Ocular Trauma Score: A Useful Predictor

of Visual Outcome at Six Weeks in Patients

with Traumatic Cataract
Mehul A. Shah, MD, Shreya M. Shah, MD, Adway Applewar, MD, Chintan Patel, MBBS,
Shashank Shah, MBBS, Utsav Patel, MBBS
Objective: To validate the predictive value of the Ocular Trauma Score (OTS) in injury cases with traumatic
cataracts.
Design: Retrospective cohort study.
Participants: A total of 787 eyes.
Methods: A total of 787 eyes of 787 subjects with traumatic cataracts were enrolled using specic inclusion
criteria. The eyes were examined to review comorbidities caused by trauma. Surgery was performed for
traumatic cataracts, lenses were implanted, and patients were treated for amblyopia, as applicable. The patients
were reexamined 6 weeks postoperatively. On the basis of ocular trauma described according to the Birmingham
Eye Trauma Terminology System, the patients were divided into 2 traumatic cataract groups: open globe injury
and closed globe injury. The relationship of visual acuity (VA) with demographic and clinical variables was
analyzed. The visual outcomes were predicted using the OTS, and the predictions were compared with the actual
outcomes using statistical tests.
Main Outcome Measures: Visual acuity.
Results: At 6 weeks postoperatively, 245 eyes (31%) had a VA 20/40 and 480 eyes (61.0%) had a VA
20/200. The OTS prediction was not signicantly different when compared with actual visual outcome at 6
weeks postoperatively in all OTS categories.
Conclusions: The relationship of VA at 6 weeks with demographic and clinical variables was analyzed. In this
study, the OTS was found as a reliable tool to predict visual outcome in cases of traumatic cataracts 6 weeks
postoperatively.
Financial Disclosure(s): The author(s) have no proprietary or commercial interest in any materials discussed
in this article. Ophthalmology 2012;119:13361341 2012 by the American Academy of Ophthalmology.
Trauma is a major cause of monocular blindness in the
developed world, although few studies have addressed the
problem of trauma in rural areas.
1
The cause of ocular injury
is likely to differ between urban and rural areas and is
worthy of investigation.
24
The development of strategies
for the prevention of injuries requires knowledge of the
causes. In eye injuries, both the victims, especially children,
in whom ocular injury has a poor prognosis, and society
bear a large, potentially preventable burden.
3
More appro-
priate targeting of resources toward preventing eye injuries
may reduce this burden.
One consequence of ocular trauma is the formation of
cataracts.
1
Methods have been established for evaluating
visual outcomes in eyes with cataracts due to trauma or
other causes,
5
but damage to surrounding ocular tissues may
compromise the visual gain in eyes after surgery for trau-
matic cataracts. Thus, the success rate may differ between
eyes with traumatic versus nontraumatic cataracts.
The introduction of the Birmingham Eye Trauma Ter-
minology System (BETTS) has led to standardized deni-
tions of ocular trauma,
5
making it possible to compare
visual outcomes after traumatic cataract surgery and to
understand the determinants in predicting the outcomes.
Studies have reported visual outcomes of traumatic cata-
racts,
6,7
but most have involved small samples or were case
studies. Zhang et al
6
and Gradin and Yorston
7
reported a
patient series focusing on the primary management of trau-
matic cataracts and perforating injuries.
Various models, including the Ocular Trauma Score
(OTS) and the Classication and Regression Tree, have
been proposed for predicting the visual outcome based on
an initial examination. Although both of these models have
been shown to be effective in the general population, only a
few studies have tried to validate prognostic models in cases
of traumatic cataracts with ocular injuries, and these have
reported variable results. It is important to validate predic-
tive methods in a larger patient series.
We investigated the value of the OTS for predicting
visual outcomes after surgery in cases of traumatic cat-
aracts. Our study was conducted in a city located at the
1336 2012 by the American Academy of Ophthalmology ISSN 0161-6420/12/$see front matter
Published by Elsevier Inc. doi:10.1016/j.ophtha.2012.01.020
nexus of 3 states, Gujarat, Madhya Pradesh, and Rajas-
than, in central Western India. Qualied ophthalmolo-
gists at Drashti Netralaya provide low-cost eye services
mainly to the poor among the tribal populations of 4.2
million people in this area.
Patients and Methods
Approval for this study was obtained from the hospital adminis-
trators and research committee. The study had a retrospective
design. All of the patients had been diagnosed with traumatic
cataracts in either eye between January 2003 and December 2009.
Patients who had no other serious bodily injuries and who gave
consent were enrolled. Historical medical data were retrieved from
medical records and collected using a specic pretested online
form.
For each patient enrolled in the study, we obtained a detailed
history regarding the injury and treatment and surgery per-
formed to manage the ocular trauma. Data for both the initial
and follow-up reports were collected using the online BETTS
format of the International Society of Ocular Trauma. Details of
the surgery were also collected using a specic pretested online
form.
The cases of traumatic cataract were divided into 2 groups:
open globe and closed globe injury groups. Open globe injuries
were further categorized into laceration and rupture groups. Lac-
erations of the eyeball were subcategorized as perforating injury,
penetrating injury, and injury involving an intraocular foreign
body. The closed globe group was divided into lamellar laceration
and contusion groups.
Demographic details included patient characteristics, residence,
activity at the time of injury, cause of injury, and previous exam-
inations and treatments. After enrollment, all patients were exam-
ined using a standard method.
Cataracts were classied according to lenticular opacity. Cat-
aracts with no clear lens matter between the capsule and the
nucleus were classied as total cataracts. Those in which the
capsule and organized matter were fused to form a membrane of
varying density were classied as membranous cataracts. When
loose cortical material was observed in the anterior chamber to-
gether with a ruptured lens capsule, the cataract was classied as
a white, soft cataract with ruptured capsule. Rosette-type cataracts
were those in which the lens exhibited a rosette pattern of opacity.
By using this classication, we were able to categorize all of the
cataract cases.
8
The morphology was inuenced mainly by the
type, force, and cause of injury, and the time interval between
injury and examination.
Ocular injuries
causing cataracts
(n = 787)
Eyes with open
globe injuries
causing cataracts
(n = 558)
Eyes with closed
globe injuries
causing cataracts
(n = 229)
Laceration
(n = 500)
Ruptured globe
(n = 58)
Contusion
(n= 210)
Lamellar
laceration
(n= 19)
Penetrating injuries
(n = 473)
Perforating injuries
(n = 19)
Intraocular foreign body
(n = 8)
Figure 1. Distribution of cataracts based on ocular injury according to the Birmingham Eye Trauma Terminology System classication.
Shah et al Ocular Trauma Score in Traumatic Cataracts
1337
For a partially opaque lens, a posterior segment examination
was performed with an indirect ophthalmoscope and a 20 diopter
lens. B-scan ultrasonography was performed as appropriate to
evaluate the posterior segment.
The surgical technique was selected according to the morphol-
ogy and the condition of the surrounding tissues other than the
lens. Phacoemulsication was used to operate on cataracts with
hard, large nuclei. For a lens with a white soft or rosette type of
cataract, unimanual or bimanual aspiration was used. Mem-
branectomy and anterior vitrectomy, via an anterior or pars
plana route, were performed for membranous cataracts.
In patients undergoing corneal wound repair, the traumatic cata-
ract was managed using a second procedure. Recurrent inammation
was more prominent in patients who had undergone previous surgery
for trauma.
9,10
When the media appeared hazy because of inamma-
tion of the anterior vitreous, a capsulectomy and vitrectomy were
performed via an anterior/pars plana route.
In children aged younger than 2 years, both a lensectomy and
vitrectomy via the pars plana route were performed, leaving a rim
of the anterior capsule for the secondary implant. The same sur-
gical procedures were used to manage the traumatic cataract. Lens
implantation as part of the primary procedure was avoided in all
children younger than 2 years; these children were rehabilitated
with optical correction, and a secondary implant was performed
after 2 years. All children were treated by a qualied pediatric
orthoptist for supportive amblyopia therapy and by a pediatric
ophthalmologist for strabismus therapy.
All patients with injuries and without infection were treated
with topical and systemic corticosteroids and cycloplegics. The
duration of medical treatment depended on the degree of inam-
mation in the anterior and posterior segments of the operated eye.
The operated patients were reexamined after 24 hours, 3 days, and
1, 2, and 6 weeks to enable refractive correction. Follow-up was
scheduled for day 3, weekly for 6 weeks, monthly for 3 months,
and then every 3 months for 1 year.
At every follow-up examination, visual acuity (VA) was
tested according to age using the American Academy of Oph-
thalmology guidelines. The anterior segment was examined
with a slit lamp, and the posterior segment was examined with
an indirect ophthalmoscope. Eyes with vision 20/60 at the
6-week follow-up were dened as having a satisfactory grade of
vision.
The posttreatment visual outcome was predicted from the OTS
by calculating the raw score based on the presenting vision and
condition. This prediction was compared with the actual visual
outcome using a statistical analysis.
During the examination, data were entered online using a
specic pretested format designed by the International Society
of Ocular Trauma (initial and follow-up forms) and exported
into a Microsoft Excel spreadsheet (Microsoft Corp., Redmond,
WA). Data were audited periodically to ensure complete data
collection. The Statistical Package for Social Sciences (v. 17;
SPSS Institute Inc., Chicago, IL) was used to analyze the data.
Descriptive statistics and cross-tabulation were used to compare
the cause and effect of different variables. The dependent
variable was VA 20/60 at the 6-week follow-up after cataract
surgery. The independent variables were age, gender, residence,
time interval between injury and cataract surgery, primary
posterior capsulectomy and vitrectomy procedure, and type of
ocular injury. We analyzed all variables for both the open globe
and closed globe groups, and variables between these groups.
Table 6. Comparison of Ocular Trauma ScorePredicted Vision with Actual Vision
No PL HM to PL 1/20020/190 20/20020/50 >20/40
Achieved OTS Achieved OTS Achieved OTS Achieved OTS Achieved OTS
OTS-1 75 73 25 17 0 7 0 2 0 1
OTS-2 10.4 28 28.6 26 14.3 18 33.7 13 13 15
OTS-3 0.3 2 17.4 11 18.5 15 29.8 28 32.8 44
OTS-4 0 1 4.5 2 9.1 2 31.8 21 54.5 74
OTS-5 0 0 0 1 0 2 0 5 100 5
P 0.241 P 0.220 P 0.259 P 0.241 P 0.220
HM hand movements; OTS ocular trauma score; PL perception of light.
Values are number of cases.
Table 7. Comparison of Postoperative Vision According to Ocular Trauma Score
Vision Category
Ocular Trauma Score
Total 1 2 3 4 5
Uncooperative 0 0 10 0 0 9
No perception of light 3 8 5 0 0 15
Hand movement perceived 1 55 459 2 1 516
Perception of light 0 14 189 2 0 204
1/20020/190 0 0 19 18 0 36
20/20020/50 0 0 1 0 0 1
20/40
Total 3 76 680 21 1 781
P 0.0001. Values are number of cases.
Ophthalmology Volume 119, Number 7, July 2012
1338
Results
The enrolled patient group consisted of 787 patients with traumatic
cataracts (Fig 1), comprising 575 male patients (73.1%) and 212
female patients (26.9%); 6 patients did not follow up for 6 weeks.
The mean patient age was 27.1918.7 years (range, 80 years)
(Table 1, available at http://aaojournal.org). Visual acuity 6 weeks
postoperatively signicantly varied according to age group
(P 0.0001; Table 2, available at http://aaojournal.org).
Among the injured eyes, 557 (70.8%) were open globe ocular
injuries and 230 (29.2%) were closed globe injuries. According
to cross-tabulation and statistical analysis, the demographic
factors analyzed, including socioeconomic status (75% were of
lower socioeconomic status) and residence (93.3% were from
rural areas), had no signicant relationship to the VA 6 weeks
postoperatively.
With regard to patient entry, 10.1% of the patients had received
primary treatment before reaching our center, and this was not
associated with a signicant difference in the l visual outcome at
6 weeks (P 0.2). Of the total patients enrolled, 31.6% entered
via an outreach activity and 68.4% were self-referred.
Among the injuries, 22.2% were reported within the rst 24
hours, 38.8% were reported within 30 days, and 39% were re-
ported after 1 month. A wooden stick was the most common object
causing eye injury (50.1%). Neither the injury-causing object (P
0.3) nor the activity at the time of injury (P0.3) was signicantly
associated with the VA at 6 weeks.
A comparison between pre- and postoperative VA showed that
treatment signicantly improved VA (P 0.0001, Pearsons chi-
square test, P 0.001; Table 3, available at http://aaojournal.org).
An intraocular lens was implanted in 631 cases (80.2%). Aspira-
tion, which was performed using 1 or 2 ports in 48.6% of the
patients in the open globe group, was signicantly associated with
improved VA (P 0.0001).
We also compared these variables between the open globe and
closed globe subgroups. Signicant differences were seen in the
different categories of traumatic cataracts caused by penetrating
injuries (Tables 4 and 5, available at http://aaojournal.org;
P 0.0001, P 0.002).
An intraocular lens was implanted in 80.2% of the cases;
primary lens implantation has signicantly improved visual out-
come at 6 weeks (P 0.0001), and 30% of the cases required
more than 1 operation. The follow-up period ranged from 45 to
1076 days, with a mean of 71 days. Of all cases, 683 (97.1%) had
OTS-3; an overall signicant difference was observed among the
OTS groups (Tables 6 and 7; P 0.0001).
The visual outcomes at 6 weeks and according to the OTS
predictions in cases with traumatic cataracts are presented in Table
6. Analysis showed that visual outcome achieved at 6 weeks and
that predicted by OTS were not signicantly different (P 0.241,
0.22, 0.259, 0.241, -0.220) (Figs 26) in cases of traumatic cata-
racts.
Time interval between injury and intervention was also studied
and found to be signicant (P 0.0001; Table 8). Common causes
for no improvement in vision were intraocular inammation
0
75
25
0 0 0
0
10
20
30
40
50
60
70
80
uncoop no pl hm / pl 1/200 to
20/190
20/200 to
20/50
>/=20/40
OTS - 1
Figure 2. Comparison between ocular trauma score (OTS) and achieved
results in OTS-1 score category. hm hand movements; pl perception
of light.
0
10.4
28.6
14.3
33.7
13
0
5
10
15
20
25
30
35
40
uncoop no pl hm / pl 1/200 to
20/190
20/200 to
20/50
>/=20/40
OTS - 2
Figure 3. Comparison between ocular trauma score (OTS) and achieved
results in OTS-2 score category. hm hand movements; pl perception
of light.
1.1
0.3
17.4
18.5
29.8
32.8
0
5
10
15
20
25
30
35
uncoop no pl hm / pl 1/200 to
20/190
20/200 to
20/50
>/=20/40
OTS - 3
Figure 4. Comparison between ocular trauma score (OTS) and achieved
results in OTS-3 score category. hm hand movements; pl perception
of light.
0 0
4.5
9.1
31.8
54.5
0
10
20
30
40
50
60
uncoop no pl hm / pl 1/200 to
20/190
20/200 to
20/50
>/=20/40
OTS - 4
Figure 5. Comparison between ocular trauma score (OTS) and achieved
results in OTS-4 score category. hm hand movements; pl perception
of light.
Shah et al Ocular Trauma Score in Traumatic Cataracts
1339
(1.8%), extensive posterior segment injury (1.5%), and corneal
opacities (1.2%).
Discussion
Visual gain after surgery for traumatic cataracts is a com-
plex issue. Electrophysiologic
10
and radioimaging
6,11,12
in-
vestigations are important tools for assessing comorbidities
associated with an opaque lens.
In the present study, a satisfactory grade of vision after
the management of traumatic cataracts was achieved signif-
icantly more often after open globe injuries compared with
closed globe injuries (P 0.0001; Tables 35, available at
http://aaojournal.org). Many studies have documented vi-
sual outcomes in cases with traumatic cataracts. Shah et al
4
reported that 56% of patients obtained a VA 20/60, and
Kumar et al
13
reported a VA 6/18 in 50% of cases.
Staferi et al
14
reported a VA 6/12 in 35% of cases,
Bekibele and Fasina
15
reported a VA 6/18 in 35.6% of
cases, and Gradin and Yorston
7
reported a VA 20/60 in
64.7% of cases. Brar et al
16
reported a VA 0.2 in 62% of
cases, Cheema and Lukaris
17
reported a VA 6/18 in 68%
of cases, and Karim et al
18
reported a VA 0.2 in 62% of
cases. Krishnamachary et al
12
reported a VA 20/60 in
74% of cases, and Knight-Nanan et al
19
reported a VA20/60
in 64% of cases. Bienfait et al
20
reported a VA0.7 in 27% of
cases, and Anwar et al
21
reported a VA 20/40 in 73% of
cases. The visual outcomes with poly(methyl methacrylate)
lens implants reported by Verma et al
22
were similar to the
ndings in our study.
Eckstein et al
23
and Zou et al
24
showed that a primary
intraocular lens can improve visual outcome, again similar to
the results observed in our study. Vajpayee et al
25
and Gupta et
al
26
suggested that the primary insertion of an intraocular lens
for posterior capsular rupture was also important. The same
trend was observed in our study. According to Shah et al,
27
improved visual outcome can be achieved when intervention is
performed between 5 and 30 days after injury in adults with
traumatic cataracts. Staferi et al
14
reported the use of a pri-
mary implant in 62% of the cases in that study, whereas a
primary implant was used in 80.2% of the cases in the present
study.
Our study is the rst to compare the visual outcome at 6
weeks in children between open globe and closed globe injury
groups classied by BETTS. Shah et al
28
made this compari-
son in adults, but we are not aware of any investigation using
a large cohort of successfully treated traumatic cataracts.
In our study, visual outcomes at 6 weeks were achieved
according to the OTS
29
prediction in cases with traumatic
cataracts. Although similar ndings have been reported by
others,
3032
our study presents one of the largest reported
databases following cases of traumatic cataracts classied
according to BETTS. Despite the long time delay between
injury and treatment in many of the cases in our study, the
OTS was still relevant.
Lesniak et al
30
reported no signicant differences be-
tween the VAs at 6 weeks and the VAs predicted by OTS in
traumatic cataracts. Sharma et al
31
proposed that the OTS
calculated at the initial examination may be of prognostic
value in children with penetrating eye injuries. However,
Unver et al
32
suggested that OTS calculations may have
limited value as predictors of visual outcome. Lima-Gomez
et al
33
reported estimates for a 6-month visual prognosis,
but some of the variables required evaluation by an oph-
thalmologist. By using the OTS, 98.9% of the eyes in the
general population could be graded in a trauma room. Kn-
yazer et al
34
reported the prognostic value of the OTS in
zone-3 open globe injuries, and Man and Steel
35
claimed
equal prognostic effectiveness of both the OTS and Classi-
cation and Regression Tree in the general population.
In conclusion, in this study, the OTS was a reliable predic-
tor of the nal visual outcome in cases of traumatic cataracts.
0 0 0 0 0
100
0
20
40
60
80
100
120
uncoop no pl hm / pl 1/200 to
20/190
20/200 to
20/50
>/=20/40
OTS - 5
Figure 6. Comparison between ocular trauma score (OTS) and achieved
results in OTS-5 score category. hm hand movements; pl perception
of light.
Table 8. Comparison of Vision According to Time Interval between Injury and Start of Treatment
Time
Interval
in Days
Postoperative Vision
Total Uncooperative
No Light
Perception
Hand Movement Perceived
Perception of Light 1/20020/190 20/20020/50 20/40
01 3 3 37 25 55 52 175
25 1 5 11 15 32 41 105
615 0 0 23 12 41 56 132
1630 2 0 14 10 16 25 67
2 5 57 76 91 71 302
Total 8 13 142 138 235 245 781
P 0.0001. Values are number of cases.
Ophthalmology Volume 119, Number 7, July 2012
1340
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Footnotes and Financial Disclosures
Originally received: October 17, 2011.
Final revision: January 11, 2012.
Accepted: January 11, 2012.
Available online: March 27, 2012. Manuscript no. 2011-1512.
Drashti Netralaya, Dahod, Gujarat, India.
Financial Disclosure(s):
The author(s) have no proprietary or commercial interest in any materials
discussed in this article.
Correspondence:
Mehul A. Shah, MD, Drashti Netralaya, Nr. GIDC, Chakalia Road, Dahod-
389151, Gujarat. E-mail: omtrust@rediffmail.com
Shah et al Ocular Trauma Score in Traumatic Cataracts
1341