45 patients, 21 patients (46.66%) had vision between 6/12-6/6 following penetrating injury while 6 patients (13.33%) had vision 6/12-6/6 following blunt trauma.6 patients. 2 patients had vision PL+ PR accurate following surgery due to posterior segment involvement (RD,vitreous hemmorage).

It is shown that out of the total 47 patients, 29 patients (64.44%) had corneal edema as the most common post operative day 1 complication. Most common complication causing decreased visual acuity postoperative after a month was noted to be corneal opacity in 14 patients (31.11%),followed by others like posterior capsular opacification, in 5 patients(11.11%). One patient had Retinal Detachment led to poor visual outcome later treatment done by VR Surgeon.

Traumatic cataract is the commonest complication causing diminution of the vision following any type of ocular injury. It causes serious visual disability in young working population. The incidence of traumatic cataract reflected in ophthalmic literature varies from 1% to 15% of all ocular injuries.

Age wise analysis of this study showed that traumatic cataract was more commonly affecting the younger age group. This is due to the fact that traumatic cataract is more common in people working out door in our study. In our study the mean age was 31years. Which was similar to Daljit singh et al48 in which average age was 22.9 years

Out of  the 45 patients 20 patients (44.44%) were male and 25 cases were female (55.55%).This is different from other studies having much more female male patients, because working class in Southern Rajasthan  has female population too making them at risk of traumatic cataract as much as males. Memon et al  reported that 75.65 % patients were males as compared to 24.4% female. V.L. Loncar41 in which 79% were male and 21% were female.

Geographical distribution is also a significant factor in india for traumatic cataract as the life style and medical facilities and awareness is very much different in rural and urban areas. In our study, most of the cases were of rural background (68.88%) 31 cases as compared to 14 cases (33.12%) in urban areas.

In a study conducted in urban population of southern India, Dandona et al41 reported that blindness was higher for lower socioeconomic status.it also concluded that ocular trauma affects one in 25 people in urban population in india.

Similar results were seen in a study by Sthapi et al [50] who concluded that 60.7% ocular trauma cases were from rural area and rest from urban.

In this study most common object causing trauma was wood 57.1%  .Our study has a much higher percentage of wood being the source of trauma because of the more outdoor nature of work our population in our area.

Memon et al [32] also showed that most of the injuries were caused by wooden stick(31.7%) followed by thorn (22%).Our results were similar to Mehul Shah et al [44] in which 56.4% cases got injured from wooden stick.

Similarly sthapit et al [50](2011) found that ocular injuries were most commonly caused by wooden object (19.6%).

In our study the time duration between trauma and operation varied from within week to more than years. 21 cases (46.7%) were operated within 7 days of the injury followed by 15 cases (33.33%) which were operated within 1 month of injury. However ,9 cases (20.0%) presented after more than 3 months .

Most children were brought to the hospital by their parents without much delay, indicating the seriousness with which the injury was taken. It also explains why age of patient and preoperative vision did not affect visual outcome as amblyopia could not develop.

Similar results was seen in study by Parikshit Gogate et al (2010-2011)30 where the median time of presentation was 4 days

22 cases (48.8%) had cataract along with corneal tear followed by 11 cases (24.44%) with iris injury. 2 patients(4.2%) had associated posterior segment involvement. In study conducted by Memon et al 32 observed that Anterior Capsular rupture and corneal scar were the common associated ophthalmic injuries found in 20 (44%) and 12 (29.3%) patients respectively.

Ashvini and colleagues [70 ]also concluded that anterior capsule violation (56%) and corneal laceration (52%) were the most frequent associations with traumatic cataract.

Penetrating injuries are the most common cause of ocular injuries69; the same was observed in our study. Majority of the injuries were done by penetrating sharp objects (82.98%) as compared to blunt objects (17.02%)

Similar results were found by study conducted by Rajiv Mundana et al 1having penetrating injury in 67.74% cases. Study conducted by Memon et al 32 showed that twenty eight patients (68.3%) sustained penetrating injury whereas 13 patients (31.7%) presented with blunt injury.

Our study show that 75% patients of blunt trauma and 71% of penetrating injuries have post-operative vision between 6/12-6/6. The difference is not significant showing that if timely intervention and proper intervention was done results can be similar in both blunt and penetrating injuries.

Similarly no significant difference was found in visual prognosis in blunt and penetrating trauma in study conducted by Ying-Nan Xu et al[64]. Similarly there was no marked difference regarding causative agents seen on BCVA postoperatively in study conducted by Memon et al [32].

In our study 45 cases of traumatic cataract were underwent for surgery and all patients were follow up to 1 month and final visual outcome assess at last follow up. The visual outcome in these cases was categorized based on WHO vision categories[65]

• Vision below 3/60 as blind ● Vision between 3/60 – 6/18 Visually impaired ( low vision)
• Vision 6/18 and above as adequate vision.

The best corrected visual acuity of operated eye was assessed at 1 month. We found final visual acuity were 6/12 or better in 60.0% cases. 20 % cases have 6/36- 6/18 and 4.3% had vision PL+PR accurate. (due to vitreous hemorrhage and retinal detachment)

Study conducted by Memon et al 32 concluded that 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[71] and Cheema et al[72]reported visual acuity of 6/18 or better in 68.7% of patients.

Gradin et al. [66 ]reported that 64.7% had vision better than 6/18 after surgery for traumatic cataract.

In our study 19.2% patients did not gain satisfactory vision because of the corneal opacity and involvement of posterior segment (vitreous hemorrhage, retinal detachment) and a few due to posterior capsule opacification.

70. L. Loncar41found 70.83% cases have better visual acuity post operatively and 29.17% patient have no improvement from cataract surgery because of the posterior segment and posterior capsular opacification.

According to Boo Sup Oum et al67 the most common complication of ocular emergencies is corneal opacification . (50.1%).

This shows that visual outcome post operatively in traumatic cataracts is also affected by anterior segment and posterior segment involvement. Factors like age, gender, source of injury, time interval between presentation and outcome play a much less significant role.

In our study the most common cause of post operative compromised vision is cornea involvement as opposed to PCO formation in various studies due to shorter duration of study period. PCO formation may take longer than 1 month to be visually significant.

Patients presenting within 7 days of injury had best visual outcome of 6/12-6/614 pts (29.8%).It was 23.4% if patient presented between 7 days to one month and 19.1% if presented after 3 months,So the time of presentation and visual prognosis are inversely proportional.

This shows that patients presenting early and getting early treatment have better prognosis than those presenting late. Patients with childhood traumatic cataract if not treated timely may develop amblyopia leading to poorer visual prognosis even after surgery.

Thus our study concludes that Traumatic cataract can be successfully managed surgically with intraocular lens implantation with good visual outcome unless there is an associated anterior and posterior segment injury. Which is similar to others studies.

In our study males were predominantly affected by traumatic cataract because of their nature of work and outdoor occupation in southern Rajasthan. The age group of below 40 years formed the core group of people to get traumatic cataract. Though, in our study all the patient underwent cataract extraction by Phacoemulsification with IOL implantation. The final visual outcome showed good result however the final visual outcome depends upon the extent of associated ocular injuries. Effective Intervention and timely management are the key points in preventing monocular blindness due to traumatic cataract.

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