Traumatic Cataracts

Background
Traumatic cataracts occur secondary to blunt or penetrating ocular
trauma. Infrared energy (glass-blower's cataract), electric shock, and
ionizing radiation are other rare causes of traumatic cataracts.[1]
Cataracts caused by blunt trauma classically form stellate- or rosetteshaped posterior axial opacities that may be stable or progressive,
whereas penetrating trauma with disruption of the lens capsule forms
cortical changes that may remain focal if small or may progress
rapidly to total cortical opacification.
Note the images below.

Classic
rosette-shaped
cataract in a 36-year-old man, 4 weeks after blunt ocular injury.

Same cataract as seen in

previous image, viewed by retroillumination.
Lens dislocation and subluxation are commonly found in conjunction
with traumatic cataract. Other associated complications include
phacolytic, phacomorphic, pupillary block, and angle-recession
glaucoma; phacoanaphylactic uveitis; retinal detachment; choroidal
rupture; hyphema; retrobulbar hemorrhage; traumatic optic
neuropathy; and globe rupture.[2, 3, 4]
Traumatic cataract can present many medical and surgical challenges
to the ophthalmologist. Careful examination and a management plan
can simplify these difficult cases and provide the best possible
outcome.[4, 5]
Pathophysiology
Blunt trauma is responsible for coup and contrecoup ocular injury.
Coup is the mechanism of direct impact. It is responsible for Vossius
ring (imprinted iris pigment) sometimes found on the anterior lens
capsule following blunt injury. Contrecoup refers to distant injury
caused by shockwaves traveling along the line of concussion. [6]
When the anterior surface of the eye is struck bluntly, there is a rapid
anterior-posterior shortening accompanied by equatorial expansion.
This equatorial stretching can disrupt the lens capsule, zonules, or
both. Combination of coup, contrecoup, and equatorial expansion is
responsible for formation of traumatic cataract following blunt ocular
injury.[7, 8, 9]
Penetrating trauma that directly compromises the lens capsule leads
to cortical opacification at the site of injury. If the rent is sufficiently
large, the entire lens rapidly opacifies, but when small, cortical
cataract can seal itself off and remain localized.
Epidemiology
Frequency
United States
Approximately 2.5 million eye injuries occur annually in the United
States. It is estimated that approximately 4-5% of a comprehensive
ophthalmologist's patients are seen secondary to ocular injury.
Traumatic cataract may present as acute, subacute, or late sequela of
ocular trauma.
Mortality/Morbidity
Trauma is the leading cause of monocular blindness in people
younger than 45 years. Annually, approximately 50,000 people are
left unable to read newsprint as a result of ocular trauma. Only 85%
patients who experience anterior segment injury reach a final visual

acuity of 20/40 or better, whereas only 40% patients with posterior

segment injury reach this level.[7, 8]
Sex
The male-to-female ratio in cases of ocular trauma is 4:1.
Age
Work- and sports-related eye injuries most commonly occur in
children and young adults. Between 1985-1991, a National Eye
Trauma System study reported a median age of 28 years in 648
assault-related cases.
History
Note the following:
Mechanism of injury - Sharp versus blunt
Past ocular history - Previous eye surgery, glaucoma, retinal
detachment, diabetic eye disease
Past medical history - Diabetes, sickle cell, Marfan syndrome,
homocystinuria, hyperlysinemia, sulfate oxidase deficiency
Visual complaints - Decreased vision (cataract, lens subluxation,
lens dislocation, ruptured globe, traumatic optic neuropathy,
vitreous hemorrhage, retinal detachment); monocular diplopia (lens
subluxation with partial phakic and aphakic vision); binocular
diplopia (traumatic nerve palsy, orbital fracture); pain (glaucoma
secondary to hyphema, pupillary block, or lens particles;
retrobulbar hemorrhage; iritis)
Physical
Complete ophthalmic examination (defer in case of globe
compromise), to include the following:
Vision and pupils - Presence of afferent pupillary defect (APD)
indicative of traumatic optic neuropathy
Extraocular motility - Orbital fractures or traumatic nerve palsy
Intraocular pressure - Secondary glaucoma, retrobulbar
hemorrhage
Anterior chamber - Hyphema, iritis, shallow chamber, iridodonesis,
angle recession
Lens - Subluxation, dislocation, capsular integrity (anterior and
posterior), cataract (extent and type), swelling, phacodonesis
Vitreous - Presence or absence of hemorrhage, posterior vitreous
detachment
Fundus - Retinal detachment, choroidal rupture, commotio retinae,
preretinal hemorrhage, intraretinal hemorrhage, subretinal
hemorrhage, optic nerve pallor, optic nerve avulsion
Causes
Traumatic cataracts occur secondary to blunt or penetrating ocular
trauma.
Differential Diagnoses
Cataract, Senile
Choroidal Rupture
Ectopia Lentis
Glaucoma, Angle Recession
Hyphema
Laceration, Corneoscleral
Sudden Visual Loss
Imaging Studies
Perform the following:
B-scan - If the posterior pole cannot be visualized
A-scan - Prior to cataract extraction
CT scan of the orbits - Fractures and foreign bodies[10, 11]
Medical Care
If glaucoma is a problem, control intraocular pressure with standard
medications. Add corticosteroids if lens particles are the cause or if
iritis is present.
For focal cataract, observation is warranted if the cataract is outside
the visual axis. Miotic therapy may be of benefit if the cataract is
close to the visual axis.
In some cases of lens subluxation, miotics may correct monocular
diplopia. Mydriatics may allow for vision around the lens with
aphakic correction.
Surgical Care
Planning the surgical approach is of the utmost importance in cases
of traumatic cataract. Preoperative capsular integrity and zonular
stability should be surmised.

In cases of posterior dislocation without glaucoma, inflammation, or

visual obstruction, surgery may be avoided.
Indications for surgery include the following:
Unacceptable decreased vision
Obstructed view of posterior pathology
Lens-induced inflammation or glaucoma
Capsular rupture with lens swelling
Other trauma-induced ocular pathology necessitating surgery
Standard phacoemulsification may be performed if the lens capsule is
intact and sufficient zonular support remains.
Intracapsular cataract extraction is required in cases of anterior
dislocation or extreme zonular instability. Anterior dislocation of the
lens into the anterior chamber requires emergency surgery for its
removal, as it can cause pupillary block glaucoma.
Pars plana lensectomy and vitrectomy may be best in cases of
posterior capsular rupture, posterior dislocation, or extreme zonular
instability.
Automated irrigation/aspiration can be used in patients younger than
35 years.
Lens implantation[12] is as follows:
Capsular fixation is the preferred placement if the lens capsule and
zonular support are intact.
Polymethyl methacrylate (PMMA) capsular tension rings allow
capsular fixation in cases of zonular dialysis less than 180 degrees.
Sulcus fixation is safe if the posterior capsule is compromised but
zonular support is maintained.[13]
Suture fixation is chosen if both capsular and zonular supports are
insufficient and the angle is minimally damaged.
Anterior chamber placement is an option if no posterior support
remains and iris or ciliary body trauma prevents suture fixation.
Aphakia may be a better choice in young children and in patients
with highly inflamed eyes, as they may experience better outcomes
if lens implantation is deferred.[14]
Consultations
Vitreoretinal consultation is necessary if a pars plana approach is
mandated and the surgeon is untrained in posterior segment surgery.
Further Outpatient Care
Patients should receive follow-up care as needed.
Deterrence/Prevention
Protective eyewear should be worn when participating in any highrisk activities. Most serious eye trauma can be avoided if proper eye
and face protectors are used.
Complications
Lens dislocation and subluxation are commonly found in conjunction
with traumatic cataract.[3]
Other
associated
complications
include
the
following: phacolytic, phacomorphic, pupillary block, and anglerecession
glaucoma;
phacoanaphylactic
uveitis;
retinal
detachment; choroidal rupture; hyphema; retrobulbar hemorrhage;
traumatic optic neuropathy; and globe rupture.[4]
Prognosis
The prognosis is dependent on the extent of the injury.
Patient Education
Protective eyewear is important in high-risk activities to avoid injury.
For
excellent
patient
education
resources,
visit
eMedicineHealth's Eye
and
Vision
Center.
Also,
see
eMedicineHealth's patient education article Cataracts.