Traumatic cataract is an opacity of the lens caused by trauma, and it is more common in younger individuals compared to age-related cataract. When unilateral cataract is found in a young patient without underlying disease, traumatic cataract should be suspected first. The lifetime prevalence of ocular trauma in the general population is about 14%, with a higher incidence in children and young males. 27–65% of ocular trauma cases lead to cataract, and most of these significantly affect visual function and require surgery 3).
Traumatic cataracts often involve damage to other ocular tissues and frequently occur in younger individuals, making them a significant public health burden. Even in the absence of cataracts that severely affect visual function, subluxation of the lens due to damage to the zonules of Zinn may occur, sometimes requiring surgical intervention.
Mechanism of Cataract Formation
Rapid opacification: Aqueous humor enters the lens fibers due to rupture of the lens capsule
Delayed opacification: Even without capsule rupture, trauma can damage lens fibers, leading to cataract formation months to years later.
Typical appearance: Rosette-shaped or stellate opacity
Characteristics of Traumatic Cataract
Commonly affected group: Children and young males
Other ocular injury complications: Iris injury, Zinn zonule injury, vitreous prolapse, etc.
Urgency: Emergency extraction is required in cases of capsule rupture or elevated intraocular pressure.
A major clinical classification is the mechanical and non-mechanical classification based on the mechanism of injury.
| Classification | Mechanism | Characteristics |
|---|---|---|
| Blunt trauma | Ocular contusion / ocular concussion | Progresses gradually over months to years after injury. May be associated with angle recession and zonular rupture. |
| Penetrating trauma | Perforating wound, laceration, contusion | Metal fragments, etc., perforate the corneosclera and enter the lens and vitreous. Rapid cataract formation occurs immediately after injury. |
| Foreign body | Intraocular foreign body retention | Formation of siderosis lentis (iron cataract) and chalcosis lentis |
| Infrared cataract | Chronic infrared exposure | Glassblower’s cataract. Characterized by posterior subcapsular opacity |
| Electric cataract | Lightning strike / electric shock | Characterized by cortical and subcapsular opacities |
| Radiation cataract | X-rays, gamma rays | Posterior subcapsular opacity. See separate article “Radiation cataract”. |
| Drug-induced | Steroids, etc. | See separate article “Effects of Steroids on the Eye” |
Blunt trauma object size and opacity pattern:
Siderosis lentis and chalcosis lentis:
If an iron foreign body remains in the eye, it can cause siderosis lentis, presenting with characteristic opacities. Retention of a copper foreign body leads to chalcosis lentis. If a retained foreign body is suspected, CT or other imaging for localization and early removal are necessary.
Visual acuity and intraocular pressure
Preoperative visual acuity is useful for predicting postoperative best-corrected visual acuity. Regarding intraocular pressure, asymmetrically low pressure may suggest open globe injury or cyclodialysis cleft. Elevated intraocular pressure can reflect lens-induced glaucoma, hyphema, or angle-recession glaucoma.
Pupillary findings
Relative afferent pupillary defect (rAPD) is observed in traumatic optic neuropathy and serves as an indicator of postoperative visual prognosis. Cataract alone does not cause rAPD.
Anterior segment findings
| Examination site | Evaluation point |
|---|---|
| Cornea | Degree of opacity / Impact on IOL calculation |
| Anterior chamber | Hemorrhage, lens material, vitreous prolapse |
| Iris | Transillumination defect, iridodialysis, pupillary dilation disorder, posterior synechiae |
| Lens | Opacity location, anterior capsule rupture, subluxation, Vossius ring |
In blunt trauma, if findings such as posterior synechiae, anterior capsule opacity, or localized cortical opacity are observed in only one eye, traumatic cataract is strongly suspected. Carefully observe for differences in anterior chamber depth between the eyes, presence of angle recession, zonular rupture, vitreous prolapse into the anterior chamber, and ora serrata tears.
Diagnostic System
The Birmingham Eye Trauma Terminology (BETT) system is used to record trauma.
Imaging tests
Yes. In perforating trauma, the lens capsule is damaged and aqueous humor enters, causing rapid opacification immediately after injury. Small wounds (e.g., from a needle) result in localized anterior subcapsular opacification, while large wounds (e.g., from a cutter) lead to rapid spread of opacification. In contrast, blunt trauma can cause metabolic disturbances and osmotic changes due to external force even without capsular rupture, and opacification often progresses gradually over several months to years after injury.
The diagnosis of traumatic cataract itself is straightforward, but it is important to confirm that the cause is trauma. Since cataract surgery for traumatic cataracts is more likely to be a difficult case compared to routine cataract surgery, thorough preoperative evaluation is essential.
Key differentiation points: If posterior synechiae, anterior capsule opacity, and localized cortical opacity are observed in only one eye, suspect traumatic origin. In penetrating trauma, it is essential to assess the condition of the wound, the lens capsule (presence of posterior capsule rupture), the posterior segment, and the presence, nature, and location of any foreign body.
Generally, lens reconstruction is performed after opacification becomes severe and visual impairment progresses. On the other hand, urgent surgery may be necessary in some cases, such as for lens-induced uveitis (due to leakage of lens proteins) upon capsule rupture, or to prevent bacterial endophthalmitis after foreign body or laceration.
Removal of traumatic cataract is broadly divided into “primary removal” immediately after open globe injury and “secondary removal” several weeks to months after the injury.
Primary repair of open globe injuries is ideally performed within 24 hours, and the group repaired within 24 hours has a significantly lower risk of endophthalmitis (OR 0.39, 95% CI 0.19-0.79)1).
Indications for emergency (primary) enucleation:
Advantages of secondary resection:
| Timing of removal | Advantages |
|---|---|
| Primary | Single surgery, cost reduction, reduced amblyopia risk (children) |
| Secondary | IOL calculation accuracy, visibility, inflammation control |
Emergency surgery is common. First, suturing of the corneoscleral perforation wound is necessary. If the anterior chamber can be maintained and there is a relatively small perforation only in the anterior capsule with no intraocular foreign body, standard ultrasonic cataract surgery (PEA) is possible. In cases of perforation extending to the posterior capsule, foreign bodies often reach the vitreous, so simultaneous vitrectomy is required. Topical and systemic administration of antibiotics is necessary.
Surgical indications are determined in the same way as for ordinary cataracts. Zinn zonules are often fragile or torn, so the ultrasound device settings should be set to low perfusion and low aspiration pressure. Use a capsule expander or capsular tension ring (CTR) as appropriate. If extensive zonular dialysis is present, consider intraocular lens suturing.
Evaluation of anterior capsule integrity: Intraoperative use of trypan blue helps identify anterior capsule tears and allows visualization of the capsule even in white cataracts. If a capsular tear is suspected, perform hydrodissection conservatively and carefully.
Surgery by cataract type:
IOL selection:
If the extent of the tear is 1/4 or more, use a CTR (capsular tension ring) to fix the intraocular lens within the capsule. If fixation within the capsule is not possible, suture the intraocular lens to the ciliary sulcus or fix it within the sclera (e.g., Yamane method)6).
In cases of complete dislocation, liquid perfluorocarbon (LPFC/PFCL) is used during vitreous surgery to float the lens up to the iris plane, and it is removed via a transscleral approach.
Regular checkups are performed on postoperative day 1, week 1, and month 1. Complete the course of topical antibiotics and steroid eye drops. If complications occur, follow up more frequently and adjust steroids or administer intraocular pressure-lowering medications. In cases with zonular rupture, be aware of the risk of intraocular lens dislocation or drop postoperatively, and conduct long-term follow-up.
Traumatic cataract surgery is more difficult than standard cataract surgery. Many intraoperative difficulties are anticipated, such as possible rupture of the anterior capsule, lens instability due to zonular damage, difficulty in dilating the pupil due to posterior synechiae, anterior capsule fibrosis, and a high risk of posterior capsule rupture. It is important to make full use of auxiliary tools such as trypan blue, CTR, and Malyugin ring, and to carefully plan the surgical strategy according to the cataract morphology and associated injuries. Adequate preparation of instruments before surgery is also essential.
If the opacity is mild and does not significantly affect vision, observation is possible. However, if there is rupture of the lens capsule, increased intraocular pressure, or lens-induced uveitis (a condition where lens proteins leak and cause inflammation), emergency surgery is indicated. In children, due to the risk of amblyopia, more aggressive early intervention is required compared to adults.
If the lens capsule is preserved, primary insertion is possible. If the capsule is damaged, secondary insertion is performed via ciliary sulcus suturing or intrascleral fixation (Yamane method). IOL insertion may be postponed if axial length measurement is difficult or the risk of infection is high.
Children are disproportionately susceptible to the effects of ocular trauma and require special management due to the risk of stimulus deprivation amblyopia, which differs from that in adults.
Preoperative considerations
In children, the threshold for determining a significant impact on visual function is lower than in adults. If there is opacity exceeding 3 mm on the visual axis, extraction should be considered. Since delay increases the risk of amblyopia, primary extraction is recommended as an emergency procedure 5).
In perforating trauma, remove the lens immediately and insert an IOL if possible. In blunt trauma, perform surgery based on the progression of the cataract.
Intraoperative considerations
In children under 2 years of age, pars plana vitrectomy is often performed simultaneously with cataract extraction. In this age group, IOL implantation is deferred and performed as a secondary procedure.
Postoperative considerations
Postoperative amblyopia treatment (optical correction and occlusion of the healthy eye) is essential. Active amblyopia therapy combining optical correction with glasses or contact lenses and occlusion therapy of the healthy eye should be continued. Posterior capsule opacification (PCO) is a common postoperative complication in children and requires early intervention as it can lead to amblyopia if left untreated. Young patients have a strong inflammatory response and are at risk for fibrinous uveitis, so aggressive preoperative and postoperative steroid eye drop management is necessary.
In children, there is a risk of amblyopia, so more aggressive early intervention is required than in adults. If there is opacity exceeding 3 mm on the central visual axis, extraction is indicated, and emergency primary extraction is recommended. Delay in surgery increases the risk of amblyopia and may lead to permanent visual impairment. After surgery, active amblyopia treatment such as occlusion therapy of the healthy eye and optical correction is necessary.
Sharp trauma (perforating): Damage to the lens capsule allows aqueous humor to rapidly enter the lens fibers, causing rapid opacification due to osmotic changes and metabolic disturbances. Small perforations result in localized anterior subcapsular opacities, while large perforations lead to total rapid opacification.
Blunt trauma: Sudden deformation of the eyeball applies mechanical stress to the lens fibers. Even without capsular rupture, metabolic disturbances and osmotic changes are induced, leading to gradual opacification over months to years. Mechanical stress on the zonules of Zinn may also cause rupture.
Lens swelling (intumescent cataract): The lens becomes swollen, causing an increase in intraocular pressure. Leakage of lens proteins into the aqueous humor induces lens-induced uveitis, leading to further elevation of intraocular pressure and worsening of inflammation.
Mechanism of Vossius ring formation: When the eyeball is abruptly deformed by blunt external force, the iris is strongly pressed against the anterior surface of the lens. At this time, pigment from the iris pigment epithelial cells is transferred to the anterior lens capsule surface, forming a circular ring-shaped deposit (Vossius ring) corresponding to the pupillary margin.
The Ocular Trauma Score (OTS) is widely used to predict visual prognosis in traumatic cataract. The OTS calculates prognosis from six factors: initial visual acuity, presence of globe rupture, endophthalmitis, penetrating injury, retinal detachment, and relative afferent pupillary defect 2). A retrospective study of over 300 children showed that the OTS reliably predicts visual prognosis in pediatric traumatic cataract 5).
There remains conflicting data regarding the superiority of primary versus secondary enucleation, and no consensus has been reached4). A report indicates that primary repair of open globe injuries within 24 hours is associated with a reduced risk of endophthalmitis (OR 0.39), supporting early intervention1).
For scleral-fixated IOLs, sutureless fixation methods such as the Yamane technique are also options. In cases without capsular support, selecting a fixation method based on associated injuries and surgeon experience is important 6). For prognostic evaluation of traumatic cataracts, individualized assessment combining the OTS and findings from pediatric trauma studies is required 2,5).
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Kuhn F, Maisiak R, Mann L, Mester V, Morris R, Witherspoon CD. The Ocular Trauma Score (OTS). Ophthalmology clinics of North America. 2002;15(2):163-5, vi. doi:10.1016/s0896-1549(02)00007-x. PMID:12229231.
Mehul A Shah, Shreya M Shah, Shashank B Shah, Chintan G Patel, Utsav A Patel. Morphology of traumatic cataract: does it play a role in final visual outcome?. BMJ Open. 2011;1(1):e000060. doi:10.1136/bmjopen-2011-000060.
Rumelt S, Rehany U. The influence of surgery and intraocular lens implantation timing on visual outcome in traumatic cataract. Graefe’s archive for clinical and experimental ophthalmology = Albrecht von Graefes Archiv fur klinische und experimentelle Ophthalmologie. 2010;248(9):1293-7. doi:10.1007/s00417-010-1378-x. PMID:20585800.
Ram J, Verma N, Gupta N, Chaudhary M. Effect of penetrating and blunt ocular trauma on the outcome of traumatic cataract in children in northern India. The journal of trauma and acute care surgery. 2012;73(3):726-30. doi:10.1097/TA.0b013e31825eeac9. PMID:22929502.
Shin Yamane, Shimpei Sato, Maiko Maruyama-Inoue, Kazuaki Kadonosono. Flanged Intrascleral Intraocular Lens Fixation with Double-Needle Technique. Ophthalmology. 2017;124(8):1136-1142. doi:10.1016/j.ophtha.2017.03.036.
Morikawa S, Okamoto F, Okamoto Y, Mitamura Y, Ishikawa H, Harimoto K, et al. Clinical characteristics and visual outcomes of work-related open globe injuries in Japanese patients. Scientific reports. 2020;10(1):1208. doi:10.1038/s41598-020-57568-9. PMID:31988287; PMCID:PMC6985116.
