Mishermaliyani

I11105026
 Cataract
• A cataract is a clouding of the lens of the eye
that can impair vision.
 Etiology
• Senile
• Traumatic
• Metabolic
• Complicated
• Maternal Infections
• Presenile Cataract
• Syndromes with Cataract
• Hereditary
• Secondary Cataract
 Etiology
• Rarely, cataracts can present at birth or in early
childhood as a result of
– hereditary enzyme defects
– severe trauma to the eye
– eye surgery
– intraocular inflammation
• Other factors that may lead to development of
cataracts at an earlier age include
– excessive ultraviolet-light exposure
– diabetes
– Smoking
– use of certain medications
 Chronological Types
• Congenital (since birth)
• Infantile (first year of life)
• Juvenile (1 to 13 years of life)
• Presenile (13 to 35 years of life)
• Senile
 Types of Cataract
• The lens consists of three
layers
• The outer layer is a thin,
clear membrane
• It surrounds a soft, clear
material (cortex)
• The hard center of the
lens is the nucleus
• A cataract can form in any
part of the lens
 Morphological types:
• Nuclear cataract develops in the nucleus or
centre of the lens.
• As it increases, there is an associated yellow
or brown discolouration of the lens.
• smoking, heavy alcohol consumption, sunlight
exposure and diabetes increased the risk of
nuclear cataract.
 Morphological types:
• Cortical cataract develops in the outer shell of
the lens as spokes and wedges and commonly
causes increasing glare sensitivity.
• A history of diabetes or previous heart attack,
and a blood factor (fibrinogen) associated
with vascular conditions appeared to increase
the risk
 Morphological types:
• Subcapsular Cataract : Starts as a small, opaque
area just under the capsule shell, usually at the back
of the lens, right in the path of light on its way to the
retina
• This type of cataract may occur in both eyes but
tends to be more advanced in one eye than the other
• Often interferes with reading vision, reduces your
vision in bright light and causes glare or halos around
lights at night
 Morphological types:
• Posterior subcapsular cataract develops at
the back of the lens, often in the visual axis,
and so affects vision rapidly and severely.
• The majority of people needing cataract
surgery have some posterior subcapsular
cataract present at that time
 Morphological types:
• The use of steroid therapy, particularly long-
term use of inhaled steroids increased the risk
of cataract in a moderate, dose-related
manner
• Other associations with posterior subcapsular
cataract included long-standing myopia,
diabetes, higher salt intake, smoking, blood
coagulation factors (fibrinogen) and kidney
disease.
 Maturity types
• Immature : Scattered opacities are separated
by clear zones.
• Mature : Cortex and nucleus become totally
opaque, Lens appears pearly white.
 Maturity types
• Intumescent
– Sometime during the course maturation the lens
imbibes lot of fluid and becomes swollen.
– Anterior chamber becomes shallow.
– Angle of anterior chamber may close resulting in
glaucoma (Phacomorphic Glaucoma).
Maturity types
• Morgagnian Cataract : A Hyper-mature
cataract, in which total liquefaction of cortex
allows the nucleus to sink inferiorly.
 Hypermature Cataract
• A cataract isn't dangerous to
the eye unless the cataract
becomes completely white, a
condition known as an
overripe (hypermature)
cataract
• Mature cataract, which has
become smaller and has a
wrinkled capsule as a result of
leakage of water out of lens.
• This can cause inflammation,
eye pain and headache
• A hypermature cataract is
extremely rare and needs
removal
 Congenital cataracts
• Cause :
– Without systemic association : isolated hereditary
cataracts
– Systemic association : metabolic(galactosemia,
galaktokinase deficiency), prenatal
infection,chromosomal abnormalities, skeletal
syndrom
 Infantile cataracts
• Infantile cataracts develop in the child’s early
years, and might represent metabolic
diseases, trauma, but, most importantly,
might herald the presence of intraocular
tumor.
 Etiology of Pediatric Cataracts
• Hereditary
– Autosomal dominant form most common
• Genetic and Metabolic Diseases
– Down syndrome
– Marfan’s syndrome
– Myotonic Dystrophy
• Maternal Infections
– Rubella, Syphilis, Toxoplasmosis, Varicella
 Secondary cataracts
• Chronic anterior uveitis
• Acute congestive angle closure glaucoma
• High(pathological) myopia
Drug induced Cataracts
• Steroid-induced cataract
– This occurs as a result of excess intake of oral steroid
or putting steroid drops in the eye.
– The longer a patient is on steroids, the greater is his
risk for developing two types of cataract, the
posterior subscapular cataract (PSC) and the nuclear
cataract.
– In PSC, the cataract develops in the rear area while in
nuclear cataract; the cataract develops in the center
of the lens
• Drugs induced: Chlorpromazine, Miotics,
Busulphan, Amiodarone, gold
 Metabolic Cataract
• Diabetes
• Galactosaemia -inborn error of metabolism
• Calcium disorders
 Metabolic Cataract
• Cataracts develop sooner in diabetic patients
than in non-diabetic patients
• This is caused by shifts in the glucose,
electrolyte, and water balance within the lens
• Fluctuating vision and rapid shift to near
sightedness are symptoms of diabetes
 Traumatic Cataracts
• Due to a direct penetrating injury.
• Concussion- Electric shock and lightning.
• Ionizing radiation to ocular tumours.
• Surgical trauma
 Pathogenesis
• Two main pathogenetic processes are involved
in most (especially senile) cataract:
– Hydration
– Sclerosis
 Hydration
• Increased hydration leads to lamellar separation
and collection of protein-deficient fluid between
lens fibers.
• Leads to increased scattering of light and loss of
transparency.
• Hydration also leads to denaturation of lens
proteins and results in irreversible opacification.
• Mechanisms of increased hydration are:
– Failure of active pump mechanism
– Increased leakage across posterior or anterior capsule
– Increased Osmotic pressure
 Sclerosis
• This process is seen mostly in senile cataract
and involves predominantly the nucleus.
• Increased compaction of lens proteins and
fibers due to inter-lamellar binding of proteins
by sulfide bonds.
• Resultant aggregates of very high molecular
weight proteins lead to increased scattering of
light and loss of transparency.
• It is part of normal aging phenomenon.
 Symptoms
• Glare: When patient
looks at a point source of
bright light the diffusion
of white and colored light
around it drastically
reduces vision.
• Image Blur: Opacification
of lens leads to
diminution of vision
which is characteristically
painless and progressive
(& does not improve with
pin-hole).
 Symptoms
• 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.
• 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.
 Symptoms
• Altered Color Perception:
The yellowing of lens
nucleus is steadily
progressive leading to
change in color saturation
of the image seen.
• Black Spots: Patient may
complaint of seeing black
spots fixed in his field of
vision.
 Symptoms
• 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.
 Signs
• Visual Acuity: Vision is diminished proportionate
to the degree of cataract
• 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.
 Signs
• 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.
 Signs
• Fundus: In early stages of cataract the retina may
be seen by ophthalmoscopy and appear normal.
In advanced cataract the retina cannot be seen.
• Intraocular Pressure: IOP is normal in cataract
unless lens induced glaucoma (phacolytic or
phacomorphic) develops
• 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,
 Methods of evaluation of cataract :
• Visual acuity : Checking vision of both eyes unaided and aided
with glasses and pin-hole vision to know the improvement as
well as to get the general idea about the macular function of
the eyes. This will help in prognostic evaluation of visual
recovery after cataract surgery.
• Intra ocular pressure : If intra-ocular pressure increases as a
secondary to cataract, surgery is needed to prevent further
complications.
• Slit-lamp examination : To know the type of cataract along
with its opacity, morphology and etiology or any associated
ocular pathology.
• Direct and indirect ophthalmoscopy : Dense opacity (cataract
will prevent retinal evaluation)
 Differentiating Various Stages of
Cataract
Features Immature Mature Hypermature
Anterior Normal (shallow in Normal (shallow in to deep
Chamber intumescent) intumescent)
Color of Lens Grayish white Pearly white Milky white (with
brown crescent of
nucleus) or chalky
white
Iris shadow Seen Not seen Not seen
 Indications for Cataract Surgery
• Optical
• Medical
• Cosmetic
 Optical
• 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.
• Glare is another optical indication especially in
individuals involved in night driving.
 Medical
• 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:
– Hypermature cataract
– Lens induced glaucoma
– Lens induced uveitis
– Dislocated / subluxated lens
– Intra-lenticular foreign body
– Diabetic Retinopathy to give Laser photocoagulation
– Retinal Detachment or any other posterior segment
pathology
 Cosmetic
• 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
 Treatment
• Extra-capsular cataract extraction (ECCE)
• Intra-capsular cataract extraction (ICCE)
• Phacoemulsifiation
 Extra-capsular cataract extraction
(ECCE)
• Extra-Capsular Cataract Extraction (ECCE): is a
conventional technique. It requires
– ECCE requires an incision of 10-12mm
– The doctor removes the clouded lens in one piece.
– Multiple stitches are required.
– He implants a non-foldable lens.
• Hence, this procedure requires multiple
stitches  There are increased chances of
post-operative cylindrical power astigmatism.
 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 : Vitreous loss, corneal edema,
endophthalmitis, cystoid macular edema, aphakic
glaucoma, etc.
ECCE
 Intra-capsular cataract extraction
(ICCE)
• The lens is removed 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.
 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.
 ECCE ICCE
Lens removal Nucleus removed out of Lens removed as single
the capsule and cortex piece within its capsule
sucked out
Posterior capsule & Intact Removed
zonules
Incision Smaller (8 mm) Larger (10 mm)
Peripheral iridectomy Not performed Required to avoid
pupillary block glaucoma
Sophisticated equipment Required Not required
Time taken More Less
IOL Implantation Posterior chamber Anterior chamber (with its
associated risk of
damage to corneal
endothelium leading to
Pseudo-phakic Bullous
Keratopathy)
Expertise required Difficult technique Easier to learn
Cost More Less
 ECCE ICCE

Complications which are After-Cataract 1.Vitreous prolapse & loss

increased 2.Cystoid Macular Edema
3.Endophthalmitis
4.Aphakic Glaucoma
5.Fibrous & Endothelial ingrowth
6.Neovascular Glaucoma in
Proliferative Diabetic
Retinopathy
Compications which are All the complications mentioned After-Cataract
decreased for ICCE

Indications A routine procedure for all forms 1.Dislocated Lens

of cataract (except where contra- 2.Subluxated Lens (>1/3rd
indicated) zonules broken)
3.Chronic Lens Induced Uveitis
4.Hypermature Shrunken
Cataract with thick anterior
capsule
5.Intra-lenticular Foreign Body
when integrity of posterior
capsule is compromised.
Contraindications 1.Dislocated lens Young Patients (<35 years) who
2.Subluxated lens (>1/3rd have strong attachment between
zonules broken) lens and vitreous (Ligament of
Weigert)