Adult Cataract: Cortical or Soft Cataract

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ADULT CATARACT

Age Related
Cataract

The lens becomes thicker and heavier and the protein fibers begin to break down
The proteins form clumps that distort light as it penetrates the lens and reaches the retina
Nuclear sclerosis: Age-related change in the density of the crystalline lens nucleus that occurs in all elderly caused by compression of older lens fibers in the
new formation. It is a normal condensation process in the lens nucleus

nucleus by

Earliest symptom of Age-related cataract:


improved near vision without glasses ("second sight"). This occurs from an increase in the refractive index of the central lens, creating a myopic shift in
Other symptoms may include poor hue discrimination or monocular diplopia. Most nuclear cataracts are bilateral but may be asymmetric

Immature Cataract
Lens is partially opaque

Mature Cataract
Lens is completely opaque

CLASSIFICATION ACCORDING TO MATURITY


Hypermature Cataract
Morgagnian Cataract
Shrunken and wrinkled anterior
A hypermature cataract in which
capsule; often milky
total liquefaction of cortex allows
the nucleus to sink inferiorly

SYMPTOMS
1) Painless gradual diminution of vision: due to
a) Lenticular opacity
b) Refractive error induced : due to the changes in refractive index of lens
Cortical cataract index hypermetropia
Nuclear cataract index myopia. , a previously ,ie presbyopic patient may be able to read again
without the aid of spectacles. This known as 'second sight'.
2) Seeing fixed black spots in the field of vision
3) Monocular diplopia or polyopia due to irregular refraction by the lens.
Vision steadily diminishes until only light perception (LP) remains in the mature stage of cataract

refraction.

Indumescent
If the lens takes up water

SIGNS
Cortical or soft cataract:
hydration followed by coagulation of proteins appears primarily in the cortex of the lens.
Incipient stage: Wedge shaped spokes of opacity striae) extend from the periphery of the cortex, to the
center. The areas between them are clear.
Immature stage: The process of opacification advanced further. The lens appears greyish. Clear lens
are still present in the cortex and therefore iris shadow is present
Progressive sometimes rapid hydration of the cortical layers may cause swelling of the lens, thus making
the AC shallow (intumescent cataract) leading to increase IOP.
Mature stage: Eventually the entire cortex becomes opaque and white. The cataract is said to ripe or
mature no iris shadow is seen. The vision is now reduced to HM or PL
Slit lamp findings reveal that lens is completely opacified; ROR (red
orange reflex) cannot be seen. This is visualized with pupils fully dilated
In performing cataract surgery, it is important for the surgeon to prevent
ENDOTHELIAL TOUCH. The corneal endothelium is a single layer for cells
which do not regenerate. It touched, scratched or manipulated during
surgery, it will decompensate and opacify. You might have removed the
cataract but there is still opacification due to poor surgical technique.

Subscapular

- Lies directly under the


lens capsule
- form after anterior lens
epithelial cells become
necrotic from a variety of
causes including iritis,
keratitis, inflammation
associated with atopic
dermatitis, irradiation, or
electrical burns.
- The opacification of the
lens is due to a migration
of adjacent epithelial cells
into the damaged area
and subsequent
transformation of these
cells into a plaque of
multiple layers of
myofibroblasts.
- The most posterior layer
of these cells remain
epithelial cells and will
produce a new lens
capsule.
- Over time the
myofibroblasts resolve
leaving a wrinkled
appearance to the lens
capsule

- lies just in front of the


posterior capsule
- more common than
anterior
- more profound effect
on vision than a
comparable nuclear or
cortical cataract.
- Patients troubled by
headlights of incoming
cars and bright light
- Near vision more
impaired than distance
vision.
- Common in aging
where near vision is
worse; more profound
effect
on
vision
associated with poorer
outcomes

Nuclear

- Associated with myopia.


Myopic Shift
Near vision is better. Patient may feel
that their vision is restored. However,
this is only temporary.
Overtime, the lens will grow and
thicken and the cataract will mature.
Near vision may appear normal.
However, if Snellen chart and other
tests will be done, patients visual
acuity is still low
- second sight of the aged
- Yellowish early and brunescent in
later stages
- Hard in consistency.
Since the opacity is central vision is
good in dim light (when pupil dilates)
and poor in bright light (when pupil
constricts).
Gives rise to index myopia. (second
sight)
Appears brown or even black due to
deposition of melanin.
Progress is very slow and takes a
long time to mature

Cortical

May involve the anterior, posterior, or


equatorial cortex
Start as clefts and vacuoles
Typical cuneiform (wedge-shaped) or
radial spoke like opacities
Does not affect vision that much
Since the opacity is peripheral vision is
good in bright light (when the pupil
constricts) and poor in dim light when
Pupil dilates.
Gives rise to index nypetmetropia
Appear greyish in immature stage and
white in mature stage
Progress is gradual

Christmas Tree Cataract

- Uncommon
- Polychromatic (glows when you check on slitlamp exam), needle-like deposits in the deep
cortex and nucleus.
- Shape is similar to Christmas tree.

Presenile Cataract

Mean age of cataract development at 65 y.o. (according to the American Academy of Ophthalmology and the Philippine Board of Ophthalmology)
Presence of systemic disorders may cause earlier onset of cataract formation
DIABETES MELLITUS
Aside from cataract, can affect refractive
index of lens and its amplitude of
accommodation,
Prevention: good sugar control
can affect refractive index and affect, can
affect amplitude of accommodation
cataract starts 50+ y.o.

a) Classical Diabetic Cataract


sorbitol accumulates within the lens
snowflake cortical opacities in the
young diabetic
b) Age-related Cataract
Occurs earlier in DM patients
nuclear opacities are common and
progress rapidly
c) Premature presbyopia
Due to reduced pliability of lens
Early loss of accommodation or
ability of the eye to adjust to distance
due to agin

MYOTONIC DYSTROPHY
Visually innocuous, fine cortical
Evolves into visually disabling stellate
posterior subcapsular
Iridescent opacities in the 3rd decade.
Cataract by the 5th decade.
Develops slowly, takes about 2 decades for
cataract to develop.

ATOPIC DERMATITIS
in 10% of patients with severe dermatitis,
cataract develop.
a) shield-likedense anterior subcapsular
plaque
b) posteriorsubcapsular

NEUROFIBROOMATOSIS TYPE 2
Posterior subcapsular or posterior cortical
opacities.

Traumatic Cataract

Trauma is the most common cause of unilateral cataract in young individuals secondary to physical trauma due to their active lifestyle and risk taking behaviors.
Bilateral cataracts are not as common but are possible depending on the extent of injury
is most commonly due to a foreign body injury to the lens or blunt trauma to the eyeball. Air rifle pellets are a frequent cause; less frequent causes include arrows, rocks, contusions, overexposure to
heat ("glassblower's cataract"), and ionizing radiation. Most traumatic cataracts are preventable. In industry, the best safety measure is a good pair of safety goggles

Traumatic "star-shaped" cataract in the posterior lens. This is usually due to ocular contusion and is only detectable through a well-dilated pupil
Traumatic cataract with wrinkled anterior capsule
Imprint of iris pigment on anterior surface of lens
ELECTRIC SHOCK OR LIGHTNING
IONIZING RADIATION
DIRECT PENETRATING
CONCUSSION

Injury to lens; once capsule is torn


and vitreous aqueous sips into the
lens lens will opacify

Can cause an imprinting of iris


pigment on the anterior lens capsule
(Vossius Ring) and rosette cataracts
blunt trauma to anterior segment of
eye

Can denature the lens

Tumor Treatment

INFRARED RADIATION

If intense, may cause true exfoliation


or lamellar delamination of anterior
lens capsule

Drug-induced
Cataract

Corticosteroids administered over a long period of time, either systemically or in drop form, can cause lens opacities. Other drugs associated with cataract include phenothiazines,
amiodarone, and strong miotic drops such as phospholine iodide, used in the treatment of glaucoma.

STEROIDS

Systemic, topical, (even


inhaled form) are
cataractogenic
opacities are initially
posterior subcapsular then
later affect anterior
subcapsular region then
later becomes mature
cataract
Early opacities may regress if
steroids discontinued but
May also progress even if
steroids have been stopped
Given in uveitis

CHLORPROMAZINE

Innocuous fine, stellate,


yellowish brown granules
on anterior lens capsule
within the pupillary area
Dose-related and
irreversible
central, anterior capsular
granules

BUSULPHAN (MYERAN)

AMIODARONE

GOLD

used in treatment of chronic


myelocytic leukemia, may
occasionally cause lens
opacity

in treatment of cardiac
arrhythmias, causes
inconsequential anterior
subcapsular opacities

in treatment of rheumatoid
arthritis, innocuous anterior
capsular opacities in 50% of
pts of >3yrs treatment

ALLOPURINOL
increases the risk of
cataracts in the elderly if
dose exceeds 400g or
duration of >3yrs Treatment

Secondary
Cataract

complicated cataract, develop as a result of some other primary ocular disease


Cataract may develop as a direct effect of intraocular disease upon the physiology of the lens (eg, severe recurrent uveitis). The cataract usually begins in the posterior
subcapsular area and eventually involves the entire lens structure. Intraocular diseases commonly associated with the development of cataracts are chronic or recurrent
uveitis, glaucoma, retinitis pigmentosa, and retinal detachment. These cataracts are usually unilateral. The visual prognosis is not as good as in ordinary age-related cataract

CHRONIC ANTERIOR UVEITIS

ACUTE CONGESTIVE ANGLE

is the most common cause of secondary


cataract
uvea: iris, choroid, cilliary body
polychromatic lustre at posterior pole is
earliest finding which may not progress if
uveitis is arrested
posterior or anterior opacities progress to
maturity

Closure glaucoma
Lens-induced glaucoma can present in two
forms: phacomorphic and phacolytic
Phacomorphic glaucoma increased IOP d/t
tumescent lens covering the pupil; aqueous
cant drain to the pupil
Phacolytic glaucoma lens appear to be
mature but there is problem with the lens
proteins such that they escape onto the
anterior chamber and clog up the trabecular
meshwork
For both cases, treatment remains to be
cataract removal
small, grey-white, anterior subcapsular or
capsular opacities within the pupillary area
(glaukomflecken)

HIGH (PATHOLOGIC) MYOPIA

HEREDITARY FUNDUS DYSTROPHY

posterior subcapsular opacities and


early onset nuclear sclerosis

retinitis pigmentosa, Leber congenital


amaurosis, gyrate atrophy, Stickler
syndrome;
posterior
subcapsular
cataracts
Retinitis pigmentosa progressive
degenerative dse that leads to complete
blindness, no cure, hereditary

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