CATARACT

AUDI ADIBAH | AFFAN SYAFIQI | AMANINA NASIR | NURUL HIDAYU | NIK NOR LIYANA | ARINA ZAHARI
ANATOMY OF THE LENS
A biconvex structure attached to
the ciliary process by the zonular
fibre, between iris & vitreous
humour
Non-vascular, colourless and
transparent
Index of refraction 1.336
Consists of stiff elongated,
prismatic cells known as lens fibre,
very tightly packed together
Divided into nucleus, cortex and
capsule
The whole lens enclosed within an
elastic capsule
Helps to refract incoming light
and focus it into the retina
ANATOMY OF THE LENS

STRUCTURE OF THE
LENS:
LENS CAPSULE
ANTERIOR LENS
EPITHELIUM
LENS FIBER
ANATOMY OF THE LENS
LENS CAPSULE

Thin transparent, collagen

membrane
Surrounds lens
completely
Elastic in nature but
contain no any elastic
tissue
Anteriorly secreted by
lens epithelium and
posteriorly by basal cells
of elongating fibers
ANATOMY OF THE LENS
ANTERIOR LENS EPITHELIUM
Single layer below the lens
capsule
Formed of cuboidal cells
Become columnar at equatorial
region
LENS FIBER
The epithelial cells elongated to
form lens fibers which have a
complicated structural forms .
Mature lens fibers are cells
which have lost their nuclei.
As the lens fibers are formed
throughout the life, these are
arranged compactly as nucleus
& cortex of the lens.
 ANATOMY OF THE LENS
CORTEX NUCLEUS

Its is the peripheral part which Its is the central part containing
compromises the youngest the oldest fibres. It consists of
lens fibres. different zones, which are laid
down successively as the
development proceeds.
Different zones:
I. Embryonic nucleus
II. Fetal nucleus
III. Infantile nucleus
IV. Adult nucleus
 LENS TRASPARENCY
Its transparency is due to the arrangement of its
fibres, internal structure and the biochemistry of
the lens cells and fibres.

A cataractous lens is when the lens become

opaque.
 CATARACT
WHAT IS CATARACT?
Cataract is a clouding of the lens or any opacity within the lens
which leads to a decrease in vision.
CATARACT
 INCIDENCE
Incidence of Lens opacities in the “normal”
population with aging.
(Cinotti & Patti, 1968)

AGE GROUP (YEARS) LENS OPACITY (%)

50 – 59 65
60 – 69 83
70 – 79 91
> 80 100
CLASSIFICATION
MORPHOLOGICAL CLASSIFICATION
CLASSIFICATION
MORPHOLOGICAL CLASSIFICATION
CLASSIFICATION
CLASSIFICATION
BASED ON DEGREE OF MATURITY
MATURE IMMATURE

Cataract is one in which Cataract is one in which

the lens is completely the lens is partially
opaque. opaque.

HYPERMATURE MORGAGNIAN
Cataract is a
Cataract is shrunken hypermature cataract in
and wrinkled anterior which liquefaction of
capsule due to leakage the cortex has allowed
of water out of the lens the nucleus to sink
inferiorly
IMMATURE CATARACT
Features:
 Opacification becomes more diffuse and irregular.
 Iris shadow still visible.
 Lens is not completely opaque
 Wedge shaped opacities at periphery of the lens
 Progress gradually
IMMATURE CATARACT
IRIS SHADOW IN IMMATURE CATARACT
When there is any clear cortex between the iris and
the opacity (greyish white in immature senile
cataract), the shadow of the iris which falls upon
the opacity, as light is cast upon the eye is visible
through the clear cortex. This is called the ‘iris
shadow’ and is a common sign in immature senile
catarct.
IMMATURE CATARACT
WHAT IS THE IRIS SHADOW?
 Black crescent
 Due to the presence of clear interval between
iris and lens opacity
 MATURE CATARACT
 Symptoms
- Usually severe decrease in vision.

 Features
- Complete opacification of the lens capsule, cortex and the
nucleus
- Lens appears pearly white in colour.

 Also known as ripe cataract.

 May progress to hypermature cataract

 May be complicated with phacolytic glaucoma.

 MATURE VS IMMATURE
HOW TO DIFFERENTIATE MATURE AND IMMATURE CATARACT?

IMMATURE CATARACT MATURE CATARACT

Visual acuity is reduced to Visual acuity is reduced to hand
counting fingers movement or perception of light
Lens is partially opaque Lens in totally opaque
Iris shadow is present No iris shadow is present
Fundus may be visible No fundus details
MATURE CATARACT
HYPERMATURE CATARACT

Which is characterized by wrinkling of the capsule due

to liquefied lens cortex and morgagnian
cataract (sinking of lens nucleus inferiorly within the
capsule)

This can cause inflammation, eye pain and headache

(if complicated by glaucoma)

A hypermature cataract is rare and needs removal

HYPERMATURE CATARACT
MORGAGNIAN CATARACT

 Complete cortex is liquefied and appears milky white in

colour.

Nucleus settles at the bottom

 Calcium deposits may also be seen on the lens capsule.

PATHOPHYSIOLOGY
The lens is made mostly of water and
protein fibers.

Opacity occur when the lens protein

(crystallins) clump together

Ability for lens to refract lights reduce

which cause reduce visual acuity.

Chemical modification of the lens

cause it to be thicken and harden
CLINICAL PRESENTATION
PAST MEDICAL HISTORY

May reveal risk factors such as

- Trauma
- Intrauterine infections
- Diabetes or other metabolic disorders

FAMILY HISTORY

Cataract may have occurred in other members of the

family in the hereditary variants.
CLINICAL PRESENTATION
PRESENTING COMPLAINTS AND HISTORY

 Decreased visual acuity is the commonest complaint.

- Progressive and painless
- Worse in bright light

 There may be complaint of glare and monocular diplopia if the

cataract splits the visual axis

 A myopic shift in the refraction with progression of cataract may

also be noted

 Some complain of a white reflex in the pupil

 VISUAL ACUITY

Blurred vision due to scattering of light on the retina

VISUAL ACUITY
VISUAL ACUITY
 LENS OPACITY

Normal eye – Good Cataractous eye – Poor red

red reflex reflex
A.Morphological classification:
1.capsular cataract
-Anterior capsular cataract
-posterior capsular cataract
2.Subcapsular cataract
-Anterior subcapsular cataract
-posteripor subcapsular cataract
3.Cortical cataract
4.Supranuclear cataract
5.Nuclear cataract
6.Polar cataract
-Anterior polar cataract
-Posterior polar cataract
B.Etiological classification:
1.Congenital and developmental
cataract
2.Acquired cataract
-senile cataract
-traumatic cataract
-complicated cataract
-metabolic cataract
-Electric cataract
-radiational cataract
-Toxic cataract
Eg:cortical induced cataract
miotics induced cataract
copper induced cataract
-Cataract associated with skin diseases
-Cataract associated with osseous diseases
-Cataract with miscellaneous syndromes
a)Dystrophica myotonica
b)Down’s syndrome
c)Lowe’s syndrome
d)Treacher collin’s syndrome
Congenital and developmental
cataracts:
-These occur due to some disturbance in the
normal growth of the lens.When the disturbance
occurs before birth, the child is born with a
congenital cataract.
-Developmental cataract may occur from infancy to
adolescence.Therefore such opacities may involve
infantile or adult nucleus,deeper parts of cortex or
capsule.This type of cataract typically affects the
particular zone which is being formed when this
process is disturbed.
 Definition
:
• A congenital opacity of
the crystalline lens.
Cloudiness in the lens
of the eye that is
present
at, or develops shortly
after birth. Congenital
cataracts are also the
most frequent cause of
leukocoria (white pupil)
in children.
Etiology
BILATERAL
:
• Idiopathic (60%)
UNILATERAL
• Hereditary (30%)
• Idiopathic (80%)
• Intrauterine infection
• Intrauterine
• Associated with ocular infection
disorders
• Ocular
• Tumor abnormalities
• Metabolic (10%)
• Maternal drug • Trauma (9%)
ingestion/
malnutrition
• Trauma
(Friedman, NJ & Kaiser,
Etiology:
1.Idiopathic
2.Heredity
3.Maternal factors include
-malnutrition during pregnancy
-Infections
-Drug ingestion
-Radiation
4.Foetal or infantile factors
-Deficient oxygenation
-birth trauma
-Metabolic disorders of foetus as
galactosemia,galactokinase deficiency and
neonatal hypoglycemia.
-Cataract associated with other congenital
anomalies: as Down’s syndrome,Lowe’s
syndrome, myotonia dystrophica and
congenital icthyosis.
-
Clinical types:
1.Congenital polar cataract
-Anterior capsular cataract
-Posterior capsular cataract
2.Polar cataract
-Anterior polar cataract
-Posterior polar cataract
3.Congenital nuclear cataracts
-Cataracta pulverulenta
-Lamellar cataract
-sutural and axial cataracts
*floriform cataract
*coralliform cataract
 *spear shaped cataract
*anterior axial embryonic cataract
*dendritic suture cataract
-total nuclear cataract
4.Generalised cataract
-coronary cataract
-Blue dot cataract
-Total congenital cataract
-Congenital membranous cataract
1.Congenital capsular cataracts
a)Anterior capsular cataracts are
nonaxial,stationary & visually insignificant
b)Posterior polar cataracts are rare

2.Polar cataracts
a)Anterior polar cataract
-It involves the central part of the anterior
capsule and adjoining superficial most cortex.
-It may be due to delayed development of
anterior chamber
-due to corneal perforation
Morphological types
*Thickened white plaque in the centre of
anterior capsule.
*Anterior pyramidal cataract
*Reduplicated cataract(double cataract)
2.Posterior polar cataract
-It is very common lens anomaly & consists of
a small circular circumscribed opacity involving
the posterior pole.
Associations:
-persistent hyaloid artery remnants
-posterior lenticonus
-persistent hyperplastic primary vitreaous
Types:
1.Stationary form
2.Progressive form which progress after birth. It
has an tipical ‘Onion whorl appearance’.

3.Congenital nuclear cataracts

a)Cataracta centralis pulverulenta-is
embryonic,bilateral & characterised by small
rounded opacity lying exactly in the centre of
the lens.Opacity has powdery appearance.
b)Lamellar cataract
-most common type of cataract presenting with
visual impairment.
Etiology: Genetic or environmental in origin
-Genetic pattern is usually of familial
autosomal dominant variety.
-environmental form is associated with vit-D
def,hypocalcaemia,maternal rubella infection.
-bilateral
-main mass of lens inernal & external to zone
of cataract is clear except for small linear
opacities like spokes of wheel(riders)
-occasionally two rings of opacity are seen.
• Consist of concentric,
Zonular
sharply (Lamellar)
demarcated
Cataract
zones(lamellae) of
opacities surrounding a
core, that is clear, &
enveloped by the clear
cortex externally.
• May be linear opacities,
like spokes of a wheel
(Called riders) that
extends outwards
towards the equator
pathognomonic.
• Child present with
photophobia (due to
light scattering)
• Surgery when VA less
than 6/18 (Basak, SK.,
2007)
3.Sutural and axial cataracts
-These are comparatively of common
occurance and cosists of series of punctate
opacities scattered around the anterior and
posterior Y sutures.
-These are usually static and bilateral.
-Have diff pattern as
a)Floriform cataract-opacities are arranged like
pearls of a flower.
b)Coralliform cataract-known as fusiform spindle
shaped axial cataract.
c)Spear shaped cataract-lenticular opacities are
in the form of scattered heaps of shining
crystalline needles.
d)Anterior axial embryonic cataract-occurs as fine
dot near the anterior Y suture of foetal nucleus.
e)Dendritic sutural cataract: occurs as fine dots
along the dendritic sutures.

4.Total nuclear cataract

-Involves the embryonic and foetal nucleus
-c/b dense chalky white central opacity
-bilateral and non-progressive
Generalised cataracts:
1.Coronary cataract
-It is an extremely common form of
developmental cataract occuring about puberty.
-opacities have regular radial distribution in
periphery of lens.
-vision is usually un affected.
2.Blue dot cataract
-k/a cataracta punctata caerulea
-most common type of congenital cataract.
-usually forms in first 2 decades of life.
-char. Punctate opacities are in the form of
rounded bluish dots situated in the peripheral part
of adolescent nucleus and deeper layer of the
3.Total congenital cataract
-It is common variety may be unilateral
/bilateral.
-hereditory ,other imp cause is maternal
rubella.

Rubella cataract
-maternal rubella infection aquired
during first trimester may cause rubella
cataract.
-Rubella cataract- child is born with
pearly white nuclear cataract.
Rubella syndrome:
1.Ocular defects- congenital cataract, salt and
pepper chorioretinopathy.
2. Ear defects- deafness
3.Heart defects-patent ductus arteriosus

4.Congenital membranous cataract

-Total or partial absorption of congenital
cataract leaving behind membranous cataract.
•Diagnosi
History:
s:
• 1. Duration
• 2. Family history of congenital cataracts
• 3. Visual status: Ambulation in familiar &
unfamiliar surroundings.
• 4. Behavioural pattern & school performance.

• Birth history:
• 1. History & Degree of consanguinity
• 2. History of maternal infection during 1st
trimester
• 3. Gestational age & birth weight
• 4. Birth trauma
• 5. Supplemental O2 therapy in perinatal period.
• 6. Developmental milestone

(Joseph, E., 2006) & (The Royal College of

 CONGENITAL CATARACTS:LABORATORY
EVALUATION
RESULT POSSIBLE
DIAGNOSIS

+ REDUCING GALACTOKINASE
SUBSTANCE DEFICIENCY
AMINOACIDURI LOWE’S
urine A HEMATURIA , SYNDROME
PROTEINURIA FABRY’S DISEASE
‘’MALTESE
CROSS”
FIGURES

Blood GALACTOKINASE
ERYTHROCYTE DEFICIENCY
ENZYMES HYPER/HYPO GLYCEMIA
GLUCOSE RUBELLA.TOXOPLASMOSI
TORCH S,CMV,H
titres,VDRL ERPES,SYPHILIS,HYPOPA
test RATHYRO IDISM
CALCIUM,
CONGENITAL CATARACT:DIAGNOSTIC
EVALUATION
CONDITION LABORATORY
GALACTOSEMIA TEST
URINE REDUCING
SUBSTANCE
RUBELLA ANTIBODY TITERS
SYPHILIS VDRL TEST
HYPOPARATHYROIDISM SERUM
CALCIUM,PHOSPHORUS,
ALKALINE
PHOSPHATASE
WILSON’S DISEASE SERUM CERULOPLASMIN
HYPERGLYCEMIA/HYPOGLYC BLOOD GLUCOSE
EMIA
FABRY’S DISEASE URINE”MALTESE
CROSS”(POLARIZED IIGHT)
LOWE’S SYNDROME URINE AMINO ACIDS
• Indications for surgery:
Managemen
-They are interfering with a person’s quality of life
t:
-There is a reasonable prospect that surgery will lead to a significant
improvement in vision.
-All dense cataract( unilateral/bilateral) & partial cataract with vision
less than 6/18.

• Timing for surgery

-The critical period for development of fixation reflex is between 6

weeks & 6 months of age. So, best time for surgery is before this
period to prevent stimulus-deprivation amblyopia.
-In dense monocular cataract, the surgery should be done as early as
possible, may be on the
(Basak, SK.,
next day after birth. 2007)
 TREATMENT IS
INDICATED ONLY IF THE
VISION IS CONSIDERABLY
IMPAIRED
• IF THE PATIENT HAS • IF VISION IMPROVES 6/18
SMALL OPACITIES IN THEN NO
WHOM THE RED SURGERY REQUIRED
REFLEX IS NOT • WHO REQUIRES CHRONIC
CONSIDERED
CYCLOPLEGIC AGENTS TO
SIGNIFICANTLY
MAINTAIN DILATION & IN
IMPAIRED
VISUAL ACUITY HAS
• IN SOME PATIENTS IMPROVED –SURGICAL
WITH SMALL OPTICAL IRIDECTOMY
CENTRAL OPACITY{3 SHOULD BE CONSIDERED.
MM OR
Classic LESS}anomaly –central cataract + corneal opacity but has a
eg.-peter
• clear peripheral lens & cornea
PATCHING
optical iridectomy better than corneal transplant & cataract
extraction.
• DILATATION WITH
TROPICAMIDE 0.5%OR
Surgical Techniques:
• Options available for children are:

-Lensectomy
-Lens aspiration with IOL
-Lens aspiration with Primary Posterior
Capsulotomy (PPC) and IOL
-Lens aspiration with PPC, Anterior Vitrectomy
(AV) and IOL
-Lens aspiration with PPC, AV, IOL and Posterior
capsular optic capture (PCOC)

(Basak, SK.,
2007)
 APHAKIC
SPECTACLES

ADVANTAGES: THEY CAN DISADVANTAGES:LENS

EASILY BE UPDATED TO THIKNESS & WEIGHT AS WELL AS
MATCH THE RAPIDLY OPTICAL DISTORTIONS
CHANGING REFRACTIONS
IN YOUNG CHILDREN
Patching of normal eye is necessary
IN NEW BORNS LENS when the child is using aphakic specs
POWER OF +24 TO
+26D
Which can be accomplished with
very thick bubble shaped lens in
older children the thinner high
ensity aphakic specs can be used .
 CONTA
CT
MOST COMMON ADVANTAGES:OPTICAL
METHOD FOR
LENS QUALITY IS GOOD
BOTH BILATERAL *SOME CL CAN BE WORN
AND UNILATERAL THROUGHOUT 24 HOURS
APHAKIA. A DAY

LENS : SILICONE – HIGH O2

DISADVANTAGES- PERMEABILITY CHILDREN
-RELATIVELY THICK YOUNGER THAN 6 MONTHS-36 D
-CAN BE WASHED OR Gas permeable lens can also be
RUBBED OUT EASILY used
-TIDIOUS FOR
PARENTS
-ASSOCIATED WITH
CORNEAL
COMPLICATIONS AS
INFECTIONS & ULCERS
MASTITIS

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