Management of adult cataract II.ppt

Management of Adult Cataract

Prof. Naimatullah Khan KundiHead, Department of Ophthalmology

Khyber Teaching HospitalPeshawar

Cataract Surgery

Types:

1. ICCE

1. ECCE

Standard (Manual Nuclear Expression)

Phacoemulsification (Ultrasonic Nuclear

Fragmentation)

Management of Adult Cataract

Cataract Surgery

Intra Capsular Cataract Extraction (ICCE)

Definition:

Removal of cataractous lens in its

entirety from the eye

Complete removal of the lens and its

capsule

Cataract Surgery

Extra Capsular Cataract Extraction (ECCE)

Definition:

ECCE involves removal of the nucleus and

cortex through an opening in the anterior

capsule, leaving the posterior capsule in

place

Cataract Surgery

ICCE ICCE evolved into a very successful operation

Preferred surgical technique before the

refinement of modern ECCE surgery

However there remained 5% rate of

potentially blinding complications including: Infection Hemorrhage RD CME

Cataract Surgery

ECCE has replaced ICCE, almost entirely in

most parts of the world:

1. Better operating microscopes

2. More sophisticated surgical aspiration

systems

3. More sophisticated IOL implants

Pre-operative evaluation and information

General health

Drug History

Ocular and social histories

Ocular examination

Measurement of visual function

Preoperative measurement


General health

A complete medical history starting point

Ophthalmic surgeon should work with

patient’s primary care physician to achieve

optimal management of all medical problems

like: DM IHD COPD Bleeding Disorders Adrenal Suppression by Corticosteroids


Awareness of any Drug sensitivities and

medications:

Immunosuppressants

Anticoagulants:

These may alter the outcome of surgery


Ocular history Helps ophthalmologist identify conditions

that could affect: Surgical Approach Visual Prognosis

Hx of: Trauma Inflammation Amblyopia can affect visual

prognosis Glaucoma Optic nerve Retinal disease

Past record may show patient’s visual acuity prior to development of cataract


Ocular history (cont’d)

Information about the postoperative course

in fellow eye

Any problem in the first operation: IOP Vitreous loss CME Endophthalmitis Hemorrhage

The surgical approach & post operative follow-up can be modified for the 2nd operation to risk of similar complications


Social History

Important for documenting patient’s

subjective visual disability

Surgeons should be aware of patient’s

occupation and life style

External examination (pre-op Evaluation)

Body habits: Bull Neck, Kyphosis, Obesity, Head Tremor

These have effect on surgical approach

Enophthalmos, prominent brow

Entropion, Ectropion & other lid abnormalities

noted and treated

Blepharitis: Diagnosed and treated

Abnormal tear dynamics, exposure keratitis

corneal sensation noted


Motility:

Ocular alignment evaluated

EOM tested for their range of movements

Cover testing (muscle balance):

Any abnormality might suggest pre-existing

strabismus with amblyopia as cause of visual

loss

Tropia: may result in diplopia following

surgery


Pupil

Pupillary responses to light and

accommodation evaluated

Direct & consensual constriction of pupil

Swinging-flashlight Test:

To detect RAPD (Indicative of serious

retinal / optic nerve dysfunction)


Biomicroscopic examination

Conjunctiva Scarring / lack of mobility over sclera

Symblepharon / shortening of fornices (underlying systemic/ocular surface disease): Can limit surgical approach

Loss of vascularization (Previous chemical injury / scarring from ocular surgery): Change in surgical approach



Conrnea

Corneal thickness, presence of Guttata

and marked abnormalities of

endothelium

Specular reflection and SL examination

provide estimate of endothelial cell count

and morphology



Conrnea (cont’d)

Thickness> 600 µm suggest poor

prognosis for corneal clarity following

cataract surgery. Surgery tailored to

minimize trauma to corneal endothelium

Cornea inspected for corneal arcus /

stromal opacities (may limit view during

surgery)


Biomicroscopic examination Anterior Chamber

Shallow AC: Intumescent lens Forward displacement by posterior

pathology (e.g. CB Tumor)

AC depth observation and lens nucleus size:

Help surgeon plan and choose between expression / phacoemulsification

Preoperative gonioscopy (esp. when AC-IOL is anticipated)

PAS Neovascularization Prominent major arterial circle

External examination (pre-op Evaluation) Biomicroscopic examination

Iris Pupil size after dilation noted (important

for planning surgical technique) Presence of PS noted Poor pupillary dilation: the following

measures may provide adequate exposure

1. Radial iridotomy2. Sector iridectomy3. Posterior synechiolysis4. Sphincterotomy5. Iris retraction



Lens

Lens appearance noted before and after dilation

of pupil

Visual significance of “oil droplet” nuclear

cataracts and small PSCs best appreciated before

dilation of pupil

Exfoliation syndrome best seen following dilation

Nuclear size and brunescence evaluated for

phacoemulcification (after dilation)



Lens (cont’d)

Medial clarity in visual axis evaluated to assess lenticular contribution to the visual deficit

Posterior capsule focused with thin SL beam, the light then changed to cobalt blue and if PC no longer illuminated, the media is 20/50 or worse (blue light scatter)



Lens (cont’d)

PSC (small) may cause severe visual

loss:

Conversely dense brunescent nuclear

sclerotic cataracts may allow surprisingly

good visual acuity


Biomicroscopic examination Lens (cont’d)

Lens position and zonular fibers integrity also evaluated Lens decentration Excessive distance between lens and

pupillary margin (may indicate subluxation)

Indentation/flattening of lens periphery might indicate focal loss of zonular support

Fundus Evaluation

Ophthalmoscopy (Direct & Indirect)

1. Anatomical integrity of posterior segment

assessed

2. Media clarity (direct opthalmoscope)

3. Macular, ON, Retinal vessels, Retinal

periphery evaluated

4. ARM may limit visual rehabilitation after

otherwise uneventful cataract ext.

Fundus Evaluation

Ophthalmoscopy (Direct & Indirect) (cont’d)

5. Diabetic patients examined carefully for:

Macular edema

Retinal ischaemia

Neovascularization ±

Retinal ischaemia may progress to posterior or

anterior neovascularization in case of

ICCE or

ECCE (with PC rupture)

Fundus Evaluation Ophthalmoscopy (Direct & Indirect)

(cont’d)

6. Peripheral retinal examination may reveal:

Vitreo-retinal traction

Lattice degeneration

Preexisting retinal holes

ICCE & Primary decision of PC are associated

with

incidence of RD and CME

Which may warrant preoperative treatment

Optic Nerve

Examined for color, CD ratio or any other

abnormality

ON functions further evaluated by:

VA

Confrontation VF testing

Pupillary Examination

Other Methods

Mature cataract prevents direct visualization

of

posterior segment

B-Scan ultrasonography RD Posterior segment tumor

Light projection

Maddox Rod projection

Helpful in detecting

retinal pathology

Measurements of visual function

1. VA Testing

2. Brightness Acuity

3. Contrast Sensitivity

4. Visual Field Testing


1. VA Testing

Test both near and distant visual acuity

Refraction to determine BCVA

PH VA

VA can improve after pupillary dilation (esp. in

PSC)


2. Brightness Acuity

Test near and distance visual acuity in well

lighted room of patient with complaint of glare

Under these conditions, patient with cataract

shows 3 or more lines compared with VA in

the dark

Variety of instruments available to standardize

and facilitate this measurement


3. Contrast Sensitivity

Patients with cataracts may experience

contrast sensitivity even when Snellen

acuity is preserved

Variety of instruments and charts available

to test in clinical setting


4. Visual Field Testing (VFT) VFT may help to identify visual loss from other

disease process: Glaucoma ON disease Retinal abnormalities

Confrontation VFs should be tested Goldmann or automated VF testing helps to

document degree of preoperative visual loss Light projection helpful to test peripheral VF in

patients with dense cataracts


5. Special Tests

1. Potential acuity estimation

Helpful in assessing the lenticular

contribution to visual loss

Methods:

Laser interferometry

Potential acuity meter


5. Special Tests

1. Potential acuity estimation (cont’d)

Laser interferometer:

Twin sources of monochromic helium-neon laser light creates a diffraction fringe pattern on the retinal surface

Transmission of this pattern mostly independent of lens opacities

Retinal VA estimated by varying the spacing of the fringe


5. Special Tests


Laser interferometer (cont’d) The area of pattern subtending the retina is

considerably larger than fovea

Thus small foveal lesions that limit VA may not be detected

Potential acuity meter: Projects a numerical or snellen vision chart through a small entrance pupil

Image can be projected into the eye around lenticular opacities


5. Special Tests


Potential acuity meter

Projects a numerical or Snellen vision chart

through a small entrance pupil

Image can be projected into the eye around

lenticular opacities

Measurements of visual function5. Special Tests

1. Potential acuity estimation (cont’d) Laser interfermeter & potential acuity meter

determinations useful in estimating VA before surgery

Both much predictive in moderate lens opacities Misleading In:

ARM Amblyopia Glaucoma Serous Retinal Detachment Small macular scar Macular edema

Accurate clinical examination of the eye is as good a predictor of the visual outcome as these tests


Cataracts obstruct fundus view

Direct examination may be difficult

1. Maddox Rod

2. Photo-Stress Recovery Test

3. Blue-light entoptoscopy

4. Purkinje’s entoptic phenomenon

5. Electro-retino-graphy (ERG)

These tests measure function rather than appearance


1. Maddox Rod

Red line viewed by the patient (orientation)

Grossly evaluates macular function

Large scotoma appears as loss of red line as

viewed by the patient


2. Photo-stress recovery test Photo stress recovery time used to semiquantitavely

judge macular function

Penlight shown into a normal eye (photo stress) and recovery period noted

This period is necessary before the patient can identify the Snellen letters one line larger than that individual’s baseline VA (photo stress recovery time)

Normal average time: 27 sec. With std. Deviation of 11 sec.

In most cases this time is 50 sec. Or less

Prolonged time is an indication of macular disease


3. Blue-light entoptoscopy

Patient is asked to view intense,

homogenous blue-light background

White blood cells produce shadows as they

course through perifoveal capillaries

If the patient sees these shadows, macular

function is probably intact

Many patients find the test difficult to

comprehend, which limits its usefulness


4. Purkingje’s Entoptic Phenomenon

Subjective test

Rapidly oscillating point source of light is

shown through closed eye lids

Ability of the patient to detect shadow

images of his/her retinal vasculature

provides a very rough indication that retina

is attached


5. Electro-retino-Graphy (ERG) & Visual

Evoked Response (VER)

In rare cases these tests can be

done to evaluate retinal and or ON

function where other testing is

inconclusive

Health & Medicine

Management of adult cataract II.ppt