Learning Log

Learning Log

Part A

Presentation Decreased vision in both eyes for 6 months; Watery discharge from both eyes for 5 monthsMain diagnosis Age related cataract

History taken Yes

Patient examined Yes

Where seen (OPD/ER/ Specialty Ward): OPD When seen (insert date): 28th June, 2015Age: 72 years Gender: Female

History of Presenting Complaints and associated featuresPatient was apparently well six months ago. She then started to have decreased vision in both her eyes. Decrease in vision was gradual in onset, painless and progressive in nature. She has diminished vision in both far and near distance. She also has history of intermittent watery discharge from same eye which was gradual in onset, painless and was progressive; aggravated in bright light during day and relieved at night in low light. She denied history of coloured halos, flashes and floaters. She also denied history of double vision, redness, itching. She doesnt use glasses.

Past medical and surgical HistoryShe had visited eye hospital two years to cut her eye lashes that were disturbing her vision. Otherwise, she doesnt have diabetes mellitus, hypertension and other chronic systemic disease and ophthalmic problems.Drug and allergy historyShe hasnt been under any medication; no allergies known yet.Family HistoryNo history of similar illness in the family.

Personal history

She is non-smoker and non-alcoholic.Summary of history72 years female, non-smoker and non-alcoholic, presented with chief complaint of painless, gradual loss of vision of both eyes for six months associated with intermittent watery discharge.

Summary of examinationOn examination, she had symmetrical forehead crease. Eyebrows were normal and no swelling, redness in eyelids. Torch light examination of both the eyes showed no congestion in conjunctiva and no opacity and deposits in cornea. Iris was dark brown in colour with normal pattern. Pupils were round, regular and reactive to light. Anterior chamber depth was normal. Opacity was seen in the lens of right eye which was more pronounced than in left eye. Ocular motility test was normal. Her vision on right eye was 5/6 while left eye was 6/60 unaided. IOP was 13 and 14 on right and left eyes respectively. Her BP was 130/80 mmHg. Provisional diagnosisAge related cataractSummary of investigationsShe was sent for Biometry.Management including medications

No any medication was given. ManagementShe was advised for surgery for treatment of cataract- Phacoemulsification with Intraocular lens.Part B

What causes this condition (summarize the pathophysiology)?

Cataract is development of opacity in lens or its capsule. It can be congenital or acquired. Senile cataract is the commonest type of acquired cataract and usually occurs after 50 years of age. It is usually bilateral and affects both sexes. Senile cataract is aging process so age is the most important risk factors. Other factors like heredity, UV radiation exposure, diet deficient in certain proteins, amino acids, vitamins and essential elements, previous dehydration crises due to diarrhoea and cholera have role in incidence, age of onset and maturation of the disease. Besides, smoking is associated with increased frequency of disease.Morphologically, senile cataract is of two types-cortical where hydration and decrease synthesis of protein followed by denaturation of proteins occurs primarily in cortex and nuclear cataract where slow sclerosis occurs in nucleus of lens. As the cataract is a gradually progressing disease, maturation of cataract takes place in following stages:Maturation of cortical type of senile cataract: Stage of lamellar separation

Stage of incipient cataract

Immature senile cataract

Mature senile cataract

Hyper-mature senile cataract

Maturation of nuclear senile cataract:Nuclear sclerosis begins centrally and spreads slowly peripherally almost upto the capsule when it becomes mature. It typically blurs distant vision more than near vision.How may it be prevented?

Cataract cannot be prevented as it is a natural age-related process. But, following measures can reduce the risk of disease and slow down the progression: Avoiding radiation exposure

Wearing dark goggles

Smoking cessation

Having nutritious diet

Controlling diabetes

Commonly presenting features

Symptoms Intolerance of bright light (glare)

Uniocular polyopia

Coloured halos

Black spots in front of eyes

Blurring and distorting of image

Loss of visionSigns Visual acuity: decreased

Oblique illumination: colour of lens in pupillary area

Iris shadow: crescentric shadow of papillary margin of iris present in immature cataract Direct ophthalmoscope: black shadow against red glow or absence of red glow (if complete opacity)

Slit lamp examination: complete morphology of opacityNatural history/prognosis

When not treated in time, decrease in vision can ultimately result in complete loss of vision. Besides, it can cause following complications Phacoanaphylactic uveitis Phacolytic glaucoma due to leakage of proteins into anterior chamber from hypermature cataract

Subluxation or dislocation of lens (due to degeneration of zonules in hypermature cataractMost useful investigations

Diagnosis of senile cataract is basically based on thorough history and physical examinations. Some of the investigations are:

Visual acuity testing

Tonometry

Ocular imaging studies (USG, CT, MRI) if posterior pole pathology is suspected Preoperative screening for coexisting disease (DM, HTN, cardiac anomalies)

Evidence for treatment The only treatment for cataract is to surgically remove the opacified lens from the eye to restore transparency of the visual axis. Treatment of senile cataract consists of the following measures: Surgical management

Intracapsular cataract extraction

Extracapsular cataract extraction

Conventional extracapsular cataract extraction

Manual small incision cataract surgery

Phaecoemulsification

Laser phaecoemulsificationStudent reflection on patient/presentationFrom this case, I learned that senile cataract is one of the most common types of acquired cataract. It is one of the most important differential diagnoses of gradually progressive painless loss of vision. It is essentially an age related process and occurs usually after 50 years. I learned about its risk factors, pathogenesis, types, clinical features and its management options. The knowledge which I have learned following this case will help me in future when I come across similar problems. Cataract has been an important cause of decreased vision and thus proper history followed by a proper examination is crucial to diagnosis of cataract. After making the diagnosis of the condition, I would counsel the patient and refer him/her to the higher centre..