Key Points
Question
What are the visual acuity outcomes and adverse events after surgery for traumatic cataract in children?
Findings
In this cohort study of 72 patients undergoing surgery for traumatic cataract, substantial vision loss due to trauma occurred by 15 months after surgery, with a median visual acuity of 20/63 in eyes with pseudophakia; strabismus was diagnosed in 23 cases (cumulative proportion, 43%, with exotropia in 14 [61%]) and glaucoma was diagnosed in 4 cases (cumulative proportion, 6%). In eyes with pseudophakia, visual axis opacification was diagnosed in 3 of 30 (cumulative proportion, 11%) with and 18 of 27 (cumulative proportion, 77%) without primary posterior capsulotomy.
Meaning
In this study, within 15 months after lensectomy for traumatic cataract in children, substantial ocular morbidity including permanent vision loss was common, suggesting the need for monitoring for development of strabismus and visual axis opacification.
Abstract
Importance
The Pediatric Eye Disease Investigator Group Cataract Registry provides a multicenter assessment of visual outcomes and complications after lensectomy for traumatic pediatric cataract.
Objective
To report visual acuity (VA) and the cumulative proportion with strabismus, glaucoma, and other ocular complications by 15 months after lensectomy for traumatic cataract among children younger than 13 years at the time of surgery.
Design, Setting, and Participants
From June 18, 2012, to July 8, 2015, 1266 eyes of 994 children from 33 pediatric eye care practices seen within 45 days after lensectomy were enrolled in a multicenter, prospective observational registry. Of these, 74 eyes of 72 participants undergoing lensectomy for traumatic cataract were included in a cohort study. Follow-up was completed by November 2, 2015, and data were analyzed from March 20, 2018, to July 7, 2020.
Exposures
Lensectomy after ocular trauma.
Main Outcomes and Measures
Best-corrected VA from 9 to 15 months after lensectomy for traumatic cataract (for those 3 years or older) and the cumulative proportion with strabismus, glaucoma, and other ocular complications by 15 months.
Results
Of 994 participants in the registry, 84 (8%) had traumatic cataract. The median age at lensectomy for 72 participants examined within 15 months after surgery was 7.3 (range, 0.1-12.6) years; 46 (64%) were boys. An intraocular lens was placed in 57 of 74 eyes (77%). In children 3 years or older at outcome, the median best-corrected VA was 20/250 (range, 20/20 to worse than 20/800) in 6 eyes with aphakia and 20/63 (range, 20/20 to 20/200) in 26 eyes with pseudophakia. Postoperative visual axis opacification was reported in 18 of 27 eyes with pseudophakia without primary posterior capsulotomy (15-month cumulative proportion, 77%; 95% CI, 58%-92%). The cumulative proportion with strabismus was 43% (95% CI, 31%-58%) in 64 participants with ocular alignment data; exotropia was present in 14 of 23 participants (61%). The cumulative proportion with glaucoma was 6% (95% CI, 2%-16%).
Conclusions and Relevance
Trauma was not a common cause of pediatric cataract requiring surgery. For children with traumatic cataract, substantial ocular morbidity including permanent vision loss was found, and long-term eye and vision monitoring are needed for glaucoma, strabismus, and capsular opacification.
This cohort study assesses visual acuity and the cumulative proportion with strabismus, glaucoma, and other ocular complications by 15 months after lensectomy for traumatic cataract among children younger than 13 years.
Introduction
Ocular trauma has been reported to be a major cause of childhood cataract and visual impairment worldwide.1,2,3 Surgical rehabilitation of visually meaningful traumatic pediatric cataract is necessary for good visual outcomes.4,5,6 Reports of lensectomy for traumatic cataract in children younger than 18 years have shown that 20% to 70% of eyes achieve a postoperative visual acuity (VA) better than 20/60, with poor outcomes of 20/200 or worse in 2% to 39%.4,5,6 Better visual outcomes and fewer repeated operations have been associated with nonpenetrating injuries, primary posterior capsulotomy, use of an intraocular lens (IOL), and less ocular damage.5,7,8,9 Most pediatric cataract series are limited by their retrospective design and short follow-up. The multicenter cataract registry on which the present study was based had been designed to prospectively collect data on visual outcomes, complications, and adverse events after lensectomy in childhood.10 The present report focuses on VA measured from 9 to 15 months after lensectomy and the cumulative proportion of eyes with complications reported by 15 months after surgery for traumatic cataract.
Methods
This cohort study obtained an investigational device exemption from the US Food and Drug Administration because of the use of an IOL for an unapproved indication. The study protocol (found in Supplement 1) and informed consent forms compliant with the Health Insurance Portability and Accountability Act were approved by each participating site’s institutional review board. A parent or guardian of each enrolled child provided written informed consent, and assent was obtained from children 7 years or older.
From June 18, 2012, to July 8, 2015, 994 children younger than 13 years who had undergone lensectomy in 1266 eyes during the preceding 45 days were enrolled at 33 sites in a prospective clinical research registry of lensectomy outcomes (Pediatric Eye Disease Investigator Group [PEDIG] Cataract Registry). Medical and ophthalmic data were collected from a medical record review for each child at enrollment and annually thereafter.11 The data reported herein, collected through November 2, 2015, are from 84 participants (86 eyes) enrolled after lensectomy for the removal of traumatic cataract. Glaucoma and glaucoma suspect have been defined previously11 (eTable in Supplement 3). Other complications reported in this report were based on investigator diagnosis.
Annual Data Collection
Each year after lensectomy, clinical data including best-corrected optotype VA, refractive error, intraocular pressure, and IOL centration documented at the most recent office visit (or examination under anesthesia) completed during the annual review period were collected. Information pertaining to medical history, treatment, complications, and subsequent intraocular surgical procedures reported since the last annual review were also collected. The date of VA testing, dates when surgical procedures were first performed, and the date of the most recently completed office visit were collected.
Statistical Analysis
Data were analyzed from March 20, 2018, to July 7, 2020. To be included in the analysis, the participant must have had an office visit within 15 months after lensectomy. Complications were considered to have occurred within 15 months after lensectomy if the most recent office visit documented on the annual form on which the complication was reported had occurred within 15 months after lensectomy or if surgical treatment for a complication was performed within 15 months after lensectomy.
The Kaplan-Meier method was used to estimate the cumulative proportion of eyes with each reported complication or surgery and the corresponding 95% CI for each. Because the date of complication onset was not collected, the date of the most recent office visit at which the complication was reported was used to estimate the cumulative proportion of eyes that developed each complication. The actual date of surgery was used to document the timing of each additional surgery. If the complication or the surgical procedure was not reported, the date of last follow-up within the 15-month window was used in the analysis unless the participant had completed a later visit (beyond the 15-month window) and was confirmed to not have had the complication. In that case, the date of last follow-up was considered the end date of the 15-month window.
Estimates of cumulative proportions were calculated for the entire study cohort and separately for cases with aphakia and pseudophakia. Estimates of the cumulative proportion may differ from the raw proportion owing to loss to follow-up before 15 months.
Visual acuity was included for children at least 3 years of age at the time of testing if performed from 9 to 15 months after lensectomy. The median best-corrected VA (BCVA) was reported for all eyes for which data were available and for eyes with aphakia and pseudophakia separately. The difference in BCVA between the study and the fellow eyes of participants enrolled after unilateral cataract surgery and the corresponding 95% CI were calculated. Visual acuity measurements were converted to the logarithm of the minimum angle of resolution (logMAR) for analysis. Visual acuity worse than 20/800 was assigned 1.70 logMAR (1 line worse than 20/800).
The distribution of BCVA and the cumulative proportion of strabismus are reported according to (1) the method of IOL fixation (ie, sulcus or capsular bag) and (2) whether anterior vitrectomy was performed at initial lensectomy. The 15-month cumulative proportion of eyes with pseudophakia and visual axis opacification was reported separately for eyes that received primary capsulotomy at lensectomy and those that did not. The difference in the cumulative proportions were calculated, and a z test was used to calculate the 95% CI for the difference between these groups.
When describing the mean length of time for which participants were followed up, length of follow-up was defined as the time from lensectomy to last office visit documented within the 15-month window unless the participant had completed a visit beyond the 15-month window. In that case, length of follow-up was defined as 15 months for this report. Analyses were performed using SAS, version 9.4 (SAS Institute Inc). More information can be found in the statistical analysis plan in Supplement 2.
Results
Traumatic cataract was reported in 84 of 994 children (8%) in the registry; cataracts were unilateral in 82 and bilateral in 2. An office visit was documented within 15 months after lensectomy for 72 participants (74 eyes). Baseline characteristics for the 74 eyes (72 participants) evaluated within 15 months after lensectomy and the 12 eyes (12 participants) not seen within that period are listed in Table 1. When compared with the participants who underwent evaluation within 15 months after lensectomy, those not seen within 15 months were more likely to have pseudophakia (12 of 12 eyes [100%] vs 57 of 74 eyes [77%]) and have had their lensectomy performed at an older age (mean [SD] age, 8.4 [2.7] vs 7.2 [3.5] years).
Table 1. Baseline Characteristics.
| Characteristic | Study groupa | ||
|---|---|---|---|
| Office visit within 15 mo after lensectomy | All eyes enrolled after lensectomy for traumatic cataract (n = 86) | ||
| Yes (n = 74) | No (n = 12) | ||
| Age at initial surgery | |||
| <6 mo | 3 (4) | 0 | 3 (3) |
| 6 mo to <1 y | 1 (1) | 0 | 1 (1) |
| 1 to <4 y | 10 (14) | 1 (8) | 11 (13) |
| 4 to <7 y | 21 (28) | 2 (17) | 23 (27) |
| 7 to <13 y | 39 (53) | 9 (75) | 48 (56) |
| Mean (SD), y | 7.2 (3.5) | 8.4 (2.7) | 7.4 (3.4) |
| Median (range), y | 7.3 (0.1-12.6) | 7.9 (3.6-12.9) | 7.4 (0.1-12.9) |
| IOL implantation | |||
| Yes (pseudophakia) | 57 (77) | 12 (100) | 69 (80) |
| No (aphakia) | 17 (23) | 0 | 17 (20) |
| Primary capsulotomy | |||
| Limbus approach | 30 (41) | 6 (50) | 36 (42) |
| Pars plana/plicata approach | 12 (16) | 1 (8) | 13 (15) |
| None | 29 (39) | 4 (33) | 33 (38) |
| Other | 2 (3) | 0 | 2 (2) |
| Unknown | 1 (1) | 1 (8) | 2 (2) |
| Anterior vitrectomy | |||
| Yes | 48 (65) | 9 (75) | 57 (66) |
| No | 25 (34) | 3 (25) | 28 (33) |
| Unknown | 1 (1) | 0 | 1 (1) |
| Other concomitant procedures | |||
| Corneal transplant | 0 | 0 | 0 |
| Glaucoma | 0 | 0 | 0 (0) |
| Lysis of synechiae | 12 (16) | 0 | 12 (14) |
| None | 49 (66) | 9 (75) | 58 (67) |
| Otherb | 12 (16) | 3 (25) | 15 (17) |
| Unknown | 1 (1) | 0 | 1 (1) |
| Operative complicationsc | |||
| Cloudy cornea | 0 | 0 | 0 |
| Hyphema | 2 (3) | 0 | 2 (2) |
| Iris | |||
| Damage | 0 | 0 | 0 |
| Prolapsed | 0 | 0 | 0 |
| Sphincterotomy | 2 (3) | 0 | 2 (2) |
| Lens fragment in vitreous | 1 (1) | 0 | 1 (1) |
| Retained cortex | 2 (3) | 0 | 2 (2) |
| Ruptured posterior capsule | 1 (1) | 0 | 1 (1) |
| Unplanned iridectomy | 0 | 0 | 0 |
| Otherd | 5 (7) | 1 (8) | 6 (7) |
Abbreviation: IOL, intraocular lens.
Unless otherwise indicated, data are expressed as number (percentage) of eyes. Percentages have been rounded and may not total 100.
Among participants who had an office visit in the analysis window, other concomitant surgical procedures include anterior segment reconstruction (n = 1), capsular tension ring implant (n = 1), corneal laceration repair (n = 1), iridodialysis repair (n = 2), pars plana vitrectomy (n = 1), posterior synechiolysis (n = 1), scleral buckle (n = 1), and suture removal (n = 4); among participants who did not have an office visit in the analysis window, surgical procedures include suture removals (n = 2) and reported iridodialysis repair (n = 1). Multiple concomitant procedures were performed in 4 eyes.
Multiple complications were reported for some eyes. The denominator is the total number of eyes.
Among participants who had an office visit in the analysis window, other complications include anterior capsule tear (n = 2), IOL exchanged intraoperatively (n = 1), IOL haptic broke off original lens with removal and replacement (n = 1), and iris bleeding (n = 1); among participants who did not have an office visit in the analysis window, complications include anterior and posterior capsule dialysis (n = 1).
Twelve of 84 participants (14%) were lost to follow-up. Of 72 participants with follow-up, 46 (64%) were boys and 26 (36%) were girls; 59 (82%) were 4 years or older at lensectomy. The median age at time of lensectomy was 7.3 (range, 0.1-12.6) years, and the median length of follow-up was 15 (range, 1.1-15.0) months. An intraoperative complication was identified in 10 of 74 eyes (14%): 3 of 17 (18%) with aphakia and 7 of 57 (12%) with pseudophakia. Additional baseline characteristics and operative details for eyes with aphakia and pseudophakia are listed in Table 2.
Table 2. Characteristics of Eyes With Aphakia and Pseudophakia at Lensectomy.
| Characteristic | Study groupa | ||
|---|---|---|---|
| Aphakia (n = 17) | Pseudophakia (n = 57) | All (n = 74) | |
| Age at initial surgery | |||
| <6 mo | 3 (18) | 0 | 3 (4) |
| 6 mo to <1 y | 1 (6) | 0 | 1 (1) |
| 1 to <4 y | 3 (18) | 7 (12) | 10 (14) |
| 4 to <7 y | 2 (12) | 19 (33) | 21 (28) |
| 7 to <13 y | 8 (47) | 31 (54) | 39 (53) |
| Mean (SD), y | 6.1 (4.3) | 7.6 (3.1) | 7.2 (3.5) |
| Median (range), y | 6.0 (0. 1-11.5) | 7.3 (1.3-12.6) | 7.3 (0.1-12.6) |
| IOL fixation | |||
| Capsular bag | NA | 40 (70) | NA |
| Sulcus | NA | 16 (28) | NA |
| Unknown | NA | 1 (2) | NA |
| Primary capsulotomy | |||
| Limbus approach | 12 (71) | 18 (32) | 30 (41) |
| Pars plana/plicata approach | 2 (12) | 10 (18) | 12 (16) |
| None | 2 (12) | 27 (47) | 29 (39) |
| Other | 0 | 2 (4) | 2 (3) |
| Unknown | 1 (6) | 0 | 1 (1) |
| Anterior vitrectomy | |||
| Yes | 17 (100) | 31 (54) | 48 (65) |
| No | 0 | 25 (44) | 25 (34) |
| Unknown | 0 | 1 (2) | 1 (1) |
| Other concomitant surgeries | |||
| Corneal transplant | 0 | 0 | 0 |
| Glaucoma | 0 | 0 | 0 |
| Lysis of synechiae | 4 (24) | 8 (14) | 12 (16) |
| None | 10 (59) | 39 (68) | 49 (66) |
| Other | 3 (18) | 9 (16) | 12 (16) |
| Unknown | 0 | 1 (2) | 1 (1) |
| Operative complicationsb | |||
| Cloudy cornea | 0 | 0 | 0 |
| Hyphema | 0 | 2 (4) | 2 (3) |
| Iris | |||
| Damage | 0 | 0 | 0 |
| Prolapsed | 0 | 0 | 0 |
| Sphincterotomy | 0 | 2 (4) | 2 (3) |
| Lens fragment in vitreous | 0 | 1 (2) | 1 (1) |
| Retained cortex | 2 (12) | 0 | 2 (3) |
| Ruptured posterior capsule | 1 (6) | 0 | 1 (1) |
| Unplanned iridectomy | 0 | 0 | 0 |
| Otherc | 1 (6) | 4 (7) | 5 (7) |
Abbreviations: IOL, intraocular lens; NA, not applicable.
Unless otherwise indicated, data are expressed as number (percentage) of eyes. Percentages have been rounded and may not total 100.
Multiple complications were reported for some eyes. The denominator is the total number of eyes.
Among eyes with aphakia, complications include anterior capsule tear (n = 1); among eyes with pseudophakia, complications include anterior capsule tear (n = 1), IOL exchanged intraoperatively (n = 1), IOL haptic broke off original lens with removal and replacement (n = 1), and iris bleeding (n = 1).
Quantitative BCVA was reported for 32 of 67 children (48%) (6 eyes with aphakia and 26 with pseudophakia) who were 3 years or older at follow-up. The median BCVA was 20/250 (range, 20/20 to worse than 20/800) in eyes with aphakia and 20/63 (range, 20/20 to 20/200) in eyes with pseudophakia (Figure). The mean BCVA in the study eyes was 20/63 for 25 participants who received an IOL after unilateral surgery and 20/20 in the fellow eyes (mean logMAR difference, 0.45; 95% CI, 0.34-0.56). One participant was excluded from this analysis because the BCVA in the fellow eye was not reported. Visual acuity outcomes for eyes with pseudophakia did not differ by capsular bag or sulcus IOL fixation (median BCVA, 20/63 [range, 20/20 to 20/200] vs 20/40 [range, 20/32 to 20/80]) or by performance of anterior vitrectomy at initial surgery (median BCVA, 20/80 [range, 20/20 to worse than 20/800] with vs 20/63 [range, 20/20 to 20/200] without anterior vitrectomy) (Figure).
Figure. Distribution of Best-Corrected Visual Acuity Measured From 9 to 15 Months After Lensectomy According to Procedures Performed at Lensectomy.
The top and bottom of each box represent the 75th and 25th percentiles of the data, respectively. Group medians are represented by the horizontal line in each box; group means are represented by filled circles. The bars extending above and below each box represent 1.5 times the interquartile range (difference between the 75th and 25th percentiles) or the maximum (or minimum) observed value within the range if not as extreme as the calculated value. The open circles represent statistical outliers. Visual acuity was reported for 32 eyes (21 with and 11 without anterior vitrectomy and 26 with and 6 without intraocular lens [IOL] implantation). An intraocular lens was placed in the capsular bag in 19 eyes, in the sulcus in 6 eyes, and placement was unknown in 1 eye. Statistical comparisons were not performed due to the small sample sizes.
Glaucoma was diagnosed in 4 of 74 eyes (15-month cumulative proportion, 6%; 95% CI, 2%-16%). All 4 eyes were among the 57 with pseudophakia (15-month cumulative proportion in pseudophakia, 8%; 95% CI, 3%-21%). Glaucoma was not reported in the 17 eyes with aphakia. No cases of glaucoma suspect were reported.
Visual axis opacification was reported in 2 of 17 eyes with aphakia (15-month cumulative proportion, 13%; 95% CI, 3%-41%). In eyes with pseudophakia, visual axis opacification was identified in 3 of 30 (15-month cumulative proportion, 11%; 95% CI, 4%-30%) when lensectomy was performed with primary posterior capsulotomy and 18 of 27 (15-month cumulative proportion, 77%; 95% CI, 58%-92%) without primary capsulotomy (difference, −66%; 95% CI, −88% to −45%). Surgery to clear the visual axis was reported in 18 of 21 eyes with pseudophakia and visual axis opacification (surgical membranectomy in 3 and YAG capsulotomy in 15). Additional complications and intraocular surgical procedures were uncommon within 15 months after lensectomy (Table 3).
Table 3. Cumulative Proportion of Eyes With Complications and Intraocular Surgery Within 15 Months After Lensectomy.
| Event | Eyes, No. (cumulative proportion, %) [95% CI]a | ||
|---|---|---|---|
| Aphakia (n = 17) | Pseudophakia (n = 57) | All (n = 74) | |
| Ocular complications | |||
| Corneal calcification/opacification | 1 (6) [1-35] | 2 (4) [1-15] | 3 (4) [1-13] |
| Glaucoma | 0 (0) [NA] | 4 (8) [3-21] | 4 (6) [2-16] |
| Glaucoma suspect | 0 (0) [NA] | 0 (0) [NA] | 0 (0) [NA] |
| Intraocular inflammation | 0 (0) [NA] | 2 (4) [1-15] | 2 (3) [1-12] |
| Iris posterior synechiae | 1 (6) [1-37] | 4 (8) [3-19] | 5 (7) [3-17] |
| Peripheral anterior synechiae | 1 (6) [1-37] | 2 (4) [1-14] | 3 (4) [1-13] |
| Surgically caused iris abnormalities | 0 (0) [NA] | 1 (2) [0-15] | 1 (2) [0-11] |
| Retinal detachment | 0 (0) [NA] | 3 (6) [2-16] | 3 (4) [1-12] |
| Visual axis opacification | 2 (13) [3-41] | 21 (42) [29-57] | 23 (34) [24-47] |
| Intraocular surgical procedure | |||
| Glaucoma | 0 (0) [NA] | 0 (0) [NA] | 0 (0) [NA] |
| Secondary IOL implantation | 3 (18) [6-45] | 0 (0) [NA] | 3 (5) [2-14] |
| Retinal detachment repair | 0 (0) [NA] | 2 (4) [1-14] | 2 (3) [1-11] |
| Clearing of visual axisb | 1 (6) [1-35] | 18 (36) [24-51] | 19 (28) [19-41] |
| Membranectomy | 1 (100) [NA] | 3 (17) [NA] | 4 (21) [NA] |
| Laser capsulotomy | 0 (0) [NA] | 15 (83) [NA] | 15 (79) [NA] |
Abbreviations: IOL, intraocular lens; NA, not applicable.
The Kaplan-Meier method was used to estimate the cumulative proportion of eyes with each reported complication or procedure. Estimates of the cumulative proportion of eyes that develop each event by 15 months may differ from the tabulation of the proportion of events that occurred during the 15-month period owing to loss to follow-up before 15 months. The Kaplan-Meier method does not estimate 95% CIs when the event rate is 0%.
Proportion calculated by dividing the number of eyes in which the procedure was performed by the number of eyes in which the procedure was performed to clear the visual axis; 95% CIs were not calculated for these percentages. Estimates are meant to describe the participants in the study; they are not meant to be generalized to all patients who undergo lensectomy due to trauma.
Data on ocular alignment were available for 64 participants. Strabismus was reported in 23 of 64 participants (15-month cumulative proportion, 43%; 95% CI, 31%-58%), including 9 of 15 participants with aphakia (15-month cumulative proportion, 63%; 95% CI, 40%-86%) and 14 of 49 participants with pseudophakia (15-month cumulative proportion, 36%; 95% CI, 23%-53%). Exotropia was present in 14 of the 23 participants (61%) for whom strabismus was reported, esotropia in 5 (22%), hypertropia (isolated or combined with a horizontal deviation) in 4 (17%), and not specified for 3 (13%). Table 4 lists strabismus rates according to (1) whether vitrectomy was performed at lensectomy and (2) whether an IOL was placed in the capsular bag or the sulcus.
Table 4. Cumulative Proportion of Participants With Strabismus Within 15 Months After Lensectomy According to Procedures Performed at Lensectomy.
| Event | No. of participants with ocular alignment data | Cumulative proportion of participants with strabismus by 15 mo, % (95% CI)b | |
|---|---|---|---|
| Within 15 mo after lensectomya | Developed strabismus within 15 mo after lensectomy | ||
| IOL implanted at initial lensectomyc | |||
| Yes, pseudophakia | 49 | 14 | 36 (23-53) |
| No, aphakia | 15 | 9 | 63 (40-86) |
| IOL fixationd | |||
| Capsular bag | 35 | 9 | 32 (18-53) |
| Sulcus | 14 | 5 | 46 (22-79) |
| Anterior vitrectomye | |||
| Yes | 42 | 19 | 52 (37-70) |
| No | 21 | 3 | 18 (6-46) |
Abbreviation: IOL, intraocular lens.
Excludes 8 participants (1 with aphakia and 7 with pseudophakia) for whom the presence or absence of strabismus was unknown.
Estimates of the cumulative proportion of eyes that develop strabismus by 15 months may differ from the tabulation of the proportion of events that occurred during the 15-month period owing to loss to follow-up before 15 months.
Median age was 6.0 (range, 0.1-11.5) years in participants with aphakia and 7.4 (range, 1.3-12.6) in those with pseudophakia.
Data were limited to 49 participants with pseudophakia for whom the presence or absence of strabismus was known.
Unknown in 1 eye.
Discussion
Lensectomy for traumatic cataract represented 8% of the participants in the PEDIG registry of children younger than 13 years undergoing cataract surgery10; this total is less than the 29% reported previously for similar age and sex distributions.3 Most surgical procedures included an IOL placed in the capsular bag. Few intraoperative complications were noted. Vision loss was very common, with a median BCVA of 20/63 for eyes with pseudophakia and 20/250 for eyes with aphakia among children who were old enough to have quantitative measurements. Whether owing to ocular damage, amblyopia, or a combination of these factors, the children in our cohort had permanent visual impairment after lensectomy for traumatic cataract.
Glaucoma was infrequent (15-month cumulative proportion, 6%) after lensectomy, with or without an IOL. Strabismus developed in nearly half the children, although more commonly in children with aphakia, who were also younger at the time of injury.
Visual axis opacification was a common postoperative complication, with a cumulative proportion of 42% among children with IOLs (77% by 15 months if no primary capsulotomy was performed). Most of these patients subsequently underwent laser capsulotomy. Previous reports suggest that posterior capsular opacity is frequent after traumatic cataract and that primary removal of the posterior capsule is associated with decreased rates of repeated operations and improved vision.5,6,12 The higher rate of visual axis opacification observed in eyes with pseudophakia that did not undergo primary posterior capsulotomy in this study is consistent with data from prior reports.6,12 When able to be performed safely, surgeons should be prepared to perform a primary posterior capsulotomy or plan for a secondary capsulotomy when managing cataracts caused by trauma in children.
In this cohort, aphakia was associated with young age. In addition, every child with aphakia had an anterior vitrectomy at the time of lensectomy. Similarly, IOL placement and lower performance rate of anterior vitrectomy may have been associated with older age and less severe trauma. These factors, along with small subgroup sizes, made it difficult to evaluate whether outcomes were associated with procedures during lensectomy and to control for potential confounders. Therefore, these subgroups were not compared.
Limitations
The limitations of this study include missing annual data reviews or examinations for some participants and a 14% loss to follow-up. In particular, VA data were available for only 48% of the children 3 years of age or older at their outcome visit. In addition, we could not differentiate between vision loss due to amblyopia and ocular damage due to trauma. However, patients were treated with the best clinical care possible, so the impact of residual amblyopia would be minimized and accurately reflect individual outcomes.
Conclusions
In this cohort study, we identified a traumatic etiology in 8% of lensectomies in the PEDIG Cataract Registry. The practice of our investigators was to implant an IOL in most cases. Permanent visual impairment was common. Primary posterior capsulotomy was associated with a lower rate of visual axis opacification. Within the 15 months after lensectomy, strabismus was common, whereas glaucoma was not.
Study Protocol
Statistical Analysis Plan
eTable. Definitions of Glaucoma and Glaucoma Suspect
Nonauthor Collaborators
References
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Associated Data
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Supplementary Materials
Study Protocol
Statistical Analysis Plan
eTable. Definitions of Glaucoma and Glaucoma Suspect
Nonauthor Collaborators