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 specific 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 significantly 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;119:1336 1341 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.2 4 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 appropriate 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 traumatic cataracts. Thus, the success rate may differ between
eyes with traumatic versus nontraumatic cataracts.
The introduction of the Birmingham Eye Trauma Terminology System (BETTS) has led to standardized defini-

1336

2012 by the American Academy of Ophthalmology

Published by Elsevier Inc.

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 cataracts,6,7 but most have involved small samples or were case
studies. Zhang et al6 and Gradin and Yorston7 reported a
patient series focusing on the primary management of traumatic cataracts and perforating injuries.
Various models, including the Ocular Trauma Score
(OTS) and the Classification 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 predictive methods in a larger patient series.
We investigated the value of the OTS for predicting
visual outcomes after surgery in cases of traumatic cataracts. Our study was conducted in a city located at the
ISSN 0161-6420/12/$see front matter
doi:10.1016/j.ophtha.2012.01.020

Shah et al Ocular Trauma Score in Traumatic Cataracts

nexus of 3 states, Gujarat, Madhya Pradesh, and Rajasthan, in central Western India. Qualified ophthalmologists 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 administrators 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 specific pretested online
form.
For each patient enrolled in the study, we obtained a detailed
history regarding the injury and treatment and surgery performed 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 specific 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. Lacerations 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 examinations and treatments. After enrollment, all patients were examined using a standard method.
Cataracts were classified according to lenticular opacity. Cataracts with no clear lens matter between the capsule and the
nucleus were classified as total cataracts. Those in which the
capsule and organized matter were fused to form a membrane of
varying density were classified as membranous cataracts. When
loose cortical material was observed in the anterior chamber together with a ruptured lens capsule, the cataract was classified 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 classification, we were able to categorize all of the
cataract cases.8 The morphology was influenced 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)

Laceration
(n = 500)

Ruptured globe
(n = 58)

Eyes with closed

globe injuries
causing cataracts
(n = 229)

Lamellar
laceration
(n= 19)

Contusion
(n= 210)

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 classification.

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Ophthalmology Volume 119, Number 7, July 2012

Table 6. Comparison of Ocular Trauma ScorePredicted Vision with Actual Vision
No PL
Achieved
OTS-1
OTS-2
OTS-3
OTS-4
OTS-5

OTS

75
73
10.4
28
0.3
2
0
1
0
0
P 0.241

HM to PL
Achieved

1/20020/190

OTS

Achieved

25
17
28.6
26
17.4
11
4.5
2
0
1
P 0.220

OTS

20/20020/50
Achieved

0
7
14.3
18
18.5
15
9.1
2
0
2
P 0.259

OTS

>20/40
Achieved

0
2
33.7
13
29.8
28
31.8
21
0
5
P 0.241

OTS

0
1
13
15
32.8
44
54.5
74
100
5
P 0.220

HM hand movements; OTS ocular trauma score; PL perception of light.

Values are number of cases.

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 morphology and the condition of the surrounding tissues other than the
lens. Phacoemulsification 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. Membranectomy and anterior vitrectomy, via an anterior or pars
plana route, were performed for membranous cataracts.
In patients undergoing corneal wound repair, the traumatic cataract was managed using a second procedure. Recurrent inflammation
was more prominent in patients who had undergone previous surgery
for trauma.9,10 When the media appeared hazy because of inflammation 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 surgical 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 qualified 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 inflammation 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 Ophthalmology 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 defined 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
specific 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 7. Comparison of Postoperative Vision According to Ocular Trauma Score

Ocular Trauma Score
Vision Category

Total

Uncooperative
No perception of light
Hand movement perceived
Perception of light
1/20020/190
20/20020/50
20/40
Total

0
3
1
0
0
0

0
8
55
14
0
0

10
5
459
189
19
1

0
0
2
2
18
0

0
0
1
0
0
0

9
15
516
204
36
1

76

680

21

781

P 0.0001. Values are number of cases.

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Shah et al Ocular Trauma Score in Traumatic Cataracts

75

80

OTS - 1

70

30

60

25

50

20

40

0
uncoop

no pl

hm / pl

32.8

18.5

17.4

10

20

29.8

15

25

30

10

OTS - 3

35

1/200 to
20/190

20/200 to
20/50

>/=20/40

5
0

1.1

0.3

uncoop

no pl

hm / pl

1/200 to
20/190

20/200 to
20/50

>/=20/40

Figure 2. Comparison between ocular trauma score (OTS) and achieved

results in OTS-1 score category. hm hand movements; pl perception
of light.

Figure 4. Comparison between ocular trauma score (OTS) and achieved

results in OTS-3 score category. hm hand movements; pl perception
of light.

Results

A comparison between pre- and postoperative VA showed that

treatment significantly improved VA (P 0.0001, Pearsons chisquare test, P 0.001; Table 3, available at http://aaojournal.org).
An intraocular lens was implanted in 631 cases (80.2%). Aspiration, which was performed using 1 or 2 ports in 48.6% of the
patients in the open globe group, was significantly associated with
improved VA (P 0.0001).
We also compared these variables between the open globe and
closed globe subgroups. Significant 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 significantly improved visual outcome 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 significant 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 significantly different (P 0.241,
0.22, 0.259, 0.241, -0.220) (Figs 2 6) in cases of traumatic cataracts.
Time interval between injury and intervention was also studied
and found to be significant (P 0.0001; Table 8). Common causes
for no improvement in vision were intraocular inflammation

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 significantly 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 significant 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 significant 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 first 24
hours, 38.8% were reported within 30 days, and 39% were reported 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 significantly
associated with the VA at 6 weeks.

OTS - 2

40
35

40

25
20

13

10.4

10

31.8

30

14.3

15

54.5

50

28.6

30

OTS - 4

60

33.7

20
10

0
uncoop

no pl

hm / pl

1/200 to
20/190

20/200 to
20/50

>/=20/40

Figure 3. Comparison between ocular trauma score (OTS) and achieved

results in OTS-2 score category. hm hand movements; pl perception
of light.

uncoop

no pl

4.5
hm / pl

9.1

1/200 to
20/190

20/200 to
20/50

>/=20/40

Figure 5. Comparison between ocular trauma score (OTS) and achieved

results in OTS-4 score category. hm hand movements; pl perception
of light.

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Ophthalmology Volume 119, Number 7, July 2012

OTS - 5

120

100

100
80
60
40
20
0

uncoop

no pl

hm / pl

1/200 to
20/190

20/200 to
20/50

>/=20/40

Figure 6. Comparison between ocular trauma score (OTS) and achieved

results in OTS-5 score category. hm hand movements; pl perception
of light.

(1.8%), extensive posterior segment injury (1.5%), and corneal

opacities (1.2%).

Discussion
Visual gain after surgery for traumatic cataracts is a complex issue. Electrophysiologic10 and radioimaging6,11,12 investigations 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 significantly 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 visual outcomes in cases with traumatic cataracts. Shah et al4
reported that 56% of patients obtained a VA 20/60, and
Kumar et al13 reported a VA 6/18 in 50% of cases.
Staffieri et al14 reported a VA 6/12 in 35% of cases,
Bekibele and Fasina15 reported a VA 6/18 in 35.6% of
cases, and Gradin and Yorston7 reported a VA 20/60 in
64.7% of cases. Brar et al16 reported a VA 0.2 in 62% of
cases, Cheema and Lukaris17 reported a VA 6/18 in 68%
of cases, and Karim et al18 reported a VA 0.2 in 62% of
cases. Krishnamachary et al12 reported a VA 20/60 in
74% of cases, and Knight-Nanan et al19 reported a VA 20/60
in 64% of cases. Bienfait et al20 reported a VA 0.7 in 27% of
cases, and Anwar et al21 reported a VA 20/40 in 73% of

cases. The visual outcomes with poly(methyl methacrylate)

lens implants reported by Verma et al22 were similar to the
findings in our study.
Eckstein et al23 and Zou et al24 showed that a primary
intraocular lens can improve visual outcome, again similar to
the results observed in our study. Vajpayee et al25 and Gupta et
al26 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. Staffieri et al14 reported the use of a primary 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 first to compare the visual outcome at 6
weeks in children between open globe and closed globe injury
groups classified by BETTS. Shah et al28 made this comparison 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 OTS29 prediction in cases with traumatic
cataracts. Although similar findings have been reported by
others,30 32 our study presents one of the largest reported
databases following cases of traumatic cataracts classified
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 al30 reported no significant differences between the VAs at 6 weeks and the VAs predicted by OTS in
traumatic cataracts. Sharma et al31 proposed that the OTS
calculated at the initial examination may be of prognostic
value in children with penetrating eye injuries. However,
Unver et al32 suggested that OTS calculations may have
limited value as predictors of visual outcome. Lima-Gomez
et al33 reported estimates for a 6-month visual prognosis,
but some of the variables required evaluation by an ophthalmologist. By using the OTS, 98.9% of the eyes in the
general population could be graded in a trauma room. Knyazer et al34 reported the prognostic value of the OTS in
zone-3 open globe injuries, and Man and Steel35 claimed
equal prognostic effectiveness of both the OTS and Classification and Regression Tree in the general population.
In conclusion, in this study, the OTS was a reliable predictor of the final visual outcome in cases of traumatic cataracts.

Table 8. Comparison of Vision According to Time Interval between Injury and Start of Treatment
Time
Interval
in Days
01
25
615
1630
Total

Postoperative Vision
Uncooperative

No Light
Perception

Hand Movement Perceived

Perception of Light

1/20020/190

20/20020/50

20/40

Total

3
1
0
2
2
8

3
5
0
0
5
13

37
11
23
14
57
142

25
15
12
10
76
138

55
32
41
16
91
235

52
41
56
25
71
245

175
105
132
67
302
781

P 0.0001. Values are number of cases.

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Shah et al Ocular Trauma Score in Traumatic Cataracts

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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.
Drashti Netralaya, Dahod, Gujarat, India.

Financial Disclosure(s):
The author(s) have no proprietary or commercial interest in any materials
discussed in this article.
Manuscript no. 2011-1512.

Correspondence:
Mehul A. Shah, MD, Drashti Netralaya, Nr. GIDC, Chakalia Road, Dahod389151, Gujarat. E-mail: omtrust@rediffmail.com

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