Purpose
To characterize the clinical course of cataract wound dehiscence.
Design
Retrospective, comparative case series.
Methods
Charts of open globe injuries (848 injuries in 846 patients) treated surgically at the Massachusetts Eye and Ear Infirmary between 2000 and 2009 were retrospectively reviewed. Time from original surgery to wound dehiscence, type of initial surgery, Ocular Trauma Score, age, gender, mechanism of injury, and visual acuity were analyzed.
Results
Of 846 patients with 848 open globe injuries, 63 experienced cataract wound dehiscence. The majority of these cataract wounds (89%) were extracapsular cataract extraction (ECCE), with only 7 (11%) phacoemulsification wounds. The mean patient age in the wound rupture group was 78.2 years. Female patients comprised the majority (67%) of this subpopulation. The most common mechanisms of injury were fall (65%), blunt trauma (23%), and motor vehicle accident (7%). The median raw ocular trauma score was 47 in wound dehiscence patients. Visual acuity at presentation was light perception in the wound dehiscence group. The best postoperative visual acuity was significantly worse in the wound dehiscence group (hand motion) than in the remaining patients (20/40; P = .0002). When considering the phacoemulsification patients alone, these patients fared much better, with a median postoperative vision of 20/60.
Conclusions
Despite recent advances in cataract surgery, wound dehiscence remains a significant source of visual disability, mainly in the geriatric population. Rupture ECCE wound patients have a poor visual prognosis. Fortunately, patients with phacoemulsification site dehiscence appear to regain the majority of their vision after open globe repair
As the technology of phacoemulsification improves, traditional extracapsular cataract extraction (ECCE), in which a large limbal incision or scleral tunnel is created through which the lens is manually extracted and subsequently sutured to achieve wound closure, is less frequently chosen as a primary method of cataract extraction. This technique continues to be employed for extraction of selected dense brunescent cataracts and for conversion from phacoemulsification during complicated cases. In the aging pseudophakic population, there remains a significant proportion of elderly patients who underwent cataract extraction via traditional ECCE prior to the widespread use of phacoemulsification. An alternative to the traditional large-incision ECCE is manual small-incision cataract surgery (SICS), a commonly chosen method of cataract extraction in developing countries because it offers a quick, cost-effective procedure to large populations. SICS is usually performed as a sutureless procedure using a scleral tunnel that is shorter than that used for the traditional, large-incision ECCE for lens expression.
Cataract extraction by phacoemulsification is performed through a small scleral tunnel or, more commonly, a beveled incision at the limbus or peripheral clear cornea. Phacoemulsification provides many advantages over ECCE, including enhanced surgical wound strength, which is demonstrated in previous studies by lower phacoemulsification wound dehiscence rates and more rapid healing time.
Surgical scleral wounds are susceptible to dehiscence with blunt trauma. Prior studies have described small series of patients with dehisced cataract surgery wounds, predominately resulting from rupture of pre-existing ECCE incisions. There are few reports of dehisced phacoemulsification wounds in the literature. Patients described in these studies have achieved variable recovery of vision following repair of the dehisced wounds. Our aim was to characterize traumatic cataract wound rupture at a major ophthalmic trauma referral center.
Methods
A retrospective chart review was conducted on 846 patients comprising 848 open globe injuries at the Massachusetts Eye and Ear Infirmary between January 1, 2000 and April 30, 2009. An open globe injury was defined as a traumatic full-thickness break in the corneoscleral wall of the eye. The patients in this cohort represent consecutive patients treated by the ocular trauma service either with isolated open globe injuries or an open globe injury as part of a multi-system trauma. Demographic and clinical data from all patients were entered into a computerized database for review and analysis. The data included age, sex, information about the time and place of injury, mechanism of injury, initial examination, open globe repair specifics, follow-up examinations, surgical procedures, and outcomes. If a specific data field was not available for a patient then that patient was excluded from that particular analysis.
Patients are evaluated and treated for open globe injuries at the Massachusetts Eye and Ear Infirmary according to a previously published standardized protocol. Upon arrival to the emergency room a standard history and ocular examination is completed. A noncontrast computed tomography (CT) scan with thin cuts through the orbits is obtained, the patient’s tetanus is updated, and intravenous antibiotics are started. Repair of the open globe is completed within 24 hours when not prohibited by a late presentation or other active medical issues. After surgery, the patient is observed as an inpatient and continued on intravenous antibiotics for 48 hours. When possible, an ocular trauma score (OTS) was calculated based on the data available at presentation, as described by Kuhn and associates. This scoring system helps determine severity of injury and predict visual outcome by assigning point values to initial visual acuity, afferent pupillary defect (APD), endophthalmitis, retinal detachment, and mechanism of injury. The raw score ranges from 0 to 100, with 100 being the least traumatic.
Statistical analysis was performed using an unpaired t test to compare means between groups, a Mann-Whitney test for nonparametric data, or a 2-tailed Fisher exact test to compare categorical data. A P value <.05 was considered statistically significant.
Results
Characteristics of the patients are shown in the Table . A total of 848 open globe injuries were evaluated and managed at MEEI from 2000 to 2009. Sixty-three (7.4%) of these injuries represented a traumatic dehiscence of a cataract surgery wound. While most of the wound ruptures (56/63, or 89%) followed extracapsular cataract extractions, the remaining 7 patients (11%) had previously undergone phacoemulsification. The date of original cataract extraction was available in 25 instances. For these 25 patients, the mean time between cataract surgery and wound rupture was 102 months (range 2 weeks to 24 years). The time from surgery to rupture was longer in the ECCE group than the phacoemulsification group ( P = .0145); the mean time from ECCE surgery to injury was 127 months (range 2 weeks to 24 years), whereas the mean time from phacoemulsification to wound dehiscence was 3.7 months (range 2 weeks to 1 year).
| Full Cohort | Cataract Wound Dehiscence | Non-cataract Wound Dehiscence | P Value a | |
|---|---|---|---|---|
| No. of injuries | 848 | 63 | 785 | |
| Mean age (range), years | 41.5 (<1 to 97) | 78.2 (29 to 95) | 38.6 (<1 to 97) | <.0001 |
| Male (%) | 666 (79) | 21 (33) | 649 (82) | <.0001 |
| Female (%) | 182 (21) | 42 (67) | 140 (18) | <.0001 |
| Mechanism of injury, no. (%) | ||||
| Falls | 129 (16) | 39 (65) | 92 (12) | <.0001 |
| Blunt (other than falls) | 126 (16) | 14 (23) | 111 (14) | .0951 |
| Motor vehicle accidents | 30 (4) | 4 (7) | 25 (3) | .2646 |
| Projectile | 168 (21) | 0 (0) | 143 (18) | <.0001 |
| Nail | 106 (13) | 0 (0) | 104 (13) | .0004 |
| Glass | 36 (5) | 0 (0) | 35 (4) | .1021 |
| Assault | 22 (3) | 1 (2) | 21 (3) | 1.0000 |
| Mean ocular trauma score | 67 | 48 | 69 | <.0001 |
| Median ocular trauma score | 70 | 47 | 70 | <.0001 |
| Ruptured globes | 332 | 60 | 275 | <.0001 |
| Perforating injuries | 5 | 0 | 5 | 1.0000 |
| Intraocular foreign bodies | 123 | 0 | 123 | <.0001 |
a P values were calculated using an unpaired t test for continuous data, Mann-Whitney test for nonparametric data, or a 2-tailed Fisher exact test for categorical data. A P value < .05 was considered statistically significant.
Patients suffering traumatic cataract wound dehiscence tended to be 65 years or older. The mean age of patients with cataract wound dehiscence was 78.2 years (range 29-95), which was significantly older than the mean age of the patients without cataract wound dehiscence (38.6 years; range 9 months to 97 years; P < .0001). Consequently, one-third of geriatric open globe injuries (54/166, or 33%) were a result of cataract wound dehiscence. There were only 6 patients (6/63 or 10%) under 65 years old that suffered a ruptured cataract wound. Two-thirds of the patients in the wound dehiscence group were female (42/63, or 67%), which was a significantly greater proportion than in the group presenting with other injuries (140/785, or 18%; P < .0001). The mean follow-up time for the cataract wound dehiscence patients was 4 months, compared to 10 months for the remaining patients.
Falls were the most common mechanism of injury in those who presented with ruptured cataract wounds (39/63, or 65%). The other frequent mechanisms of injury in this group were blunt trauma (14/63, or 23%), motor vehicle collisions (4/63, or 7%), assault (1/63, or 2%), and other (5/63, or 3%). The mean ocular trauma score was more severe for patients with wound dehiscence (48) than patients without surgical wound dehiscence (69; P < .0001).
Preoperative visual acuities were worse in the cataract wound dehiscence group. The median preoperative vision for the wound rupture group was light perception, which was significantly worse than the patients without wound dehiscence (hand motion; P = .0005). Furthermore, 17 of the wound dehiscence patients (17/63, or 27%) presented with an afferent pupillary defect.
The initial open globe injury repair in the cataract wound group often required multiple procedures. Of 63 total patients, 42 (67%) required uveal repositioning, 15 (24%) underwent an anterior vitrectomy, 4 (6%) necessitated a lid laceration repair, and 2 (3%) needed disinsertion of the rectus muscles.
Postoperative visual outcomes were worse in the cataract wound dehiscence group than in the remaining patients. The median best postoperative vision for the wound dehiscence group was hand motion, which was significantly worse than the patients without wound dehiscence (20/40; P = .0002). Over half (35/63, or 56%) of the cataract wound dehiscence patients developed a postoperative hyphema. Additionally, many cataract wound dehiscence patients were diagnosed with posterior segment pathology: 25 vitreous hemorrhages (25/63, or 40%), 9 retinal detachments (9/63, or 14%), 2 choroidal detachments (2/63, or 3%), 2 retinal hemorrhages (2/63, or 3%), and 3 retinal scars (3/63, or 5%). One injury resulted in phthisis. Twenty-four cataract wound patients (24/63, or 38%) continued to have an APD after open globe repair. Five ruptured cataract wound dehiscence patients (5/63, or 8%) developed traumatic glaucoma. There were no primary or secondary enucleations performed on the cataract wound rupture patients at this institution. There were also no cases of endophthalmitis in this group.
There were 7 ruptured phacoemulsification wounds included in this study. The mean age for these patients was 71.0 years (range 42 to 90). There were 4 male and 3 female patients in this group. The most common mechanism of injury was fall (4), followed by other blunt trauma (2) and assault (1). The mean ocular trauma score was 64 for this group. All 7 of these injuries resulted in ruptured globes, with no perforating injuries. There were no intraocular foreign bodies in this group. All of the ruptured phacoemulsification wound patients regained 20/200 or better vision postoperatively. The median best postoperative vision in this group was 20/60. However, this may underestimate ultimate visual outcomes because the mean follow-up time for the phacoemulsification group was only 24 days. During follow-up, 3 of the patients developed vitreous hemorrhages, 1 patient had a postoperative hyphema, and 1 patient suffered traumatic glaucoma. However, there were no cases of retinal detachment, choroidal detachment, phthisis, endophthalmitis, or postoperative APD in the phacoemulsification dehiscence group. No follow-up vitreoretinal surgery was performed at this institution for any ruptured phacoemulsification wound patients.
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