TRAUMA

Comparative study of final visual outcomebetween open- and closed-globe injuries following surgicaltreatment of traumatic cataract

Mehul Ashvin Shah & Shreya Mehul Shah &Shashank B. Shah & Chintan G. Patel & Utsav A. Patel &Adway Appleware & Ashish Gupta

Received: 2 March 2011 /Revised: 17 May 2011 /Accepted: 17 May 2011 /Published online: 7 July 2011# Springer-Verlag 2011

AbstractObjective The objective of this work is to compare finalvisual outcomes in cases of surgically treated traumaticcataract between open-globe and closed-globe groups, asclassified by the Birmingham Eye Trauma Terminologysystem.Design Observational cohort study.

Setting Tertiary eye-care center at the trijunction of Gujarat,Madhya Pradesh, and Rajasthan states in central westernIndia.Methods We enrolled patients meeting specific inclusioncriteria, examined their eyes to review any co-morbiditiesdue to trauma, performed surgery for traumatic cataracts, andimplanted lenses. The patients were re-examined 6 weekspostoperatively. We classified the cases of traumatic cataract aseither open-globe (group 1) or closed-globe (group 2),according to the Birmingham Eye Trauma Terminology(BETT) system, and compared visual acuity.Outcome measures Visual Acuity.Results Our cohort of 687 eyes with traumatic cataractsincluded 496 eyes in group 1 and 191 in group 2. Six weekspostoperatively, the visual acuity was >20/60 in 298 (58%)and 75 (39.1%) operated eyes in groups 1 and 2,respectively (p20/60vision was significantly higher in group 1 than in group 2(OR=1.61; 95% CI, 0.853.02). Overall, 373 eyes (54.3%)regained final visual acuity >20/60.Conclusions Open-globe injury has a more favorableprognosis for satisfactory (>20/60) visual recovery aftermanagement of traumatic cataracts.

Keywords Final visual outcome . Betts . Open-globeinjury . Closed-globe injury . Predictor of visual acuity forocular injury

Introduction

Trauma is a cause of monocular blindness in the developedworld, although few studies have addressed the problemof trauma in rural areas [1]. The etiology of ocular injury

No financial support was received from any company or institution.

This study has not been presented at any conference or meeting.

The authors have no financial interest in any aspect of this study.

Electronic supplementary material The online version of this article(doi:10.1007/s00417-011-1732-7) contains supplementary material,which is available to authorized users.

M. A. Shah (*) : S. M. Shah : S. B. Shah :C. G. Patel :U. A. Patel :A. Appleware :A. GuptaDrashti Netralaya, Nr. GIDC,Chakalia Road,Dahod 389151 Gujarat, Indiae-mail: omtrust@rediffmail.com

S. M. Shahe-mail: shah_shreya2000@yahoo.com

S. B. Shahe-mail: sbshah@indiatimes.com

C. G. Patele-mail: cgp@drashtinetralaya.org

U. A. Patele-mail: uap@drashtinetralaya.org

A. Applewaree-mail: aha@drashtinetralaya.org

A. Guptae-mail: ags@drashtinetralaya.org

Graefes Arch Clin Exp Ophthalmol (2011) 249:17751781DOI 10.1007/s00417-011-1732-7

http://dx.doi.org/10.1007/s00417-011-1732-7

is likely to differ from that in urban areas and is worthy ofinvestigation [24]. Any strategy for prevention requiresknowledge of the cause of injury, which may enable moreappropriate targeting of resources toward preventing suchinjuries. Eye trauma represents a large, potentially pre-ventable burden on both victims and society as a whole[3].

Ocular trauma can cause cataracts [1]. The methods usedto evaluate the visual outcome in eyes managed fortraumatic cataracts and senile cataracts are similar [5], butthe damage to other ocular tissues due to trauma maycompromise the visual gain in eyes operated on fortraumatic cataracts. Hence, the success rates may differbetween eyes with these two types of cataract.

With the introduction of the Birmingham Eye TraumaTerminology system (BETT), the documentation of oculartrauma has been standardized [5]. Consequently, it ispossible to study the visual outcomes following traumaticcataract surgery and the determinants predicting theoutcome, in relation to BETT scoring. Visual outcomes oftraumatic cataracts have been reported in some cases,although most studies have involved small samples or havebeen case studies. Weinand et al. [6] and Bayakara et al. [7]reported studies focusing on the primary management oftraumatic cataracts and of perforating injuries.

In the present study, we examined visual outcomesfollowing cataract surgery in eyes sustaining injuries, andthe predictors of satisfactory visual outcomes following themanagement of traumatic cataracts. Our study was con-ducted in a city located at the intersection of three Indianstates: Gujarat, Madhya Pradesh, and Rajasthan [11].Qualified ophthalmologists at our institute provide low-cost eye services, mainly to the poor belonging to the tribalpopulation of 4.2 million in this area.

Patients and methods

We obtained approval from hospital administrators and itsresearch committee to conduct this study and all partic-ipants provided written consent.

This was a observational cohort study, designed in 2002.All cases of traumatic cataract in either eye, diagnosed andmanaged between January 2003 and December 2009, werein the initial pool. Patients consenting to participate andwithout other serious injuries were enrolled. Data wasretrieved from medical records, and collected in a pre-testedonline form.

For each patient enrolled in our study, we obtained ahistory, including details of the injury, eye treatments, andof surgery performed to manage ocular trauma. Data forboth the initial and follow-up reports were collected usingthe online BETT format of the International Society of

Ocular Trauma. Details of the surgeries were also collectedusing a pre-tested online form.

The cases of traumatic cataract were classified as eitheropen- or closed-globe injuries. The open-globe injuries werefurther categorized into those with laceration or rupture.Lacerations of the eyeball were subcategorized into perforat-ing injuries, penetrating injuries, or injuries involving anintraocular foreign body. The closed-globe group was sub-divided into lamellar laceration and contusion.

Based on monthly family income, each patient wasclassified as rich (>US $300/15,000 Indian rupees [INR]),poor (US $50300/2,50015,000 INR), or very poor (

vitrectomy, via an anterior/pars plana route. If sulcus fixatedlens found Subluxated we corrected it surgically andrecurrent developed membrane if any was removed with asurgical procedure.

In children younger than 2 years of age, both lensectomyand vitrectomy via a pars plana route were performed,leaving a rim of anterior capsule for a secondary implant,and the same surgical procedures were used to manage thetraumatic cataract. Lens implantation as part of the primaryprocedure was avoided in all children younger than 2 yearsof age.

All patients with injuries and without infection weretreated with topical and systemic corticosteroids andcycloplegics. The duration of medical treatment dependedupon the degree of inflammation in the anterior andposterior segments of the operated eye. The operatedpatients were re-examined after 24 h, 3 days, and 1, 2,and 6 weeks, to enable refractive correction. Follow-up wasscheduled for these dates, then monthly for 3 months, andevery 3 months for 1 year.

At every follow-up examination, visual acuity was testedusing a Snellen chart. The anterior segment was examinedwith a slit lamp, and the posterior segment with an indirectophthalmoscope. Eyes with vision better than 20/60 at6 weeks were defined as having a satisfactory grade ofvision.

During the examination, data were entered online usingpre-tested forms designed by the International Society ofOcular Trauma (initial and follow-up forms), which wereexported to a Microsoft Excel spreadsheet. The data wereaudited periodically to ensure completion. We used theStatistical Package for the Social Sciences (SPSS 15) toanalyze the data. We used descriptive statistics and crosstabulation to evaluate the role of each variable. Thedependent variable was vision >20/60 at follow-up, 6 weeksafter cataract surgery. The independent variables were age,gender, place of residence, time interval between injury andcataract surgery, primary posterior capsulectomy andvitrectomy procedure, and type of ocular injury.

Results

The cohort consisted of 687 patients with traumaticcataracts, including 496 eyes with open-globe ocularinjuries and 191 (27.8%) eyes with closed-globe injuries(Fig. 1). Of the patients, 492 (71.6%) were male and 195(28.4%) female. The mean patient age was 27.118.54 years (range, 180 years).

We analyzed several demographic factors, including originof patient referral, socioeconomic status (79% were from alower socioeconomic class), and residence (95% were from arural area); none had a significant relationship with final visual

acuity. The object causing the injury and the activity at thetime of the injury were also not significantly associated withsatisfactory final visual acuity (Table 1). Wooden sticks werethe most common agent of injury (56.3%). A comparison ofpre- and post-operative visual acuity showed that treatmentsignificantly improved visual acuity (Table 1; Pearsons 2

test, p

Table 1 Comparative results amongst open- and closed-globe injuries

Parameter Open-globe injury Closed-globe injury Total

No % No % No % p value

Socio-economic status

Poor 386 56.2 154 22.4 540 78.6Rich 108 15.7 36 5.2 144 21.0

Very poor 2 0.3 1 0.15 3 0.4

Total 496 72.2 191 27.8 687 100

Entry

Camp 114 16.6 67 9.6 181 26.3 0.03Door-to-door 1 0.1 1 0.1 2 0.3

Other 6 0.9 1 0.1 7 1.0

Referral 15 2.2 2 0.3 6 0.9

School 2 0.3 1 0.1 16 2.3

Self 358 52.1 119 17.3 475 69.1

Total 496 72.2 191 27.8 687 100

Previous surgical treatment

No 485 70.6 183 26.6 668 97.2 0.126Yes 11 1.6 8 1.2 19 2.7

Total 496 72.2 191 27.8 687 100

Age distribution

0 to 10 134 19.5 22 3.2 155 22.6 0.00011 to 20 145 21.1 39 5.7 184 26.8

21 to 30 70 10.1 20 2.9 90 13.1

31 to 40 54 7.7 25 3.6 79 11.5

41 to 50 52 7.5 43 6.3 95 13.8

51 to 60 25 3.6 30 4.3 55 8.0

61 to 70 15 2.1 9 1.3 24 3.5

71 to 80 1 0.1 3 0.4 4 0.5

Total 496 72.2 191 27.8 687 100

Gender

Female 152 22.1 43 6.3 195 28.4 0.020Male 344 50.1 148 21.5 492 71.6

Total 496 72.8 191 27.8 687 100

Object of injury

Ball 0 0 6 0.9 6 0.9 0.031Cattle Horn 6 0.9 6 0.9 12 1.60

Cattle Tail 1 0.1 3 0.4 4 0.6

Fireworks 6 0.9 4 0.5 10 1.5

Other 34 4.9 40 5.8 74 10.8

Sharp object 49 7.1 10 1.5 59 8.6

Stone 55 8.0 38 5.5 93 13.5

Wooden stick 312 45.4 20 2.9 54 7.9

Unknown 34 4.9 72 10.5 384 55.9

Total 496 72.8 191 27.8 687 100

Object of injury compared to wooden stick

Wooden stick object 312 45.4 72 10.5 384 55.9 0.000Other object 184 26.8 119 17.3 303 44.1

Total 496 72.8 191 27.8 687 100

Reporting

0 to 1 132 19.2 40 5.8 172 25.0 0.0002 to 4 69 10.0 9 1.3 78 11.4

5 to 30 163 23.7 38 5.5 201 29.3

More 132 19.2 104 15.1 236 34.4

1778 Graefes Arch Clin Exp Ophthalmol (2011) 249:17751781

Table 1 (continued)

Parameter Open-globe injury Closed-globe injury Total

No % No % No % p value

Total 496 78.2 191 27.8 687 100

Habitat

Rural 479 69.7 176 25.6 655 95.3 0.014Urban 17 2.5 15 2.1 32 4.7

Total 496 78.2 191 27.8 687 100

Morphology

Membranous 63 9.1 20 2.9 83 12.1 0.000Rosette 6 0.8 3 0.4 9 1.3

Soft fluffy 329 47.9 83 12.1 412 60.0

Total cataract 98 14.3 85 12.3 183 26.6

Total 496 72.8 191 27.8 687 100

Surgical technique

Aspiration 292 42.5 55 8.0 347 50.5 0.000Lensectomy and vitrectomy 90 13.1 36 5.2 126 18.3

Delivery and vitrectomy 114 16.6 100 14.6 214 31.1

Total 496 72.2 191 27.8 687 100

Primary posterior capsulectomy vitrectomy

Not performed 364 53.0 141 20.5 505 73.5 0.495Performed 132 19.2 50 7.3 182 26.5

Total 496 72.2 191 27.8 687 100

Number of surgeries

1.00 411 59.8 173 25.1 584 85 0.0102.00 76 11.1 18 2.6 94 13.7

3.00 9 1.3 0 0.0 9 1.3

Total 496 72.2 191 27.8 687 100

Lens Implant

No Implant 65 9.5 58 8.4 123 17.9 0.000Implant 431 62.7 133 19.4 564 82.0

Total 496 72.2 191 27.8 687 100

Final visual outcome

When we have studied time interval between injury andinitial intervention we found best results achieved if initialintervention done between 2 and 30 days (Tables 2, 3). Wehave also studied main reasons for no improvement invision (Table 4).

Discussion

Visual gain following surgery for traumatic cataracts is acomplex process. Electrophysiological [10] and radio-imaging [1113] investigations are important tools forassessing co-morbidities associated with an opaque lens.

In our study of patients with open-globe and closed-globe injuries leading to traumatic cataract, a satisfactorygrade of vision following surgical management wassignificantly more common in those with open-globeinjuries (Table 1).

Brar et al. found that postoperative complicationsfollowing ocular injuries were the main factor responsiblefor poor outcomes, with 20/40 or better vision seen in38.8% of eyes with closed-globe injuries and in 86.4% ofeyes with open-globe injuries [14]. This difference insuccess rates could be attributed to differences in the typeof ocular trauma, the presence of other ocular tissuedamage, or variation in surgical procedures. In contrast, ina case series of 60 eyes with traumatic cataracts, Wos et al.found no significant difference in visual outcome betweenthose developing cataracts after perforating injuries andafter non-perforating injuries [15].

Wos et al. noted that a large proportion of the populationwith traumatic cataracts in their series was male [15].Baclouti et al. did not find a gender difference in traumaticcataracts in their study in Tunisia [16]. Although we had alarge proportion of males in our cohort, the differencebetween the numbers of males and females was notstatistically significant. Many working women in tribalareas may be at increased risk for ocular injuries andtraumatic cataracts; this may explain the gender distributionnoted in our study. We found a significant (p=0.020)difference in open-globe injuries by gender, with malesbeing predominantly affected.

Our cohort of patients with traumatic cataracts was muchyounger than those in other studies [17, 18]. Thus,appropriate intervention to avoid visual disability in ourcohort would be more cost-effective because the disability-

adjusted life-years saved by successful intervention wouldbe much higher.

Using a large database, we attempted to systematicallyclassify the morphology of traumatic cataract and to selectsurgical techniques accordingly. We used a practical gradingof cataracts to enable ophthalmologists to determine thebest mode of managing them. This grading differs from thestandard grading used for senile cataracts [19]. We are notaware of any other reported study that has compared finalvisual outcomes between these two groups, using the BETTclassification system [20].

Behbehani [21] reported 20/40 final visual outcome in40% cases of open-globe injuries. Cillino [22] also reportedfinal visual acuity of 20/40 in 48.3% of all injury cases.Smith [23] similarly reported 47.8% of cases reaching 20/40 vision, combining open- and closed-globe injuries.

Various studies have touched on this topic. Krishnamacharyet al. found 52.3% of cataracts to be total, whereas our resultsrevealed 26.6% total cataracts [24]. Vajpayee reported type-1and -2 openings in the posterior capsule with penetratinginjury [25], whereas we found a membranous type ofcataract in 12.1% of cases. This is suggestive of latereporting, as membranous transformation of the lens withfusion of the anterior and posterior capsules may occur overtime.

Conclusions

We obtained good visual outcomes after managing trau-matic cataracts. According to results satisfactory visualacuity following cataract surgery was more likely withopen-globe injuries than with closed-globe injuries.

Reporting interval in days 01 24 530 More Total

Vision better than 20/80 48.8% 63.6% 63.0% 48.0 54.4

Table 3 Distribution of report-ing time in days and percentageof patients with a final visualacuity >20/60

Table 4 Reasons for non-improvement of vision following treatment

Reason for poor outcome No. of patients

Optic atrophy 4

Macular scar 3

Inflammation 14

Infection 2

Extensive post-segment trauma 12

Corneal opacity 9

Secondary glaucoma 5

1780 Graefes Arch Clin Exp Ophthalmol (2011) 249:17751781

Conflicting interests None.

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c.417_2011_Article_1732.pdfComparative...AbstractAbstractAbstractAbstractAbstractAbstractAbstractAbstractIntroductionPatients and methodsResultsDiscussionConclusionsReferences