Traumatic cataract

From department of Ophthalmology

Dr Samuel Ponraj MS Ophthal [Final year Pg]

Preliminary data:

• Name : Mr.Vasanth• Age : 15 yrs• Sex : Male• Occupation : School Student• Residence : kanchipuram

Complaints:

• Complaints of defective vision in Right eye for past 1 week

Presenting illness:

• Injury to Right eye 1 week back by stick near his home followed by

defective vision of sudden ,profound nature , Pain ,Redness, Watering, Photophobia

No other complaints.• Left eye : no complaints

Past history

• No significant past history

PERSONAL HISTORY

o Mixed diet

General examination

• Conscious• Oriented• Afebrile• Vitals stable

Examination of eye RIGHT EYE LEFT EYE

VA 1/60 NIP 6/6

LIDS NORMAL NORMAL

CONJUCTIVA Circum corneal congestion CLEAR

CORNEA OPACITY + AT 10 `o CLOCK POSITION- Probably wound of entry.

CLEAR

ANTERIOR CHAMBER Irregular in depth,pigments dispersed, mild flare + Lens matter [cortex] + at 5,6,8 ‘o’ clock

NORMAL

IRISSphincter tear+ at 10` O clock Posterior Synecheae at 2 ,8 ` O Clock

CPN

PUPIL Dilated, Irregular, NRTL NORMAL-RTL

LENS Anterior Capsular tear 2 to 8 ‘o’ clockCataract

CLEAR

DIAGNOSIS

RE : TRAUMATIC CATARACT

INVESTIGATIONS

• B SCAN :

NORMAL STUDY

TREATMENT

• For right eye……….• Homide eye drops 1 drop 2 times/day • Gatiquin –P eye drops 1 drop 4 times /day• Tab Prednisolone 10 mg • Plan for Cataract surgery with IOL

implantation later – soon after suspected inflammation subsides – to avoid amblyopia from setting in.

Child hood blindness

• It is estimated that there are as many as 1.5 million blind children in the world .

• A large number of them live in Asia and Africa.

Causes of Childhood blindness

• Uncorrected Refractive error• Congenital Cataract• Congenital glaucoma• Vitamin A deficiency• Retinopathy of prematurity• Ophthalmia neonatrum• Trauma

THANK YOU

• Cataract formation is a common sequel to trauma.

Also associated with Subluxation ,dislocation

It is the most common cause of Unilateral cataract in young individuals.

1 Penetrating trauma

2 Blunt trauma may cause a characteristic flower-shaped opacity

3 Electric shock and lightning strike are very rare causes that may result in anterior and posterior iridescent opacities that have a stellate pattern

4 Infrared radiation, if intense as in glassblowers, may rarely cause true exfoliation of the anterior lens capsule

5 Ionizing radiation for ocular tumours may cause posterior subcapsular opacities that may develop months or years later.

• Penetrating injury refers to a single full-thickness wound, usually caused by a sharp object, without an exit wound. A penetrating injury may be associated with intraocular retention of a foreign body

• Risk factors for infection are delay in primary repair, ruptured lens capsule and a dirty wound.

Postulated mechanisms

Traumatic damage to the lens fibres

Ruptures in the lens capsule

influx of aqueous humour

Hydration of lens fibres

OPACIFICATION

Complications:

• Corneal perforated wound• Anterior & posterior scleral lacerations• Iris incarceration• Iridociliary prolapse• Flat AC• Anterior capsular tear• Vitreous incarceration• Tractional Retinal detachment

Clinical features:• Mechanical injury: 1.Globe penetration- of corneoscleral & uveal 2.Anterior segment – Angle recession iridodialysis hyphaema, lens capsule injury Cataract Zonular dehiscence Subluxation

3. Posterior segment : Vitreous liquefaction Vitreous haemorrhage Vitreoretinal traction-

Detachment Retinal tear & haemorrhage• Introduction of infection: - Endophthalmitis - Panophthalmitis

• Toxicity: - Chalcosis - Siderosis

Fungal Keratitis• Fungal keratitis remains to be a therapeutic challenge

due to paucity of antifungal drugs and extent to which they penetrate the corneal tissue.

• In India the largest series of fungal isolates being Aspergillus sp followed by fusarium sp , penicillium sp

• Etiology : - Defect in epithelial barrier due to external trauma including Contact lens previous surgery compromised ocular surface Systemic immunosuppression Diabetes mellitus

• Once inside the stromal tissue causes tissue necrosis,host inflammatory reaction.

• Hence once access to Anterior chamber the eradication is difficult.

• Due to cornea being avascular blood borne inhibiting agents may not reach thus fungi continue to grow and persists in these areas inspite of antifungal drugs.

• Presentation is with a gradual onset of pain, grittiness, photophobia, blurred vision and watery or mucopurulent discharge.

• Signs • a Candida keratitis • Yellow-white densely suppurative infiltrate

• A collar-stud morphology may be seen.

b Filamentous keratitis

• A grey or yellow-white stromal infiltrate with indistinct fluffy margins. • Progressive infiltration, often with satellite lesions. • Feathery branch-like extensions or a ring-shaped infiltrate may develop.

- white Immune mid peripheral ring- Wessley ring • Rapid progression with necrosis and thinning can occur. • Penetration of an intact Descemet membrane may occur and lead to endophthalmitis without evident perforation.

• c Other features include anterior uveitis hypopyon endothelial plaque raised IOP scleritis and sterile or infective

endophthalmitis

Investigations• 1 Staining a Gram and Giemsa staining about 50% sensitive.

b Periodic acid-Schiff (PAS) and Grocott–Gömöri methenamine-silver (GMS) stains may also be used , but are more commonly performed on histological sections.

2 Culture • Corneal scrapes should be plated on Sabouraud dextrose agar, KOH although most fungi will also grow on blood agar or in enrichment media. • If applicable, contact lenses and cases should be sent for culture.

3 Corneal biopsy is indicated in the absence of clinical improvement after 3–4 days and if no growth develops from scrapings after a week. A 2–3 mm block should be taken, using a technique similar to the scleral block excision during trabeculectomy. The excised block is sent for culture and histopathological analysis

Treatment:• 1. Removal of the epithelium over the lesion may enhance

penetration of antifungal agents. It may also be helpful to regularly remove mucus and necrotic tissue with a spatula.

2. Topical treatment should initially be given hourly for 48 hours and then reduced as signs permit. Because most antifungals are only fungistatic, treatment should be continued for at least 12 weeks.

a Candida is treated with amphotericin B 0.15% or econazole 1%; alternatives include natamycin 5%, fluconazole 2%, and clotrimazole 1%.

b Filamentous infection is treated with natamycin 5% or econazole 1%; alternatives are amphotericin B 0.15% and miconazole 1%. c A broad-spectrum antibiotic should also be considered to address or prevent bacterial co-infection. d Cycloplegia as for bacterial keratitis.

• Subconjunctival fluconazole may be used in severe cases. 5 Systemic antifungals may be given in severe cases for suspected endophthalmitis.

• voriconazole 400 mg b.d. for one day then 200 mg b.d., itraconazole 200 mg daily, reduced to 100 mg daily, or fluconazole 200 mg b.d. 6 Tetracycline (e.g. doxycycline 100 mg b.d.) may be given for its anticollagenase effect when there is significant thinning. 7 IOP should be monitored 8 Superficial keratectomy can be effective to de-bulk the lesion. 9 Therapeutic keratoplasty (penetrating or deep anterior lamellar) is considered when medical therapy is ineffective or following perforation.

MANAGEMENT

• SURGERY DELAYED• WAIT TILL INFLAMMATION SUBSIDES

• Inflammation: In case of synechiae,pupil seclusion,distorsion

- Gentle sweeping to dilate, pupilloplasty, Peripheral iridectomy – to prevent pupillary block.

- Cycloplegics , topical & oral steroid therapy.

Lens implantation

• Primary IOL insertion when intraocular inflammation and haemorrhage are nil and view of anterior segment structures is good.

• ECCE/SICS/PHACO can be done with guarded visual prognosis.

• Retained foreign matter:

Indirect ophthalmoscopy if view is clear. Ct scan/Ultrasound if inadequate view MRI if not metallic body.

Pars plana /anterior approach along with lens implantation then PPV.

Irrigating solutions to dislodge foreign body intracamerally.

• Damage to other ocular tissues: In sphincter rupture ,distortion and

iridodialysis – Repair by suturing iris root to scleral spur.

Surgical technique :

• Cataract resulted from small corneal perforation is treated as follows.

• Through a limbal incision ,aspiration is done after a cystitome is used on anterior lens capsule.

• Cautious irrigation-aspiration is done to remove lens material.

• Wide incision is made for ECCE and subsequent anterior vitrectomy

• Treatment of corneal perforated wound: - small wounds may seal owing to swelling of the margins and

the AC is restored /soft bandage contact lens. - It may heal quickly when treated on the lines of corneal

ulcer. -Deep corneal wounds need repair. - If prolapsed iris ,it should be reposited but if non viable it

should be abscised and wound closed with 10 -0 ethilon suture.

- Infected cases should be treated with local and systemic antibiotics.

- If there is a potential threat for perforation ,therapeutic keratoplasty should be performed.

Operative complications of Traumatic cataract

• Fibrinous uveitis is a common postoperative complication due to increased tissue reactivity in children that may lead to posterior central synechiae, pupillary block glaucoma and lenticular membrane formation where there is more tissue damage and breakdown of the blood-aqueous barrier

• Increased uveal contact in eyes with sulcus fixation of IOL leads to a persistent low-grade uveitis that predisposes to synechiae formation and subsequent pupillary capture.

The most serious and vision-impairing complication of traumatic cataract surgery is VAO [vision axis obstruction]

• Retinal detachment • Cystoid macular edema• Vitreous prolapse• Endophthalmitis