Lens&Cataract

LENS AND CATARACT Dr.
Sanjay Dhawan MBBS, MS (Gold Medallist) DO
Lens and Cataract

Topics of Study
I. Cataract
V Causes of Cataract
V Global / National distribution & population
characteristics of Cataract
V Diagnosis of cataract. Distinction between immature,
mature and hypermature.
V Appropriate referral of cataract patient
V Outline of surgical management
V Visual rehabilitation of Aphakia
V Outline of cataract management in young age
II. Congenital Abnormalities of Lens

V Ectopia Lentis (Subluxation & Dislocation)
V Lenticonus
Crystalline Lens
Embryology
V Derived from surface Ectoderm overlying the optic
vesicle.
V Ectoderm invaginates and break from surface as two
layer structure
V Basement membrane of epithelium, which is now on
the outer side, forms the lens capsule.
V Posterior epithelium cells expand to form the
embryonic nucleus.
V Anterior epithelium continues to regenerate and develop lens
fibers throughout life. These fibers continue to get deposited
inwards making earliest fibers the deepest.
Anatomy
V A globular structure lies behind the iris and in a concavity in the
anterior face of vitreous called the Patellar Fossa.
V Suspended from the ciliary processes by Zonules
V In young patients (< 35 years) lens is adherent to vitreous by
Ligament of Weigert.
URL http://sdhawan.com/ophthalmology/lens&cataract.pdf E-mail: [email protected]

LENS AND CATARACT Dr. Sanjay Dhawan MBBS, MS (Gold Medallist) DO
Layers (from without inwards):

V Lens capsule (thinnest at posterior pole)
V Epithelium (missing from posterior surface)
V Cortex
V Epinuclear Cortex
Nucleus (from without inwards):

V Adult
V Adolescent
V Infantile
V Fetal (contains anterior & posterior Y-sutures)
Epithelium divides most actively in the periphery and differentiates in the lens
fibers.
Physiology
Functions:
Refraction of light (+18 D)

Accommodation: ability to increase refractive power in order to focus near
objects.
V Metabolism is both aerobic and anaerobic.
V Cations and fluid move actively across anterior capsule but passively
across posterior capsule (Pump-Leak Mechanism).
V Metabolic homeostasis is essential for maintenance of lens
transparency.
V Glutathione, glutathione reductase and super-oxide dismutase are
actively involved in preventing damage from free O2 radical injury.
Optics
V + 18 Dioptre of refraction is contributed by the lens. And in
accommodation this power increases.
V Typical structure of lens in the form of anterior cortex, nucleus and
posterior cortex is optically important as each of these three portions
act as a separate lens (lenticules) because the refractive index of
nucleus is more than that of cortex. This results in an increase in the
total power of the lens, decrease in optical aberration and greater
effectiveness of the accommodation.
V Accommodation: Contraction of ciliary muscles results in laxity of
zonules, which leads to increase convexity of lens due to its inherent
elasticity.
V Iris not only controls the amount of light that enters the eye by varying
the size of pupil (aperture) but also covers the periphery of the lens
thereby cutting the optical (spherical) aberrations from it.

Cataract
Definition
Any opacity of the lens or loss of transparency of the lens that causes
diminution or impairment of vision is called Cataract.
Although any lens opacity whether or not it leads to decrease in vision is
technically cataract, yet an opacity in the periphery of the lens, which is
stationary and not hampering vision should be diagnosed just Lens Opacity in
order to avoid causing unnecessary anxiety to the patient.
Classification
V Etiological
V Morphological
V Stage of Maturity
Etiological Classification
1. Senile
2. Traumatic
V Penetrating
V Concussion (Rosette Cataract)
V Infrared irradiation (Glass Blower’s Cataract)
V Electrocution
3. Metabolic
V Diabetes (Snow Storm Cataract)
V Hypoglycaemia
V Galactosemia (Oil Drop Cataract)
V Galactokinase Deficiency
V Mannosidosis
V Fabry’s Disease
V Lowe’s Syndrome
V Wilson’s Disease (Sunflower Cataract)
V Hypocalcaemia
4. Toxic
V Corticosteroids
V Chlorpromazine
V Miotics
V Busulphan
V Gold
V Amiodarone
5. Complicated
V Anterior Uveitis
V Hereditary Retinal & Vitreoretinal Disorders
V High Myopia
V Glaucomflecken
V Intraocular Neoplasia

6. Maternal Infections
V Rubella
V Toxoplasmosis
V Cytomegalovirus
7. Maternal Drug Ingestion
V Thalidomide
V Corticosteroid
8. Presenile Cataract
V Myotonic Dystrophy
V Atopic Dermatitis (Syndermatotic Cataract)
V GPUT & GK Enzyme Deficiencies
9. Syndromes with Cataract
V Down’s Syndrome
V Werner’s Syndrome
V Rothmund’s Syndrome
V Lowe’s Syndrome
10. Hereditary
11. Secondary Cataract
After-Cataract (after the cataract surgery)

Morphological Classification
1. Capsular
V Congenital (Anterior Polar & Posterior Polar)
V Acquired
2. Subcapsular
V Posterior Subcapsular (Cupuliform)
V Anterior Subcapsular
3. Nuclear
V Congenital (Discoid, etc.)
V Senile
4. Cortical
V Congenital (Coronary, Coralliform, etc)
V Senile (Cuneiform)
5. Lamellar or Zonular
6. Sutural
7. Others
V Blue-Dot (Cataracta caerulea)
V Membranous
V Cataracta Pulveranta Centralis
V Reduplicated Cataract

Stage of Maturity
Immature
Mature
Intumescent
Hypermature
Morgagnian
Chronological
Congenital (since birth)
Infantile (first year of life)
Juvenile (1 to 13 years of life)
Presenile (13 to 35 years of life)
Senile
Pathogenesis
Two main pathogenetic processes are involved in most (especially senile)
cataract:
V Hydration
V Sclerosis
Hydration
V Increased hydration leads to lamellar separation and collection of
protein-deficient fluid between lens fibers.
V Leads to increased scattering of light and loss of transparency.
V Hydration also leads to denaturation of lens proteins and results in
irreversible opacification.
V Mechanisms of increased hydration are:
Failure of active pump mechanism
Increased leakage across posterior or anterior capsule
Increased Osmotic pressure
Sclerosis
V This process is seen mostly in senile cataract and involves
predominantly the nucleus.
V Increased compaction of lens proteins and fibers due to inter-lamellar
binding of proteins by sulfide bonds.
V Resultant aggregates of very high molecular weight proteins lead to
increased scattering of light and loss of transparency.
V It is part of normal aging phenomenon.
Senile Cataract
Epidemiology
Global
V 38 million people are blind
V 41 % because of cataract
National
V 71 % of blindness in Nepal is because of cataract
V About 72 % of blindness in India is caused by Cataract

Progression
I. Stage of Lamellar Separation
V Hydration leads to separation of cortex from nucleus
V Appreciated on slit lamp biomicroscopy
II. Stage of Incipient Cataract
V Early opacities appear
V Vision unaffected but other symptoms e.g., glare, appear.
III. Immature Cataract
Opacification leading to diminution of vision.
Two morphological forms are seen:
1. Cuneiform Cataract: Wedge shaped opacities appear in the
peripheral cortex and progress towards the nucleus. Vision is worse
in low ambient illumination when the pupil is dilated.
2. Cupuliform Cataract: A disc or saucer shaped area of the cortex
beneath the posterior capsule undergo opacification. The opacity
being central, the vision is worst in bright ambient illumination when
the pupil is constricted.
V Lens appears grayish white in color.
V Iris shadow can be seen on the opacity with oblique
illumination.
IV. Intumescent Cataract
V Sometime during the course maturation the lens imbibes lot of fluid
and becomes swollen.
V Anterior chamber becomes shallow.
V Angle of anterior chamber may close resulting in glaucoma
(Phacomorphic Glaucoma).
V. Mature Cataract
V Entire cortex becomes opaque.
V Vision reduced to just perception of light
V Iris shadow is not seen
V Lens appears pearly white.

VI. Hypermature Cataract

This may take any of two forms:
1. Liquefactive or Morgagnian Type: The cortex undergoes auto-lytic
liquefaction and turns uniformly milky white. The nucleus loses support
and settles to the bottom.
2. Sclerotic Cataract: The fluid from the cortex gets absorbed and the lens
becomes shrunken. There may be deposition of calcific material on the lens
capsule. Anterior chamber deepens and iris becomes tremulous
(Iridodonesis). The zonules become weak increasing the risk of subluxation
/ dislocation of lens.
V Liquefied cortex may leak out of the lens resulting in either uveitis or
glaucoma (Phacolytic Glaucoma).
V Very rarely the entire cortex and nucleus can get completely liquefied
and absorbed leaving behind clear anterior and posterior capsules
(Pseudo-aphakia). Vision improves to about finger counting at 1
meter.
Nuclear Cataract
Goes through stage of immaturity and maturity but never becomes
intumescent or hypermature.
Urochrome or melanin pigment deposition may take place giving nucleus a
typical color:
V Yellow
V Black (Cataracta nigra)
V Brown (Cataracta brunescnence)
V Red (Cataracta rubra)
In early stages there is shift of refraction towards myopia. This improves the
near vision of the patient. Consequently the patient who so far required thick
near glasses for reading, can read small print easily without them
(phenomenon of Second Sight).
Clinical Presentation
Symptoms
Glare: When patient looks at a point source of bright light the diffusion of white
and colored light around it drastically reduces vision. Night driving becomes
especially troublesome. Posterior subcapsular cataract (cupuliform) notably
causes disabling glare.
Image Blur: Opacification of lens leads to diminution of vision which is

characteristically painless and progressive (& does not improve with pin-hole).
From a normal of 6/6 the vision continues to deteriorate as the cataract
progresses, but as long as the cataract is immature patient will at least be able
to count fingers. When cataract matures the vision is reduced to barely
perception of light. In hypermature, rarely, the vision may improve a little if the
cortex gets absorbed (but not better that finger counting at 1 meter).
In early stages, however, the near vision may sometimes improve (the
phenomenon of Second Sight).

Diurnal Variation of Vision: In central (cupuliform) cataract the vision is worse

in bright light of the noon (day-blindness or hemerelopia) but improves as the
sun sets. Whereas in peripheral cortical cataract (cuneiform) the reverse is
true i.e. vision is better in bright light than dim light.
Distortion: Cataract may make straight edges appear wavy or curved

(Metamorphopsia).
Colored Halos: Ring of colors of rainbow may be seen around point source of
bright light. Since colored halos are important symptom of glaucoma
therefore, they have to be differentiated. This can be done easily by Fincham’s
Test in which a vertical slit in a black disc (Staenopic Slit) is passed across
patient’s eye while he gazes at a point source of bright light. Colored halos
caused by cataract (lenticular) seem to break into a moving fan but not that
caused by glaucoma (corneal) which only become slightly dim. Moreover, the
VIBGYOR of the rainbow is within outwards in lenticular halos and without
inwards in corneal halos.
Diplopia / Polyopia: Multiple images of one object may form on the retina due
to irregular refraction from the cataractous lens giving rise to Monocular
Diplopia or Polyopia. This can be differentiated from binocular diplopia by
cover-test and pin-hole test. Binocular diplopia disappears on covering any of
the eye. Monocular diplopia does not disappear if the other eye is covered,
however, it disappears if a pin-hole is placed in front of this eye.
Altered Color Perception: The yellowing of lens nucleus is steadily progressive
leading to change in color saturation of the image seen. The artists with
cataract may render their paintings browner or yellower than real.
Black Spots: Patient may complaint of seeing black spots fixed in his field of
vision. This is unlike black spots seen in vitreo-retinal disorders, which seem to
move around as floaters (muscae volitantes).
Behavioral Changes: Seen especially in children with cataract, who can not
verbalize their complaints. Stumbling over objects, poor performance in
school, loss of interest in surroundings, etc. can be some of the changes that
may draw parents attention towards child’s visual handicap.
Signs
Visual Acuity: Vision is diminished proportionate to the degree of cataract

(immature from 6/9 to finger counting close to face; mature perception of
light or hand movements). However, vision recorded in dimly lit room may not
sometimes give true estimate of the patient’s disability especially in small
central opacities.
Leukocoria: “White pupil”, infact the pupil appears grayish white in immature,
pearly white in mature and milky white in hypermature stages of cataract.
Anterior Chamber: Depth of anterior chamber is normal except in intumescent

cataract where it is shallow, and hypermature shrunken cataract where it is
deep. It may contain cells and flare in case if lens induced uveitis.

Cornea & Conjunctiva: These are usually normal. Cornea may become hazy
due to edema if the IOP is increased by lens induced glaucoma. Conjunctiva
may be congested in lens induced glaucoma or uveitis, or if there is
associated infection.
Iris Shadow: In immature cataract a crescentic shadow of the iris is seen in

the pupil on oblique illumination. In mature cataract iris shadow is not visible
as the opacity extends right to the anterior capsule.
Distant Direct Ophthalmoscopy (DDO): Viewing the dilated pupil using an

ophthalmoscope from a distance of 25 cm reveals the cataract as black
patches against the background of red glow from the fundus. This is very
helpful in differentiating early immature cataract from nuclear sclerosis.
Although the lens appears grayish white in both these conditions but on DDO
cataract shows up as black patches but clear red glow is seen in nuclear
sclerosis. Also, in mature cataract no red glow is seen as the lens becomes
completely opaque.
Fundus: In early stages of cataract the retina may be seen by ophthalmoscopy
and appear normal. It may appear deep red in color in nuclear cataract. In
advanced cataract the retina cannot be seen.
Intraocular Pressure: IOP is normal in cataract unless lens induced glaucoma
(phacolytic or phacomorphic) develops. It may be low in lens induced uveitis.
Purkinje-Sanson Images: All optical interfaces (junction of media to different

refractive index) of the eye not only refract the light but also reflect it forming
images (Catoptric) which the observer can see. Purkinje (pronounced as pur
kine’) described 4 such images (or reflections) arising from anterior and
posterior surfaces (1 & 2) of cornea, and from anterior and posterior surfaces
of the lens (3 & 4). To this Sanson added 2 more images arising from anterior
and posterior surfaces of the nucleus (5 & 6). So using a point source of bright
illumination and with subject’s pupil dilated one can observe 6 reflected
(catoptric) Purkinje-Sanson images from the eye.
In immature cataract the 4th image arising from the posterior surface of lens
disappears and in mature cataract 4th, 5th and 6th images disappear.
Other Signs: Signs of aging may be observed along with cataract and are just
co-incidental e.g., arcus senilis, skin laxity (dermatochalasis), senile entropion
or ectropion, senile ptosis, age related macular degeneration (ARMD), grayish
white granular material on lens surface or iris in pseudoexfoliation, scrolls of
split layers of anterior capsule (exfoliation), tremulous lens (Phacodonesis) if
the zonules are very lax or broken, dry eye syndrome, etc.

Differentiating Various Stages of Cataract
Features Immature Mature Hypermature

Vision 6/9 - FC HM - PL HM – FC
Anterior Chamber Normal (shallow in Normal (shallow in Normal to deep
intumescent) intumescent) Milky white (with brown
Color of Lens Grayish white Pearly white crescent of nucleus) or
Iris shadow Seen Not seen chalky white
Distant Direct Black patches No red glow seen Not seen
Ophthalmoscopy against red glow No red glow seen
Purkinje-Sanson 4th image not seen 4, 5 & 6th images 4, 5 & 6th images not
Images not seen seen
Complications of Cataract
I. Lens Induced Glaucoma

Cataract in give rise to secondary glaucoma in any of 3 ways:
V Phacomorphic Glaucoma: Lens may swell up by absorbing fluid resulting in
shallow anterior chamber. The angle may close blocking the trabecular
meshwork and IOP rises. A type of secondary angle closure glaucoma.
V Phacolytic Glaucoma: In hypermature stage the lens proteins leak out
into the anterior chamber and are engulfed by macrophages. These swollen
macrophages clog the trabecular meshwork leading to increase in IOP. A type of
secondary open angle glaucoma.
V Phacotopic Glaucoma: Hypermature lens may dislocate and can give
rise to increase in IOP by physically blocking the pupil or angle, or displacing
the vitreous which causes the block.
II. Lens Induced Uveitis
Lens proteins are sequestered antigens i.e. not exposed to the body’s immune
mechanisms during development. When these leak into theanterior chamber
they are treated as foreign, inciting immune reaction. This results in anterior
uveitis (inflammation involving iris and ciliary body). This is characterized by
ciliary congestion and cells and flare in the aqueous.
III. Subluxation or Dislocation of Lens
In stage of hypermaturity the zonules of the lens may weaken and break.
This leads to subluxation of the lens (when at least some zonules are still intact
and a part of the lens still lies in the patellar fossa) or dislocation (when all
zonules have broken and no part of the lens lies in the patellar fosssa.

Investigation
It involves further evaluation of the eye and general condition of the patient
with regards to the feasibility and prognosis of surgical management of
cataract.
Pupillary Reflexes: Special emphasis is placed on examining the pupillary signs
as they may reveal presence of any visual pathway (afferent) or 3rd nerve
(efferent) disorder. This may affect the final visual outcome e.g., afferent
pupillary defect caused by optic atrophy may prognosticate poor visual result.
Special care should be taken to look for presence of Marcus-Gunn Pupil in which
although both direct and consensual reflexes are present in both the eyes and
pupils appear to be normal, yet on doing swinging flash light test (i.e. rapidly
shifting light from one eye to the other and back) one pupil seems to dilate in
response to light whereas the other constricts. This denotes presence of a
relative afferent pupillary defect (RAPD) in the eye whose pupil seems to dilate.
Note that the defect is partial and unequal in the two eyes.
Intraocular Pressure: Presence of lens induced glaucoma or co-existent primary
glaucoma should always be looked for because increased IOP seriously affect
the course and result of surgery. The IOP has to be well under control before
the surgery for cataract is under-taken because not only high pressure
increases the risk of intra-operative complications (viz. Vitreous loss, expulsive
hemorrhage, etc.) but also there is a high risk of loosing vision (or visual field)
postoperatively as the IOP tends to rise to high level about 2 hours after
cataract operation even in an otherwise normal eye.
Fundus Examination: Detailed retina examination to rule out any pathology in

the posterior segment (behind the lens) which may compromise visual
outcome.
Lacrimal Syringing: It is important to rule out any block or focus of infection in

the lacrimal drainage system by doing syringing. Focus of infection around the
eye or even elsewhere in the body (e.g. teeth, chest, urinary tract, etc.)
increase the risk of postoperative intraocular infection or Endophthalmitis which
can be devastating for vision.
Blood Pressure: Hypertension not only leads to development of hypertensive

retinopathy but also increases the chances of expulsive hemorrhage during
surgery. In expulsive hemorrhage choroidal blood vessels rupture leading to
bleeding between choroid and scleral, which pushes the choroid inwards and, if
severe, expelling the contents of the globe.
Hypertension must be well under control in the peri-operative period and the
use of phenylepherine or adrenalin should be avoided. Anti-hypertensives must
be added to the preoperative medication.
Blood Sugar: Diabetes must be ruled out, and if present must be controlled
before surgery. Diabetes can adversely affect any part of the eye especially the
retina (diabetic retinopathy), wound healing is impaired and the risk of infection
is extremely high. Blood sugar should be carefully monitored and kept in strict
control in the peri-operative period.
On the day of operation, however, the anti-diabetics (hypoglycemics) are
omitted to avoid the chance of severe hypoglycemia, and are resumed from the
first postoperative day.

General Investigation: General body check-up and some investigations like

hemoglobin, blood sugar, urine examination, ECG and X-ray Chest (where
required) should be done to rule out any significant systemic disorder. If any
disease is detected patient should be referred to concerned specialist for
appropriate treatment.
Macular Function Tests: These are done to preoperatively assess the

postoperative visual outcome (potential vision) based on which a prognosis is
given to the patient.
These tests are:

With clear media
V Visual Acuity: as tested by Snellen’s charts, if disproportionately less
than what can be explained by the degree of cataract points to
possibility of macular dysfunction.
V Color Vision: Color appreciation and discrimination is best at macula
because of aggregation of cones. It can be deranged in any macular
pathology.
V Photostress Test: Visual acuity of patient is determined and then his
macula is dazzled by bright light of a 3.5 Volt Ophthalmoscope. Then
the time it takes for his visual acuity to return to initial level is noted.
V Normal is 52 seconds but if it takes longer macular function is
abnormal.
V Haidinger Brushes: Using an instrument called Synoptophore a
rotating beam of plane polarized blue light is shown to the patient.
An image of rotating blue brushes is seen if the macula is healthy
because of typical radial distribution of nerve fibers at the macula.
V Potential Acuity Meter (PAM) or Visometer: Using this device reduced
Snellen’s Chart is projected onto patient’s macula through the clear
area in his lens. The smallest line that patient reads gives patient’s
potential vision. This test correlates the best with final postoperative
visual acuity of the patient.
With opaque media
V Two Point Discrimination Test: A cardboard with 2 pinholes 2 mm
apart is placed 2 cm from patient’s eye and a light is shone 2 feet
behind it. If patient reports seeing two lights then his macula is
probably normal.
V Maddox Rod Test: Maddox Rod is a set of small high power red
cylindrical lenses placed close to each other (or grooves cut in a red
glass). A point source of white light seen through it appears as a red
line. If macula is deranged the line would appear distorted, irregular,
broken or would just not be seen.
V Entoptic View: Rubbing a lighted bare bulb of a torch pressed over
closed eyelids makes individual’s own retinal (macular) blood vessels
visible as dark red branches of a tree against an orange background.
In macular pathology the vessels are either not seen or black patches
are seen scattered with the vessels. This test should first be done on
the normal eye to demonstrate to patient what he is expected to
observe.
V Laser Interferometry: Two beams of plane polarized light are
projected on to patient’s pupil. These beams undergo interference
and form interference fringes of light and dark bands behind

patient’s lens. Then the width of these fringes is reduced and the
narrowest fringes seen by the patient are indicative of his visual
potential.
V Visually Evoked Response (VER): Stimulation of retina by light pattern
leads to suppression of alpha-wave of the EEG recorded from the
occipital cortex. The smallest pattern stimulus which generates this
response denotes the potential vision of the patient. Other
electrophysiological tests can also be used to assess the function of
the macula especially Electroretinogram (ERG) with focal foveal
stimulation.
9. Ultrasonography (USG B-Scan): If the cataract is advanced then the retina
cannot be visualized by ophthalmoscopy, therefore, ultrasound (B-scan) is
used to detect any structural abnormalities.
10. Intraocular Lens Power Calculation: The power of the intraocular lens to be
implanted has to be calculated for each individual.
Three parameters are required as follows:
V Keratometry (K): gives the refractive power of the cornea (in diopters),
using an instrument called Keratometer.
V Biometry or Axial Length of Globe (L): The distance (in mm) from the
apex of cornea to the posterior pole of the eye is measured by a
special ultrasound the A-Scan Biometer.
V A Constant (A): It is supplied by the IOL manufacturer and it’s value
depend on the design of the lens and it’s intended location in the
eye (anterior or posterior chambers).
These values are put in a formula (SRK Formula) to get the power of the lens
to be implanted:
IOL Power = A – 2.5L – 0.9 K
This would make the patient emmetropic. However, in some cases it is
desirable to deliberatively induce a preplanned refractive error postoperatively
e.g. when the other eye has a high refractive error then the planned refractive
error in eye to be operated should be within + 2.5 dioptre of the other eye, in
order to avoid anisometropia (unequal refrctive error) and aniseikonia
(unequal image size).
Indications for Cataract Surgery
Classified in 3 groups:
I. Optical indications
Whenever the vision of the patient is diminished to an extent that it interferes
with his normal daily life, the cataract can be operated. There is no sharp cut-
off level of visual acuity below which cataract should be operated rather the
decision about timing of surgery is subjective to the patient’s own visual
requirement. A word of caution here is that in mild diminution of vision e.g. 6/
12, patient should be informed about the disadvantage of loss of
accommodation that results from cataract surgery, which may offset the
advantage of gain of 2-3 lines in visual acuity. Glare is another optical
indication especially in individuals involved in night driving.
II. Medical Indications

In following conditions cataract needs to be removed urgently even if patient is
not interested in visual gain or the visual prognosis is not favorable:

V Hypermature cataract
V Lens induced glaucoma
V Lens induced uveitis
V Dislocated / subluxated lens
V Intra-lenticular foreign body
V Diabetic Retinopathy to give Laser photocoagulation
V Retinal Detachment or any other posterior segment pathology, the
dignosis or treatment of which is being hindered by opacity of the lens.
III. Cosmetic Indication

If the vision is permanently lost because of some retinal or optic nerve
pathology e.g. optic atrophy, but the white pupil caused by cataract is
cosmetically unacceptable to a young patient, cataract surgery is indicated just
make the pupil appear black even though is known that the vision will not
recover.
Surgery for Cataract
Choice of Operation
The operation of choice for cataract is:
Extra-Capsular Cataract Extraction with Posterior Chamber Lens
Implantation
Or simply
ECCE with PCL
Unless contraindicated or better technique (Phacoemulsification &
Foldable IOL) is available.
Operative techniques available:

Extra-capsular cataract extraction (ECCE)
Intra-capsular cataract extraction (ICCE)
Pars plana lensectomy
Phacoemulsifiation
Intra-ocular lens (IOL) types:

Posterior chamber lens (PCL)
Anterior chamber lens (ACL)
NB: The best position for implantation of IOL is within the capsular bag in
the posterior chamber. The IOLs are made of PMMA (Polymethyl
Methacrylate), Silicone or Acrylic (foldable).
Principles of Various Techniques
Extra-capsular Cataract Extraction (ECCE)

The nucleus and the cortex is removed out of the capsule leaving behind

intact posterior capsule, peripheral part of the anterior capsule and the
zonules. This not only provides support of placement of IOL but also
prevents vitreous from bulging forwards and acts as a barrier between
anterior and posterior segment. All this results in decreasing the incidence
of complications viz. Vitreous loss, corneal edema, endophthalmitis,
cystoid macular edema, aphakic glaucoma, etc. However, capsular
remnants are prone to develop after-cataract.
Intra-capsular Cataract Extraction

The lens is removed in toto as one single piece i.e., the nucleus and the
cortex are removed within the capsule of the lens after breaking the
zonules. There is no support left for posterior chamber IOL, therefore, only
anterior chamber IOL (ACL) can be implanted which has risk of adverse
corneal complications. Also, there is no barrier left between anterior and
posterior segment, which increases the incidence of other complications
e.g., vitreous loss, aphakic glaucoma, cystoid macular edema,
endophthalmitis, etc. However, the only advantage is that after-cataract
does not develop as the entire capsule is removed.
Pars Plana Lensectomy
A special technique used in very young children. The lens and anterior part
of vitreous is nibbled out using an instrument called Vitrectomy Probe or
VISC (Vitreous Irrigation Suction Cutting) probe which is introduced
through the pars plana region of the ciliary body about 3.5 mm behind the
limbus. The advantage being that the body’s active immune mechanism is
not exposed to the sequestered lens protein antigens thereby preventing
inflammatory response, and removal of anterior vitreous removes scaffold
for deposition of fibrous tissue deposition. Inflammatory response to lens
protein and extensive fibrosis are troublesome consequences of cataract
surgery in very young children.
Phacoemulsification
It is essentially an advancement in the method of doing ECCE. Here the
nucleus is converted into pulp or emulsified using high frequency (40,000
MHz) sound waves, and then is sucked out of the eye through a small (3.2
mm) incision. A special foldable IOL is then inserted into the posterior
chamber through the same incision. The advantages being no or
negligible surgically induced astigmatism and rapid recovery of the
patient.
In contrast to this, in conventional ECCE the incision is large (about 8
mm), therefore, surgical astigmatism poses problems postoperatively and
the wound healing being slow, the visual rehabilitation of the patient is
delayed to about 6-8 weeks.
So, if facilities are available, phacoemulsification is the choice of operation
for cataract.

ECCE vs. ICCE
ECCE ICCE
Lens removal Nucleus removed out of the Lens removed as single piece within its
capsule and cortex sucked out capsule
Posterior capsule & zonules Intact
Incision Smaller (8 mm) Removed
Peripheral iridectomy Not performed Larger (10 mm)
Sophisticated equipment Required Required to avoid pupillary block glaucoma
Time taken More Not required
IOL Implantation Posterior chamber Less
Anterior chamber (with its associated risk of
damage to corneal endothelium leading to
Expertise required Difficult technique Pseudo-phakic Bullous Keratopathy)
Cost More Easier to learn
Complications which are After-Cataract Less
increased Vitreous prolapse & loss Cystoid Macular
Edema Endophthalmitis Aphakic Glaucoma
Fibrous & Endothelial ingrowth Neovascular
Compications which are All the complications mentioned Glaucoma in Proliferative Diabetic Retinopathy
decreased for ICCE After-Cataract
Dislocated Lens Subluxated Lens (>1/3rd
Indications A routine procedure for all zonules broken) Chronic Lens Induced Uveitis
forms of cataract (except where Hypermature Shrunken Cataract with thick
contra-indicated) anterior capsule Intra-lenticular Foreign Body
when integrity of posterior capsule is
Contraindications Dislocated lens Subluxated lens compromised.
(>1/3rd zonules broken) Young Patients (<35 years) who have strong
attachment between lens and vitreous
(Ligament of Weigert)
Preoperative Preparation
Patient preferably admitted to the hospital on previous evening (however,

surgery can also be done on OPD basis).
Informed consent is taken.
The eye-lashes of the eye to be operated are trimmed carefully and the eye is
cleaned with Povidone-Iodine 5 % solution, and marked.
Antibiotic drops are instilled every 6 hourly
A mild sedative (Diazepam 5 mg) may be given on the night before if the
patient is anxious.
On the day of surgery patient is kept fasting (NPO or nil per orally) since
morning.
Pupils are dilated by instillation of following eye-drops starting about 2 hours
before operation:
Tropicamide 1% or Homatropine 2% being parasympatholytic relax the
sphincter pupillae.
Phenylepherine 5-10% (avoided in hypertensive patient) being
sympathomimetic contract the dilator pupillae.
Flurbiprofen 0.3% a non-steroidal anti-inflammatory drug prevent release of
prostaglandins during surgery thereby preventing intraoperative constriction of
pupil that may be caused by surgical trauma.
These drops are instilled every 15 minutes.
Other medications may be given as required e.g., antiglaucoma drugs,
antihypertensives, anti-asthamatics, etc. But anti-diabetic drugs are omitted
on the day of surgery to prevent hypoglycaemia, and are resumed from the
first postoperative day.

Anesthesia
Most cases of cataract are operated under local anesthesia except in young
children. The techniques used are:
Retrobulbar anesthesia.*
Peribulbar anesthesia
Facial nerve block*
* These two are given in combination.
The anesthetic agent used is a solution of following;

V Lignocaine or Xylocaine 2 % which the main anesthetic agent
Bupivacaine 0.75 % which has a prolonged duration of action and
analgesia. It is used primarily for increasing duration of action and for
postoperative analgesia.
V Adrenalin 1 in 200,000 leads to constriction of blood vessels thereby
decreasing absorption of anesthetics and thus prolonging duration of
action and decreasing side effects. It should be avoided in hypertensive
patients.
V Hyaluronidase 7-15 IU per mL is used to promote diffusion of the
anesthetic into the orbital tissues.
V Retrobulbar Anesthesia
Patient is asked to look straight up. A point is chosen 2 mm above the
junction of medial 2/3rd and lateral 1/3rd of the inferior orbital margin. A
2.5 inch 20 G needle with rounded tip is introduced vertically at this point
for 2 cm. Then the direction of the needle is turned towards the apex of
the orbit i.e., posterior, superior and medially, and needle is advanced fully
into the muscle cone. About 2-4 mL of above solution is injected and the
needle is withdrawn. Pressure is applied intermittently over a cotton pad
placed on the eye, to diffuse the anesthetic agent and to bring down the
intra-ocular pressure.
Effects:
Analgesia
Akinesia
Mydriasis
Decrease in IOP
Loss of Oculo-cardiac reflex (reflex stimulation of vagus caused by painful
stimulus of the globe or pulling of muscle, which leads to bradycardia and
can even cause cardiac arrest).
Complications:
Retrobulbar hemorrhage (operation has to be postponed for 2 weeks and

hyperosmotic agents given to decrease IOP).
Damage to the optic nerve
Perforation of globe
Accidental injection into the optic nerve sheath from where it tracks to the
brain

Infection
V Peribulbar Anesthesia
This technique virtually eliminates the risk of above complications. With patient
looking straight ahead, a point is chosen 2 mm the junction of medial 2/3rd and
lateral 1/3rd of the inferior orbital margin. A 26 G 1 inch needle is introduced
vertically in completely and 5 mL of the above anesthetic solution is injected. Then
another point is chosen diagonally opposite to it i.e., 2 mm below the junction of
medial 1/3rd and lateral 2/3rd of the superior orbital margin and 3 mL of the
solution is injected. Intermittent pressure is applied as described above.
V Facial Nerve Block
The technique commonly used is called O’Briens Technique. The condylar process
of the mandible is palpated anterior to the tragus by asking the patient to open
and close his mouth. A point is chosen 1 cm below this marking the position of
neck of the mandible. A 23 G needle is introduced at this point till it strikes the
bone (neck of mandible) and then withdrawn a little. 5 mL of the above anesthetic
solution is injected at this point and the needle withdrawn. The effect of the block
is observed by asking to forcibly close his eyes or to show his teeth, an inability to
close the eye or angulation of mouth to the other side indicated blockage of facial
nerve. This prevents squeezing of the eyes by the patient. However, with
peribulbar anesthesia facial block is not required because some anesthetic solution
diffuses directly into the orbicularis oculi muscle and cause its anesthesia.
V Extra-Capsular Cataract Extraction
After anesthesia the eye is cleaned with Povidone-Iodine solution 5% and a sterile
drape is put to isolate the surgical field. Povidone-Iodine 2% is irrigated in the
conjunctival sac and washed with Normal Saline.
V Eye-lids are retracted using a wire speculum.
Superior rectus bridle suture is passed to turn the superior limbus down and
stabilize the globe. Superior rectus forceps are used to hold the insertion of
superior rectus and a 4.0 Silk suture is passed under it.
V Fornix based conjunctival flap is raised by cutting the conjunctiva where it is
attached to the limbus from 10 O’clock to 2 O’clock meridian. Bleeding points and
large vessels are coagulated using a bipolar electro-cautery.
V A groove or partial thickness incision is made at the limbus (mid or blue limbus)
using a piece of razor mounted on blade breaker-holder. This groove extends from
10 O’clock to 2 O’clock meridian and is perpendicular to the limbal surface.
V Anterior chamber is entered by stabbing within this groove at the 11 O’clock
meridian keeping the blade obliquely (parallel to iris plane). Thus the incision gets
a two plane or bi-planar configuration.
V A visco-elastic fluid (Poly-propyl hydroxy methyl cellulose or sodium hyaluronate) is
injected into the anterior chamber. This fluid coats the corneal endothelium
preventing any damage to it, and deepens the anterior chamber giving more
working space.
V An opening is made in the anterior capsule of the lens called the anterior
capsulotomy, using a bent hypodermic 26 or 30 G needle. There are various
techniques of performing anterior capsulotomy e.g., bear-can opener, Christmas
tree, envelope, capsulorrhexis, etc.
V The limbal incision or section is enlarged by cutting in the groove to its entire
extent, using a corneal scissors keeping its blades parallel to the iris plane. So a bi-
planar incision is made extending from 10 O’clock to 2 O’clock meridian.
V The nucleus is expressed by applying alternating pressure at 12 O’clock and 6
O’clock meridian.
V The cortex which remains is removed by suction. This is performed by a special
cannula called the IA Cannula (Irrigation-Aspiration) which has two channels in it;
one for the fluid to go in (irrigation) and second for the fluid and cortex to be

sucked out (aspiration). A balanced salt solution (BSS) or Ringer’s Lactate

solution is constantly irrigated into the eye while the cortex is sucked out.
V If IOL implantation is planned, visco-elastic substance is injected again
into the anterior chamber.
V IOL is inserted into the capsular bag and then rotated into proper
position.
V Visco-elastic substance is aspirated out using IA cannula.
V The limbal incision is sutured using 10.0 Prolene or Nylon sutures passed
to about 3/4th the depth of cornea and sclera (& not full thickness) in a
interrupted or continuos fashion. If the knots are properly buried under
the surface, these sutures are not required to be removed. If the knots are
not buried or thicker suture is used (9.0, 8.0, etc.) they are removed after
about 6-8 weeks. Corneal wounds take about 6-8 weeks for an acceptable
level of healing and about 1-3 years for complete healing.
V The conjunctiva is repositioned back to cover the limbal wound.
A combination of an antibiotic and a steroid is injected sub-conjunctivally,
and the eye is patched for 24 hours.
V Intra-Capsular Cataract Extraction
The steps of entering into the eye and the closure of the limbal wound are
the same as described above for ECCE. However, the method of removal of
lens is different and also the fact that the incision is a little larger (9:30
O’clock to 2:30 O’clock or more) and a peripheral iridectomy is performed
before removing the lens. The techniques used for removal of lens are:
V Cryo-extraction: by applying a cryoprobe through which N--2O is passed
leading to lowering of the temperature at the tip to about – 40 C. This
causes adherence of the lens to the probe. Then the lens is delivered out
of the eye by gentle side and up-wards motion. This is the most
commonly used technique.
V Erysiphake
V Sliding Technique
V Tumbling technique
V Lens Forceps technique
V Wire-vectis technique
Postoperative Care
24 hours after the operation the bandage is removed and the eye is cleaned.
The eye is examined thoroughly with special emphasis on the visual acuity,
discharge in conjunctival sac, apposition of the wound, corneal clarity, anterior
chamber for depth and hyphaema, etc., pupil, IOL, posterior capsule, retina
and intra-ocular pressure. If any problem is encountered, it has to be dealt
with appropriately.
Topical antibiotic-steroid eye drops are advised to be instilled every 4-6 hourly
and ointment to be instilled at bed time. These drugs are used to control
postoperative inflammation and infection, and are gradually tapered over next
4-6 weeks.
Patient is instructed to avoid head-bath for 1 week, lifting heavy weights for
about 3 months and abstain from contact-sports for about 1 year.
Complications of Cataract Surgery
These can be grouped as:
Intra-operative
Post-operative
V Early
V Late

Intra-operative Complications
The most important are:

V Damage to corneal endothelium.
V Rupture of posterior capsule.
V Vitreous prolapse and loss.
V Hyphaema
V Expulsive hemorrhage
V Dislocation of nucleus into vitreous
Post-operative Complications
Early
V Corneal edema
V Wound leak
V Iris prolapse
V Shallow or flat anterior chamber
V Hyphaema
V Hypotony
V Glaucoma
V De-centered or displaced IOL
V Endophthalmitis
Late
V After-cataract
V Cystoid macular edema (CME)
V Vitreous touch syndrome
V Vitreous wick syndrome
V Irvine Gass syndrome (vitreous touch or wick & CME)
V UGH syndrome (uveitis, glaucoma and hyphaema)
V Bullous Keratopathy
V Glaucoma
V Visual Rehabilitation after Cataract Surgery (Aphakia)
The Problem
Removal of the lens from the eye or aphakia leads to:
V Absolute high hypermetropia (caused by loss of about 18 dioptre of
convergence power).
V Astigmatism
V Loss of accommodation
V Altered Color Perception
V More of UV rays (in A-band) reach the retina
V The hypermetropia is high (about 10 dioptre) because of loss of
convergence provided by the lens and it is absolute because no part of it
can be compensated by exertion of accommodation as theaccommodation
is lost.
Rehabilitation
Three methods are mainly used to tackle the problems of aphakia:
Intra-Ocular Lens (IOL)
Spectacles
V Contact-Lenses
V IOL Implantation
This the best method to manage the optical and visual problems of
aphakia. Currently available IOLs are safe, inexpensive and of good
optical quality. Implantation of IOL is easy if done at the time of
removing cataract. As a secondary procedure it may be difficult and

risky. The advantages of IOL become obvious when one looks at the
disadvantages of aphakic spectacles as follows. However, the
problem of loss of accommodation is still not solved with IOLs and
the patient may need to wear near correction for reading (although
multi-focal IOL are available but they are not very successful).
V Aphakic Spectacles
To correct the refractive error in aphakia about 10 dioptre of convex
lenses are required for distance vision and about 13 dioptre for near
vision. Such high power lenses are associated with numerous
physical and optical problems. And these problems become even
more troublesome if the aphakia is unilateral (the other eye being
normal). The most important of these problems are:
V Physical Problems: These glasses are heavy and wearing them
constantly can be associated with great physical discomfort. IOL
does not cause any discomfort.
V Magnification: Each dioptre of convex power leads to about 3 %
magnification of image and a difference of image size between
the two eyes of about 7 % is tolerable. Thus 10 dioptre aphakic
spectacles lead to about 30 % magnification of the image
which give rise to diplopia i.e., two images of one object are
seen one small (from normal eye) and other larger (from
aphakic eye). Moreover, when the objects appear larger they
appear falsely closer than reality, and this leads to physical in-
coordination. In IOL magnification is only about 1-2 %.
V Roving Ring Scotoma: The edge of a convex lens acts as a prism
and the higher the power of the convex lens the greater is the
prism angle (alpha). The light falling on the prism bends
towards its base by an angle alpha/2 , therefore, greater the
angle alpha the more will be the bending. In aphakic
spectacles, the angle alpha being large, the light falling at the
edge of the lens bends towards the center of the lens (base of
prism) and does not reach the pupil and is, therefore, not seen.
This results in an area of the visual field which is not visible to
the patient, or scotoma. And because the edge of the lens is
present all around the lens like a ring, so it gives rise to a ring
shaped scotoma. The position of this scotoma is not fixed in the
visual field because the eye keeps moving (or roving) in relation
to the aphakic spectacle. Hence, the result is a roving ring
scotoma. This is not seen with IOL.
V Jack-in-the-box Phenomenon: The presence of the above
scotoma leads to another interesting phenomenon. If an
interesting object appears in the periphery of the patients
visual field, it appears blurred (because the light is passing from
the side of the spectacle frame). The person tends to move his
head towards the object in order to see it clearly. But as he
turns the head the object comes to lie in the area of scotoma
and thus disappears. As he turns his head further the object
comes to lie in from of the spectacle in the visible area and so
reappears again clear and sharp. This sudden disappearance
and sharp reappearance of the objects is called jack-in-the-box
phenomenon. Not seen with IOL.
V Pin Cushion Effect: The magnification of image is more at the
periphery of the lens due to prism effect. Therefore, all the
objects appear stretched out at the corners like a pin-cushion.
Not seen with IOL.

V Spherical Aberrations: The light converges more near the edge

of the lens than at the center so the rays of light falling near
the edge are brought to focus in front of the rays falling at the
center. This results poor quality of image despite appropriate
correction of refractive error. Less with IOL.
V Chromatic Aberrations: The shorter the wave-length the more is
the refraction a ray of light undergoes. Therefore, in VIBGYOR
the violet end undergoes greater refraction than the red end of
the spectrum. This causes diffraction of light and makes the
edges of white object appear rain-bow colored. Less with IOL.
These optical problems can be minimized to a some extent by making some

modification is construction of aphakic lenses:
V Aspherical lenses
V High index lenses
V Lenticular lenses
V Large lenses with their edge cut off
Contact Lenses
Contact lenses, also, solve most of the problems related to the aphakic
spectacles and reduce the magnification to about 3-4 %. But for the old
patients handling the contact lenses is difficult due poor vision and lack of
physical dexterity. In the young they are a very good alternative to aphakic
spectacles and sometimes the only choice e.g., in unilateral aphakia (in
absence of adequate support for IOL).
Pediatric Cataract
Cataract occurring in a child assumes special importance because of some

characteristic differences in the way a child’s developing eye behaves.
Following are the main problems to be tackled while managing pediatric
cataract:
V Visual Assessment: It is very difficult to assess visual acuity of a pre-verbal
child and also young children do not complain of diminished vision.
Therefore, cataract is usually discovered in children by their parents in
advanced stages when the pupil appears white or the child becomes
severely visually handicapped.
V Vision Deprivation Amblyopia: The young developing visual system of a
child needs constant stimulation by a clear image on the retina in order to
develop normally. If visual stimulus is absent or disturbed by poor vision
due to cataract or any other cause then the development of visual system
is arrested leading to amblyopia. If macula is deprived of clear image in
the first 6-8 weeks of life then it can lead to failure of development of
fixation and causes nystagmus. This problems is even worse if only one
eye has the problem and the other is normal.
Therefore, if cataract is detected in a young child it has to be treated urgently
and the postoperative visual rehabilitation also involves treatment of
amblyopia.

Postoperative Inflammation and Fibrosis: The immune system of the child being
very active responds violently to surgery and thereby, leads to severe
postoperative uveitis and fibrosis. This severely mar the results of operation. To
deal with this problem some surgeons advocate Pars Plana Lensectomy as the
technique of choice for removal of cataract in children. But this technique make
implantation of IOL difficult.
After-cataract: The epithelial cells of the anterior capsule being very actively
dividing a child is very prone to develop dense and thick after-cataract. This can
be very difficult to treat because the children do not cooperate for YAG Laser
treatment and being thick the laser sometimes fail to penetrate it. Therefore,
some surgeons make an opening in the posterior capsule at the end of operation
for cataract (Primary Posterior Capsulotomy).
IOL Power Calculation: As the eyeball of the child is still growing it poses a
problem in calculating the power of the IOL to be implanted as the later is based
on the axial length of the globe. If a IOL of emmetropic power is implanted this
leads to myopia as the child grows up. Therefore, it is recommended that the
child be made hypermetropic by about 3 dioptre, so that as the child grow the
eye becomes nearly emmetropic.
Dislocation of Lens
Causes
Congenital
Familial
Ectopia lentis
Ectopia lentis et pupillae
Marfan’s Syndrome
Weil-Marchesani Syndrome
Homocystinuria
Hyperlysinemia
Sulphite-di-oxide Deficiency
Aniridia
Acquired
Hypermature cataract
Trauma
Chronic uveitis
Intra-ocular tumor
High myopia
Buphthalmos
Treatment
V Spectacles: If the clear lens is subluxated in such a way that most of the
pupil is still occupied by the lens then spectacle correction of the
refractive error is all that requires to be done.
V Extra-capsular Cataract Extraction: If the subluxated lens is cataractous
but only 1/3rd zonules are broken then ECCE with IOL can be done.
V Intra-capsular Cataract Extraction (Wire vectis technique): If more than 1/
3rd zonules are broken or the lens is dilocated into the anterior chamber
then it can be removed by ICCE using the wire vectis technique. An
instrument shaped like a loop of wire is inserted behind the lens to
remove it.

V Pars Plana Surgery: If the lens is dislocated into the vitreous then pars
plana route is used to remove it. The lens is nibbled out if it is soft using a
VISC probe. If lens is hard then it is first brought to anterior chamber from
where it is removed using a wire vectis.
Miscellaneous Conditions of Lens
Lenticonus
Anterior surface of the lens (rarely posterior surface) is projected into a
conical projection giving rise to high myopia. This condition is commonly
associated with renal anomalies in Alport’s Syndrome.
Lens Coloboma
A notch shaped defect is found as a rare congenital anomaly in the
equator of the lens. It can even be acquired if an intra-ocular tumor
presses on the lens.
After-Cataract
Opacification of posterior capsule after ECCE or Pahcoemulsification
caused by proliferation of lens epithelial cells from the anterior capsule, is
called after-cataract. If it leads to significant diminution of vision (> 2 lines
on Snellen’s Chart) then an opening can be created in the posterior
capsule with the help of Nd-YAG Laser (Neodymium - Yttrium Aluminium
Garnet Laset with a wavelength of 1064 nm) by photodisruption. This
opacification may take two characteristic forms: Elschnig’s pearls & Ring of
Sommering.
Author – Dr. Sanjay Dhawan
Authored on - 3 March 2005

Any suggestions or criticism are welcome and may be e-mailed to me.
URL http://sdhawan.com/ophthalmology/lens.html
E-mail: [email protected]

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LENS AND CATARACT Dr.

Sanjay Dhawan MBBS, MS (Gold Medallist) DO

Lens and Cataract

II. Congenital Abnormalities of Lens

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Layers (from without inwards):

Nucleus (from without inwards):

Refraction of light (+18 D)

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After-Cataract (after the cataract surgery)

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URL http://sdhawan.com/ophthalmology/lens&cataract.pdf E-mail: [email protected]

VI. Hypermature Cataract

Image Blur: Opacification of lens leads to diminution of vision which is

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Diurnal Variation of Vision: In central (cupuliform) cataract the vision is worse

Distortion: Cataract may make straight edges appear wavy or curved

Visual Acuity: Vision is diminished proportionate to the degree of cataract

Anterior Chamber: Depth of anterior chamber is normal except in intumescent

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Iris Shadow: In immature cataract a crescentic shadow of the iris is seen in

Distant Direct Ophthalmoscopy (DDO): Viewing the dilated pupil using an

Purkinje-Sanson Images: All optical interfaces (junction of media to different

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Differentiating Various Stages of Cataract

Features Immature Mature Hypermature

I. Lens Induced Glaucoma

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Fundus Examination: Detailed retina examination to rule out any pathology in

Lacrimal Syringing: It is important to rule out any block or focus of infection in

Blood Pressure: Hypertension not only leads to development of hypertensive

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General Investigation: General body check-up and some investigations like

Macular Function Tests: These are done to preoperatively assess the

These tests are:

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Indications for Cataract Surgery

II. Medical Indications

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III. Cosmetic Indication

Surgery for Cataract

Operative techniques available:

Intra-ocular lens (IOL) types:

Principles of Various Techniques

Extra-capsular Cataract Extraction (ECCE)

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Intra-capsular Cataract Extraction

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ECCE vs. ICCE

Patient preferably admitted to the hospital on previous evening (however,

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The anesthetic agent used is a solution of following;

Retrobulbar hemorrhage (operation has to be postponed for 2 weeks and

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sucked out (aspiration). A balanced salt solution (BSS) or Ringer’s Lactate

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The most important are: