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Traumatic cataract :Traumatic lens damage caused by mechanical injury and by physical forces (Ionising radiation,IR radiation, electrical current).
ETIOLOGY
• Blunt Trauma• Penetrating Trauma• Electric shock /Lightning strike : anterior / posterior capsular iridescent opacity with stellate pattern
• Infrared Radiation [Glass blowers] : True exfoliation of anterior lens capsule
• Ionising Radiation:PSCO
Incidence
• Ocular injuries accounts for 1‐2% of total injuries
• Gender ‐ M:F =3:1• More exposed to outdoor activities, indulge more sports ,violence ,rash driving , industry & travel
• Age – Maximum incidence in 21‐30 yrs• Higher incidence as this is the wage earning period .
2016-1-19
Birmingham Eye Trauma Terminology System [BETTS]
EYE INJURY
OPEN GLOBE CLOSED GLOBE
RUPTURE LACERATION
PENETRATING INJURY IOFB PERFORATING
INJURY
CONTUSION LAMELLALR LACERATION
BLUNT TRAUMAMECHANISM
Cortical matter in ACRosette Cataract
Membranous cataractTotal cataract
A‐P Compression forceLeads to equatorial expansion
Effect of blunt trauma on lens
• VOSSIUS ring• Minute anterior subcapsular opacities• Concussion cataract• Early Rosette cataract• Late Rosette cataract• Subluxation of lens• Dislocation of lens
Vossius Ring
CIRCULAR RING OF FAINT STIPPLED OPACITIES [BROWN AMORPHOUS GRANULES] ON ANTERIOR CAPSULEDIAMETER SAME AS CONTRACTED PUPIL
PRESSURE ON EYEBALL
DRIVES CORNEA &
IRIS BACKWARDS
IMPRESSION OF IRIS ON
LENS
Concussion cataract
• Due to mechanical effects of injury on lens fibres.
Aqueous hits the capsule impairing its
permeability
Capsular tear covered with Iris ‐>opacity remains/regresses
Open capsular tear ‐>allows more aqueuos into lens : cataract
Early rosette cataract
• Posterior cortex involved • Few hours –months• Accumulation of fluid along the sutural arrangement of lens fibres
• Thus, the stellate/feathery outline delineated.
Late rosette cataract
• Posterior cortex involved• 1‐2 years after the trauma• Small , compact with short sutural extensions.
Subluxation and Dislocation
Blunt trauma
Compression
Rapid equatorial expansion of globe
Disruption of zonular fibres
Subluxation or Dislocation : Ant[AC] or
Post [vitreous]
Symptoms of traumatic lens subluxation
• Fluctuation of vision• Impaired accommodation• Monocular diplopia[Edge crosses the pupil]• High astigmatism.• Hypermetropic through the aphakic part.[needs correction]
• Myopic[curvatural] through subluxated part
Signs of traumatic lens subluxation • Suspensory ligament torn by To‐and‐Fro compression pressureI‐>lateral movement or rotation of lens.
• Iridodonesis• Phacodonesis • Oblique illumination : Grey cortex line • Ophthalmoscope : Black cortex line• Retroillumination of the lens at the slit lamp through a dilated pupil :zonular disruption.
Traumatic Lens Dislocation
Dislocation
AC
[a/w spasm of sphincter pupillae]
Iridocyclitis Intractable secondary glaucoma
Vitreous
Aphakia
[=couching]
Signs and symptoms
• Blurred vision• [ posterior dislocation = hypermetropia]• Anterior dislocation : appears likeOIL drop in AC[globular lens]
• It is difficult to see a clear lens in AC
• Posterior dislocation : leads to aphakia deep AC
– Anteriorly dislocated lens – Leads to Pupil block – Immediate removal – Miotics to trap lens in AC
– Posteriorly dislocated lens– Effects vision – Impairs retinal function
Zonular incompetence
• Decentration of lens in the bag• Vitreous prolapse into the anterior chamber with loss of efficient nuclear removal.
Effect of Perforating and Penetrating Injury
• Rupture of the lens capsule leads to rapid hydration of the lens cortex at the site of the rupture, progressing rapidly to complete opacification .
• Occasionally, small perforating injury of the lens capsule heals, resulting in a stationary focal cortical cataract
• Lens protein may leak into the aqueous and vitreous and cause uveitis or glaucoma.
• Secondary glaucoma can mask infectious endophthalmitis
EVALUATION – VISUAL ACUITY , PUPLIS– SLIT LAMP EXAMINATION– DIRECT & INDIRECT OPHTHALMOSCOPY– INTRA OCULAR PRESSURE
• INFLAMMATION • PAS• LENS SUBLUXATION• PUPIL BLOCK • ANGLE RECESSION
– GONIOSCOPY– KERATOMETRY & A‐SCAN– LACRIMAL SYRINGING&PROBING– B‐SCAN– CT/MRI
TREATMENT‐MEDICAL• Systemic stabilisation• Ocular • Thorough Saline Wash• Topical cycloplegics‐Homatropine eye drops 2% BD• Topical steroids‐Prednisolone acetate eye drops 1% 6 times‐ a
‐day• Topical Antibiotics‐Moxifloxacin eye drops QID• Artificial tear supplements‐Methyl cellulose eye drops 1% QID• Oral steroids ‐T.Prednisolone 40mg OD• [Given with Antacids‐T.Ranitidine 150 mg BD before food]• Vitamin C supplements‐ T.Limcee OD • NSAIDs+Serratiopeptidase‐T.Lyser‐D OD
SURGICAL INDICATIONS
– Traumatic cataract with decrease in functional visual acuity
– Subluxated lens with Lens induced glaucoma and Lens induced uveitis
– To improve visualization of posterior segment
ANTERIOR LIMBAL APPROACH
– Traumatic cataract
– Capsular rupture
– Anterior subluxation / dislocation
PARS PLANA APPROACH
– Gross posterior lens dislocation
– Posterior capsular rupture
SURGICAL MANAGEMENT
Phacoemulsification in Traumatic cataract‐Zonular dehiscence
• Phacoemulsification can sometimes be used to extract a cataract in the presence of limited zonular support.
• A generous capsulorrhexis will facilitate nucleus extraction; however, be careful to avoid extending the capsular tear into the area of zonular fiber insertion on the anterior capsule.
• Reducing the flow rate helps decrease anterior chamber turbulence and the risk of vitreous prolapse through the zonular dehiscence.
• Lowering the height of the irrigating bottle reduces the risk of a very deep anterior chamber, which can further stress the zonular fibers
• Viscoelstic tamponade of vitreous is used for areas of zonular incompetence.
• If a nuclear cataract is present before the trauma, sufficient ultrasound power should be used to emulsify the nucleus without movingit excessively.
• If vitreous has migrated into the anterior chamber, anterior vitrectomy before starting phacoemulsification or cortical aspiration in order to avoid vitreous aspiration with resulting retinal traction.
Not enough capsular support ??
• A capsular tension ring (CTR) can be inserted into the capsular bag. This device provides adequate support for nuclear and cortical removal, as well as for in‐the‐bag 10L insertion.
• Insufficient zonular support can be addressed with a Cionni‐modified CTR sutured to the scleral wall.
• If a CTR is not available and zonular support sufficient for in‐the‐bag IOL placement, a 3‐piece IOL with the haptics placed in the area of zonular weakness helps prevent capsular contraction
.
IOL PLACEMENT
• Primary or secondary implantation • Bag / sulcus / AC/ trans scleral suture
1
2
3
41 – ACIOL2 – SULCUS FIXATED IOL3 – SCLERAL FIXATED IOL4 ‐ PCIOL
Lens Implantation
• Primary IOL insertion can be considered when intraocular inflammation and hemorrhage are minimal and the view of anterior segment structures is good.
• Primary IOL insertion has the advantage of avoiding an additional operation, thus reducing the cost and risks associated with further intraocular surgery.
Ideal Implantation
• Removal of nucleus without compromising capsular bag integrity and implanting the IOL in the bag
Ocular trauma‐other Manifestations
Lids Conjunctiva Cornea Iris AC
Sclera Lens Choroid Retina Macula ON
Orbit
Other manifestations
• Corneal laceration• Hyphaema• Iridodialysis• Synechiae• Retinal detachment• Intra ocular foreign body
Cornea‐Laceration
• Corneal laceration or edema may impair the surgeon's ability to remove lens material safely and may indicate the need for an open‐sky approach.
• Corneal laceration is sutured with 10‐0 prolene.
Hyphaema
• Hemorrhage can occur during lens removal and further interfere with visualization
• Paracentesis is done• Use of Viscoelastics or air may be helpful. If visualization remains insufficient, the eye should be closed to allow an adequate clot to form.
Synechiae
• During the acute phase of ocular trauma, fibrin rapidly forms membranes on the iris that can cause synechiae, pupil seclusion, and distortion of intraocular structures.
• Gentle sweeping of the posterior synechiae may allow the pupil to dilate, but if it does not, pupilloplasty may be necessary.
• A peripheral iridectomy done to prevent postoperative pupillary block.
Iris‐Iridodialysis
• Sphincter ruptures needs repair when clinically significant pupillary distortion has resulted.
• The dialyses repaired by suturing the iris root to the scleral spur.
Retina
• Cataract extraction may be necessary to allow adequate visualization if a retinal detachment occurs early or late in the course.
Intra Ocular Foreign Body
• If media is clear, Indirect ophthalmoscopy is done• If view inadequate, CT scan or ultrasound can be helpful.• MRI C/I because the metallic foreign body could be
dislodged by the magnet.
• Significant cataract in the presence of retained foreign matter in the posterior chamber may be handled via parsplana approach or an anterior approach followed by a PPV and foreign‐ body removal.
• Intra‐cameral foreign bodies may be easier to see when the patient is seated at the slit lamp rather than positioned horizontally under the operating microscope.
• In addition, Irrigating solutions can dislodge aforeign body from its preoperative position