Cataract By Col Rana Intisarul Haq MCPS, FCPS (AFIO)

Cataract

By

Col Rana Intisarul Haq

MCPS, FCPS (AFIO)

Lens

The lens is a biconvex structure located directly behind the posterior chamber and pupil It is the lesser of the two refractive elements in the dioptric system The equatorial diameter in adult is about 9-10 mm The anteroposterior width of the lens is about 6 mm The lens has certain unusual features. It lacks innervation and is avascular.

Detail view of the anatomy of the eye

cataract

DefinitionAny congenital or acquired opacity in the

lens capsule or substance of the lens , irrespective of the effects on vision is called cataract.

Classification of Cataract

According to Age

According to Morphology

According to Etiology

According to maturity

Congenital and acquired

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Age Related Senile Cataract

Age related cataract is universal in persons over 70 years of age. Both sexes are involved equally.

There is considerable genetic influence.

Average age of onset of cataract is approximately 10 years earlier in tropical countries.

Age Related Cataracts senile

Presenile Cataracts

Diabetes Mellitus

Myotonic Dystrophy

Atopic Dermatitis

Neurofibromatosis-2

Traumatic Cataract

Direct Penetrating Injury

Concussion

Electric Shock & Lightening

Ionizing Radiation

Toxic Cataracts

Steroids

Chlorpromazine

Miotics

Busulphan

Amiodarone

Gold

Secondary Cataracts

Ch Ant Uveitis

Ac Congestive Glaucoma

High Myopia

Hereditary Fundus Dystrophy

According to Morphology

Posterior Subcapsular Cataract

Ant Subcapsualr Cataract

Nuclear Cataract

Cortical Cataract

Mature Cataract

This diagram illustrates the different morphological characteristics of cataract together with their depth and location within the lens. The following illustrations demonstrate clinical examples of these anatomical entities.

CATARACT

THE LENS

CLASSIFICATION ON BASIS OF MATURITY

IMMATURE CATARACT

MATURE

HYPERMATURE

MORGAGNIAN

Causes

Hereditary

Age

DM

Steroids

UV Rays

Poor Nutrition

Smoking

Epidemiology

Cataract surgery is the most commonly performed surgery in elderly patient

Any Age

Two peaks

<10 Years

>65 Years

Pathology

Depends on type of Cataract

Early Changes – tiny areas of liquefaction called morgagnian degeneration seen as cortical spokes

Progress to involve entire cortex

Later on homogeneous appearance

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Etiopathogenesis of Cataract

Caused by degeneration and opacification of existing lens fibres, formation of aberrant fibres or deposition of other material in their place.Loss of transparency occurs because of abnormalities of lens protein and consequent disorganization of the lens fibres

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Any factor that disturbs the critical intra and extra cellular equilibrium of water and electrolytes or deranges the colloid system within the fibres causing opacification.

Fibrous metaplasia of lens fibres occurs in complicated cataract.

Epithelial cell necrosis occurring in angle closure glaucoma leads to focal opacification of the lens epithelium (Glaucomflecken)

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Abnormal products of metabolism, drugs or metals can be deposited in storage diseases (Febry), metabolic diseases (Wilson) and toxic reactions (Siderosis)

Nuclear Cataract

Mature Cataract

Hypermature Cataract

Traumatic Cataract(Penetrating Trauma)

Vossius Ring

PSC in Atopic Dermatitis

Congenital Cataract

Stellate PSC in Myotonic Dystrophy

Shield Anterior Subcapsular Cataract

(Atopic Dermatitis)

PSC in Atopic Dermatitis

Progression of Steroid-induced Cataract

Anterior Subcapsular Opacities (Ch Ant Uveitis)

Adv Cataract & Posterior Synechiae

(Ch Ant Uveitis)

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Symptoms of Cataract

1. Blurring of vision2. Frequent change of glasses due to rapid

change in refractive index of the lens 3. Painless, progressive, gradual diminution

of vision due to reduction in transparency of the lens

4. Second sight or myopic shift in case of nuclear cataract causing index myopia, improving near vision.

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5. Loss or marked diminution of vision in bright sunlight or bright light beam in central posterior sub-capsular cataract.

6. Monocular diplopia or polyopia in presence of cortical spoke opacities

7. Glare in posterior sub-capsular cortical cataract due to increased scattering of light

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8. Colored haloes around the light as seen in cortical cataract due to irregular refractive index in different parts of the lens.

9. Color shift , reds are accentuated

10. Visual field loss, generalized reduction in sensitivity due to loss of transparency

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Signs of senile cataract

Positive findings

1. Diminution of vision

2. Anterior chamber is shallow in cases of intumescent cataract and deep in cases of hypermature (shrunken) cataract

3. Tremulousness of iris in cases of hypermature shrunken cataract

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4. Lenticular opacity , grey or white opacity in lens. Iris shadow in immature cataract. No iris shadow in mature cataract

5. Morgagnian Cataract- is characterized by liquefied cortex, which is milky and nucleus is seen as brown mass, seen as semicircular line, altering its position with change in position of head

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6. Distant direct ophthalmoscopy will reveal black shadow against red background in cases of immature cataract.

Thank you

Management of Cataract

HISTORYAge of Onset

Decreased Vision Painless, effecting daily routine? If the patient is bothered

about his decreased vision. Trauma

Any Ophthalmological Problems

Drugs Intake

Exposure to Radiations

Systemic Diseases Skin disease, joint pains, etc.

Family History

Examination GPE

SYSTEMIC EXAMINATION

OCULAR EXAMINATIONVISUAL ACUITYADNEXACORNEAANTERIOR CHAMBERPUPILVITROUSRETINA

Investigations

Blood Glucose

ECG

Chest x-rays (PA view)

Blood Complete Picture

Any specific relevant investigation (if indicated)

Indication for Surgery

Visual Improvement When the patient is bothered.

Medical IndicationsWhen cataract is adversely affecting the

health of the eye e.g.:Phacolytic Glaucoma Intumescent CataractDiabetic Retinopathy

Cosmetic IndicationsTo restore black pupil

Optimal Post Op Refraction

If monocular correction is reqd. e.g.

in contralateral dense or amblyopia

best post op refraction is -1DS.

If binocular correction is reqd

difference between the two eyes should not be more than 3DS.

SURGICAL TECHNIQUES

ICCE

ECCE

ECCE with posterior chamber IOL implant

Phacoemulcification

ECCE

IOL Implantation

Phacoemulcification

Operative Complications Complications of Local AnaesthesiaRetrobulbar HemorrhagePerforation of the globe, optic nerve

or sheath

Operative Complications:Bridle Suture Perforation of the globeStripping of Descemet’s MembraneDamage to ciliary body

Operative Complications(Contd)

Rupture of the Posterior CapsuleCapsular Rupture without Vitreous Loss

Small TearLarge Tear or Zonular Tear

Capsular Rupture with Vitreous Lossvitrectomy

Posterior Loss of Lens FragmentsSmall FragmentsLarge Fragments

Nuclear Material in Vitreous


Suprachoroidal HemorrhageSource

long or short ciliary arteryContributing Factors

sudden in IOPcoughing Valsalva ManoeuvreVitreous LossSudden rise in B.P.Retrobulbar anaesthetic without adrenaline


Suprachoroidal Hemorrhage(Contd)Presentation

after lens delivery, progressive shallowing of anterior chamber, increased IOP & iris prolapse, vitreous extrusion, loss of red reflex. In severe cases all intraocular contents may be extruded

Immediate TreatmentClosure of the IncisionAdministration of Hyperosmotic Agent


Suprachoroidal Hemorrhage(Contd)Subsequent Treatment

Topical & Systemic SteroidsBetween 7 & 14 Day drainage of the blood,

pars plana vitrectomy & air-fluid exchange

Early Post-Operative Complications

Iris Prolapse Cause - inadequate

suturing Complications -

defective wound healing, ch ant uveitis, epithelial ingrowth, cystoid macular edema, excessive astigmatism.

Treatment


Striate KeratopathyCause - damage to

corneal endothelium

Hyphema


Acute Bacterial EndophthalmitisPathogenesis

Causative Organisms Staph Epidermidis, Staph Aureus, Pseudomonas sp etc

Source of InfectionPrevention

Treatment of local infections of the Patients Preoperative instillation of Povidine-iodine Meticulous draping Technique Postoperative injection

Draping of Eyes


Acute Bacterial Endophthalmitis(contd)Clinical Features

severityTime Interval

Staph Aureus - 1st to 3rd day Staph Epidermidis - 4rth to 10th day

Differential Diagnosis Retained Lens Matter Toxic Reaction Difficult or Prolonged surgery

Fibrinous Exudation in Severe Acute Endophthalmitis

Small Hypopyon

Acute Bacterial Endophthalmitis(contd)Clinical Features

Differential Diagnosis Retained Lens Matter Toxic Reaction Difficult or Prolonged surgery


Acute Bacterial Endophthalmitis(contd) Management

Identification of causative organism aqueous samples vitreous samples

Antibiotics Vitrectomy Steroids Subsequent therapy

Late Post-Operative Complications

Opacification of the Posterior Capsule Types

Elschnig’s Pearls Capsular Fibrosis

Indications for Treatment Visual Acuity Impaired Visualization of Fundus Monocular Diplopia or severe glare

Nd:YAG Laser Capsulotomy Complications

Elschnig Pearls

Fibrosis of Posterior Capsule

Technique of Nd:YAG Laser capsulotomy


Malposition of IOL Tilting Decentration Treatment

Corneal Decompensation Causes Treatment


Retinal Detachment Risk Factors

Disruption of Posterior Capsule

Vitreous Loss Lattice Degeneration

Sunset Syndrome Cause Traetment


Chronic Endophthalmitis Causative Organism

Propionibacterium Acnes Staph Epidermidis

Clinical Features Treatment Strategy

steroids & antibiotics Removal of IOL,

remaining cortex

& entire capsular bag

Documents

Cataract By Col Rana Intisarul Haq MCPS, FCPS (AFIO)