Graefes Arch Clin Exp Ophthalmol (2011) 249:17751781

DOI 10.1007/s00417-011-1732-7

TRAUMA

Comparative study of final visual outcome

between open- and closed-globe injuries following surgical
treatment of traumatic cataract
Mehul Ashvin Shah & Shreya Mehul Shah &
Shashank B. Shah & Chintan G. Patel & Utsav A. Patel &
Adway Appleware & Ashish Gupta

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

Abstract
Objective The objective of this work is to compare final
visual outcomes in cases of surgically treated traumatic
cataract between open-globe and closed-globe groups, as
classified by the Birmingham Eye Trauma Terminology
system.
Design Observational cohort study.

No financial support was received from any company or institution.

This study has not been presented at any conference or meeting.
The authors have no financial interest in any aspect of this study.
Electronic supplementary material The online version of this article
(doi:10.1007/s00417-011-1732-7) contains supplementary material,
which is available to authorized users.
M. A. Shah (*) : S. M. Shah : S. B. Shah : C. G. Patel :
U. A. Patel : A. Appleware : A. Gupta
Drashti Netralaya, Nr. GIDC,
Chakalia Road,
Dahod 389151 Gujarat, India
e-mail: omtrust@rediffmail.com
S. M. Shah
e-mail: shah_shreya2000@yahoo.com
S. B. Shah
e-mail: sbshah@indiatimes.com
C. G. Patel
e-mail: cgp@drashtinetralaya.org
U. A. Patel
e-mail: uap@drashtinetralaya.org
A. Appleware
e-mail: aha@drashtinetralaya.org
A. Gupta
e-mail: ags@drashtinetralaya.org

Setting Tertiary eye-care center at the trijunction of Gujarat,

Madhya Pradesh, and Rajasthan states in central western
India.
Methods We enrolled patients meeting specific inclusion
criteria, examined their eyes to review any co-morbidities
due to trauma, performed surgery for traumatic cataracts, and
implanted lenses. The patients were re-examined 6 weeks
postoperatively. We classified the cases of traumatic cataract as
either open-globe (group 1) or closed-globe (group 2),
according to the Birmingham Eye Trauma Terminology
(BETT) system, and compared visual acuity.
Outcome measures Visual Acuity.
Results Our cohort of 687 eyes with traumatic cataracts
included 496 eyes in group 1 and 191 in group 2. Six weeks
postoperatively, the visual acuity was >20/60 in 298 (58%)
and 75 (39.1%) operated eyes in groups 1 and 2,
respectively (p<0.001, ANOVA). At follow-up, >20/60
vision was significantly higher in group 1 than in group 2
(OR=1.61; 95% CI, 0.853.02). Overall, 373 eyes (54.3%)
regained final visual acuity >20/60.
Conclusions Open-globe injury has a more favorable
prognosis for satisfactory (>20/60) visual recovery after
management of traumatic cataracts.
Keywords Final visual outcome . Betts . Open-globe
injury . Closed-globe injury . Predictor of visual acuity for
ocular injury

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

1776

is likely to differ from that in urban areas and is worthy of

investigation [24]. 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 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 (BETT), the documentation of ocular
trauma has been standardized [5]. Consequently, it is
possible to study the visual outcomes following traumatic
cataract surgery and the determinants predicting the
outcome, in relation to BETT scoring. Visual outcomes of
traumatic cataracts have been reported in some cases,
although most studies have involved small samples or have
been case studies. Weinand et al. [6] and Bayakara et al. [7]
reported studies focusing on the primary management of
traumatic cataracts and of perforating injuries.
In the present study, we examined visual outcomes
following cataract surgery in eyes sustaining injuries, and
the predictors of satisfactory visual outcomes following the
management of traumatic cataracts. Our study was conducted in a city located at the intersection of three Indian
states: Gujarat, Madhya Pradesh, and Rajasthan [11].
Qualified ophthalmologists at our institute provide lowcost eye services, mainly to the poor belonging to the tribal
population of 4.2 million in this area.

Patients and methods

We obtained approval from hospital administrators and its
research committee to conduct this study and all participants provided written consent.
This was a observational cohort study, designed in 2002.
All cases of traumatic cataract in either eye, diagnosed and
managed between January 2003 and December 2009, were
in the initial pool. Patients consenting to participate and
without other serious injuries were enrolled. Data was
retrieved from medical records, and collected in a pre-tested
online form.
For each patient enrolled in our study, we obtained a
history, including details of the injury, eye treatments, and
of surgery performed to manage ocular trauma. Data for
both the initial and follow-up reports were collected using
the online BETT format of the International Society of

Graefes Arch Clin Exp Ophthalmol (2011) 249:17751781

Ocular Trauma. Details of the surgeries were also collected

using a pre-tested online form.
The cases of traumatic cataract were classified as either
open- or closed-globe injuries. The open-globe injuries were
further categorized into those with laceration or rupture.
Lacerations of the eyeball were subcategorized into perforating injuries, penetrating injuries, or injuries involving an
intraocular foreign body. The closed-globe group was subdivided into lamellar laceration and contusion.
Based on monthly family income, each patient was
classified as rich (>US $300/15,000 Indian rupees [INR]),
poor (US $50300/2,50015,000 INR), or very poor (<US
$50/2,500 INR). Other demographic details collected
included origin of referral to our clinic, place of residence,
activity at the time of injury, object causing injury, and
previous examinations and treatments. After enrolment, all
patients were examined using a standardized method.
Visual acuity was checked using a Snellen chart, and the
anterior segment was examined using a slit lamp.
The cataracts were classified based on lenticular opacity.
When an examiner did not observe clear lens matter between
the capsule and nucleus, the cataract was defined as total.
When the capsule and organized 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 a white soft cataract with ruptured
capsule. A lens with a rosette pattern of opacity was classified
as a rosette-type cataract majority of them were partial
cataracts. We were able to cover all cataract cases in this
study using this classification. Cataract morphology was
primarily influenced by the type, force, or object of injury,
and by the 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 Bscan was performed to evaluate the posterior segment. All
comorbidities identified during examination in both groups.
The surgical technique chosen was selected according to
morphology and by the condition of tissues other than the
lens. Phacoemulsification was used to treat cataracts with
hard, large nuclei. With lenses 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 has been observed to be more
prominent in patients who had undergone previous surgery
for trauma [8, 9, 10]. In such cases in adults, when ocular
media was found to be hazy due to inflammation of the
anterior vitreous, we performed a capsulectomy and

Graefes Arch Clin Exp Ophthalmol (2011) 249:17751781

vitrectomy, via an anterior/pars plana route. If sulcus fixated

lens found Subluxated we corrected it surgically and
recurrent developed membrane if any was removed with a
surgical procedure.
In children younger than 2 years of age, both lensectomy
and vitrectomy via a pars plana route were performed,
leaving a rim of anterior capsule for a secondary implant,
and the same surgical procedures were used to manage the
traumatic cataract. Lens implantation as part of the primary
procedure was avoided in all children younger than 2 years
of age.
All patients with injuries and without infection were
treated with topical and systemic corticosteroids and
cycloplegics. The duration of medical treatment depended
upon 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 these dates, then monthly for 3 months, and
every 3 months for 1 year.
At every follow-up examination, visual acuity was tested
using a Snellen chart. The anterior segment was examined
with a slit lamp, and the posterior segment with an indirect
ophthalmoscope. Eyes with vision better than 20/60 at
6 weeks were defined as having a satisfactory grade of
vision.
During the examination, data were entered online using
pre-tested forms designed by the International Society of
Ocular Trauma (initial and follow-up forms), which were
exported to a Microsoft Excel spreadsheet. The data were
audited periodically to ensure completion. We used the
Statistical Package for the Social Sciences (SPSS 15) to
analyze the data. We used descriptive statistics and cross
tabulation to evaluate the role of each variable. The
dependent variable was vision >20/60 at follow-up, 6 weeks
after cataract surgery. The independent variables were age,
gender, place of residence, time interval between injury and
cataract surgery, primary posterior capsulectomy and
vitrectomy procedure, and type of ocular injury.

Results
The cohort consisted of 687 patients with traumatic
cataracts, including 496 eyes with open-globe ocular
injuries and 191 (27.8%) eyes with closed-globe injuries
(Fig. 1). Of the patients, 492 (71.6%) were male and 195
(28.4%) female. The mean patient age was 27.1
18.54 years (range, 180 years).
We analyzed several demographic factors, including origin
of patient referral, socioeconomic status (79% were from a
lower socioeconomic class), and residence (95% were from a
rural area); none had a significant relationship with final visual

1777

Fig. 1 Distribution of cataracts based on type of ocular injury, as per

the BETT classification

acuity. The object causing the injury and the activity at the
time of the injury were also not significantly associated with
satisfactory final visual acuity (Table 1). Wooden sticks were
the most common agent of injury (56.3%). A comparison of
pre- and post-operative visual acuity showed that treatment
significantly improved visual acuity (Table 1; Pearsons 2
test, p<0.001; ANOVA, p=0.001). An intraocular lens was
implanted in 453 (82%) cases. Aspiration was performed
using one or two ports in 48.6% of the patients in the openglobe group, and was significantly associated with improved
visual acuity (p<0.001).
In comparing open-globe and closed-globe groups
(Table 1), we found significant differences in variables
other than final visual outcome, including age, gender,
origin of patient referral, object of injury, early reporting,
urban vs. rural residence, cataract morphology, surgical
technique, number of surgeries, and lens implantation.
Postoperative vision was compared according to the type
of injury. Primary posterior capsulectomy and anterior
vitrectomy, commonly performed for eyes with significant
inflammation, resulted in a significant improvement in final
visual acuity (Table 1; p<0.001). We performed IOL
relocation in 5 cases and secondary membranectomy in 4
cases.
At 6 weeks postoperatively, the visual acuity in the operated
eye was >20/60 in 298 (58%) eyes in the open-globe group,
and 75 (39.1%) eyes in the closed-globe group (p<0.001,
ANOVA, 2); this difference was significant (OR=1.61, 95%
CI 0.853.02). Overall, 373 (54.3%) eyes regained a final
visual acuity >20/60 (Table 1).

1778

Graefes Arch Clin Exp Ophthalmol (2011) 249:17751781

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

Parameter

Open-globe injury

Closed-globe injury

Total

No

No

No

Poor
Rich

386
108

56.2
15.7

154
36

22.4
5.2

540
144

78.6
21.0

Very poor

0.3

0.15

0.4

Total

496

72.2

191

27.8

687

100

114
1

16.6
0.1

67
1

9.6
0.1

181
2

26.3
0.3
1.0

p value

Socio-economic status

Entry
Camp
Door-to-door
Other

0.9

0.1

Referral

15

2.2

0.3

0.9

School

0.3

0.1

16

2.3

Self

358

52.1

119

17.3

475

69.1

Total

496

72.2

191

27.8

687

100

No
Yes

485
11

70.6
1.6

183
8

26.6
1.2

668
19

97.2
2.7

Total

496

72.2

191

27.8

687

100

0 to 10
11 to 20

134
145

19.5
21.1

22
39

3.2
5.7

155
184

22.6
26.8

21 to 30

70

10.1

20

2.9

90

13.1

31 to 40

54

7.7

25

3.6

79

11.5

41 to 50

52

7.5

43

6.3

95

13.8

51 to 60

25

3.6

30

4.3

55

8.0

61 to 70

15

2.1

1.3

24

3.5

71 to 80

0.1

0.4

0.5

Total

496

72.2

191

27.8

687

100

Female
Male

152
344

22.1
50.1

43
148

6.3
21.5

195
492

28.4
71.6

Total

496

72.8

191

27.8

687

100

Ball
Cattle Horn

0
6

0
0.9

6
6

0.9
0.9

6
12

0.9
1.60

Cattle Tail

0.1

0.4

0.6

Fireworks

0.9

0.5

10

1.5

Other

34

4.9

40

5.8

74

10.8

Sharp object

49

7.1

10

1.5

59

8.6

Stone

55

8.0

38

5.5

93

13.5

Wooden stick

312

45.4

20

2.9

54

7.9

Unknown

34

4.9

72

10.5

384

55.9

Total

496

72.8

191

27.8

687

100

0.03

Previous surgical treatment

0.126

Age distribution
0.000

Gender
0.020

Object of injury
0.031

Object of injury compared to wooden stick

Wooden stick object
Other object

312
184

45.4
26.8

72
119

10.5
17.3

384
303

55.9
44.1

Total

496

72.8

191

27.8

687

100

0 to 1
2 to 4

132
69

19.2
10.0

40
9

5.8
1.3

172
78

25.0
11.4

5 to 30

163

23.7

38

5.5

201

29.3

More

132

19.2

104

15.1

236

34.4

0.000

Reporting
0.000

Graefes Arch Clin Exp Ophthalmol (2011) 249:17751781

1779

Table 1 (continued)
Parameter

Open-globe injury

Closed-globe injury

Total

No

No

No

496

78.2

191

27.8

687

100

Rural
Urban

479
17

69.7
2.5

176
15

25.6
2.1

655
32

95.3
4.7

Total

496

78.2

191

27.8

687

100

63
6

9.1
0.8

20
3

2.9
0.4

83
9

12.1
1.3

Total

p value

Habitat
0.014

Morphology
Membranous
Rosette
Soft fluffy

329

47.9

83

12.1

412

60.0

Total cataract

98

14.3

85

12.3

183

26.6

Total

496

72.8

191

27.8

687

100

292
90

42.5
13.1

55
36

8.0
5.2

347
126

50.5
18.3

0.000

Surgical technique
Aspiration
Lensectomy and vitrectomy
Delivery and vitrectomy

114

16.6

100

14.6

214

31.1

Total

496

72.2

191

27.8

687

100

0.000

Primary posterior capsulectomy vitrectomy

Not performed
Performed

364
132

53.0
19.2

141
50

20.5
7.3

505
182

73.5
26.5

Total

496

72.2

191

27.8

687

100

1.00
2.00

411
76

59.8
11.1

173
18

25.1
2.6

584
94

85
13.7

3.00

1.3

0.0

1.3

Total

496

72.2

191

27.8

687

100

No Implant
Implant

65
431

9.5
62.7

58
133

8.4
19.4

123
564

17.9
82.0

Total

496

72.2

191

27.8

687

100

<1/60
1/60 to 3/60

110
38

22.2
7.7

64
18

33.5
9.4

171
56

24.9
8.1

20/200 to 20/80

38

7.7

27

14.1

64

9.3

20/60 to 20/40

110

22.1

38

19.8

145

21.1

20/40 to 20/20

188

37.9

37

19.3

223

32.5

Uncooperative

12

2.4

3.1

17

2.5

Total

496

100

191

100

687

100

0.495

Number of surgeries
0.010

Lens Implant
0.000

Final visual outcome

Table 2 Final visual outcome

according to reporting time in
days

p=0.02

0.000

Vision

01 days

24 days

530 days

More

Total

Uncooperative
<1/60
1/60 to 3/60
20/200 to 20/120
20/80 to 20/60
20/40 to 20/20
Total

3
51
12
22
34
50
172

2
13
7
7
16
33
78

4
49
9
12
48
79
201

8
59
30
26
50
63
236

17
172
56
67
148
225
687

1780
Table 3 Distribution of reporting time in days and percentage
of patients with a final visual
acuity >20/60

Graefes Arch Clin Exp Ophthalmol (2011) 249:17751781

Reporting interval in days

01

24

530

More

Total

Vision better than 20/80

48.8%

63.6%

63.0%

48.0

54.4

When we have studied time interval between injury and

initial intervention we found best results achieved if initial
intervention done between 2 and 30 days (Tables 2, 3). We
have also studied main reasons for no improvement in
vision (Table 4).

Discussion
Visual gain following surgery for traumatic cataracts is a
complex process. Electrophysiological [10] and radioimaging [1113] investigations are important tools for
assessing co-morbidities associated with an opaque lens.
In our study of patients with open-globe and closedglobe injuries leading to traumatic cataract, a satisfactory
grade of vision following surgical management was
significantly more common in those with open-globe
injuries (Table 1).
Brar et al. found that postoperative complications
following ocular injuries were the main factor responsible
for poor outcomes, with 20/40 or better vision seen in
38.8% of eyes with closed-globe injuries and in 86.4% of
eyes with open-globe injuries [14]. This difference in
success rates could be attributed to differences in the type
of ocular trauma, the presence of other ocular tissue
damage, or variation in surgical procedures. In contrast, in
a case series of 60 eyes with traumatic cataracts, Wos et al.
found no significant difference in visual outcome between
those developing cataracts after perforating injuries and
after non-perforating injuries [15].
Wos et al. noted that a large proportion of the population
with traumatic cataracts in their series was male [15].
Baclouti et al. did not find a gender difference in traumatic
cataracts in their study in Tunisia [16]. Although we had a
large proportion of males in our cohort, the difference
between the numbers of males and females was not
statistically significant. Many working women in tribal
areas may be at increased risk for ocular injuries and
traumatic cataracts; this may explain the gender distribution
noted in our study. We found a significant (p=0.020)
difference in open-globe injuries by gender, with males
being predominantly affected.
Our cohort of patients with traumatic cataracts was much
younger than those in other studies [17, 18]. Thus,
appropriate intervention to avoid visual disability in our
cohort would be more cost-effective because the disability-

adjusted life-years saved by successful intervention would

be much higher.
Using a large database, we attempted to systematically
classify the morphology of traumatic cataract and to select
surgical techniques accordingly. We used a practical grading
of cataracts to enable ophthalmologists to determine the
best mode of managing them. This grading differs from the
standard grading used for senile cataracts [19]. We are not
aware of any other reported study that has compared final
visual outcomes between these two groups, using the BETT
classification system [20].
Behbehani [21] reported 20/40 final visual outcome in
40% cases of open-globe injuries. Cillino [22] also reported
final visual acuity of 20/40 in 48.3% of all injury cases.
Smith [23] similarly reported 47.8% of cases reaching 20/
40 vision, combining open- and closed-globe injuries.
Various studies have touched on this topic. Krishnamachary
et al. found 52.3% of cataracts to be total, whereas our results
revealed 26.6% total cataracts [24]. Vajpayee reported type-1
and -2 openings in the posterior capsule with penetrating
injury [25], whereas we found a membranous type of
cataract in 12.1% of cases. This is suggestive of late
reporting, as membranous transformation of the lens with
fusion of the anterior and posterior capsules may occur over
time.

Conclusions
We obtained good visual outcomes after managing traumatic cataracts. According to results satisfactory visual
acuity following cataract surgery was more likely with
open-globe injuries than with closed-globe injuries.

Table 4 Reasons for non-improvement of vision following treatment

Reason for poor outcome

No. of patients

Optic atrophy
Macular scar
Inflammation
Infection
Extensive post-segment trauma
Corneal opacity
Secondary glaucoma

4
3
14
2
12
9
5

Graefes Arch Clin Exp Ophthalmol (2011) 249:17751781

Conflicting interests None.

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