Characteristics of Traumatic Cataract Wound
CAROLYN E. KLOEK, MICHAEL T. ANDREOLI, AND CHRISTOPHER M. ANDREOLI
● PURPOSE: To characterize the clinical course of cata-
ract 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 inju-
ries, 63 experienced cataract wound dehiscence. The
majority of these cataract wounds (89%) were extracap-
sular 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 consider-
ing the phacoemulsification patients alone, these patients
fared much better, with a median postoperative vision of
● 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 prog-
nosis. Fortunately, patients with phacoemulsification site
dehiscence appear to regain the majority of their vision
after open globe repair(Am J Ophthalmol 2011;152:
229–233. © 2011 by Elsevier Inc. All rights reserved.)
scleral tunnel is created through which the lens is manu-
S THE TECHNOLOGY OF PHACOEMULSIFICATION
improves, traditional extracapsular cataract extrac-
tion (ECCE), in which a large limbal incision or
ally extracted and subsequently sutured to achieve wound
closure, is less frequently chosen as a primary method of
cataract extraction. This technique continues to be em-
ployed for extraction of selected dense brunescent cata-
racts 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.1An
alternative to the traditional large-incision ECCE is man-
ual small-incision cataract surgery (SICS), a commonly
chosen method of cataract extraction in developing coun-
tries because it offers a quick, cost-effective procedure to
large populations.2SICS is usually performed as a suture-
less procedure using a scleral tunnel that is shorter than
that used for the traditional, large-incision ECCE for lens
Cataract extraction by phacoemulsification is per-
formed through a small scleral tunnel or, more com-
monly, a beveled incision at the limbus or periph-
eral clear cornea.4Phacoemulsification provides many
advantages over ECCE, including enhanced surgical
wound strength,5,6which is demonstrated in previous
studies by lower phacoemulsification wound dehiscence
rates7and more rapid healing time.8
Surgical scleral wounds are susceptible to dehiscence
with blunt trauma.9Prior studies have described small
series of patients with dehisced cataract surgery wounds,
predominately resulting from rupture of pre-existing ECCE
incisions.10–15There are few reports of dehisced phaco-
emulsification wounds in the literature.16–18Patients de-
scribed 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.
A RETROSPECTIVE CHART REVIEW WAS CONDUCTED ON 846
patients comprising 848 open globe injuries at the Massa-
chusetts 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
Accepted for publication Jan 19, 2011.
From the Massachusetts Eye and Ear Infirmary (C.E.K., M.T.A.,
C.M.A.), Harvard Medical School (C.E.K., M.T.A., C.M.A.), Boston
University School of Medicine (M.T.A.), and Harvard Vanguard Medi-
cal Associates (C.M.A.), Boston, Massachusetts.
Inquiries to Christopher M. Andreoli, 133 Brookline Ave, Boston, MA
02215; e-mail: email@example.com
© 2011 BY ELSEVIER INC. ALL RIGHTS RESERVED.
of a multi-system trauma. Demographic and clinical data
from all patients were entered into a computerized data-
base 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 out-
comes. If a specific data field was not available for a patient
then that patient was excluded from that particular
Patients are evaluated and treated for open globe
injuries at the Massachusetts Eye and Ear Infirmary
according to a previously published standardized proto-
col.19–22Upon arrival to the emergency room a standard
history and ocular examination is completed. A non-
contrast 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.23This scoring system helps determine sever-
ity 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 consid-
ered statistically significant.
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 dehis-
cence 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 phaco-
emulsification 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 phacoemul-
sification to wound dehiscence was 3.7 months (range 2
weeks to 1 year).
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). Conse-
quently, one-third of geriatric open globe injuries (54/166,
TABLE. Characteristics of Open Globe Injury Patients
Full Cohort Cataract Wound DehiscenceNon-cataract Wound Dehiscence
No. of injuries
Mean age (range), years
Mechanism of injury, no. (%)
Blunt (other than falls)
Motor vehicle accidents
Mean ocular trauma score
Median ocular trauma score
Intraocular foreign bodies
41.5 (?1 to 97)
78.2 (29 to 95)
38.6 (?1 to 97)
aP 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.
AMERICAN JOURNAL OF OPHTHALMOLOGY
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 propor-
tion 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 ?
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%) necessi-
tated a lid laceration repair, and 2 (3%) needed disinser-
tion of the rectus muscles.
Postoperative visual outcomes were worse in the cata-
ract 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 dehis-
cence (20/40; P ? .0002). Over half (35/63, or 56%) of the
cataract wound dehiscence patients developed a postoper-
ative hyphema. Additionally, many cataract wound dehis-
cence patients were diagnosed with posterior segment
pathology: 25 vitreous hemorrhages (25/63, or 40%), 9
retinal detachments (9/63, or 14%), 2 choroidal detach-
ments (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 pri-
mary 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 in-
cluded 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 postopera-
tively. 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 phaco-
emulsification 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 detach-
ment, 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
THE RESULTS OF THIS STUDY SHOW THAT RUPTURED CAT-
aract surgery wounds account for approximately one third
of open globe injuries in the elderly population. Despite
the decreasing frequency of cataract extraction performed
via ECCE, ruptured ECCE wounds account for a signifi-
cant fraction of all open globe injuries. The higher prev-
alence of dehisced ECCE wounds as compared with
phacoemulsification wounds in the current study corrobo-
rates previously published studies demonstrating the rela-
tive strength of phacoemulsification wounds.7Patients
with cataract extraction performed by SICS presumably
will be at a lower risk for traumatic wound dehiscence than
a population of patients with larger wounds from tradi-
tional ECCE, because of the narrower and longer scleral
incision in SICS. Future studies are needed to accurately
describe the response of this population to blunt trauma.
The most common mechanism of injury resulting in
ruptured cataract wounds was falls. Despite ongoing research,
falls remain a significant source of injury in the elderly.
Multifactorial approaches to fall prevention have yielded
varying degrees of success.24,25By recognizing the ocular risk
factors for such falls,26,27ophthalmologists can participate in
a multidisciplinary approach to fall prevention.
Ruptured ECCE wounds were associated with a high
rate of retinal pathology, contributing to the poor visual
outcome before and after surgical repair seen in this patient
population. The common finding of hemorrhagic choroi-
dal and retinal detachment following ruptured ECCE
wound is likely multifactorial, resulting from the signifi-
cant degree of force the eye must have sustained in order
to dehisce the surgical wound, the rapid drop in intraocular
pressure, and the age of the patient.
The group of patients who presented with dehisced
phacoemulsification wounds had a unique clinical course.
None of these injuries resulted in significant retinal pa-
CATARACT WOUND DEHISCENCE
VOL. 152, NO. 2
thology. While the ages, mechanisms of injury, and ocular
trauma scores of the phacoemulsification patients were
similar to the ECCE group, the patients with ruptured
phacoemulsification wounds had a better visual prognosis,
with a median best postoperative visual acuity of 20/60.
Consequently, these patients were only followed for a few
weeks at a trauma center before returning to the care of
their primary ophthalmologist.
Based on the results of this study, we suggest that
ophthalmologists have a low threshold to perform globe
exploration to exclude the possibility of a ruptured cataract
wound in the pseudophakic elderly population, particularly
in the setting of bullous subconjunctival hemorrhage and
with poor view to the fundus. With the increasing use of
SICS in developing countries as a primary method of
cataract extraction, it remains particularly important for
clinicians to be aware of these clinical signs of ruptured
cataract wounds. Furthermore, patients can suffer wound
dehiscence more than 20 years after the original cataract
surgery, suggesting that there may be no time limit on the
weakness of these surgical wounds.
Previous studies have demonstrated the safety of cata-
ract surgery, even in the very elderly.28This study shows a
poor prognosis for certain ruptured cataract surgery
wounds. Although there are rare cases of patients with
ruptured ECCE wounds who recover useful vision, most do
not. This information is important when counseling pa-
tients and their families both preoperatively and postop-
erativelyin order toestablish
expectations. While there are still cases in which tradi-
tional ECCE is the appropriate method for cataract extrac-
tion given the density of the lens or other factors, the
potential risk of subsequent rupture of the wound in the
elderly population should be taken into consideration
when choosing this method for cataract extraction when
phacoemulsification is a possible alternative.
THE AUTHORS INDICATE NO FINANCIAL SUPPORT OR FINANCIAL CONFLICT OF INTEREST. INVOLVED IN DESIGN AND
conduct of study (C.E.K., C.M.A., M.T.A.); collection (C.M.A., M.T.A.), management (C.E.K., C.M.A., M.T.A.), analysis (C.E.K., C.M.A., M.T.A.),
and interpretation of data (C.E.K., C.M.A., M.T.A.); and preparation, review, or approval of manuscript (C.E.K., C.M.A., M.T.A.). The study protocol
was approved by the Massachusetts Eye and Ear Infirmary Institutional Review Board (IRB #05-06-037X). The study is in accordance with Health
Insurance Portability and Accountability Act regulations and conforms to the tenets of the Declaration of Helsinki.
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REPORTING VISUAL ACUITIES
The AJO encourages authors to report the visual acuity in the manuscript using the same nomenclature that was used in
gathering the data provided they were recorded in one of the methods listed here. This table of equivalent visual acuities
is provided to the readers as an aid to interpret visual acuity findings in familiar units.
Table of Equivalent Visual Acuity Measurements
Snellen Visual Acuities
Decimal FractionLogMAR 4 Meters6 Meters20 Feet
From Ferris FL III, Kassoff A, Bresnick GH, Bailey I. New visual acuity charts for clinical research. Am J Ophthalmol 1982;94:91–96.
CATARACT WOUND DEHISCENCE
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