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Morphology of traumatic cataract: does it play role in final visual outcome? A hospital based cohort study
Journal: BMJ Open
Manuscript ID: BMJ Open.2011.000060
Article Type: Research
Date Submitted by the Author:
20-Jan-2011
Complete List of Authors: Shah, Mehul; Drashti Netralaya, Ophthalmology; Drashti Netralaya, Ophthalmology Shah, Shreya; Drashti Netralaya, Ophthalmology Shah, Shashank; Drashti Netralaya, Ophthalmology Patel, Chintan; Drashti Netralaya, Ophthalmology
Patel, Utsav; Drashti Netralaya, Ophthalmology
<b>Subject Heading</b>: Ophthalmology
Keywords: Cataract and refractive surgery < OPHTHALMOLOGY, Vetreoretinal < OPHTHALMOLOGY, Paediatric ophthalmology < OPHTHALMOLOGY
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Title: Morphology of traumatic cataract: does it play role in final visual outcome?
Short running head: Morphology of traumatic cataract.
Authors:
Name Degree E-mail
Dr. Mehul A. Shah
MD omtrust@rediffmail.com
Dr Shreya M. Shah
MD shah_shreya2000@yahoo.com
Dr. Shashank B. Shah MBBS sbshah@indiatimes.com
Dr. Chintan G. Patel MBBS cgp@drashtinetralaya.org
Dr Utsav A. Patel MBBS uap@drashtinetralaya.org
Affiliations all authors:
Drashti Netralaya, Dahod, Gujarat, India
Address of corresponding author:
Drashti Netralaya,
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Nr. GIDC, Chakalia Road.
Dahod-389151
Gujarat
Ph: 00-91-2673-645364 Fax: 00-91-2673-221232
Email: omtrust@rdiffmail.com
• No financial support received from any company or institution
• This study is not presented at any conference or meeting
• Authors do not have any financial interest in any aspect of this study
Article Summery:
Aricle Focus:
Morphological Classification of traumatic cataract which may be helpful for guidelines of surgical technique.
Key Message:
Standardization of classification and treatment of traumatic cataract
Strength and weakness:
Strength: Larger database and Usage of stabdard classification method-BETTS Limitation: Included meny
neglected injury cases.
Contributor statement:
Mehul Shah: Conceptdesign study, surgeon, writing
Shreya Shah: Administrative support, writing, data analyses
Shashank Shah:Data collection, language editing
Chintan Patel: Data collection proof reading and editing
Utsav Patel: Data collection and editing
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Abstract:
Purpose: To provide evidence-based care to patients with traumatic cataract.
Setting: Tertiary eye care center –Dahod at the trijunction of Gujarat, Madhya Pradesh, and
Rajasthan states in central western India.
Methods: It is a Prospective cohort study All patients presented at our hospital with traumatic
cataracts between January 2003 and December 2009. All information regarding demographic
and ocular trauma was collected on a pre-tested World Eye Trauma Registry form for both the
first visit and follow-up.
In particular, we collected specific information about the morphology of traumatic cataracts;
surgical technique was determined accordingly.
Data were entered and analyzed with regard to the relationship between type of trauma and
resulting injury, results achieved with particular surgical techniques, and the relationship
between morphology and final visual outcome.
Outcome measures: Final visual outcome.
Results: Morphology of traumatic cataract made significant difference as far as final visual
outcome is concerned. (Table-5 χ 2 test, P = 0.014)
Conclusion: The morphology of traumatic cataract plays important roles in determining both the
appropriate surgical technique and final visual outcome.
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Introduction:
Trauma is a cause of monocular blindness in the developed world, although few studies
have addressed the problem of trauma in rural areas.1 The etiology of ocular injury in rural areas
is likely to differ from that in urban areas and is worthy of investigation.2-4
Any strategy for
prevention requires a knowledge of the cause of injury, which may enable more appropriate
targeting of resources toward preventing such injuries. Both eye trauma victims and society bear
a large, potentially preventable burden.3
Ocular trauma can cause cataracts.1 The methods used to evaluate the visual outcome in
eyes managed for traumatic cataracts and senile cataracts are similar,5 but the damage to other
ocular tissues due to trauma may compromise the visual gain in eyes operated on for traumatic
cataracts. Hence, the success rates may differ between eyes with these two types of cataract.
With the introduction of the Birmingham Eye Trauma Terminology System (BETTS),
the documentation of ocular trauma has been standardized.5
Our study was conducted in a city located at the intersection of the borders of three states
in India: Gujarat, Madhya Pradesh, and Rajasthan.11
Qualified ophthalmologists at our institute
provide low-cost eye services mainly to the poor belonging to the tribal population of 4.2 million
in this area.
There is no standard methodology for classification of traumatic cataract.
Patients and Methods:
We obtained approval from the hospital administrators and research committee to
conduct this study, and we received the participants’ written consent.
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This was a prospective study designed in 2002. All traumatic cataracts in either eye
diagnosed and managed between January 2003 and December 2009 were enrolled in our study,
and those consenting to participate and not having other serious body injuries were included.
For each patient enrolled in our study, we obtained a detailed history, including details of
the injury and information on eye treatment and surgery performed to manage past ocular
trauma. Data for both the initial and follow-up reports were collected using the online BETTS
format of the International Society of Ocular Trauma. Details of the surgery were also collected
using a specified pre-tested online form.
The cases of traumatic cataract were grouped as those with open- and those with closed-
globe injuries. The open-globe injuries were further categorized into those with lacerations and
those with rupture. Lacerations of the eyeball were subcategorized into eyes with perforating
injuries, penetrating injuries, or injuries involving an intraocular foreign body. The closed-globe
group was subdivided into lamellar laceration and contusion.
Other demographic details collected included patient entry, residence, activity at the time
of injury, object of injury, and previous examinations and treatments. After enrollment, all
patients were examined using a standard method. Visual acuity was checked using the Snellen
chart, and the anterior segment was examined using a slit lamp. Visual acuity in younger age
group was examined according guidelines of AAO vision check up in children.
Based on lenticular opacity, the cataracts were classified as total, when an examiner did
not observe clear lens matter between the capsule and nucleus, the cataract was defined as total.
(Figure 1), membranous, when the capsule and organized matter were fused and formed a
membrane of varying density, it was defined as a membranous cataract, in which both capsules
fused with scant or no cortical material (Figure 2), white soft cataract with ruptured capsule
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when loose cortical material was found in the anterior chamber together with a ruptured lens
capsule, the cataract was defined as white soft cataract with ruptured capsule. (Figure 3), and
rosette types A lens with a rosette pattern of opacity was classified as a rosette type cataract.
(Figure 4). We could cover all cataract cases presented to us under this classification.
Morphology mainly influenced by type, force, object of injury and time interval between injury
and examination.
For a partially opaque lens, the posterior segment examination was carried out with an indirect
ophthalmoscope and a +20 D lens. When the optical medium was not clear, a B-scan was
performed to evaluate the posterior segment.
The surgical technique was selected according to morphology and the condition of
tissues other than the lens. Phacoemulsification was used to operate on cataracts with hard, large
nuclei. With a lens that had either a white soft or rosette type of cataract, unimanual or bimanual
aspiration was used. Membranectomy and anterior vitrectomy, either via an anterior or pars
plana route, were performed when the cataract was membranous.
In all patients undergoing corneal wound repair, the traumatic cataract was managed in a
second procedure. Recurrent inflammation was more prominent in patients who had undergone
previous surgery for trauma.9, 10
in such cases, when ocular media found hazy due to
inflammation of the anterior vitreous, we performed a capsulectomy and vitrectomy via an
anterior/pars plana route in adults.
In children younger than 2 years of age, both lensectomy and vitrectomy via a pars plana
route was performed leaving rim of anterior capsule for secondary implant, and the same
surgical procedures were used to manage the traumatic cataract. Lens implantation as part of the
primary procedure was avoided in all children younger than 2 years of age.
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All patients with injuries and without an infection were treated with topical and systemic
corticosteroids and cycloplegics. The duration of medical treatment depended on the degree of
inflammation in the anterior and posterior segments of the operated eye. The operated patients
were re-examined after 24 h, 3 days, and 1, 2, and 6 weeks to enable refractive correction.
Follow-up was scheduled for the third day, weekly for 6 weeks, monthly for 3 months, and every
3 months for one year.
At every follow-up examination, visual acuity was tested using the Snellen chart and
vision in children checked with guidelines of AAO. The anterior segment was examined with a
slit lamp, and the posterior segment was examined with an indirect ophthalmoscope. Eyes with
vision better than 20/60 at the glasses appointment (6 weeks) were defined as having a
satisfactory grade of vision.
During the examination, data were entered online using a specified pretested format
designed by the International Society of Ocular Trauma (initial and follow-up forms), which was
exported to a Microsoft Excel spreadsheet. The data were audited periodically to ensure
completeness. We used the Statistical Package for Social Studies (SPSS 15) to analyze the data.
The univariate parametric method was used to calculate frequency, percentage, proportion, and
95% confidence interval (95% CI). We used binominal regression analysis to determine the
predictors of postoperative satisfactory vision (>20/60). The dependent variable was vision
>20/60 noted at the follow-up 6 weeks after cataract surgery. The independent variables were
age, gender, residence, time interval between injury and cataract surgery, primary posterior
capsulectomy and vitrectomy procedure, and type of ocular injury.
Results:
Our cohort consisted of 687 patients with traumatic cataracts (Figure 5) including 496 eyes with
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open-globe ocular injuries and 191 (27.8%) eyes with closed-globe injuries (Figure 5). The
patients were 492 (71.6%) males and 195 (28.4%) females. The mean patient age was 27.1 ±
18.54 years (range, 1–80).
We analyzed several demographic factors, including age (p=0.00), sex (p=0.340), patient
entry (p = 0.4) and socioeconomic status (79% were from lower socioeconomic class and
residence; 95% were from a rural area), and none had a significant relationship with final visual
acuity except age, according to cross tabulation and statistical tests. The object causing the
injury (p = 0.3) and the activity at the time of the injury (p = 0.3) were also not significantly
associated with satisfactory final visual acuity.
All traumatic cataracts were classified according to morphology (Tables 1 and 2) and
were surgically treated using morphology as a guideline. (Table-3)
The number of surgeries required varied significantly with morphology (p = 0.000)
(Table 4).
Final visual outcome was found to vary according to morphology and surgical technique.
White soft cataracts were found to have a better prognosis and achieved significantly higher
rates of positive outcome compared with other morphologies (p = 0.014) (Table 5).
We were able to do lens implants in 82% of cases; details are shown in Table-6.
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Discussion:
Using a large database, we attempted to systematically classify the morphology of
traumatic cataract and to select surgical techniques accordingly.
Various studies have touched on this topic. One study found 52.3% total cataracts,
whereas our results revealed 26.6% total cataracts 7.
Vajpayee reported an opening in the
posterior capsule with types 1 and 2 openings with penetrating injury 8, whereas we found
another membranous type of cataract (12.1%) suggestive of late reporting, as membranous
transformation of the lens with fusion of the anterior and posterior capsules may occur over
time.
We were able to perform intraocular lens implants in 82.1% of cases. Krishnamachary
reported implants in 65.5% cases, Churchill et al. reported implants in 46.8% cases, and
Fyodrove reported Sputnik implant in all cases7, 9, 10
.
Fyodrove reported surgical techniques according to pathology and degree of lens
absorption, but did not systematically classify similar factors taken into account in our study 10
.
These differences in findings may reflect the fact that of the 687 patients in our study,
30% came from outreach activities and did not approach treatment facilities on their own.
Therefore, the time period between ocular injury and reporting ranged widely, and morphology
was also influenced by this interval.
We propose a specific morphological classification for traumatic cataract, which may
provide guidelines for management that incorporate available technology and improve care for
these patients.
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The English in this document has been checked by at least two professional editors, both native
speakers of English. For a certificate, please see:
http://www.textcheck.com/certificate/wY0Ejf
References:
1. Khatry SK, Lewis AE, Schein OD, Thapa MD, Pradhan EK, Katz J, et al. The
epidemiology of ocular trauma in rural Nepal. Br J Ophthalmol. 2004; 88:456-60.
2. Abraham, D. I.; Vitale, S. I.; West, S. I.; Isseme, I. Epidemiology of eye injuries in rural
Tanzania. Ophthalmic Epidemiol.1999; 6:85-94
3. D. Virgil Alfaro, Eric P. Jablon, Monica Rodriguez Fontal, Simon J. Villalba, Robert
E.Morris, Michael Grossman, Enrique Roig-Melo et al. Fishing-related ocular trauma.
American Journal of Ophthalmology.2005; 139: 488-492
4. Shah M, Shah S, Khandekar R. Ocular injuries and visual status before and after Their
management in the tribal areas of Western India-A historical cohort study Grafes Arch
Clin Exp Ophthalmol 2008; 246:191–197.
5. Kuhn F, Morris R, Witherspoon CD, Mester V,) The Birmingham Eye Trauma
Terminology system (BETT). J Fr Ophtalmol. 2004; 27:206-10.
6. Vajpayee RB, Sharma N, Dada T, Gupta V, Kumar A, Dada VK. Management of
posterior capsule tears. Surv Ophthalmol 2001;45:473-88.
7. Krishnamachary M, Rathi V, Gupta S. Management of traumatic cataract in children. J
Cataract Refract Surg 1997;23 Suppl 1:681-7.
8. Churchill AJ, Noble BA, Etchells DE, George NJ. Factors affecting visual outcome in
children following uniocular traumatic cataract. Eye (Lond) 1995;9 ( Pt 3):285-91
9. Thylefors B, Chylack LT Jr, Konyama K, Sasaki K, Sperduto R, Taylor HR, et al. A simplified
cataract grading system. Ophthalmic Epidemiol. 2002; 9:83-95.
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10. Fyodorov SN, Egorova EV, Zubareva LN. 1004 cases of traumatic cataract surgery with
implantation of an intraocular lens. J Am Intraocul Implant Soc 1981;7:147-53.
Legends:
Fig-1: When no clear lens matter was visible between the capsule and the
nucleus, the cataract was defined as a total cataract..
Fig-2: When loose cortical material was found in the anterior chamber together
with a ruptured lens capsule, the cataract was defined as a white soft cataract
Fig-3: When the capsule and organized matter were fused and formed a
membrane of varying density, it was defined as a membranous cataract
Fig-4: A lens with a rosette pattern of opacity was classified as a rosette type
cataract.
Fig-5: Distribution of cataracts based on the ocular injuries, as per the BETTS
classification.
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Table 1. Distribution of different morphologies of traumatic cataract
Morphology N Percent
84 12.2
8
1.2
412
60.0
183 26.6
Membranous
Rosette
White soft
Total
Total 687 100.0
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Table 2. Morphology of traumatic cataract according to type of injury
Closed globe Open globe Total
20 64 84
3 5 8
83 329 412
Membranous
Rosette
Soft fluffy
Total
85 98 183
Total
191 496 687
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Table 3. Surgical techniques used according to morphology of cataract
Technique Morphology
Membranous Rosette White soft Total Total
7 5 316 19 347
46 0 60 20 126
3 2 17 108 130
Aspiration
Lensectomy +
Vitrectomy
Phaco/SICS
Delivery + vitrectomy 28 0 20 36 84
Total 83 7 412 183 687
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Table 4. Morphology of cataract in relation to number of surgical procedures
Morphology Total
Membranous Rosette White soft Total
70 6 349 159 584
12 2 58 22 94
2 0 5 2 9
1.00
2.00
3.00
Total 84 8 412 183 687
χ 2 test, P = 0.000
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Table 5. Final visual outcome in relation to morphology of cataract
Final visual outcome Morphology Total
Membranous Rosette White soft Total
2 0 10 5 17
24 2 88 57 171
12 0 26 18 56
7 1 32 24 64
21 1 90 33 145
Uncooperative
<1/60
1/60 to 3/60
20/200 to 20/120
20/80 to 20/60
20/40 to 20/20 17 4 160 42 223
Total 83 8 406 179 676
χ 2 test, P = 0.014
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Table 6. Lens implant in relation to morphology of traumatic cataract
Morphology No implant Implant Total
17 67 84
2 6 8
58 354 412
46 137 183
Membranous
Rosette
White soft
Total
Total 123 564 687
χ 2 test, p = 0.004
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Fig-1: When no clear lens matter was visible between the capsule and the nucleus, the cataract was defined as a total cataract. 203x160mm (96 x 96 DPI)
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Fig-2: When loose cortical material was found in the anterior chamber together with a ruptured lens capsule, the cataract was defined as a white soft cataract with ruptured anterior capsule.
91x106mm (96 x 96 DPI)
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Fig-3: When the capsule and organized matter were fused and formed a membrane of varying density, it was defined as a membranous cataract
26x22mm (96 x 96 DPI)
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Fig-4: A lens with a rosette pattern of opacity was classified as a rosette type cataract
74x78mm (96 x 96 DPI)
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Fig-5: Distribution of cataracts based on the ocular injuries, as per the BETTS classification. 188x190mm (96 x 96 DPI)
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STROBE 2007 (v4) checklist of items to be included in reports of observational studies in epidemiology*
Checklist for cohort, case-control, and cross-sectional studies (combined)
Section/Topic Item # Recommendation Reported on page #
(a) Indicate the study’s design with a commonly used term in the title or the abstract 4 Title and abstract 1
(b) Provide in the abstract an informative and balanced summary of what was done and what was found 4
Introduction
Background/rationale 2 Explain the scientific background and rationale for the investigation being reported 5
Objectives 3 State specific objectives, including any pre-specified hypotheses 5
Methods
Study design 4 Present key elements of study design early in the paper 6
Setting 5 Describe the setting, locations, and relevant dates, including periods of recruitment, exposure, follow-up, and data
collection 5,6
(a) Cohort study—Give the eligibility criteria, and the sources and methods of selection of participants. Describe
methods of follow-up
Case-control study—Give the eligibility criteria, and the sources and methods of case ascertainment and control
selection. Give the rationale for the choice of cases and controls
Cross-sectional study—Give the eligibility criteria, and the sources and methods of selection of participants
5,6 Participants 6
(b) Cohort study—For matched studies, give matching criteria and number of exposed and unexposed
Case-control study—For matched studies, give matching criteria and the number of controls per case
Variables 7 Clearly define all outcomes, exposures, predictors, potential confounders, and effect modifiers. Give diagnostic
criteria, if applicable 6,7
Data sources/ measurement 8* For each variable of interest, give sources of data and details of methods of assessment (measurement). Describe
comparability of assessment methods if there is more than one group 6,7,8
Bias 9 Describe any efforts to address potential sources of bias Nil
Study size 10 Explain how the study size was arrived at Time period
Quantitative variables 11 Explain how quantitative variables were handled in the analyses. If applicable, describe which groupings were chosen
and why Morphology group
(a) Describe all statistical methods, including those used to control for confounding 7,8
(b) Describe any methods used to examine subgroups and interactions 7,8
(c) Explain how missing data were addressed Excluded
Statistical methods 12
(d) Cohort study—If applicable, explain how loss to follow-up was addressed
Case-control study—If applicable, explain how matching of cases and controls was addressed Follow up forms used
from ISOT
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Cross-sectional study—If applicable, describe analytical methods taking account of sampling strategy
(e) Describe any sensitivity analyses
Results
Participants 13* (a) Report numbers of individuals at each stage of study—eg numbers potentially eligible, examined for eligibility,
confirmed eligible, included in the study, completing follow-up, and analysed 9
(b) Give reasons for non-participation at each stage
(c) Consider use of a flow diagram Figure-5
Descriptive data 14* (a) Give characteristics of study participants (eg demographic, clinical, social) and information on exposures and
potential confounders 9
(b) Indicate number of participants with missing data for each variable of interest 9
(c) Cohort study—Summarise follow-up time (eg, average and total amount) 9
Outcome data 15* Cohort study—Report numbers of outcome events or summary measures over time 9
Case-control study—Report numbers in each exposure category, or summary measures of exposure
Cross-sectional study—Report numbers of outcome events or summary measures
Main results 16 (a) Give unadjusted estimates and, if applicable, confounder-adjusted estimates and their precision (eg, 95%
confidence interval). Make clear which confounders were adjusted for and why they were included 9 and tables
(b) Report category boundaries when continuous variables were categorized Tables
(c) If relevant, consider translating estimates of relative risk into absolute risk for a meaningful time period Tables
Other analyses 17 Report other analyses done—eg analyses of subgroups and interactions, and sensitivity analyses 9 and tables
Discussion
Key results 18 Summarise key results with reference to study objectives 10
Limitations 19 Discuss limitations of the study, taking into account sources of potential bias or imprecision. Discuss both direction
and magnitude of any potential bias 10
Interpretation 20 Give a cautious overall interpretation of results considering objectives, limitations, multiplicity of analyses, results
from similar studies, and other relevant evidence 10
Generalisability 21 Discuss the generalisability (external validity) of the study results 10
Other information 10
Funding 22 Give the source of funding and the role of the funders for the present study and, if applicable, for the original study on
which the present article is based 1
*Give information separately for cases and controls in case-control studies and, if applicable, for exposed and unexposed groups in cohort and cross-sectional studies.
Note: An Explanation and Elaboration article discusses each checklist item and gives methodological background and published examples of transparent reporting. The STROBE
checklist is best used in conjunction with this article (freely available on the Web sites of PLoS Medicine at http://www.plosmedicine.org/, Annals of Internal Medicine at
http://www.annals.org/, and Epidemiology at http://www.epidem.com/). Information on the STROBE Initiative is available at www.strobe-statement.org.
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Limitations:ord-late presentation biased data
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Morphology of traumatic cataract: does it play role in final
visual outcome? A hospital based cohort study
Journal: BMJ Open
Manuscript ID: BMJ Open.2011.000060.R1
Article Type: Research
Date Submitted by the Author:
22-Feb-2011
Complete List of Authors: Shah, Mehul; Drashti Netralaya, Ophthalmology; Drashti Netralaya, Ophthalmology Shah, Shreya; Drashti Netralaya, Ophthalmology Shah, Shashank; Drashti Netralaya, Ophthalmology Patel, Chintan; Drashti Netralaya, Ophthalmology Patel, Utsav; Drashti Netralaya, Ophthalmology
<b>Primary Subject
Heading</b>: Ophthalmology
Keywords: Cataract and refractive surgery < OPHTHALMOLOGY, Vetreoretinal < OPHTHALMOLOGY, Paediatric ophthalmology < OPHTHALMOLOGY
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Title: Morphology of traumatic cataract: does it play a role in final visual outcome?
Short running head: Morphology of traumatic cataract
Authors:
Name Degree E-mail
Dr. Mehul A. Shah
MD omtrust@rediffmail.com
Dr Shreya M. Shah
MD shah_shreya2000@yahoo.com
Dr. Shashank B. Shah MBBS sbshah@indiatimes.com
Dr. Chintan G. Patel MBBS cgp@drashtinetralaya.org
Dr Utsav A. Patel MBBS uap@drashtinetralaya.org
Affiliations of all authors:
Drashti Netralaya, Dahod, Gujarat, India
Address of corresponding author:
Drashti Netralaya,
Nr. GIDC, Chakalia Road.
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Dahod-389151
Gujarat
Ph: 00-91-2673-645364 Fax: 00-91-2673-221232
Email: omtrust@rdiffmail.com
No financial support was received from any company or institution.
This study has not been presented at any conference or meeting.
The authors do not have any financial interests in any aspect of this study.
Conflicting interests: None to declare.
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Abstract:
Purpose: To provide evidence-based care to patients with traumatic cataract.
Setting: Tertiary eye care centre in Dahod at the trijunction of Gujarat, Madhya Pradesh, and
Rajasthan states in central western India.
Methods: This was a prospective cohort study among all patients presenting at our hospital with
traumatic cataracts between January 2003 and December 2009. All information regarding
demographic and ocular trauma was collected on a pre-tested World Eye Trauma Registry form
for both the first visit and follow-up.
In particular, we collected specific information about the morphology of traumatic cataracts;
surgical technique was determined accordingly.
Data were entered and analysed with regard to the relationship between type of trauma and
resulting injury, results achieved with particular surgical techniques, and the relationship
between morphology and final visual outcome.
Outcome measures: Final visual outcome.
Results: Traumatic cataracts of different morphologies showed significant differences in final
visual outcome (χ2 test, P = 0.014).
Conclusion: The morphology of traumatic cataract plays an important role in determining both
the appropriate surgical technique and final visual outcome.
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Article Summery:
Article Focus:
Morphological Classification of traumatic cataract which may be helpful for guidelines of
surgical technique.
Key Message:
Standardization of classification and treatment of traumatic cataract
Strength and weakness:
Strength: Larger database and Usage of standard classification method-BETTS Limitation:
Included many neglected injury cases. Weakness: Short follow up.
Introduction:
Trauma is a cause of monocular blindness in the developed world, although few studies
have addressed the problem of trauma in rural areas.1 The aetiology of ocular injury in rural
areas is likely to differ from that in urban areas and is worthy of investigation.2-4
Any strategy
for prevention requires knowledge of the cause of injury, which may enable more appropriate
targeting of resources toward preventing such injuries. Eye trauma represents a large, potentially
preventable burden on both victims and society as a whole.3
Ocular trauma can cause cataracts.1 The methods used to evaluate the visual outcome in
eyes managed for traumatic cataracts and senile cataracts are similar,5 but the damage to other
ocular tissues due to trauma may compromise the visual gain in eyes treated surgically for
traumatic cataracts. Hence, the success rates may differ between eyes with these two types of
cataract.
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With the introduction of the Birmingham Eye Trauma Terminology System (BETTS),
the documentation of ocular trauma has been standardised.5
Our study was conducted in a city located at the intersection of the borders of three states
in India: Gujarat, Madhya Pradesh, and Rajasthan.11
Qualified ophthalmologists at our institute
provide low-cost eye services mainly to the poor belonging to the tribal population of 4.2 million
in this area.
There is no standard methodology for classification of traumatic cataract.
Patients and Methods:
We obtained approval from the hospital administrators and research committee to
conduct this study, and all participants provided written informed consent.
This was a prospective study designed in 2002. All traumatic cataracts in either eye
diagnosed and managed between January 2003 and December 2009 were included in the study,
and patients consenting to participate and without other serious body injuries were included.
For each patient enrolled in our study, we obtained a detailed history, including details of
the injury and information on eye treatment and surgery performed to manage past ocular
trauma. Data for both the initial and follow-up reports were collected using the online BETTS
format of the International Society of Ocular Trauma. Details of the surgery were also collected
using a specified pre-tested online form.
The cases of traumatic cataract were grouped as those with open- and those with closed-
globe injuries. The open-globe injuries were further categorised into those with lacerations and
those with rupture. Lacerations of the eyeball were subcategorised into eyes with perforating
injuries, penetrating injuries, or injuries involving an intraocular foreign body. The closed-globe
group was subdivided into lamellar laceration and contusion.
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Other demographic details collected included patient entry, residence, activity at the time
of injury, object of injury, and previous examinations and treatments. After enrolment, all
patients were examined using a standard method. Visual acuity was checked using a Snellen
chart, and the anterior segment was examined using a slit lamp.
Based on lenticular opacity, the cataracts were classified as total (Figure 1), membranous
in which both capsules fused with scant or no cortical material (Figure 2), white soft (Figure 3),
and rosette types (Figure 4). When an ophthalmologist did not observe clear lens matter between
the capsule and nucleus, the cataract was defined as total. When the capsule and organised
matter were fused and formed a membrane of varying density, it was defined as a membranous
cataract. When loose cortical material was found in the anterior chamber together with a
ruptured lens capsule, the cataract was defined as white soft. A lens with a rosette pattern of
opacity was classified as a rosette type cataract.
For a partially opaque lens, the posterior segment examination was carried out with an
indirect ophthalmoscope and a +20 D lens. When the optical medium was not clear, a B-scan
was performed to evaluate the posterior segment.
The surgical technique was selected according to morphology and the condition of
tissues other than the lens. Phacoemulsification was used to treat cataracts with hard, large
nuclei. With a lens that had either a white soft or rosette type of cataract, unimanual or bimanual
aspiration was used. Membranectomy and anterior vitrectomy, via either the anterior or pars
plana route, were performed when the cataract was membranous.
In all patients undergoing corneal wound repair, the traumatic cataract was managed in a
second procedure. Recurrent inflammation was more prominent in patients who had undergone
previous surgery for trauma.9,10
In these cases, the ocular medium may become hazy owing to
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condensation of the anterior vitreous unless a vitrectomy is performed. Hence, we performed a
capsulectomy and vitrectomy via the anterior/pars plana route in adults.
In children younger than 2 years of age, both a lensectomy and vitrectomy via the pars
plana route were performed, and the same surgical procedures were used to manage the
traumatic cataract, with secondary implants done as a separate procedure after the age of 2 years.
Lens implantation as part of the primary procedure was avoided in all children younger than 2
years of age. All children were evaluated for amblyopia and were treated with the aid of
paediatric ophthalmologists and paediatric optometrists.
All patients with injuries and without infection were treated with topical and systemic
corticosteroids and cycloplegics. The duration of medical treatment depended on the degree of
inflammation in the anterior and posterior segments of the operated eye. The operated patients
were re-examined after 24 h, 3 days, and 1, 2, and 6 weeks to enable refractive correction.
Follow-up was scheduled for the third day, weekly for 6 weeks, monthly for 3 months, and every
3 months for 1 year.
At all follow-up examinations, visual acuity was tested using a Snellen chart. The
anterior segment was examined with a slit lamp, and the posterior segment was examined with
an indirect ophthalmoscope. Eyes with vision better than 20/60 at the glasses appointment (6
weeks) were defined as having a satisfactory grade of vision.
During the examination, data were entered online using a specified pre-tested format
designed by the International Society of Ocular Trauma (initial and follow-up forms), which was
exported to a Microsoft Excel spreadsheet. The data were audited periodically to ensure
completeness. We used SPSS 15 software to analyse the data. The univariate parametric method
was used to calculate frequency, percentage, proportion, and 95% confidence interval (95% CI).
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We used binominal regression analysis to determine the predictors of postoperative satisfactory
vision (> 20/60). The dependent variable was vision >20/60 noted at follow-up 6 weeks after
cataract surgery. The independent variables were age, gender, residence, time interval between
injury and cataract surgery, primary posterior capsulectomy and vitrectomy procedure, and type
of ocular injury.
Results:
Our cohort consisted of 687 (72.2) patients with traumatic cataracts (Figure 5), including 496
eyes with open-globe ocular injuries and 191 (27.8%) eyes with closed-globe injuries (Figure 5).
The patients were 492 (71.6%) males and 195 (28.4%) females. The mean patient age was
27.1 ± 18.54 years (range, 1–80).
We analysed several demographic factors, including gender (P = 0.340), patient entry
(P = 0.4), and socioeconomic status (79% were from lower socioeconomic class and residence;
95% were from rural areas). None of these showed a significant relationship with final visual
acuity, according to cross-tabulation and statistical tests. The object causing the injury (P = 0.3)
and the activity at the time of the injury (P = 0.3) were also not significantly associated with
satisfactory final visual acuity. A significant relationship was found between age and final visual
outcome (P = 0.000). There was no significant difference in final visual outcome in children
between open and closed injury groups (P = 0.06).
All traumatic cataracts were classified according to morphology (Tables 1 and 2) and
were surgically treated using morphology as a guideline. (Table 3)
The number of surgeries required varied significantly with morphology (P = 0.000)
(Table 4).
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Final visual outcome was found to vary according to morphology and surgical technique.
White soft cataracts had a better prognosis and achieved significantly higher rates of positive
outcome compared with other morphologies (P = 0.014) (Table 5).
Lens implants were applied in 82% of the cases; the details are shown in Table 6. There
was a significant difference between open and closed injury groups for various age groups (P =
0.000).
Discussion:
Using a large database, we attempted to systematically classify the morphology of
traumatic cataract and to select surgical techniques accordingly.
Previous studies have touched on this topic. One study found 52.3% total cataracts,
whereas our results revealed 26.6% total cataracts.7 Vajpayee reported opening in the posterior
capsule with type 1 and 2 openings with penetrating injury,8 whereas we found another
membranous type of cataract (12.1%) suggestive of late reporting, as membranous
transformation of the lens with fusion of the anterior and posterior capsules may occur over
time.
We were able to perform intraocular lens implants in 82.1% of the cases.
Krishnamachary reported implants in 65.5% of cases, Churchill et al. reported implants in
46.8%, and Fyodrove reported Sputnik implants in all cases.7,9,10
Fyodrove reported surgical techniques according to pathology and degree of lens
absorption, but did not systematically classify similar factors taken into account in our study.10
These differences in findings may reflect the fact that of the 687 patients in our study,
30% came from outreach activities and did not approach treatment facilities on their own.
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Therefore, the time period between ocular injury and reporting ranged widely, and morphology
was also influenced by this interval.
We propose a specific morphological classification for traumatic cataract, which may
provide guidelines for management that incorporate available technology and improve care for
these patients.
References:
1. Khatry SK, Lewis AE, Schein OD, Thapa MD, Pradhan EK, Katz J, et al. The
epidemiology of ocular trauma in rural Nepal. Br J Ophthalmol. 2004; 88:456-60.
2. Abraham, D. I.; Vitale, S. I.; West, S. I.; Isseme, I. Epidemiology of eye injuries in rural
Tanzania. Ophthalmic Epidemiol.1999; 6:85-94
3. D. Virgil Alfaro, Eric P. Jablon, Monica Rodriguez Fontal, Simon J. Villalba, Robert
E.Morris, Michael Grossman, Enrique Roig-Melo et al. Fishing-related ocular trauma.
American Journal of Ophthalmology.2005; 139: 488-492
4. Shah M, Shah S, Khandekar R. Ocular injuries and visual status before and after Their
management in the tribal areas of Western India-A historical cohort study Grafes Arch
Clin Exp Ophthalmol 2008; 246:191–197.
5. Kuhn F, Morris R, Witherspoon CD, Mester V,) The Birmingham Eye Trauma
Terminology system (BETT). J Fr Ophtalmol. 2004; 27:206-10.
6. Vajpayee RB, Sharma N, Dada T, Gupta V, Kumar A, Dada VK. Management of
posterior capsule tears. Surv Ophthalmol 2001;45:473-88.
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7. Krishnamachary M, Rathi V, Gupta S. Management of traumatic cataract in children. J
Cataract Refract Surg 1997;23 Suppl 1:681-7.
8. Churchill AJ, Noble BA, Etchells DE, George NJ. Factors affecting visual outcome in
children following uniocular traumatic cataract. Eye (Lond) 1995;9 ( Pt 3):285-91
9. Thylefors B, Chylack LT Jr, Konyama K, Sasaki K, Sperduto R, Taylor HR, et al. A simplified
cataract grading system. Ophthalmic Epidemiol. 2002; 9:83-95.
10. Fyodorov SN, Egorova EV, Zubareva LN. 1004 cases of traumatic cataract surgery with
implantation of an intraocular lens. J Am Intraocul Implant Soc 1981;7:147-53.
Table 1. Distribution of traumatic cataract morphologies
Morphology N Percentage
Membranous 84 12.2
Rosette 8 1.2
Soft material 412 60.0
Capsular rupture 183 26.6
Total 687 100.0
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Table 2. Morphology of traumatic cataracts according to type of injury
Morphology Closed globe
injury
Open globe
injury
Total
Membranous 20 64 84
Rosette
3 5
8
Soft fluffy
83 329
412
Total 85 98 183
Total 191 496 687
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Table 3. Surgical techniques used according to morphology of cataract
Technique Morphology
Membranous Rosette White soft Total Total
7 5 316 19 347
46 0 60 20 126
3 2 17 108 130
Aspiration
Lensectomy +
Vitrectomy
Phaco/SICS
Delivery + vitrectomy 28 0 20 36 84
Total 83 7 412 183 687
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Table 4. Morphology of cataract in relation to number of surgical procedures
Morphology Total
No. Membranous Rosette White soft Total
1 70 6 349 159 584
2 12 2 58 22 94
3 2 0 5 2 9
Total 84 8 412 183 687
χ2 test, P = 0.000
Table 5. Final visual outcome in relation to morphology of cataract
Final visual outcome Morphology Total
Membranous Rosette White soft Total
3 0 11 5 19
24 2 89 58 173
12 0 27 19 58
7 1 33 25 66
21 1 91 34 147
Uncooperative
<1/60
1/60 to 3/60
20/200 to 20/120
20/80 to 20/60
20/40 to 20/20 17 4 161 42 224
Total 83 7 412 183 687
χ2 test, P = 0.014
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Table 6. Lens implant in relation to morphology of traumatic cataract
Morphology No implant Implant Total
Membranous 17 67 84
Rosette 2 6 8
White soft 58 354 412
Total 46 137 183
Total 123 564 687
χ2 test, P = 0.004
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Table 7. Comparison of open and closed globe injuries in children
Category Closed
globe
Open
globe Total
Paediatric 53 253 306
Adult 137 243 380
Total 190 496 686
P = 0.000
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Figure Legends:
Fig. 1: When no clear lens matter was visible between the capsule and the nucleus, the cataract
was defined as a total cataract.
Fig. 2: When loose cortical material was found in the anterior chamber together with a ruptured
lens capsule, the cataract was defined as a white soft cataract.
Fig. 3: When the capsule and organised matter were fused and formed a membrane of varying
density, the cataract was defined as a membranous cataract.
Fig. 4: A lens with a rosette pattern of opacity was classified as a rosette type cataract.
Fig. 5: Distribution of cataracts based on the ocular injury, as per the BETTS classification.
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The English in this document has been checked by at least two professional editors, both native speakers
of English. For a certificate, please see:
http://www.textcheck.com/certificate/rbgCMs
Contributor ship Statement:
Mehul Shah: Concept design study, surgeon, writing
Shreya Shah: Administrative support, writing, data analyses
Shashank Shah: Data collection, language editing
Chintan Patel: Data collection proof reading and editing
Utsav Patel: Data collection and editing
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STROBE 2007 (v4) checklist of items to be included in reports of observational studies in epidemiology*
Checklist for cohort, case-control, and cross-sectional studies (combined)
Section/Topic Item # Recommendation Reported on page #
(a) Indicate the study’s design with a commonly used term in the title or the abstract 4 Title and abstract 1
(b) Provide in the abstract an informative and balanced summary of what was done and what was found 4
Introduction
Background/rationale 2 Explain the scientific background and rationale for the investigation being reported 5
Objectives 3 State specific objectives, including any pre-specified hypotheses 5
Methods
Study design 4 Present key elements of study design early in the paper 6
Setting 5 Describe the setting, locations, and relevant dates, including periods of recruitment, exposure, follow-up, and data
collection 5,6
(a) Cohort study—Give the eligibility criteria, and the sources and methods of selection of participants. Describe
methods of follow-up
Case-control study—Give the eligibility criteria, and the sources and methods of case ascertainment and control
selection. Give the rationale for the choice of cases and controls
Cross-sectional study—Give the eligibility criteria, and the sources and methods of selection of participants
5,6 Participants 6
(b) Cohort study—For matched studies, give matching criteria and number of exposed and unexposed
Case-control study—For matched studies, give matching criteria and the number of controls per case
Variables 7 Clearly define all outcomes, exposures, predictors, potential confounders, and effect modifiers. Give diagnostic
criteria, if applicable 6,7
Data sources/ measurement 8* For each variable of interest, give sources of data and details of methods of assessment (measurement). Describe
comparability of assessment methods if there is more than one group 6,7,8
Bias 9 Describe any efforts to address potential sources of bias Nil
Study size 10 Explain how the study size was arrived at Time period
Quantitative variables 11 Explain how quantitative variables were handled in the analyses. If applicable, describe which groupings were chosen
and why Morphology group
(a) Describe all statistical methods, including those used to control for confounding 7,8
(b) Describe any methods used to examine subgroups and interactions 7,8
(c) Explain how missing data were addressed Excluded
Statistical methods 12
(d) Cohort study—If applicable, explain how loss to follow-up was addressed
Case-control study—If applicable, explain how matching of cases and controls was addressed Follow up forms used
from ISOT
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Cross-sectional study—If applicable, describe analytical methods taking account of sampling strategy
(e) Describe any sensitivity analyses
Results
Participants 13* (a) Report numbers of individuals at each stage of study—eg numbers potentially eligible, examined for eligibility,
confirmed eligible, included in the study, completing follow-up, and analysed 9
(b) Give reasons for non-participation at each stage
(c) Consider use of a flow diagram Figure-5
Descriptive data 14* (a) Give characteristics of study participants (eg demographic, clinical, social) and information on exposures and
potential confounders 9
(b) Indicate number of participants with missing data for each variable of interest 9
(c) Cohort study—Summarise follow-up time (eg, average and total amount) 9
Outcome data 15* Cohort study—Report numbers of outcome events or summary measures over time 9
Case-control study—Report numbers in each exposure category, or summary measures of exposure
Cross-sectional study—Report numbers of outcome events or summary measures
Main results 16 (a) Give unadjusted estimates and, if applicable, confounder-adjusted estimates and their precision (eg, 95%
confidence interval). Make clear which confounders were adjusted for and why they were included 9 and tables
(b) Report category boundaries when continuous variables were categorized Tables
(c) If relevant, consider translating estimates of relative risk into absolute risk for a meaningful time period Tables
Other analyses 17 Report other analyses done—eg analyses of subgroups and interactions, and sensitivity analyses 9 and tables
Discussion
Key results 18 Summarise key results with reference to study objectives 10
Limitations 19 Discuss limitations of the study, taking into account sources of potential bias or imprecision. Discuss both direction
and magnitude of any potential bias 10
Interpretation 20 Give a cautious overall interpretation of results considering objectives, limitations, multiplicity of analyses, results
from similar studies, and other relevant evidence 10
Generalisability 21 Discuss the generalisability (external validity) of the study results 10
Other information 10
Funding 22 Give the source of funding and the role of the funders for the present study and, if applicable, for the original study on
which the present article is based 1
*Give information separately for cases and controls in case-control studies and, if applicable, for exposed and unexposed groups in cohort and cross-sectional studies.
Note: An Explanation and Elaboration article discusses each checklist item and gives methodological background and published examples of transparent reporting. The STROBE
checklist is best used in conjunction with this article (freely available on the Web sites of PLoS Medicine at http://www.plosmedicine.org/, Annals of Internal Medicine at
http://www.annals.org/, and Epidemiology at http://www.epidem.com/). Information on the STROBE Initiative is available at www.strobe-statement.org.
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Limitations:ord-late presentation biased data
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Morphology of traumatic cataract: does it play role in final
visual outcome? A hospital based cohort study
Journal: BMJ Open
Manuscript ID: BMJ Open.2011.000060.R2
Article Type: Research
Date Submitted by the Author:
03-Apr-2011
Complete List of Authors: Shah, Mehul; Drashti Netralaya, Ophthalmology; Drashti Netralaya, Ophthalmology Shah, Shreya; Drashti Netralaya, Ophthalmology Shah, Shashank; Drashti Netralaya, Ophthalmology Patel, Chintan; Drashti Netralaya, Ophthalmology Patel, Utsav; Drashti Netralaya, Ophthalmology
<b>Primary Subject
Heading</b>: Ophthalmology
Keywords: Cataract and refractive surgery < OPHTHALMOLOGY, Vetreoretinal < OPHTHALMOLOGY, Paediatric ophthalmology < OPHTHALMOLOGY
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Title: Morphology of traumatic cataract: does it play a role in final visual outcome?
Short running head: Morphology of traumatic cataract
Authors:
Name Degree E-mail
Dr. Mehul A. Shah
MD omtrust@rediffmail.com
Dr Shreya M. Shah
MD shah_shreya2000@yahoo.com
Dr. Shashank B. Shah MBBS sbshah@indiatimes.com
Dr. Chintan G. Patel MBBS cgp@drashtinetralaya.org
Dr Utsav A. Patel MBBS uap@drashtinetralaya.org
Affiliations of all authors:
Drashti Netralaya, Dahod, Gujarat, India
Address of corresponding author:
Drashti Netralaya,
Nr. GIDC, Chakalia Road.
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Dahod-389151
Gujarat
Ph: 00-91-2673-645364 Fax: 00-91-2673-221232
Email: omtrust@rdiffmail.com
No financial support was received from any company or institution.
This study has not been presented at any conference or meeting.
The authors do not have any financial interests in any aspect of this study.
Conflicting interests: None to declare.
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Abstract:
Purpose: To provide evidence-based care to patients with traumatic cataract.
Setting: Tertiary eye care centre in Dahod at the trijunction of Gujarat, Madhya Pradesh, and
Rajasthan states in central western India.
Methods: This was a retrospective observational cohort study among all patients presenting at
our hospital with traumatic cataracts between January 2003 and December 2009. All information
regarding demographic and ocular trauma was collected on a pre-tested World Eye Trauma
Registry form for both the first visit and follow-up.
In particular, we collected specific information about the morphology of traumatic cataracts;
surgical technique was determined accordingly.
Data were entered and analysed with regard to the relationship between type of trauma and
resulting injury, results achieved with particular surgical techniques, and the relationship
between morphology and final visual outcome.
Outcome measures: Final visual outcome.
Results: Traumatic cataracts of different morphologies showed significant differences in final
visual outcome (χ2 test, P = 0.014).
Conclusion: The morphology of traumatic cataract plays an important role in determining both
the appropriate surgical technique and final visual outcome.
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Article Summery:
Article Focus:
Morphological Classification of traumatic cataract which may be helpful for guidelines of
surgical technique.
Key Message:
Proposal of new classification which may suggest surgical treatment of traumatic cataract
Strength and weakness:
Strength: Larger database and Usage of standard classification method-BETTS Limitation:
Included many neglected injury cases. Weakness: Short follow up.
Introduction:
Trauma is a cause of monocular blindness in the developed world, although few studies
have addressed the problem of trauma in rural areas.1 The aetiology of ocular injury in rural
areas is likely to differ from that in urban areas and is worthy of investigation.2-4
Any strategy
for prevention requires knowledge of the cause of injury, which may enable more appropriate
targeting of resources toward preventing such injuries. Eye trauma represents a large, potentially
preventable burden on both victims and society as a whole.3
Ocular trauma can cause cataracts.1 The methods used to evaluate the visual outcome in
eyes managed for traumatic cataracts and senile cataracts are similar,5 but the damage to other
ocular tissues due to trauma may compromise the visual gain in eyes treated surgically for
traumatic cataracts. Hence, the success rates may differ between eyes with these two types of
cataract.
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With the introduction of the Birmingham Eye Trauma Terminology System (BETTS),
the documentation of ocular trauma has been standardised.5
Our study was conducted in a city located at the intersection of the borders of three states
in India: Gujarat, Madhya Pradesh, and Rajasthan.11
Qualified ophthalmologists at our institute
provide low-cost eye services mainly to the poor belonging to the tribal population of 4.2 million
in this area.
There is no standard methodology for classification of traumatic cataract.
Patients and Methods:
We obtained approval from the hospital administrators and research committee to
conduct this study, and all participants provided written informed consent.
This was a prospective study designed in 2002. All traumatic cataracts in either eye
diagnosed and managed between January 2003 and December 2009 were included in the study,
and patients consenting to participate and without other serious body injuries were included.
For each patient enrolled in our study, we obtained a detailed history, including details of
the injury and information on eye treatment and surgery performed to manage past ocular
trauma. Data for both the initial and follow-up reports were collected using the online BETTS
format of the International Society of Ocular Trauma. Details of the surgery were also collected
using a specified pre-tested online form.
The cases of traumatic cataract were grouped as those with open- and those with closed-
globe injuries. The open-globe injuries were further categorised into those with lacerations and
those with rupture. Lacerations of the eyeball were subcategorised into eyes with perforating
injuries, penetrating injuries, or injuries involving an intraocular foreign body. The closed-globe
group was subdivided into lamellar laceration and contusion.
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Other demographic details collected included patient entry, residence, activity at the time
of injury, object of injury, and previous examinations and treatments. After enrolment, all
patients were examined using a standard method. Visual acuity was checked using a Snellen
chart, and the anterior segment was examined using a slit lamp.
Based on lenticular opacity, the cataracts were classified as total (Figure 1), membranous
in which both capsules fused with scant or no cortical material (Figure 2), white soft (Figure 3),
and rosette types (Figure 4). When an ophthalmologist did not observe clear lens matter between
the capsule and nucleus, the cataract was defined as total. When the capsule and organised
matter were fused and formed a membrane of varying density, it was defined as a membranous
cataract. When loose cortical material was found in the anterior chamber together with a
ruptured lens capsule, the cataract was defined as white soft. A lens with a rosette pattern of
opacity was classified as a rosette type cataract.
For a partially opaque lens, the posterior segment examination was carried out with an
indirect ophthalmoscope and a +20 D lens. When the optical medium was not clear, a B-scan
was performed to evaluate the posterior segment.
The surgical technique was selected according to morphology and the condition of
tissues other than the lens. Phacoemulsification was used to treat cataracts with hard, large
nuclei. With a lens that had either a white soft or rosette type of cataract, unimanual or bimanual
aspiration was used. Membranectomy and anterior vitrectomy, via either the anterior or pars
plana route, were performed when the cataract was membranous.
In all patients undergoing corneal wound repair, the traumatic cataract was managed in a
second procedure. Recurrent inflammation was more prominent in patients who had undergone
previous surgery for trauma.9,10
In these cases, the ocular medium may become hazy owing to
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condensation of the anterior vitreous unless a vitrectomy is performed. Hence, we performed a
capsulectomy and vitrectomy via the anterior/pars plana route in adults.
In children younger than 2 years of age, both a lensectomy and vitrectomy via the pars
plana route were performed, and the same surgical procedures were used to manage the
traumatic cataract, with secondary implants done as a separate procedure after the age of 2 years.
Lens implantation as part of the primary procedure was avoided in all children younger than 2
years of age. All children were evaluated for amblyopia and were treated with the aid of
paediatric ophthalmologists and paediatric optometrists.
All patients with injuries and without infection were treated with topical and systemic
corticosteroids and cycloplegics. The duration of medical treatment depended on the degree of
inflammation in the anterior and posterior segments of the operated eye. The operated patients
were re-examined after 24 h, 3 days, and 1, 2, and 6 weeks to enable refractive correction.
Follow-up was scheduled for the third day, weekly for 6 weeks, monthly for 3 months, and every
3 months for 1 year.
At all follow-up examinations, visual acuity was tested using a Snellen chart. The
anterior segment was examined with a slit lamp, and the posterior segment was examined with
an indirect ophthalmoscope. Eyes with vision better than 20/60 at the glasses appointment (6
weeks) were defined as having a satisfactory grade of vision.
During the examination, data were entered online using a specified pre-tested format
designed by the International Society of Ocular Trauma (initial and follow-up forms), which was
exported to a Microsoft Excel spreadsheet. The data were audited periodically to ensure
completeness. We used SPSS 15 software to analyse the data. The univariate parametric method
was used to calculate frequency, percentage, proportion, and 95% confidence interval (95% CI).
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We used binominal regression analysis to determine the predictors of postoperative satisfactory
vision (> 20/60). The dependent variable was vision >20/60 noted at follow-up 6 weeks after
cataract surgery. The independent variables were age, gender, residence, time interval between
injury and cataract surgery, primary posterior capsulectomy and vitrectomy procedure, and type
of ocular injury.
Results:
Our cohort consisted of 687 (72.2) patients with traumatic cataracts (Figure 5), including 496
eyes with open-globe ocular injuries and 191 (27.8%) eyes with closed-globe injuries (Figure 5).
The patients were 492 (71.6%) males and 195 (28.4%) females. The mean patient age was
27.1 ± 18.54 years (range, 1–80).
We analysed several demographic factors, including gender (P = 0.340), patient entry
(P = 0.4), and socioeconomic status (79% were from lower socioeconomic class and residence;
95% were from rural areas). None of these showed a significant relationship with final visual
acuity, according to cross-tabulation and statistical tests. The object causing the injury (P = 0.3)
and the activity at the time of the injury (P = 0.3) were also not significantly associated with
satisfactory final visual acuity. A significant relationship was found between age and final visual
outcome (P = 0.000). There was no significant difference in final visual outcome in children
between open and closed injury groups (P = 0.06).
All traumatic cataracts were classified according to morphology (Tables 1 and 2) and
were surgically treated using morphology as a guideline. (Table 3)
The number of surgeries required varied significantly with morphology (P = 0.000)
(Table 4).
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Final visual outcome was found to vary according to morphology and surgical technique.
White soft cataracts had a better prognosis and achieved significantly higher rates of positive
outcome compared with other morphologies (P = 0.014) (Table 5).
Lens implants were applied in 82% of the cases; the details are shown in Table 6. There
was a significant difference between open and closed injury groups for various age groups (P =
0.000).
Discussion:
Using a large database, we attempted to systematically classify the morphology of
traumatic cataract and to select surgical techniques accordingly.
Previous studies have touched on this topic. One study found 52.3% total cataracts,
whereas our results revealed 26.6% total cataracts.7 Vajpayee reported opening in the posterior
capsule with type 1 and 2 openings with penetrating injury,8 whereas we found another
membranous type of cataract (12.1%) suggestive of late reporting, as membranous
transformation of the lens with fusion of the anterior and posterior capsules may occur over
time.
We were able to perform intraocular lens implants in 82.1% of the cases.
Krishnamachary reported implants in 65.5% of cases, Churchill et al. reported implants in
46.8%, and Fyodorov reported Sputnik implants in all cases.7,9,10
Fyodorov reported surgical techniques according to pathology and degree of lens
absorption, but did not systematically classify similar factors taken into account in our study.10
These differences in findings may reflect the fact that of the 687 patients in our study,
30% came from outreach activities and did not approach treatment facilities on their own.
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Therefore, the time period between ocular injury and reporting ranged widely, and morphology
was also influenced by this interval.
We propose a specific morphological classification for traumatic cataract, which may
provide guidelines for management that incorporate available technology and improve care for
these patients.
References:
1. Khatry SK, Lewis AE, Schein OD, Thapa MD, Pradhan EK, Katz J, et al. The
epidemiology of ocular trauma in rural Nepal. Br J Ophthalmol. 2004; 88:456-60.
2. Abraham, D. I.; Vitale, S. I.; West, S. I.; Isseme, I. Epidemiology of eye injuries in rural
Tanzania. Ophthalmic Epidemiol.1999; 6:85-94
3. D. Virgil Alfaro, Eric P. Jablon, Monica Rodriguez Fontal, Simon J. Villalba, Robert
E.Morris, Michael Grossman, Enrique Roig-Melo et al. Fishing-related ocular trauma.
American Journal of Ophthalmology.2005; 139: 488-492
4. Shah M, Shah S, Khandekar R. Ocular injuries and visual status before and after Their
management in the tribal areas of Western India-A historical cohort study Grafes Arch
Clin Exp Ophthalmol 2008; 246:191–197.
5. Kuhn F, Morris R, Witherspoon CD, Mester V,) The Birmingham Eye Trauma
Terminology system (BETT). J Fr Ophtalmol. 2004; 27:206-10.
6. Vajpayee RB, Sharma N, Dada T, Gupta V, Kumar A, Dada VK. Management of
posterior capsule tears. Surv Ophthalmol 2001;45:473-88.
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7. Krishnamachary M, Rathi V, Gupta S. Management of traumatic cataract in children. J
Cataract Refract Surg 1997;23 Suppl 1:681-7.
8. Churchill AJ, Noble BA, Etchells DE, George NJ. Factors affecting visual outcome in
children following uniocular traumatic cataract. Eye (Lond) 1995;9 ( Pt 3):285-91
9. Thylefors B, Chylack LT Jr, Konyama K, Sasaki K, Sperduto R, Taylor HR, et al. A simplified
cataract grading system. Ophthalmic Epidemiol. 2002; 9:83-95.
10. Fyodorov SN, Egorova EV, Zubareva LN. 1004 cases of traumatic cataract surgery with
implantation of an intraocular lens. J Am Intraocul Implant Soc 1981;7:147-53.
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Table 1. Distribution of different morphologies of traumatic cataract
Morphology N Percent
84 12.2
8
1.2
412
60.0
183 26.6
Membranous
Rosette
White soft
Total
Total 687 100.0
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Table 2. Morphology of traumatic cataract according to type of injury
BETT Category Closed globe Open globe Total
Morphology N % N % N %
20 2.9 64 9.3 84 12.2
3 0.4 5 0.7 8 1.1
83 12.1 329 47.9 412 59.9
Membranous
Rosette
White Soft with ruptured
Anterior capsule
Total
85 12.4 98 14.3 183 26.6
Total
191 27.8 496 72.2 687 100
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Table 3. Surgical techniques used according to morphology of cataract
Morphology
Membranous Rosette White soft Total
Total
Surgical Technique
N % N % N % N % N %
7 1 5 0.7 316 45.9 19 2.7 347 50.5
46 6.7 0 0 60 8.7 20 2.9 126 18.3
3 0.4 2 0.3 17 2.4 108 15.7 130 18.9
Aspiration
Lensectomy + Vitrectomy
Phaco/SICS*
Delivery + vitrectomy
28 4 0 0 20 2.9 36 5.2 84 12.2
Total 83 12.1 7 1 412 59.9 183 26.6 687 100
*Small Incision Cataract Surgery
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Table 4. Morphology of cataract in relation to number of surgical procedures
Morphology
Membranous Rosette White soft Total Total
N N % N % N % N % N &
70 10.1 6 0.8 349 50.8 159 23.1 584 85.0
12 1.7 2 0.2 58 8.4 22 3.2 94 13.7
2 0.3 0 0 5 0.7 2 0.2 9 1.3
1.00
2.00
3.00
Total 84 12.2 8 1 412 59.9 183 26.6 687 100
χ 2 test, P = 0.000
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Table 5. Final visual outcome in relation to morphology of cataract
Final visual outcome Morphology
Membranous Rosette White soft Total Total
N % N % N % N % N %
3 0.4 0 0 11 1.6 5 0.7 19 2.7
24 3.5 2 0.3 89 12.9 58 8.4 173 25.1
12 1.7 0 0 27 3.9 19 2.7 58 8.4
7 1.0 1 0.1 33 4.8 25 3.6 66 9.6
21 3.0 1 0.1 91 13.2 34 4.9 147 21.4
Uncooperative
<1/60
1/60 to 3/60
20/200 to 20/120
20/80 to 20/60
20/40 to 20/20 17 2.5 4 0.5 161 23.4 42 6.1 224 32.6
Total 83 12.1 7 1.0 412 59.9 183 26.6 687 100
χ 2 test, P = 0.014
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Table 6. Lens implant in relation to morphology of traumatic cataract
Morphology No implant Implant Total
N % N % N %
17 2.5 67 9.8 84 12.2
2 0.3 6 0.9 8 1.2
58 8.4 354 51.5 412 60.0
46 6.7 137 19.9 183 26.6
Membranous
Rosette
White soft
Total
Total 123 17.9 564 82.1 687 100
χ 2 test, p = 0.004
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Table-7. Comparison of open closed globe injuries in children
Category Closed globe Open globe Total
N % N % N %
54 7.7 253 36.8 307 44.7 Pediatric
Adult 137 19.9 243 35.3 380 55.3
Total 191 27.8 496 72.1 687 100
χ 2 test, p=0.000
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Figure Legends:
Fig. 1: When no clear lens matter was visible between the capsule and the nucleus, the cataract
was defined as a total cataract.
Fig. 2: When loose cortical material was found in the anterior chamber together with a ruptured
lens capsule, the cataract was defined as a white soft cataract.
Fig. 3: When the capsule and organised matter were fused and formed a membrane of varying
density, the cataract was defined as a membranous cataract.
Fig. 4: A lens with a rosette pattern of opacity was classified as a rosette type cataract.
Fig. 5: Distribution of cataracts based on the ocular injury, as per the BETTS classification.
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The English in this document has been checked by at least two professional editors, both native speakers
of English. For a certificate, please see:
http://www.textcheck.com/certificate/rbgCMs
Contributor ship Statement:
Mehul Shah: Concept design study, surgeon, writing
Shreya Shah: Administrative support, writing, data analyses
Shashank Shah: Data collection, language editing
Chintan Patel: Data collection proof reading and editing
Utsav Patel: Data collection and editing
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STROBE 2007 (v4) checklist of items to be included in reports of observational studies in epidemiology*
Checklist for cohort, case-control, and cross-sectional studies (combined)
Section/Topic Item # Recommendation Reported on page #
(a) Indicate the study’s design with a commonly used term in the title or the abstract 4 Title and abstract 1
(b) Provide in the abstract an informative and balanced summary of what was done and what was found 4
Introduction
Background/rationale 2 Explain the scientific background and rationale for the investigation being reported 5
Objectives 3 State specific objectives, including any pre-specified hypotheses 5
Methods
Study design 4 Present key elements of study design early in the paper 6
Setting 5 Describe the setting, locations, and relevant dates, including periods of recruitment, exposure, follow-up, and data
collection 5,6
(a) Cohort study—Give the eligibility criteria, and the sources and methods of selection of participants. Describe
methods of follow-up
Case-control study—Give the eligibility criteria, and the sources and methods of case ascertainment and control
selection. Give the rationale for the choice of cases and controls
Cross-sectional study—Give the eligibility criteria, and the sources and methods of selection of participants
5,6 Participants 6
(b) Cohort study—For matched studies, give matching criteria and number of exposed and unexposed
Case-control study—For matched studies, give matching criteria and the number of controls per case
Variables 7 Clearly define all outcomes, exposures, predictors, potential confounders, and effect modifiers. Give diagnostic
criteria, if applicable 6,7
Data sources/ measurement 8* For each variable of interest, give sources of data and details of methods of assessment (measurement). Describe
comparability of assessment methods if there is more than one group 6,7,8
Bias 9 Describe any efforts to address potential sources of bias Nil
Study size 10 Explain how the study size was arrived at Time period
Quantitative variables 11 Explain how quantitative variables were handled in the analyses. If applicable, describe which groupings were chosen
and why Morphology group
(a) Describe all statistical methods, including those used to control for confounding 7,8
(b) Describe any methods used to examine subgroups and interactions 7,8
(c) Explain how missing data were addressed Excluded
Statistical methods 12
(d) Cohort study—If applicable, explain how loss to follow-up was addressed
Case-control study—If applicable, explain how matching of cases and controls was addressed Follow up forms used
from ISOT
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Cross-sectional study—If applicable, describe analytical methods taking account of sampling strategy
(e) Describe any sensitivity analyses
Results
Participants 13* (a) Report numbers of individuals at each stage of study—eg numbers potentially eligible, examined for eligibility,
confirmed eligible, included in the study, completing follow-up, and analysed 9
(b) Give reasons for non-participation at each stage
(c) Consider use of a flow diagram Figure-5
Descriptive data 14* (a) Give characteristics of study participants (eg demographic, clinical, social) and information on exposures and
potential confounders 9
(b) Indicate number of participants with missing data for each variable of interest 9
(c) Cohort study—Summarise follow-up time (eg, average and total amount) 9
Outcome data 15* Cohort study—Report numbers of outcome events or summary measures over time 9
Case-control study—Report numbers in each exposure category, or summary measures of exposure
Cross-sectional study—Report numbers of outcome events or summary measures
Main results 16 (a) Give unadjusted estimates and, if applicable, confounder-adjusted estimates and their precision (eg, 95%
confidence interval). Make clear which confounders were adjusted for and why they were included 9 and tables
(b) Report category boundaries when continuous variables were categorized Tables
(c) If relevant, consider translating estimates of relative risk into absolute risk for a meaningful time period Tables
Other analyses 17 Report other analyses done—eg analyses of subgroups and interactions, and sensitivity analyses 9 and tables
Discussion
Key results 18 Summarise key results with reference to study objectives 10
Limitations 19 Discuss limitations of the study, taking into account sources of potential bias or imprecision. Discuss both direction
and magnitude of any potential bias 10
Interpretation 20 Give a cautious overall interpretation of results considering objectives, limitations, multiplicity of analyses, results
from similar studies, and other relevant evidence 10
Generalisability 21 Discuss the generalisability (external validity) of the study results 10
Other information 10
Funding 22 Give the source of funding and the role of the funders for the present study and, if applicable, for the original study on
which the present article is based 1
*Give information separately for cases and controls in case-control studies and, if applicable, for exposed and unexposed groups in cohort and cross-sectional studies.
Note: An Explanation and Elaboration article discusses each checklist item and gives methodological background and published examples of transparent reporting. The STROBE
checklist is best used in conjunction with this article (freely available on the Web sites of PLoS Medicine at http://www.plosmedicine.org/, Annals of Internal Medicine at
http://www.annals.org/, and Epidemiology at http://www.epidem.com/). Information on the STROBE Initiative is available at www.strobe-statement.org.
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Limitations:ord-late presentation biased data
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Morphology of traumatic cataract: does it play role in final
visual outcome? A hospital based cohort study
Journal: BMJ Open
Manuscript ID: BMJ Open.2011.000060.R3
Article Type: Research
Date Submitted by the Author:
07-Apr-2011
Complete List of Authors: Shah, Mehul; Drashti Netralaya, Ophthalmology; Drashti Netralaya, Ophthalmology Shah, Shreya; Drashti Netralaya, Ophthalmology Shah, Shashank; Drashti Netralaya, Ophthalmology Patel, Chintan; Drashti Netralaya, Ophthalmology Patel, Utsav; Drashti Netralaya, Ophthalmology
<b>Primary Subject
Heading</b>: Ophthalmology
Keywords: Cataract and refractive surgery < OPHTHALMOLOGY, Vetreoretinal < OPHTHALMOLOGY, Paediatric ophthalmology < OPHTHALMOLOGY
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Title: Morphology of traumatic cataract: does it play a role in final visual outcome?
Short running head: Morphology of traumatic cataract
Authors:
Name Degree E-mail
Dr. Mehul A. Shah
MD omtrust@rediffmail.com
Dr Shreya M. Shah
MD shah_shreya2000@yahoo.com
Dr. Shashank B. Shah MBBS sbshah@indiatimes.com
Dr. Chintan G. Patel MBBS cgp@drashtinetralaya.org
Dr Utsav A. Patel MBBS uap@drashtinetralaya.org
Affiliations of all authors:
Drashti Netralaya, Dahod, Gujarat, India
Address of corresponding author:
Drashti Netralaya,
Nr. GIDC, Chakalia Road.
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Dahod-389151
Gujarat
Ph: 00-91-2673-645364 Fax: 00-91-2673-221232
Email: omtrust@rdiffmail.com
No financial support was received from any company or institution.
This study has not been presented at any conference or meeting.
The authors do not have any financial interests in any aspect of this study.
Conflicting interests: None to declare.
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Abstract:
Purpose: To provide evidence-based care to patients with traumatic cataract.
Setting: Tertiary eye care centre in Dahod at the trijunction of Gujarat, Madhya Pradesh, and
Rajasthan states in central western India.
Methods: This was a retrospective observational cohort study among all patients presenting at
our hospital with traumatic cataracts between January 2003 and December 2009. All information
regarding demographic and ocular trauma was collected on a pre-tested World Eye Trauma
Registry form for both the first visit and follow-up.
In particular, we collected specific information about the morphology of traumatic cataracts;
surgical technique was determined accordingly.
Data were entered and analysed with regard to the relationship between type of trauma and
resulting injury, results achieved with particular surgical techniques, and the relationship
between morphology and final visual outcome.
Outcome measures: Final visual outcome.
Results: Traumatic cataracts of different morphologies showed significant differences in final
visual outcome (χ2 test, P = 0.014).
Conclusion: The morphology of traumatic cataract plays an important role in determining both
the appropriate surgical technique and final visual outcome.
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Article Summery:
Article Focus:
Morphological Classification of traumatic cataract which may be helpful for guidelines of
surgical technique.
Key Message:
Proposal of new classification which may suggest surgical treatment of traumatic cataract
Strength and weakness:
Strength: Larger database and Usage of standard classification method-BETTS Limitation:
Included many neglected injury cases. Weakness: Short follow up.
Introduction:
Trauma is a cause of monocular blindness in the developed world, although few studies
have addressed the problem of trauma in rural areas.1 The aetiology of ocular injury in rural
areas is likely to differ from that in urban areas and is worthy of investigation.2-4
Any strategy
for prevention requires knowledge of the cause of injury, which may enable more appropriate
targeting of resources toward preventing such injuries. Eye trauma represents a large, potentially
preventable burden on both victims and society as a whole.3
Ocular trauma can cause cataracts.1 The methods used to evaluate the visual outcome in
eyes managed for traumatic cataracts and senile cataracts are similar,5 but the damage to other
ocular tissues due to trauma may compromise the visual gain in eyes treated surgically for
traumatic cataracts. Hence, the success rates may differ between eyes with these two types of
cataract.
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With the introduction of the Birmingham Eye Trauma Terminology System (BETTS),
the documentation of ocular trauma has been standardised.5
Our study was conducted in a city located at the intersection of the borders of three states
in India: Gujarat, Madhya Pradesh, and Rajasthan.11
Qualified ophthalmologists at our institute
provide low-cost eye services mainly to the poor belonging to the tribal population of 4.2 million
in this area.
There is no standard methodology for classification of traumatic cataract.
Patients and Methods:
We obtained approval from the hospital administrators and research committee to
conduct this study, and all participants provided written informed consent.
This was a prospective study designed in 2002. All traumatic cataracts in either eye
diagnosed and managed between January 2003 and December 2009 were included in the study,
and patients consenting to participate and without other serious body injuries were included.
For each patient enrolled in our study, we obtained a detailed history, including details of
the injury and information on eye treatment and surgery performed to manage past ocular
trauma. Data for both the initial and follow-up reports were collected using the online BETTS
format of the International Society of Ocular Trauma. Details of the surgery were also collected
using a specified pre-tested online form.
The cases of traumatic cataract were grouped as those with open- and those with closed-
globe injuries. The open-globe injuries were further categorised into those with lacerations and
those with rupture. Lacerations of the eyeball were subcategorised into eyes with perforating
injuries, penetrating injuries, or injuries involving an intraocular foreign body. The closed-globe
group was subdivided into lamellar laceration and contusion.
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Other demographic details collected included patient entry, residence, activity at the time
of injury, object of injury, and previous examinations and treatments. After enrolment, all
patients were examined using a standard method. Visual acuity was checked using a Snellen
chart, and the anterior segment was examined using a slit lamp.
Based on lenticular opacity, the cataracts were classified as total (Figure 1), membranous
in which both capsules fused with scant or no cortical material (Figure 2), white soft (Figure 3),
and rosette types (Figure 4). When an ophthalmologist did not observe clear lens matter between
the capsule and nucleus, the cataract was defined as total. When the capsule and organised
matter were fused and formed a membrane of varying density, it was defined as a membranous
cataract. When loose cortical material was found in the anterior chamber together with a
ruptured lens capsule, the cataract was defined as white soft. A lens with a rosette pattern of
opacity was classified as a rosette type cataract.
For a partially opaque lens, the posterior segment examination was carried out with an
indirect ophthalmoscope and a +20 D lens. When the optical medium was not clear, a B-scan
was performed to evaluate the posterior segment.
The surgical technique was selected according to morphology and the condition of
tissues other than the lens. Phacoemulsification was used to treat cataracts with hard, large
nuclei. With a lens that had either a white soft or rosette type of cataract, unimanual or bimanual
aspiration was used. Membranectomy and anterior vitrectomy, via either the anterior or pars
plana route, were performed when the cataract was membranous.
In all patients undergoing corneal wound repair, the traumatic cataract was managed in a
second procedure. Recurrent inflammation was more prominent in patients who had undergone
previous surgery for trauma.9,10
In these cases, the ocular medium may become hazy owing to
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condensation of the anterior vitreous unless a vitrectomy is performed. Hence, we performed a
capsulectomy and vitrectomy via the anterior/pars plana route in adults.
In children younger than 2 years of age, both a lensectomy and vitrectomy via the pars
plana route were performed, and the same surgical procedures were used to manage the
traumatic cataract, with secondary implants done as a separate procedure after the age of 2 years.
Lens implantation as part of the primary procedure was avoided in all children younger than 2
years of age. All children were evaluated for amblyopia and were treated with the aid of
paediatric ophthalmologists and paediatric optometrists.
All patients with injuries and without infection were treated with topical and systemic
corticosteroids and cycloplegics. The duration of medical treatment depended on the degree of
inflammation in the anterior and posterior segments of the operated eye. The operated patients
were re-examined after 24 h, 3 days, and 1, 2, and 6 weeks to enable refractive correction.
Follow-up was scheduled for the third day, weekly for 6 weeks, monthly for 3 months, and every
3 months for 1 year.
At all follow-up examinations, visual acuity was tested using a Snellen chart. The
anterior segment was examined with a slit lamp, and the posterior segment was examined with
an indirect ophthalmoscope. Eyes with vision better than 20/60 at the glasses appointment (6
weeks) were defined as having a satisfactory grade of vision.
During the examination, data were entered online using a specified pre-tested format
designed by the International Society of Ocular Trauma (initial and follow-up forms), which was
exported to a Microsoft Excel spreadsheet. The data were audited periodically to ensure
completeness. We used SPSS 15 software to analyse the data. The univariate parametric method
was used to calculate frequency, percentage, proportion, and 95% confidence interval (95% CI).
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We used binominal regression analysis to determine the predictors of postoperative satisfactory
vision (> 20/60). The dependent variable was vision >20/60 noted at follow-up 6 weeks after
cataract surgery. The independent variables were age, gender, residence, time interval between
injury and cataract surgery, primary posterior capsulectomy and vitrectomy procedure, and type
of ocular injury.
Results:
Our cohort consisted of 687 (72.2) patients with traumatic cataracts (Figure 5), including 496
eyes with open-globe ocular injuries and 191 (27.8%) eyes with closed-globe injuries (Figure 5).
The patients were 492 (71.6%) males and 195 (28.4%) females. The mean patient age was
27.1 ± 18.54 years (range, 1–80).
We analysed several demographic factors, including gender (P = 0.340), patient entry
(P = 0.4), and socioeconomic status (79% were from lower socioeconomic class and residence;
95% were from rural areas). None of these showed a significant relationship with final visual
acuity, according to cross-tabulation and statistical tests. The object causing the injury (P = 0.3)
and the activity at the time of the injury (P = 0.3) were also not significantly associated with
satisfactory final visual acuity. A significant relationship was found between age and final visual
outcome (P = 0.000). There was no significant difference in final visual outcome in children
between open and closed injury groups (P = 0.06).
All traumatic cataracts were classified according to morphology (Tables 1 and 2) and
were surgically treated using morphology as a guideline. (Table 3)
The number of surgeries required varied significantly with morphology (P = 0.000)
(Table 4).
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Final visual outcome was found to vary according to morphology and surgical technique.
White soft cataracts had a better prognosis and achieved significantly higher rates of positive
outcome compared with other morphologies (P = 0.014) (Table 5).
Lens implants were applied in 82% of the cases; the details are shown in Table 6. There
was a significant difference between open and closed injury groups for various age groups (P =
0.000).
Discussion:
Using a large database, we attempted to systematically classify the morphology of
traumatic cataract and to select surgical techniques accordingly.
Previous studies have touched on this topic. One study found 52.3% total cataracts,
whereas our results revealed 26.6% total cataracts.7 Vajpayee reported opening in the posterior
capsule with type 1 and 2 openings with penetrating injury,8 whereas we found another
membranous type of cataract (12.1%) suggestive of late reporting, as membranous
transformation of the lens with fusion of the anterior and posterior capsules may occur over
time.
We were able to perform intraocular lens implants in 82.1% of the cases.
Krishnamachary reported implants in 65.5% of cases, Churchill et al. reported implants in
46.8%, and Fyodorov reported Sputnik implants in all cases.7,9,10
Fyodorov reported surgical techniques according to pathology and degree of lens
absorption, but did not systematically classify similar factors taken into account in our study.10
These differences in findings may reflect the fact that of the 687 patients in our study,
30% came from outreach activities and did not approach treatment facilities on their own.
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Therefore, the time period between ocular injury and reporting ranged widely, and morphology
was also influenced by this interval.
We propose a specific morphological classification for traumatic cataract, which may
provide guidelines for management that incorporate available technology and improve care for
these patients.
References:
1. Khatry SK, Lewis AE, Schein OD, Thapa MD, Pradhan EK, Katz J, et al. The
epidemiology of ocular trauma in rural Nepal. Br J Ophthalmol. 2004; 88:456-60.
2. Abraham, D. I.; Vitale, S. I.; West, S. I.; Isseme, I. Epidemiology of eye injuries in rural
Tanzania. Ophthalmic Epidemiol.1999; 6:85-94
3. D. Virgil Alfaro, Eric P. Jablon, Monica Rodriguez Fontal, Simon J. Villalba, Robert
E.Morris, Michael Grossman, Enrique Roig-Melo et al. Fishing-related ocular trauma.
American Journal of Ophthalmology.2005; 139: 488-492
4. Shah M, Shah S, Khandekar R. Ocular injuries and visual status before and after Their
management in the tribal areas of Western India-A historical cohort study Grafes Arch
Clin Exp Ophthalmol 2008; 246:191–197.
5. Kuhn F, Morris R, Witherspoon CD, Mester V,) The Birmingham Eye Trauma
Terminology system (BETT). J Fr Ophtalmol. 2004; 27:206-10.
6. Vajpayee RB, Sharma N, Dada T, Gupta V, Kumar A, Dada VK. Management of
posterior capsule tears. Surv Ophthalmol 2001;45:473-88.
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7. Krishnamachary M, Rathi V, Gupta S. Management of traumatic cataract in children. J
Cataract Refract Surg 1997;23 Suppl 1:681-7.
8. Churchill AJ, Noble BA, Etchells DE, George NJ. Factors affecting visual outcome in
children following uniocular traumatic cataract. Eye (Lond) 1995;9 ( Pt 3):285-91
9. Thylefors B, Chylack LT Jr, Konyama K, Sasaki K, Sperduto R, Taylor HR, et al. A simplified
cataract grading system. Ophthalmic Epidemiol. 2002; 9:83-95.
10. Fyodorov SN, Egorova EV, Zubareva LN. 1004 cases of traumatic cataract surgery with
implantation of an intraocular lens. J Am Intraocul Implant Soc 1981;7:147-53.
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Table 1. Distribution of different morphologies of traumatic cataract
Morphology N Percent
84 12.2
8
1.2
412
60.0
183 26.6
Membranous
Rosette
White soft
Total
Total 687 100.0
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Table 2. Morphology of traumatic cataract according to type of injury
BETT Category Closed globe Open globe Total
Morphology N % N % N %
20 2.9 64 9.3 84 12.2
3 0.4 5 0.7 8 1.1
83 12.1 329 47.9 412 59.9
Membranous
Rosette
White Soft with ruptured
Anterior capsule
Total
85 12.4 98 14.3 183 26.6
Total
191 27.8 496 72.2 687 100
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Table 3. Surgical techniques used according to morphology of cataract
Morphology
Membranous Rosette White soft Total
Total
Surgical Technique
N % N % N % N % N %
7 1 5 0.7 316 45.9 19 2.7 347 50.5
46 6.7 0 0 60 8.7 20 2.9 126 18.3
3 0.4 2 0.3 17 2.4 108 15.7 130 18.9
Aspiration
Lensectomy + Vitrectomy
Phaco/SICS*
Delivery + vitrectomy
28 4 0 0 20 2.9 36 5.2 84 12.2
Total 83 12.1 7 1 412 59.9 183 26.6 687 100
*Small Incision Cataract Surgery
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Table 4. Morphology of cataract in relation to number of surgical procedures
Morphology
Membranous Rosette White soft Total Total
N N % N % N % N % N &
70 10.1 6 0.8 349 50.8 159 23.1 584 85.0
12 1.7 2 0.2 58 8.4 22 3.2 94 13.7
2 0.3 0 0 5 0.7 2 0.2 9 1.3
1.00
2.00
3.00
Total 84 12.2 8 1 412 59.9 183 26.6 687 100
χ 2 test, P = 0.000
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Table 5. Final visual outcome in relation to morphology of cataract
Final visual outcome Morphology
Membranous Rosette White soft Total Total
N % N % N % N % N %
3 0.4 0 0 11 1.6 5 0.7 19 2.7
24 3.5 2 0.3 89 12.9 58 8.4 173 25.1
12 1.7 0 0 27 3.9 19 2.7 58 8.4
7 1.0 1 0.1 33 4.8 25 3.6 66 9.6
21 3.0 1 0.1 91 13.2 34 4.9 147 21.4
Uncooperative
<1/60
1/60 to 3/60
20/200 to 20/120
20/80 to 20/60
20/40 to 20/20 17 2.5 4 0.5 161 23.4 42 6.1 224 32.6
Total 83 12.1 7 1.0 412 59.9 183 26.6 687 100
χ 2 test, P = 0.014
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Table 6. Lens implant in relation to morphology of traumatic cataract
Morphology No implant Implant Total
N % N % N %
17 2.5 67 9.8 84 12.2
2 0.3 6 0.9 8 1.2
58 8.4 354 51.5 412 60.0
46 6.7 137 19.9 183 26.6
Membranous
Rosette
White soft
Total
Total 123 17.9 564 82.1 687 100
χ 2 test, p = 0.004
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Table-7. Comparison of open closed globe injuries in children
Category Closed globe Open globe Total
N % N % N %
54 7.7 253 36.8 307 44.7 Pediatric
Adult 137 19.9 243 35.3 380 55.3
Total 191 27.8 496 72.1 687 100
χ 2 test, p=0.000
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Figure Legends:
Fig. 1: When no clear lens matter was visible between the capsule and the nucleus, the cataract
was defined as a total cataract.
Fig. 2: When loose cortical material was found in the anterior chamber together with a ruptured
lens capsule, the cataract was defined as a white soft cataract.
Fig. 3: When the capsule and organised matter were fused and formed a membrane of varying
density, the cataract was defined as a membranous cataract.
Fig. 4: A lens with a rosette pattern of opacity was classified as a rosette type cataract.
Fig. 5: Distribution of cataracts based on the ocular injury, as per the BETTS classification.
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The English in this document has been checked by at least two professional editors, both native speakers
of English. For a certificate, please see:
http://www.textcheck.com/certificate/rbgCMs
Contributor ship Statement:
Mehul Shah: Concept design study, surgeon, writing
Shreya Shah: Administrative support, writing, data analyses
Shashank Shah: Data collection, language editing
Chintan Patel: Data collection proof reading and editing
Utsav Patel: Data collection and editing
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Morphology of traumatic cataract: does it play role in final
visual outcome? A hospital based cohort study
Journal: BMJ Open
Manuscript ID: BMJ Open.2011.000060.R4
Article Type: Research
Date Submitted by the Author:
15-Apr-2011
Complete List of Authors: Shah, Mehul; Drashti Netralaya, Ophthalmology; Drashti Netralaya, Ophthalmology Shah, Shreya; Drashti Netralaya, Ophthalmology Shah, Shashank; Drashti Netralaya, Ophthalmology Patel, Chintan; Drashti Netralaya, Ophthalmology Patel, Utsav; Drashti Netralaya, Ophthalmology
<b>Primary Subject
Heading</b>: Ophthalmology
Keywords: Cataract and refractive surgery < OPHTHALMOLOGY, Vetreoretinal < OPHTHALMOLOGY, Paediatric ophthalmology < OPHTHALMOLOGY
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Title: Morphology of traumatic cataract: does it play a role in final visual outcome?
Short running head: Morphology of traumatic cataract
Authors:
Name Degree E-mail
Dr. Mehul A. Shah
MD omtrust@rediffmail.com
Dr Shreya M. Shah
MD shah_shreya2000@yahoo.com
Dr. Shashank B. Shah MBBS sbshah@indiatimes.com
Dr. Chintan G. Patel MBBS cgp@drashtinetralaya.org
Dr Utsav A. Patel MBBS uap@drashtinetralaya.org
Affiliations of all authors:
Drashti Netralaya, Dahod, Gujarat, India
Address of corresponding author:
Drashti Netralaya,
Nr. GIDC, Chakalia Road.
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Dahod-389151
Gujarat
Ph: 00-91-2673-645364 Fax: 00-91-2673-221232
Email: omtrust@rdiffmail.com
No financial support was received from any company or institution.
This study has not been presented at any conference or meeting.
The authors do not have any financial interests in any aspect of this study.
Conflicting interests: None to declare.
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Abstract:
Purpose: To provide evidence-based care to patients with traumatic cataract.
Setting: Tertiary eye care centre in Dahod at the trijunction of Gujarat, Madhya Pradesh, and
Rajasthan states in central western India.
Methods: This was a prospective observational cohort study among all patients presenting at our
hospital with traumatic cataracts between January 2003 and December 2009. All information
regarding demographic and ocular trauma was collected on a pre-tested World Eye Trauma
Registry form for both the first visit and follow-up.
In particular, we collected specific information about the morphology of traumatic cataracts;
surgical technique was determined accordingly.
Data were entered and analysed with regard to the relationship between type of trauma and
resulting injury, results achieved with particular surgical techniques, and the relationship
between morphology and final visual outcome.
Outcome measures: Final visual outcome.
Results: Traumatic cataracts of different morphologies showed significant differences in final
visual outcome (χ2 test, P = 0.014).
Conclusion: The morphology of traumatic cataract plays an important role in determining both
the appropriate surgical technique and final visual outcome.
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Article Summery:
Article Focus:
Morphological Classification of traumatic cataract which may be helpful for guidelines of
surgical technique.
Key Message:
Proposal of new classification which may suggest surgical treatment of traumatic cataract
Strength and weakness:
Strength: Larger database and Usage of standard classification method-BETTS Limitation:
Included many neglected injury cases. Weakness: Short follow up. Loss of follow up of 12
patients at various stages of study.
Introduction:
Trauma is a cause of monocular blindness in the developed world, although few studies
have addressed the problem of trauma in rural areas.1 The aetiology of ocular injury in rural
areas is likely to differ from that in urban areas and is worthy of investigation.2-4
Any strategy
for prevention requires knowledge of the cause of injury, which may enable more appropriate
targeting of resources toward preventing such injuries. Eye trauma represents a large, potentially
preventable burden on both victims and society as a whole.3
Ocular trauma can cause cataracts.1 The methods used to evaluate the visual outcome in
eyes managed for traumatic cataracts and senile cataracts are similar,5 but the damage to other
ocular tissues due to trauma may compromise the visual gain in eyes treated surgically for
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traumatic cataracts. Hence, the success rates may differ between eyes with these two types of
cataract.
With the introduction of the Birmingham Eye Trauma Terminology System (BETTS),
the documentation of ocular trauma has been standardised.5
Our study was conducted in a city located at the intersection of the borders of three states
in India: Gujarat, Madhya Pradesh, and Rajasthan.11
Qualified ophthalmologists at our institute
provide low-cost eye services mainly to the poor belonging to the tribal population of 4.2 million
in this area.
There is no standard methodology for classification of traumatic cataract.
Patients and Methods:
We obtained approval from the hospital administrators and research committee to
conduct this study, and all participants provided written informed consent.
This was a prospective study designed in 2002. All traumatic cataracts in either eye
diagnosed and managed between January 2003 and December 2009 were included in the study,
and patients consenting to participate and without other serious body injuries were included.
For each patient enrolled in our study, we obtained a detailed history, including details of
the injury and information on eye treatment and surgery performed to manage past ocular
trauma. Data for both the initial and follow-up reports were collected using the online BETTS
format of the International Society of Ocular Trauma. Details of the surgery were also collected
using a specified pre-tested online form.
The cases of traumatic cataract were grouped as those with open- and those with closed-
globe injuries. The open-globe injuries were further categorised into those with lacerations and
those with rupture. Lacerations of the eyeball were subcategorised into eyes with perforating
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injuries, penetrating injuries, or injuries involving an intraocular foreign body. The closed-globe
group was subdivided into lamellar laceration and contusion.
Other demographic details collected included patient entry, residence, activity at the time
of injury, object of injury, and previous examinations and treatments. After enrolment, all
patients were examined using a standard method. Visual acuity was checked using a Snellen
chart, and the anterior segment was examined using a slit lamp.
Based on lenticular opacity, the cataracts were classified as total (Figure 1), membranous
in which both capsules fused with scant or no cortical material (Figure 2), white soft (Figure 3),
and rosette types (Figure 4). When an ophthalmologist did not observe clear lens matter between
the capsule and nucleus, the cataract was defined as total. When the capsule and organised
matter were fused and formed a membrane of varying density, it was defined as a membranous
cataract. When loose cortical material was found in the anterior chamber together with a
ruptured lens capsule, the cataract was defined as white soft. A lens with a rosette pattern of
opacity was classified as a rosette type cataract.
For a partially opaque lens, the posterior segment examination was carried out with an
indirect ophthalmoscope and a +20 D lens. When the optical medium was not clear, a B-scan
was performed to evaluate the posterior segment.
The surgical technique was selected according to morphology and the condition of
tissues other than the lens. Phacoemulsification was used to treat cataracts with hard, large
nuclei. With a lens that had either a white soft or rosette type of cataract, unimanual or bimanual
aspiration was used. Membranectomy and anterior vitrectomy, via either the anterior or pars
plana route, were performed when the cataract was membranous.
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In all patients undergoing corneal wound repair, the traumatic cataract was managed in a
second procedure. Recurrent inflammation was more prominent in patients who had undergone
previous surgery for trauma.9,10
In these cases, the ocular medium may become hazy owing to
condensation of the anterior vitreous unless a vitrectomy is performed. Hence, we performed a
capsulectomy and vitrectomy via the anterior/pars plana route in adults.
In children younger than 2 years of age, both a lensectomy and vitrectomy via the pars
plana route were performed, and the same surgical procedures were used to manage the
traumatic cataract, with secondary implants done as a separate procedure after the age of 2 years.
Lens implantation as part of the primary procedure was avoided in all children younger than 2
years of age. All children were evaluated for amblyopia and were treated with the aid of
paediatric ophthalmologists and paediatric optometrists.
All patients with injuries and without infection were treated with topical and systemic
corticosteroids and cycloplegics. The duration of medical treatment depended on the degree of
inflammation in the anterior and posterior segments of the operated eye. The operated patients
were re-examined after 24 h, 3 days, and 1, 2, and 6 weeks to enable refractive correction.
Follow-up was scheduled for the third day, weekly for 6 weeks, monthly for 3 months, and every
3 months for 1 year.
At all follow-up examinations, visual acuity was tested using a Snellen chart. The
anterior segment was examined with a slit lamp, and the posterior segment was examined with
an indirect ophthalmoscope. Eyes with vision better than 20/60 at the glasses appointment (6
weeks) were defined as having a satisfactory grade of vision.
During the examination, data were entered online using a specified pre-tested format
designed by the International Society of Ocular Trauma (initial and follow-up forms), which was
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exported to a Microsoft Excel spreadsheet. The data were audited periodically to ensure
completeness. We used SPSS 15 software to analyse the data. The univariate parametric method
was used to calculate frequency, percentage, proportion, and 95% confidence interval (95% CI).
We used binominal regression analysis to determine the predictors of postoperative satisfactory
vision (> 20/60). The dependent variable was vision >20/60 noted at follow-up 6 weeks after
cataract surgery. The independent variables were age, gender, residence, time interval between
injury and cataract surgery, primary posterior capsulectomy and vitrectomy procedure, and type
of ocular injury.
Results:
Our cohort consisted of 687 (72.2) patients with traumatic cataracts (Figure 5), including 496
eyes with open-globe ocular injuries and 191 (27.8%) eyes with closed-globe injuries (Figure 5).
The patients were 492 (71.6%) males and 195 (28.4%) females. The mean patient age was
27.1 ± 18.54 years (range, 1–80).
We analysed several demographic factors, including gender (P = 0.340), patient entry
(P = 0.4), and socioeconomic status (79% were from lower socioeconomic class and residence;
95% were from rural areas). None of these showed a significant relationship with final visual
acuity, according to cross-tabulation and statistical tests. The object causing the injury (P = 0.3)
and the activity at the time of the injury (P = 0.3) were also not significantly associated with
satisfactory final visual acuityAll traumatic cataracts were classified according to morphology
(Tables 1 and 2) and were surgically treated using morphology as a guideline. (Table 3)
The number of surgeries required varied significantly with morphology (P = 0.000)
(Table 4).
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Final visual outcome was found to vary according to morphology and surgical technique.
White soft cataracts had a better prognosis and achieved significantly higher rates of positive
outcome compared with other morphologies (P = 0.014) (Table 5).
Lens implants were applied in 82% of the cases; the details are shown in Table 6. There
was a significant difference between open and closed injury groups for various age groups (P =
0.000).
There was no significant difference in final visual outcome in children between open
and closed injury groups (P = 0.06). Significant difference found if we compare final visual
outcome before and after treatment. (P=000)Table-8 A significant relationship was found
between age and final visual outcome (P = 0.000) final visual outcome is better in younger age
group. (Table-9)
Discussion:
Using a large database, we attempted to systematically classify the morphology of
traumatic cataract and to select surgical techniques accordingly.
Previous studies have touched on this topic. One study found 52.3% total cataracts,
whereas our results revealed 26.6% total cataracts.7 Vajpayee reported opening in the posterior
capsule with type 1 and 2 openings with penetrating injury,8 whereas we found another
membranous type of cataract (12.1%) suggestive of late reporting, as membranous
transformation of the lens with fusion of the anterior and posterior capsules may occur over
time.
We were able to perform intraocular lens implants in 82.1% of the cases.
Krishnamachary reported implants in 65.5% of cases, Churchill et al. reported implants in
46.8%, and Fyodorov reported Sputnik implants in all cases.7,9,10
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Fyodorov reported surgical techniques according to pathology and degree of lens
absorption, but did not systematically classify similar factors taken into account in our study.10
These differences in findings may reflect the fact that of the 687 patients in our study,
30% came from outreach activities and did not approach treatment facilities on their own.
Therefore, the time period between ocular injury and reporting ranged widely, and morphology
was also influenced by this interval.
We propose a specific morphological classification for traumatic cataract, which may
provide guidelines for management that incorporate available technology and improve care for
these patients.
References:
1. Khatry SK, Lewis AE, Schein OD, Thapa MD, Pradhan EK, Katz J, et al. The
epidemiology of ocular trauma in rural Nepal. Br J Ophthalmol. 2004; 88:456-60.
2. Abraham, D. I.; Vitale, S. I.; West, S. I.; Isseme, I. Epidemiology of eye injuries in rural
Tanzania. Ophthalmic Epidemiol.1999; 6:85-94
3. D. Virgil Alfaro, Eric P. Jablon, Monica Rodriguez Fontal, Simon J. Villalba, Robert
E.Morris, Michael Grossman, Enrique Roig-Melo et al. Fishing-related ocular trauma.
American Journal of Ophthalmology.2005; 139: 488-492
4. Shah M, Shah S, Khandekar R. Ocular injuries and visual status before and after Their
management in the tribal areas of Western India-A historical cohort study Grafes Arch
Clin Exp Ophthalmol 2008; 246:191–197.
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5. Kuhn F, Morris R, Witherspoon CD, Mester V,) The Birmingham Eye Trauma
Terminology system (BETT). J Fr Ophtalmol. 2004; 27:206-10.
6. Vajpayee RB, Sharma N, Dada T, Gupta V, Kumar A, Dada VK. Management of
posterior capsule tears. Surv Ophthalmol 2001;45:473-88.
7. Krishnamachary M, Rathi V, Gupta S. Management of traumatic cataract in children. J
Cataract Refract Surg 1997;23 Suppl 1:681-7.
8. Churchill AJ, Noble BA, Etchells DE, George NJ. Factors affecting visual outcome in
children following uniocular traumatic cataract. Eye (Lond) 1995;9 ( Pt 3):285-91
9. Thylefors B, Chylack LT Jr, Konyama K, Sasaki K, Sperduto R, Taylor HR, et al. A simplified
cataract grading system. Ophthalmic Epidemiol. 2002; 9:83-95.
10. Fyodorov SN, Egorova EV, Zubareva LN. 1004 cases of traumatic cataract surgery with
implantation of an intraocular lens. J Am Intraocul Implant Soc 1981;7:147-53.
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Table 1. Distribution of different morphologies of traumatic cataract
Morphology N Percent
84 12.2
8
1.2
412
60.0
183 26.6
Membranous
Rosette
White soft
Total
Total 687 100.0
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Table 2. Morphology of traumatic cataract according to type of injury
BETT Category Closed globe Open globe Total
Morphology N % N % N %
20 2.9 64 9.3 84 12.2
3 0.4 5 0.7 8 1.1
83 12.1 329 47.9 412 59.9
Membranous
Rosette
White Soft with ruptured
Anterior capsule
Total
85 12.4 98 14.3 183 26.6
Total
191 27.8 496 72.2 687 100
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Table 3. Surgical techniques used according to morphology of cataract
Morphology
Membranous Rosette White soft Total
Total
Surgical Technique
N % N % N % N % N %
7 1 5 0.7 316 45.9 19 2.7 347 50.5
46 6.7 0 0 60 8.7 20 2.9 126 18.3
3 0.4 2 0.3 17 2.4 108 15.7 130 18.9
Aspiration
Lensectomy + Vitrectomy
Phaco/SICS*
Delivery + vitrectomy
28 4 0 0 20 2.9 36 5.2 84 12.2
Total 83 12.1 7 1 412 59.9 183 26.6 687 100
*Small Incision Cataract Surgery
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Table 4. Morphology of cataract in relation to number of surgical procedures
Morphology
Membranous Rosette White soft Total Total
N N % N % N % N % N &
70 10.1 6 0.8 349 50.8 159 23.1 584 85.0
12 1.7 2 0.2 58 8.4 22 3.2 94 13.7
2 0.3 0 0 5 0.7 2 0.2 9 1.3
1.00
2.00
3.00
Total 84 12.2 8 1 412 59.9 183 26.6 687 100
χ 2 test, P = 0.000
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Table 5. Final visual outcome in relation to morphology of cataract
Final visual outcome Morphology
Membranous Rosette White soft Total Total
N % N % N % N % N %
3 0.4 0 0 11 1.6 5 0.7 19 2.7
24 3.5 2 0.3 89 12.9 58 8.4 173 25.1
12 1.7 0 0 27 3.9 19 2.7 58 8.4
7 1.0 1 0.1 33 4.8 25 3.6 66 9.6
21 3.0 1 0.1 91 13.2 34 4.9 147 21.4
Uncooperative
<1/60
1/60 to 3/60
20/200 to 20/120
20/80 to 20/60
20/40 to 20/20 17 2.5 4 0.5 161 23.4 42 6.1 224 32.6
Total 83 12.1 7 1.0 412 59.9 183 26.6 687 100
χ 2 test, P = 0.014
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Table 6. Lens implant in relation to morphology of traumatic cataract
Morphology No implant Implant Total
N % N % N %
17 2.5 67 9.8 84 12.2
2 0.3 6 0.9 8 1.2
58 8.4 354 51.5 412 60.0
46 6.7 137 19.9 183 26.6
Membranous
Rosette
White soft
Total
Total 123 17.9 564 82.1 687 100
χ 2 test, p = 0.004
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Table-7. Comparison of open closed globe injuries in children
Category Closed globe Open globe Total
N % N % N %
54 7.7 253 36.8 307 44.7 Pediatric
Adult 137 19.9 243 35.3 380 55.3
Total 191 27.8 496 72.1 687 100
χ 2 test, p=0.000
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Table-8, Comparative visual acuity before and after treatment
Post treatment vision Pre op vision uncooperative <1/60
1/60 to 3/60
20/200 to 20/120
20/80 to 20 /60
20/40 to 20/20
Total E
uncooperative 7 1.01 0 0 0 0 0 0 1 0.14 2 0.29 10 1.45
<1/60
10 1.45 164 23.87 53 7.71 54 7.86 110 16.01 191 27.80 582 84.71
1/60 to 3/60
0 0 4 0.58 3 0.43 8 1.16 21 3.05 10 1.45 46 6.69
6/60 to 6/36
0 0 0 0 0 0 1 0.14 7 1.01 12 1.74 20 2.91
6/24 to 6/18
0 0 3 0.43 0 0 1 0.14 6 0.87 7 1.01 17 2.47
6/12 to 6/6
0 0 0 0 0 0 0 0 0 0 1 0.14 1 0.14
Total 17 2.47 171 24.89 55 8.00 64 9.31 145 21.10 223 32.45 675 98.5
χ 2 test, p=0.000
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Table-9, Effect age group on final visual outcome.
Age Un
cooperative <1/60 1/60 to
3/60 20/200 to
20/120 20/80 to
20/60 20/40 to
20/20 Total
n % n % n % n % n % n % n %
0 to 10 9 1.31 46 6.69 15 2.18 12 1.74 37 5.38 34 4.94 153 22.27
11 to 20
2 0.29 30 4.36 14 2.03 17 2.47 33 4.80 87 12.66 183 26.63
21 to 30
2 0.29 19 2.76 8 1.16 6 0.87 12 1.74 42 6.11 89 12.95
31 to 40
1 0.14 23 3.35 5 0.73 7 1.01 16 2.32 25 3.63 77 11.2
41 to 50
3 0.43 23 3.35 6 0.87 12 1.74 28 4.07 22 3.20 94 13.68
51 to 60
0 0.0 21 3.00 7 1.01 6 0.87 8 1.16 11 1.60 53 7.71
61 to 70
0 0.0 8 1.16 0 0 2 0.29 10 1.45 2 0.29 22 3.20
71 to 80
0 0.0 1 0.14 0 0 2 0.29 1 0.14 0 0 4 0.58
Total 17 2.47 173 25.18 55 8.00 64 9.31 146 21.25 223 32.45 675 98.5
χ 2 test, p=0.000
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Figure Legends:
Fig. 1: When no clear lens matter was visible between the capsule and the nucleus, the cataract
was defined as a total cataract.
Fig. 2: When loose cortical material was found in the anterior chamber together with a ruptured
lens capsule, the cataract was defined as a white soft cataract.
Fig. 3: When the capsule and organised matter were fused and formed a membrane of varying
density, the cataract was defined as a membranous cataract.
Fig. 4: A lens with a rosette pattern of opacity was classified as a rosette type cataract.
Fig. 5: Distribution of cataracts based on the ocular injury, as per the BETTS classification.
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The English in this document has been checked by at least two professional editors, both native speakers
of English. For a certificate, please see:
http://www.textcheck.com/certificate/rbgCMs
Contributor ship Statement:
Mehul Shah: Concept design study, surgeon, writing
Shreya Shah: Administrative support, writing, data analyses
Shashank Shah: Data collection, language editing
Chintan Patel: Data collection proof reading and editing
Utsav Patel: Data collection and editing
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Morphology of traumatic cataract: does it play role in final
visual outcome? A hospital based cohort study
Journal: BMJ Open
Manuscript ID: BMJ Open.2011.000060.R5
Article Type: Research
Date Submitted by the Author:
29-Apr-2011
Complete List of Authors: Shah, Mehul; Drashti Netralaya, Ophthalmology; Drashti Netralaya, Ophthalmology Shah, Shreya; Drashti Netralaya, Ophthalmology Shah, Shashank; Drashti Netralaya, Ophthalmology Patel, Chintan; Drashti Netralaya, Ophthalmology Patel, Utsav; Drashti Netralaya, Ophthalmology
<b>Primary Subject
Heading</b>: Ophthalmology
Keywords: Cataract and refractive surgery < OPHTHALMOLOGY, Vetreoretinal < OPHTHALMOLOGY, Paediatric ophthalmology < OPHTHALMOLOGY
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Title: Morphology of traumatic cataract: does it play a role in final visual outcome?
Short running head: Morphology of traumatic cataract
Authors:
Name Degree E-mail
Dr. Mehul A. Shah
MD omtrust@rediffmail.com
Dr Shreya M. Shah
MD shah_shreya2000@yahoo.com
Dr. Shashank B. Shah MBBS sbshah@indiatimes.com
Dr. Chintan G. Patel MBBS cgp@drashtinetralaya.org
Dr Utsav A. Patel MBBS uap@drashtinetralaya.org
Affiliations of all authors:
Drashti Netralaya, Dahod, Gujarat, India
Address of corresponding author:
Drashti Netralaya,
Nr. GIDC, Chakalia Road.
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Dahod-389151
Gujarat
Ph: 00-91-2673-645364 Fax: 00-91-2673-221232
Email: omtrust@rdiffmail.com
No financial support was received from any company or institution.
This study has not been presented at any conference or meeting.
The authors do not have any financial interests in any aspect of this study.
Conflicting interests: None to declare.
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Abstract:
Purpose: To study morphology of traumatic cataract as a important predictor for final visual
outcome after treatment of traumatic cataracts.
Setting: Tertiary eye care centre in Dahod at the trijunction of Gujarat, Madhya Pradesh, and
Rajasthan states in central western India.
Methods: This was a prospective observational cohort study among all patients presenting at our
hospital with traumatic cataracts between January 2003 and December 2009. All information
regarding demographic and ocular trauma was collected on a pre-tested World Eye Trauma
Registry form for both the first visit and follow-up.
In particular, we collected specific information about the morphology of traumatic cataracts;
surgical technique was determined accordingly.
Data were entered and analysed with regard to the relationship between type of trauma and
resulting injury, results achieved with particular surgical techniques, and the relationship
between morphology and final visual outcome.
Outcome measures: Final visual outcome.
Results: Traumatic cataracts of different morphologies showed significant differences in final
visual outcome (χ2 test, P = 0.014).
Conclusion: The morphology of traumatic cataract plays an important role in final visual
outcome.
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Article Summery:
Article Focus:
Morphological Classification of traumatic cataract which may be helpful for guidelines of
surgical technique.
Key Message:
Proposal of new classification which may suggest surgical treatment of traumatic cataract
Strength and weakness:
Strength: Larger database and Usage of standard classification method-BETTS Limitation:
Included many neglected injury cases. Weakness: Short follow up. Loss of follow up of 12
patients at various stages of study.
Introduction:
Trauma is a cause of monocular blindness in the developed world, although few studies
have addressed the problem of trauma in rural areas.1 The aetiology of ocular injury in rural
areas is likely to differ from that in urban areas and is worthy of investigation.2-4
Any strategy
for prevention requires knowledge of the cause of injury, which may enable more appropriate
targeting of resources toward preventing such injuries. Eye trauma represents a large, potentially
preventable burden on both victims and society as a whole.3
Ocular trauma can cause cataracts.1 The methods used to evaluate the visual outcome in
eyes managed for traumatic cataracts and senile cataracts are similar,5 but the damage to other
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ocular tissues due to trauma may compromise the visual gain in eyes treated surgically for
traumatic cataracts. Hence, the success rates may differ between eyes with these two types of
cataract.
With the introduction of the Birmingham Eye Trauma Terminology System (BETTS),
the documentation of ocular trauma has been standardised.5
Our study was conducted in a city located at the intersection of the borders of three states
in India: Gujarat, Madhya Pradesh, and Rajasthan.11
Qualified ophthalmologists at our institute
provide low-cost eye services mainly to the poor belonging to the tribal population of 4.2 million
in this area.
There is no standard methodology for classification of traumatic cataract.
Patients and Methods:
We obtained approval from the hospital administrators and research committee to
conduct this study, and all participants provided written informed consent.
This was a prospective study designed in 2002. All traumatic cataracts in either eye
diagnosed and managed between January 2003 and December 2009 were included in the study,
and patients consenting to participate and without other serious body injuries were included.
For each patient enrolled in our study, we obtained a detailed history, including details of
the injury and information on eye treatment and surgery performed to manage past ocular
trauma. Data for both the initial and follow-up reports were collected using the online BETTS
format of the International Society of Ocular Trauma. Details of the surgery were also collected
using a specified pre-tested online form.
The cases of traumatic cataract were grouped as those with open- and those with closed-
globe injuries. The open-globe injuries were further categorised into those with lacerations and
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those with rupture. Lacerations of the eyeball were subcategorised into eyes with perforating
injuries, penetrating injuries, or injuries involving an intraocular foreign body. The closed-globe
group was subdivided into lamellar laceration and contusion.
Other demographic details collected included patient entry, residence, activity at the time
of injury, object of injury, and previous examinations and treatments. After enrolment, all
patients were examined using a standard method. Visual acuity was checked using a Snellen
chart, and the anterior segment was examined using a slit lamp.
Based on lenticular opacity, the cataracts were classified as total (Figure 1), membranous
in which both capsules fused with scant or no cortical material (Figure 2), white soft (Figure 3),
and rosette types (Figure 4). When an ophthalmologist did not observe clear lens matter between
the capsule and nucleus, the cataract was defined as total. When the capsule and organised
matter were fused and formed a membrane of varying density, it was defined as a membranous
cataract. When loose cortical material was found in the anterior chamber together with a
ruptured lens capsule, the cataract was defined as white soft. A lens with a rosette pattern of
opacity was classified as a rosette type cataract.
For a partially opaque lens, the posterior segment examination was carried out with an
indirect ophthalmoscope and a +20 D lens. When the optical medium was not clear, a B-scan
was performed to evaluate the posterior segment.
The surgical technique was selected according to morphology and the condition of
tissues other than the lens. Phacoemulsification was used to treat cataracts with hard, large
nuclei. With a lens that had either a white soft or rosette type of cataract, unimanual or bimanual
aspiration was used. Membranectomy and anterior vitrectomy, via either the anterior or pars
plana route, were performed when the cataract was membranous.
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In all patients undergoing corneal wound repair, the traumatic cataract was managed in a
second procedure. Recurrent inflammation was more prominent in patients who had undergone
previous surgery for trauma.9,10
In these cases, the ocular medium may become hazy owing to
condensation of the anterior vitreous unless a vitrectomy is performed. Hence, we performed a
capsulectomy and vitrectomy via the anterior/pars plana route in adults.
In children younger than 2 years of age, both a lensectomy and vitrectomy via the pars
plana route were performed, and the same surgical procedures were used to manage the
traumatic cataract, with secondary implants done as a separate procedure after the age of 2 years.
Lens implantation as part of the primary procedure was avoided in all children younger than 2
years of age. All children were evaluated for amblyopia and were treated with the aid of
paediatric ophthalmologists and paediatric optometrists.
All patients with injuries and without infection were treated with topical and systemic
corticosteroids and cycloplegics. The duration of medical treatment depended on the degree of
inflammation in the anterior and posterior segments of the operated eye. The operated patients
were re-examined after 24 h, 3 days, and 1, 2, and 6 weeks to enable refractive correction.
Follow-up was scheduled for the third day, weekly for 6 weeks, monthly for 3 months, and every
3 months for 1 year.
At all follow-up examinations, visual acuity was tested using a Snellen chart. The
anterior segment was examined with a slit lamp, and the posterior segment was examined with
an indirect ophthalmoscope. Eyes with vision better than 20/60 at the glasses appointment (6
weeks) were defined as having a satisfactory grade of vision.
During the examination, data were entered online using a specified pre-tested format
designed by the International Society of Ocular Trauma (initial and follow-up forms), which was
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exported to a Microsoft Excel spreadsheet. The data were audited periodically to ensure
completeness. We used SPSS 15 software to analyse the data. The univariate parametric method
was used to calculate frequency, percentage, proportion, and 95% confidence interval (95% CI).
We used binominal regression analysis to determine the predictors of postoperative satisfactory
vision (> 20/60). The dependent variable was vision >20/60 noted at follow-up 6 weeks after
cataract surgery. The independent variables were age, gender, residence, time interval between
injury and cataract surgery, primary posterior capsulectomy and vitrectomy procedure, and type
of ocular injury.
Results:
Our cohort consisted of 687 (72.2) patients with traumatic cataracts (Figure 5), including 496
eyes with open-globe ocular injuries and 191 (27.8%) eyes with closed-globe injuries (Figure 5).
The patients were 492 (71.6%) males and 195 (28.4%) females. The mean patient age was
27.1 ± 18.54 years (range, 1–80).
We analysed several demographic factors, including gender (P = 0.340), patient entry
(P = 0.4), and socioeconomic status (79% were from lower socioeconomic class and residence;
95% were from rural areas). None of these showed a significant relationship with final visual
acuity, according to cross-tabulation and statistical tests. The object causing the injury (P = 0.3)
and the activity at the time of the injury (P = 0.3) were also not significantly associated with
satisfactory final visual acuityAll traumatic cataracts were classified according to morphology
(Tables 1 and 2) and were surgically treated using morphology as a guideline. (Table 3)
The number of surgeries required varied significantly with morphology (P = 0.000)
(Table 4).
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Final visual outcome was found to vary according to morphology and surgical technique.
White soft cataracts had a better prognosis and achieved significantly higher rates of positive
outcome compared with other morphologies (P = 0.014) (Table 5).
Lens implants were applied in 82% of the cases; the details are shown in Table 6. There
was a significant difference between open and closed injury groups for various age groups (P =
0.000).
There was no significant difference in final visual outcome in children between open
and closed injury groups (P = 0.06). Significant difference found if we compare final visual
outcome before and after treatment. (P=000)Table-8 A significant relationship was found
between age and final visual outcome (P = 0.000) final visual outcome is better in younger age
group. (Table-9) When time interval between injury and intervention was study there is
significant (p=0.000) effect on final visual outcome.11
Discussion:
Using a large database, we attempted to systematically classify the morphology of
traumatic cataract and to select surgical techniques accordingly.
Previous studies have touched on this topic. One study found 52.3% total cataracts,
whereas our results revealed 26.6% total cataracts.7 Vajpayee reported opening in the posterior
capsule with type 1 and 2 openings with penetrating injury,8 whereas we found another
membranous type of cataract (12.1%) suggestive of late reporting, as membranous
transformation of the lens with fusion of the anterior and posterior capsules may occur over
time.
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We were able to perform intraocular lens implants in 82.1% of the cases.
Krishnamachary reported implants in 65.5% of cases, Churchill et al. reported implants in
46.8%, and Fyodorov reported Sputnik implants in all cases.7,9,10
Fyodorov reported surgical techniques according to pathology and degree of lens
absorption, but did not systematically classify similar factors taken into account in our study.10
These differences in findings may reflect the fact that of the 687 patients in our study,
30% came from outreach activities and did not approach treatment facilities on their own.
Therefore, the time period between ocular injury and reporting ranged widely, and morphology
was also influenced by this interval.
We propose a specific morphological classification for traumatic cataract, which may
provide guidelines for management that incorporate available technology and improve care for
these patients.
References:
1. Khatry SK, Lewis AE, Schein OD, Thapa MD, Pradhan EK, Katz J, et al. The
epidemiology of ocular trauma in rural Nepal. Br J Ophthalmol. 2004; 88:456-60.
2. Abraham, D. I.; Vitale, S. I.; West, S. I.; Isseme, I. Epidemiology of eye injuries in rural
Tanzania. Ophthalmic Epidemiol.1999; 6:85-94
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3. D. Virgil Alfaro, Eric P. Jablon, Monica Rodriguez Fontal, Simon J. Villalba, Robert
E.Morris, Michael Grossman, Enrique Roig-Melo et al. Fishing-related ocular trauma.
American Journal of Ophthalmology.2005; 139: 488-492
4. Shah M, Shah S, Khandekar R. Ocular injuries and visual status before and after Their
management in the tribal areas of Western India-A historical cohort study Grafes Arch
Clin Exp Ophthalmol 2008; 246:191–197.
5. Kuhn F, Morris R, Witherspoon CD, Mester V,) The Birmingham Eye Trauma
Terminology system (BETT). J Fr Ophtalmol. 2004; 27:206-10.
6. Vajpayee RB, Sharma N, Dada T, Gupta V, Kumar A, Dada VK. Management of
posterior capsule tears. Surv Ophthalmol 2001;45:473-88.
7. Krishnamachary M, Rathi V, Gupta S. Management of traumatic cataract in children. J
Cataract Refract Surg 1997;23 Suppl 1:681-7.
8. Churchill AJ, Noble BA, Etchells DE, George NJ. Factors affecting visual outcome in
children following uniocular traumatic cataract. Eye (Lond) 1995;9 ( Pt 3):285-91
9. Thylefors B, Chylack LT Jr, Konyama K, Sasaki K, Sperduto R, Taylor HR, et al. A simplified
cataract grading system. Ophthalmic Epidemiol. 2002; 9:83-95.
10. Fyodorov SN, Egorova EV, Zubareva LN. 1004 cases of traumatic cataract surgery with
implantation of an intraocular lens. J Am Intraocul Implant Soc 1981;7:147-53.
11. Shah MA, Shah SM, Shah SB, Patel UA Effect of interval between time of injury and
timing of intervention on final visual outcome in cases of traumatic cataract. Eur J
Ophthalmol. 2011 Mar 24. pii: 338AC21D-E9FB-42DF-9C28-6FDE61928C9D. doi:
10.5301/EJO.2011.6482. [Epub ahead of print]
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Table 1. Distribution of different morphologies of traumatic cataract
Morphology N Percent
84 12.2
8
1.2
Membranous
Rosette
White soft
412
60.0
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183 26.6
Total
Total 687 100.0
Table 2. Morphology of traumatic cataract according to type of injury
BETT Category Closed globe Open globe Total
Morphology N % N % N %
Membranous
20 2.9 64 9.3 84 12.2
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3 0.4 5 0.7 8 1.1
83 12.1 329 47.9 412 59.9
Rosette
White Soft with ruptured
Anterior capsule
Total
85 12.4 98 14.3 183 26.6
Total
191 27.8 496 72.2 687 100
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Table 3. Surgical techniques used according to morphology of cataract
Morphology
Membranous Rosette White soft Total
Total
Surgical Technique
N % N % N % N % N %
7 1 5 0.7 316 45.9 19 2.7 347 50.5
46 6.7 0 0 60 8.7 20 2.9 126 18.3
3 0.4 2 0.3 17 2.4 108 15.7 130 18.9
Aspiration
Lensectomy + Vitrectomy
Phaco/SICS*
Delivery + vitrectomy
28 4 0 0 20 2.9 36 5.2 84 12.2
Total 83 12.1 7 1 412 59.9 183 26.6 687 100
*Small Incision Cataract Surgery
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Table 4. Morphology of cataract in relation to number of surgical procedures
Morphology
Membranous Rosette White soft Total Total
N N % N % N % N % N &
70 10.1 6 0.8 349 50.8 159 23.1 584 85.0
12 1.7 2 0.2 58 8.4 22 3.2 94 13.7
2 0.3 0 0 5 0.7 2 0.2 9 1.3
1.00
2.00
3.00
Total 84 12.2 8 1 412 59.9 183 26.6 687 100
χ 2 test, P = 0.000
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Table 5. Final visual outcome in relation to morphology of cataract
Final visual outcome Morphology
Membranous Rosette White soft Total Total
N % N % N % N % N %
3 0.4 0 0 11 1.6 5 0.7 19 2.7
24 3.5 2 0.3 89 12.9 58 8.4 173 25.1
12 1.7 0 0 27 3.9 19 2.7 58 8.4
7 1.0 1 0.1 33 4.8 25 3.6 66 9.6
21 3.0 1 0.1 91 13.2 34 4.9 147 21.4
Uncooperative
<1/60
1/60 to 3/60
20/200 to 20/120
20/80 to 20/60
20/40 to 20/20 17 2.5 4 0.5 161 23.4 42 6.1 224 32.6
Total 83 12.1 7 1.0 412 59.9 183 26.6 687 100
χ 2 test, P = 0.014
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Table 6. Lens implant in relation to morphology of traumatic cataract
Morphology No implant Implant Total
N % N % N %
17 2.5 67 9.8 84 12.2
2 0.3 6 0.9 8 1.2
58 8.4 354 51.5 412 60.0
46 6.7 137 19.9 183 26.6
Membranous
Rosette
White soft
Total
Total 123 17.9 564 82.1 687 100
χ 2 test, p = 0.004
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Table-7. Comparison of open closed globe injuries in children
Category Closed globe Open globe Total
N % N % N %
54 7.7 253 36.8 307 44.7 Pediatric
Adult 137 19.9 243 35.3 380 55.3
Total 191 27.8 496 72.1 687 100
χ 2 test, p=0.000
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Table-8, Comparative visual acuity before and after treatment
Post treatment vision Pre op vision uncooperative <1/60
1/60 to 3/60
20/200 to 20/120
20/80 to 20 /60
20/40 to 20/20
Total E
uncooperative 7 1.01 0 0 0 0 0 0 1 0.14 2 0.29 10 1.45
<1/60
10 1.45 164 23.87 53 7.71 54 7.86 110 16.01 191 27.80 582 84.71
1/60 to 3/60
0 0 4 0.58 3 0.43 8 1.16 21 3.05 10 1.45 46 6.69
6/60 to 6/36
0 0 0 0 0 0 1 0.14 7 1.01 12 1.74 20 2.91
6/24 to 6/18
0 0 3 0.43 0 0 1 0.14 6 0.87 7 1.01 17 2.47
6/12 to 6/6
0 0 0 0 0 0 0 0 0 0 1 0.14 1 0.14
Total 17 2.47 171 24.89 55 8.00 64 9.31 145 21.10 223 32.45 675 98.5
χ 2 test, p=0.000
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Table-9, Effect age group on final visual outcome.
Age Un
cooperative <1/60 1/60 to
3/60 20/200 to
20/120 20/80 to
20/60 20/40 to
20/20 Total
n % n % n % n % n % n % n %
0 to 10 9 1.31 46 6.69 15 2.18 12 1.74 37 5.38 34 4.94 153 22.27
11 to 20
2 0.29 30 4.36 14 2.03 17 2.47 33 4.80 87 12.66 183 26.63
21 to 30
2 0.29 19 2.76 8 1.16 6 0.87 12 1.74 42 6.11 89 12.95
31 to 40
1 0.14 23 3.35 5 0.73 7 1.01 16 2.32 25 3.63 77 11.2
41 to 50
3 0.43 23 3.35 6 0.87 12 1.74 28 4.07 22 3.20 94 13.68
51 to 60
0 0.0 21 3.00 7 1.01 6 0.87 8 1.16 11 1.60 53 7.71
61 to 70
0 0.0 8 1.16 0 0 2 0.29 10 1.45 2 0.29 22 3.20
71 to 80
0 0.0 1 0.14 0 0 2 0.29 1 0.14 0 0 4 0.58
Total 17 2.47 173 25.18 55 8.00 64 9.31 146 21.25 223 32.45 675 98.5
χ 2 test, p=0.000
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Figure Legends:
Fig. 1: When no clear lens matter was visible between the capsule and the nucleus, the cataract
was defined as a total cataract.
Fig. 2: When loose cortical material was found in the anterior chamber together with a ruptured
lens capsule, the cataract was defined as a white soft cataract.
Fig. 3: When the capsule and organised matter were fused and formed a membrane of varying
density, the cataract was defined as a membranous cataract.
Fig. 4: A lens with a rosette pattern of opacity was classified as a rosette type cataract.
Fig. 5: Distribution of cataracts based on the ocular injury, as per the BETTS classification.
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The English in this document has been checked by at least two professional editors, both native speakers
of English. For a certificate, please see:
http://www.textcheck.com/certificate/rbgCMs
Contributor ship Statement:
Mehul Shah: Concept design study, surgeon, writing
Shreya Shah: Administrative support, writing, data analyses
Shashank Shah: Data collection, language editing
Chintan Patel: Data collection proof reading and editing
Utsav Patel: Data collection and editing
Aashish Gupta: Editing revisions
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Morphology of traumatic cataract: does it play role in final
visual outcome? A hospital based cohort study
Journal: BMJ Open
Manuscript ID: BMJ Open.2011.000060.R6
Article Type: Research
Date Submitted by the Author:
24-May-2011
Complete List of Authors: Shah, Mehul; Drashti Netralaya, Ophthalmology; Drashti Netralaya, Ophthalmology Shah, Shreya; Drashti Netralaya, Ophthalmology Shah, Shashank; Drashti Netralaya, Ophthalmology Patel, Chintan; Drashti Netralaya, Ophthalmology Patel, Utsav; Drashti Netralaya, Ophthalmology
<b>Primary Subject
Heading</b>: Ophthalmology
Keywords: Cataract and refractive surgery < OPHTHALMOLOGY, Vetreoretinal < OPHTHALMOLOGY, Paediatric ophthalmology < OPHTHALMOLOGY
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Title: Morphology of traumatic cataract: does it play a role in final visual outcome?
Short running head: Morphology of traumatic cataract
Authors:
Name Degree E-mail
Dr. Mehul A. Shah
MD omtrust@rediffmail.com
Dr Shreya M. Shah
MD shah_shreya2000@yahoo.com
Dr. Shashank B. Shah MBBS sbshah@indiatimes.com
Dr. Chintan G. Patel MBBS cgp@drashtinetralaya.org
Dr Utsav A. Patel MBBS uap@drashtinetralaya.org
Affiliations of all authors:
Drashti Netralaya, Dahod, Gujarat, India
Address of corresponding author:
Drashti Netralaya,
Nr. GIDC, Chakalia Road.
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Dahod-389151
Gujarat
Ph: 00-91-2673-645364 Fax: 00-91-2673-221232
Email: omtrust@rdiffmail.com
No financial support was received from any company or institution.
This study has not been presented at any conference or meeting.
The authors do not have any financial interests in any aspect of this study.
Conflicting interests: None to declare.
This research received no specific grant from any funding agency in the public, commercial or
not-for-profit sectors’
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Abstract:
Purpose: To study morphology of traumatic cataract as a important predictor for final visual
outcome after treatment of traumatic cataracts.
Setting: Tertiary eye care centre in Dahod at the trijunction of Gujarat, Madhya Pradesh, and
Rajasthan states in central western India.
Methods: This was a prospective observational cohort study among all patients presenting at our
hospital with traumatic cataracts between January 2003 and December 2009. All information
regarding demographic and ocular trauma was collected on a pre-tested World Eye Trauma
Registry form for both the first visit and follow-up.
In particular, we collected specific information about the morphology of traumatic cataracts;
surgical technique was determined accordingly.
Data were entered and analysed with regard to the relationship between type of trauma and
resulting injury, results achieved with particular surgical techniques, and the relationship
between morphology and final visual outcome.
Outcome measures: Final visual outcome.
Results: Traumatic cataracts of different morphologies showed significant differences in final
visual outcome (χ2 test, P = 0.014).
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Conclusion: The morphology of traumatic cataract plays an important role in final visual
outcome.
Article Summery:
Article Focus:
Morphological Classification of traumatic cataract which may be helpful for guidelines of
surgical technique.
Key Message:
Proposal of new guidelines of surgical treatment of traumatic cataract for different morphologies of
traumatic cataract."
Strength and weakness:
Strength: Larger database and Usage of standard classification method-BETTS Limitation:
Included many neglected injury cases.
Weakness: Uncontrolled study, One third enrolment from outreach limits generalization of
findings,Short follow up. Loss of follow up of 12 patients at various stages of study.
Introduction:
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Trauma is a cause of monocular blindness in the developed world, although few studies
have addressed the problem of trauma in rural areas.1 The aetiology of ocular injury in rural
areas is likely to differ from that in urban areas and is worthy of investigation.2-4
Any strategy
for prevention requires knowledge of the cause of injury, which may enable more appropriate
targeting of resources toward preventing such injuries. Eye trauma represents a large, potentially
preventable burden on both victims and society as a whole.3
Ocular trauma can cause cataracts.1 The methods used to evaluate the visual outcome in
eyes managed for traumatic cataracts and senile cataracts are similar,5 but the damage to other
ocular tissues due to trauma may compromise the visual gain in eyes treated surgically for
traumatic cataracts. Hence, the success rates may differ between eyes with these two types of
cataract.
With the introduction of the Birmingham Eye Trauma Terminology System (BETTS),
the documentation of ocular trauma has been standardised.5
Our study was conducted in a city located at the intersection of the borders of three states
in India: Gujarat, Madhya Pradesh, and Rajasthan.11
Qualified ophthalmologists at our institute
provide low-cost eye services mainly to the poor belonging to the tribal population of 4.2 million
in this area.
There is no standard methodology for classification of traumatic cataract.
Patients and Methods:
We obtained approval from the hospital administrators and research committee to
conduct this study, and all participants provided written informed consent.
This was a prospective study designed in 2002. All traumatic cataracts in either eye
diagnosed and managed between January 2003 and December 2009 were included in the study,
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and patients consenting to participate and without other serious body injuries were included.
Outreach activities included five different service deliveries mobile diagnostic camps, school
screening, mobile vision center, door to door call of patients and health worker network.
For each patient enrolled in our study, we obtained a detailed history, including details of
the injury and information on eye treatment and surgery performed to manage past ocular
trauma. Data for both the initial and follow-up reports were collected using the online BETTS
format of the International Society of Ocular Trauma. Details of the surgery were also collected
using a specified pre-tested online form.
The cases of traumatic cataract were grouped as those with open- and those with closed-
globe injuries. The open-globe injuries were further categorised into those with lacerations and
those with rupture. Lacerations of the eyeball were subcategorised into eyes with perforating
injuries, penetrating injuries, or injuries involving an intraocular foreign body. The closed-globe
group was subdivided into lamellar laceration and contusion.
Other demographic details collected included patient entry, residence, activity at the time
of injury, object of injury, and previous examinations and treatments. After enrolment, all
patients were examined using a standard method. Visual acuity was checked using a Snellen
chart, and the anterior segment was examined using a slit lamp.
Based on lenticular opacity, the cataracts were classified as total (Figure 1), membranous
in which both capsules fused with scant or no cortical material (Figure 2), white soft (Figure 3),
and rosette types (Figure 4). When an ophthalmologist did not observe clear lens matter between
the capsule and nucleus, the cataract was defined as total. When the capsule and organised
matter were fused and formed a membrane of varying density, it was defined as a membranous
cataract. When loose cortical material was found in the anterior chamber together with a
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ruptured lens capsule, the cataract was defined as white soft. A lens with a rosette pattern of
opacity was classified as a rosette type cataract.
For a partially opaque lens, the posterior segment examination was carried out with an
indirect ophthalmoscope and a +20 D lens. When the optical medium was not clear, a B-scan
was performed to evaluate the posterior segment.
The surgical technique was selected according to morphology and the condition of
tissues other than the lens. Phacoemulsification was used to treat cataracts with hard, large
nuclei. With a lens that had either a white soft or rosette type of cataract, unimanual or bimanual
aspiration was used. Membranectomy and anterior vitrectomy, via either the anterior or pars
plana route, were performed when the cataract was membranous.
In all patients undergoing corneal wound repair, the traumatic cataract was managed in a
second procedure. Recurrent inflammation was more prominent in patients who had undergone
previous surgery for trauma.9,10
In these cases, the ocular medium may become hazy owing to
condensation of the anterior vitreous unless a vitrectomy is performed. Hence, we performed a
capsulectomy and vitrectomy via the anterior/pars plana route in adults.
In children younger than 2 years of age, both a lensectomy and vitrectomy via the pars
plana route were performed, and the same surgical procedures were used to manage the
traumatic cataract, with secondary implants done as a separate procedure after the age of 2 years.
Lens implantation as part of the primary procedure was avoided in all children younger than 2
years of age. All children were evaluated for amblyopia and were treated with the aid of
paediatric ophthalmologists and paediatric optometrists.
All patients with injuries and without infection were treated with topical and systemic
corticosteroids and cycloplegics. The duration of medical treatment depended on the degree of
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inflammation in the anterior and posterior segments of the operated eye. The operated patients
were re-examined after 24 h, 3 days, and 1, 2, and 6 weeks to enable refractive correction.
Follow-up was scheduled for the third day, weekly for 6 weeks, monthly for 3 months, and every
3 months for 1 year.
At all follow-up examinations, visual acuity was tested using a Snellen chart. The
anterior segment was examined with a slit lamp, and the posterior segment was examined with
an indirect ophthalmoscope. Eyes with vision better than 20/60 at the glasses appointment (6
weeks) were defined as having a satisfactory grade of vision.
During the examination, data were entered online using a specified pre-tested format
designed by the International Society of Ocular Trauma (initial and follow-up forms), which was
exported to a Microsoft Excel spreadsheet. The data were audited periodically to ensure
completeness. We used SPSS 15 software to analyse the data. The univariate parametric method
was used to calculate frequency, percentage, proportion, and 95% confidence interval (95% CI).
We used binominal regression analysis to determine the predictors of postoperative satisfactory
vision (> 20/60). The dependent variable was vision >20/60 noted at follow-up 6 weeks after
cataract surgery. The independent variables were age, gender, residence, time interval between
injury and cataract surgery, primary posterior capsulectomy and vitrectomy procedure, and type
of ocular injury.
Results:
Our cohort consisted of 687 (72.2) patients with traumatic cataracts (Figure 5), including 496
eyes with open-globe ocular injuries and 191 (27.8%) eyes with closed-globe injuries (Figure 5).
The patients were 492 (71.6%) males and 195 (28.4%) females. The mean patient age was
27.1 ± 18.54 years (range, 1–80).
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We analysed several demographic factors, including gender (P = 0.340), patient entry
(P = 0.4), and socioeconomic status (79% were from lower socioeconomic class and residence;
95% were from rural areas). None of these showed a significant relationship with final visual
acuity, according to cross-tabulation and statistical tests. The object causing the injury (P = 0.3)
and the activity at the time of the injury (P = 0.3) were also not significantly associated with
satisfactory final visual acuityAll traumatic cataracts were classified according to morphology
(Tables 1 and 2) and were surgically treated using morphology as a guideline. (Table 3)
The number of surgeries required varied significantly with morphology (P = 0.000)
(Table 4).
Final visual outcome was found to vary according to morphology and surgical technique.
White soft cataracts had a better prognosis and achieved significantly higher rates of positive
outcome compared with other morphologies (P = 0.014) (Table 5).
Lens implants were applied in 82% of the cases; the details are shown in Table 6. There
was a significant difference between open and closed injury groups for various age groups (P =
0.000).
There was no significant difference in final visual outcome in children between open
and closed injury groups (P = 0.06). Significant difference found if we compare final visual
outcome before and after treatment. (P=000)Table-8 A significant relationship was found
between age and final visual outcome (P = 0.000) final visual outcome is better in younger age
group. (Table-9) When time interval between injury and intervention was study there is
significant (p=0.000) effect on final visual outcome.11
Discussion:
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Using a large database, we attempted to systematically classify the morphology of
traumatic cataract and to select surgical techniques accordingly.
Previous studies have touched on this topic. One study found 52.3% total cataracts,
whereas our results revealed 26.6% total cataracts.7 Vajpayee reported opening in the posterior
capsule with type 1 and 2 openings with penetrating injury,8 whereas we found another
membranous type of cataract (12.1%) suggestive of late reporting, as membranous
transformation of the lens with fusion of the anterior and posterior capsules may occur over
time.
We were able to perform intraocular lens implants in 82.1% of the cases.
Krishnamachary reported implants in 65.5% of cases, Churchill et al. reported implants in
46.8%, and Fyodorov reported Sputnik implants in all cases.7,9,10
Fyodorov reported surgical techniques according to pathology and degree of lens
absorption, but did not systematically classify similar factors taken into account in our study.10
These differences in findings may reflect the fact that of the 687 patients in our study,
30% came from outreach activities and did not approach treatment facilities on their own.
Therefore, the time period between ocular injury and reporting ranged widely, and morphology
was also influenced by this interval. While this uncontrolled study cannot provide firm evidence
that using a clear morphological classification to guide surgical decision led to improved
outcomes.
We propose a specific treatment strategy for different morphological verities of
traumatic cataract, which may provide guidelines for management that incorporate available
technology and improve care for these patients.
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References:
1. Khatry SK, Lewis AE, Schein OD et al. The epidemiology of ocular trauma in rural
Nepal. Br J Ophthalmol. 2004; 88:456-60.
2. Abraham, DI; Vitale SI; West SI et al. Epidemiology of eye injuries in rural Tanzania.
Ophthalmic Epidemiol.1999; 6:85-94
3. D. Virgil Alfaro, Eric P. Jablon, Monica Rodriguez Fontal et al. Fishing-related ocular
trauma. American Journal of Ophthalmology.2005; 139: 488-492
4. Shah M, Shah S, Khandekar R. Ocular injuries and visual status before and after Their
management in the tribal areas of Western India-A historical cohort study Grafes Arch
Clin Exp Ophthalmol 2008; 246:191–197.
5. Kuhn F, Morris R, Witherspoon CD et al. The Birmingham Eye Trauma Terminology
system (BETT). J Fr Ophtalmol. 2004; 27:206-10.
6. Vajpayee RB, Sharma N, Dada T et al. Management of posterior capsule tears. Surv
Ophthalmol 2001;45:473-88.
7. Krishnamachary M, Rathi V, Gupta S. Management of traumatic cataract in children. J
Cataract Refract Surg 1997;23 :681-7.
8. Churchill AJ, Noble BA, Etchells DE et al. Factors affecting visual outcome in children
following uniocular traumatic cataract. Eye (Lond) 1995;9:285-91
9. Thylefors B, Chylack LT Jr, Konyama K, et al. A simplified cataract grading system.
Ophthalmic Epidemiol. 2002; 9:83-95.
10. Fyodorov SN, Egorova EV, Zubareva LN. 1004 cases of traumatic cataract surgery with
implantation of an intraocular lens. J Am Intraocul Implant Soc 1981;7:147-53.
11. Shah MA, Shah SM, Shah SB, et al Effect of interval between time of injury and timing
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of intervention on final visual outcome in cases of traumatic cataract. Eur J Ophthalmol.
2011 Mar 24. pii: 338AC21D-E9FB-42DF-9C28-6FDE61928C9D. doi:
10.5301/EJO.2011.6482. [Epub ahead of print]
Table 1. Distribution of different morphologies of traumatic cataract
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Morphology N Percent
84 12.2
8
1.2
412
60.0
183 26.6
Membranous
Rosette
White soft
Total
Total 687 100.0
Table 2. Morphology of traumatic cataract according to type of injury
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BETT Category Closed globe Open globe Total
Morphology N % N % N %
20 2.9 64 9.3 84 12.2
3 0.4 5 0.7 8 1.1
83 12.1 329 47.9 412 59.9
Membranous
Rosette
White Soft with ruptured
Anterior capsule
Total
85 12.4 98 14.3 183 26.6
Total
191 27.8 496 72.2 687 100
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Table 3. Surgical techniques used according to morphology of cataract
Morphology
Membranous Rosette White soft Total
Total
Surgical Technique
N % N % N % N % N %
7 1 5 0.7 316 45.9 19 2.7 347 50.5
46 6.7 0 0 60 8.7 20 2.9 126 18.3
3 0.4 2 0.3 17 2.4 108 15.7 130 18.9
Aspiration
Lensectomy + Vitrectomy
Phaco/SICS*
Delivery + vitrectomy
28 4 0 0 20 2.9 36 5.2 84 12.2
Total 83 12.1 7 1 412 59.9 183 26.6 687 100
*Small Incision Cataract Surgery
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Table 4. Morphology of cataract in relation to number of surgical procedures
Morphology
Membranous Rosette White soft Total Total
N N % N % N % N % N &
70 10.1 6 0.8 349 50.8 159 23.1 584 85.0
12 1.7 2 0.2 58 8.4 22 3.2 94 13.7
2 0.3 0 0 5 0.7 2 0.2 9 1.3
1.00
2.00
3.00
Total 84 12.2 8 1 412 59.9 183 26.6 687 100
χ 2 test, P = 0.000
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Table 5. Final visual outcome in relation to morphology of cataract
Final visual outcome Morphology
Membranous Rosette White soft Total Total
N % N % N % N % N %
3 0.4 0 0 11 1.6 5 0.7 19 2.7
24 3.5 2 0.3 89 12.9 58 8.4 173 25.1
12 1.7 0 0 27 3.9 19 2.7 58 8.4
7 1.0 1 0.1 33 4.8 25 3.6 66 9.6
21 3.0 1 0.1 91 13.2 34 4.9 147 21.4
Uncooperative
<1/60
1/60 to 3/60
20/200 to 20/120
20/80 to 20/60
20/40 to 20/20 17 2.5 4 0.5 161 23.4 42 6.1 224 32.6
Total 83 12.1 7 1.0 412 59.9 183 26.6 687 100
χ 2 test, P = 0.014
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Table 6. Lens implant in relation to morphology of traumatic cataract
Morphology No implant Implant Total
N % N % N %
17 2.5 67 9.8 84 12.2
2 0.3 6 0.9 8 1.2
58 8.4 354 51.5 412 60.0
46 6.7 137 19.9 183 26.6
Membranous
Rosette
White soft
Total
Total 123 17.9 564 82.1 687 100
χ 2 test, p = 0.004
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Table-7. Comparison of open closed globe injuries in children
Category Closed globe Open globe Total
N % N % N %
54 7.7 253 36.8 307 44.7 Pediatric
Adult 137 19.9 243 35.3 380 55.3
Total 191 27.8 496 72.1 687 100
χ 2 test, p=0.000
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Table-8, Comparative visual acuity before and after treatment
Post treatment vision Pre op vision uncooperative <1/60
1/60 to 3/60
20/200 to 20/120
20/80 to 20 /60
20/40 to 20/20
Total E
uncooperative 7 1.01 0 0 0 0 0 0 1 0.14 2 0.29 10 1.45
<1/60
10 1.45 164 23.87 53 7.71 54 7.86 110 16.01 191 27.80 582 84.71
1/60 to 3/60
0 0 4 0.58 3 0.43 8 1.16 21 3.05 10 1.45 46 6.69
6/60 to 6/36
0 0 0 0 0 0 1 0.14 7 1.01 12 1.74 20 2.91
6/24 to 6/18
0 0 3 0.43 0 0 1 0.14 6 0.87 7 1.01 17 2.47
6/12 to 6/6
0 0 0 0 0 0 0 0 0 0 1 0.14 1 0.14
Total 17 2.47 171 24.89 55 8.00 64 9.31 145 21.10 223 32.45 675 98.5
χ 2 test, p=0.000
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Table-9, Effect age group on final visual outcome.
Age Un
cooperative <1/60 1/60 to
3/60 20/200 to
20/120 20/80 to
20/60 20/40 to
20/20 Total
n % n % n % n % n % n % n %
0 to 10 9 1.31 46 6.69 15 2.18 12 1.74 37 5.38 34 4.94 153 22.27
11 to 20
2 0.29 30 4.36 14 2.03 17 2.47 33 4.80 87 12.66 183 26.63
21 to 30
2 0.29 19 2.76 8 1.16 6 0.87 12 1.74 42 6.11 89 12.95
31 to 40
1 0.14 23 3.35 5 0.73 7 1.01 16 2.32 25 3.63 77 11.2
41 to 50
3 0.43 23 3.35 6 0.87 12 1.74 28 4.07 22 3.20 94 13.68
51 to 60
0 0.0 21 3.00 7 1.01 6 0.87 8 1.16 11 1.60 53 7.71
61 to 70
0 0.0 8 1.16 0 0 2 0.29 10 1.45 2 0.29 22 3.20
71 to 80
0 0.0 1 0.14 0 0 2 0.29 1 0.14 0 0 4 0.58
Total 17 2.47 173 25.18 55 8.00 64 9.31 146 21.25 223 32.45 675 98.5
χ 2 test, p=0.000
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Figure Legends:
Fig. 1: When no clear lens matter was visible between the capsule and the nucleus, the cataract
was defined as a total cataract.
Fig. 2: When loose cortical material was found in the anterior chamber together with a ruptured
lens capsule, the cataract was defined as a white soft cataract.
Fig. 3: When the capsule and organised matter were fused and formed a membrane of varying
density, the cataract was defined as a membranous cataract.
Fig. 4: A lens with a rosette pattern of opacity was classified as a rosette type cataract.
Fig. 5: Distribution of cataracts based on the ocular injury, as per the BETTS classification.
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The English in this document has been checked by at least two professional editors, both native speakers
of English. For a certificate, please see:
http://www.textcheck.com/certificate/rbgCMs
Contributor ship Statement:
Mehul Shah: Concept design study, surgeon, writing
Shreya Shah: Administrative support, writing, data analyses
Shashank Shah: Data collection, language editing
Chintan Patel: Data collection proof reading and editing
Utsav Patel: Data collection and editing
Aashish Gupta: Editing revisions
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Morphology of traumatic cataract: does it play role in final
visual outcome? A hospital based cohort study
Journal: BMJ Open
Manuscript ID: BMJ Open.2011.000060.R7
Article Type: Research
Date Submitted by the Author:
06-Jun-2011
Complete List of Authors: Shah, Mehul; Drashti Netralaya, Ophthalmology; Drashti Netralaya, Ophthalmology Shah, Shreya; Drashti Netralaya, Ophthalmology Shah, Shashank; Drashti Netralaya, Ophthalmology Patel, Chintan; Drashti Netralaya, Ophthalmology Patel, Utsav; Drashti Netralaya, Ophthalmology
<b>Primary Subject
Heading</b>: Ophthalmology
Keywords: Vetreoretinal < OPHTHALMOLOGY, Anaesthesia in ophthalmology < ANAESTHETICS, Cataract and refractive surgery < OPHTHALMOLOGY
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Title: Morphology of traumatic cataract: does it play a role in final visual outcome?
Short running head: Morphology of traumatic cataract
Authors:
Name Degree E-mail
Dr. Mehul A. Shah
MD omtrust@rediffmail.com
Dr Shreya M. Shah
MD shah_shreya2000@yahoo.com
Dr. Shashank B. Shah MBBS sbshah@indiatimes.com
Dr. Chintan G. Patel MBBS cgp@drashtinetralaya.org
Dr Utsav A. Patel MBBS uap@drashtinetralaya.org
Affiliations of all authors:
Drashti Netralaya, Dahod, Gujarat, India
Address of corresponding author:
Drashti Netralaya,
Nr. GIDC, Chakalia Road.
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Dahod-389151
Gujarat
Ph: 00-91-2673-645364 Fax: 00-91-2673-221232
Email: omtrust@rdiffmail.com
No financial support was received from any company or institution.
This study has not been presented at any conference or meeting.
The authors do not have any financial interests in any aspect of this study.
Conflicting interests: None to declare.
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Abstract:
Purpose: To study morphology of traumatic cataract as a important predictor for final visual
outcome after treatment of traumatic cataracts.
Setting: Tertiary eye care centre in Dahod at the trijunction of Gujarat, Madhya Pradesh, and
Rajasthan states in central western India.
Methods: This was a prospective observational cohort study among all patients presenting at our
hospital with traumatic cataracts between January 2003 and December 2009. All information
regarding demographic and ocular trauma was collected on a pre-tested World Eye Trauma
Registry form for both the first visit and follow-up.
In particular, we collected specific information about the morphology of traumatic cataracts;
surgical technique was determined accordingly.
Data were entered and analysed with regard to the relationship between type of trauma and
resulting injury, results achieved with particular surgical techniques, and the relationship
between morphology and final visual outcome.
Outcome measures: Final visual outcome.
Results: Traumatic cataracts of different morphologies showed significant differences in final
visual outcome (χ2 test, P = 0.014).
Conclusion: The morphology of traumatic cataract plays an important role in final visual
outcome.
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Article Summery:
Article Focus:
Morphological Classification of traumatic cataract which may be helpful for guidelines of
surgical technique.
Key Message:
Treatment strategies based on morphology of traumatic cataract may provide guidelines of surgical
treatment of traumatic cataracts.
Strength and weakness:
Strength: Larger database and Usage of standard classification method-BETTS Limitation:
Included many neglected injury cases.
Weakness: Uncontrolled study, One third enrolment from outreach limits generalization of
findings,Short follow up. Loss of follow up of 12 patients at various stages of study.
Introduction:
Trauma is a cause of monocular blindness in the developed world, although few studies
have addressed the problem of trauma in rural areas.1 The aetiology of ocular injury in rural
areas is likely to differ from that in urban areas and is worthy of investigation.2-4
Any strategy
for prevention requires knowledge of the cause of injury, which may enable more appropriate
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targeting of resources toward preventing such injuries. Eye trauma represents a large, potentially
preventable burden on both victims and society as a whole.3
Ocular trauma can cause cataracts.1 The methods used to evaluate the visual outcome in
eyes managed for traumatic cataracts and senile cataracts are similar,5 but the damage to other
ocular tissues due to trauma may compromise the visual gain in eyes treated surgically for
traumatic cataracts. Hence, the success rates may differ between eyes with these two types of
cataract.
With the introduction of the Birmingham Eye Trauma Terminology System (BETTS),
the documentation of ocular trauma has been standardised.5
Our study was conducted in a city located at the intersection of the borders of three states
in India: Gujarat, Madhya Pradesh, and Rajasthan.11
Qualified ophthalmologists at our institute
provide low-cost eye services mainly to the poor belonging to the tribal population of 4.2 million
in this area.
There is no standard methodology for classification of traumatic cataract.
Patients and Methods:
We obtained approval from the hospital administrators and research committee to
conduct this study, and all participants provided written informed consent.
This was a prospective study designed in 2002. All traumatic cataracts in either eye
diagnosed and managed between January 2003 and December 2009 were included in the study,
and patients consenting to participate and without other serious body injuries were included.
Outreach activities included five different service deliveries mobile diagnostic camps, school
screening, mobile vision center, door to door call of patients and health worker network.
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For each patient enrolled in our study, we obtained a detailed history, including details of
the injury and information on eye treatment and surgery performed to manage past ocular
trauma. Data for both the initial and follow-up reports were collected using the online BETTS
format of the International Society of Ocular Trauma. Details of the surgery were also collected
using a specified pre-tested online form.
The cases of traumatic cataract were grouped as those with open- and those with closed-
globe injuries. The open-globe injuries were further categorised into those with lacerations and
those with rupture. Lacerations of the eyeball were subcategorised into eyes with perforating
injuries, penetrating injuries, or injuries involving an intraocular foreign body. The closed-globe
group was subdivided into lamellar laceration and contusion.
Other demographic details collected included patient entry, residence, activity at the time
of injury, object of injury, and previous examinations and treatments. After enrolment, all
patients were examined using a standard method. Visual acuity was checked using a Snellen
chart, and the anterior segment was examined using a slit lamp.
Based on lenticular opacity, the cataracts were classified as total (Figure 1), membranous
in which both capsules fused with scant or no cortical material (Figure 2), white soft (Figure 3),
and rosette types (Figure 4). When an ophthalmologist did not observe clear lens matter between
the capsule and nucleus, the cataract was defined as total. When the capsule and organised
matter were fused and formed a membrane of varying density, it was defined as a membranous
cataract. When loose cortical material was found in the anterior chamber together with a
ruptured lens capsule, the cataract was defined as white soft. A lens with a rosette pattern of
opacity was classified as a rosette type cataract.
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For a partially opaque lens, the posterior segment examination was carried out with an
indirect ophthalmoscope and a +20 D lens. When the optical medium was not clear, a B-scan
was performed to evaluate the posterior segment.
The surgical technique was selected according to morphology and the condition of
tissues other than the lens. Phacoemulsification was used to treat cataracts with hard, large
nuclei. With a lens that had either a white soft or rosette type of cataract, unimanual or bimanual
aspiration was used. Membranectomy and anterior vitrectomy, via either the anterior or pars
plana route, were performed when the cataract was membranous.
In all patients undergoing corneal wound repair, the traumatic cataract was managed in a
second procedure. Recurrent inflammation was more prominent in patients who had undergone
previous surgery for trauma.9,10
In these cases, the ocular medium may become hazy owing to
condensation of the anterior vitreous unless a vitrectomy is performed. Hence, we performed a
capsulectomy and vitrectomy via the anterior/pars plana route in adults.
In children younger than 2 years of age, both a lensectomy and vitrectomy via the pars
plana route were performed, and the same surgical procedures were used to manage the
traumatic cataract, with secondary implants done as a separate procedure after the age of 2 years.
Lens implantation as part of the primary procedure was avoided in all children younger than 2
years of age. All children were evaluated for amblyopia and were treated with the aid of
paediatric ophthalmologists and paediatric optometrists.
All patients with injuries and without infection were treated with topical and systemic
corticosteroids and cycloplegics. The duration of medical treatment depended on the degree of
inflammation in the anterior and posterior segments of the operated eye. The operated patients
were re-examined after 24 h, 3 days, and 1, 2, and 6 weeks to enable refractive correction.
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Follow-up was scheduled for the third day, weekly for 6 weeks, monthly for 3 months, and every
3 months for 1 year.
At all follow-up examinations, visual acuity was tested using a Snellen chart. The
anterior segment was examined with a slit lamp, and the posterior segment was examined with
an indirect ophthalmoscope. Eyes with vision better than 20/60 at the glasses appointment (6
weeks) were defined as having a satisfactory grade of vision.
During the examination, data were entered online using a specified pre-tested format
designed by the International Society of Ocular Trauma (initial and follow-up forms), which was
exported to a Microsoft Excel spreadsheet. The data were audited periodically to ensure
completeness. We used SPSS 15 software to analyse the data. The univariate parametric method
was used to calculate frequency, percentage, proportion, and 95% confidence interval (95% CI).
We used binominal regression analysis to determine the predictors of postoperative satisfactory
vision (> 20/60). The dependent variable was vision >20/60 noted at follow-up 6 weeks after
cataract surgery. The independent variables were age, gender, residence, time interval between
injury and cataract surgery, primary posterior capsulectomy and vitrectomy procedure, and type
of ocular injury.
Results:
Our cohort consisted of 687 (72.2) patients with traumatic cataracts (Figure 5), including 496
eyes with open-globe ocular injuries and 191 (27.8%) eyes with closed-globe injuries (Figure 5).
The patients were 492 (71.6%) males and 195 (28.4%) females. The mean patient age was
27.1 ± 18.54 years (range, 1–80).
We analysed several demographic factors, including gender (P = 0.340), patient entry
(P = 0.4), and socioeconomic status (79% were from lower socioeconomic class and residence;
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95% were from rural areas). None of these showed a significant relationship with final visual
acuity, according to cross-tabulation and statistical tests. The object causing the injury (P = 0.3)
and the activity at the time of the injury (P = 0.3) were also not significantly associated with
satisfactory final visual acuityAll traumatic cataracts were classified according to morphology
(Tables 1 and 2) and were surgically treated using morphology as a guideline. (Table 3)
The number of surgeries required varied significantly with morphology (P = 0.000)
(Table 4).
Final visual outcome was found to vary according to morphology and surgical technique.
White soft cataracts had a better prognosis and achieved significantly higher rates of positive
outcome compared with other morphologies (P = 0.014) (Table 5).
Lens implants were applied in 82% of the cases; the details are shown in Table 6. There
was a significant difference between open and closed injury groups for various age groups (P =
0.000).
There was no significant difference in final visual outcome in children between open
and closed injury groups (P = 0.06). Significant difference found if we compare final visual
outcome before and after treatment. (P=000)Table-8 A significant relationship was found
between age and final visual outcome (P = 0.000) final visual outcome is better in younger age
group. (Table-9) When time interval between injury and intervention was study there is
significant (p=0.000) effect on final visual outcome.11
Discussion:
Using a large database, we attempted to systematically classify the morphology of
traumatic cataract and to select surgical techniques accordingly.
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Previous studies have touched on this topic. One study found 52.3% total cataracts,
whereas our results revealed 26.6% total cataracts.7 Vajpayee reported opening in the posterior
capsule with type 1 and 2 openings with penetrating injury,8 whereas we found another
membranous type of cataract (12.1%) suggestive of late reporting, as membranous
transformation of the lens with fusion of the anterior and posterior capsules may occur over
time.
We were able to perform intraocular lens implants in 82.1% of the cases.
Krishnamachary reported implants in 65.5% of cases, Churchill et al. reported implants in
46.8%, and Fyodorov reported Sputnik implants in all cases.7,9,10
Fyodorov reported surgical techniques according to pathology and degree of lens
absorption, but did not systematically classify similar factors taken into account in our study.10
These differences in findings may reflect the fact that of the 687 patients in our study,
30% came from outreach activities and did not approach treatment facilities on their own.
Therefore, the time period between ocular injury and reporting ranged widely, and morphology
was also influenced by this interval. While this uncontrolled study cannot provide firm evidence
that using a clear morphological classification to guide surgical decision led to improved
outcomes.
We share our experience with treatment strategy for different morphological verities of
traumatic cataracts, which may provide guidelines for management that incorporate available
technology and improve care for these patients.
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References:
1. Khatry SK, Lewis AE, Schein OD et al. The epidemiology of ocular trauma in rural
Nepal. Br J Ophthalmol. 2004; 88:456-60.
2. Abraham, DI; Vitale SI; West SI et al. Epidemiology of eye injuries in rural Tanzania.
Ophthalmic Epidemiol.1999; 6:85-94
3. D. Virgil Alfaro, Eric P. Jablon, Monica Rodriguez Fontal et al. Fishing-related ocular
trauma. American Journal of Ophthalmology.2005; 139: 488-492
4. Shah M, Shah S, Khandekar R. Ocular injuries and visual status before and after Their
management in the tribal areas of Western India-A historical cohort study Grafes Arch
Clin Exp Ophthalmol 2008; 246:191–197.
5. Kuhn F, Morris R, Witherspoon CD et al. The Birmingham Eye Trauma Terminology
system (BETT). J Fr Ophtalmol. 2004; 27:206-10.
6. Vajpayee RB, Sharma N, Dada T et al. Management of posterior capsule tears. Surv
Ophthalmol 2001;45:473-88.
7. Krishnamachary M, Rathi V, Gupta S. Management of traumatic cataract in children. J
Cataract Refract Surg 1997; 23:681-7.
8. Churchill AJ, Noble BA, Etchells DE et al. Factors affecting visual outcome in children
following uniocular traumatic cataract. Eye (Lond) 1995;9:285-91
9. Thylefors B, Chylack LT Jr, Konyama K, et al. A simplified cataract grading system.
Ophthalmic Epidemiol. 2002; 9:83-95.
10. Fyodorov SN, Egorova EV, Zubareva LN. 1004 cases of traumatic cataract surgery with
implantation of an intraocular lens. J Am Intraocul Implant Soc 1981;7:147-53.
11. Shah MA, Shah SM, Shah SB, et al Effect of interval between time of injury and timing
of intervention on final visual outcome in cases of traumatic cataract. Eur J Ophthalmol.
2011 Mar 24. pii: 338AC21D-E9FB-42DF-9C28-6FDE61928C9D. doi:
10.5301/EJO.2011.6482. [Epub ahead of print]
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Table 1. Distribution of different morphologies of traumatic cataract
Morphology N Percent
84 12.2
8
1.2
412
60.0
Membranous
Rosette
White soft
Total 183 26.6
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Total
687 100.0
Table 2. Morphology of traumatic cataract according to type of injury
BETT Category Closed globe Open globe Total
Morphology N % N % N %
20 2.9 64 9.3 84 12.2
Membranous
Rosette 3 0.4 5 0.7 8 1.1
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83 12.1 329 47.9 412 59.9
White Soft with ruptured
Anterior capsule
Total
85 12.4 98 14.3 183 26.6
Total
191 27.8 496 72.2 687 100
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Table 3. Surgical techniques used according to morphology of cataract
Morphology
Membranous Rosette White soft Total
Total
Surgical Technique
N % N % N % N % N %
7 1 5 0.7 316 45.9 19 2.7 347 50.5
46 6.7 0 0 60 8.7 20 2.9 126 18.3
3 0.4 2 0.3 17 2.4 108 15.7 130 18.9
Aspiration
Lensectomy + Vitrectomy
Phaco/SICS*
Delivery + vitrectomy
28 4 0 0 20 2.9 36 5.2 84 12.2
Total 83 12.1 7 1 412 59.9 183 26.6 687 100
*Small Incision Cataract Surgery
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Table 4. Morphology of cataract in relation to number of surgical procedures
Morphology
Membranous Rosette White soft Total Total
N N % N % N % N % N &
70 10.1 6 0.8 349 50.8 159 23.1 584 85.0
12 1.7 2 0.2 58 8.4 22 3.2 94 13.7
2 0.3 0 0 5 0.7 2 0.2 9 1.3
1.00
2.00
3.00
Total 84 12.2 8 1 412 59.9 183 26.6 687 100
χ 2 test, P = 0.000
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Table 5. Final visual outcome in relation to morphology of cataract
Final visual outcome Morphology
Membranous Rosette White soft Total Total
N % N % N % N % N %
3 0.4 0 0 11 1.6 5 0.7 19 2.7
24 3.5 2 0.3 89 12.9 58 8.4 173 25.1
12 1.7 0 0 27 3.9 19 2.7 58 8.4
7 1.0 1 0.1 33 4.8 25 3.6 66 9.6
21 3.0 1 0.1 91 13.2 34 4.9 147 21.4
Uncooperative
<1/60
1/60 to 3/60
20/200 to 20/120
20/80 to 20/60
20/40 to 20/20 17 2.5 4 0.5 161 23.4 42 6.1 224 32.6
Total 83 12.1 7 1.0 412 59.9 183 26.6 687 100
χ 2 test, P = 0.014
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Table 6. Lens implant in relation to morphology of traumatic cataract
Morphology No implant Implant Total
N % N % N %
17 2.5 67 9.8 84 12.2
2 0.3 6 0.9 8 1.2
58 8.4 354 51.5 412 60.0
46 6.7 137 19.9 183 26.6
Membranous
Rosette
White soft
Total
Total 123 17.9 564 82.1 687 100
χ 2 test, p = 0.004
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Table-7. Comparison of open closed globe injuries in children
Category Closed globe Open globe Total
N % N % N %
54 7.7 253 36.8 307 44.7 Pediatric
Adult 137 19.9 243 35.3 380 55.3
Total 191 27.8 496 72.1 687 100
χ 2 test, p=0.000
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Table-8, Comparative visual acuity before and after treatment
Post treatment vision Pre op vision uncooperative <1/60
1/60 to 3/60
20/200 to 20/120
20/80 to 20 /60
20/40 to 20/20
Total E
uncooperative 7 1.01 0 0 0 0 0 0 1 0.14 2 0.29 10 1.45
<1/60
10 1.45 164 23.87 53 7.71 54 7.86 110 16.01 191 27.80 582 84.71
1/60 to 3/60
0 0 4 0.58 3 0.43 8 1.16 21 3.05 10 1.45 46 6.69
6/60 to 6/36
0 0 0 0 0 0 1 0.14 7 1.01 12 1.74 20 2.91
6/24 to 6/18
0 0 3 0.43 0 0 1 0.14 6 0.87 7 1.01 17 2.47
6/12 to 6/6
0 0 0 0 0 0 0 0 0 0 1 0.14 1 0.14
Total 17 2.47 171 24.89 55 8.00 64 9.31 145 21.10 223 32.45 675 98.5
χ 2 test, p=0.000
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Table-9, Effect age group on final visual outcome.
Age Un
cooperative <1/60 1/60 to
3/60 20/200 to
20/120 20/80 to
20/60 20/40 to
20/20 Total
n % n % n % n % n % n % n %
0 to 10 9 1.31 46 6.69 15 2.18 12 1.74 37 5.38 34 4.94 153 22.27
11 to 20
2 0.29 30 4.36 14 2.03 17 2.47 33 4.80 87 12.66 183 26.63
21 to 30
2 0.29 19 2.76 8 1.16 6 0.87 12 1.74 42 6.11 89 12.95
31 to 40
1 0.14 23 3.35 5 0.73 7 1.01 16 2.32 25 3.63 77 11.2
41 to 50
3 0.43 23 3.35 6 0.87 12 1.74 28 4.07 22 3.20 94 13.68
51 to 60
0 0.0 21 3.00 7 1.01 6 0.87 8 1.16 11 1.60 53 7.71
61 to 70
0 0.0 8 1.16 0 0 2 0.29 10 1.45 2 0.29 22 3.20
71 to 80
0 0.0 1 0.14 0 0 2 0.29 1 0.14 0 0 4 0.58
Total 17 2.47 173 25.18 55 8.00 64 9.31 146 21.25 223 32.45 675 98.5
χ 2 test, p=0.000
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Figure Legends:
Fig. 1: When no clear lens matter was visible between the capsule and the nucleus, the cataract
was defined as a total cataract.
Fig. 2: When loose cortical material was found in the anterior chamber together with a ruptured
lens capsule, the cataract was defined as a white soft cataract.
Fig. 3: When the capsule and organised matter were fused and formed a membrane of varying
density, the cataract was defined as a membranous cataract.
Fig. 4: A lens with a rosette pattern of opacity was classified as a rosette type cataract.
Fig. 5: Distribution of cataracts based on the ocular injury, as per the BETTS classification.
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The English in this document has been checked by at least two professional editors, both native speakers
of English. For a certificate, please see:
http://www.textcheck.com/certificate/rbgCMs
Contributor ship Statement:
Mehul Shah: Concept design study, surgeon, writing
Shreya Shah: Administrative support, writing, data analyses
Shashank Shah: Data collection, language editing
Chintan Patel: Data collection proof reading and editing
Utsav Patel: Data collection and editing
Aashish Gupta: Editing revisions
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Morphology of traumatic cataract: does it play role in final
visual outcome? A hospital based cohort study
Journal: BMJ Open
Manuscript ID: BMJ Open.2011.000060.R8
Article Type: Research
Date Submitted by the Author:
10-Jun-2011
Complete List of Authors: Shah, Mehul; Drashti Netralaya, Ophthalmology; Drashti Netralaya, Ophthalmology Shah, Shreya; Drashti Netralaya, Ophthalmology Shah, Shashank; Drashti Netralaya, Ophthalmology Patel, Chintan; Drashti Netralaya, Ophthalmology Patel, Utsav; Drashti Netralaya, Ophthalmology Gupta, Asheesh; Drashti Netralaya, Ocular Trauma
<b>Primary Subject Heading</b>:
Ophthalmology
Keywords: Vetreoretinal < OPHTHALMOLOGY, Anaesthesia in ophthalmology < ANAESTHETICS, Cataract and refractive surgery < OPHTHALMOLOGY
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Title: Morphology of traumatic cataract: does it play a role in final visual outcome?
Short running head: Morphology of traumatic cataract
Authors:
Name Degree E-mail
Dr. Mehul A. Shah
MD omtrust@rediffmail.com
Dr Shreya M. Shah
MD shah_shreya2000@yahoo.com
Dr. Shashank B. Shah MBBS sbshah@indiatimes.com
Dr. Chintan G. Patel MBBS cgp@drashtinetralaya.org
Dr Utsav A. Patel MBBS uap@drashtinetralaya.org
Affiliations of all authors:
Drashti Netralaya, Dahod, Gujarat, India
Address of corresponding author:
Drashti Netralaya,
Nr. GIDC, Chakalia Road.
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Dahod-389151
Gujarat
Ph: 00-91-2673-645364 Fax: 00-91-2673-221232
Email: omtrust@rdiffmail.com
No financial support was received from any company or institution.
This study has not been presented at any conference or meeting.
The authors do not have any financial interests in any aspect of this study.
Conflicting interests: None to declare.
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Abstract:
Purpose: To study morphology of traumatic cataract as a important predictor for final visual
outcome after treatment of traumatic cataracts.
Setting: Tertiary eye care centre in Dahod at the trijunction of Gujarat, Madhya Pradesh, and
Rajasthan states in central western India.
Methods: This was a prospective observational cohort study among all patients presenting at our
hospital with traumatic cataracts between January 2003 and December 2009. All information
regarding demographic and ocular trauma was collected on a pre-tested World Eye Trauma
Registry form for both the first visit and follow-up.
In particular, we collected specific information about the morphology of traumatic cataracts;
surgical technique was determined accordingly.
Data were entered and analysed with regard to the relationship between type of trauma and
resulting injury, results achieved with particular surgical techniques, and the relationship
between morphology and final visual outcome.
Outcome measures: Final visual outcome.
Results: Traumatic cataracts of different morphologies showed significant differences in final
visual outcome (χ2 test, P = 0.014).
Conclusion: The morphology of traumatic cataract plays an important role in final visual
outcome.
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Article Summery:
Article Focus:
Morphological Classification of traumatic cataract which may be helpful for guidelines of
surgical technique.
Key Message:
• It is an uncontrolled prospective cohort study
• Using morphological classification to guide decisions on operative technique; that
outcomes after surgery are reported by morphology and surgical technique; and the
possible role of morphology is explored.
Strength and weakness:
Strength: Larger database and Usage of standard classification method-BETTS Limitation:
Included many neglected injury cases.
Weakness: Uncontrolled study, One third enrolment from outreach limits generalization of
findings, Short follow up. Loss of follow up of 12 patients at various stages of study.
Introduction:
Trauma is a cause of monocular blindness in the developed world, although few studies
have addressed the problem of trauma in rural areas.1 The aetiology of ocular injury in rural
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areas is likely to differ from that in urban areas and is worthy of investigation.2-4
Any strategy
for prevention requires knowledge of the cause of injury, which may enable more appropriate
targeting of resources toward preventing such injuries. Eye trauma represents a large, potentially
preventable burden on both victims and society as a whole.3
Ocular trauma can cause cataracts.1 The methods used to evaluate the visual outcome in
eyes managed for traumatic cataracts and senile cataracts are similar,5 but the damage to other
ocular tissues due to trauma may compromise the visual gain in eyes treated surgically for
traumatic cataracts. Hence, the success rates may differ between eyes with these two types of
cataract.
With the introduction of the Birmingham Eye Trauma Terminology System (BETTS),
the documentation of ocular trauma has been standardised.5
Our study was conducted in a city located at the intersection of the borders of three states
in India: Gujarat, Madhya Pradesh, and Rajasthan.11
Qualified ophthalmologists at our institute
provide low-cost eye services mainly to the poor belonging to the tribal population of 4.2 million
in this area.
There is no standard methodology for classification of traumatic cataract.
Patients and Methods:
We obtained approval from the hospital administrators and research committee to
conduct this study, and all participants provided written informed consent.
This was a prospective study designed in 2002. All traumatic cataracts in either eye
diagnosed and managed between January 2003 and December 2009 were included in the study,
and patients consenting to participate and without other serious body injuries were included.
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Outreach activities included five different service deliveries mobile diagnostic camps, school
screening, mobile vision center, door to door call of patients and health worker network.
For each patient enrolled in our study, we obtained a detailed history, including details of
the injury and information on eye treatment and surgery performed to manage past ocular
trauma. Data for both the initial and follow-up reports were collected using the online BETTS
format of the International Society of Ocular Trauma. Details of the surgery were also collected
using a specified pre-tested online form.
The cases of traumatic cataract were grouped as those with open- and those with closed-
globe injuries. The open-globe injuries were further categorised into those with lacerations and
those with rupture. Lacerations of the eyeball were subcategorised into eyes with perforating
injuries, penetrating injuries, or injuries involving an intraocular foreign body. The closed-globe
group was subdivided into lamellar laceration and contusion.
Other demographic details collected included patient entry, residence, activity at the time
of injury, object of injury, and previous examinations and treatments. After enrolment, all
patients were examined using a standard method. Visual acuity was checked using a Snellen
chart, and the anterior segment was examined using a slit lamp.
Based on lenticular opacity, the cataracts were classified as total (Figure 1), membranous
in which both capsules fused with scant or no cortical material (Figure 2), white soft (Figure 3),
and rosette types (Figure 4). When an ophthalmologist did not observe clear lens matter between
the capsule and nucleus, the cataract was defined as total. When the capsule and organised
matter were fused and formed a membrane of varying density, it was defined as a membranous
cataract. When loose cortical material was found in the anterior chamber together with a
ruptured lens capsule, the cataract was defined as white soft. A lens with a rosette pattern of
opacity was classified as a rosette type cataract.
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For a partially opaque lens, the posterior segment examination was carried out with an
indirect ophthalmoscope and a +20 D lens. When the optical medium was not clear, a B-scan
was performed to evaluate the posterior segment.
The surgical technique was selected according to morphology and the condition of
tissues other than the lens. Phacoemulsification was used to treat cataracts with hard, large
nuclei. With a lens that had either a white soft or rosette type of cataract, unimanual or bimanual
aspiration was used. Membranectomy and anterior vitrectomy, via either the anterior or pars
plana route, were performed when the cataract was membranous.
In all patients undergoing corneal wound repair, the traumatic cataract was managed in a
second procedure. Recurrent inflammation was more prominent in patients who had undergone
previous surgery for trauma.9,10
In these cases, the ocular medium may become hazy owing to
condensation of the anterior vitreous unless a vitrectomy is performed. Hence, we performed a
capsulectomy and vitrectomy via the anterior/pars plana route in adults.
In children younger than 2 years of age, both a lensectomy and vitrectomy via the pars
plana route were performed, and the same surgical procedures were used to manage the
traumatic cataract, with secondary implants done as a separate procedure after the age of 2 years.
Lens implantation as part of the primary procedure was avoided in all children younger than 2
years of age. All children were evaluated for amblyopia and were treated with the aid of
paediatric ophthalmologists and paediatric optometrists.
All patients with injuries and without infection were treated with topical and systemic
corticosteroids and cycloplegics. The duration of medical treatment depended on the degree of
inflammation in the anterior and posterior segments of the operated eye. The operated patients
were re-examined after 24 h, 3 days, and 1, 2, and 6 weeks to enable refractive correction.
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Follow-up was scheduled for the third day, weekly for 6 weeks, monthly for 3 months, and every
3 months for 1 year.
At all follow-up examinations, visual acuity was tested using a Snellen chart. The
anterior segment was examined with a slit lamp, and the posterior segment was examined with
an indirect ophthalmoscope. Eyes with vision better than 20/60 at the glasses appointment (6
weeks) were defined as having a satisfactory grade of vision.
During the examination, data were entered online using a specified pre-tested format
designed by the International Society of Ocular Trauma (initial and follow-up forms), which was
exported to a Microsoft Excel spreadsheet. The data were audited periodically to ensure
completeness. We used SPSS 15 software to analyse the data. The univariate parametric method
was used to calculate frequency, percentage, proportion, and 95% confidence interval (95% CI).
We used binominal regression analysis to determine the predictors of postoperative satisfactory
vision (> 20/60). The dependent variable was vision >20/60 noted at follow-up 6 weeks after
cataract surgery. The independent variables were age, gender, residence, time interval between
injury and cataract surgery, primary posterior capsulectomy and vitrectomy procedure, and type
of ocular injury.
Results:
Our cohort consisted of 687 (72.2) patients with traumatic cataracts (Figure 5), including 496
eyes with open-globe ocular injuries and 191 (27.8%) eyes with closed-globe injuries (Figure 5).
The patients were 492 (71.6%) males and 195 (28.4%) females. The mean patient age was
27.1 ± 18.54 years (range, 1–80).
We analysed several demographic factors, including gender (P = 0.340), patient entry
(P = 0.4), and socioeconomic status (79% were from lower socioeconomic class and residence;
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95% were from rural areas). None of these showed a significant relationship with final visual
acuity, according to cross-tabulation and statistical tests. The object causing the injury (P = 0.3)
and the activity at the time of the injury (P = 0.3) were also not significantly associated with
satisfactory final visual acuityAll traumatic cataracts were classified according to morphology
(Tables 1 and 2) and were surgically treated using morphology as a guideline. (Table 3)
The number of surgeries required varied significantly with morphology (P = 0.000)
(Table 4).
Final visual outcome was found to vary according to morphology and surgical technique.
White soft cataracts had a better prognosis and achieved significantly higher rates of positive
outcome compared with other morphologies (P = 0.014) (Table 5).
Lens implants were applied in 82% of the cases; the details are shown in Table 6. There
was a significant difference between open and closed injury groups for various age groups (P =
0.000).
There was no significant difference in final visual outcome in children between open
and closed injury groups (P = 0.06). Significant difference found if we compare final visual
outcome before and after treatment. (P=000)Table-8 A significant relationship was found
between age and final visual outcome (P = 0.000) final visual outcome is better in younger age
group. (Table-9) When time interval between injury and intervention was study there is
significant (p=0.000) effect on final visual outcome.11
Discussion:
Using a large database, we attempted to systematically classify the morphology of
traumatic cataract and to select surgical techniques accordingly.
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Previous studies have touched on this topic. One study found 52.3% total cataracts,
whereas our results revealed 26.6% total cataracts.7 Vajpayee reported opening in the posterior
capsule with type 1 and 2 openings with penetrating injury,8 whereas we found another
membranous type of cataract (12.1%) suggestive of late reporting, as membranous
transformation of the lens with fusion of the anterior and posterior capsules may occur over
time.
We were able to perform intraocular lens implants in 82.1% of the cases.
Krishnamachary reported implants in 65.5% of cases, Churchill et al. reported implants in
46.8%, and Fyodorov reported Sputnik implants in all cases.7,9,10
Fyodorov reported surgical techniques according to pathology and degree of lens
absorption, but did not systematically classify similar factors taken into account in our study.10
These differences in findings may reflect the fact that of the 687 patients in our study,
30% came from outreach activities and did not approach treatment facilities on their own.
Therefore, the time period between ocular injury and reporting ranged widely, and morphology
was also influenced by this interval.
We share our experience with treatment strategy for different morphological verities of
traumatic cataracts, which may provide guidelines for management that incorporate available
technology and improve care for these patients. As an uncontrolled study it cannot provide firm
evidence that this strategy led to improved outcomes, but it does provide a large dataset to help
develop further research questions.
Morphology of traumatic cataract appeared to be associated with final visual outcome
following surgical treatment.
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References:
1. Khatry SK, Lewis AE, Schein OD et al. The epidemiology of ocular trauma in rural
Nepal. Br J Ophthalmol. 2004; 88:456-60.
2. Abraham, DI; Vitale SI; West SI et al. Epidemiology of eye injuries in rural Tanzania.
Ophthalmic Epidemiol.1999; 6:85-94
3. D. Virgil Alfaro, Eric P. Jablon, Monica Rodriguez Fontal et al. Fishing-related ocular
trauma. American Journal of Ophthalmology.2005; 139: 488-492
4. Shah M, Shah S, Khandekar R. Ocular injuries and visual status before and after Their
management in the tribal areas of Western India-A historical cohort study Grafes Arch
Clin Exp Ophthalmol 2008; 246:191–197.
5. Kuhn F, Morris R, Witherspoon CD et al. The Birmingham Eye Trauma Terminology
system (BETT). J Fr Ophtalmol. 2004; 27:206-10.
6. Vajpayee RB, Sharma N, Dada T et al. Management of posterior capsule tears. Surv
Ophthalmol 2001;45:473-88.
7. Krishnamachary M, Rathi V, Gupta S. Management of traumatic cataract in children. J
Cataract Refract Surg 1997; 23:681-7.
8. Churchill AJ, Noble BA, Etchells DE et al. Factors affecting visual outcome in children
following uniocular traumatic cataract. Eye (Lond) 1995;9:285-91
9. Thylefors B, Chylack LT Jr, Konyama K, et al. A simplified cataract grading system.
Ophthalmic Epidemiol. 2002; 9:83-95.
10. Fyodorov SN, Egorova EV, Zubareva LN. 1004 cases of traumatic cataract surgery with
implantation of an intraocular lens. J Am Intraocul Implant Soc 1981;7:147-53.
11. Shah MA, Shah SM, Shah SB, et al Effect of interval between time of injury and timing
of intervention on final visual outcome in cases of traumatic cataract. Eur J Ophthalmol.
2011 Mar 24. pii: 338AC21D-E9FB-42DF-9C28-6FDE61928C9D. doi:
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10.5301/EJO.2011.6482. [Epub ahead of print]
Table 1. Distribution of different morphologies of traumatic cataract
Morphology N Percent
84 12.2
8
1.2
Membranous
Rosette
White soft
412
60.0
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183 26.6
Total
Total 687 100.0
Table 2. Morphology of traumatic cataract according to type of injury
BETT Category Closed globe Open globe Total
Morphology N % N % N %
Membranous
20 2.9 64 9.3 84 12.2
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3 0.4 5 0.7 8 1.1
83 12.1 329 47.9 412 59.9
Rosette
White Soft with ruptured
Anterior capsule
Total
85 12.4 98 14.3 183 26.6
Total
191 27.8 496 72.2 687 100
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Table 3. Surgical techniques used according to morphology of cataract
Morphology
Membranous Rosette White soft Total
Total
Surgical Technique
N % N % N % N % N %
7 1 5 0.7 316 45.9 19 2.7 347 50.5
46 6.7 0 0 60 8.7 20 2.9 126 18.3
3 0.4 2 0.3 17 2.4 108 15.7 130 18.9
Aspiration
Lensectomy + Vitrectomy
Phaco/SICS*
Delivery + vitrectomy
28 4 0 0 20 2.9 36 5.2 84 12.2
Total 83 12.1 7 1 412 59.9 183 26.6 687 100
*Small Incision Cataract Surgery
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Table 4. Morphology of cataract in relation to number of surgical procedures
Morphology
Membranous Rosette White soft Total Total
N N % N % N % N % N &
70 10.1 6 0.8 349 50.8 159 23.1 584 85.0
12 1.7 2 0.2 58 8.4 22 3.2 94 13.7
2 0.3 0 0 5 0.7 2 0.2 9 1.3
1.00
2.00
3.00
Total 84 12.2 8 1 412 59.9 183 26.6 687 100
χ 2 test, P = 0.000
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Table 5. Final visual outcome in relation to morphology of cataract
Final visual outcome Morphology
Membranous Rosette White soft Total Total
N % N % N % N % N %
3 0.4 0 0 11 1.6 5 0.7 19 2.7
24 3.5 2 0.3 89 12.9 58 8.4 173 25.1
12 1.7 0 0 27 3.9 19 2.7 58 8.4
7 1.0 1 0.1 33 4.8 25 3.6 66 9.6
21 3.0 1 0.1 91 13.2 34 4.9 147 21.4
Uncooperative
<1/60
1/60 to 3/60
20/200 to 20/120
20/80 to 20/60
20/40 to 20/20 17 2.5 4 0.5 161 23.4 42 6.1 224 32.6
Total 83 12.1 7 1.0 412 59.9 183 26.6 687 100
χ 2 test, P = 0.014
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Table 6. Lens implant in relation to morphology of traumatic cataract
Morphology No implant Implant Total
N % N % N %
17 2.5 67 9.8 84 12.2
2 0.3 6 0.9 8 1.2
58 8.4 354 51.5 412 60.0
46 6.7 137 19.9 183 26.6
Membranous
Rosette
White soft
Total
Total 123 17.9 564 82.1 687 100
χ 2 test, p = 0.004
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Table-7. Comparison of open closed globe injuries in children
Category Closed globe Open globe Total
N % N % N %
54 7.7 253 36.8 307 44.7 Pediatric
Adult 137 19.9 243 35.3 380 55.3
Total 191 27.8 496 72.1 687 100
χ 2 test, p=0.000
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Table-8, Comparative visual acuity before and after treatment
Post treatment vision Pre op vision uncooperative <1/60
1/60 to 3/60
20/200 to 20/120
20/80 to 20 /60
20/40 to 20/20
Total E
uncooperative 7 1.01 0 0 0 0 0 0 1 0.14 2 0.29 10 1.45
<1/60
10 1.45 164 23.87 53 7.71 54 7.86 110 16.01 191 27.80 582 84.71
1/60 to 3/60
0 0 4 0.58 3 0.43 8 1.16 21 3.05 10 1.45 46 6.69
6/60 to 6/36
0 0 0 0 0 0 1 0.14 7 1.01 12 1.74 20 2.91
6/24 to 6/18
0 0 3 0.43 0 0 1 0.14 6 0.87 7 1.01 17 2.47
6/12 to 6/6
0 0 0 0 0 0 0 0 0 0 1 0.14 1 0.14
Total 17 2.47 171 24.89 55 8.00 64 9.31 145 21.10 223 32.45 675 98.5
χ 2 test, p=0.000
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Table-9, Effect age group on final visual outcome.
Age Un
cooperative <1/60 1/60 to
3/60 20/200 to
20/120 20/80 to
20/60 20/40 to
20/20 Total
n % n % n % n % n % n % n %
0 to 10 9 1.31 46 6.69 15 2.18 12 1.74 37 5.38 34 4.94 153 22.27
11 to 20
2 0.29 30 4.36 14 2.03 17 2.47 33 4.80 87 12.66 183 26.63
21 to 30
2 0.29 19 2.76 8 1.16 6 0.87 12 1.74 42 6.11 89 12.95
31 to 40
1 0.14 23 3.35 5 0.73 7 1.01 16 2.32 25 3.63 77 11.2
41 to 50
3 0.43 23 3.35 6 0.87 12 1.74 28 4.07 22 3.20 94 13.68
51 to 60
0 0.0 21 3.00 7 1.01 6 0.87 8 1.16 11 1.60 53 7.71
61 to 70
0 0.0 8 1.16 0 0 2 0.29 10 1.45 2 0.29 22 3.20
71 to 80
0 0.0 1 0.14 0 0 2 0.29 1 0.14 0 0 4 0.58
Total 17 2.47 173 25.18 55 8.00 64 9.31 146 21.25 223 32.45 675 98.5
χ 2 test, p=0.000
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Figure Legends:
Fig. 1: When no clear lens matter was visible between the capsule and the nucleus, the cataract
was defined as a total cataract.
Fig. 2: When loose cortical material was found in the anterior chamber together with a ruptured
lens capsule, the cataract was defined as a white soft cataract.
Fig. 3: When the capsule and organised matter were fused and formed a membrane of varying
density, the cataract was defined as a membranous cataract.
Fig. 4: A lens with a rosette pattern of opacity was classified as a rosette type cataract.
Fig. 5: Distribution of cataracts based on the ocular injury, as per the BETTS classification.
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The English in this document has been checked by at least two professional editors, both native speakers
of English. For a certificate, please see:
http://www.textcheck.com/certificate/rbgCMs
Contributor ship Statement:
Mehul Shah: Concept design study, surgeon, writing
Shreya Shah: Administrative support, writing, data analyses
Shashank Shah: Data collection, language editing
Chintan Patel: Data collection proof reading and editing
Utsav Patel: Data collection and editing
Aashish Gupta: Editing revisions
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Morphology of traumatic cataract: does it play role in final
visual outcome? A hospital based cohort study
Journal: BMJ Open
Manuscript ID: BMJ Open.2011.000060.R9
Article Type: Research
Date Submitted by the Author:
16-Jun-2011
Complete List of Authors: Shah, Mehul; Drashti Netralaya, Ophthalmology; Drashti Netralaya, Ophthalmology Shah, Shreya; Drashti Netralaya, Ophthalmology Shah, Shashank; Drashti Netralaya, Ophthalmology Patel, Chintan; Drashti Netralaya, Ophthalmology Patel, Utsav; Drashti Netralaya, Ophthalmology Gupta, Asheesh; Drashti Netralaya, Ocular Trauma
<b>Primary Subject Heading</b>:
Ophthalmology
Keywords: Vetreoretinal < OPHTHALMOLOGY, Anaesthesia in ophthalmology < ANAESTHETICS, Cataract and refractive surgery < OPHTHALMOLOGY
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Title: Morphology of traumatic cataract: does it play a role in final visual outcome?
Short running head: Morphology of traumatic cataract
Authors:
Name Degree E-mail
Dr. Mehul A. Shah
MD omtrust@rediffmail.com
Dr Shreya M. Shah
MD shah_shreya2000@yahoo.com
Dr. Shashank B. Shah MBBS sbshah@indiatimes.com
Dr. Chintan G. Patel MBBS cgp@drashtinetralaya.org
Dr Utsav A. Patel MBBS uap@drashtinetralaya.org
Affiliations of all authors:
Drashti Netralaya, Dahod, Gujarat, India
Address of corresponding author:
Drashti Netralaya,
Nr. GIDC, Chakalia Road.
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Dahod-389151
Gujarat
Ph: 00-91-2673-645364 Fax: 00-91-2673-221232
Email: omtrust@rdiffmail.com
No financial support was received from any company or institution.
This study has not been presented at any conference or meeting.
The authors do not have any financial interests in any aspect of this study.
Conflicting interests: None to declare.
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Abstract:
Purpose: To study morphology of traumatic cataract as a important predictor for final visual
outcome after treatment of traumatic cataracts.
Setting: Tertiary eye care centre in Dahod at the trijunction of Gujarat, Madhya Pradesh, and
Rajasthan states in central western India.
Methods: This was a prospective observational cohort study among all patients presenting at our
hospital with traumatic cataracts between January 2003 and December 2009. All information
regarding demographic and ocular trauma was collected on a pre-tested World Eye Trauma
Registry form for both the first visit and follow-up.
In particular, we collected specific information about the morphology of traumatic cataracts;
surgical technique was determined accordingly.
Data were entered and analysed with regard to the relationship between type of trauma and
resulting injury, results achieved with particular surgical techniques, and the relationship
between morphology and final visual outcome.
Outcome measures: Final visual outcome.
Results: Traumatic cataracts of different morphologies showed significant differences in final
visual outcome (χ2 test, P = 0.014).
Conclusion: The morphology of traumatic cataract plays an important role in final visual
outcome.
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Article Summery:
Article Focus:
• Using morphological classification to guide decisions on operative technique; that
outcomes after surgery are reported by morphology and surgical technique; and the
possible role of morphology is explored.
Key Message:
• It is an uncontrolled prospective cohort study
Strength and weakness:
Strength: Larger database and Usage of standard classification method-BETTS Limitation:
Included many neglected injury cases.
Weakness: Uncontrolled study, One third enrolment from outreach limits generalization of
findings, Short follow up. Loss of follow up of 12 patients at various stages of study.
Introduction:
Trauma is a cause of monocular blindness in the developed world, although few studies
have addressed the problem of trauma in rural areas.1 The aetiology of ocular injury in rural
areas is likely to differ from that in urban areas and is worthy of investigation.2-4
Any strategy
for prevention requires knowledge of the cause of injury, which may enable more appropriate
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targeting of resources toward preventing such injuries. Eye trauma represents a large, potentially
preventable burden on both victims and society as a whole.3
Ocular trauma can cause cataracts.1 The methods used to evaluate the visual outcome in
eyes managed for traumatic cataracts and senile cataracts are similar,5 but the damage to other
ocular tissues due to trauma may compromise the visual gain in eyes treated surgically for
traumatic cataracts. Hence, the success rates may differ between eyes with these two types of
cataract.
With the introduction of the Birmingham Eye Trauma Terminology System (BETTS),
the documentation of ocular trauma has been standardised.5
Our study was conducted in a city located at the intersection of the borders of three states
in India: Gujarat, Madhya Pradesh, and Rajasthan.11
Qualified ophthalmologists at our institute
provide low-cost eye services mainly to the poor belonging to the tribal population of 4.2 million
in this area.
There is no standard methodology for classification of traumatic cataract.
Patients and Methods:
We obtained approval from the hospital administrators and research committee to
conduct this study, and all participants provided written informed consent.
This was a prospective study designed in 2002. All traumatic cataracts in either eye
diagnosed and managed between January 2003 and December 2009 were included in the study,
and patients consenting to participate and without other serious body injuries were included.
Outreach activities included five different service deliveries mobile diagnostic camps, school
screening, mobile vision center, door to door call of patients and health worker network.
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For each patient enrolled in our study, we obtained a detailed history, including details of
the injury and information on eye treatment and surgery performed to manage past ocular
trauma. Data for both the initial and follow-up reports were collected using the online BETTS
format of the International Society of Ocular Trauma. Details of the surgery were also collected
using a specified pre-tested online form.
The cases of traumatic cataract were grouped as those with open- and those with closed-
globe injuries. The open-globe injuries were further categorised into those with lacerations and
those with rupture. Lacerations of the eyeball were subcategorised into eyes with perforating
injuries, penetrating injuries, or injuries involving an intraocular foreign body. The closed-globe
group was subdivided into lamellar laceration and contusion.
Other demographic details collected included patient entry, residence, activity at the time
of injury, object of injury, and previous examinations and treatments. After enrolment, all
patients were examined using a standard method. Visual acuity was checked using a Snellen
chart, and the anterior segment was examined using a slit lamp.
Based on lenticular opacity, the cataracts were classified as total (Figure 1), membranous
in which both capsules fused with scant or no cortical material (Figure 2), white soft (Figure 3),
and rosette types (Figure 4). When an ophthalmologist did not observe clear lens matter between
the capsule and nucleus, the cataract was defined as total. When the capsule and organised
matter were fused and formed a membrane of varying density, it was defined as a membranous
cataract. When loose cortical material was found in the anterior chamber together with a
ruptured lens capsule, the cataract was defined as white soft. A lens with a rosette pattern of
opacity was classified as a rosette type cataract.
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For a partially opaque lens, the posterior segment examination was carried out with an
indirect ophthalmoscope and a +20 D lens. When the optical medium was not clear, a B-scan
was performed to evaluate the posterior segment.
The surgical technique was selected according to morphology and the condition of
tissues other than the lens. Phacoemulsification was used to treat cataracts with hard, large
nuclei. With a lens that had either a white soft or rosette type of cataract, unimanual or bimanual
aspiration was used. Membranectomy and anterior vitrectomy, via either the anterior or pars
plana route, were performed when the cataract was membranous.
In all patients undergoing corneal wound repair, the traumatic cataract was managed in a
second procedure. Recurrent inflammation was more prominent in patients who had undergone
previous surgery for trauma.9,10
In these cases, the ocular medium may become hazy owing to
condensation of the anterior vitreous unless a vitrectomy is performed. Hence, we performed a
capsulectomy and vitrectomy via the anterior/pars plana route in adults.
In children younger than 2 years of age, both a lensectomy and vitrectomy via the pars
plana route were performed, and the same surgical procedures were used to manage the
traumatic cataract, with secondary implants done as a separate procedure after the age of 2 years.
Lens implantation as part of the primary procedure was avoided in all children younger than 2
years of age. All children were evaluated for amblyopia and were treated with the aid of
paediatric ophthalmologists and paediatric optometrists.
All patients with injuries and without infection were treated with topical and systemic
corticosteroids and cycloplegics. The duration of medical treatment depended on the degree of
inflammation in the anterior and posterior segments of the operated eye. The operated patients
were re-examined after 24 h, 3 days, and 1, 2, and 6 weeks to enable refractive correction.
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Follow-up was scheduled for the third day, weekly for 6 weeks, monthly for 3 months, and every
3 months for 1 year.
At all follow-up examinations, visual acuity was tested using a Snellen chart. The
anterior segment was examined with a slit lamp, and the posterior segment was examined with
an indirect ophthalmoscope. Eyes with vision better than 20/60 at the glasses appointment (6
weeks) were defined as having a satisfactory grade of vision.
During the examination, data were entered online using a specified pre-tested format
designed by the International Society of Ocular Trauma (initial and follow-up forms), which was
exported to a Microsoft Excel spreadsheet. The data were audited periodically to ensure
completeness. We used SPSS 15 software to analyse the data. The univariate parametric method
was used to calculate frequency, percentage, proportion, and 95% confidence interval (95% CI).
We used binominal regression analysis to determine the predictors of postoperative satisfactory
vision (> 20/60). The dependent variable was vision >20/60 noted at follow-up 6 weeks after
cataract surgery. The independent variables were age, gender, residence, time interval between
injury and cataract surgery, primary posterior capsulectomy and vitrectomy procedure, and type
of ocular injury.
Results:
Our cohort consisted of 687 (72.2) patients with traumatic cataracts (Figure 5), including 496
eyes with open-globe ocular injuries and 191 (27.8%) eyes with closed-globe injuries (Figure 5).
The patients were 492 (71.6%) males and 195 (28.4%) females. The mean patient age was
27.1 ± 18.54 years (range, 1–80).
We analysed several demographic factors, including gender (P = 0.340), patient entry
(P = 0.4), and socioeconomic status (79% were from lower socioeconomic class and residence;
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95% were from rural areas). None of these showed a significant relationship with final visual
acuity, according to cross-tabulation and statistical tests. The object causing the injury (P = 0.3)
and the activity at the time of the injury (P = 0.3) were also not significantly associated with
satisfactory final visual acuityAll traumatic cataracts were classified according to morphology
(Tables 1 and 2) and were surgically treated using morphology as a guideline. (Table 3)
The number of surgeries required varied significantly with morphology (P = 0.000)
(Table 4).
Final visual outcome was found to vary according to morphology and surgical technique.
White soft cataracts had a better prognosis and achieved significantly higher rates of positive
outcome compared with other morphologies (P = 0.014) (Table 5).
Lens implants were applied in 82% of the cases; the details are shown in Table 6. There
was a significant difference between open and closed injury groups for various age groups (P =
0.000).
There was no significant difference in final visual outcome in children between open
and closed injury groups (P = 0.06). Significant difference found if we compare final visual
outcome before and after treatment. (P=000)Table-8 A significant relationship was found
between age and final visual outcome (P = 0.000) final visual outcome is better in younger age
group. (Table-9) When time interval between injury and intervention was study there is
significant (p=0.000) effect on final visual outcome.11
Discussion:
Using a large database, we attempted to systematically classify the morphology of
traumatic cataract and to select surgical techniques accordingly.
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Previous studies have touched on this topic. One study found 52.3% total cataracts,
whereas our results revealed 26.6% total cataracts.7 Vajpayee reported opening in the posterior
capsule with type 1 and 2 openings with penetrating injury,8 whereas we found another
membranous type of cataract (12.1%) suggestive of late reporting, as membranous
transformation of the lens with fusion of the anterior and posterior capsules may occur over
time.
We were able to perform intraocular lens implants in 82.1% of the cases.
Krishnamachary reported implants in 65.5% of cases, Churchill et al. reported implants in
46.8%, and Fyodorov reported Sputnik implants in all cases.7,9,10
Fyodorov reported surgical techniques according to pathology and degree of lens
absorption, but did not systematically classify similar factors taken into account in our study.10
These differences in findings may reflect the fact that of the 687 patients in our study,
30% came from outreach activities and did not approach treatment facilities on their own.
Therefore, the time period between ocular injury and reporting ranged widely, and morphology
was also influenced by this interval.
We share our experience with treatment strategy for different morphological verities of
traumatic cataracts, As an uncontrolled study it cannot provide firm evidence that this strategy
led to improved outcomes, but it does provide a large dataset to help develop further research
questions.
Morphology of traumatic cataract appeared to be associated with final visual outcome
following surgical treatment.
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References:
1. Khatry SK, Lewis AE, Schein OD et al. The epidemiology of ocular trauma in rural
Nepal. Br J Ophthalmol. 2004; 88:456-60.
2. Abraham, DI; Vitale SI; West SI et al. Epidemiology of eye injuries in rural Tanzania.
Ophthalmic Epidemiol.1999; 6:85-94
3. D. Virgil Alfaro, Eric P. Jablon, Monica Rodriguez Fontal et al. Fishing-related ocular
trauma. American Journal of Ophthalmology.2005; 139: 488-492
4. Shah M, Shah S, Khandekar R. Ocular injuries and visual status before and after Their
management in the tribal areas of Western India-A historical cohort study Grafes Arch
Clin Exp Ophthalmol 2008; 246:191–197.
5. Kuhn F, Morris R, Witherspoon CD et al. The Birmingham Eye Trauma Terminology
system (BETT). J Fr Ophtalmol. 2004; 27:206-10.
6. Vajpayee RB, Sharma N, Dada T et al. Management of posterior capsule tears. Surv
Ophthalmol 2001;45:473-88.
7. Krishnamachary M, Rathi V, Gupta S. Management of traumatic cataract in children. J
Cataract Refract Surg 1997; 23:681-7.
8. Churchill AJ, Noble BA, Etchells DE et al. Factors affecting visual outcome in children
following uniocular traumatic cataract. Eye (Lond) 1995;9:285-91
9. Thylefors B, Chylack LT Jr, Konyama K, et al. A simplified cataract grading system.
Ophthalmic Epidemiol. 2002; 9:83-95.
10. Fyodorov SN, Egorova EV, Zubareva LN. 1004 cases of traumatic cataract surgery with
implantation of an intraocular lens. J Am Intraocul Implant Soc 1981;7:147-53.
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11. Shah MA, Shah SM, Shah SB, et al Effect of interval between time of injury and timing
of intervention on final visual outcome in cases of traumatic cataract. Eur J Ophthalmol.
2011 Mar 24. pii: 338AC21D-E9FB-42DF-9C28-6FDE61928C9D. doi:
10.5301/EJO.2011.6482. [Epub ahead of print]
Table 1. Distribution of different morphologies of traumatic cataract
Morphology N Percent
Membranous
84 12.2
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8
1.2
412
60.0
183 26.6
Rosette
White soft
Total
Total 687 100.0
Table 2. Morphology of traumatic cataract according to type of injury
BETT Category Closed globe Open globe Total
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Morphology N % N % N %
20 2.9 64 9.3 84 12.2
3 0.4 5 0.7 8 1.1
83 12.1 329 47.9 412 59.9
Membranous
Rosette
White Soft with ruptured
Anterior capsule
Total
85 12.4 98 14.3 183 26.6
Total
191 27.8 496 72.2 687 100
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Table 3. Surgical techniques used according to morphology of cataract
Morphology
Membranous Rosette White soft Total
Total
Surgical Technique
N % N % N % N % N %
7 1 5 0.7 316 45.9 19 2.7 347 50.5
46 6.7 0 0 60 8.7 20 2.9 126 18.3
3 0.4 2 0.3 17 2.4 108 15.7 130 18.9
Aspiration
Lensectomy + Vitrectomy
Phaco/SICS*
Delivery + vitrectomy
28 4 0 0 20 2.9 36 5.2 84 12.2
Total 83 12.1 7 1 412 59.9 183 26.6 687 100
*Small Incision Cataract Surgery
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Table 4. Morphology of cataract in relation to number of surgical procedures
Morphology
Membranous Rosette White soft Total Total
N N % N % N % N % N &
70 10.1 6 0.8 349 50.8 159 23.1 584 85.0
12 1.7 2 0.2 58 8.4 22 3.2 94 13.7
2 0.3 0 0 5 0.7 2 0.2 9 1.3
1.00
2.00
3.00
Total 84 12.2 8 1 412 59.9 183 26.6 687 100
χ 2 test, P = 0.000
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Table 5. Final visual outcome in relation to morphology of cataract
Final visual outcome Morphology
Membranous Rosette White soft Total Total
N % N % N % N % N %
3 0.4 0 0 11 1.6 5 0.7 19 2.7
24 3.5 2 0.3 89 12.9 58 8.4 173 25.1
12 1.7 0 0 27 3.9 19 2.7 58 8.4
7 1.0 1 0.1 33 4.8 25 3.6 66 9.6
21 3.0 1 0.1 91 13.2 34 4.9 147 21.4
Uncooperative
<1/60
1/60 to 3/60
20/200 to 20/120
20/80 to 20/60
20/40 to 20/20 17 2.5 4 0.5 161 23.4 42 6.1 224 32.6
Total 83 12.1 7 1.0 412 59.9 183 26.6 687 100
χ 2 test, P = 0.014
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Table 6. Lens implant in relation to morphology of traumatic cataract
Morphology No implant Implant Total
N % N % N %
17 2.5 67 9.8 84 12.2
2 0.3 6 0.9 8 1.2
58 8.4 354 51.5 412 60.0
46 6.7 137 19.9 183 26.6
Membranous
Rosette
White soft
Total
Total 123 17.9 564 82.1 687 100
χ 2 test, p = 0.004
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Table-7. Comparison of open closed globe injuries in children
Category Closed globe Open globe Total
N % N % N %
54 7.7 253 36.8 307 44.7 Pediatric
Adult 137 19.9 243 35.3 380 55.3
Total 191 27.8 496 72.1 687 100
χ 2 test, p=0.000
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Table-8, Comparative visual acuity before and after treatment
Post treatment vision Pre op vision uncooperative <1/60
1/60 to 3/60
20/200 to 20/120
20/80 to 20 /60
20/40 to 20/20
Total E
uncooperative 7 1.01 0 0 0 0 0 0 1 0.14 2 0.29 10 1.45
<1/60
10 1.45 164 23.87 53 7.71 54 7.86 110 16.01 191 27.80 582 84.71
1/60 to 3/60
0 0 4 0.58 3 0.43 8 1.16 21 3.05 10 1.45 46 6.69
6/60 to 6/36
0 0 0 0 0 0 1 0.14 7 1.01 12 1.74 20 2.91
6/24 to 6/18
0 0 3 0.43 0 0 1 0.14 6 0.87 7 1.01 17 2.47
6/12 to 6/6
0 0 0 0 0 0 0 0 0 0 1 0.14 1 0.14
Total 17 2.47 171 24.89 55 8.00 64 9.31 145 21.10 223 32.45 675 98.5
χ 2 test, p=0.000
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Table-9, Effect age group on final visual outcome.
Age Un
cooperative <1/60 1/60 to
3/60 20/200 to
20/120 20/80 to
20/60 20/40 to
20/20 Total
n % n % n % n % n % n % n %
0 to 10 9 1.31 46 6.69 15 2.18 12 1.74 37 5.38 34 4.94 153 22.27
11 to 20
2 0.29 30 4.36 14 2.03 17 2.47 33 4.80 87 12.66 183 26.63
21 to 30
2 0.29 19 2.76 8 1.16 6 0.87 12 1.74 42 6.11 89 12.95
31 to 40
1 0.14 23 3.35 5 0.73 7 1.01 16 2.32 25 3.63 77 11.2
41 to 50
3 0.43 23 3.35 6 0.87 12 1.74 28 4.07 22 3.20 94 13.68
51 to 60
0 0.0 21 3.00 7 1.01 6 0.87 8 1.16 11 1.60 53 7.71
61 to 70
0 0.0 8 1.16 0 0 2 0.29 10 1.45 2 0.29 22 3.20
71 to 80
0 0.0 1 0.14 0 0 2 0.29 1 0.14 0 0 4 0.58
Total 17 2.47 173 25.18 55 8.00 64 9.31 146 21.25 223 32.45 675 98.5
χ 2 test, p=0.000
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Figure Legends:
Fig. 1: When no clear lens matter was visible between the capsule and the nucleus, the cataract
was defined as a total cataract.
Fig. 2: When loose cortical material was found in the anterior chamber together with a ruptured
lens capsule, the cataract was defined as a white soft cataract.
Fig. 3: When the capsule and organised matter were fused and formed a membrane of varying
density, the cataract was defined as a membranous cataract.
Fig. 4: A lens with a rosette pattern of opacity was classified as a rosette type cataract.
Fig. 5: Distribution of cataracts based on the ocular injury, as per the BETTS classification.
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The English in this document has been checked by at least two professional editors, both native speakers
of English. For a certificate, please see:
http://www.textcheck.com/certificate/rbgCMs
Contributor ship Statement:
Mehul Shah: Concept design study, surgeon, writing
Shreya Shah: Administrative support, writing, data analyses
Shashank Shah: Data collection, language editing
Chintan Patel: Data collection proof reading and editing
Utsav Patel: Data collection and editing
Aashish Gupta: Editing revisions
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Title: Morphology of traumatic cataract: does it play a role in final visual outcome?
Short running head: Morphology of traumatic cataract
Authors:
Name Degree E-mail
Dr. Mehul A. Shah
MD omtrust@rediffmail.com
Dr Shreya M. Shah
MD shah_shreya2000@yahoo.com
Dr. Shashank B. Shah MBBS sbshah@indiatimes.com
Dr. Chintan G. Patel MBBS cgp@drashtinetralaya.org
Dr Utsav A. Patel MBBS uap@drashtinetralaya.org
Affiliations of all authors:
Drashti Netralaya, Dahod, Gujarat, India
Address of corresponding author:
Drashti Netralaya,
Nr. GIDC, Chakalia Road.
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Dahod-389151
Gujarat
Ph: 00-91-2673-645364 Fax: 00-91-2673-221232
Email: omtrust@rdiffmail.com
No financial support was received from any company or institution.
This study has not been presented at any conference or meeting.
The authors do not have any financial interests in any aspect of this study.
Conflicting interests: None to declare.
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Abstract:
Purpose: To study morphology of traumatic cataract as a important predictor for final visual
outcome after treatment of traumatic cataracts.
Setting: Tertiary eye care centre in Dahod at the trijunction of Gujarat, Madhya Pradesh, and
Rajasthan states in central western India.
Methods: This was a prospective observational cohort study among all patients presenting at our
hospital with traumatic cataracts between January 2003 and December 2009. All information
regarding demographic and ocular trauma was collected on a pre-tested World Eye Trauma
Registry form for both the first visit and follow-up.
In particular, we collected specific information about the morphology of traumatic cataracts;
surgical technique was determined accordingly.
Data were entered and analysed with regard to the relationship between type of trauma and
resulting injury, results achieved with particular surgical techniques, and the relationship
between morphology and final visual outcome.
Outcome measures: Final visual outcome.
Results: Traumatic cataracts of different morphologies showed significant differences in final
visual outcome (χ2 test, P = 0.014).
Conclusion: The morphology of traumatic cataract plays an important role in final visual
outcome.
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Article Summery:
Article Focus:
• Using morphological classification to guide decisions on operative technique; that
outcomes after surgery are reported by morphology and surgical technique; and the
possible role of morphology is explored.
Key Message:
• It is an uncontrolled prospective cohort study
Strength and weakness:
Strength: Larger database and Usage of standard classification method-BETTS Limitation:
Included many neglected injury cases.
Weakness: Uncontrolled study, One third enrolment from outreach limits generalization of
findings, Short follow up. Loss of follow up of 12 patients at various stages of study.
Introduction:
Trauma is a cause of monocular blindness in the developed world, although few studies
have addressed the problem of trauma in rural areas.1 The aetiology of ocular injury in rural
areas is likely to differ from that in urban areas and is worthy of investigation.2-4
Any strategy
for prevention requires knowledge of the cause of injury, which may enable more appropriate
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targeting of resources toward preventing such injuries. Eye trauma represents a large, potentially
preventable burden on both victims and society as a whole.3
Ocular trauma can cause cataracts.1 The methods used to evaluate the visual outcome in
eyes managed for traumatic cataracts and senile cataracts are similar,5 but the damage to other
ocular tissues due to trauma may compromise the visual gain in eyes treated surgically for
traumatic cataracts. Hence, the success rates may differ between eyes with these two types of
cataract.
With the introduction of the Birmingham Eye Trauma Terminology System (BETTS),
the documentation of ocular trauma has been standardised.5
Our study was conducted in a city located at the intersection of the borders of three states
in India: Gujarat, Madhya Pradesh, and Rajasthan.11
Qualified ophthalmologists at our institute
provide low-cost eye services mainly to the poor belonging to the tribal population of 4.2 million
in this area.
There is no standard methodology for classification of traumatic cataract.
Patients and Methods:
We obtained approval from the hospital administrators and research committee to
conduct this study, and all participants provided written informed consent.
This was a prospective study designed in 2002. All traumatic cataracts in either eye
diagnosed and managed between January 2003 and December 2009 were included in the study,
and patients consenting to participate and without other serious body injuries were included.
Outreach activities included five different service deliveries mobile diagnostic camps, school
screening, mobile vision center, door to door call of patients and health worker network.
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For each patient enrolled in our study, we obtained a detailed history, including details of
the injury and information on eye treatment and surgery performed to manage past ocular
trauma. Data for both the initial and follow-up reports were collected using the online BETTS
format of the International Society of Ocular Trauma. Details of the surgery were also collected
using a specified pre-tested online form.
The cases of traumatic cataract were grouped as those with open- and those with closed-
globe injuries. The open-globe injuries were further categorised into those with lacerations and
those with rupture. Lacerations of the eyeball were subcategorised into eyes with perforating
injuries, penetrating injuries, or injuries involving an intraocular foreign body. The closed-globe
group was subdivided into lamellar laceration and contusion.
Other demographic details collected included patient entry, residence, activity at the time
of injury, object of injury, and previous examinations and treatments. After enrolment, all
patients were examined using a standard method. Visual acuity was checked using a Snellen
chart, and the anterior segment was examined using a slit lamp.
Based on lenticular opacity, the cataracts were classified as total (Figure 1), membranous
in which both capsules fused with scant or no cortical material (Figure 2), white soft (Figure 3),
and rosette types (Figure 4). When an ophthalmologist did not observe clear lens matter between
the capsule and nucleus, the cataract was defined as total. When the capsule and organised
matter were fused and formed a membrane of varying density, it was defined as a membranous
cataract. When loose cortical material was found in the anterior chamber together with a
ruptured lens capsule, the cataract was defined as white soft. A lens with a rosette pattern of
opacity was classified as a rosette type cataract.
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For a partially opaque lens, the posterior segment examination was carried out with an
indirect ophthalmoscope and a +20 D lens. When the optical medium was not clear, a B-scan
was performed to evaluate the posterior segment.
The surgical technique was selected according to morphology and the condition of
tissues other than the lens. Phacoemulsification was used to treat cataracts with hard, large
nuclei. With a lens that had either a white soft or rosette type of cataract, unimanual or bimanual
aspiration was used. Membranectomy and anterior vitrectomy, via either the anterior or pars
plana route, were performed when the cataract was membranous.
In all patients undergoing corneal wound repair, the traumatic cataract was managed in a
second procedure. Recurrent inflammation was more prominent in patients who had undergone
previous surgery for trauma.9,10
In these cases, the ocular medium may become hazy owing to
condensation of the anterior vitreous unless a vitrectomy is performed. Hence, we performed a
capsulectomy and vitrectomy via the anterior/pars plana route in adults.
In children younger than 2 years of age, both a lensectomy and vitrectomy via the pars
plana route were performed, and the same surgical procedures were used to manage the
traumatic cataract, with secondary implants done as a separate procedure after the age of 2 years.
Lens implantation as part of the primary procedure was avoided in all children younger than 2
years of age. All children were evaluated for amblyopia and were treated with the aid of
paediatric ophthalmologists and paediatric optometrists.
All patients with injuries and without infection were treated with topical and systemic
corticosteroids and cycloplegics. The duration of medical treatment depended on the degree of
inflammation in the anterior and posterior segments of the operated eye. The operated patients
were re-examined after 24 h, 3 days, and 1, 2, and 6 weeks to enable refractive correction.
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Follow-up was scheduled for the third day, weekly for 6 weeks, monthly for 3 months, and every
3 months for 1 year.
At all follow-up examinations, visual acuity was tested using a Snellen chart. The
anterior segment was examined with a slit lamp, and the posterior segment was examined with
an indirect ophthalmoscope. Eyes with vision better than 20/60 at the glasses appointment (6
weeks) were defined as having a satisfactory grade of vision.
During the examination, data were entered online using a specified pre-tested format
designed by the International Society of Ocular Trauma (initial and follow-up forms), which was
exported to a Microsoft Excel spreadsheet. The data were audited periodically to ensure
completeness. We used SPSS 15 software to analyse the data. The univariate parametric method
was used to calculate frequency, percentage, proportion, and 95% confidence interval (95% CI).
We used binominal regression analysis to determine the predictors of postoperative satisfactory
vision (> 20/60). The dependent variable was vision >20/60 noted at follow-up 6 weeks after
cataract surgery. The independent variables were age, gender, residence, time interval between
injury and cataract surgery, primary posterior capsulectomy and vitrectomy procedure, and type
of ocular injury.
Results:
Our cohort consisted of 687 (72.2) patients with traumatic cataracts (Figure 5), including 496
eyes with open-globe ocular injuries and 191 (27.8%) eyes with closed-globe injuries (Figure 5).
The patients were 492 (71.6%) males and 195 (28.4%) females. The mean patient age was
27.1 ± 18.54 years (range, 1–80).
We analysed several demographic factors, including gender (P = 0.340), patient entry
(P = 0.4), and socioeconomic status (79% were from lower socioeconomic class and residence;
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95% were from rural areas). None of these showed a significant relationship with final visual
acuity, according to cross-tabulation and statistical tests. The object causing the injury (P = 0.3)
and the activity at the time of the injury (P = 0.3) were also not significantly associated with
satisfactory final visual acuityAll traumatic cataracts were classified according to morphology
(Tables 1 and 2) and were surgically treated using morphology as a guideline. (Table 3)
The number of surgeries required varied significantly with morphology (P = 0.000)
(Table 4).
Final visual outcome was found to vary according to morphology and surgical technique.
White soft cataracts had a better prognosis and achieved significantly higher rates of positive
outcome compared with other morphologies (P = 0.014) (Table 5).
Lens implants were applied in 82% of the cases; the details are shown in Table 6. There
was a significant difference between open and closed injury groups for various age groups (P =
0.000).
There was no significant difference in final visual outcome in children between open
and closed injury groups (P = 0.06). Significant difference found if we compare final visual
outcome before and after treatment. (P=000)Table-8 A significant relationship was found
between age and final visual outcome (P = 0.000) final visual outcome is better in younger age
group. (Table-9) When time interval between injury and intervention was study there is
significant (p=0.000) effect on final visual outcome.11
Discussion:
Using a large database, we attempted to systematically classify the morphology of
traumatic cataract and to select surgical techniques accordingly.
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Previous studies have touched on this topic. One study found 52.3% total cataracts,
whereas our results revealed 26.6% total cataracts.7 Vajpayee reported opening in the posterior
capsule with type 1 and 2 openings with penetrating injury,8 whereas we found another
membranous type of cataract (12.1%) suggestive of late reporting, as membranous
transformation of the lens with fusion of the anterior and posterior capsules may occur over
time.
We were able to perform intraocular lens implants in 82.1% of the cases.
Krishnamachary reported implants in 65.5% of cases, Churchill et al. reported implants in
46.8%, and Fyodorov reported Sputnik implants in all cases.7,9,10
Fyodorov reported surgical techniques according to pathology and degree of lens
absorption, but did not systematically classify similar factors taken into account in our study.10
These differences in findings may reflect the fact that of the 687 patients in our study,
30% came from outreach activities and did not approach treatment facilities on their own.
Therefore, the time period between ocular injury and reporting ranged widely, and morphology
was also influenced by this interval.
We share our experience with treatment strategy for different morphological verities of
traumatic cataracts, As an uncontrolled study it cannot provide firm evidence that this strategy
led to improved outcomes, but it does provide a large dataset to help develop further research
questions.
Morphology of traumatic cataract appeared to be associated with final visual outcome
following surgical treatment.
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References:
1. Khatry SK, Lewis AE, Schein OD et al. The epidemiology of ocular trauma in rural
Nepal. Br J Ophthalmol. 2004; 88:456-60.
2. Abraham, DI; Vitale SI; West SI et al. Epidemiology of eye injuries in rural Tanzania.
Ophthalmic Epidemiol.1999; 6:85-94
3. D. Virgil Alfaro, Eric P. Jablon, Monica Rodriguez Fontal et al. Fishing-related ocular
trauma. American Journal of Ophthalmology.2005; 139: 488-492
4. Shah M, Shah S, Khandekar R. Ocular injuries and visual status before and after Their
management in the tribal areas of Western India-A historical cohort study Grafes Arch
Clin Exp Ophthalmol 2008; 246:191–197.
5. Kuhn F, Morris R, Witherspoon CD et al. The Birmingham Eye Trauma Terminology
system (BETT). J Fr Ophtalmol. 2004; 27:206-10.
6. Vajpayee RB, Sharma N, Dada T et al. Management of posterior capsule tears. Surv
Ophthalmol 2001;45:473-88.
7. Krishnamachary M, Rathi V, Gupta S. Management of traumatic cataract in children. J
Cataract Refract Surg 1997; 23:681-7.
8. Churchill AJ, Noble BA, Etchells DE et al. Factors affecting visual outcome in children
following uniocular traumatic cataract. Eye (Lond) 1995;9:285-91
9. Thylefors B, Chylack LT Jr, Konyama K, et al. A simplified cataract grading system.
Ophthalmic Epidemiol. 2002; 9:83-95.
10. Fyodorov SN, Egorova EV, Zubareva LN. 1004 cases of traumatic cataract surgery with
implantation of an intraocular lens. J Am Intraocul Implant Soc 1981;7:147-53.
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11. Shah MA, Shah SM, Shah SB, et al Effect of interval between time of injury and timing
of intervention on final visual outcome in cases of traumatic cataract. Eur J Ophthalmol.
2011 Mar 24. pii: 338AC21D-E9FB-42DF-9C28-6FDE61928C9D. doi:
10.5301/EJO.2011.6482. [Epub ahead of print]
Table 1. Distribution of different morphologies of traumatic cataract
Morphology N Percent
Membranous
84 12.2
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8
1.2
412
60.0
183 26.6
Rosette
White soft
Total
Total 687 100.0
Table 2. Morphology of traumatic cataract according to type of injury
BETT Category Closed globe Open globe Total
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Morphology N % N % N %
20 2.9 64 9.3 84 12.2
3 0.4 5 0.7 8 1.1
83 12.1 329 47.9 412 59.9
Membranous
Rosette
White Soft with ruptured
Anterior capsule
Total
85 12.4 98 14.3 183 26.6
Total
191 27.8 496 72.2 687 100
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Table 3. Surgical techniques used according to morphology of cataract
Morphology
Membranous Rosette White soft Total
Total
Surgical Technique
N % N % N % N % N %
7 1 5 0.7 316 45.9 19 2.7 347 50.5
46 6.7 0 0 60 8.7 20 2.9 126 18.3
3 0.4 2 0.3 17 2.4 108 15.7 130 18.9
Aspiration
Lensectomy + Vitrectomy
Phaco/SICS*
Delivery + vitrectomy
28 4 0 0 20 2.9 36 5.2 84 12.2
Total 83 12.1 7 1 412 59.9 183 26.6 687 100
*Small Incision Cataract Surgery
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Table 4. Morphology of cataract in relation to number of surgical procedures
Morphology
Membranous Rosette White soft Total Total
N N % N % N % N % N &
70 10.1 6 0.8 349 50.8 159 23.1 584 85.0
12 1.7 2 0.2 58 8.4 22 3.2 94 13.7
2 0.3 0 0 5 0.7 2 0.2 9 1.3
1.00
2.00
3.00
Total 84 12.2 8 1 412 59.9 183 26.6 687 100
χ 2 test, P = 0.000
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Table 5. Final visual outcome in relation to morphology of cataract
Final visual outcome Morphology
Membranous Rosette White soft Total Total
N % N % N % N % N %
3 0.4 0 0 11 1.6 5 0.7 19 2.7
24 3.5 2 0.3 89 12.9 58 8.4 173 25.1
12 1.7 0 0 27 3.9 19 2.7 58 8.4
7 1.0 1 0.1 33 4.8 25 3.6 66 9.6
21 3.0 1 0.1 91 13.2 34 4.9 147 21.4
Uncooperative
<1/60
1/60 to 3/60
20/200 to 20/120
20/80 to 20/60
20/40 to 20/20 17 2.5 4 0.5 161 23.4 42 6.1 224 32.6
Total 83 12.1 7 1.0 412 59.9 183 26.6 687 100
χ 2 test, P = 0.014
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Table 6. Lens implant in relation to morphology of traumatic cataract
Morphology No implant Implant Total
N % N % N %
17 2.5 67 9.8 84 12.2
2 0.3 6 0.9 8 1.2
58 8.4 354 51.5 412 60.0
46 6.7 137 19.9 183 26.6
Membranous
Rosette
White soft
Total
Total 123 17.9 564 82.1 687 100
χ 2 test, p = 0.004
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Table-7. Comparison of open closed globe injuries in children
Category Closed globe Open globe Total
N % N % N %
54 7.7 253 36.8 307 44.7 Pediatric
Adult 137 19.9 243 35.3 380 55.3
Total 191 27.8 496 72.1 687 100
χ 2 test, p=0.000
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Table-8, Comparative visual acuity before and after treatment
Post treatment vision Pre op vision uncooperative <1/60
1/60 to 3/60
20/200 to 20/120
20/80 to 20 /60
20/40 to 20/20
Total E
uncooperative 7 1.01 0 0 0 0 0 0 1 0.14 2 0.29 10 1.45
<1/60
10 1.45 164 23.87 53 7.71 54 7.86 110 16.01 191 27.80 582 84.71
1/60 to 3/60
0 0 4 0.58 3 0.43 8 1.16 21 3.05 10 1.45 46 6.69
6/60 to 6/36
0 0 0 0 0 0 1 0.14 7 1.01 12 1.74 20 2.91
6/24 to 6/18
0 0 3 0.43 0 0 1 0.14 6 0.87 7 1.01 17 2.47
6/12 to 6/6
0 0 0 0 0 0 0 0 0 0 1 0.14 1 0.14
Total 17 2.47 171 24.89 55 8.00 64 9.31 145 21.10 223 32.45 675 98.5
χ 2 test, p=0.000
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Table-9, Effect age group on final visual outcome.
Age Un
cooperative <1/60 1/60 to
3/60 20/200 to
20/120 20/80 to
20/60 20/40 to
20/20 Total
n % n % n % n % n % n % n %
0 to 10 9 1.31 46 6.69 15 2.18 12 1.74 37 5.38 34 4.94 153 22.27
11 to 20
2 0.29 30 4.36 14 2.03 17 2.47 33 4.80 87 12.66 183 26.63
21 to 30
2 0.29 19 2.76 8 1.16 6 0.87 12 1.74 42 6.11 89 12.95
31 to 40
1 0.14 23 3.35 5 0.73 7 1.01 16 2.32 25 3.63 77 11.2
41 to 50
3 0.43 23 3.35 6 0.87 12 1.74 28 4.07 22 3.20 94 13.68
51 to 60
0 0.0 21 3.00 7 1.01 6 0.87 8 1.16 11 1.60 53 7.71
61 to 70
0 0.0 8 1.16 0 0 2 0.29 10 1.45 2 0.29 22 3.20
71 to 80
0 0.0 1 0.14 0 0 2 0.29 1 0.14 0 0 4 0.58
Total 17 2.47 173 25.18 55 8.00 64 9.31 146 21.25 223 32.45 675 98.5
χ 2 test, p=0.000
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Figure Legends:
Fig. 1: When no clear lens matter was visible between the capsule and the nucleus, the cataract
was defined as a total cataract.
Fig. 2: When loose cortical material was found in the anterior chamber together with a ruptured
lens capsule, the cataract was defined as a white soft cataract.
Fig. 3: When the capsule and organised matter were fused and formed a membrane of varying
density, the cataract was defined as a membranous cataract.
Fig. 4: A lens with a rosette pattern of opacity was classified as a rosette type cataract.
Fig. 5: Distribution of cataracts based on the ocular injury, as per the BETTS classification.
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The English in this document has been checked by at least two professional editors, both native speakers
of English. For a certificate, please see:
http://www.textcheck.com/certificate/rbgCMs
Contributor ship Statement:
Mehul Shah: Concept design study, surgeon, writing
Shreya Shah: Administrative support, writing, data analyses
Shashank Shah: Data collection, language editing
Chintan Patel: Data collection proof reading and editing
Utsav Patel: Data collection and editing
Aashish Gupta: Editing revisions
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Fig-1: When no clear lens matter was visible between the capsule and the nucleus, the cataract was defined as a total cataract. 65x51mm (300 x 300 DPI)
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Fig-2: When loose cortical material was found in the anterior chamber together with a ruptured lens capsule, the cataract was defined as a white soft cataract with ruptured anterior capsule.
29x33mm (300 x 300 DPI)
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Fig-3: When the capsule and organized matter were fused and formed a membrane of varying density, it was defined as a membranous cataract
42x49mm (300 x 300 DPI)
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Fig-4: A lens with a rosette pattern of opacity was classified as a rosette type cataract 23x25mm (300 x 300 DPI)
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Fig-5: Distribution of cataracts based on the ocular injuries, as per the BETTS classification. 60x60mm (300 x 300 DPI)
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