Traumatic cataracts are a significant cause of preventable blindness in the pediatric population, representing 12% to 46% of all childhood cataracts.1 The initial injury can have associated ocular comorbidities that also lead to vision loss, and subsequent amblyopia has been reported in up to 51% of cases.2 Although timely surgical intervention and refractive correction are associated with good visual recovery, potential visual gains after surgery depend on traumatic pathology, intraoperative decisions, and perioperative visual rehabilitation.3 Identifying modifiable factors to optimize recovery of functional vision should be prioritized.
Many groups have evaluated the ability of ocular trauma scoring algorithms to predict the visual prognosis in cases of pediatric traumatic cataracts. Using the Birmingham Eye Trauma Terminology system in a large cohort, closed globe traumatic cataracts were reported to have a significantly more favorable prognosis than open globe injuries.4 The Ocular Trauma Score has been validated to predict visual outcomes following pediatric traumatic cataract surgery, but other scoring systems such as the Pediatric Ocular Trauma Score and Toddler/Infant Ocular Trauma Score further account for the affect of amblyopia and challenges of accurate initial examinations.5–7 These prognostic scoring systems highlight the importance of appropriate intervention for all traumatic ocular injuries, including lens/cataract pathology, in affecting final visual outcomes.
Despite a predominance of open globe injuries in traumatic cataract cases, overall postoperative visual outcomes in children are fairly promising. Epidemiological studies in various countries have shown that the average age of injury is typically between 6 and 11 years,5,8–13 with some studies showing a peak between 2 and 8 years and a significantly younger mean age in open globe compared to closed globe injuries (6.9 vs 10.4 years).1,14 Good final best corrected visual acuity of 20/60 or better (Snellen) has been documented in more than 50% of patients in most of the large retrospective cohorts analyzed, corroborating closed globe injuries as a positive prognostic factor.2,6,14 Because the younger population is more frequently affected by traumatic cataracts, it is crucial to identify methods to maximize surgical outcomes.
There remains some controversy regarding the preferred timing of cataract removal and intraocular lens (IOL) insertion in traumatic cases. Primary IOL implantation at the time of cataract extraction can be challenging due to poor visualization from associated injuries, inability to obtain accurate IOL calculations, and the risk of increased postoperative complications. However, delayed secondary IOL insertion can affect the child's binocular function, induce strabismus development, and decrease efficacy of amblyopia management due to high anisometropia and difficulty tolerating aphakic contact lenses.15 Few studies have demonstrated the safety and favorable visual outcomes of primary IOL implantation, comparable to secondary IOL insertion, especially when combined with primary posterior capsulotomy.16,17 Further investigation into which option is preferable under various circumstances is necessary to optimize visual prognosis.
Although many controlled trials have been performed to standardize the management of congenital cataracts, no preferred practice patterns have been established for preoperative decision-making or peri-operative management of patients with pediatric traumatic cataract. Our goal was to facilitate the development of these guidelines by cross-sectional analysis of current practices regarding the care of patients with pediatric traumatic cataract. To our knowledge, no comprehensive survey of ophthalmologic surgeons managing pediatric traumatic cataracts has been published. By exploring multi-institutional trends in the surgical techniques and treatment strategies for these patients, we aimed to provide a foundation for creating standardized, evidence-based protocols for optimal patient care outcomes.
Patients and Methods
We designed a 24-question survey to assess surgeon background, preoperative planning and testing, surgical timing, intraoperative techniques, and postoperative management of pediatric traumatic cataracts (Table A, available in the online version of this article). This survey was sent once electronically to members of the Pediatric Ophthalmology (Ped-Ophth) listserv, which is open to pediatric ophthalmologists around the world. Currently, approximately 1,500 fellowship-trained pediatric ophthalmologists, or those for whom pediatric ophthalmology represents a sizable portion of their practice, are members. Physicians performing pediatric traumatic cataract surgeries were encouraged to respond within a 1-month period (survey open from September 1 to September 30, 2018). All questions had suggested answer choices, but most questions also had a write-in option. It was also possible to skip the question.
Management of Pediatric Traumatic Cataracts
A total of 56 anonymous participants completed the survey, and responses to each question were tabulated manually and graphed using Excel software (Microsoft Corporation, Redmond, WA). After reviewing the results, question 5 was excluded from further analysis due to redundancy, because all of the survey respondents treated and managed traumatic cataracts.
A two-sample chi-squared test of proportions was computed when appropriate using RStudio (RStudio, Inc., Boston, MA) for descriptive statistical analysis. This study was approved by the institutional review board of Johns Hopkins Wilmer Eye Institute. No formal consent was required for this anonymous data collection.
A literature review of all English language studies published on management approaches and surgical outcomes of pediatric traumatic cataracts from January 1970 to February 2019 was also performed using PubMed and the institution's print collection database. The results were compared to the published data when applicable.
Demographics of Study Participants and Their Practices. Of the 56 pediatric ophthalmologists who treat and manage traumatic cataracts, 35 (62.5%) work in an academic hospital setting (Figure AA, available in the online version of this article). Of the 21 (37.5%) respondents who work in private practice, the practice models are fairly evenly divided between solo practitioner (6 respondents, 28.6%), pediatric group practice (7 respondents, 33.3%), and multi-subspecialty group practice (8 respondents, 38.1%) (Figure AB). The majority of physicians (34 respondents, 60.7%) see both adult and pediatric patients while on call, whereas few physcians (6 respondents, 10.7%) do not take any calls (Figure AC). Most ophthalmologists stated the major sources for their cases were referrals from outside providers (48 respondents, 85.7%), from within their practice (45 respondents, 80.4%), or through emergency room consultations (41 respondents, 73.2%) (Figure AD).
Demographics of survey participants and their practices. Graphical results depicting responses to (A) question 1, (B) question 2, (C) questions 3 and 4, and (D) question 6. Percentage (%) of respondents (number of respondents) is indicated above each bar or slice. ER = emergency room
Factors Affecting Timing of Traumatic Cataract Extraction. Of the 49 respondents (87.5% of total) who stated that they perform ruptured globe repair, only 4.1% would remove a traumatic cataract at the time of globe repair if there was no obvious violation of the anterior capsule. The number increased significantly to 20 respondents (41.7%) who stated they would perform simultaneous cataract extraction if there was an obvious violation of the anterior capsule, but the number decreased to 13 respondents (27.7%) if there was concern for delayed presentation and/or dirty mechanism of globe injury (P < .001) (Figure 1A). Of note, 20 respondents (41.7%) stated they would not remove the cataract at the time of globe repair even if there was an obvious violation of the anterior capsule.
Factors affecting timing of cataract extraction in traumatic cases. Graphical results depicting responses to (A) questions 8, 9, and 10, and (B) questions 11 and 12. The percentage (%) of respondents (number of respondents) is indicated above each bar.
Most ophthalmologists (28 respondents, 50.9%) prefer to remove a visually significant traumatic cataract within 4 weeks of trauma if the child is within the amblyogenic age range (defined as younger than 7 years), but only 16 respondents (29.1%) would perform cataract extraction within 4 weeks if the child was outside of the amblyogenic age range (P = .02). Similarly, 35 respondents (63.6%) would prefer to wait between 1 and 4 months after globe trauma if the child is outside the amblyogenic age range (Figure 1B). However, a few respondents stated that it would further depend on the patient's exact age regardless of whether the child was within (4 respondents, 7.3%) or outside (3 respondents, 5.5%) the amblyogenic age range, because they may choose to operate on an infant earlier than a 6 year old, or the decision may depend on the child's functional needs and schedule if they are school-aged.
Preoperative Planning and Ancillary Testing. Forty-six respondents (82.1%) would only obtain B-scan ultrasonography at the time of the initial evaluation if there was a limited view of the fundus, although 6 respondents (10.7%) would wait until the time of surgery (Figure 2A). Of those who obtain preoperative B-scan ultrasonography, 23 respondents (41.1%) would repeat it at least once prior to surgery (Figure 2B).
Preoperative planning, intraocular lens (IOL) calculation, and ancillary testing preferences for pediatric traumatic cataracts. Graphical results depicting responses to (A) question 13, (B) question 14, (C) question 15, (D) question 16, and (E) question 17. Percentage (%) of respondents (number of respondents) is indicated above each bar or slice. Ks = keratometry values
If the initial globe trauma required corneal laceration repair, most physicians preferred to wait 4 to 6 weeks prior to removing corneal sutures (40 respondents, 71.4%), whereas a few qualified that they would try to remove the sutures simultaneously at the time of cataract surgery (Figure 2C). Only 7 respondents (12.5%) would remove the corneal sutures within 1 month of repair. When planning IOL insertion in cases involving corneal injury, most of the respondents (44 respondents, 78.6%) use keratometric values from the contralateral eye, but 6 respondents (10.7%) would try to postpone cataract surgery until the cornea healed after suture removal (Figure 2D). Most respondents (41 respondents, 73.2%) also affirmed that their targeted postoperative refraction would depend on the patient's age if planning IOL insertion, but 9 respondents (16.1%) would use the same refractive target that they use for other pediatric cataracts (Figure 2E).
Intraoperative Techniques. The preferred approaches to IOL implantation vary by the amount of zonular weakness encountered intraoperatively. If less than 180 degrees of zonular weakness is present, significantly more surgeons would prefer to place a three-piece IOL in the sulcus (26 respondents, 46.4%; P = .002) or a one-piece IOL in the bag with (12 respondents, 21.4%) or without (9 respondents, 16.1%) a capsular tension ring (P < .001) (Figure 3A). However, if more than 180 degrees of zonular weakness is noted, a significant majority (37 respondents, 66.1%; P < .001) would intentionally leave the patient aphakic and presumably perform a secondary IOL insertion or use an aphakic contact lens or glasses to correct aphakia. Additionally, most surgeons (45 respondents, 80.4%) would perform an intraoperative primary posterior capsulotomy in all patients younger than 7 years or if they do not think the child is cooperative enough for YAG laser (Figure 3B).
Intraoperative approaches for pediatric traumatic cataracts. Graphical results depicting responses to (A) questions 18 and 19 and (B) question 20. Percentage (%) of respondents (number of respondents) is indicated above each bar or slice. IOL = intraocular lens; CTR = capsular tension ring
Postoperative Management and Visual Rehabilitation Planning. In cases of traumatic cataracts, 34 respondents (60.7%) use intracameral antibiotics during cataract surgery, but only 21 (37.5%) use intracameral steroids. Postoperatively, most respondents (42 respondents, 75%) do not change their eye drop regimen compared to other pediatric cataract cases, whereas a small proportion (8 respondents, 14.3%) increase frequency of postoperative eye drops for traumatic cataracts (Figure 4A).
Postoperative management and visual rehabilitation planning for pediatric traumatic cataracts. Graphical results depicting responses to (A) question 23 and (B) question 24. Percentage (%) of respondents (number of respondents) is indicated above each bar or slice.
Most of our survey respondents agreed on the importance of amblyopia therapy in children within the amblyogenic age range, regardless of postoperative vision. Although only 7 respondents (12.5%) would initiate amblyopia therapy prior to traumatic cataract surgery, 23 respondents (41.1%) would initiate it within 1 week of surgery. Approximately 11 respondents (20%) would wait until refractive correction was obtained (Figure 4B).
The purpose of our study was to survey practicing pediatric ophthalmologists' individual practice patterns surrounding preoperative evaluation, surgical techniques, and postoperative management of patients with pediatric traumatic cataract. Of the 56 respondents, 87.5% perform ruptured globe repair and 62.5% work in academic hospitals, suggesting the majority of our survey population may primarily manage acute ocular traumatic injuries in tertiary care settings, and thus may be the initial ophthalmologists to diagnose and treat pediatric traumatic cataracts. This reinforces the need for evidence-based protocols, focusing on the unique surgical considerations and perioperative management of patients with traumatic cataract, to help guide physicians who are the primary responders to ocular trauma as to what factors and subsequent therapeutic pathways can optimize visual recovery if lens pathology is present.
The timing of traumatic cataract removal remains a debated issue. Removal of lens material at the time of primary trauma repair has long been recommended when anterior capsular violation is noted, due to increased risk of severe inflammation, IOP elevation, and endophthalmitis.18 However, only 41.7% of our survey respondents stated they would perform simultaneous cataract extraction at the time of open globe repair, even with obvious violation of the anterior capsule, with significantly fewer electing for combined traumatic cataract extraction if there was no anterior capsule violation or if concerned for delayed presentation and/or dirty mechanism of injury. Despite the known risks of additional anesthesia and delaying traumatic cataract removal in cases of penetrating ocular injury, most of our responding surgeons reported a more conservative approach, instead prioritizing the ability to safely remove lens material and/or possibly insert an IOL by allowing time for initial healing of globe repair. Supplementary evidence supporting that this approach does not place a child at greater risk of inflammation, IOP spikes, or endophthalmitis would be beneficial.
Most respondents (63.6%) would wait more than 1 month to remove a visually significant cataract if the patient was outside the amblyogenic age range, and 36.4% would wait if the patient was within the amblyogenic age range, which suggests a strong preference for delaying cataract surgery to optimize perioperative factors despite the risk of amblyopia. A few respondents also reported that their timing of cataract extraction would further depend on the patient's specific age, regardless of whether it was within the amblyogenic range or not. This indicates that further inquiries are necessary into which age cutoffs are most appropriate for grouping management decisions, because many physicians may treat traumatic cataract differently in an infant than a school-aged child, even if both children are technically within the amblyogenic age range.
Little consensus exists regarding what ancillary testing is essential to perform preoperatively. The majority of our respondents agree that B-scan ultrasonography should be obtained at the time of initial evaluation if there is a limited view to the fundus, given the importance of posterior comorbidities as a prognostic factor for visual outcomes and logistical planning purposes in case a retinal surgeon is needed.3,6,7 IOL power calculation is also a major challenge with ocular trauma cases when considering primary IOL implantation, because injuries can distort the corneal surface, rendering biometry unreliable. Small studies using keratometry values from the contralateral eye in ocular trauma cases have had acceptable refractive outcomes, corroborated by other larger studies showing that mean refractive anisometropia in children aged between 4 and 18 years is generally less than 1.00 diopters.16,19 This validates the 78.6% of our survey respondents who follow this practice when planning IOL insertion in cases of corneal injury. Most respondents also stated their targeted postoperative refraction depends on the patient's exact age, implying that additional exploration of age-based refractive outcomes is warranted to develop standardized nomograms for decreasing undesired postoperative refractive error.
Surgeon-specific preferences regarding the approach for IOL implantation varied widely but mainly depended on the amount of zonular weakness. With less than 180 degrees of zonular weakness, most surgeons elected primary IOL insertion with either a three-piece IOL in the sulcus or a one-piece IOL in the capsular bag. However, if more than 180 degrees of zonular weakness was encountered, most surgeons would intentionally leave the patient aphakic. This controversial aspect requires further investigation because it directly affects the visual rehabilitation process. Because the Infant Aphakia Treatment Study found a reduced rate of reoperations among infants aphakic after congenital cataract surgery, it is plausible that a similar conclusion could be reached with traumatic cataracts, because early studies have shown higher rates of lens dislocation and pupillary optic capture with primary IOL insertion after traumatic cataract extraction.16 Advances in surgical techniques for scleral-fixated IOL implantation and adoption of adjunct IOL implants (eg, Artisan phakic IOL; Ophtec, Inc., Sunrise, FL) may allow secondary insertion to have superior safety and refractive outcomes.20,21
Due to the increased vascular permeability and breakdown of the blood–aqueous barrier secondary to trauma, a higher incidence of postoperative fibrinous uveitis has been reported following pediatric traumatic cataract surgery.22 Thus, some surgeons advocate for the use of intracameral steroids to reduce severe postoperative inflammation.23 However, only 37.5% of our survey respondents routinely use intracameral steroids and most do not change their postoperative eye drop regimen, so this is also a subject that requires supplementary research to resolve whether any benefit exists to amplifying postoperative steroids in traumatic cases. There is also a wide range of opinions regarding when amblyopia therapy should be initiated. Unlike the Infant Aphakia Treatment Study where the penalization regimen and refractive correction process was explicitly known, the timing of refraction correction is more variable in traumatic cataract cases because it depends on IOL insertion and tolerance of aphakic correction. Nevertheless, this is a critical topic to study because ultimate visual outcomes will predominantly depend on appropriate amblyopia treatment.
Our conclusions on individual practice patterns surrounding management of pediatric traumatic cataracts were limited by the cross-sectional, observational study design. Although the sample size of 56 respondents is relatively small, this may be a representative sample of the surgeons who have significant experience with pediatric traumatic cataracts, given the recruitment bias inherent to the nature of the survey. Our respondents are likely those who frequently encounter and treat traumatic ocular injuries in the pediatric population. We were also unable to characterize institutional and/or geographic variations in responses due to the survey's anonymity, and management options may fluctuate widely in different locations. However, our goal was to generalize trends in preoperative decision-making, intraoperative techniques, and perioperative treatment of patients with pediatric traumatic cataract as a foundation to promote development of preferred practice pattern protocols within the United States.
As shown by the lack of consensus on most survey questions, there exists a role for standardized guidelines to optimize the surgical management of traumatic cataracts in pediatric patients. Although general agreement on the importance of visual rehabilitation therapy and refractive correction was apparent, our study emphasized the fact that little evidence exists for specific techniques to augment overall functional outcomes in cases associated with trauma. The pediatric ophthalmology community has frequently conducted multi-institutional trials to elucidate confirmatory data supporting protocols for management of certain conditions and could consider focusing on optimizing aspects of traumatic cataract cases. In particular, ideal timing for traumatic cataract extraction, IOL insertion (primary vs secondary), and initiation of amblyopia therapy must be better delineated through evidence-based protocols. These factors may continue to evolve as surgical instrumentation and technology improves, such as with new devices or techniques for IOL power calculation and secondary IOL insertion in challenging traumatic cases.
- Yardley AM, Ali A, Najm-Tehrani N, Mireskandari K. Refractive and visual outcomes after surgery for pediatric traumatic cataract. J Cataract Refract Surg. 2018;44(1):85–90. doi:10.1016/j.jcrs.2017.09.033 [CrossRef]
- Khokhar S, Gupta S, Yogi R, Gogia V, Agarwal T. Epidemiology and intermediate-term outcomes of open- and closed-globe injuries in traumatic childhood cataract. Eur J Ophthalmol. 2014;24(1):124–130. doi:10.5301/ejo.5000342 [CrossRef]
- Qiu H, Fischer NA, Patnaik JL, Jung JL, Singh JK, McCourt EA. Frequency of pediatric traumatic cataract and simultaneous retinal detachment. J AAPOS. 2018;22(6):429–432. doi:10.1016/j.jaapos.2018.08.006 [CrossRef]
- Shah MA, Shah SM, Gosai SR, et al. Comparative study of visual outcome between open- and closed-globe injuries following surgical treatment of traumatic cataract in children. Eur J Ophthalmol. 2018;28(4):406–411. doi:10.1177/1120672117747021 [CrossRef]
- Shah MA, Shah SM, Applewar A, Patel C, Patel K. Ocular Trauma Score as a predictor of final visual outcomes in traumatic cataract cases in pediatric patients. J Cataract Refract Surg. 2012;38(6):959–965. doi:10.1016/j.jcrs.2011.12.032 [CrossRef]
- Shah MA, Agrawal R, Teoh R, et al. Pediatric ocular trauma score as a prognostic tool in the management of pediatric traumatic cataracts. Graefes Arch Clin Exp Ophthalmol. 2017;255(5):1027–1036. doi:10.1007/s00417-017-3616-y [CrossRef]
- Read SP, Cavuoto KM. Traumatic open globe injury in young pediatric patients: characterization of a novel prognostic score. J AAPOS. 2016;20(2):141–144. doi:10.1016/j.jaapos.2015.11.008 [CrossRef]
- Puodžiuviene E, Jokubauskiene G, Vieversyte M, Asselineau K. A five-year retrospective study of the epidemiological characteristics and visual outcomes of pediatric ocular trauma. BMC Ophthalmol. 2018;18(1):10. doi:10.1186/s12886-018-0676-7 [CrossRef]
- Jinagal J, Gupta G, Gupta PC, et al. Visual outcomes of pediatric traumatic cataracts. Eur J Ophthalmol. 2019;29(1):23–27. doi:10.1177/1120672118757657 [CrossRef]
- Gogate P, Sahasrabudhe M, Shah M, Patil S, Kulkarni A. Causes, epidemiology, and long-term outcome of traumatic cataracts in children in rural India. Indian J Ophthalmol. 2012;60(5):481–486. doi:10.4103/0301-4738.100557 [CrossRef]
- Xu YN, Huang YS, Xie LX. Pediatric traumatic cataract and surgery outcomes in eastern China: a hospital-based study. Int J Ophthalmol. 2013;6(2):160–164.
- Kinori M, Tomkins-Netzer O, Wygnanski-Jaffe T, Ben-Zion I. Traumatic pediatric cataract in southern Ethiopia—results of 49 cases. J AAPOS. 2013;17(5):512–515. doi:10.1016/j.jaapos.2013.06.008 [CrossRef]
- Burgos-Elías VY, Marroquín-Sarti MJ, Zimmermann-Paiz MA, Marissa Ordoñez Rivas A, Quezada-Del Cid NC. Traumatic cataract surgery in pediatric patients. Experience in a site. Arch Argent Pediatr. 2018;116(3):216–219. doi:10.5546/aap.2018.eng.216 [CrossRef]
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- Koenig SB, Ruttum MS, Lewandowski MF, Schultz RO. Pseudophakia for traumatic cataracts in children. Ophthalmology. 1993;100(8):1218–1224. doi:10.1016/S0161-6420(93)31502-2 [CrossRef]
- Sen P, Shah C, Sen A, Jain E, Mohan A. Primary versus secondary intraocular lens implantation in traumatic cataract after open-globe injury in pediatric patients. J Cataract Refract Surg. 2018;44(12):1446–1453. doi:10.1016/j.jcrs.2018.07.061 [CrossRef]
- Kamlesh DS, Dadeya S. Management of paediatric traumatic cataract by epilenticular intraocular lens implantation: long-term visual results and postoperative complications. Eye (Lond). 2004;18(2):126–130. doi:10.1038/sj.eye.6700605 [CrossRef]
- Muga R, Maul E. The management of lens damage in perforating corneal lacerations. Br J Ophthalmol. 1978;62(11):784–787. doi:10.1136/bjo.62.11.784 [CrossRef]
- Hu YY, Wu JF, Lu TL, et al. Prevalence and associations of anisometropia in children. Invest Ophthalmol Vis Sci. 2016;57(3):979–988. doi:10.1167/iovs.15-18647 [CrossRef]
- Caca I, Sahin A, Ari S, Alakus F. Posterior chamber lens implantation with scleral fixation in children with traumatic cataract. J Pediatr Ophthalmol Strabismus. 2011;48(4):226–231. doi:10.3928/01913913-20100719-01 [CrossRef]
- Sminia ML, Odenthal MT, Wenniger-Prick LJ, Gortzak-Moorstein N, Völker-Dieben HJ. Traumatic pediatric cataract: a decade of follow-up after Artisan aphakia intraocular lens implantation. J AAPOS. 2007;11(6):555–558. doi:10.1016/j.jaapos.2007.06.015 [CrossRef]
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Management of Pediatric Traumatic Cataractsa
|Survey Questions||No. (%)|
|Demographics of Study Participants and Practice Populations|
| 1. What is your practice model?||56 (100.0%)|
| 2. If in private practice, what type?b||21 (37.5%)|
| 3. Do you take calls?||56 (100.0%)|
| 4. What is your on-call population?||54 (96.4%)|
| 5. Do you treat and manage traumatic cataracts?c||56 (100.0%)|
| 6. What are the primary sources for your cases?||56 (100.0%)|
| 7. Do you perform ruptured globe repair?||56 (100.0%)|
|Factors Affecting Timing of Cataract Surgery|
| 8. If cataract is present at the time of globe repair without obvious violation of the capsule, do you remove the lens at the time of primary globe repair?||54 (96.4%)|
| 9. If cataract is present at the time of globe repair with obvious violation of the capsule, do you remove the lens at the time of primary globe repair?||53 (94.6%)|
| 10. If cataract is present at the time of globe repair with concern for delayed presentation of globe trauma and/or dirty mechanism of injury, do you remove the lens at the time of primary globe repair?||52 (92.9%)|
| 11. How long do you wait to remove a visually significant cataract in a child within the||55 (98.2%)|
|amblyogenic age range?|
| 12. How long do you wait to remove a visually significant cataract in a child outside the amblyogenic age range?||55 (98.2%)|
|Preoperative Planning and Ancillary Testing|
| 13. Do you routinely obtain B-scan ultrasonography at time of initial evaluation?||56 (100.0%)|
| 14. Do you repeat B-scan ultrasonography prior to surgery?||56 (100.0%)|
| 15. If globe trauma includes corneal laceration, when do you remove sutures?||56 (100.0%)|
| 16. If globe trauma includes corneal laceration, what do you use for keratometry in IOL calculations?||56 (100.0%)|
| 17. Do you adjust your targeted refraction in traumatic cataracts compared to other pediatric cataracts?||56 (100.0%)|
| 18. When <180 degrees of zonular weakness is encountered, what approach do you take for IOL implantation?||56 (100.0%)|
| 19. When >180 degrees of zonular weakness is encountered, what approach do you take for IOL implantation?||56 (100.0%)|
| 20. Do you perform a primary posterior capsulotomy?||56 (100.0%)|
|Postoperative Management and Visual Rehabilitation|
| 21. Do you use intracameral antibiotics during cataract surgery?||56 (100.0%)|
| 22. Do you use intracameral steroids during cataract surgery?||56 (100.0%)|
| 23. Do you change your postoperative drop regimen for traumatic cataracts?||56 (100.0%)|
| 24. When do you initiate amblyopia therapy for children within the amblyogenic age range?||56 (100.0%)|