Traumatic Cataract

Traumatic cataract is lens opacification after blunt, penetrating or perforating injury, or from electrical, radiational or chemical injury.

• Blunt trauma: a rosette (stellate) cataract at the posterior capsule or anterior capsule, Vossius ring (pigment imprint of the iris on the anterior capsule), contusion cataract, with zonular damage and lens subluxation.
• Penetrating trauma: capsule rupture lets aqueous hydrate the lens, producing rapid white cataract within hours to days, with lens matter in the anterior chamber, inflammation, secondary glaucoma, and phacoantigenic uveitis (lens induced granulomatous inflammation).
• Other causes: infrared radiation (glassblowers), ionising radiation, electric shock and lightning, siderosis and chalcosis from retained intraocular foreign bodies, and alkali burns.
• Frequently associated with other injuries: hyphaema, angle recession, vitreous haemorrhage, retinal detachment, optic nerve injury, and zonular dialysis.

• Reduced vision after an injury, immediate (penetrating) or delayed (days to years after blunt trauma).
• Lens opacity with variable morphology; rosette pattern is typical of blunt injury; white, swollen lens with fluffy cortical material in penetrating injury.
• Phacodonesis, iridodonesis, lens subluxation, vitreous in the anterior chamber, irregular pupil, sphincter tears.
• Elevated or low intraocular pressure; inflammatory reaction.

• Detailed history (mechanism, time, foreign body risk), visual acuity, pupil (relative afferent pupillary defect), Seidel test, intraocular pressure (avoid if open globe suspected).
• Slit lamp: capsule integrity, lens position and zonules, angle recession (gonioscopy later), iris.
• CT orbits for suspected intraocular foreign body; B-scan ultrasound if no view of the posterior segment (retinal detachment, vitreous haemorrhage, dislocated lens fragments); ultrasound biomicroscopy for zonular and angle assessment.
• Systemic injuries and tetanus status.

• Open globe: primary closure of the wound, antibiotics (intravenous or oral moxifloxacin 400 mg or levofloxacin 750 mg, intracameral cefuroxime where indicated), tetanus prophylaxis; the lens decision follows the findings.
• Anti-inflammatory therapy: topical prednisolone acetate 1 percent every 1 to 2 hours, with cycloplegia (atropine 1 percent twice daily) and pressure control (timolol 0.5 percent, dorzolamide 2 percent, acetazolamide 250 mg four times daily).
• Timing of cataract surgery:
  • Primary lens removal at the time of wound repair when the capsule is ruptured with lens matter in the anterior chamber, severe inflammation, or raised pressure, or a lens fragment is obstructing the view of the posterior segment.
  • Delayed surgery (1 to 2 weeks to months) when inflammation has settled and the eye is stable, which allows complete assessment, biometry using the fellow eye if the injured eye cannot be measured, and better prediction of outcome.
• Surgical technique: phacoemulsification or aspiration with capsular support (capsular tension ring, capsular tension segments, iris hooks, sutured or scleral fixated intraocular lens when support is inadequate); anterior vitrectomy for vitreous in the anterior chamber; posterior segment surgery for retinal detachment or dislocated fragments.
• Intraocular lens options: in-the-bag lens when the capsule is intact, sulcus lens, scleral fixated, iris fixated, or anterior chamber lens; aphakic correction with contact lenses where implantation is not possible.
• Children: early surgery to prevent amblyopia, with amblyopia treatment.
• Follow up for glaucoma (angle recession can cause glaucoma years later), retinal detachment, and posterior capsule opacification.
• Prevention: protective eyewear in sports and work, and supervision of children.