Traumatic cataracts are among the most challenging conditions in ophthalmic surgery. Unlike age-related cataracts, which tend to follow a predictable pattern, traumatic cataracts require a highly individualized, case-by-case approach — from initial assessment through to surgery and long-term follow-up.

In this expert Q&A, Dr Ferenc Kuhn, an ocular trauma specialist (having designed the BETT and the OTS systems) and Chairman of the International Society of Ocular Trauma, shares his insights into the assessment and management of traumatic cataracts and the principles that guide his surgical decision-making.

While the diagnosis and staging of an age-related cataract are relatively straightforward, the same cannot be said for a traumatic cataract. Several challenges may complicate the assessment, including swollen eyelids that limit visual inspection, poor visibility caused by corneal oedema and the presence of light-blocking material in the anterior chamber such as fibrin, pus, blood or swollen lens particles. A small pupil can also make the assessment challenging. Additionally, any observed lens cloudiness may be temporary and not necessarily a sign of permanent damage.

These difficulties are compounded by two conflicting demands on the surgeon: the need to remove the damaged lens as early as possible to allow proper assessment of the posterior segment, and the necessity of avoiding the removal of a lens that may not be irreversibly damaged. Making the correct decision about how to manage an injured lens therefore requires individualised planning and extensive experience in ocular trauma.

Visibility is the most critical factor; the surgeon must have a clear view of all ocular structures before proceeding. The correct sequence should always be:

• Diagnosis – What pathology am I dealing with?
• Surgical planning – How can I restore the anatomy as close to normal as possible?
• Execution (tissue tactics) – Implementing the plan, while remaining flexible and ready to adjust based on how the tissues react during the surgery.

A few key principles should always be followed:

• Never proceed without a clear plan – Decisions should not be based on instinct, reflex or routine habits (“I always do this”).
• Apply the carpenter’s rule – Measure twice, cut once.

Looking more closely at managing cases with additional ocular injuries:

• Hyphaema – Irrigate thoroughly to remove the clot before attempting to assess the condition of deeper structures.
• Vitreous prolapse – Use triamcinolone repeatedly to determine whether vitreous has entered the lens proper or the anterior chamber. If vitreous is present, or if its absence cannot be confirmed, use a vitrector rather than the phaco probe to remove the vitreous and lens material.
• Zonular damage – It is generally not advised to use a capsular tension ring in a traumatized eye. The condition of the remaining zonules is often uncertain, and a ring may place excessive tension on them. What appears stable intraoperatively can lead to late dislocation of the capsular bag and IOL.

Careful judgement, thorough planning and adaptability are essential in managing these complex cases.

The surgeon must recognize that a traumatic cataract is an entirely different challenge from an age-related cataract (it is like comparing a rodent to a computer mouse!). With age-related cataracts, most surgeons develop their own preferred technique that they refine over time and apply consistently across cases; rarely does the situation require a deviation from this approach.

This is not the case in a traumatized eye. Every decision, from diagnosis through to tissue manipulations, must be based on a case-specific plan, free from dogmas, routine or preconceived methods. Perhaps the most important distinction between the two types of cataract lies in the risk of vitreous prolapse. Vitreous prolapse is rare in age-related cataracts but relatively common in traumatic cases. If it goes unrecognized and is inadvertently aspirated, it often leads to retinal tears or detachment in the traumatized eye

Surgery for an age-related cataract is widely regarded as the most successful surgical intervention in medicine. Today’s cataract surgeons are highly skilled, and iatrogenic complications are uncommon. However, the same cannot be said for traumatic cataracts.

Isolated traumatic cataract – that is, without any associated injury-related pathology – is very rare. In most cases, other ocular tissues, from the cornea to the retina, are also involved. The surgeon’s aim, therefore, is not simply to “remove the cataract and place an IOL in the bag”; it is to consider the eye as a whole. Lens removal and, possibly, IOL placement are part of the overall management plan, but it is crucial to understand that the lens is not the primary determinant of surgical success. The idea that “there must be an IOL in the bag at the end of the operation” is the wrong philosophy.

While most patients undergoing surgery for an age-related cataract require no long-term follow-up, patients with traumatic cataracts must be followed very closely and for extended periods. Complications, whether related to the lens (or IOL) or something else, are common and may present several weeks after the last intervention or patient visit.

Disclosures: Dr Ferenc Kuhn has nothing to disclose in relation to this article. No fees or funding were associated with this article.

Citation: Expert pearls on traumatic cataract management. touchOPHTHALMOLOGY.com. 8 July 2025.

Register now to receive the touchOPHTHALMOLOGY newsletter!

Don’t miss out on hearing about our latest peer reviewed articles, expert opinions, conference news, podcasts and more.

Register Register