TRAUMATIC CATARACT DR.KHUTEJA FATIMA IIND YEAR PG DEPT OF OPHTHALMOLOGY

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1 TRAUMATIC CATARACT DR.KHUTEJA FATIMA IIND YEAR PG DEPT OF OPHTHALMOLOGY

2 Traumatic cataract :Traumatic lens damage caused by mechanical injury and by physical forces (Ionising radiation,ir radiation, electrical current).

3 ETIOLOGY Blunt Trauma Penetrating Trauma Electric shock /Lightning strike : anterior / posterior capsular iridescent opacity with stellate pattern Infrared Radiation [Glass blowers] : True exfoliation of anterior lens capsule Ionising Radiation:PSCO

5 Incidence Ocular injuries accounts for 1 2% of total injuries Gender M:F =3:1 More exposed to outdoor activities, indulge more sports,violence,rash driving, industry & travel Age Maximum incidence in yrs Higher incidence as this is the wage earning period.

6 Birmingham Eye Trauma Terminology System [BETTS] EYE INJURY OPEN GLOBE CLOSED GLOBE RUPTURE LACERATION CONTUSION LAMELLALR LACERATION PENETRATING INJURY IOFB PERFORATING INJURY

7 BLUNT TRAUMA MECHANISM Cortical matter in AC Rosette Cataract Membranous cataract A P Compression force Leads to equatorial expansion Total cataract

8 Effect of blunt trauma on lens VOSSIUS ring Minute anterior subcapsular opacities Concussion cataract Early Rosette cataract Late Rosette cataract Subluxation of lens Dislocation of lens

9 Vossius Ring PRESSURE ON EYEBALL DRIVES CORNEA & IRIS BACKWARDS IMPRESSION OF IRIS ON LENS CIRCULAR RING OF FAINT STIPPLED OPACITIES [BROWN AMORPHOUS GRANULES] ON ANTERIOR CAPSULE DIAMETER SAME AS CONTRACTED PUPIL

10 Concussion cataract Due to mechanical effects of injury on lens fibres. Aqueous hits the capsule impairing its permeability Capsular tear covered with Iris >opacity remains/regresses Open capsular tear >allows more aqueuos into lens : cataract

11 Early rosette cataract Posterior cortex involved Few hours months Accumulation of fluid along the sutural arrangement of lens fibres Thus, the stellate/feathery outline delineated.

12 Late rosette cataract Posterior cortex involved 1 2 years after the trauma Small, compact with short sutural extensions.

13 Total cataract Early rosette Total cataract Late rosette

14 Subluxation and Dislocation Blunt trauma Compression Rapid equatorial expansion of globe Disruption of zonular fibres Subluxation or Dislocation : Ant[AC] or Post [vitreous]

15 Symptoms of traumatic lens subluxation Fluctuation of vision Impaired accommodation Monocular diplopia[edge crosses the pupil] High astigmatism. Hypermetropic through the aphakic part.[needs correction] Myopic[curvatural] through subluxated part

16 Signs of traumatic lens subluxation Suspensory ligament torn by To and Fro compression pressurei >lateral movement or rotation of lens. Iridodonesis Phacodonesis Oblique illumination : Grey cortex line Ophthalmoscope : Black cortex line Retroillumination of the lens at the slit lamp through a dilated pupil :zonular disruption.

17 Traumatic Lens Dislocation Dislocation AC [a/w spasm of sphincter pupillae] Vitreous Iridocyclitis Intractable secondary glaucoma Aphakia [=couching]

drop in AC[globular lens] It is difficult to see a clear

18 Signs and symptoms Blurred vision [ posterior dislocation = hypermetropia] Anterior dislocation : appears likeoil drop in AC[globular lens] It is difficult to see a clear lens in AC Posterior dislocation : leads to aphakia deep AC

19 Anteriorly dislocated lens Leads to Pupil block Immediate removal Miotics to trap lens in AC Posteriorly dislocated lens Effects vision Impairs retinal function

20 Zonular incompetence Decentration of lens in the bag Vitreous prolapse into the anterior chamber with loss of efficient nuclear removal.

Effect of Perforating and Penetrating Injury

21 Effect of Perforating and Penetrating Injury Rupture of the lens capsule leads to rapid hydration of the lens cortex at the site of the rupture, progressing rapidly to complete opacification. Occasionally, small perforating injury of the lens capsule heals, resulting in a stationary focal cortical cataract

22 Lens protein may leak into the aqueous and vitreous and cause uveitis or glaucoma. Secondary glaucoma can mask infectious endophthalmitis

INFLAMMATION PAS LENS SUBLUXATION PUPIL BLOCK ANGLE

23 EVALUATION VISUAL ACUITY, PUPLIS SLIT LAMP EXAMINATION DIRECT & INDIRECT OPHTHALMOSCOPY INTRA OCULAR PRESSURE INFLAMMATION PAS LENS SUBLUXATION PUPIL BLOCK ANGLE RECESSION GONIOSCOPY KERATOMETRY & A SCAN LACRIMAL SYRINGING&PROBING B SCAN CT/MRI

24 TREATMENT MEDICAL Systemic stabilisation Ocular Thorough Saline Wash Topical cycloplegics Homatropine eye drops 2% BD Topical steroids Prednisolone acetate eye drops 1% 6 times a day Topical Antibiotics Moxifloxacin eye drops QID Artificial tear supplements Methyl cellulose eye drops 1% QID Oral steroids T.Prednisolone 40mg OD [Given with Antacids T.Ranitidine 150 mg BD before food] Vitamin C supplements T.Limcee OD NSAIDs+Serratiopeptidase T.Lyser D OD

25 SURGICAL INDICATIONS Traumatic cataract with decrease in functional visual acuity Subluxated lens with Lens induced glaucoma and Lens induced uveitis To improve visualization of posterior segment

26 SURGICAL MANAGEMENT ANTERIOR LIMBAL APPROACH PARS PLANA APPROACH Traumatic cataract Capsular rupture Anterior subluxation / dislocation Gross posterior lens dislocation Posterior capsular rupture

27 Phacoemulsification in Traumatic cataract Zonular dehiscence Phacoemulsification can sometimes be used to extract a cataract in the presence of limited zonular support. A generous capsulorrhexis will facilitate nucleus extraction; however, be careful to avoid extending the capsular tear into the area of zonular fiber insertion on the anterior capsule. Reducing the flow rate helps decrease anterior chamber turbulence and the risk of vitreous prolapse through the zonular dehiscence. Lowering the height of the irrigating bottle reduces the risk of a very deep anterior chamber, which can further stress the zonular fibers

28 Viscoelstic tamponade of vitreous is used for areas of zonular incompetence. If a nuclear cataract is present before the trauma, sufficient ultrasound power should be used to emulsify the nucleus without movingit excessively. If vitreous has migrated into the anterior chamber, anterior vitrectomy before starting phacoemulsification or cortical aspiration in order to avoid vitreous aspiration with resulting retinal traction.

29 Not enough capsular support??. A capsular tension ring (CTR) can be inserted into the capsular bag. This device provides adequate support for nuclear and cortical removal, as well as for in thebag 10L insertion. Insufficient zonular support can be addressed with a Cionni modified CTR sutured to the scleral wall. If a CTR is not available and zonular support sufficient for in the bag IOL placement, a 3 piece IOL with the haptics placed in the area of zonular weakness helps prevent capsular contraction

30 Endo capsular Tensionrings MECTR

31 SUPERIOR HAPTIC IS USED TO STRETCH THE CAPSULAR BAG

32 IOL PLACEMENT Primary or secondary implantation Bag / sulcus / AC/ trans scleral suture ACIOL 2 SULCUS FIXATED IOL 3 SCLERAL FIXATED IOL 4 PCIOL 3 4

33 Lens Implantation Primary IOL insertion can be considered when intraocular inflammation and hemorrhage are minimal and the view of anterior segment structures is good. Primary IOL insertion has the advantage of avoiding an additional operation, thus reducing the cost and risks associated with further intraocular surgery.

34 Ideal Implantation Removal of nucleus without compromising capsular bag integrity and implanting the IOL in the bag

35 Ocular trauma other Manifestations Orbit Lens Lids Sclera Conjunctiva Choroid Cornea Retina AC Iris Macula ON

36 Other manifestations Corneal laceration Hyphaema Iridodialysis Synechiae Retinal detachment Intra ocular foreign body

37 Cornea Laceration Corneal laceration or edema may impair the surgeon's ability to remove lens material safely and may indicate the need for an opensky approach. Corneal laceration is sutured with 10 0 prolene.

38 Hyphaema Hemorrhage can occur during lens removal and further interfere with visualization Paracentesis is done Use of Viscoelastics or air may be helpful. If visualization remains insufficient, the eye should be closed to allow an adequate clot to form.

Synechiae During the acute phase of ocular trauma, fibrin rapidly forms membranes on the iris that can cause synechiae, pupil seclusion, and distortion of intraocular structures.

39 Synechiae During the acute phase of ocular trauma, fibrin rapidly forms membranes on the iris that can cause synechiae, pupil seclusion, and distortion of intraocular structures. Gentle sweeping of the posterior synechiae may allow the pupil to dilate, but if it does not, pupilloplasty may be necessary. A peripheral iridectomy done to prevent postoperative pupillary block.

40 Iris Iridodialysis Sphincter ruptures needs repair when clinically significant pupillary distortion has resulted. The dialyses repaired by suturing the iris root to the scleral spur.

41 Vitreous

42 Retina Cataract extraction may be necessary to allow adequate visualization if a retinal detachment occurs early or late in the course.

43 Intra Ocular Foreign Body If media is clear, Indirect ophthalmoscopy is done If view inadequate, CT scan or ultrasound can be helpful. MRI C/I because the metallic foreign body could be dislodged by the magnet.

44 Significant cataract in the presence of retained foreign matter in the posterior chamber may be handled via parsplana approach or an anterior approach followed by a PPV and foreign body removal. Intra cameral foreign bodies may be easier to see when the patient is seated at the slit lamp rather than positioned horizontally under the operating microscope. In addition, Irrigating solutions can dislodge aforeign body from its preoperative position

45 Prevention Sports injuries protective helmet Industries protective goggles

46 THANK YOU

Pediatric traumatic cataract Presentation and Management. Dr. Kavitha Kalaivani Pediatric ophthalmology Sankara Nethralaya Nov 7, 2017

Pediatric traumatic cataract Presentation and Management Dr. Kavitha Kalaivani Pediatric ophthalmology Sankara Nethralaya Nov 7, 2017 Management of Traumatic Cataract Ocular trauma presents many problems