Comparative study of final visual outcome between open- and ...

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 Graefe's Archive for Clinical and Experimental Ophthalmology Incorporating German Journal of Ophthalmology ISSN 0721-832X Graefes Arch Clin Exp Ophthalmol DOI 10.1007/ s00417-011-1732-7

1 23

Your article is protected by copyright and all rights are held exclusively by SpringerVerlag. This e-offprint is for personal use only and shall not be self-archived in electronic repositories. If you wish to self-archive your work, please use the accepted author’s version for posting to your own website or your institution’s repository. You may further deposit the accepted author’s version on a funder’s repository at a funder’s request, provided it is not made publicly available until 12 months after publication.

1 23

Author's personal copy Graefes Arch Clin Exp Ophthalmol 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 # 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: [email protected] S. M. Shah e-mail: [email protected] S. B. Shah e-mail: [email protected] C. G. Patel e-mail: [email protected] U. A. Patel e-mail: [email protected] A. Appleware e-mail: [email protected] A. Gupta e-mail: [email protected]

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 (p20/60 vision was significantly higher in group 1 than in group 2 (OR=1.61; 95% CI, 0.85–3.02). 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

Author's personal copy Graefes Arch Clin Exp Ophthalmol

is likely to differ from that in urban areas and is worthy of investigation [2–4]. 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

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 $50–300/2,500–15,000 INR), or very poor (20/60

Reporting interval in days

0–1

2–4

5–30

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 [11–13] 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

Author's personal copy Graefes Arch Clin Exp Ophthalmol Conflicting interests

None.

References 1. Khatry SK, Lewis AE, Schein OD, Thapa MD, Pradhan EK, Katz J (2004) The epidemiology of ocular trauma in rural Nepal. Br J Ophthalmol 88:456–460 2. Abraham DI, Vitale SI, West SI, Isseme I (1999) Epidemiology of eye injuries in rural Tanzania. Ophthalmic Epidemiol 6:85–94 3. Alfaro DV, Jablon EP, Rodriguez Fontal M, Villalba SJ, Morris RE, Grossman M, Roig-Melo E (2005) Fishing-related ocular trauma. Am J Ophthalmol 139:488–492 4. Shah M, Shah S, Khandekar R (2008) Ocular injuries and visual status before and after their management in the tribal areas of western India—a historical cohort study. Grafes Arch Clin Exp Ophthalmol 246:191–197 5. Kuhn F, Morris R, Witherspoon CD, Mester V (2004) The Birmingham Eye Trauma Terminology system (BETT). J Fr Ophtalmol 27:206–210 6. Weinand F, Plag M, Pavlovic S (2003) Primary implantation of posterior chamber lenses after traumatic cataract penetration. Ophthalmology 100:843–846 7. Baykara M, Dogru M, Ozçetin H, Ertürk H (2002) Primary repair and intraocular lens implantation after perforating eye injury. J Cataract Refract Surg 28:1832–1835 8. Mohammad pour M, Jafarinasab MR, Javadi MA (2007) Outcomes of acute postoperative inflammation after cataract surgery. Eur J Ophthalmol 17:20–28 9. Khvatova AV, Kruglova TB (1992) Intraocular correction in the restorative therapy of children with congenital and traumatic cataracts. Vestn Oftalmol 108:18–21 10. Corbett MC, Shilling JS, Holder GE (1995) The assessment of clinical investigations: the Greenwich Grading System and its application to electro diagnostic testing in ophthalmology. Eye 9:59–64 11. Segev Y, Goldstein M, Lazar M, Reider-Groswasser I (1995) CT appearance of a traumatic cataract. AJNR Am J Neuroradiol 16:1174–1175

12. McWhae JA, Crichton AC, Rinke M (2003) Ultrasound biomicroscopy for the assessment of zonules after ocular trauma. Ophthalmology 110:1340–1343 13. Zhang Y, Zhang J, Shi S (1998) Determination of posterior lens capsule status in traumatic cataract with B-ultrasonography. Zhonghua Yan Ke Za Zhi 34:298–299 14. Brar GS, Ram J, Pandav SS, Reddy GS, Singh U, Gupta A (2001) Postoperative complications and visual results in uniocular pediatric traumatic cataract. Ophthalmic Surg Lasers 32:233–238 15. Wos M, Mirkiewicz-Sieradzka B (2004) Traumatic cataract— treatment results. Klin Oczna 106:31–34 16. Baklouti K, Mhiri N, Mghaieth F, El Matri L (2005) Traumatic cataract: clinical and therapeutic aspects. Bull Soc Belge Ophtalmol 298:13–17 17. Vatavuk Z, Pentz A (2004) Combined clear cornea phacoemulsification, vitrectomy, foreign body extraction, and intraocular lens implantation. Croat Med J 45:295–298 18. Morgan KS (1993) Cataract surgery and intraocular lens implantation in children. Curr Opin Ophthalmol 4:54–60 19. Thylefors B, Chylack LT Jr, Konyama K, Sasaki K, Sperduto R, Taylor HR (2002) A simplified cataract grading system. Ophthalmic Epidemiol 9:83–95 20. American Society of Ocular Trauma. Ocular trauma Score (OTS) http://www.asotonline.org/ots.html accessed on 10/12/2008 21. Behbehani AM, Lotfy N, Ezzdean H, Albader S, Kamel M, Abul N (2002) Open eye injuries in the pediatric population in Kuwait. Med Princ Pract 11:183–189 22. Cillino S, Casuccio A, Di Pace F, Pillitteri F, Cillino GA (2008) Five-year retrospective study of the epidemiological characteristics and visual outcomes of patients hospitalized for ocular trauma in a Mediterranean area. BMC Ophthalmol 22:6–8 23. Smith AR, O'Hagan SB, Gole GA (2006) Epidemiology of openand closed-globe trauma presenting to Cairns Base Hospital, Queensland. Clin Exp Ophthalmol 34:252–259 24. Krishnamachary M, Rathi V, Gupta S (1997) Management of traumatic cataract in children. J Cataract Refract Surg 23:681–687 25. Vajpayee RB, Sharma N, Dada T, Gupta V, Kumar A, Dada VK (2001) Management of posterior capsule tears. Surv Ophthalmol 45:473–488