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Secondary and traumatic cataract

TL;DR — "Secondary" cataract here means lens opacity with an identifiable cause other than ageing: trauma, intraocular inflammation, prior intraocular surgery, drugs, radiation and inherited retinal disease. These eyes behave differently at every step. In non-infectious anterior uveitis, cataract developed at 54 per 1,000 eye-years (95% CI 49–59) across 3,923 eyes, with posterior synechiae (aHR 3.71, 2.83–4.87) and IOP ≥30 mmHg (aHR 2.57, 1.38–4.77) the strongest predictors (Papaliodis 2023, PMID 37414328); in intermediate uveitis cumulative incidence reached 36.6% (31.2–41.6) by 10 years (Minkus 2021, PMID 33713679). Eyes with prior vitrectomy make up 1.1% of European registry cataract surgery, and achieve a corrected acuity of 0.5 or better in 82.8% versus 95.6% of other eyes (Lundström 2020, PMID 32649433). Twelve or more unilateral anti-VEGF injections raised the 10-year cumulative incidence of cataract surgery from 7.2% in fellow eyes to 40.7% in injected eyes (HR 8.17, 5.77–11.59) (Choi 2026, PMID 41825596). Traumatic cataract is a children's disease in much of the world: 636 of 1,656 children with cataract in a ten-centre Nigerian series (38.4%) had traumatic cataract, only 15.3% presenting within four weeks (Ademola-Popoola 2024, PMID 37749376). The unifying practical point is that the lens is rarely the only injured structure, so the prognosis belongs to the eye, not to the cataract.

Traumatic cataract

Mechanism determines both morphology and the rest of the surgical problem. Blunt (closed-globe) injury produces contusion rosette opacities, zonular dehiscence and lens subluxation; penetrating injury violates the capsule and often admits an intraocular foreign body.

Finding Value Population Source
Share of childhood cataract that is traumatic 636/1,656 (38.4%) 10 Nigerian tertiary child-eye centres, 2017–2021 PMID 37749376
Sex ratio 2:1 male:female same PMID 37749376
Presentation within 4 weeks of injury 15.3% same PMID 37749376
Closed-globe mechanism 475/636 (74.7%); open-globe injuries more likely to present within 24 h (P < 0.001) same PMID 37749376
Injury location home 59.8%, school 16.8%; self-inflicted 13%, caused by close relatives/contacts 64.0% same PMID 37749376
Traumatic cataract among combat ocular injuries 26% of all eye injuries; 181 eyes of 167 service members Walter Reed, 7-year retrospective Smith 2015, PMID 26432127
Combat traumatic cataract visual outcome Final acuity 0.86 ± 1.01 logMAR (44 NLP, 26 LP eyes) from initial 2.41 ± 0.88 logMAR (P ≤ .001); Ocular Trauma Score reliably predicted outcome same PMID 26432127
Primary lensectomy during open-globe repair 19/107 (17.8%); performed later after injury (6.1 ± 14.6 vs 1.3 ± 1.9 days, P = 0.010), with shorter wounds (2.3 ± 1.4 vs 4.7 ± 3.2 mm, P = 0.003), more capsule violation (89.5% vs 50%, P = 0.010) and more intraocular foreign bodies (52.6% vs 17.0%, P = 0.004) Wills Eye, zone I–II open-globe injuries with lens involvement, 2017–2022 Shoshany 2024, PMID 38801873

Two lessons recur. First, delay is the norm outside high-income settings and is itself prognostic, because amblyopia in a child and corneal/retinal sequelae in an adult accrue while the eye waits (PMID 37749376). Second, primary lensectomy at the time of globe repair is not a neutral decision — the eyes selected for it differ systematically from those left alone, so single-arm outcome comparisons are confounded by indication (PMID 38801873).

Severely subluxated traumatic cataracts require capsular support strategies rather than routine phacoemulsification, and the management literature is a case-series literature rather than a trial literature (Chee 2011, PMID 21310378). See surgical technique.

Uveitic cataract

Cataract in uveitis is caused by both the inflammation and its treatment, which is why the risk-factor structure is informative.

Uveitis type Incidence / cumulative risk Predictors (adjusted HR, 95% CI) Source
Non-infectious anterior uveitis (3,923 eyes, 2,567 patients, 6 US centres 1978–2010) 507 eyes developed cataract; 54 per 1,000 eye-years (49–59) Age ≥65 vs <18: 5.04 (3.04–8.33); higher anterior chamber cell grade (P trend = 0.001); prior incisional glaucoma surgery 1.86 (1.10–3.14); band keratopathy 2.23 (1.47–3.37); posterior synechiae 3.71 (2.83–4.87); IOP ≥30 vs 6–20 mmHg 2.57 (1.38–4.77). Primary acute (0.59, 0.30–1.15) and recurrent acute (0.74, 0.55–0.98) uveitis carried lower risk than chronic anterior uveitis Papaliodis 2023, PMID 37414328
Intermediate uveitis (2,190 eyes, 1,302 patients) 7.6% (6.2–9.1) at 1 year, rising to 36.6% (31.2–41.6) by 10 years Concurrent anterior uveitis with posterior synechiae HR 2.68 (2.00–3.59, P < .001); epiretinal membrane also associated Minkus 2021, PMID 33713679
Fuchs uveitis Cataract is part of the defining triad (heterochromia, cataract, glaucoma); diagnosis often delayed; corticosteroids are only moderately effective and carry cataract and glaucoma risk — Daas 2017, PMID 28424877; Jones 1996, PMID 8656395
Juvenile idiopathic arthritis-related uveitis Topical corticosteroid exposure is the specific paediatric concern — Kramer 2020, PMID 32200820

Surgical timing is governed by inflammation, not by the lens. Consensus practice from the review literature is at least three months of quiescence before surgery, with perioperative corticosteroid prophylaxis to reduce cystoid macular oedema and recurrence, antimicrobial prophylaxis in infectious uveitis, and management of synechiae, membranes and pupil abnormalities that limit access (Chan 2017, PMID 29208813). Outcomes depend on educated patient selection, meticulous technique and aggressive pre- and postoperative inflammation control (Jancevski 2010, PMID 19829114; Mehta 2015, PMID 26035765; Lobo 2010, PMID 20057302). Paediatric uveitic cataract carries its own literature and its own tolerance for primary IOL implantation (Bodaghi 2008, PMID 18645408; Roesel 2008, PMID 18675697).

Cataract after intraocular procedures

Vitrectomy. Post-vitrectomy cataract is common enough that it is treated as an expected consequence rather than a complication. In EUREQUO, previous vitrectomy was recorded in 19,416 of 1,715,348 cataract extractions (1.1%), a stable proportion over 2008–2018. Those patients were younger (mean 64.1 vs 73.7 years) with worse preoperative corrected acuity (0.45 vs 0.25), and after surgery achieved 0.5 or better in 82.8% versus 95.6% of non-vitrectomised eyes, with mean absolute biometry prediction error 0.52 D versus 0.43 D (PMID 32649433). Vitrectomised eyes also carry higher rates of posterior capsule opacification and retinal detachment, and optical biometry — though better than ultrasound in these eyes — still performs worse than in non-vitrectomised eyes (Shousha 2010, PMID 19855278). Prior vitrectomy was an independent risk factor for early PCO (OR 2.664, P = 0.003) (Gu 2022, PMID 34727350) and for dropped nucleus in EUREQUO (Lundström 2020, PMID 32126043). Presbyopia-correcting IOLs are generally not recommended in these eyes (PMID 19855278). Formula selection is covered in IOL power calculation.

Intravitreal injections. In 603 patients receiving ≥12 unilateral anti-VEGF injections and followed a median of 74 months, the 10-year cumulative incidence of cataract surgery was 40.7% (95% CI 35.9–45.1) in injected eyes versus 7.2% (4.1–10.3) in fellow eyes (HR 8.17, 5.77–11.59); all opacity grades were higher in injected eyes at the time of surgery, with the largest difference in posterior subcapsular opacity (PMID 41825596). Prior injections also complicate the subsequent operation: in 203,643 Medicare beneficiaries, a history of intravitreal injection raised the risk of retained lens fragment removal within 28 days (HR 2.26, 1.19–4.30) and of acute endophthalmitis (HR 2.29) (Hahn 2016, PMID 26278863).

Glaucoma and other intraocular surgery. Prior incisional glaucoma surgery was an independent predictor of cataract in the anterior uveitis cohort (aHR 1.86, 1.10–3.14) (PMID 37414328), and cataract progression is a recognised consequence of trabeculectomy — one reason that combined or sequenced surgery is debated in surgery with coexisting eye disease.

Drug-induced cataract

Corticosteroids are the archetype, producing posterior subcapsular opacity with a route- and duration-dependent gradient: oral use >5 years RR 3.25 (95% CI 1.39–7.58); parenteral 1.56 (1.34–1.82); inhaled 1.58 (1.46–1.71); nasal 1.33 (1.21–1.45); ear drops 1.31 (1.19–1.45); skin 1.43 (1.36–1.50) (Prokofyeva 2013, PMID 22715900). The mechanism and clinical picture are reviewed in (Kačmař 2019, PMID 31238690) and (Jian 2025, PMID 41080769); post-transplant patients on long-term immunosuppression are a high-incidence group (Albert 2011, PMID 22099821). Chlorpromazine at ≥300 mg for ≥90 days carried RR 8.8 (3.1–25.1) (PMID 22715900).

Pharmacovigilance broadens the list without quantifying absolute risk: 24 drugs showed disproportional cataract signals in 54,800 FAERS reports, led by difluprednate (BCPNN 7.83, median onset 74 days), prednisolone (6.84, 141 days) and erdafitinib (5.44), with glucocorticoids, insulin analogues, nitisinone and ranibizumab prominent (Hong 2025, PMID 40707607). Signals for insulin and ranibizumab are almost certainly confounding by indication — diabetes and retinal disease themselves cause cataract.

Radiation cataract

Ionising radiation causes posterior subcapsular opacity and is the one exposure with a formal regulatory dose framework. The ICRP's 2012 tissue-reactions report assumed that radiation-related minor opacities progress to vision-impairing cataract, that protracted exposure carries the same risk per unit dose as acute exposure, and that a threshold exists near 0.5 Gy. A review of the epidemiological basis found only limited support for the progression assumption, no compelling evidence of reduced effect at low dose rates (data compatible with a dose-rate effectiveness factor of unity, though with wide uncertainty), and most data suggesting a threshold somewhere between several hundred mGy and 1 Gy; studies of low-dose medical and occupational exposure show little or no excess below 100 mGy, while interventional cardiology personnel with substantial lens doses show elevated opacity risk (Shore 2016, PMID 27919333). Occupational reviews place ionising radiation in the "suggestive" rather than "strong" evidence tier for age-related cataract generally, with UV in the strong tier (Iwundu 2024, PMID 39850981). Radiation therapy to the head is listed among established cataract risk factors in clinical reviews (Chen 2025, PMID 40227658).

Cataract in inherited retinal disease

Posterior subcapsular cataract is near-universal in retinitis pigmentosa, plausibly driven by chronic inflammation (Hong 2020, PMID 33489339). Surgery is worthwhile but the eyes are fragile: in 80 eyes of 47 RP patients operated at a mean age of 48.9 years, PSC was present in 97.5%, mean corrected acuity improved from 20/340 to 20/129 within three months (P < .0001), and among eyes starting at 20/40–20/200 acuity improved from 20/81 to 20/43 (P < .0001) — but posterior capsule opacification occurred in 66 eyes (82.5%) with Nd:YAG capsulotomy in 42 (52.5%) at a mean of 10.8 months, and zonular insufficiency was found in 18.8% (Dikopf 2013, PMID 23628349). Reported complication excess also includes intraoperative phototoxic retinal damage, capsular contraction syndrome, pseudophakic cystoid macular oedema, IOP rise and IOL dislocation (PMID 33489339).

Why these eyes need separate evidence

  • The lens is not the only damaged structure. Final acuity in traumatic cataract tracks the Ocular Trauma Score, not the cataract (PMID 26432127).
  • Zonular and capsular integrity is compromised. Trauma, pseudoexfoliation, RP and uveitis all present with zonular weakness — 18.8% in the RP series (PMID 23628349) — which changes technique, IOL choice and the risk of late dislocation (Pueringer 2011, PMID 21683329).
  • Biometry is less accurate. Prediction error is worse after vitrectomy (0.52 vs 0.43 D) (PMID 32649433) and in eyes with irregular corneas.
  • Complication rates are systematically higher. PCO, macular oedema, IOP spikes and dislocation all rise (PMID 33489339; PMID 34727350).
  • Registry "good outcome" benchmarks do not apply. The 95.6% ≥0.5 corrected acuity benchmark in EUREQUO is a benchmark for uncomplicated adult eyes (PMID 32649433).

Open questions

  • When should the lens be removed during open-globe repair? Primary lensectomy is performed in a minority of eyes that differ systematically from those left alone (PMID 38801873); no randomised or prospective matched comparison of primary versus deferred lensectomy with visual and retinal-detachment endpoints exists in this evidence set.
  • Does earlier presentation change outcomes in childhood traumatic cataract? Only 15.3% of Nigerian children presented within four weeks (PMID 37749376), yet no study has quantified the acuity loss attributable to each additional week of delay, which is the number a public-health intervention would need.
  • Does anti-VEGF injection cause cataract or reveal it? The fellow-eye design gives a strong internal control (HR 8.17) (PMID 41825596), but injection number, underlying disease severity and steroid co-exposure are collinear, and no dose–response analysis separating injection count from disease duration has been published here.
  • What inflammation-free interval is actually required before uveitic cataract surgery? Three months of quiescence is the conventional recommendation (PMID 29208813) but rests on expert synthesis rather than a comparative study of different intervals.
  • Is the ICRP lens-dose threshold correct? Available data suggest a threshold between several hundred mGy and 1 Gy, with progression of minor opacities to vision-impairing cataract only weakly supported and further longitudinal data explicitly called for (PMID 27919333).

References

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