Eur J Ophthalmol 2011 ; 00 (00): 000-000

DOI:

ORIGINAL ARTICLE

Effect of interval between time of injury and timing of intervention on final visual outcome in cases of traumatic cataract
Mehul A. Shah, Shreya M. Shah, Shashank B. Shah, Utsav A. Patel
Drashti Netralaya, Dahod, Gujarat - India

Purpose. There are no clear guidelines to treat traumatic cataract. This study was conducted to provide evidence-based care to patients with traumatic cataracts and to examine the effect of the time interval between injury and the first intervention on the final visual outcome. Methods. In a prospective cohort study, all patients presenting to our hospital with traumatic cataracts between January 2003 and December 2009 were enrolled. Information regarding demographics and ocular trauma was collected on the pretested World Eye Trauma Registry form for both the first and follow-up visits. In particular, we collected specific information on the time interval between the injury and intervention. The relationship between this time interval and the final visual outcome was analyzed. The study was conducted at a tertiary eye care center, in Dahod, at the junction of Gujarat, Madhya Pradesh, and Rajasthan states, in central western India. Results. The time interval between the injury and first intervention had a significant effect on the final visual outcome (p = 0.02, 2 test). Conclusions. The morphology of traumatic cataracts plays an important role in determining the appropriate surgical technique and the final visual outcome. Key Words. Final visual outcome, Time interval, Traumatic cataract
Accepted: February 3, 2011

INTRODUCTION
Few studies have addressed trauma in rural areas (1). The etiology of ocular injury in rural areas likely differs from that in urban areas and is worthy of investigation (2-4). Any prevention strategy requires knowledge of causes of injuries, 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 visual outcome in eyes managed for traumatic 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. Thus, the success rates may differ between eyes with these 2 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 3 states in India: Gujarat, Madhya Pradesh, and Rajasthan. Qualified ophthalmologists at our institute provide low-cost eye services, primarily to the poor belonging to the tribal population of 4.2 million living in this area. There was much variation in the time interval between injury and first intervention. The literature suggested that it was important to study the effect of this time interval on the final visual outcome. 1

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PATIENTS AND METHODS

We obtained approval to conduct this study from the hospital administrators and research committee. Written consent was obtained from participants. 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 with no other serious injury 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 pretested online form. Cases of traumatic cataracts were grouped as those with open- or 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 causing the 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. Based on lenticular opacity, the cataracts were classified as total, membranous (in which both capsules fused with scant or no cortical material), white soft, and rosette types. When an ophthalmologist 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 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 was examined with an indirect ophthalmoscope and a +20 D lens. When the optical medium was not clear, a B-scan was per2

formed to evaluate the posterior segment. The surgical technique was selected according to morphology and the condition of the tissues other than the lens. Phacoemulsification was used to operate on cataracts with large, hard 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 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. In such cases, the ocular medium turns hazy due to condensation of the anterior vitreous unless a vitrectomy is performed. Thus, we performed a capsulectomy and vitrectomy via an anterior/pars plana route in adults. In children younger than 2 years, both lensectomy and vitrectomy via a pars plana route were performed, 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 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 hours, 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 then every 3 months for 1 year. At each follow-up examination, visual acuity was tested using the 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 pretested format designed by the International Society of Ocular Trauma (initial and follow-up forms), which were then 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. We used binomial regression

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Fig. 1 - Distribution of cases according to BETTS.

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 (100%) patients with traumatic cataracts including 496 (72.2%) eyes with open-globe ocular injuries and 191 (27.8%) eyes with closed-globe injuries (Fig. 1). The patients consisted of 492 (71.6%) males and 195 (28.4%) females. The mean patient age was 27.118.5 years (range 180). We analyzed several demographic factors, including patient entry (p=0.4) and socioeconomic status (79% were from the lower socioeconomic class) and residence (95% were from a rural area); none had 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. We grouped our patients into 4 groups according to the interval between injury and the start of intervention: 25% patients within 24 h, 11.4% between 2 and 4 days, 29% within 30 days, and 34.4% after 30 days. Patients residing in rural areas reported significantly later
TABLE I - R  EPORTING INTERVAL ACCORDING TO RESIDENCE
Days 0-1 2-4 5-30 More Total
p=0.011.

Rural 157 75 198 225 655

Urban 15 3 3 11 32

Total 172 78 201 236 687

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(p=0.011; Tab. I). A significant difference was found for socioeconomic status (p=0.008). Self-reporting patients reported early, while patients who came from an outreach program reported late (p<0.001; Tab. II). The final visual outcome differed significantly among the 4 groups (Tab. III). Of the patients who reported between 2 and 30 days, 63% recovered vision >20/80, while 48% of the patients who reported within 24 h and after 30 days recovered vision >20/80 (Tab. IV). More surgery was
TABLE II -  REPORTING TIME DISTRIBUTED ACCORDING TO PATIENT ENTRY
Entry Self ORD Total 0-1 142 30 172 2-4 73 5 78 5-30 153 48 201 More 105 131 236 Total 473 214 687

performed in cases who reported early (Tab. V). Patients who had open-globe injury reported significantly earlier (p<0.001; Tab. VI). Lens implantation was done in 82% of cases, and no significant difference was found among the groups (p=0.357). There was no significant difference in the incidence of infection among the groups (p=0.931). Comparing final visual outcome among adult and pediatric groups, we did found no significant difference (p=0.06, Tab. VII).

DISCUSSION
Of the patients who reported between 2 and 30 days after their injury, 63% recovered vision >20/80, while 48% of the patients who reported within 24 hours or after 30 days recovered vision >20/80. Patients who underwent intervention within 24 hours did not do as well as those who

p<0.001. ORD = ORD-Outreach Department.

TABLE III - FINAL VISUAL OUTCOME ACCORDING TO REPORTING TIME

Vision Uncooperative <1/60 1/60-3/60 20/200-20/120 20/80-20/60 20/40-20/20 Total
p=0.02.

0-1 3 51 12 22 34 50 172

2-4 2 13 7 7 16 33 78

5-30 4 49 9 12 48 79 201

More 8 59 30 26 50 63 236

Total 17 172 56 67 148 225 687

TABLE IV - DISTRIBUTION OF REPORTING TIME AND PERCENTAGE OF PATIENTS WITH A FINAL VISUAL ACUITY >20/80
Reporting interval, % 0-1 Vision better than 20/80 48.8 2-4 63.6 5-30 63.0 More 48.0 Total 54.4

TABLE V - NUMBER OF SURGERIES

Number 1 2 3 Total
p<0.001.

0-1 129 38 5 172

2-4 58 19 1 78

5-30 181 18 2 201

More 216 19 1 236

Total 584 94 9 687

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TABLE VI - REPORTING TIME ACCORDING TO THE TYPE OF INJURY ACCORDING TO BETTS

Type of injury Closed globe Open globe Total
BETTS = Birmingham Eye Trauma Terminology System. p<0.001.

0-1 40 132 172

2-4 9 69 78

5-30 38 163 201

More 104 132 236

Total 191 496 687

TABLE VII -  FINAL VISUAL OUTCOME COMPARED AMONG ADULT AND PEDIATRIC GROUPS
Vision Uncooperative <1/60 1/60-3/60 20/200-20/120 20/80-20/60 20/40-20/20 Total
p=0.0680

Pediatric 11 73 30 23 62 110 309

Adult 6 100 27 45 85 115 378

Total 17 173 57 68 147 225 687

communities (17). Dandona and Dandona (18) reported that ocular injury can cause significant blindness in the population but in the majority of it it is preventable.

CONCLUSIONS
Following primary repair of any ocular injury, the final visual outcome in terms of traumatic cataracts may be better if treatment is delayed for a week.
The authors report no proprietary interest or financial support. Address for correspondence: Mehul A. Shah, MD Drashti Netralaya Nr. GIDC Chakalia Road Dahod-389151 Gujarat, India omtrust@rdiffmail.com

reported between 2 and 30 days in terms of final visual outcome. This might be attributed to open-globe injuries being reported early, undergoing primary repair, and developing inflammation, while late injuries were predominantly closed-globe injuries and did not require more surgery (6). Many studies have reported that early intervention is an important factor in better visual outcome (7-9). Gupta et al (7) and Zhang et al (8) reported that the incidence of infection is higher if primary closure is late, although the incidence of infection did not vary significantly in our study. Overall, the rate of infection in open-globe injury in our study was 0.4%, while reported values range from 2% to 17% (10, 11). Wo and Mirkiewicz-Sieradzka (12) and Behbehani et al (13) reported that the time interval between injury and intervention did not make a difference in terms of the final visual outcome. Jonas et al (14), Jonas and Budde (15), and Yang et al (16) reported that the final visual outcome was better with early intervention with an intraocular foreign body. We are not aware of a study that examined the time interval between injury and treatment start for traumatic cataracts. Injury places a social and economic burden on families and

REFERENCES
1. Khatry SK, Lewis AE, Schein OD, Thapa MD, Pradhan EK, Katz J. The epidemiology of ocular trauma in rural Nepal. Br J Ophthalmol 2004; 88: 456-60. Abraham DI, Vitale SI, West SI, Isseme I. Epidemiology of eye injuries in rural Tanzania. Ophthalmic Epidemiol 1999; 6: 85-94. Alfaro DV III, Jablon EP, Rodriguez Fontal M, et al. Fishingrelated ocular trauma. Am J Ophthalmol 2005; 139: 488-92. 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. Graefes Arch Clin Exp Ophthalmol 2008; 246:191-7. Kuhn F, Morris R, Witherspoon CD, Mester V. The Birmingham Eye Trauma Terminology system (BETT). J Fr Ophtalmol 2004; 27: 206-10. Mohammadpour M, Jafarinasab MR, Javadi MA. Outcomes

2.

3. 4.

5.

6.

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EJO-D-10-00627_SHAH.indd 5

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Effect of time interval on final visual outcome

7.

8.

9.

10. 11.

12. 13.

of acute postoperative inflammation after cataract surgery. Eur J Ophthalmol 2007; 17: 20-8. Gupta A, Srinivasan R, Gulnar D, Sankar K, Mahalakshmi T. Risk factors for post-traumatic endophthalmitis in patients with positive intraocular cultures. Eur J Ophthalmol 2007; 17: 642-7. Zhang Y, Zhang MN, Jiang CH, Yao Y, Zhang K. Endophthalmitis following open globe injury. Br J Ophthalmol 2010; 94: 111-4. Narang S, Gupta V, Simalandhi P, Gupta A, Raj S, Dogra MR. Paediatric open globe injuries: visual outcome and risk factors for endophthalmitis. Indian J Ophthalmol 2004; 52: 2934. Cebulla CM, Flynn HW Jr. Endophthalmitis after open globe injuries. Am J Ophthalmol 2009; 147: 567-8. Andreoli CM, Andreoli MT, Kloek CE, Ahuero AE, Vavvas D, Durand ML. Low rate of endophthalmitis in a large series of open globe injuries. Am J Ophthalmol 2009; 147: 601-8. Wo M, Mirkiewicz-Sieradzka B. Traumatic cataract: treatment results. Klin Oczna 2004; 106: 31-4. Behbehani AM, Lotfy N, Ezzdean H, Albader S, Kamel M,

14.

15. 16.

17.

18.

Abul N. Open eye injuries in the pediatric population in Kuwait. Med Princ Pract 2002; 11: 183-9. Jonas JB, Knorr HL, Budde WM. Prognostic factors in ocular injuries caused by intraocular or retrobulbar foreign bodies. Ophthalmology 2000; 107: 823-8. Jonas JB, Budde WM. Early versus late removal of retained intraocular foreign bodies. Retina 1999; 19: 193-7. Yang CS, Lu CK, Lee FL, Hsu WM, Lee YF, Lee SM. Treatment and outcome of traumatic endophthalmitis in open globe injury with retained intraocular foreign body. Ophthalmologica 2010; 224: 79-85. Winthrop AL, Brasel KJ, Stahovic L, Paulson J, Schneeberger B, Kuhn EM. Quality of life and functional outcome after pediatric trauma. J Trauma 2005; 58: 468-73; discussion 473-4. Dandona R, Dandona L. Corneal blindness in a southern Indian population: need for health promotion strategies. Br J Ophthalmol 2003; 87: 133-41.

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