Cataract

By : Reci Maulita
I11110032
 Anatomy of the crystalline lense

Position Shape
Immediately behind the iris Biconvex
Held in place by zonules that attach to the About 9 mm on diameter and 4 mm thick
ciliary body. Avascular, receive its nutrients from the aqueous
Anterior to the lens is the aqueous humor; humor
posterior to it, the vitreous humor. Transparant
composed of 4 layers
o Capsule
o Subcapsular epithelium
o Cortex
o Nucleus
 Function of the crystalline lense
Contributes 15-20 D of refractive power.
Provides accommodation
 Composition of the crystalline lense
Contains water (65%), protein (35%) and minerals.
Kalium mineral higher than other tissues
 Crystalline Lens metabolisme
1. glucose metabolism
Glucose enter the lense from aquos humor by
difusse facilitated process.
90-95% glucose fosforilated by heksokinase ->
glukose-6 phosphate -> glikolisis anaerob and
pentosa phosphate pathway
Sorbitol pathway more active on
hyperglicemia condition,
2. protein metabolism
Lens have higher protein concentrate than other
tissues
Protein degradation can inhibit, lens can control
protein degradation by marking the protein with
ubiquitin
This process happen on the epithelial and need
ATP
Protein lens changes into peptidase by
endopeptidase, then changes again into amino
acid by eksopeptidase
3. Glutation
Maintain the transparency of the lens by
prevent crystalline agregation and protect
oxidative stress

4. Antioxidan mechanism
Lens have glutation peroksidase, katalase dan
superoksida dismutase enzymes to protect
itself from free radical.
5. Regulation for balancing water and cation (Kalium
and Natrium)
Important for maintain the transparency of the lens
Cataract
 Definiton
Greece => Katarrhakies
England => Cataract WaterFall
Latin => Cataracta
Indonesian => Bular

A cataract is any opacity of the lens, whether it is a

small local opacity or a diffuse general loss of
transparency.
 Etiology
Aging
Free radical
UV radiation
Trauma
Infection
Systemic disease (such as diabetes)
Smoking
Heredity
 Epidemiology

On the developing country, 1 - 3 % of the

society had blind and cataract (50%) mostly
present as the cause of blindness.
On the developed country, cataract present
1,2% as the cause of the blindness
 Cause of blindness in Indonesia
1. Cataract 0,78 %
2. Glaucoma 0,20 %
3. Refraction anomali 0,14 %
4. Retina disorders 0,13 %
5. Cornea disorder 0,10 %
6. Other 0,15 %
 General Symptoms
Patients experience the various symptoms such as
Fotofobia
seeing only shades of gray
Halo
visual impairment
Altered color perception
blurred vision
Monocular double vision due to the cataracts
 Examination
Visual acuity testing. The visual acuity may range from 6/9 to
just PL +
Test for iris shadow
Direct ophthalmoscopic examination. Partial cataractous lens
shows black shadow against the red reflex in the area of
cataract. Complete cataractous lens does not even reveal red
reflex
Slit-lamp examination. Should be performed with a fully-
dilated pupil. The examination reveals complete morphology
of opacity (site, size, shape, colour pattern and hardness of the
nucleus).
 Classification
Cataracts may be classified according to
several different criteria.
Time of occurrence (acquired and
congenital)
Maturity
Morphological
 Classification according to time of occurrence
Acquired cataracts (over 99%)
Senil cataract Congenital cataracts (less than 1%)
Presenil cataract
Diabetes melitus
Miotonic dystrophy
Atopic dermatitis
Neurofibroma type 2
Traumatic cataract
direct penetrating inury to the lens
Concussion
Electric shock
Ionizing radiation
Infrared radiation
Drug induce cataract
Steroid
Chlorpromazine
Busulphan
Amiodarone
Gold
allupurinol
Secondary cataract
Classification according to maturity

1. Intumescent cataract: occur when the lens has

become swollen by imbibed water.
2. Immature cataract: it have scattered opacities that
are separated by clear areas.
3. Mature cataract: the lens is diffusely white due to
complete opacities of the cortex.
4. Hypermature cataract: a mature cataract that have
become swollen with a wrinkled capsule as a result
of water leakage out of the lens.
5. Morgagnian cataract: a hypermature cataract
leading to total liquefaction of the cortex causing
the nucleus to sink inferiorly.
 Classification according to morphology

Capsular cataract
Subcapsular cataract
Nuclear cataract
Cortical cataract
 Senile cataract
All of the opacity condition of the lens that
happen above 50 years old
 Incipient Cataract
- Cloudiness starting from the edge of the equator, grilled-
shaped head to anterior and posterior (cortical cataract)
- This cloudiness can lead to polioplia where the
refraction index is not the same in all of the part of the
lens
 Intumescent Cataract
- Cloudiness start and acommpanying by swollen of
the lens, where the degenerative lens absorbed
water
- The swollen pushing the iris and make the eye
chamber became shallow than normal
 Immature Cataract
- Only part of the cloudiness found in the lens (not affected all
the part),
- The volume of the degenerative lens will increase due to the
osmotic pressures rise

The nucleus of this lens is apaque (nuclear cataract), while the cortical layers
remain clear. The opacity appears as a dark shadow againts the red reflex.
 Mature Cataract
- The cloudiness already covered the masses of the
lens, which caused by calcium ions deposition
- If there is no surgical procedure during
intumescent or immature cataract, then the liquid
will came out of the lens bring out the cloudiness
all over the lens, which in prolonged condition will
cause the calcification of the lens
- The anterior eye chamber will be in the same
normal depth
 Hypermature Cataract
- A continuation of degenerative stage of cataract , will result
in hard, soft, or melting
- The degenerative lens mass will be out of the lens capsule
and the lens will be shrink, yellow and dry.
- Sometime the shrink process will continue and make the
zonular of zinn got loosen.
- If the cataract process continue, accompanied by thick
capsule, the degenerative cortex will shown like a box of
milk-shape with a drowning heavy nucleus inside the cortex
lens (condition knows as Morgagni cataract)
 Senile Cataract: Morgagnian Cataract

Morgagnis cataract the final stage in a cataract

that has usually developed over the course of two
decades
A hypermature cataract in which the lens nucleus
floats freely in the capsular bag is called a
morgagnian cataract.
Senile Cataract: Morgagnian Cataract
PRESENIL CATARACT
 Diabetic Cataract
Hyperglicemia condition, glucose metabolize by aldolase reductase
into sorbitol -> accumulated sorbitol resulting in osmotic
overhydration -> swollen lens -> impairment of sitoskeletal -> lens
opacity
 Myotonic Dystrophy

Opacities first occur between

the ages of 30-50, which
evolve into visually disabling
stellae posterior subcapsular
cataract.
 Atopic dermatitis
10% of patient with severe
atopic dermatitis develop
cataract in the 2-4 decades.
The opacities are often
bilateral and may mature
quickly
shield like dence anterior
subcapsular plaque which
wrinkles the anterior capsule
is characteristic
 Traumatic cataract
Trauma is common cause of unilateral cataract
in young individuals, the following may be
responsible:
Direct penetrating injury to the lens
 Frequent Traumatic Cataracts
Contusion cataract: Contusion of the eyeball
will produce a rosette shaped subcapsular
opacity on the anterior surface of the lens. It
will normally remain unchanged but will
migrate into the deeper cortex over time due
to the apposition of new fibers.
 Rare Traumatic Cataract
Infrared radiation cataract (glassblowers cataract): This type
of cataract occurs after decades of prolonged exposure to the
infrared radiation of fire without eye protection.
Characteristic findings include splitting of the anterior lens
capsule, whose edges will be observed to curl up and float in
the anterior chamber.Occupational safety regulations have
drastically reduced the incidence of this type of cataract.
Electrical injury: This dense subcapsular cataract can be
caused by lightning or high-voltage electrical shock.
 Drug induced cataract
Steroids, both systemic and topical are cataractogenic. The
lens opacities are initially posterior subcapsular, later the
anterior subcapsular region becomes affected
 Chlorpromazine, may cause the deposition of innocous,
fine, stealle, yellowship-brown granules on the
anteriorlens capsule.
 Busulphan, used in treatment of chronic myeloid
leukimia may occasionally cause lense opacity
Amiodarone, used in treatment of cardiac
arrythmias, cause visually inconsequential
anterior subcapsular lens deposits.
Gold, used in treatment of rheumathoid arthritis,
causes innocous anterior capsular deposits.
Allupurinol, used in treatment of hyperuricaemia
and chronic gout. Increase the risk of cataract
formation in elderly patient.
Secondary cataract
Its develops as a result of some
other primary occular disease
1. Chronic anterior uveitis.
The earliest finding is a
polychromatic lustre at the
posterior pole of the lens.
If the inflammation persist,
posterior and anterior
opacities develop and may
progress more rapdily in the
presence of posterior
synechiae
 Acute congestive angle clossure
glaucoma
It May cause gray-white,
anterior, subcapsular or
capsular opacities within
the pupllary area
(glaukomflecken).
They represent focal infarcts
of the lens epithelium.
 Management of age related cataract
Indication for surgery
Visual improvement
Medical indication
Cosmetic indication
 Pre operative evaluation
General medical examination
Pertinent ophtalmic examination
Cover test
Pupillary response
Occular adnexa
Cornea
Anterior segment
Lens
IOP
Fundus
Biometry
Biometry affords calculation of the lens power
likely to result in emmetropia. Involves two
occular parameters:
Keratometry, the curvature of the anterior corneal
surface, in milimeter or dioptres
Axial length, the anteroposterior dimensions of
the eye in milimeter, measured on A-scan
ultrasonography
 SRK formula, the most common formula to
calculate IOL power is that develop by Sander,
Retzlaff and Kraff which states that :

P = A 2,5 L 0,9 K

P = lens power required to generate postoperative

emmetropia
A = The A constant, which varries between 14-19
with different IOL
L = The axial length in milimetres
K = The average keratometry reading in dioptres.
 Intraocular lens
1. Positioning

2. Design
Rigid
foldable
 Treatment
SURGICAL TREATMENT

Intra Capsular Cataract Extraction(ICCE)

Extra Capsular Cataract Extraction(ECCE)
Phacoemulsion
 Intracapsular Cataract Extraction
In this method, the entire lens is removed
within its capsule
The suspensory ligaments of the lens are
dissolved by the enzyme chymotrypsin a
hole cut in the iris (iridectomy) allows the
aqueous to bypass the pupil.
Intracapsular surgery is still a useful
procedure, particularly when facilities for
extracapsular surgery are not available
Intracapsular Cataract Extraction
ICCE
 Extracapsular Cataract Extraction
The anterior capsule is opened (capsulorrhexis)
incision in the eye (about 10 mm in length)
anterior capsule is cut open with the tip of a sharp
needle
Then only the cortex and nucleus of the lens are
removed (extracapsular extraction); the posterior
capsule and zonule suspension remain intact
provides a stable base for implantation of the
posterior chamber intraocular lens.
 Extracapsular Cataract Extraction
The large nucleus is then expressed whole and the
remaining soft lens fibres aspirated. A non-folding
lens is then inserted into the empty lens capsular bag
and the incision closed with fine sutures.
The surgical techniques of ECCE presently in vogue
are:
Conventional extracapsular cataract extraction
(ECCE),
Manual small incision cataract surgery (SICS),
Coventional ECCE
ECCE Conventional
 Small incision cataract surgery (SICS)

Surgical steps of SICS: F. Sclero-corneal tunnel with crescent

A. Superior rectus bridle suture; knife;
B. Conjunctival flap and exposure of sclera; ision; G. Internal corneal incision;
C, D & E. External Scleral incisions (straight, frown shaped, and H. Side port entry;
chevron, respectively) part of tunnel inc
Small incision cataract surgery (SICS)
I. Large CCC;
J. Hydrodissection;
K. Prolapse of nucleus into
anterior chamber;
L. Nucleus delivery with
irrigating wire vectis;
M. Aspiration of cortex;
N. Insertion of inferior haptic
of posterior chamber IOL;
O. Insertion of superior haptic
of PCIOL;
P. Dialing of the IOL,
Q. Reposition and anchoring of
conjunctival flap.
SICS
 Phacoemulsification
Offers the surgeon the possibility to break the
nucleus into smaller pieces and even into a fine
emulsion of material
Phacoemulsification
Phacoemulsification
CONGENITAL CATARACT
 Hereditary Congenital Cataracts
Familial forms of congenital cataracts may be autosomal
dominant, autosomal recessive, or X-linked. They are easily
diagnosed on the basis of their characteristic symmetric
morphology.
Forms of hereditary congenital
cataract:
Zonullar cataract, in which opacity
occupies a discrete zone in the
lens.
Nuclear
Lamellar
Capsular
Sutural
Polaris cataract, in which the
opacities occupy the
subcapsular cortex at the
anterior or posterior pole of
the lens
Anterior polar
Posterior polar
 Systemic association
1. Galactosemia involves severe
impairment of galactose
utilization caused by absence of
the enzyme galactose 1-
phosphate uridyl transferase
(GPUT). Inheritance in AR
Characterized by a central oil
droplet opacity develops within
the first few days or weeks.
2. Galactokinase deficiency involves the first
enzyme in the pathway of galactose
metabolisme, Inheritance in AR
Cataract consist of lamellar opacities, may
develop in fetus or in early infancy.
 Prenatal infection
1. Congenital rubella is associated with cataract
about 15%.
2. Other intrauterine infections that may be
associated with neonatal cataract are
toxoplasmosis, cytomegalovirus, herpes
simplex and variecella.
 Chromosal abnormalities
Down syndrome (trisomy 21)
Cataract of various morphological occurs in
about 5% of patients. The opacities are
usually symmetrical and often develop late to
childhood.
Other chromosomal abnormalities associated
with cataract include Patau (trisomy 13) and
Edward (trisomy 18) syndrome
 Management
Occular examination
Since a formal estimate of visual acuity
cannot be obtained on the neonate, reliance is
required on the density and morphological of
the opacity.
 Timing of surgery
1. Bilateral dense, require early surgery
2. Bilateral partial cataract may not require
surgery untill later.
3. Unilateral dense cataract merit urgent
surgery
4. Partial unilateral cataract can usually be
observed or treated non surgically
 Surgical technique
1. A scleral tunnel 6 mm in width, is fashioned
2. The anterior chamber is entered with keratome (usually 3 mm wide) and the
anterior chamber filled with viscoelasic substance
3. The anterior capsulorhexis id performed. In children the anterior capsule is
more elastic than in adults and the rhexia My be difficult due to a tendency to
run outwards.
4. The lens matter is aspirated with a vitreus cutter or a simcoe cannula
5. A capsulorhexis is then performed on the posterior capsule
6. A limited anterior vitrectomy is performed with a vitrector
7. A PMMA posterior chamber IOL is implanted into the capsular bag.
8. The viscoelastic substance is aspirated
9. Intra ocular scissor and forceps may be required to exice thick capsular
material or retrolenticular plaques in eyes with associated persistent
hyperplasticprimary vitreus.
10. A well constructed scleral tunnel often will not require a suture.
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