Treatment of traumatic cataracts

Treatment of traumatic cataracts Marcus Blum, MD, Manfred R. Tetz, MD, Claudia Greiner, MD, Hans E. Voelcker, MD

ABSTRACT Purpose: To analyze the postoperative outcome and complication rate following cataract extraction because of post-traumatic lens opacification. Setting: University medical center. Methods: A retrospective analysis was done of 148 eyes with traumatic cataracts operated on between 1978 and 1992. Age, sex, traumatic sequelae, surgical strategies, and postoperative complications were reviewed for all eyes. Results: In 85 eyes, Group A, a history of blunt trauma could be ascertained . In 63 eyes, Group B, there had been a penetrating injury. Secondary glaucoma was observed more frequently in patients with blunt trauma. A posterior chamber intraocular lens was implanted in 85% of Group A eyes and in 67% of Group B eyes. Mild or moderate postoperative complications occurred in 15% of all cases. Postoperatively, the incidence of glaucoma remained unchanged. Visual acuity improved in 90% of eyes. Ten percent of eyes did not benefit from cataract surgery because of severe traumatic involvement of the retina or optic nerve. Conclusions: In this study, a majority of eyes with traumatic cataract were safely rehabilitated with posterior chamber lens implantation. Visual acuity improved in 90% of eyes; complications were seen in 15%. J Cataract Refract Surg 1996;

22:342-346

C

ataract extraction with implantation of an intraocular lens (IOL) is a well-established procedure for visual rehabilitation in cases of crystalline lens opacification. The development of a cataract is a known complication following blunt or penetrating trauma to the eye. I However, traumatic cataract is only one complication of injured ocular tissues. Often these eyes present with a variety of morphological and functional pathologies of the anterior and posterior segments. 2 In the present

From the Department of Ophthalmology, University of Heidelberg, Germany. Presented in part at the 3rd American-International Congress on Cataract, JOL and Refractive Surgery, Seattle, May 1993. Reprint requests to Marcus Blum, MD. Arvid-Harnack Strasse 26, 07743 lena, Germany.

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study, we evaluated the outcome in 148 eyes following surgery for traumatic cataract.

Materials and Methods In this retrospective clinical study, we analyzed 148 eyes with traumatic cataracts. Cataract extractions had been performed between 1987 and 1992. All patients had a monocular cataract with a history of trauma to the eye. They were separated into two groups: Group A, eyes with blunt trauma; Group B, eyes with penetrating lnJury. Patients who could not remember any history of trauma were not included in this study. An exception was made for 11 patients in the blum trauma group who denied any trauma but had obvious traumatic damage

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to the eye (e.g., dislocation of the lens or traumatic anterior chamber angle recession) (Figure 1). Age, sex, and type and time of blunt trauma were recorded for all patients. Preoperative visual acuity was documented, as was the extent of traumatic ocular changes. Eyes with penetrating injuries were first closed and treated with high dose steroids and intravenous antibiotics. No cataract extraction and IOL implantations were done during this treatment period. In Group A, surgical procedures included lens extraction with extracapsular cataract extraction (ECCE) or phacoemulsification with or without implantation of a posterior chamber IOL. The corneoscleral incision was placed at the 12 o'clock position. From 1987 to 1989, ECCE was performed; since 1990, phacoemulsification has been used. Cortex removal was done as completely as possible without endangering the integrity of the capsular bag. An automated irrigation/aspiration system was used. During IOL implantation a viscoelastic agent was used. When zonular support was sufficient, the surgeons attempted to place the IOL in the capsular bag with loop orientation perpendicular to the zonular defect; otherwise sulcus placement was preferred. The IOL haptics were positioned at a 90 degree angle to the zonular defect. In the absence of posterior capsular support, the IOLs were sutured transsclerally. In Group B, all cataract extractions were performed as a second surgical procedure. The surgical strategies,

including the positioning of the IOL and the use of viscoelastics, were the same as in Group A. No anterior chamber lenses were used in either group. Postoperatively, visual acuities and the rate of implantation and position of the IOLs were recorded. The absolute numbers and potential causes of complications were analyzed.

Results Group A The blunt trauma group included 85 eyes (19 women, 66 men). Average age was 56.1 years ~ 15.6 (SD). Seventy-four patients reported a history of blunt trauma. Eleven patients denied any trauma although post-traumatic eye pathology was evident. This subgroup comprised 4 men and 7 women. Because of the missing information on these patients and because other patients did not remember the exact year of the trauma, we were not able to define the exact interval between trauma and cataract surgety. However, the information we did have allowed us to determine the interval as 15 to 20 years. Causes of trauma are shown in Figure 2. Preoperative visual acuity of 46 patients (54.1%) was light perception or hand movements. Average acuity in the remaining 39 patients (45.9%) was 20/100. Posttraumatic morphological changes included anterior chamber angle recession and iris defects in almost every second eye. Anisocoria and poor response to light were noted in 30.5% of eyes. Larger colobomas were seen in 4 eyes. More than one third of eyes showed luxation or subluxation of the lens. The rate of secondary glaucoma was 14.4% (Table 1). trauma in childhood 22.6% trauma denied 13.0%

sports and home 29.7%

miscellanous 13.0%

5.9% Figure 1. (Blum) Traumatic cataract following blunt trauma.

violence 15.8%

Figure 2. (Blum) Causes of blunt trauma.

Note the rosette cataract presenting with a typical flower-shaped lenticular opacity.

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Table 1. Morphological changes seen in Group A patients (n = 85).

Change

Percentage of Eyes

Chamber angle recession and iris defects Luxation/subluxation of the lens Secondary glaucoma

44.7 35.2 14.4

Table 2. Complications of cataract surgery in Group A patients. Complication Transient lOP rise Fibrin reaction in anterior chamber Dislocation of IOL Hypotension due to wound leakage

Number of Eyes

5 3 2

In 72 patients (84.7%), a posterior chamber IOL was implanted. In 23 eyes (31.9%) the IOL was implanted in the capsular bag. In 43 eyes (59.7%)-most of which had implantation in the early period of this study-the IOL was implanted in the ciliary sulcus; two were secondary implants. Positioning the haptic at a 90 degree angle toward a zonular defect was necessary in 16 eyes (22.2%). In 1 eye, one haptic was in the bag and the other, in the ciliary sulcus. In 5 eyes (6.9%) the IOL was sutured transsclerally. Thirteen eyes (15.3%) remained aphakic. Four eyes had severe retinal damage, optic nerve damage, or both without the possibility of visual improvement. Five patients were young children and 4 eyes had suffered a complete loss of capsular support and massive alterations of tissue in the anterior segment (two large colobomas, one secondary glaucoma, one corneal transplant) . Postoperatively, 69 patients (82.1 %) with IOLs had a mean visual acuity of20/30. Nine patients with aphakia reached 20/40. Seven patients (8.2%) remained at hand movements and light perception because of severe post-traumatic retinal pathology, optic nerve atrophy, or both. Complications in this group are shown in Table 2. Intraocular pressure rise and fibrin reactions were controlled by local and systemic therapy. Both IOL dislocations occurred in sulcus-fixated IOLs; another postoperative trauma was suspected as an underlying reason. One eye was treated with a transsclerally sutured IOL; the other one was not given any more treatment as 344

the eye showed severe retinal damage. One eye with a hypotension syndrome had to be resutured.

Group B The penetrating injury group consisted of 63 eyes (12 women, 51 men). Average age was 43.6 ± 19.2 years. All patients remembered the history of the trauma. In 25 patients (39.6%) the interval between trauma and surgery for cataract was 5.6 days. In a smaller group of 9 patients (14.2%), an average of 6.8 months passed before lens removal was necessary. In 24 patients (38%) the average interval between initial trauma and cataract surgery was 19.9 years. Causes of penetrating trauma are shown in Figure 3. Preoperative visual acuity was light perception and hand movements in 28 eyes (44.4%) and 20/120 in the other 35 eyes (55.6%). Morphologically, 61.9% of the eyes showed corneal scars and 52.3%, iris defects (Table 3). In 26.9%, a defect in the lens capsule had been present, and two intralental foreign bodies were removed. In 42 eyes (66.6%), posterior chamber IOLs were implanted. Eighteen IOLs (42.8%) were implanted in the capsular bag, 16 (38.0%) in the ciliary sulcus. In 8 eyes (19%), secondary posterior chamber IOL implantation was performed. Twenty-one eyes (33.3%) with either severe tissue loss in the anterior segment or severe damage to the retina, optic nerve, or both remained aphakic. The eyes with IOLs had an average postoperative visual acuity of 20/35. In the aphakic group, 14 eyes (22.2%) had an acuity of20/45, whereas 7 eyes (11.1 %) still had hand movements and light perception because of extensive damage to the posterior segment. trauma in childhood

19.0% sports and home

traffic accident

20.8%

11.1%

miscellanous

19.0% violence

9.5% Figure 3.

(Blum) Causes of penetrating trauma.

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Table 3. Morphological changes seen in Group B patients (n = 63).

Change

Percentage of Eyes

Corneal scars Iris defects Defect in the lens capsule

61.9 52.3 26.9

Table 4. Complications of cataract surgery in Group B patients. Complication

Secondary glaucoma Fibrin reaction in anterior chamber Dislocation of IOL Hypotension due to wound leakage Postoperative intraocular hemorrhage Pupil capture

Number of Eyes

2 2

1

2 3

Complications in this group are shown in Table 4. Glaucoma and fibrin reactions were treated conservatively. Dislocation of an IOL was corrected by a transsclerally sutured IOL. Two wound leakages had to be resutured. Two of the intraocular hemorrhages resolved without treatment; the third "in the bag" hyphema was treated with a neodymium:YAG laser caps ulotomy.

Discussion The prevalence of men in blunt trauma and penetrating injuries is found in all western societies. 3- 5 A connection between ocular trauma and lens opacification has been well established. 6 The incidence of traumatic cataracts in the literature varies based on the patient selection and inclusion criteria for each study, but the prevalence of cataracts is 30 to 65%.5.7 Although it was difficult to define the exact interval between trauma and cataract surgery, the average age of patients in the blunt trauma group was at least two decades younger than the average age for senile cataract. Patients with penetrating trauma could be separated into two subgroups. The first subgroup showed a short interval between trauma and cataract surgery, and the patients were younger than patients with blunt trauma at the time of cataract surgery. These findings compare well with the data of other authors and are explained by the early surgical approach after penetrating inju-

. .. 1289Th b ' d ' .h ,, e second su group compnse patlents wIt nes a history of two decades between the penetrating injury and cataract surgery. There was no age or time difference between these patients and those in the blunt trauma group. The post-traumatic morphological changes in all patients reflect the heterogeneity of this group. One third of patients with blunt trauma had a zonular defect. This is a larger proportion than other authors have found in blunt trauma patients. 4 ,9,10 The reason might be the inclusion criterion of "traumatic cataract" in our study. The number of anterior chamber angle defects that are held responsible for 10 to 15% of secondary glaucoma in traumatized eyes compares well with the numbers in other reports. 10 - 12 The rate of glaucoma was much higher in eyes with blunt trauma than in eyes with penetrating injuries. This may be influenced by the higher patient age and the longer interval between trauma and surgery for cataract in the blunt trauma group. Posterior chamber IOL implantation following surgery for blunt trauma cataract reached almost 85.0%; following surgery for penetrating trauma, 66.6%. In eyes with small zonular defects, placing the IOL within the capsular bag is easy. The haptic should be positioned perpendicular to the zonular defect to expand fully and stabilize the capsular bag. If capsular bag implantation is unstable, the IOL can be implanted in the ciliary sulcus with a 90 degree angle of the haptic toward the zonular instability. In recent years, the use of a capsular ring has been advised,13 but this device was not available at the time of this study. Overall, 80% of patients with traumatic cataracts were rehabilitated with IOL implantation. Intraocular lenses were not implanted in patients with severe anterior segment damage, including secondary angle closure glaucoma and extended tissue loss, and in patients with such severe posterior segment damage that they would not have benefited from IOL implantation. Patients with severe anterior segment damage benefited from lens removal, whereas 10% of patients with severe posterior segment damage did not visually benefit from cataract surgery. The complication rate in both groups was higher ' l e cataract.' 14 15 Postoperatlve . .ill· surgery f than ill or,sem traocular pressure rise occurred frequently. However, no

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Figure 4. (Blum) Eye of a Group B patient preoperatively (left) and after phacoemulsification with capsulorhexis and in-the-bag posterior chamber IOL implantation (right). Visual acuity improved from light perception to 20/30.

new cases of secondary glaucoma developed because of cataract surgery. The number of IOL dislocations even in eyes with zonular and capsular defects was surprisingly low. 16 ,17 In two eyes with blunt trauma, a second trauma was the suspected underlying reason for IOL dislocation, In the penetrating trauma group, the risk for postoperative intraocular hemorrhage, including such rare conditions as an "in the bag hyphema" from a fibrol' . vascu Iar stran, mentlonmg. d 18 deserves speC!' a

10.

11.

12.

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Vorgehen und Verlaufbei Cataracta traumatica. In: Neuhann T, Hartmann e, Rochels R, eds, 6. Kongress der Deutschsprachigen Gesellschaft fur Intraokularlinsen Implantation. Berlin, Springer, 1993; 240-243 Kreutzer PH. Verletzungsfolgen nach Augenprellungen. Ergebnisse einer Studie tiber 313 faile. Klin Monatsbl Augenheilkd 1983; 182:206-209 Blanton FM. Anterior chamber angle recession and secondary glaucoma; a study of the aftereffects of traumatic hyphemas. Arch Ophthalmoll964; 72:39-43 Kaufman JH, Tolpin OW. Glaucoma after traumatic angIe recession; a ten-year prospective study. Am J Ophthalmol1974; 78:648-654 Witschel B, Legler UFC. The capsular ring. Audiovisual J Cataract Implant Surg IX(4), 1993 Apple OJ, Kincaid Me, Mamalis N, Olson RJ. Intraocular Lenses; Evolution, Designs, Complications, and Pathology. Baltimore, Williams & Wilkins Co, 1989 TetzM, Blum M, Greiner C, Vi.ilcker HE. Traumatische Katarakte; Operationsmethoden und Ergebnisse bei 106 Patienten. Ophthalmologe 1993; 90:360-363 Tetz MR, Daus W, Volcker HE. Intraokularlinsenimplantation bei Patienten mit kongenitalen oder traumatischen Kolobomen. In: Wenzel M, Reim M, Freyler H, Hartmann C. eds, 5. Kongrd~ der Deutschsprachigen Gesellschaft ftir Intraokularlinsen-Implantation. Berlin, Springer, 1991; 565-569 Vi.ilcker HE, T etz MR, Daus W. Cataract surgery in eyes with colobomas. Dev Ophthalmol1991; 22:94-100 Holz FG, Tetz M, Vi.ilcker HE. Extrakapsulare Kataraktextraktion mit Hinterkammerlinsenimplantation bei umschriebener Endophthalmitis phacoanaphylactica. In: Wenzel M, Reim M, Freyler H, Hartmann C, eds, 5. Kongress der Deutschsprachigen Gesellschaft ftir Intraokularlinsen Implantation. Berlin, Springer, 1991; 570-574

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