seminar 3 - cataract

8/8/2019 Seminar 3 - Cataract

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YIP

FARADIANAROIHAN

ARIF

TASNIM

29th March 2010

1



Mr AS68 yrs old

C/o: blurring of vision

What to ask next?????

What is your differential diagnosis???

2



Glaucoma

Cataract

Diabetic/hypertensive retinopathy

Mononeuritic multiplex CRVO (central retina vein occlusion)/CRAO

Corneal injury

Retinal detachment

Uveitis

TIA

Trauma

3



•Noticed blurring of vision since September last year

•Blurring of both vision simultaneously

•Slowly started as blurring of edges of objects but has now

his vision is limited to just shadows (he sees things as mere

shadows)•Also complains of seeing rainbow flashes upon sudden

head movements and getting up after sitting for a long time

•No pain, no headache

History of presenting illness

4



Past Med

-Newly diagnosed hypertension

Drug HX/ Occular Hx

-Tried „Permata Hijrah‟ for his blurring of vision for

two months but stopped because it did not improve

his vision-Has not had any eye ops

Family hx

-Unremarkable

5



Refractive error

Cataract

Glaucoma (primary open angle)

Retinal disease diabetic retinopathy

Age related macular degeneration

Tumours and inflammation: intraocular

tumor, tumor of optic nerve

6



All normal

Right eye post operative

Red eye reflex not symmetrical both sideReduced red reflex on left eye

Reduced diameter of red reflex on right eye

7



Congenital cataract

Senile cataractComplicated cataract (Diabetic cataract &

parathyroid tetany)

Cataract due to radiant / heat energy

Traumatic cataract

9



Pathogenesis

Heredity (genetic mutation)

Maternal (malnutrition & infection)

Foetal ( oxygenation), metabolic disorder(galactosaemia), trisomy 21

Idiopathic

10



• Symptoms

– Visual impairment

– Nystagmus

• Signs

– White reflex (leucocoria)

– Ophthalmoscopic examination (black opacity

against red background)

– Systemic congenital heart disease

11



Pathogenesis

History of “anticipation”

Sunlight exposure

Old age (“age related cataract”) Diabetes

Atopic dermatitis

Myotonic dystrophy

13



• Degeneration & opacification of lens

(hydration, denaturation & coagulation of

proteins)

•

Formation of aberrant lens• Fibrous metaplasia of lens fibres

• Abnormal product of metabolism, drugs or

metals

• Slow sclerosis of the central nucleus fibres(senile nuclear cataract) – brown pigment

14



Symptoms

Frequent changes of glasses Diminished visual acuity

Glare

Coloured halos

Monocular diplopia / polyopia “myopic shift” & Colour shift (senile nuclear

cataract)

15



Signs

Slit lamp examination (yellow layer in theposterior cortex, lost of fundus details)

Ophthalmoscopic examination (dark shadow)

Blackened pupillary reflex (senile nuclear

cataract)

16



Pathogenesis

Disturbance of nutrients in the lens (inflammatory

/ degenerative disease)

Diabetic cataract

Excess glucose sorbitol (sugar alcohol) osmotic

imbalance at lens

Parathyroid tetany

Deficiency of parathyroid hormone

18



• Symptoms

– Impaired vision

• Signs

– Anterior segment (opacification of cortex)

– Posterior segment ( posterior cortical cataract)

– Ophthlamoscopic examination (vaguely defined,

dark area seen in the posterior cortex)

– Slit lamp examination (irregular borders of

opacity, breadcrumb‟s appearance, rainbow

display, snow flakes, crystalline flakes)

19



Pathogenesis

Heat (infrared) Irradiation (X-ray)

Electric (passage of powerful current)

Ultrasonic radiation (heat & concussion)

21



Pathogenesis

Concussion

Perforating corneal injuries

• Signs

- Rosette-shaped‟ cataract (posterior cortex / anterior

cortex)

22



23



Early

Glare

Frequent changes of glasses

Black spot

Uniocular diplopia / polyopia

Coloured halo

Colour value changes

Late

Impaired central vision

24



25



Cataracts may be classified according to

1. age of onset

2. morphology

3. grade

4. maturity of cataract

26



CONGENITAL ACQUIRED

Chromosomal

Down, Edward, Turner

syndromes

Early embryonic [transplacental]

damage

Rubella

Mumps

Hepatitis

Toxoplasmosis

Age related cataract

Most common cause

Secondary cataract

Cataract form after eye surgery for other eye

problem eg. Glaucoma

cataract in patient with other health problem

such as diabetes

cataract due to use of steroids

Traumatic cataract

Cataract forms after trauma or exposed to

alkaline chemicals may form immediately or years after trauma

Radiation cataract

over exposure of ultraviolet sunlight or other

radiation

27



28

Congenital Presenile Senile

-inherited inautosomal dominant

fashion [1/3]

-birth trauma or

maternal infection

during pregnancy

-galactosaemia

[common metabolic

cause of congenital or

infantile cataract]

Systemic diseases-diabetes mellitus

-corticosteroid therapy

-atopy

-galactosaemia

-hypocalcaemia

-dystrophia myotonica

Ocular factors

-blunt or perforating trauma

-high myopia

-recurrent uveitis

-topical steroid use-ionising irradiation

-excessive ultraviolet light

exposure

-infrared irradiation

- age-related



29

http://en.wikipedia.org/wiki/File:Cataracts_due_to_Congenital_Rubella_Syndrome_(CRS)_PHIL_4284_lores.jpg



Classification of Cataract Morphology

Fibre-based Sutural Congenital sutural

Concussion

Storage disorder

Deposition

Non-sutural LamellarNuclear

Cortical

Non-fibre based Subscapular

LamellarCoronary

Blue dot

Christmas tree

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Type Picture Cause Properties




Sutural Congenital non-progressive

Concussion often flower-shaped [lens fibre

separation and fluid entry]; anterior andposterior

Storage

disorder

usually starts posteriorly

Deposition usually starts anteriorly

Nuclear Congenital non-progressive, limited to embryonic

nucleus or more extensive

Age-related increased white scatter (light scattering)

and brunescence (brown chromophores)

Lamellar Congenital /

infantile

Localized to a particular lamella (layer)

with or without extensions

- inherited, rubella, diabetes,

hypocalcaemia

Y

31




Coronary Sporadic Round opacities in the deep cortex

forming a “crown” -occasionally inherited

Cortical Age-related Spoke-like opacities in the superficial

cortex, spreading along fibres at an

unpredictable rate

Subcapsular Age-related/ presenile

granular material just beneath capsule,posterior (more common and visually

significant) or anterior

- diabetes, corticosteroids, uveitis,

radiation

32




Polar Congenital anteriorwith abnormalities of capsule ± anterior

segment

posterior

with abnormalities of capsule ± posterior

segment

Diffuse Congenital focal blue dot opacities are common and

visually significant

Age-related christmas tree cataracts are highly

reflective crystalline opacities

. . . . .

. . . . .

. . . . .

. . . . .. . .

33



Grading system is designed to quantify the degree of opacification.

These vary from simple assessment by direct ophtalmoscopy

to the Lens Opacities Classification System II [LOSCII], where

slit lamp examination is compared to a standard set of photographs [separate set for nuclear, cortical, and posterior

subcapsular].

It involves grading 4 features of the cataract:

- nuclear color (NC)

- nuclear opalescence (N)- cortical cataract (C)

- posterior subcapsular (P)

34



The clinical appearance ofA – cortical cataractB – nuclear cataractC – posterior subcapsular

cataract

The spoke opacities aresilhouetted against the red reflexin A.

A B

C

35



Maturity Description

Immature opacification is incomplete

Mature opacification is total

Hypermature lysis of cortex results in shrinkage,

seen clinically as wrinkling of the

capsule

Morgagnian liquefaction of cortex allows the harder

nucleus to drop inferiorly [but still

within the capsule]

36



38



• improve visual function depends on degree of impairment and visual needs of individual,

most patients with a vision of 6/18 or worse

in both eyes because of lens opacities

benefit from cataract surgery• diabetic retinopathy

• cataract prevents adequate retinal

examination or laser treatment

• lens induced glaucoma

• uveitis

39



• Choice of anaesthesia

• Incision: via cornea or anterior sclera

• Technique of cataract removal

• Correction of aphakia: by intraocular lens

implantation, contact lens or aphakicspectacles

• There are 2 types:

–

Phacoemulsification – ECCE (Extracapsular cataract extraction)

– Intracapsular method

40



Phacoemulsification methodA very small tunnel incision (about 3mm

wide) is made in the eye and a circular hole

(diameter about 5 mm) is made in the

anterior capsule of the lens.

41



A fine ultrasonic probe is then used to liquefy

the hard lens nucleus (phacoemulsification)

through this hole.

42



• A folded replacement lens is then inserted into the

empty lens capsular bag and allowed to unfold.

• A high viscosity gel substance (viscoelastic) often is

used to protect the delicate endothelial cells thatline the posterior surface of the cornea during the

operation.

• This is then washed out at the end of the

procedure.

43



Sutures often are not required as the tunnel

incision is self sealing.

These advances in technique have considerably

improved the speed of recovery and visual

rehabilitation after cataract surgery.

44



Break Up and Remove the Cataract Lens

45



Extracapuslar cataract extraction (ECCE)method

• conventional method may be indicated for patients

with very hard cataracts or other situations inwhich phacoemulsification is problematic

• An incision is made in the eye (about 10 mm in

length) and the anterior capsule is cut open with

the tip of a sharp needle.

• The large nucleus is then expressed whole and the

remaining soft lens fibres aspirated

•

A non-folding lens is then inserted into the emptylens capsular bag and the incision closed with fine

sutures.

46



Intracapsular method

• In this method, the entire lens isremoved within its capsule, usuallywith a cryoprobe, after the suspensory

ligaments of the lens have beendissolved by the enzyme chymotrypsin.

• As there is no remaining lens capsule,the vitreous gel in the eye can moveforward and block the flow of aqueousthrough the pupil.

• A hole cut in the iris (iridectomy)allows the aqueous to bypass the pupil.This method is now usually used only inspecial situations.

• The procedure has a relatively high

rate of complications due to the largeincision required and pressure placedon the vitreous body

47



80% achieve 6/12 vision or better following

surgery

Failure to improve usually due to pre-existing

disease

48



49



Corneal edema Elevated IOP

• water content of the corneaincreases causing thecornea to swell and losetransparency.

• Sx:Poor vision and haloes("star bursts" around lights)

• Tx: usually self limiting andimproves with anti-inflamattory eye drops

occur when the visco-

elastic is left in the eye,or is not adequately

aspirated prior to wound

closure.

The visco-elastic particleswould block the

trabecular meshwork and

raise the IOP.

Tx: control with topicaltreatment

50



Wound leak Iris prolapse

• are complication due topoor wound constructionas well as poor surgicaltechnique in closure

(loose sutures.)• If severe and persistent ,

need to return to theaterand suture wound closed

Iris tissue may prolapsethrough the surgicalwound. This is usually

due to poor surgicalclosure.

Assess vitality of extruded iris and suturewound closed

51



Late-complication

1. Posteriorcapsule

opacification

2. Cytoidmacularedema

3. Cornealdecompesation

4. Retinaldetachment

53



Posterior capsule ossification Cystoid macular oedema

• “ secondary cataract “

• clouding of the 'posteriorcapsule', the thin membranethat surrounded thecataractous lens prior to its

removal.• Sx: reduced vission, monocular

diplopia

• Tx: YAG posterior capsulotomy

• painless condition in which

swelling or thickening occursof the central retina (macula)

• Sx: usually associated withblurred or distorted vision.

• Tx: anti-inflammatory eyedrops or injections of steroidsto the back of the eye

54



Retinal detachment

• condition that occurs whenfluid seeps through a tear inthe retina.

• The seepage causes theretina to detach from theback of the eye.

•

Occurs mainly in eyes withposterior capsular rupture,vitreous loss, and eyes withperipheral retinaldegenerations like latticedegeneration.

• Sx: flashes of light or darkspots In the field of vision

• Tx: surgical

55



Steroid drops (to reduce inflammation)

Antibiotic drops (to prevent infection)

Non-pharmacology advice:

- to avoid very strenuous exertion and oculartrauma ( eg: heavy lifting )

- wear dark glasses

- prevent your eyes from coming into contact

with water and soap

seminar 3 - cataract

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