Pediatric Traumatic Cataracts at a Tertiary Eye Center in Indonesia

Background: Traumatic cataract is the leading cause of significant monocular visual impairment in children. The cause of this type of cataract is preventa-ble penetrating or blunt ocular injury. Lens extraction can improve the visual acuity but it also depends on the extent of the injury to other ocular structures. Objective: To describe the features of pediatric traumatic cataract presenting at a tertiary eye center in Indonesia. Methods: This study is a descriptive study and the data were collected retrospectively from the medical records of the patients who were diagnosed as pediatric traumatic cataract over the pe-riod of January 1 st 2019 to December 31 st 2019. Demographic data, trauma characteristics, clinical features, management, and pre- and post-operative Best Corrected Visual Acuity (BCVA) were reviewed retrospectively. Results: A total of 37 patients were diagnosed as pediatric traumatic cataract. Among these patients, 78.38% were boys, with the mean age of 9.14 ± 3.77 years old. Open globe injury was the mechanism of injury for 54.05% patients. Besides lens aspiration, additional procedures were membranectomy, anterior vitrectomy, primary posterior capsulotomy, and synechiolysis. Eighty-one percent patients had unilateral blindness preoperatively and 23.80% patients still had unilateral blindness on three months of follow-up. Conclusion: In pediatric patients, traumatic cataract occurred predominantly in boys while playing outside the house. The children who had ocular trauma still have the risk of blindness even after the surgery. Trauma prevention and avoidance by adult supervision when children engage in outdoor play activity are necessary.


Introduction
Ocular trauma is the leading cause of unilateral blindness in children [1]. About 20% -50% of ocular trauma occurs in the pediatric age group, and at least 90% of ocular trauma cases in children can be prevented [2] [3] [4] [5]. Cataracts in children result in more than one million blindness among Asian children [5]. A traumatic cataract is defined as permanent lens opacity due to blunt or penetrating trauma to the eye. Traumatic cataracts occur in 29% -57% of all cataract cases in children. They are the cause of visual impairment in children, especially in developing countries, and often cause more significant visual impairment compared to other types of cataract. This is because traumatic cataracts are usually accompanied by other ocular disorders such as corneal lacerations, iris injury, vitreous hemorrhage and retinal detachment [2] [3] [6] [7] [8].
The treatment of pediatric traumatic cataracts is challenging since these cataracts occur in the developing eyes, which is at risk of amblyopia. Traumatic cataracts can provide good visual acuity if treated with optimal surgery and timely visual rehabilitation. Postoperative visual acuity from previous studies varied, with final visual acuity ≥ 6/12 as much as 50% -80% [2] [7] [9]. To our knowledge, there was no previous study which describes the characteristics of pediatric traumatic cataracts in Indonesia. This study aims to describe the overview of pediatric traumatic cataracts at the Indonesia National Eye Center Cicendo Eye Hospital, which is the highly rated referral eye hospital in Indonesia.

Subjects and Methods
This is a descriptive study through retrospective data collection from medical records of all patients diagnosed with pediatric traumatic cataracts at Cicendo Eye Hospital Bandung from January 1 st , 2019, to December 31 st , 2019. The study adhered to the tenets of the Declaration of Helsinki and was approved by the Institutional Review Board (IRB) Universitas Padjadjaran. Inclusion criteria included all patients clinically diagnosed as traumatic cataract and aged 18 years or less. Exclusion criteria were patients with a history of other ocular abnormalities before the trauma, a history of ocular surgery before ocular trauma, and an incomplete medical record.
Pediatric traumatic cataracts are defined as lens clouding found on ophthalmological examination with a history of penetrating or blunt trauma in the age group of 18 years or less. Types of trauma are divided into traffic accidents, falls, and trauma due to blunt objects and sharp objects. A traffic accident is a trauma caused by an accident while driving, whereas fall is caused by falling from a height. Trauma due to blunt objects is caused by a hard object with a non-pointed tip. Meanwhile, sharp objects are objects with thin edges, smooth and easy to cut.
Data were taken retrospectively, consisting of data on age, gender, etiology and type of trauma, clinical characteristics, type of treatments given, and visual acuity before and after the procedure. Visual acuity in children was conducted using a Snellen chart, Cardiff visual acuity card or other pre-verbal visual acuity examination according to the child's ability. The data obtained were then presented by tables using Microsoft Excel 2016. The etiology and laterality variables were analyzed and statistically tested using the IBM SPSS version 27 with the Saphiro Wilk test.

Results
A total of 37 pediatric traumatic cataract patients were included in this study. This accounted for 13.19% of all pediatric cataract patients in 2019 at this hospital. Patient demographic data are presented in Table 1. 78.38% of all pediatric traumatic cataract patients were male. The average age of the patients was 9.14 ± 3.77 years with an age range of 3 to 16 years. 48.65% of patients belong to the 6 to 10-year age group. As many as 54.05% of cases were caused by open globe injuries (OGI) and 45.95% due to closed globe injuries (p = 0.63). In terms of locations, trauma occurred outside the building accounted for 72.93% of patients. Also, blunt objects were the cause of trauma in 78.38% of cases. In this study, all traumatic cataracts occurred unilaterally with 54.05% occurring in the right eye and 45.95% in the left eye (p = 0.63).  Table 2 shows the characteristics of traumatic cataracts in this study. A total of 37.84% had anterior capsule rupture. In 97.30% of patients, lens aspiration and irrigation were performed with the anterior approach. Meanwhile, in 94.60% of patients, IOL implantation was conducted. Table 3 shows the preoperative and postoperative visual acuity. At the preoperative stage, as many as 81.08% of patients had visual acuity < 3/60. Afterwards, at three-month-postoperative follow-up, it was found that 47.62% of 21 patients who came for follow-up had visual acuity ≥ 6/12, while five patients remained to have visual acuity < 3/60.   [11].
The causes of poor final visual acuity in this study included corneal opacification and amblyopia. This study resulted in five patients with final visual acuity < 3/60 at three-month follow-up. The comorbid ocular conditions seen in these patients included two deprivation amblyopia patients, one patient with fibrotic tissue in front of the optic disc, one patient with corneal scar and one patient with retinal detachment. As many as 81.08% of patients were in the blind category at the preoperative examination. In the three-month follow-up, 23.80% of the patients were still included in the BCVA < 3/60 category. Meanwhile, there was only one patient in the category BCVA ≥ 6/12 at the pre-operative examination, and it increased to 47.62% at the three-month follow-up examination. These results indicate that traumatic cataract extraction can improve visual acuity, but the risk of blindness can still occur.
In a study conducted in Ethiopia, Kinori et al. reported that only 10% of patients had final visual acuity > 20/40. This could be due to the more complex ocular condition of the patients in the study and the longer duration between trauma and surgery compared to other studies [3]. Inadequate health facilities in developing countries and the lack of communication among children regarding trauma events and their visual condition are the causes of delays in treatment and affect the outcome of visual acuity [3] [6].
The limitation of this study is that the data were retrospective, resulting in unequal data and duration of follow-up. Examinations carried out by different examiner could also present a bias. Further prospective studies can be performed to assess visual acuity improvement, post-treatment complications, and prognosis in traumatic cataracts with longer follow-up duration. Further research regarding the biometric accuracy or residual refractive error after IOL implantation in pediatric traumatic cataract patients can also be carried out.

Conclusion
Traumatic cataracts diagnosed at the tertiary eye center in Indonesia mostly affect school-age boys performing activities outside buildings. There was an increased visual acuity after appropriate management, but there was still risk of blindness even after surgery. The causes and mechanisms of trauma must be evaluated in order to develop strategies to prevent the incidence of trauma in children. Children, parents, teachers and policyholders should be educated with essential information to reduce the incidence of trauma. Besides, it is necessary to carry out supervision or assistance during children's activities so that the incidence of pediatric eye trauma can be prevented, both inside and outside buildings.