katarak b - k.ppt [autosaved]
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katarakTRANSCRIPT
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KULIAH KATARAK
Dr FATIN HAMAMAH SPm
RSD JOMBANG
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BiconvexAvascularTransparanTebal 4mm, diameter 9 mmAnt : humor akuosPost : vitreousPosisi : lig suspensorium (zonula) zinn
ANATOMI MATA & LENSA
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ISI LENSA
A N A T O M I :65% air35% Protein, mineral, glutation, Potasium, Ascorbid acid, dll Kalium tinggi pada lensa , sedangkan kadar asam askorbat dan natrium rendah Tidak ada syaraf nyeri, pembuluh darahNutrisi : cairan intraokuler
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Berupa:1. Kelainan Congenital
2. Degenerasi Lensa (Katarak)
3. Kelainan Letak (Dislokasi) Lensa
KELAINAN LENSA
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KATARAK
• Batasan :– Keadaan patologik lensa dimana terjadi
kekeruhan pada serabut lensa karena hidrasi cairan lensa/ denaturasi protein lensa
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KATARAK
1. Developmental : Katarak Kongenital Katarak Juvenil
2. Degeneratif : Katarak Senil3. Komplikata : Katarak karena :
Uveitis, DM4. Trauma : Katarak Traumatika
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Salah satu penyebab kebutaan
Sering dijumpai
Usia > 40 tahun
Bilateral ( kekeruhan tidak sama)
Manula >> Katarak >>
Perlu Penanganan serius
KATARAK SENIL
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GEJALA DAN TANDA
Dini
- Silau, monokuler diplopia
- Miopisasi, perbaikan lihat dekat
- Visus menurun bertahap
Lanjut
- Visus makin menurun s/d LP
- Dengan senter : pupil putih- Leukokoria : - kornea
- COA - lensa - vitreus - retina
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PEMERIKSAAN SUBYEKTIF
1. Kemunduran visus : tergantung - derajat kekeruhan
- lokasi kekeruhan
2. Bercak putih pada lapang pandangan pada stad. Insipien / imatur Stasioner Siang hari lebih kabur dari sore
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3. Artificial Myopi Lensa lebih cembung Kabur jauh Baca dekat tanpa kaca mata KM Minus
4. Diplopia – Poliplopia Refraksi ireguler lensa 2 bayangan / lebih Silau – pusing
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PEMERIKSAAN OBYEKTIF
1. Tanda inflamasi (-) kecuali:
kat. Komplikata karena penyakit intra okuli
kat. traumatika
2 Leukokoria : pupil putih
3 Iris shadow :
+ katarak insipien & imatur
- Katarak matur
4 Fundus reflek :
+ katarak insipien & imatur
- katarak matur
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DD Leukokoria
Leukoma kornea
Hipopion
Katarak
Perdarahan vitreus
Endoftalmitis
PHPV (Primary Hyperplasi Persistent Vitreous)
Ablasio retina
Retino blastoma
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CATATAN
• Bila ditemui: Orang tua
- Visus turun bertahap
- Nyeri atau sakit (-)
- Merah (-)
INGAT KATARAK !!!
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PENYEBAB
Belum diketahui secara pastiInfeksiRuda PaksaUsia Gangguan Metabolik dan NutrisiKortikosteroidRadiasi dll
Belum diketahui secara pastiInfeksiRuda PaksaUsia Gangguan Metabolik dan NutrisiKortikosteroidRadiasi dll
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KONSISTENSI KATARAK
• Katarak cair < 1 tahun Kongenital
• Katarak lembek 1-35 tahun Juvenilis
• Katarak keras > 35 tahun Senilis
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STADIUM KATARAK
• Stadium INSIPIEN
• Stadium IMATUR
• Stadium MATUR
• Stadium HIPERMATUR
(HANYA PD KATARAK SENILIS)
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1. Stadium INSIPIEN
Tajam penglihatan menurun/bisa normalKekeruhan dimulai sbg garisKekeruhan di pinggir lensaGambaran Jeruji PedatiDaerah sentral lensa masih jernihBisa stasioner
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2. Stadium IMATURE
Lensa menyerap air cembung glaukoma
• Tajam penglihatan 5/6 s/d 1/60
• Fundus reflek (+)• Kekeruhan belum
merata• Iris Shadow Test
(+)• Indikasi operasi
(+)
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• Tajam penglihatan 1/60 s/d LP (+)• Kekeruhan telah rata• Fundus reflek (-)• Iris Shadow Test (-)• Indikasi operasi mutlak
3. Stadium MATUR
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4. Stadium HIPERMATUR
Degenerasi korteks lensa & kapsul
Shrunken Katarak : lensa mengkerut dan menipis karena kehilangan cairan
Morgagnian Katarak :Korteks melunak & mencair nukleus tenggelam
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PENGOBATAN
Pencegahan (-) kacamata anti UV?
Stadium insipien / intumesen : bila ada kelainan refraksi yang dapat dikoreksi KM terbaik
Terapi paling baik dan tepat “saat ini” katarak ekstraksi dg operasi
Selama menunggu operasi : evaluasi Fundus Okuli Pertimbangan operasi dan prognosa
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INDIKASI BEDAH KATARAK
A. Optik
B. Mencegah komplikasi
C. Pengobatan dan
pemeriksaan
D. Kosmetik
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A . OPTIK
Buta : visus < 3/60
Buta sosial : produktif: - ahli bedah
- pekerja kantor
- tukang batu
: tidak produktif : manula.
Matur – tidak matur?
Ditentukan oleh kebutuhan penderita sendiri
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• Optik
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Uveitis
Luksasi/SubluksasiMorgagnian
Katarak Hipermatur
B. MENCEGAH KOMPLIKASI
Vitreus Lensa Menutup Pupil
Massa Lensa Keluar
Glaukoma Sekunder
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• Mencegah komplikasi
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C. PENGOBATAN DAN PEMERIKSAAN
Evaluasi segmen posterior
Penyakit retina
Diabetik retinopati
Degenerasi makula
Ablasio retina
Hipertensif retinopati
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• Pengobatan dan pemeriksaan
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D. KOSMETIK
Untuk penampilan yg lebih baik
Tidak mengharap visus
ECCE /ICCE
Dengan/Tanpa IOL
Penyakit yg diketahui pasti visus LP–
Ablasio retina lama/total
Papil atrofi
Kebutaan faktor sentral
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JENIS OPERASI KATARAK
I. ICCE ( Intra Capsular Cataract Extraction )
II. ECCE + IOL ( Extra Capsular Cataract Extraction + Intra Ocular Lens )
III.SICS + IOL ( Small Incision Cataract Surgery + IOL )
IV.PE + IOL ( Phaco Emulsification + IOL )
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I C C E
ICCE
Lensa dan kapsul intoto
Katarak matur dan hipermatur: zonula zinn rapuh
Katarak kongenital dan juvenil (-): zonula kuat
Kapsul & vitreus lengket
“ IOL posterior chamber (-)” Vitreus prolap
: Tehnik khusus: skleral fiksasi
Haptik dijahit
di sklera
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ECCE + IOL
Ekstra kapsuler Merobek kapsul anterior Kapsul posterior (+) IOL posterior chamber (+) Semua jenis katarak kecuali:
luksasi/subluksasi (hipermatur)
Ekstra kapsuler + IOL Alat > canggih Bahan > mahal Teknik > rumit IOL in the bag/sulcus
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PE + IOL
- Phaco Emulsification:
Gelombang Ultrasound (BUKAN LASER)Insisi 2.2-6 mmJahitan -/1Anestesi topikalHasil sangat memuaskanMesin sangat mahalBiaya mahal Waktu belajar panjang
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- SICS + IOL
Insisi 7-8 mm1 jahitan/-Alat lebih murahHasil cukup bagusBiaya lebih murah
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PERSIAPAN OPERASI
STATUS LOKALIS :
1.Keradangan ( - )2.Saluran air mata tidak buntu
→ Anel test +
3.Proyeksi iluminasi baik → 4 kuadran
4.TIO normal/ terkontrol
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STATUS UMUM :
1. DM ( - ) / teregulasi2. HT ( - ) / teregulasi3. Batuk ( - ) / sesak ( - )4. Kelainan pembekuan darah ( - )
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PRA OPERASI
• Tetes / zalf mata antibiotika
• Penenang / analgetik k/p
• Tetes mata anestesi
• Potong silia
• Pupil dilebarkan : midriatil® Efrisel®
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KOMPLIKASI OPERASI
• PRA OPERASI - Anestesi retrobulber : Alergi
schock, Retrobulber hematom Perforasi
• WAKTU OPERASI – Hifema– Iridodialisis, perdarahan khoroid– Prolaps vitreus
Anestesi lokal
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PASCA OPERASI
Jangka Pendek:• Iris prolaps• Hifema• Strie Keratopati• Luka tidak menutup• BMD dangkal• Pupilari blok• Edema kornea• Uveitis - endoftalmitis
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JANGKA PANJANG• Kekeruhan kapsul posterior (PCO)• Ablatio retina• Ephithelial growth• Filtering bleb• Vitreous Touch Syndrome• Vitreous Wick Syndrome• UGH Syndrome• Sunset Syndrome• Edema kornea dekompensated• Cystoid macular edema
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Ablatio retina
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Cystoid macular edema
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PENANGANAN PASCABEDAH KATARAK
• Perlu lensa pengganti
• Lensa afakik• Lensa kontak• Lensa intraokuler
• Akomodasi (-)
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AFAKIA : Mata tanpa lensa
• Visus 1/60 ( pre op. emetrop)
• Hipermetrop (+ 10 D )
• Akomodasi (-) baca dekat + 3.00 D
• Iris tremulan : iridodenesis
• COA dalam
• Pupil lebih hitam
Afakia Monokuler
Afakia Binokuler Masalah yang berbeda
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Tujuan koreksi afakia : Penglihatan tunggal binokuler sesuai kebutuhan penderita
Afaki monokuler : Penglihatan tunggal binokuler (-)
Afaki binokuler : Perubahan ukuran kekuatan refraksi tafsiran jarak yang berbeda dg kebiasaan sebelumnya
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LENSA AFAKIK:
•Murah, aman
•Tebal & berat (ukuran +10.00
D)
•Tampak besar dan ganjil
•Tidak bisa untuk satu mata
•Untuk melihat harus lurus
ke pusat lensa ( lapang
pandangan menyempit )
•Pembesaran bayangan + 25 %
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LENSA KONTAK:
• Lapang pandangan lebih luas• Tremor : sukar memasang • Pasang - lepas berulang-ulang
Problem kebersihan
• Bisa pada afaki monokuler dan anisometropia
• Distorsi & hilang lapang pandangan perifer (-)
• Pembesaran bayangan + 8 %
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LENSA INTRAOKULER:
• Letak lebih fisiologis
lebih nyaman
• Tidak buka-pasang• Untuk seumur hidup• Pembesaran bayangan 0 %• Jenis >>>
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PERAWATAN PASCA BEDAH KATARAK
6 - 8 minggu I:
• Jaga kebersihan mata •Cegah tekanan intra orbita • Hindari ruda pakasa mata
Silau KM gelap
• Antibiotika topikal• Steroid topikal
Perhatikan:
• Refraksi masih berubah-ubah• Kemungkinan komplikasi
2 bulan
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KATARAK TRAUMATIKA
1. Trauma Non Perforasi
Biasa oleh karena benda tumpul
Robek kapsul lensa
(+) / (-) Vossius ring :
pigmen pada kapsul ant. Lensa
bentuk bulat
2. Trauma Perforasi
Kekeruhan lensa lokal sekitar Port D’Entre
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Akibat yang dapat terjadi :
1. Pembengkakan lensa Glaukoma
2. Kapsul robek protein
masuk COA Uveitis Fakolitik
Terapi :
Istirahat
Midriatikum
Penyulit glaukoma, uveitis
segera ekstraksi Penyulit (-)
operasi ditunggu sampai tenang
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KATARAK KONGENITAL
Gangguan perkembangan embriologi lensa
Bilateral
Virus Rubella pada trimester I
tunda operasi sampai usia 2 th.
Kekeruhan bilateral
Segera operasi pada 1 mata
Mata yang lain dapat ditunggu
sampai 2 th.
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Cara operasi
- Disisi
- Aspirasi
- Linear
ekstraksi
- IOL : kontroversi
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KATARAK KOMPLIKATA
Penyakit Intraokuler : 1 mata
- Uveitis
- Glaukoma
- Ablasio retina
Terapi :
- Tergantung penyakit primer
- Prognosa
kurang baik
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Penyakit Sistemik : 2 mata
- DM
- Parathyroid tetany
- Miotonik
distrofi -
Atopik Dermatitis : Corticosteroid
- Galatosemia
- Asma : cortikosteroid
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DISLOKASI LENSA
Zonula zinn putus
• Sebagian subluksasi
• Seluruh luksasi ke
depan pupil - COA
ke belakang vitreusPenyebab :
1. Trauma
2. Kongenital ( sindroma
Marfan )
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Terapi :
Subluksasi : Koreksi terbaik bila
memungkinkan sehingga diplopia
(-) Luksasi : Ke COA
glaukoma sekunder
ekstraksi katarak
: Ke vitreous konservatif
vitrektomi
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PENUTUP
• Katarak• Kekeruhan lensa• Banyak pada > 40 tahun• Visus menurun bertahap sampai buta• Pupil putih / abu-abu• Obat (-), harus operasi
• Jumlah manula banyak katarak banyak
penanganan terpadu sangatperlu ditingkatkan• Prognose:
• Sangat bagus bila tidak ada penyakit mata lainnya,
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KERATOPLASTI
INDIKASI Optis
Terapeutik
Tektonik
Kosmetik
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KEBERHASILAN KERATOPLASTI
1. Kornea Resipien : bagian tepi
Ketebalan Kelengkungan & dalam p. darah Perlekatan iris / vitreus dengan kornea Letak kerusakan kornea Kondisi air mata dan konjungtiva
Optimal zone 6 – 7.5 mm
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2. Kornea Donor
Vitalitas dari endotel
Minimal 2000/mm2
Mempertahankan kejernihan 850/mm2
Dipengaruhi oleh :- Usia donor- Kondisi mata donor- Penyebab kematian
Bank Mata
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3. Penyulit operasi
Berkaitan dengan pra bedah resipien
4. Penyulit pasca bedah
Berkaitan dengan pra bedah dan jalannya operasi
- Bocor - TIO - infeksi
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5. Reaksi penolakan kornea donor
Relatif kecil
Keruh kembali
6. Status refraktif kornea
berhasil anatomis
berhasil fungsional ( optik – refraktif )
tergantung tingkat keteraturan dan bentuk kubah
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KEGAGALAN KERATOPLASTI
1. GRAFT FAILURE
Pasca operasi graft tidak pernah
jernih
2. GRAFT PROJECTION
Graft sempat jernih, beberapa waktu
keruh
Rx. Seluler Ag. Kornea Donor (HLA)
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PRESERVASI
1. Kamar lembab Metabolisme 4°C : 2 hr
2. Mc Carey – Kauffmann Lempeng korneo – sklera 5 –7 hr
3. MEM : Minimal Essential Medium Lar. Preservasi : 13 hr Lar. Transport : 7 hr
4. Liquid Nitrogen : penelitian
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PELAKSANAAN
I. DONOR
Almarhum Keluarga Bank Mata
Team Medis Enukleasi < 6 jam
RS / Rumah almarhum
Simpan dalam botol khusus dengan es
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II. RESIPIEN
Anestesi
Operator
Sarana - Kamar operasi -Alat anestesi
- Alat keratoplasti - Obat – obat
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Donor mata †
Rumah d.m
Rumah Sakit
Bank Mata
Rumah resipien
Persiapan ambil bola mata (< 6 jam)
Persiapan operasi
Berangkat RS
Tindakan cangkok kornea
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Tindakan :“ CANGKOK KORNEA “
(KERATOPLASTY)penderita jenazah
resipien donor
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