PediatrictraumaticcataractinChina 窑ClinicalResearch窑 Pediatrictraumaticcataractandsurgeryoutcomesin easternChina:ahospital-basedstudy

1WeifangMedicalUniversity,Weifang261053,Shandong DOI:10.3980/j.issn.2222-3959.2013.02.10 Province,China 2ShandongEyeInstitute,Qingdao266071,Shandong XuYN,HuangYS,XieLX.Pediatrictraumaticcataractandsurgery Province,China outcomesineasternChina:ahospital-basedstudy. Co-firstauthors: Ying-NanXuandYu-SenHuang 2013;6(2):160-164 Correspondenceto: Li-XinXie.ShandongEyeInstitute,5 YanerdaoRoad,Qingdao266071,ShandongProvince,China. INTRODUCTION [email protected] ediatrictraumaticcataractisoneoftheleadingcausesof Received:2012-12-04Accepted:2013-03-05 P monocularblindnessinchildren,accountingfor29%- 57%ofpediatriccataractcases [1].Pediatriceyeisin Abstract development, andtraumawillleadtomoresevere complications,suchas vitreous proliferationdiseases. · AIM:Toevaluatetheetiologies,management,and Withouteffectiveandprompttreatments,pediatriccataract outcomesofpediatrictraumaticcataractineasternChina. willdeterioratevision,includingoflossofbinocularvision, METHODS:Pediatrictraumaticcataractwerereviewed · amblyopia,strabismus,lowvisioninlife,evenblind [2].In fordemographicinformation,typeofinjury,modeof certainregionswithwell-establishedchildhoodblindness injury,timeofinjury,intervalbetweeninjuryandfirst programs,theaverageChildhoodCataractSurgicalRate visitingdoctors,hospitaloffirstvisiting,surgeries, (CCSR)rangesfrom29.2to39.8childrenpermillion complicationsandprognosis. population [3],whereasinotherpoorlyestablishedregions,the ·RESULTS:Atotalof117eyesof117patients(96boys CCSRisonly1.1 [4].AstudyfromUgandaestimatedthat and21girls)withunilateralinjuries(66rightand51left cataractwasresponsibleforover30%ofallcasesof eyes)wereincludedinthestudy.Themean(SEM)ageat blindnessandvisualimpairmentin children [5]. diagnosiswas (6.6 依3.2)years (range,1.3-13.8years). Evidence-basedinformationiscrucialforimprovingeyecare Eachcataractwascategorizedaccordingtothetypeof trauma:closed-globe ( =26)oropen-globe ( =91) inchildren.Wecouldnotfindsuchinformationonpediatric injuries.Themostcommoninjuringobjectsweresharp traumaticcataractinChina,soaretrospectivereviewof metalobjects(37.61%).Themostcommoncomplication pediatrictraumaticcataractinourophthalmologycenterwas inopen-globeinjurieswascorneallaceration,whereas performedtoexplorethetreatmentoftraumaticcataractin traumaticmydriasiswasmostcommoninclosed-globe children,withthegoalofprovidingscientificevidence injuries.Of68eyesinpatientswithopen-globeinjuries surroundingthepreventionandtreatmentof pediatric whoreceivedcataractextraction,intraocularlens(IOLs) traumaticcataractinChina. wereprimarilyimplantedin47eyes(68.12%),whereas18 SUBJECTSANDMETHODS eyes with closed-globe injuries received cataract ThisretrospectivereviewwasapprovedbytheShandongEye extraction,andIOLswereprimarilyimplantedin17eyes InstituteReviewBoard.Aretrospectivereviewwas (94.4%).Thesurgicalproceduresincludedreconstruction oftheanteriorsegment,synechiolysis,excisionofthe conductedoftherecordsofallchildren14yearsoldor membrane, lensectomy, vitrectomy and related youngerthathadadiagnosisoftraumaticcataractand techniques. Postoperative vision was significantly presentedattheQingdaoEyeHospitalbetweenJanuary2005 improvedcomparedwithpreoperativevision. andJanuary2012.Alloftheincludedpatientsweredivided ·CONCLUSION:Pediatrictraumaticcataractshouldbe intotwogroupsbasedonthetypeofinjury:closed-globe treatedintimetoattenuatethecomplications,and injuriesweredesignatedasgroupA,andopen-globeinjuries education on pediatric traumatic cataract and asgroupB.Thefoldableintraocularlenswasimplanted improvementsinpediatrichealthcareareneededforthe (Akroes,hydrophilicacrylic,Bausch&LombSurgical), earlydetectionofcataractinchildren. accordingtotheformulaSRK-T.Thepatients'medical ·KEYWORDS: children;trauma;cataract recordswerereviewedfordemographicinformation,modeof

160 陨灶贼允韵责澡贼澡葬造皂燥造熏灾燥造援 6熏晕燥援 2熏 Apr.18, 圆园13 www.IJO.cn 栽藻造押8629原愿圆圆源缘员苑圆 8629-82210956 耘皂葬蚤造押ijopress岳员远猿援糟燥皂 injury,timeofinjury,intervalbetweeninjuryandfirst visitingdoctors,hospitaloffirstvisiting,surgeries,and preoperativeandpostoperativebest-correctedvisualacuity (BCVA).Visual acuitywasgradedaccordingtothe classificationproposedbyPieramici [6]:grade1, 20/40; 逸 grade2, 20/100but<20/40;grade3, 20/400but 逸 逸 <20/100;grade4, LPbut<20/400;andgrade5,NLP.The 逸 InstitutionalReviewBoard(IRB)/Ethics Committee approvedthestudy,andtheresearchadheredtothetenetsof Figure1Thenumbersofpediatrictraumaticcataractsat theDeclarationofHelsinki. differentages. StatisticalAnalysis Thestatisticalanalysiswasconducted Table 1 The mode of injury in pediatric traumatic cataract n usinganSPSS13.0databaseprogram;aChi-squaredtestwas Mode of injury Closed-globe Open-globe Total usedtodeterminedependency,anddescriptivetestswere Sharp metal 0 44 44 usedfortheanalysis.A valueoflessthan0.05was Botanic 3 20 22 consideredtobestatisticallysignificant. Toy gun 12 2 14 RESULTS Firecracker 5 7 12 Atotalof117eyesof117consecutivepatients(96boysand Glass 0 6 6 21girls)wereincludedinthestudy.Theagerangewas1.3- Pen 0 6 6 13.8years(meanage,6.6 3.2years),and58.97%ofthe Cobble 2 2 4 依 patientswerefrom4to9yearsold(Figure1).Thefollow-up Slingshot 1 0 1 periodwasameanof(10.64 6.81)months(range,1 Key 1 0 1 依 month-29months).Allofthepatientshadunilateral Electric shock 1 0 1 cataracts,and66ofthemhadinjuredtheirrighteyes, Not clear 1 4 5 whereastheremaining51hadinjuredtheirlefteyes.The Total 26 91 117 numbersofcasesofclosed-globeinjuryandopen-globe damagewere26and91(1:3.50),respectively.Themost closed-globeinjuries,themostcommoncomplicationswere commonmodeofinjurywassharpobjects(44eyes, traumaticmydriasis, secondary glaucoma,and anterior 37.61%),includingscissors,ironwire,syringeneedles,and chamberhyphema(Figure2). nails,followedbybotanicalmaterials(22eyes,18.80%),toy Of68eyesinpatientswithopen-globeinjurieswhoreceived guns(14eyes,11.97%),andfirecrackers(12eyes,10.26%, cataractextraction,IOLswereprimarilyimplantedin47eyes Table1). (68.12%),whereasof18eyeswithclosed-globeinjuries, Therewerenoseasonaldifferencesinmorbiditythroughout IOLswereprimarilyimplantedin17eyes(94.4%).Of21 theyear( 2=4.904, =0.936),although83.33%ofthe eyesreceivingsecondaryIOLimplantationingroupB,16 injuriesduetofirecrackersoccurredinthefirstquarterofthe sufferedwithintraocularforeignbodyand/or year.Atotalof97patients(82.91%)visitedadoctorwithin endophthalmitis,andthe onereceivingsecondary 24hoursafterinjury [22(84.62%)fromgroupAand75 implantationingroupAsufferedwithhyphemaandretinal (82.42%)fromgroupB].Only29ofthepatients (24.79%) lesion.Theintervalbetweenthesecondaryimplantationand visitedourhospitalfirst;theother88(75.21%)werereferrals thecataractextractionwas(4.07 2.54)months(range, fromotherhospitals.Allofthe24patientsingroupBwho 依 0.47-8.67months),andtherewasatrendtowardbettervisual visitedourhospitalfirstreceivedemergencydebridement, sutures,orcombinationsofothersurgeries,suchascataract acuityineyeswithmorerecentsurgery,butthisdidnotreach extractionandimplantationofanIOL.However,16 statisticalsignificancesince =0.053isalmostsignificant. (23.88%)oftheotherpatientsingroupB,whowere IngroupA,additionalprocedureswereperformed,including referrals,didnotreceivetheemergencysurgeries,whichwas pupilloplasty(3eyes,11.54%),trabeculectomy(3eyes, asignificantdifference ( 2=6.594, =0.008).Althoughthe 11.54%),andenucleation(1eye,3.85%becauseofretinal 24patientswhovisitedourhospitalfirstreceivedthe detachment).IngroupB,vitrectomyandretinaldetachment emergency surgeries,the intervalbetweeninjuryand surgeryin19eyes (20.88%)werethemostcommon emergencysurgeryexceeded24hoursin8patients(33.33%) additionalprocedures,followedbyposteriorcapsulotomyin becausetheydidnotvisitadoctorpromptly. 9eyes(13.24%of68eyeswithIOLimplantation,withNd: Of91eyeswithopen-globeinjuries,themostcommon YAGlasertreatmentin5eyes),trabeculectomyin5eyes complicationswerecorneallaceration,anteriorcapsule (5.49%)andenucleation(1eye,1.10%becauseof violation, and irissynechia,whereasineyeswith endophthalmitis)(Figure3). 161 PediatrictraumaticcataractinChina

Table 2 The IOL implantation in different types of injuries n (%) Type of injuries In capsular bag In ciliary sulcus Suture scleral fixation Without implantation Closed-globe 16 (80.0) 2 (10.0) 0 2 (10.0) Open-globe 39 (47.6) 24 (29.3) 5（6.1） 14 (17.1)

Table 3 The comparison of preoperative and postoperative BCVA between types of injuries [n (%), x ± s ] BCVA Preoperative Postoperative Open-globe Closed-globe P Open-globe Closed-globe P ≥20/40 3 (3.4) 0 36 (41.4) 14 (58.3) ≥20/100 but ＜20/40 5 (5.7) 1 (4.2) 16 (18.4) 4 (16.7) ≥20/400 but ＜20/100 14 (16.1) 8 (33.3) 0.274 11 (12.6) 3 (12.5) 0.228 ≥LP but ＜20/400 55 (63.2) 13 (54.2) 13 (16.9) 0 NLP 0 0 1 (1.1) 1 (4.2) LP: light perception; NLP: no light perception.

wasperformedin1eyeingroupAand1eyeingroupB. Cataractextractionswereperformedin102eyes,between groupssuchthatIOLswereimplantedmorefrequentlyin closedglobeinjuries( 2=7.054, =0.029,Table2).The remaining6patients'informationwerelostabouttheir treatmenttocataract,duetonofollow-upinourhospital. ThepreoperativeandfinalBCVAwereexaminedin99 patients,andtheotherswerenot(12eyesbelongedto non-cooperativepatients,and6eyes'informationwere missed).Therewasnosignificantdifferenceinthe pre-operationBCVAbetweenopen-globalandclosed-global injuries( 2=3.889, =0.274,Table3),therealsowasnot significantdifferencesinpost-operationBCVA( 2=5.635, =0.228,Table3),butthepostoperativeBCVAwas significantlyimprovedcomparedwiththepreoperativevalue inopen-global ( 2=60.986, <0.001)andclosed-global injuries( 2=32.073, <0.001).Oftheeyeswithclosed-globe injuries,4eyeshadafinalvisualacuitypoorerthan20/100,3 ofwhomsufferedretinallesionsandtheremainingoneof whomreceivedanenucleationduetoeyeballatrophy Figure2Theassociatedcomplicationsofpediatrictraumatic secondarytoretinaldetachment.Moreover,intheopen-globe cataract A:Open-globeinjuries;B:Closed-globeinjuries. injuries,25eyeshadafinalvisualacuitypoorerthan20/100, ofwhich17hadnotablecornealscarring,5hadretinal lesions,2hadsecondaryglaucoma,and1receivedan enucleation. DISCUSSION SinceFebruary1999,whenWHOlaunchedaglobalinitiative fortheeliminationofavoidableblindness,"VISION2020", blindnesspreventionandophthalmicepidemiologystudiesin Chinahaveobtainedconsiderableprogress.TheCataract SurgicalRate(CSR)hasascendedfrom318.3in1999to Figure3Thesubsequentproceduresinopen-globeinjuries. 796.2in2009 [7].Therewereanestimated210,000blind childreninChinain1999,withaprevalenceofper1000 Cataractsurgerieswerenotperformedin4eyesofgroupA childrenof0.50,accordingtoWHO [8].Themostcommon and3eyesofgroupBbecauseofmildopacity.Enucleation causeofchildhoodblindnessisheredity,followedbytrauma 162 陨灶贼允韵责澡贼澡葬造皂燥造熏灾燥造援 6熏晕燥援 2熏 Apr.18, 圆园13 www.IJO.cn 栽藻造押8629原愿圆圆源缘员苑圆 8629-82210956 耘皂葬蚤造押ijopress岳员远猿援糟燥皂 andhighfeverencephalitissequelae.Althoughtheincidence childrenwiththeabovementionedsymptoms,evenwithout ofretinopathyofprematurity(ROP)andtheconsequent anidentifiedtraumatichistory,toavoidamisseddiagnosis blindnessratehasdroppedduetomanyeffectiveprophylaxis thatmaybringaboutirreparableresults. andtreatmentmeasurements [9],pediatrictraumaticcataract Therewerenosignificantdifferencesinpreoperativeand shouldreceivegreaterattentionbecauseofthecomplexityof postoperativevisionbetweenclosed-andopen-globeinjuries, theconditionandtheconsequentamblyopia. whichsuggestedthattheeffectofclosed-globeinjurieson Inourstudy,therateoftraumaticcataractwashigherinboys visionwascomparablewiththatofopen.Thepostoperative thaningirlsincoincidencewithotherstudies [10,11].Higher visionwasbetterthanthepreoperativevision.Itisnecessary ratesoftraumainmalescomparedwithfemalescouldbedue thattraumaticcataractshouldbemanagedassoonaspossible tohigherrisksoftraumaduringoutdooractivitiesandbeing toavoidothercomplications,suchasamblyopia[1,11,13,15,16]. muchmoreinclinedtocomeincontactwithdangerous Inourstudy,68.12%ofthepatientswithopen-globeinjuries articles,suchasfirecrackers [12].Mostchildrenwithtraumatic receivedprimaryIOLimplantation.Inaddition,almostallof cataractwerepreschoolage,whenchildrenarefullof theeyeswithclosed-globeinjuriesreceivedprimaryIOL curiosityabouttheworldandexploringeverythingtheycan implantation,astheylackedcorneallacerationorinfection. touchwithoutenoughrecognitionofdangerousmaterials. Theintervalbetweensecondaryimplantationandcataract Sharpmetalisthemostcommonmodeofinjury,followedby extractionhadaninsignificanteffectonthepostoperative botanicalmaterials,toygunsandfirecrackers,whichis visualacuity.Althoughsimultaneousrepairofthepenetrating differentfromReddy'sstudy [13].Traumaticcataractfrom woundandIOLimplantationaftercataractextractionwas firecrackersisprevalentinJanuaryandFebruary,whichmay advocatedbycertainarticles[17-20],inaccuratepredictionofthe beassociatedwiththeChinesetraditionofsettingoff poweroftheIOLoccurredwhenthebiometryofthefellow fireworksintheSpringFestival.Avoidingtouching eyewasused [21].Becauseofthevariableextentofacorneal dangerousmaterialandincreasingwarningswouldlikely orscleralwoundandthepossibilityofinfection,primary reducetheprevalenceoftrauma.Intraumaticcataractin implantationofIOLmightnotbepractical [22],andsecondary children, closed-globeinjuryoccursconsiderablyless implantationcouldachievethesameeffect [23].Therefore,the frequentthanopen-globeinjury,whichmaybebecausethe decisionsregardingthesurgeryshouldconsiderthetraumatic rateoflensopacityinclosed-globeinjuryislessthanthatin condition,child'sage,andotherfactors. open. Themostcommonlyassociatedophthalmicinjuriesin Overall,82.91%ofallofthepatientsvisitedan pediatricpatientsarecornealacerationandanteriorcapsule ophthalmologyservicewithin24hoursafterinjury,buta violation,similartothosefoundinReddy'sstudy [13],which portionofthepatientswithopen-globeinjuriesdidnot willincreasethesurgicalcomplexity;others,suchasvitreous receiveemergencysurgery,partiallybecauseofthelackof prolapse,endophthalmitis,andseriouscapsuleviolation,will knowledgeaboutpediatricpenetratinginjuriesbycertain changethemodeofimplantationoftheIOL(Table2).Due ophthalmologists,thechildren'spoorcooperationandless toinjuriestothecapsuleandciliaryzonule,theIOLcannot reliablehistoricalinformation.Inaddition,duetothe beimplantedinthecapsularbag;instead,itisplacedinthe shortcomingsofthemedicalsysteminChina,certainpatients ciliarysulcusorbyscleralfixationinopen-globeinjuries. withopen-globeinjurieswerenotintroducedtothepediatric Althoughthelattermethodscanincreasetherateofretinal ophthalmologistsoreyecenterintime.Inourstudy, detachment,theyareeffectiveandreliableinpatientswith enucleationwasperformedin2childrenbecauseofretinal pediatrictraumaticcataractwhohadinsufficientposterior detachmentandendophthalmitisasaresultofdelayed capsulesupport[24,25]. visitingadoctor.Severalchildrenwithopen-globeinjurydid Theassociatedophthalmicinjuriesneedadditional notvisitophthalmologistswithin24hoursafterpenetrating managementsotherthancataractextractionandIOL injuries,likelybecausetheparentsdidnotpayenough implantation.Themostcommonisvitrectomyandretinal attentiontotheirinjuries.Therefore,theeducationabout detachmentsurgerybecauseofvitreoushemorrhage,hernia publichealthshouldbeaugmented [14].Itmay,perhaps,be orretinalinjuries,andtheseassociatedinjurieswilldegrade helpfultostrengthenprimaryeyecareandadoptthe postoperativevision [26,27].Posteriorcapsuleopacity(PCO)in communityeyecareapproachinearlydetection,proper pediatricpatientswithcataractisprevalence [28],whichneeds counselingandtimelymanagement. Pediatriciansand tobemanagedbyNd:YAGlaserorsurgicalcapsulotomy ophthalmologistsshouldpaymore attentiontocertain combinedwithanteriorvitrectomy,asthisconditionwill symptoms,suchaschronicredeye,decreasedvisionand degradevisionandleadtoamblyopia.Inourseries,13.24% pain,whichshouldincreaseclinicsuspicionforpenetrating ofeyeswithIOLimplantationreceivedsurgicalcapsulotomy injuries [2].Acarefulexaminationshouldbeconductedin ineyeswithopeninjuries.Therefore,traumaticcataractin 163 PediatrictraumaticcataractinChina pediatricpatientsiscomplex,andcertainothersurgeriesare cataractsinchildren:Epidemiology,complications,andoutcomes. necessary. 2009;13(2):170-174 Inconclusion,themanagementoftraumaticcataractin 14SkikerH,LaghmariM,BoutimzineN,IbrahimyW,BenharbitM, OuazaniB,DaoudiR.Openglobeinjuriesinchildren:retrospectivestudy pediatricpatientsshouldbevariedaccordingtotheage, of62cases. 2007;(306):57-61 modeofinjury,traumatictypeandassociatedinjuries [29]. 15RumeltS,RehanyU.Theinfluenceofsurgeryandintraocularlens Carefulpreoperativeexaminationisnecessary,andcertain implantationtimingonvisualoutcomeintraumaticcataract. symptomsshouldreceivemoreattention.Thisstudysuggests 2010;248(9):1293-1297 thatdangerousmaterialshouldbestoredoutofthereachof 16SegevF,AssiaEI,HarizmanN,BarequetI,AlmerZ,RazJ,MoisseievJ. children,especiallythoseofpreschoolage.Improving Corneallacerationbysharpobjectsinchildrensevenyearsofageand strategiesforpreventingblindnessinchildrenofdeveloping younger. 2007;26(3):319-323 17PavlovicS.Primaryintraocularlensimplantationduringparsplana countriesisnecessary. vitrectomyandintraretinalforeignbodyremoval. 1999;19(5): REFERENCES 430-436 1TomkinsO,Ben-ZionI,MooreDB,HelvestonEE.Outcomesofpediatric 18MoisseievJ,SegevF,HarizmanN,AraziT,RotenstreichY,AssiaEI. cataractsurgeryatatertiarycarecenterinruralsouthernEthiopia. 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