Ординатура / Офтальмология / Учебные материалы / Clinical Diagnosis and Management of ocular trauma

88

Clinical Diagnosis and Management of Ocular Trauma

AFTER DILATION

repair even when anterior capsular rupture is present.

1. Slitlamp examination (after pupillary dilation) is

Cataract surgery can be deferred while the

recommended if feasible. This helps identify and

inflammatory response is treated with topical steroids.

document the type of cataract, the position and

Advantages of secondary cataract removal are better

stability of the lens, integrity of the lens capsule and

visibility, better IOL power calculation, anterior segment

the overall status of the anterior segment. When

reconstruction, and stabilization of a hemato-ocular

slitlamp examination is not possible in the awake

barrier. Ten of our patients (43.4%) had anterior

state, it can be done using a portable instrument

capsule rupture and crystalline lens involvement at the

in the operating room in conjunction with the

time of injury and had their cataract surgery deferred

examination using the operating microscope.

for times ranging between 2 days and 6 months

2. A posterior segment examination, including

(average 20 days).11 Cataract surgery is usually not

examination of the retinal periphery, should be

performed concurrent with the primary repair of an

carried out in detail if the view through the lens

open globe. The exception to this rule would be a

allows. Greven and colleagues8 found that only

small eyewall laceration that can be closed securely

30% of eyes that suffered from contusion injuries

prior to cataract surgery and that doesn’t significantly

had normal preoperative posterior segments;

interfere with visualization of the cataract. If cataract

emphasizing need for B-scan if the posterior pole

surgery is delayed for several weeks, it can be

cannot be visualized.

combined with the removal of the sutures used to close

3.

Gonioscopy may be helpful to evaluate the angle

the corneal laceration thereby minimizing the number

structures and for recognizing vitreous at the lens

of times the child has to be anesthetized. If it is unclear

equator or areas of loss of zonular support.

if the cataract is visually significant, cataract surgery

4.

If planning for IOL implantation, keratometry and

should be delayed until the cornea is fully healed and

immersion A-scan ultrasound for globe axial length

the child’s vision can be tested with an optical

measurement should be attempted. Even when

correction. If the cataract is visually significant, its

corneal scarring is present, keratometry of the

removal should not be delayed too long because of

injured eye should be attempted. Changes in

the potential for the child to develop amblyopia and

corneal curvature as the result of an injury will

lose binocularity. The median interval between the

change the IOL power needed to achieve the

injury and cataract was 8 weeks in a series by Gardin

refractive goal. At times the keratometry readings

and Yorston.3 Authors noted that children older than

of the fellow eye need to be used but this will

7 years at the time of surgery were more likely to have

further compromise the accuracy of the

a delay of 1 year or more (P=0.016).

postoperative refraction in relation to the

postoperative goal. Cohen9 reported a 4 D of IOL

Surgical Details

power surprise in a adult patient when the IOL

power was calculated using the K and AL of the

General principles of pediatric cataract surgery should

fellow eye.

be followed. Specific differences have been described

A Guarded prognosis for anatomical and

herein.

functional outcome is to be thoroughly explained

•

Anesthesia: In anticipation of difficult surgery,

to the patient and patient’s relatives. The full extent

general anesthesia is preferable even in older

of the eye injuries are not always known prior to

children who might otherwise be cooperative for

cataract surgery. It is also important to explain about

local anesthesia.

the possible need

for additional surgeries

•

Anterior capsule management: Performing the

depending on the

type of injury (retinal

capsulorhexis may be difficult in pediatric traumatic

detachment, keratoplasty for dense corneal scar

cataract. Besides higher elasticity of pediatric

obstructing visual axis, etc).

anterior capsule, traumatic cataracts are often

associated with ruptured anterior lens capsule or

Timing of Surgery

fibrosis of the anterior capsule. In addition,

performing the capsulorhexis may be difficult in

The timing of traumatic cataract surgery in children

a case of traumatic cataract due to a lack of the

is important. Some authors have reported cataract

usual zonular counter traction forces. To address

surgery at the time of primary repair.10 While the

this situation, initiate the capsular tear in the location

development of amblyopia in children necessitates

of the greatest zonular stability and complete it in

prompt removal of a cataract when it develops, cataract

the direction of the zonular dialysis. Very dense

surgery is not necessarily required at the time of initial

fibrous capsule can be removed with intraocular

Traumatic Cataract in Children

89

scissors, radiofrequency diathermy or Fugo plasma

• Intraocular lens implantation: Intraocular lens

blade. Staining of the anterior lens capsule may

implantation offers a constant optical correction

be helpful to enhance visibility in these eyes with

and, as such, helps in the prevention of amblyopia.

a “torn anterior capsule” or “white cataract.”

Children often have difficulty wearing contact lenses

Anterior capsule staining can be successfully done

due to poor comfort, and poor motivation to wear

using nontoxic capsular dyes such as indocyanine

the lens. In addition, aphakic contact lenses are

green 0.5% or trypan blue 0.1%. Typically, these

not suitable for the developing world because of

cataracts may be white in many instances, and

their high cost and the need for meticulous hygiene.

indocyanine green or trypan blue can be very

The use of IOLs has been studied in children with

helpful. An intact capsulorhexis is also mandatory

traumatic cataract since Choyce first reported the

for a capsular tension ring (CTR) placement. After

use of an anterior chamber lens in a child after

the capsulorhexis is complete, in cases of zonular

trauma in 1958. BenEzra and associates12

had

dialysis, capsular retractors can aid in visualization

reported a better visual acuity and less strabismus

of the lens and in its removal.

in children with traumatic cataract after implanting

• Avoid doing hydrodissection if the integrity of the

posterior capsule is in question.

an IOL, when compared to those wearing contact

• Posterior capsule and vitreous management:

lenses. Continued advances in IOL design,

Management of the posterior capsule depends on

biomaterial and power calculations are making it

the age of the patient and the status of the posterior

the preferred option.

capsule (intact v/s torn). In young patients with

In young children, it is generally best to under-

complex trauma, staged approach (leaving behind

correct an eye in anticipation of a myopic shift as

intact posterior capsule at the time of initial cataract

the child becomes older. In-the-bag fixation is

surgery and planning a secondary surgery to

believed by most to be the best site for IOL

remove the center of the posterior capsule after

implantation as it sequesters the implant from uveal

the IOL is properly fixed into the lens capsule) may

structures, reduces the chance of lens decentration,

help proper placement of the IOL. This staged

and delays PCO formation.13 In-the-bag placement

approach may not be necessary for the surgeon

of the IOL haptics improves implant stability and

who operates on children frequently. However, it

minimizes uveitis and pupillary capture.14 Fifteen

may be better for surgeons unaccustomed to

of our 21 eyes with primary implantation had the

operating on children. Posterior capsule

opacification occurs quickly in most cases of

IOL placed in the capsular bag.11 Traumatic cataract

complex traumatic cataract surgery. Therefore,

cases often present unique challenges, as it is not

prepare the family that the best vision will likely

always possible to fixate the IOL haptics in the

come after this planned second surgery. Repair of

capsular bag due to anterior and/or posterior

iris defects or other more elective surgical

capsule tears from trauma or the difficult surgical

maneuvers can also be done during this secondary

procedure. If the IOL must be placed in the ciliary

procedure, which is often done 4-8 weeks after

sulcus, as with extensive traumatic posterior capsule

the initial cataract removal. Kenalog can be used

rupture, try to capture the IOL optic through the

to identify residual vitreous (Fig. 17.3).

anterior capsulotomy. Gardin and Yorston noted

that they could implant an IOL in the capsular bag

in 32% of eyes, in the sulcus in 28% and

asymmetrical (bag/sulcus) in 5.6% of eyes (34%

unknown).3 Care should be taken to position the

haptics of the IOL on the most stable remnants

of the lens capsule. Malplacement of the IOL is

more common, however, in traumatic cataracts

since damage to the capsular bag, zonules and iris

may predispose to decentration and pupil capture.

Using ciliary sulcus-fixated IOLs in children following

traumatic cataract removal resulted in visual

outcomes similar to those for capsular bag IOLs

but with more complications, in particular uveitis

and pupillary capture. The use of multifocal capsular

Fig. 17.3: Use of kenalog in identifying residual

bag IOLs following removal of a traumatic cataract

vitreous in anterior chamber

has also been explored. In comparison with

90

Clinical Diagnosis and Management of Ocular Trauma

standard, monofocal, capsular bag IOLs, the

haptics should be oriented toward the area of

multifocal lenses resulted in improved uncorrected

incompetence in order to expand and stabilize the

near visual acuity and stereopsis, as well as

capsular bag fully. With more significant zonular

decreased spectacle dependency. However,

disruption, IOL implantation should be combined

multifocal IOLs reply on centration of the IOL and

with CTR. They are not recommended when the

the pupil. Neither are achievable in all cases of

integrity of the posterior capsule has been breeched.

trauma. Since traumatic cataracts are most often

For zonular dialysis of up to 150 degrees, the use

unilateral, the child will rely mostly on the natural

of a conventional CTR followed by standard

accommodation of the uninjured eye for near

cataract removed and IOL implantation is often

viewing. Multifocal IOLs are best when used

successful. The CTR can be implanted before or

bilaterally. For these reasons, the use of multifocal

after the cataract is removed. Although early

IOLs in pediatric trauma has remained low.

insertion provides support during cataract removal,

Several reports on groups of patients with angle-

it may create additional zonular trauma. The use

supported anterior chamber IOLs in traumatic

of iris or capsule retractors at the capsulorhexis edge

pediatric aphakia have been published. Due to the

or the use of capsular tension segments (CTS)

during cataract removal are other alternative that

high incidence of secondary glaucoma, progressive

do not induce significant capsular torque during

pupil distortion, endothelial loss, and the limited

insertion. For more significant or progressive zonular

experience with these IOLs in children, angle-

dialysis the Cionni-modified CTR is useful

supported IOLs have not gained widespread

alternative to the conventional CTR. It can be

acceptance. Scleral-fixated IOLs are considered a

sutured to the sclera without compromising the

more acceptable alternative for the bag or ciliary

capsular bag, thus allowing the CTR and capsule

sulcus implantation of posterior chamber IOLs, in

to be held in place even in the presence of significant

the absence of capsular support in children.

zonular incompetence. Otherwise one or two CTS

However, concerns have been raised about the risk

devices may be used and may also be placed in

of conjunctival and scleral erosion of scleral sutures

cases of an anterior capsular tear, incomplete

leading to infection, IOL tilt, dislocation of the lens

capsulorhexis, or posterior capsular rupture.

in the vitreous cavity, vitreous or ciliary body

•

Iris damage: Occasionally the iris may require

hemorrhage, and secondary glaucoma. Recently,

suturing. Iridodialysis defects are usually repaired at

Sminia ML and colleagues15 described the long-

the time of IOL implantation using a series of double-

term follow-up of Artisan aphakia IOL implantation

armed10.0 prolene sutures (Figs 17.4A to C) on

in five aphakic eyes without capsular support, after

a long straight STC-6 needle. A small paracentesis

cataract extraction following penetrating ocular

is made 180 degrees away from the iridodialysis.

trauma. The authors noted that the Artisan aphakic

Both needles of the double-armed prolene are

IOL offers a useful alternative for correction of

passed through the paracentesis (one at a time)

traumatic childhood aphakia. Although results were

and across the anterior chamber. The needle is

from a small series, the authors feel that

allowed to pick-up the peripheral detached edge

implantation of the Artisan aphakic IOL can be

of the iris base and then exits the sclera as close

considered a treatment option in aphakic eyes of

to where that iris segment should naturally attach

children that lack capsular support due to trauma.

as possible. Each double-armed prolene is passed

• Zonular loss: Zonular dialysis may also exist in other

in a mattress fashion and is tied external to the

conditions that are not traumatic, such as pseudo-

sclera. Rather than using a scleral flap, we simply

exfoliation or Marfan’s syndrome. The difference

leave the suture ends long and tuck then under

is that these conditions involve diffuse, progressive

the conjunctiva and Tenon fascia. This seems to

zonular disease as opposed to a one-time focal

prevent suture ends from gradually eroding

disturbance that occurs upon trauma. Although the

through the conjunctiva. Cuts and tears in the pupil

surgical approach to cataract surgery may be similar

margin are also often closed with the same type

in both scenarios, long-term capsular stability is

of suture material. This can be done at the initial

better in traumatic cases. The degree of zonular

surgery but is often easier when done as a

dehiscence dictates the management approach. The

secondary procedure in a well-healed pseudo-

choice and positioning of the IOL depends on the

phakic eye. The use of aniridia implant devices such

degree and location of zonular disruption. In eyes

as iris diaphragm rings and iris section shields may

with no zonular disruption and an intact posterior

be appropriate in cases of a significant loss of iris

capsule, a standard capsular bag-fixated IOL may

tissue. These devises are not yet FDA approved

be used. With a small area of zonular incompetence,

for use in the USA. Pupilloplasty and/or repair of

a capsular bag IOL may also be used, but the

iridodialysis may also be required.

92

Clinical Diagnosis and Management of Ocular Trauma

series originally published by Mc Kimura in 1961.

Twenty-six children with unilateral traumatic cataract

had been treated at McGill University Hospital and

the University of California Medical Center in San

Francisco. Despite treatment, most of the patient’s had

visual acuity in the range of counting fingers; only one

child retained visual acuity better than 20/200.

Binkhorst and Gobin22 recommended the use of IOLs

in this situation and suggested this treatment would

improve the visual outcomes in children with lenticular

opacity.

Our results (as well as the experience of several

other authors) confirm that good visual outcome is

frequently possible following IOL implantation in

children. In our patients, 78% achieved a best-

corrected visual acuity of 20/40 or better after a mean

follow-up of 2.3 years. Koenig et al20 reported 20/40

Fig. 17.6: Deposits on IOL optic

or better visual acuity in 87% (7 out of 8) of eyes

undergoing IOL implantation for pediatric traumatic

decentration and should, therefore, be avoided.

cataracts. The average follow-up in their series was 10

months. Gupta et al19 reported that 9 (50%) of 18

Explantation or repositioning of the IOL may be

children with unilateral traumatic cataract achieved 20/

necessary in some cases presenting with significant

40 (or greater) visual acuity after IOL implantation,

decentration/dislocation. Fracture of an implanted

with an average follow-up of 12 months. In many cases

posterior chamber IOL after trivial trauma in a child

corneal leucomata contributed to decreased

operated originally for traumatic cataract has been

postoperative visual acuity. Similarly, Anwar et al,10

reported. Such spontaneous fracture of IOL may be

BenEzra et al,12 Eckstein et al16, Pandey et al,14 and Brar

because of mechanical weakening, commonly

et al,13 reported visual acuity of 20/40 or better in

attributed to a defective lens production or repetitive

73.3%, 79.0%, 65.2%, 67.0%, 85% and 62% of cases,

movements of the IOL during psuedoaccomodative

respectively, after traumatic cataract surgery with IOL

effort. Moreover, in children extensive fibrosis around

implantation in children. Gardin and Yorston3 noted

the IOL can induce torsion at the optic haptic junction.

that amblyopia was found in 42 of 108 children

Perhaps a sudden anterior movement of the vitreous

(38.9%) 8 years or younger at the time of injury with

due to a rapid head movement induced by trauma,

a minimum follow-up of 1 month. The risk of

in the setting of a relatively fixed pupillary captured

amblyopia significantly increased when there was a

IOL, may break the IOL at its already stressed optic-

long interval between trauma and cataract surgery.

haptic junction, resulting in optic lying in the anterior

Fourteen of 23 eyes (60.9%) in children 8 years or

chamber. The possibility of this complication can be

younger at the time of injury who had surgery at least

explained while explaining while discussing a guarded

1 year after the trauma were amblyopic. Of the 85

prognosis to the parents.17

who had surgery less than 1 year after their injury,

28 (32.8%) were amblyopic (P=0.015). The authors

further noted that of the 21 eyes with unfavorable

Visual Outcome

visual outcome (worse than 20/200), amblyopia was

the most common cause (9 eyes, 42.8%), followed

The prognosis for retention of good vision in pediatric

by retinal detachment (5 eyes, 23.8%).

eyes suffering traumatic cataracts has greatly improved

over the last few decades. Primary IOL implantation

Summary

has a greatly improved visual outcome. Several

Cataract formation is a well-recognized consequence

surgeons from countries with high traumatic cataract

rates and conditions prohibitive of contact lens wear,

of blunt and penetrating ocular trauma. It results from

have recently reported successful IOL implantation in

direct lens injury, contusive ocular damage, or lens

injured children.10, 12-14, 18-21 Compliance with amblyopia

dislocation and is often associated with traumatic injury

therapy is necessary in younger children to get

to the cornea, iris, and vitreous. Traumatic cataract

maximum visual outcome, even following an excellent

can present many challenges to the ophthalmologist.

surgical result. Binkhorst and Gobin22, reviewed a case

It adds the challenges presented by childhood cataract.

Traumatic Cataract in Children

93

Comprehensive examinations, careful planning for

9.

Cohen KL. Inaccuracy of intraocular lens power

surgical management and a close follow-up are

calculation after traumatic corneal laceration and cataract.

necessary for a favorable outcome in these cases.

J Cataract Refract Surg 2001;27:1519-22.

10.

Anwar M, Bleik JH, von Noorden GK, el-Maghraby AA,

Further prospective studies are probably needed to

Attia F. Posterior chamber lens implantation for primary

specifically address the optimum timing of cataract

repair of corneal lacerations and traumatic cataracts in

surgery in cases of pediatric traumatic cataract.

children. J Pediatr Ophthalmol Strabismus 1994;31:

However, based on our experience, we suggest primary

157-61.

repair of the injury first, and cataract surgery after a

11.

Wilson ME, Trived RH, Pandey SK. Traumatic cataracts

2-4 weeks of topical steroid and atropine treatment.

in children. In: Wilson ME, Trivedi RH, Pandey SK

This delay may be helpful in achieving the optimum

(editors). Pediatric Cataract

Surgery: Techniques,

Complications, and Management Ahmedabad: Lippincott

surgical outcome by reducing the postoperative

Williams and Wilkins, 2005.

inflammation in these eyes and allowing healing to

12. BenEzra D, Cohen E, Rose L. Traumatic cataract in

occur. Long delays before cataract removal must be

children: correction of aphakia by contact lens or

avoided during the amblyopia prone years, which

intraocular lens. Am J Ophthalmol 1997;123:773-82.

extend to approximate the age of 8 years. Successful

13.

Brar GS, Ram J, Pandav SS, Reddy GS, Singh U, Gupta

surgery requires a wide variety of techniques to the

A. Postoperative complications and visual results in

uniocular pediatric traumatic cataract. Ophthalmic Surg

particular occasion and case. These factors include the

Lasers 2001;32:233-8.

history and circumstances of the ocular trauma,

14.

Pandey SK, Ram J, Werner L, et al. Visual results and

hypotony or the elevation of IOP, inflammation, and

postoperative complications of capsular bag and ciliary

the extent of associated anterior segment trauma. We

sulcus fixation of posterior chamber intraocular lenses

support the continued use of IOLs in children in eyes

in children with traumatic cataracts. J Cataract Refract Surg

with traumatic cataract.

15.

1999;25:1576-84.

Sminia ML, Odenthal MT, Wenniger-Prick LJ, Gortzak-

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