757657

research-article2018
EJO0010.1177/1120672118757657European Journal of OphthalmologyJinagal et al.

EJO European
Journal of
Ophthalmology
Original Research Article

European Journal of Ophthalmology

Visual outcomes of pediatric traumatic

1­–5
© The Author(s) 2018
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https://doi.org/10.1177/1120672118757657
DOI: 10.1177/1120672118757657
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Jitender Jinagal, Gaurav Gupta, Parul C Gupta, Sonam Yangzes,

Rishiraj Singh, Rohit Gupta and Jagat Ram

Abstract
Introduction: To report visual outcomes and risk factors of pediatric traumatic cataracts in a tertiary care referral
center in northern India.
Methods: We analyzed medical records of traumatic cataracts in the pediatric age group (1–15 years) operated for
cataract surgery with or without posterior chamber intraocular lens implantation with or without primary posterior
capsulotomy with anterior vitrectomy between 2004 and 2012. Causative agents, types of trauma, demographic factors,
surgical interventions, complications, and visual acuity were recorded and compared among different groups.
Results: A total of 147 children were documented to have undergone cataract surgery for traumatic cataract in the
study period, male-to-female ratio being approximately 5:1. Mean age was 7.67 ± 3.30 years (range, 1–15 years). Type
of primary insult was penetrating injury in 100 (68%) patients and blunt trauma in 47 (32%) patients. Mean interval
between injury and cataract surgery in penetrating injury cases was 3.84 ± 7.05 months and in the blunt injury cases
was 6.28 ± 11.13 months. Preoperatively, only 110 patients were cooperative for visual acuity. Out of them, none had
vision better than 6/18 and only 21 patients (19.9%) had vision of ≥6/60. Visual acuity of 6/18 or better (was considered
good visual outcome) was achieved by 87.9%, 97.3%, and 97.9% at 1, 6, and 36 months, postoperatively. Eyes which
underwent primary posterior capsulotomy and anterior vitrectomy during cataract surgery showed statistically better
visual outcome than those without it.
Conclusion: Phacoaspiration with posterior chamber intraocular lens implantation along with primary posterior
capsulotomy and anterior vitrectomy and timely introduction of amblyopia therapy helped in gaining good visual outcome
in pediatric traumatic cataract patients irrespective of the age of presentation and the type of injury.

Keywords
Unilateral cataract, traumatic cataract, pediatric cataract, primary posterior capsulotomy and vitrectomy

Date received: 27 November 2017; accepted: 17 January 2018

Introduction
Ocular trauma is the major cause of unilateral blindness in
the world.1 In India, incidence of ocular injuries among all
injuries is approximately 20.53%,2 and cataract is a com-
mon sequelae of ocular injuries.3 Traumatic cataract is
treatable and its management can help in decreasing the
burden of blindness in the world.
Now, with the emergence of microsurgical techniques
and better intraocular lens (IOL) designs, there are less com-
plications and better outcomes of cataract surgery. Most
common complications reported in cataract surgery in chil-
dren are fibrinous uveitis, posterior capsular opacification
(PCO), posterior synechiae, IOL decentration, pupillary
capture, precipitates over IOL surface, and amblyopia.
There are few studies reporting the outcome of trau-
matic cataract in pediatric age group and all studies which
Department of Ophthalmology, Postgraduate Institute of Medical
Education & Research, Chandigarh, India
Corresponding author:
Jagat Ram, Department of Ophthalmology, Postgraduate Institute of
Medical Education & Research, Sector-12, Chandigarh 160012, India.
Email: drjagatram@gmail.com
2 European Journal of Ophthalmology 00(0)
Table 1.  Distribution of children with traumatic cataract
according to age.
Group (age in years) Frequency (%)
A (1–5)   41 (27.9)
B (6–10)   73 (49.7)
C (11–15)   33 (22.4)
Total 147
have been conducted so far have had small sample sizes.4–6
In this study, we assessed the risk factors and visual out-
comes of pediatric traumatic cataracts at a tertiary care
referral center in Northern India.
Methods
We analyzed medical records of children <15 years with
traumatic cataracts, who underwent cataract surgery
between 2004 and 2012 at a tertiary care institute in north-
ern India. Inclusion criteria were children with visually sig-
nificant traumatic cataract, following penetrating or blunt
eye injury. Patients with minimum follow-up of 6 months
were included. Children with eye injury having posterior
segment involvement, that is, retinal detachment or optic
nerve injuries with penetrating or blunt trauma were
excluded. All cases of penetrating injuries had a primary
corneal surgery, followed by a secondary cataract surgery.
All patients were operated by a single experienced sur-
geon (J.R.). We studied the demographic causes, types of
injury, modes of trauma, demographic factors, surgical inter-
ventions, complications, primary posterior capsulotomy
(PPC) with anterior vitrectomy whether done or not, and
visual acuity. All findings of clinical examination including
best-corrected visual acuity (BCVA), intraocular pressure
(IOP), slit lamp biomicroscopy, and posterior segment evalu-
ation by indirect ophthalmoscopy or B-Scan ultrasonogra-
phy were noted in the preoperative period before cataract
surgery. Approach of cataract surgery; whether IOL implan-
tation was done or not, power, and type of IOL and position
of IOL were noted. Patients were divided into three age
groups, namely, group A (age between 1 and 5 years), group
B (age >5 up to 10 years), and group C (age >10 up to
15 years). Visual outcomes were noted at 1-, 6-, and 36-month
follow-up. Outcome was graded satisfactory if BCVA was
6/60 or more and good, if it was 6/18 or more.
Statistical analysis
Data analysis was done using Statistical Package for Social
Sciences Software (SPSS) version 17.0. Analysis of vari-
ance (ANOVA) test and Student–Newman–Keuls test at
5% level of significance were used to compare visual out-
comes between the different age groups and within the
groups. Pearson chi-square test was used for comparing
various non-parametric variables in the study groups and
to find the association between visual outcome and various
parameters at 5% level of significance.
Results
A total of 147 patients were recorded to have undergone
cataract surgery for traumatic cataract in the study period,
out of which 123 (83.7%) were males and 24 (16.3%) were
females, with male-to-female ratio of approximately 5:1.
Mean age was 7.67 ± 3.30 years (range, 1–15 years). Right
(50.3%) and left eyes (49.7%) were involved in almost
equal proportion. Maximum patients belonged to age
group B, that is, 73 (49.7%) followed by 41 (27.9%) in
group A and 33 (22.4%) in group C (Table 1). All traumatic
cataracts were unilateral.
Type of primary insult was penetrating injury in 100
(68%) patients and blunt trauma in 47 (32%) patients.
“Gulli danda” (a nonconventional game played by chil-
dren in India, using wooden sticks; 29.3%) and firecracker
injuries (15.6%) were most common modes of injury fol-
lowed by bow and arrow (8.2%), sharp metals (7.5%),
glass (4.1%), fall from height (3.4%), stone (2.7%), ball
(2.7%), pencil (2.7%), and finger nail (1.4%) in decreasing
order of their occurrence. In 25 (17%) patients, mode of
injury was not known (Figure 1). Most injuries occurred
while playing outside their homes.
Patients were classified according to morphology of
cataract. Total cataract was the most commonly noted vari-
ety in 122 patients (83%), followed by posterior subcapsu-
lar variety in 19 patients (12.9%), rosette in 3 patients
(2%), membranous in 2 patients (1.4%), and cortical in 1
patient (0.7%; Figure 2).
Children with traumatic cataracts were associated with
variety of complications related to the primary injuries
such as ruptured anterior lens capsule with cortical matter
in anterior chamber (Figure 3) in 19 (13%), hyphema in 6
(4.1%), iris injury in 8 (5.4%), center involving corneal
scarring noted in 14 cases (9.5%), posterior lens capsular
rupture in 3 (2.1%), and subluxation of crystalline lens in
1 eye (0.7%). Posterior segment examination by indirect
ophthalmoscope was possible in 13 (8.8%) eyes and
B-scan ultrasonography (USG) was done in 134 (91.2%)
eyes. Interval between injury and cataract surgery was as
early as 1 week in few cases and as late as 72 months in
one case. Mean interval between injury and cataract
surgery in penetrating injury cases was 3.84 ± 7.05 months
and in blunt injury cases was 6.28  ± 11.13 months.
However, overall mean interval between primary injury
and cataract surgery was 4.62 ± 8.61 months with median
of 2.5 months. Preoperatively, only 110 patients were
cooperative for visual acuity. Out of them, none had vision
better than 6/18 and only 21 patients (19.9%) had vision
≥6/60. Mean preoperative IOP recorded in 71 patients was
14.82 ± 4.15 mmHg. Average axial length recorded in146
Jinagal et al. 3
Figure 1.  Causes of ocular injury in children.
Figure 2.  Morphology of cataracts following trauma.
patients with B-scan USG was 22.26 ± 2.21 mm. Mean IOL
power implanted was 22.96 ± 0.89 diopters. All patients
underwent cataract surgery; phacoaspiration was done in
135 cases (91.8%) and 12 cases (8.16%) underwent extra-
capsular cataract extraction (ECCE). IOL implantation
following cataract extraction was possible in all except one
patient.
In 117 cases (79.59%), IOL was implanted in the bag, 29
cases (19.72%) in the sulcus implantation, and in 1 case
trans-scleral fixation (TSF) of IOL was done. The type of
IOL implanted was polymethyl methacrylate (PMMA) in
116 cases (80%) and foldable hydrophobic acrylic IOL in
29 eyes (20%). Visual acuity postoperatively at 1 month
could be recorded in a total of 107 patients, out of which
61.7% achieved ≥6/18 and 87.9% achieved ≥6/60. Visual
acuity postoperatively at 6 months was recorded in 109
patients; 77.1% achieved ≥6/18 and 97.30% ≥6/60. Only 47
Figure 3.  Slit lamp photograph showing ruptured anterior
lens capsule with cortical matter in anterior chamber.
patients completed 3 years of follow-up; out of those, 70.2%
had visual acuity of ≥6/18 and 97.9% had vision ≥6/60
(Table 2). Interval between primary injury and cataract sur-
gery did not affect visual outcome significantly (p = 0.19,
0.97, and 0.66 at 1, 6, and 36 months, respectively).
Visual outcome in cases due to penetrating and blunt
trauma did not have statistically significant difference
(p = 0.24, 0.06, and 0.67 at 1, 6, and 36 months, respectively)
in the postoperative period. PPC and anterior vitrectomy
was done in 33 cases (22.4%). Eyes having PPC and ante-
rior vitrectomy during cataract surgery showed statistically
better visual outcome than eyes without PPC and anterior
vitrectomy at 1 and 6 months, postoperatively (p = 0.001 and
0.047, respectively). Secondary procedures like mem-
branectomy or Nd;YAG capsulotomy were required only in
4 cases out of a total of 33 (12.1%) in which PPC and ante-
rior vitrectomy was done and in 41 (35.9%) out of 114 cases
in which PPC was not done. This difference was statistically
4 European Journal of Ophthalmology 00(0)
Table 2.  Mean visual acuity at 1, 6, and 36 months postoperatively.
Duration of follow-up Mean log MAR VA (±SD) in three groups
A (1–5 years)
1 month 0.87 (±0.70)
6 months 0.60 (±0.49)
36 months 0.46 (±0.28)
significant (p = 0.012). Amblyopia therapy was initiated in
44 cases (29.9%), out of which 21 were in age group A, 19
in age group B, and only 4 in age group C. Postoperative
complications noted were pigment on IOL surface in 38
cases (25.9%), pupillary optic capture in 24 cases (16.3%),
glaucoma in 8 cases (5.4%), and squint (exotropia or esotro-
pia) in 5 cases (3.4%).
Discussion
This study included 147 cases of traumatic cataract in
pediatric age group (age ≤15 years), which were managed
in a tertiary care center at Northern India. In this study,
male preponderance was seen (five times), which is in
correlation with the previous studies.7–9 This might be
due to involvement of male children more in sports and
outdoor activities as compared to females, who are more
involved in indoor and household activities. The most
common mode of injury in our study was “Gulli danda”
(a nonconventional game played by children in India,
using wooden sticks) followed by firecrackers, which is
supported by previous studies.7,10 However, in a recent
study, bow and arrow injury was commonest mode of
injury.4 This pattern of injuries is probably due to involve-
ment of children in high-risk sports without protective
measures and lack of adult supervision. So, we suggest
the use of protective polycarbonate glasses by children
during high-risk sports and very young children should
always play under direct supervision of adults. Penetrating
eye injury was more common than blunt eye injuries in
our study, which was also supported by previous stud-
ies,4,7 Visual outcome following cataract surgery in trau-
matic cataract was good in majority of cases and interval
between injury and cataract surgery did not affect the out-
come significantly.
In our study, visual acuity of ≥6/18 was achieved in
61.7%, 77.1%, and 70.2% of cases at 1, 6, and 36 months,
respectively, whereas visual acuity of ≥6/60 was
achieved in 87.9%, 97.3%, and 97.9% of patients,
respectively. We obtained satisfactory visual outcome in
children with traumatic cataract and did not find any sta-
tistically significant difference in outcomes of penetrat-
ing and blunt eye injuries. In cases of penetrating
injuries, we preferred repairing corneal laceration first
and subsequently performing cataract surgery when the
inflammation subsided.
B (>5–10 years) C (>10–15 years)
0.70 (±0.53) 0.45 (±0.31)
0.46 (±0.31) 0.30 (±0.14)
0.40 (±0.41) 0.19 (±0.20)
The major management challenges in such cases are
postoperative inflammation, secondary membrane forma-
tion in visual axis, and potential for developing amblyopia,
so care should be taken to prevent these complications and
early intervention should be taken in managing these com-
plications. Posterior chamber intraocular lens (PCIOL)
implantation after phacoaspiration was successfully
achieved in all but one patient, who required trans-scleral
IOL fixation due to inadequate zonular support.
Rate of PCO formation has been reported to be higher in
pediatric eyes with traumatic cataracts as compared to non-
traumatic cataracts.11 Incidence of visual axis obscuration
(VAO) as high as 100% has been reported by Benezra et al.6
in eyes which underwent traumatic cataract surgery without
PPC and anterior vitrectomy. Similarly, Brar et al.5 reported
83.33% incidence of VAO in such eyes following cataract
surgery without PPC. Verma et al.8 recorded significantly
lower incidence of VAO in group of patients who under-
went PPC during cataract surgery as compared to the group
who did not. In our study, incidence of VAO was quite low;
this may be attributed to PPC done in many cases in our
study. PPC maintained clear visual axis and required less
secondary interventions in these eyes as compared to those
not having PPC. So, we recommend PPC while operating
post-traumatic cataracts even in children older than 8 years
and especially in those having pre-existing thickened pos-
terior capsule or fibrous plaque to prevent postoperative
PCO and consecutive amblyopia.
We noticed pigments over IOL in 25.9% cases. To pre-
vent pigment deposition on IOL surface, implantation of
heparin surface-modified lenses and use of heparin in the
irrigating fluids have been advised earlier in few stud-
ies.12,13 Pupillary optic capture occurred in 16.32% of
cases in our study, which is consistent with previous stud-
ies5,6,12,14 in which it ranged from 9% to 45%. Squint
developed in five cases, which may be traumatic or may be
subsequent to development of amblyopia. Amblyopia ther-
apy was needed in nearly 30% of patients during follow-up
period. Patients mainly in group A (51.21%) and group B
(26.02%) required amblyopia therapy, while very few
patients (12.12%) in group C needed amblyopia therapy.
Amblyopia therapy contributed to comparable final visual
outcome across all age groups in our study. So this study
concluded that satisfactory visual outcome in majority of
the children could be achieved after cataract removal and
IOL implantation. Blindness from ocular trauma can be
Jinagal et al. 5
prevented by employing protective measures and children
should be supervised while playing and using firecrackers.
Education in schools should be carried out to prevent
sports-related and other ocular injuries. We recommend
phacoaspiration with PCIOL implantation along with PPC
and anterior vitrectomy in children with posterior capsular
plaque or thickening detected at the time of surgery or in
children even older than 8 years and timely induction of
amblyopia therapy as the gold standard for the manage-
ment of pediatric traumatic cataracts. Strength of this study
was large sample size as compared to previous studies and
outcome of PPC and anterior vitrectomy was also studied
in our study, which was not there in many previous studies.
Limitation of our study was that it was a retrospective
study and was conducted in a tertiary center where mostly
referred and complicated cases come, which may affect
final visual outcomes.
To conclude, since majority of childhood ocular trauma
is preventable, parents should be counseled about the
importance of supervised play and ophthalmologists
should be made aware of ocular trauma prevention and
treatment planning.
Declaration of conflicting interests
The author(s) declared no potential conflicts of interest with
respect to the research, authorship, and/or publication of this
article.
Funding
The author(s) received no financial support for the research,
authorship, and/or publication of this article.
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