CATARACTS

A cataract is an opacification of the crystalline lens of the eye.

Classification
1. Based on age of onset
• Congenital,
• Infantile,
• Juvenile,
• Adult,
• Presenile,
• Senile.
2. Based on site of opacity
• Capsular,
• Subcapsular,
• Cortical,
• Supranuclear,
• Nuclear,
• Polar,
• Total.
3. Based on degree of opacity/morphology
• Incipient,
• Immature, (partial/scattered opacification)
• Mature, (completely opaque lens)
• Intumescent, (lens is swollen due to imbibition of water)
• Hypermature, (anterior capsule becomes wrinkled and cortex a soft pultaceous
mass, may produce phacolytic glaucoma)
• Morgagnian. (complete liquefaction of cortex and nucleus sinks inferiorly).
4. Based on acquisition
• Congenital,
• Acquired.
5. Based on Aetiology
• Ageing/senility (MCC),
• Traumatic (2nd MCC),
• Secondary (due to an independent disease process e.g. DM, myotonic
dystrophy, atopic dermatitis, etc),
• Radiation,
• Ocular/Complicated (e.g. uveitis, corneal ulcer, retinitis pigmentosa, etc.),
• Toxic (from drugs - including Amiodarone, Busulphan, Chlorpromazine,
Dexamethasone)
• Associated with various syndromes (Down’s, Lowe’s, Miller’s, Rothman’s,
Werner’s).

Common Signs & Symptoms

• Gradual decreased vision
• Glare
• Diplopia
• Colour fades
• Night blindness
• Frequent change of glasses (eg with nuclear cataract, near vision improves ie myopic shift, with
cortical, far vision improves ie hypermetropic shift.)
Clinical Examination
• Visual Acuity
• Extraocular movement
• Visual field test
• Pupil examination
• Ocular adnexa
• Examination of cornea, AC, lens
• DDO
• Fundus examination
• Refractive status

Investigations
• CBC
• ESR
• Hep B & C
• Blood urea + creatinine
• Blood sugar
• Lipid profile
• BP
• ECG
• Biometry (keratometry + A-scan)
• B-scan
• Pachymetry

CONGENITAL CATARACT

The opacification of the crystalline lens, present at birth, or that may occur in early
childhood.
Inheritance
• Most commonly (2/3) autosomal dominant inheritance. Those inherited this way are usually
bilateral.
• Unilateral cataracts are more sporadic, without family history or systemic disease.

Types
• Capsular (anterior/posterior) cataract
• Polar (anterior and posterior, involving the central part of the capsule) cataract
• Sutural (following the anterior and posterior Y sutures),
• Nuclear (confined to the embryonic/fetal nucleus),
• Lamellar/Zonular (opacities affecting a particular lamella of the lens)
• Most common type (40-50%),
• Involves circular lamella of the lens both anteriorly and posteriorly which appears as a
sharply demarcated opacity with clear lens fibres within and around it,
• Results from an insult to the developing fibres during embryonic development,
• Usually bilateral & AD.
• Central Oil Droplet cataract
• Characteristic of galactosemia,
• The nucleus and deep cortex are opacified.
• Coronary/Supranuclear cataract
• Commonly occurs at puberty, and is a common form,
• Cataract is in the deep cortex and surrounds the nucleus,
• Central (axial) portion of the lens is clear so vision is unaffected,
• Autosomal dominant.
• Punctate/Blue-dot (multiple, small, opaque, scattered stationery dots seen, that don’t affect
vision) cataract
• Membranous (when the lens material is absorbed, leaving behind a thin membrane) cataract,
• Complete cataract
• Very common,
• Dense white nuclear cataract.

Aetiology
Maternal Causes
• Infections e.g. Rubella (20% of congenital cataracts),
• Intrauterine hypoxia/Placental insufficiency e.g. eclampsia,
• Radiation exposure,
• Drugs e.g. corticosteroids,
• Endocrine disorders e.g. DM.
Fetal Causes
• Heredity accounts for approx 25% of cases, mostly AD but can also be AR or X-linked,
• Chromosomal disorders e.g. Down’s,
• Ocular anomalies e.g. aniridia, persistent hyperplastic primary vitreous,
• Metabolic disorders e.g. galactosemia,
• Trauma, e.g. forceps delivery.
Unknown causes account for approx 30-50% of cases.

Signs
• Whitish reflex in pupillary area (Leukocoria)
• Abnormal eye movements
• Reduced vision
• Squint, usually convergent
• Nystagmus
• Slit lamp exam reveals the type of cataract

D/Ds of Leukocoria
• Congenital cataract
• Retinoblastoma
• Retrolental fibroplasia
• Anterior persistent hyperplastic primary vitreous (APHPV)
• Coat's Disease
• Endophthalmitis
• Toxocarial granuloma

Ocular Assessment
• Density and morphology of cataract are noted based on vision.
• In partial cataract, fundus examination and retinoscopy is done.
• In total cataract, B-scan ultrasonography is useful to assess the posterior segment of the eye to
rule out associated retinoblastoma or retinal detachment.
• A-scan ultrasonography is done to record and compare the axial lengths of the two eyes.
• IOP is noted.

Lab Investigations
• Urinalysis - to check for galactosemia or Lowe’s syndrome.
• Serum biochemistry - to check FBS, calcium, phosphorus, galactokinase and RBC transferase.
• Serological test - to check antibody titres for TORCH infections.

Treatment
The surgical technique used depends on the type and density of the cataract, and age of the patient.
• Lens aspiration
• Lensectomy

Post-Operative Complications
• Posterior capsule opacification due to proliferation of lens epithelium
• Secondary membrane
• Secondary glaucoma
• Amblyopia, which is treated with spectacles or contact lenses or intraocular implantation.

SENILE CATARACT

Most Common Types

• Posterior sub capsular (cupuliform) cataract - 5%
• More common in younger patients
• Opacity develops in the central part of the posterior cortex, just anterior to the posterior
capsule
• Gross deterioration of vision, particularly worse during daytime.
• Cortical (cuneiform) cataract - 70%
• Most common type
• Main pathological feature is hydration of the lens due to changes in permeability of the
lens capsule
 • Subtypes include lamellar separation cataract, incipient cataract, immature cataract,
intumescent cataract, and mature cataract.
• Nuclear cataract - 25%
• The lens fibres in the nucleus undergo dehydration and compactness resulting in
sclerosis.
• In sclerosis, the refractive index of the lens increases, increasing the refractive index of
the lens, resulting in a myopic shift.

Symptoms
• Painless gradual deterioration of vision
• Glare
• Monocular diplopia/polyopia
• Coloured halos
• Change in refractive power (myopic/hypermetropic shift)
• Worsening of vision during daytime
• Secondary lens induced glaucoma is also possible presentation.

Signs
• Decreased visual acuity
• Opacification of the lens

Diagnosis
• Simple torch
• DDO
• Slit lamp examination

Complications
• Phacomorphic glaucoma
• Phacolytic glaucoma
• Phacoantigenic Uveitis
• Dislocation of lens
• Incarceration into the pupil causing pupillary block glaucoma.

Indications for Surgery

• Visual improvement
• Medical indications include phacomorphic glaucoma, intumescent lens, and retinal problems
• Cosmetic reasons.

Cataract Extraction
Extra Capsular Cataract Extraction (ECCE)
 Removal of lens nucleus and cortex through an opening in the anterior capsule. Posterior capsule
stays intact.
 Types
1. Phacoemulsification: most common method of the cataract extraction. Lens is fragmented
(emulsified) by ultrasound vibrations and aspirated with probe of phacoemulsifier. *small
incision so rapid healing, less astigmatism, early visual rehabilitation
 2. Femtosecond Laser (FSL): glass laser generates focused ultrashort pulse creating
cavitation and bubbles within the tissue. *it is better than the hand-held surgical tool
3. Manual small extraction surgery: cataract is removed through a suture less, self-sealing
sclero corneal tunnel incision
4. Conventional extracapsular cataract extraction: it is the removal of cataract through
limbal or corneal section. Anterior capsulotomy, nucleus is removed intact and the residual
cortical matter is aspirated

Intracapsular Cataract Extraction (ICCE)

 it is the removal of the cataract within the capsule
 obsolete now

Pars Plana Lensectomy

 Cataract is removed through the pars plana of the ciliary body
 It is indicated in congenital cataract, when pupil doesn’t dilate,
x-------------------------------------------------------x
 Ocular infections such as blepharitis, conjunctivitis, keratitis, uveitis, dacryocystitis is a
contraindication
 IOP should be within normal

Anesthesia
Local Anesthesia
 Topical (surface)
o Xylocaine, proparacaine, tetracaine, lidocaine gel. Adequate but less effective
o Can cause endothelial and epithelial toxicity allergy and surface keratopathy
 Retrobulbar block
o Anesthetic is injected behind the eyeball in the muscle cone near the ciliary body
o Ciliary nerves, ciliary ganglion, oculomotor nerve and abducens nerve is anesthetized
 Subtenon block
o 5mm from the limbus, injected through an incision in the conjunctiva and sub-tenon capsule
o Chemosis and subconjunctival complications are common
 Peribulbar block
o Injected to the peripheral spaces of the orbit
o Orbital compression is placed for 15 mins which allows the anesthetic to infiltrate into the
retro bulbar capsule

Facial Nerve block

General Anesthesia

Phacoemulsification
 Self-sealing clear corneal or sclerocornal incision using a keratome
 Anterior chamber is maintained by injecting viscoelastic substance
 A second incision is made at right angle to the first incision
 Anterior capsulotomy (capsulorhexis) circular
 Hydrodissection is performed with water to separate the capsule from the cortex
 Hydrodelineation is performed to separate the epinucleus from nucleus
 Nucleus is rotated within the capsular bag
 Nucleus is cracked using a chopper
 Aspiration
  Capsular bag is inflated with viscoelastic substance and foldable IOL is inserted through the same
incision or rigid IOL is inserted by enlarging the incision
 No suturing required, pad and bandage

Femtosecond Laser Cataract extraction

Advantages over standard manual procedure
 Incision is more stable and self-sealing
 Lens fragmentation results in decreased intraocular instrumentation
 Astigmatism correction is done
Manual Small incision cataract surgery
 Cataract is removed through a suture less, self-sealing volvular sclerocorneal tunnel incision
Extra Capsular Cataract Extraction (ECCE)
 Partial thickness incision (through cornea or limbus)
 Anterior chamber maintained
 Anterior capsulotomy (can opener)
 Partial thickness is completed into full by corneal scissors
 Delivery of nucleus
 Removal of residual cortex
 Capsular bag is inflated IOL insertion
 Constriction of pupil
 Closure of incision
 Pad and bandage

Types of intraocular lens

Posterior chamber lens
 Lens lies entirely behind the iris, placed in the capsular bag supported by the ciliary sulcus
 Foldable IOL – made up of soft acrylic, hydrogels or silicone material
 Single piece PMMA IOL – rigid IOL used in phacosurgery
Anterior Chamber Lens
 Lens is in front of the iris supported by the angle of the anterior chamber
 Indicated in ICCE
 Higher chance of complications such as
o Anterior uveitis
o Glaucoma
o Corneal endothelial damage

Intra ocular Lenses

Each IOL consists of an optical portion for refraction and haptics for lens stability
 Rigid IOL: made from polymethylmethacrylate (PMMA), 5mm incision
 Flexible IOL: introduced through a small incision, may be folded with forceps or loaded
into an injector, made up of silicone, acrylic, hydrogel and collamer. (2.3-3.2mm incision).
Rollable IOLs are ultra-thin. They are made up of hydrogel. (1mm incision)
 Multifocal IOL: allow clear vision for near and distant objects
 Toric IOL: have cylindrical power beneficial for correction of astigmatism

Complications of Cataract Surgery

 Anesthesia
 o Local
o General
 Operative
o Intra operative
 Suprachoroidal hemorrhage, rupture of ciliary vessels
 Posterior capsule rupture
 Nucleus drop in to vitreous
 Vitreous loss
 Detachment of Descemet’s membrane
 Iridodialysis
 Hyphaema
o Post-operative
 Early
 Acute Endophthalmitis
 Corneal edema
 Wound leakage
 Iris prolapse
 Flat anterior chamber
 Secondary glaucoma (raised IOP)
 Iridodialysis
 Hyphaema
 Late
 Chronic Endophthalmitis
 Phacoantigenic uveitis
 Corneal decompensation
 Cystoid Macular edema
 Retinal detachment
 Opacification of posterior capsule (elchnig’s pearls)
 IOL related complications
o Decentration/Subluxation of IOL
o Opacfication of IOL

Aphakia

 Absence of lens in the eye

 Causes
o Removal by surgery
o Absorption of lens matter can be due to trauma or hypermature cataract
 Reduced vision both for distance and near
 Signs include
o Limbus may show linear scar or suture marks
o Deep anterior chamber
 o Iridodonesis
o Pupil appears jet black in color
 Rehabilitation after cataract extraction
o Spectacles
 Convex lens
 Safe, minimal care
 Image magnification can cause misjudgment or diplopia
 Thick spherical lens can cause distortion of image, ring scotoma, restriction
of field of vision
o Contact lenses
 Less image magnification than spectacles
o Intraocular lens
 Can be implanted primarily (at time of extraction) or secondarily (sometime
after the extraction)
 No image magnification, immediate rehabilitation,
o Keratorefractive surgery
 Surgical procedure that increases the refractive power of the cornea by
modifying the curvature of the cornea
 Types
 Epikeratoplasty
 Lasik