The Ocular Trauma Classification Group has designed a standardized system for reporting mechanical injury associated with open- and closed-globe trauma. The system is based on the injury type, grade (based on visual acuity), zone, and presence or absence of an afferent pupillary defect.²,³ We provide a short summary of the reporting system below. However, interested readers are referred to the detailed description published by Kuhn² and Pieramici³ and to the American Society of Ocular Trauma Web site (http://www.asotonline.org).

The crystalline lens may be involved in any case of ocular trauma. Traumatic cataract may be an immediate, early, or late sequel of any ocular trauma. Trauma has been reported to be responsible for up to 29% of all childhood cataracts.⁴ At the Storm Eye Institute, our database includes more than 100 cases of traumatic cataract. We analyzed 47 consecutive eyes of 47 children operated for traumatic cataract.⁵ These consecutive trauma cases represented 10.5% of the cataracts we operated during that time interval. Commonly implicated objects leading to the traumatic event include knives, BB guns, firecrackers, sticks, thorns, rocks, pencils, arrows, airbags, paintballs, and toys.

Blunt trauma is responsible for coup and countercoup ocular injury.⁶ Coup is the mechanism of direct impact. It is responsible for the Vossius ring (imprinted iris pigment) sometimes found on the anterior lens capsule following blunt injury. Countercoup refers to distant injury caused by shockwaves traveling along the line of concussion. When the anterior surface of the eye is struck bluntly, there is a rapid anterior-posterior shortening accompanied by equatorial expansion. This equatorial stretching can disrupt the lens capsule, zonule, or both. Combinations of coup, countercoup, and equatorial expansion are responsible for the formation of traumatic cataracts following blunt ocular injury. Penetrating trauma that directly compromises the lens capsule often leads to
cortical opacification at the site of injury. If the rent is sufficiently large, the entire lens rapidly opacifies. When the capsular rent is small, however, the capsule may seal, and the cortical cataract may remain localized.

Cataracts caused by blunt trauma classically form stellate or rosette-shaped posterior axial opacities that may be stable or progressive. At times, an anterior capsular scar (white fibrous capsule) can be seen at the sight of direct impact, especially in children whose eyes are more elastic than those of adults. The pupillary sphincter also often shows multiple small ruptures from blunt trauma, and these may cause a traumatic mydriasis even when the pupil shape is relatively normal.

In penetrating trauma, disruption of the lens capsule often occurs leading to cortical opacification. These cataracts may remain focal if small or may progress rapidly to total cortical opacification. Anterior and/or posterior capsule defect, intralenticular foreign body, partial/total zonular loss, dislocation, and lens subluxation are often found in combination with traumatic cataract. Other associated complications include glaucoma (phacolytic, phacomorphic, pupillary block, and angle recession), phacoanaphylactic uveitis, retinal detachment, choroidal rupture, hyphema, retrobulbar hemorrhage, traumatic optic neuropathy, and globe rupture. Anterior capsule rupture (with flocculent lens matter in the anterior chamber) is usually well tolerated in children. Although an increased IOP and/or lens-induced uveitis (e.g., phacoanaphylactic and phacotoxic endophthalmitis) are known complications of lens rupture, these rarely occur in children. We often cautiously wait 2 to 3 weeks for the eye to heal from the traumatic event before proceeding with cataract surgery (Fig. 35.1), even when flocculent material from lens rupture is seen in the anterior chamber. Outcome of cataract surgery is better when the traumatic iritis and hyphema have subsided.

In the setting of traumatic cataract, the ophthalmologist must first “take a step back” and examine other ocular injuries in detail.⁷ The cataract surgeon should be suspicious of injury to other ocular structures. Management depends on the degree and type of injury. Localized traumatic cataracts (especially if not in the visual axis) may be managed conservatively, while more significant lens opacities generally require cataract extraction. Similarly, capsular perforation may be managed with observation if small and not centrally located. Frequently, such injuries will develop only very localized opacification of the underlying cortex, without progression to generalized cataracts.

The initial patient evaluation is one of the most important critical steps in the management of traumatic cataract. Data gathered during this examination, to a large extent, direct further investigations and establish immediate priorities. One of the most important aspects of this first examination is the description of the exact circumstances of the injury. This facilitates the development of risk estimates for occult injuries, such as IOFB, chemical exposure, and posterior rupture of the globe.