JICC-286; No.

of Pages 3

journal of indian college of cardiology xxx (2015) xxx–xxx

Available online at www.sciencedirect.com

ScienceDirect

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Short Communication

Radiation-associated cataracts among

interventional physicians and support staff

Gerald R. Schultz *
Associate Clinical Professor, Loma Linda University School of Medicine, United States

article info abstract

Article history: The lens is especially sensitive to ionization from radiation which alters the protein in its
Received 31 August 2015 organized collagen fibers, making them opaque. Professional and ancillary personnel are at
Accepted 26 October 2015 risk for developing radiation-induced cataracts since the radiation can have an accumula-
Available online xxx tive effect. Appropriate detection devices, protective clothing, and shields in the exam area
as well as safe techniquest can reduce, if not eliminate this danger.
Keywords: # 2015 Indian College of Cardiology. Published by Elsevier B.V. All rights reserved.
Cataract
Lens
Ionizing radiation

1. Introduction 2. Dosages of radiation

Interventional cardiologists and their staff are in particular
danger of developing radiation-induced cataracts because
their work necessitates their being close to the patient during
catheterizations. Threshold values for visually significant
cataracts have been established by the International Commis-
sion of Radiological Protection (ICRP)1 and by the U.S. National
Council on Radiation Protection and Measurements (NCRP),2
and are constantly being revised as new data are accumulated.
Variability in the minimum radiation dosage that causes
cataracts is also based upon age, illnesses, medications, use of
protective apparatus, and an otherwise normal individual's
propensity to normally develop cataracts in the absence of
radiation exposure. Studies performed have been based on an
individual's perception of visual disability and the presence of
even the smallest opacity detected by trained professionals
using the biomicroscope, aka slit lamp.
Dose measurements are generally measured through the use
of individual dosimeters. These devices may have limited
value based upon the individuals' compliance in wearing
them, and how they are worn, whether they are in a
radiation exposed area or behind a protective lead apron.
The units of measurements are in Grays and Sieverts. A Gray
(Gy) is a unit of absorbed ionizing radiation, based on one
joule/kilogram of irradiated tissue of an exposed individual.
A Sievert (Sv) is a unit of ionizing radiation to which an
individual is exposed, weighted for the quality of radiation
and an individual's tissue response. Sieverts are subdivided
into equivalent dose and effective dose (ED). An equivalent
dose is the absorbed dose averaged over a tissue and
weighted for the quality of the radiation. The ED is the
sum of all the equivalent doses weighted for their effect on
the body's tissue.

* Tel.: +1 7603429991; fax: +1 7603427958.

E-mail address: GeraldSchultzmd@aol.com
http://dx.doi.org/10.1016/j.jicc.2015.10.016
1561-8811/# 2015 Indian College of Cardiology. Published by Elsevier B.V. All rights reserved.

Please cite this article in press as: Schultz G.R. Radiation-associated cataracts among interventional physicians and support staff, J Indian
Coll Cardiol. (2016), http://dx.doi.org/10.1016/j.jicc.2015.10.016
JICC-286; No. of Pages 3
2 journal of indian college of cardiology xxx (2015) xxx–xxx
For the human lens, the ICRP now recommends a
maximum equivalent dose limit of 20 milli-Sieverts (mSv)
per year, averaged over 5 years, with no single year exceeding
50 mSv. This is a considerable reduction from the previous
limit of 150 mSv for the equivalent dose.
3. Cataract development
Individuals at risk are interventional cardiologists and radi-
ologists and their support personnel. Also at risk are surgeons
and their support personnel who use fluoroscopy in operating
rooms who use fluoroscopy. They can be within a high-scatter
X-ray field for several hours a day during procedures.
The incidence and types of lens opacities in cardio-vascular
lab personnel vary, based upon the usage of X-ray fluoroscopic
guidance in angioplasty, the individual's medical and ocular
history, the age of the individual and years of exposure, the
types of exam equipment, the protective equipment used, and
the types of procedures being performed.
Various studies have been performed to track the incidence
of lens opacities in cardio-vascular lab personnel. A study at
Columbia University headed by Kleiman3 involved 42 cardiol-
ogists (mean age 46.7), 18 of whom (43%) had dots and vacuoles
on the back surface of the lens cortex adjacent to the posterior
capsule characteristic of nascent posterior subcapsular (PSC)
cataracts. The authors found that the frequency and severity
of the posterior lens changes increased with age and years in
practice. The rate of progression of such radiation associated
lens changes was assumed to be slow. The authors also
documented the incidence in cardiology suite nurses and
technicians (mean age 32.2). Of the 34 studied, 3 (9%) had early
onset cataracts. For a control group, 42 unexposed non-
medical professionals (mean age 40.5 years) were studied. Of
this group, 4 (10%) had the cortical dots and vacuoles, the same
incidence as cardiology suite personnel, but one-quarter the
incidence of the physicians in the same age group. The support
personnel also had one-quarter of the incidence as the
physicians probably because they work further away from
the patient and the radiation emitter, and since their age
cohort is 15 years less than the doctors, their cumulative dose
exposure is less.
Another study by the same group found that the cumula-
tive median values of lens doses in cardiologists was 6.0 Sv and
that of nurses and technicians to be 1.5 Sv, or one-fourth less.
The same study determined the threshold values for visually
disabling cataracts after a single brief exposure to be 2–10 Sv
and after protracted exposure to be about 8 Sv.4
4. Radiation exposure
Non-compliance in wearing the dosimeter radiation badges is
from 20%5,6 to 67% as determined in surveys during various
radiation protection training courses in which cardiologists
from countries around the world participated.
Exposure to radiation varies, dependent upon the patient
being examined and the equipment and the workload in the
examination facility, as well as the experience and skill of
the professional staff. Patient-related factors include the
Please cite this article in press as: Schultz G.R. Radiation-associated cataracts among interventional physicians and support staff, J Indian
Coll Cardiol. (2016), http://dx.doi.org/10.1016/j.jicc.2015.10.016
complexity of the clinical problem which translated into
fluoroscopy time and the number images made, and the size of
the patient. Equipment-related factors include the position of
the X-ray tube, whether it is over or under the table, the use
of biplane systems, the setting of doses in the machine, the
distribution of scatter radiation, and the use of personal
protective devices for the staff.
5. Pathogenesis of cataract development
In the pathogenesis of radiation-induced cataracts, ionizing
radiation is generally, but not exclusively, associated with
posterior sub-capsular, and sometimes, cortical opacities. The
damage starts at the anterior surface, where dividing cells
normally form a clear crystalline protein fiber that migrates
toward the posterior pole of the lens in the PSC region. This
differentiation is altered by exposure to ionizing radiation. The
fiber cells elongate and align with each other prematurely,
causing the lens to lose its transparency. Specifically, the
communication between the transmembrane cell adhesion
molecules and the remodeling proteases, such as metallopro-
teinases and their tissue inhibitors, is damaged, causing the
abnormal growth and differentiation of the lens fibers.7–11 On a
molecular level, the cyclin-dependent kinase inhibitor
(CDKN1A) gene, which regulates the cell cycles and DNA
synthesis, is particularly vulnerable to radiation.7
Descriptions of the level of radiation-induced cataract
formation are generally based on the Merriam–Focht grading
system.12 Stage 1+ is the lowest level usually seen in radiation-
exposed individuals. It is a discrete PCS or cortical opacity of
aggregates of dots, or vacuoles. Stage 2+ has more extensive
PSC opacities. Stage 3+ has a denser PSC opacity that blocks
the path of light. Stage 4+ involves the anterior cortical fibers,
with some areas of transparency. Stage 5+ is a totally opacified
pearly white lens.
6. Prevention
Prevention of damage from radiation has been proposed by the
ICRP and the U.S. NCRP. The occupational dose limit for eye
exposure has been set at 150 mSv/year.1,2 To achieve this goal,
equipment and facility modifications, as well as positioning of
personnel, have been recommended. These include ceiling
suspended lead screens that can reduce the dose rate by a
factor of 5 to 25 and the wearing of leaded glass eyewear which
can reduce the rate by a factor of 5 to 10. Further reduction can
be achieved by positioning the X-ray tube below the table as far
away from the patient as possible and position personnel
as far away as clinically possible from the X-ray tube and
patient. The X-ray equipment should always be in optimum
operating condition, fluoroscopy should be pulsed, and the
usage minimized.13
7. Conclusion
Exposure to low doses of ionizing radiation can have a
cumulative effect that may result in visually disabling
JICC-286; No. of Pages 3

journal of indian college of cardiology xxx (2015) xxx–xxx 3

cataracts. Interventional cardiologists as well as other profes-
sional personnel who work close to patients on a frequent
basis for extended periods of time are four times more likely to
develop cataracts than non-professionals in the same age
cohort. Adherence to appropriate safety protocols, which
include wearing the dosimeter badges and protective lead
glasses, working behind a lead curtain, and reducing exposure
time, will reduce the risk of cataract formation.
Conflicts of interest
The author has none to declare.
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Please cite this article in press as: Schultz G.R. Radiation-associated cataracts among interventional physicians and support staff, J Indian
Coll Cardiol. (2016), http://dx.doi.org/10.1016/j.jicc.2015.10.016