Research Article

Ophthalmic Res Received: November 6, 2018

Accepted after revision: January 11, 2019
DOI: 10.1159/000496865 Published online: March 28, 2019

Cortical Cataract and Refractive Error

Ralph Michael a, b Luis Pareja-Aricò b, c Franziska G. Rauscher d, e
     

Rafael I. Barraquer a, b, f  

a Centro de Oftalmología Barraquer, Barcelona, Spain; b Institut Universitari Barraquer, Universitat Autònoma de
   

Barcelona, Barcelona, Spain; c Hospital Clinico Universitario Valladolid, Universidad de Valladolid, Valladolid, Spain;
 

d Institute for Medical Informatics, Statistics and Epidemiology, Leipzig University, Leipzig, Germany; e Leipzig
   

Research Centre for Civilization Diseases, Leipzig University, Leipzig, Germany; f Universitat Internacional de
 

Catalunya, Barcelona, Spain

Keywords more cortical cataract than myopes. These cortical cataracts

Cortical cataract · Refraction · Accommodation · Presbyopia
Abstract
Purpose: To evaluate the relationship between the presence
of cortical cataract and accommodation effort, using refrac-
tive error as a proxy. Methods: Patients between 50 and 90
years, scheduled for cataract surgery, were selected with the
help of a photographic database. Nuclear and cortical cata-
ract were graded and patients grouped having no cataract,
pure cortical, mixed or pure nuclear cataract. Refraction data
at the time of the photograph was converted to estimated
spherical equivalent refractive error each patient would
have had at the age of 45 years. Results: From the initial 239
eyes from 239 patients, cases with myopia below –6.5 dpt
and hyperopia above 6.5 dpt were excluded, resulting in 199
cases for final analysis. Eyes with no cataract showed the
lowest median refractive error (–3.65 dpt), followed by the
pure nuclear group (–2.69 dpt). The median refractive error
for pure cortical (–0.23 dpt) and mixed cataracts (–0.87 dpt)
were close to emmetropia. Cortical cataracts were found in
37% of myopes, 82% of emmetropes, and 85% of hyperopes.
Conclusion: Emmetropes and hyperopes tend to develop
might be caused by shear stress inside the crystalline lens
due to accommodation efforts at the time of onset of pres-
byopia. © 2019 S. Karger AG, Basel
Introduction
It is known that the lens cortex and nucleus have dif-
ferent viscoelastic properties in young and old lenses [1–
3], the nucleus being softer than the cortex in younger
lenses (below 40 years of age), both cortex and nucleus
stiffening with age and resulting in a much stiffer nucleus
as compared to the cortex in older lenses (above 50 years
of age) (Fig. 1). It should also be noted that during accom-
modation the thickness of the nucleus changes whilst the
dimensions of the cortex remain mostly constant [4, 5].
Human cortical or cuneiform opacities are accompa-
nied by changes in lens fiber structure and architecture
mainly in the equatorial border zone between the lens nu-
cleus and the cortex [6]. This has been studied in crystal-
line lenses from human donor eyes, where not only the
frontal view, but also the cross-section of the lens was
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© 2019 S. Karger AG, Basel Ralph Michael

Institut Universitari Barraquer
Laforja 88
E-Mail karger@karger.com
ES–08021 Barcelona (Spain)
www.karger.com/ore
Univ.of Adelaide
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E-Mail ralphm @ barraquer.com

 Model D
104
Shear modulus, Pa
Cortex (Gc)
103
Nucleus (GN)
102
0 10 20 30 40 50 60
Age, years
Fig. 1. On the left side, the age-stiffness relationship for the human
lens cortex and nucleus is shown derived from lens spinning tests
[1]. Lower values of the shear modulus relate to softer tissue and
higher values represent more stiffness. In the center and to the
evaluated (Fig. 1). Measured at the lens equator, cortical
opacities are usually found between 500 and 700 µm be-
low the lens capsule [6]. This is also seen in in vivo studies
using optical coherence tomography [7, 8]. This location
corresponds to the outer dimensions of the adult lens nu-
cleus as defined by Taylor et al. [9] based on the lens ul-
trastructure. The morphology of cortical cataracts is
characterized by local disintegration of the cytoplasm
into membrane-bound vesicles and undulated, folded
and fractured groups of fiber cells at the border zone be-
tween the cortex and nucleus [6].
These observations in morphology and changes with
age of the elastic properties inside the lens suggested that
shear stress between the stiff nucleus and the softer cortex
of the lens are responsible for the cellular damage seen in
cortical cataracts. These shearing forces are expected to
occur during attempted accommodation after the onset
of presbyopia, when the nucleus is resistant to deforma-
tion and the cortex remains softer [6, 10, 11].
The suggestion that external forces during accommoda-
tion or attempted accommodation cause shear stress inside
the lens and induce cortical cataracts is not at all new. To
our knowledge, Wilhelm Schoen [12] already described in
a lecture at Leipzig University in 1896 that accommodation
might be the cause for cortical cataract. This theory has
been brought up several times during the past 100 years but
was always forgotten or ignored [13–16].
Our aim was to study the relationship between cortical
cataract and accommodation effort in patients scheduled
2 Ophthalmic Res
DOI: 10.1159/000496865
1,000 µm 1,000 µm
right, dark-field images from human donor eyes with frontal view
of an intact lens and cross-section of a lens slice showing a typical
cortical cataract [6].
for cataract surgery in order to complement our earlier
morphological studies and to support the mechanical
stress theory for cortical cataract. The hypothesis of our
current study is that people who accommodate more have
more cortical cataract. We will use the refractive error of
a person as a proxy for his or her accommodation efforts.
An eye with for instance 3 dpt of myopia and without dis-
tance correction does not need to accommodate for near
work and accommodation for this eye’s distance vision is
not possible. On the other hand, an eye with 3 dpt of hy-
peropia has to accommodate for near and far work.
Methods
Patients scheduled for cataract surgery with a minimum age of
50 years were selected with the help of a photographic database of
slit lamp images; photographs taken between 2003 and 2017. A
frontal view and a cross-sectional view of the eye, both with pupil-
lary dilation had to be available (Fig.  2). We focused on pro-
nounced cortical cataracts and pronounced nuclear cataracts dur-
ing the selection; posterior subcapsular cataracts and other unspe-
cific cataracts were not included.
After the selection, the cataract images were graded by three
ophthalmologists. The nuclear component of the cataract was
graded according to the BCN10 grading scale, a combined scale of
nucleus color and opacity, ranging from 0 to 10 [17]. The cortical
component was graded on a scale from 0 to 5, similar to the Lens
Opacities Classification System III (LOCS) intended for retro il-
lumination images [18].
The definition of “cataract” will always be arbitrary because
lens opacities increase gradually with age [19, 20]. Everyone above
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 No cataract Pure nuclear
Cortical grade: 0 Cortical grade: 0
Nuclear grade: 2 Nuclear grade: 8
Fig. 2. Sample cases for the 4 cataract groups as defined in the
Methods with cross-sectional view (top) and frontal view (bot-
tom) of the eye, taken with a slit lamp. Cortical cataract was grad-
50 years has some degree of nuclear opacity. Therefore, we choose
a nuclear cataract grade of 4 and above on the BCN10 scale (0–10)
as “nuclear cataract” for the current study. Cortical cataract, how-
ever, starts to develop at the lens equator, which is not visible in
vivo, even with a dilated pupil (Fig. 1) [21, 22]. Cortical cataracts
are already advanced when they are visible inside the pupillary
area. Therefore, we choose already a low grade of 0.5 and above on
our scale from 0 to 5 as “cortical cataract.” In this way, we defined
4 cataract groups as follows and grouped the patients accordingly:
“no cataract” with cortical scale (CS) <0.5 and nuclear scale (NS)
< 4.0; “pure cortical” cataract with CS ≥0.5 and NS < 4.0; “pure
nuclear” cataract with CS <0.5 and NS ≥4.0; and “mixed cataract”
with CS ≥0.5 and NS ≥4.0 (Fig. 2).
Subsequently, the following patient data was collected: age at
the time of the photograph; sex; axial length of the eye globe; re-
fraction and visual acuity at the time of the photograph; and refrac-
tion and visual acuity at an earlier age, if available. Eyes with vi-
sual acuity less than 0.7 logMAR (0.2 on decimal scale) were ex-
cluded. Only one randomly selected eye per patient was included
in the analysis to avoid statistical bias. Spherical equivalent refrac-
tive error was calculated. Myopia was defined as refractive error
below –1 dpt and hyperopia as above 1 dpt.
Considering the large age range among our patients (50–90
years) and the refractive change which occurs with age, we decided
to calculate an estimated spherical equivalent refractive error for a
fixed age; as an intent to normalize the refraction to allow a mean-
ingful comparison of refraction for the different cataractous
groups. Because we wanted to use the refractive error as an indica-
tor of accommodation efforts, we decided to calculate the refrac-
tive error for the age of 45 years. At this age, there is still some ac-
commodation left and cataracts have not yet developed. An esti-
mation of refractive error for even younger ages would introduce
considerably more errors for such an estimate.
Cortical Cataract and Refractive Error
Mixed cataract Pure cortical
Cortical grade: 3 Cortical grade: 4
Nuclear grade: 4 Nuclear grade: 2
ed on a scale from 0 to 5 and nuclear cataract from 0 to 10. G
­ rading
results are given below.
A literature search revealed 7 major studies on refractive
change with age, 3 cross-sectional studies [23–25], and 4 longitu-
dinal studies [26–29]. The data from these studies were trans-
formed into a format giving the refractive change in diopters per
year against age in years (Fig. 3). With the help of the data in this
graph, the common association with refraction and age was estab-
lished, we approximated an average refractive increase of 0.05 dpt
per year between the age of 35 and 65 years and a refractive de-
crease of 0.05 dpt per year above the age of 75 years. Between 65
and 75 years, we interpolated between the two values of the refrac-
tive change. These estimations of the refractive change with age
were used to calculate the individual spherical equivalent refractive
error each patient would have had at the age of 45 years.
Because most subgroups for spherical equivalent refractive er-
ror, axial length and age were not normally distributed, we used
median values and Mann-Whitney U tests for comparison.
Results
The analysis included 239 eyes from 239 patients with
valid photographs, and a visual acuity of at least 0.7 log-
MAR (0.2 on decimal scale), aging from 50 to 90 years,
with 76% of cases between 60 and 80 years.
Cataract grading was done with whole digits, taking
the mean from three graders. If the variation between the
graders was larger than 2, the extreme value was excluded
before calculating the mean; this was the case in 15% of
eyes for the nuclear gradings and in none for the cortical
gradings. Nuclear cataract grades ranged from 0 to 8 and
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 0.15

0.10

0.05
Refraction change, dpt/year

-0.05

–0.10

–0.15
30 40 50 60 70 80 90
Age, years

Study Country Type Sample size Years considered

Beaver Dam Eye Study [29] USA Longitudinal 2,783 1987–2017
Blue Mountains Eye Study [27] Australia Longitudinal 2,335 1992–1999
Shufelt et al. 2005 [24] USA Cross-sectional 5,588 1999–2003
Slataper 1950 [25] USA Cross-sectional 4,200 1940–1950
Saunders 1981 [23] UK Cross-sectional 2,688 1985–1987
Saunders 1986 [26] UK Longitudinal 140 1950–1980
Grosvenor et al. 2003 [28] New Zealand Longitudinal 45 1975–1995
Approximated average
Present Spain longitudinal 30 2007–2017

Fig. 3. Data on spherical equivalent refractive error change in di-
opters per year (dpt/year) with age derived from population-based
studies: cross-sectional (dashed lines) and longitudinal (continu-
ous lines). Thicker lines indicate studies with larger samples sizes.
Studies before about 1970 are shown in red, between 1970 and
1990 in blue, and recent studies after about 1990 are shown in
green. An average refractive change was approximated from these
studies (black continuous line). Longitudinal data from our pres-
ent study is given as well (thin continuous green line). Data in-
cluded from the following studies: Beaver Dam Eye Study [29],
Blue Mountains Eye Study [27], Shufelt et al. 2005 [24], Slataper
1950 [25], Saunders 1981 [23], Saunders 1986 [26], Grosvenor et
al. 2003 [28].

cortical grades from 0 to 4. The estimated spherical equiv-
alent refractive error at the age of 45 years for each respec-
tive patient was plotted against their cataract grading
(Fig. 4). This graph revealed some cases with high myo-
pia, which had to be excluded for further analysis of the
refraction data in order not to skew those results. All cas-
es of myopia below –6.5 dpt and hyperopia above 6.5 dpt
were excluded. The remaining 199 cases were subdivided
in the cataract groups defined in the Methods, resulting
in 22 cases with “no cataract,” 62 cases with “pure nucle-
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 Nuclear cataract No cataract No cataract Cortical cataract

10 10

Refractive error at 45 years, dpt

Refractive error at 45 years, dpt

0 0

–10 –10

–20 –20 Scale

40
–30 –30 30
20
10
–40 –40 1

10 8 6 4 2 0 0 1 2 3 4 5
Nuclear grading Cortical grading

Fig. 4. Cataract grading of all 239 cases with the corresponding
spherical equivalent estimated refractive error at the age of 45
years; left panel for the nuclear grading and right panel for the cor-
tical grading. Data points are binned for whole grading digits. Cas-
es with a nuclear grade smaller than 4 and a cortical grade smaller
than 0.5 were defined as “no cataract.” Cases with a nuclear grade
equal or above 4 and a cortical grade equal or above 0.5 were de-
fined as “mixed cataract” (dotted lines). Cases with spherical
equivalent refractive error above 6.5 and below –6.5 dpt were ex-
cluded from further analysis (dashed lines).

ar” cataract, 42 cases with “mixed cataracts” (cortical-nu-
clear), and 73 cases with “pure cortical” cataract (Fig. 4).
The majority of subjects within the “pure cortical”
group had refractive error above –2 dpt, whereas the ma-
jority of “pure nuclear” cataracts were found below –1 dpt
(Fig. 5). Almost all cases according to our “no cataract”
definition had a refractive error below –1 dpt. The “mixed
cataract” group showed a broad and quite even distribu-
tion over the entire range of refractive error studied. The
“no cataract” group showed the lowest median refractive
error (–3.65 dpt), followed by the “pure nuclear” group
(–2.69 dpt), both clearly myopic. The median refractive
error for “pure cortical” (–0.23 dpt) and “mixed cata-
racts” (–0.87 dpt) were close to emmetropia (Fig. 5).
For further analysis, we grouped all our cases into two
new groups, having cortical cataract or not. Patients with
cortical cataract had a median refractive error at 45 years
of –0.52 dpt, and without cortical cataract of –2.79 dpt;
this difference of 2.27 dpt was significant (p < 0.001). In-
terestingly, there was no difference between both groups
when comparing axial length (22.9 and 23.2, respectively
with p = 0.223) and age of the patient (72.6 and 69.7, re-
spectively with p = 0.091).
Figure 6 shows the histogram of refractive error for the
cortical cataract group and the group without cortical cat-
aract. Both histograms were divided for myopes (< –1.0
dpt), emmetropes (between –1.0 and +1.0 dpt) and hy-
peropes (> +1.0 dpt). Cortical cataracts were found in
37% of myopes, 82% of emmetropes, and 85% of hyper-
opes (Fig. 6).
Discussion
Starting from our hypothesis that people who accom-
modate more have more cortical cataract, we needed a
proxy to estimate accommodation efforts. We choose re-
fractive error, because it is common knowledge that
myopes accommodate less than emmetropes and hyper-
opes. It was shown that pre-presbyopic myopes have a
reduced distance facility of accommodation [30, 31]. Two
small limitations are possibly attached to this proxy. First,
we did not know the occupation of each patient with re-
gard to more near or more far work. However, all our pa-
tients are from developed, industrialized countries where
in the past 40 years the large majority has an occupation
requiring mostly near work. Thus, we assumed that the
large majority had a very similar demand for accommo-
dation. Secondly, the use of glasses for far and near work
was not known for each individual. However, myopes at
the onset of presbyopia can remove their distance glasses
for near work to avoid accommodation and hyperopes
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 Cortical n = 73
8 M = –0.23 dpt

Mixed n = 42
8 M = –0.87 dpt

Nuclear n = 62
8 M = –2.69 dpt
Frequency

No cataract n = 22
8 M = –3.65 dpt

All cases n = 199

20 M = –1.48 dpt

10
Fig. 5. Histogram distribution of spherical
equivalent estimated refractive error at the 0
age of 45 years for our 4 different cataract –6 –4 –2 0 2 4
groups. Median (M) is shown as dashed Refractive error at 45 years, dpt
line. Below, the overall distribution is given
for all 199 evaluated cases.

can be reluctant to use reading glasses resulting in contin-
ued more accommodation efforts. Therefore, the un-
known use of glasses probably only induced small varia-
tion overall in our estimation on accommodation efforts.
The estimation of the refractive error at the age of 45
years was based on literature data on refractive change
with age. The data from the literature was based on al-
together more than 17,000 individuals and was quite
consistent (Fig. 3). In order to check the mean refractive
change obtained from the literature with our sample of
patients, we calculated the longitudinal refractive error
change in 30 cases, where this data was available. As can
be seen in Figure 3, our data match the data from the
literature quite well until ages of 70 years. For ages
above 70 years, our data showed a higher myopic shift
as the much larger longitudinal studies Beaver Dam and
Blue Mountains and was closer to an older cross-sec-
tional study.
Patient for our study were selected based on photo-
graphs prior to cataract surgery. The refraction was not
known at that stage of the study. We found a considerable
number of high and very high myopes in our patient co-
hort. Because high myopia was not the topic of our study
and to avoid bias with our statistical calculations, we de-
cided to exclude all cases with high myopia and do the
same for any cases of high hyperopia. We choose –6.5 dpt
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 20
15
10
Frequency
20
15
10
Fig. 6. Histogram distribution of spherical
equivalent estimated refractive error at the 5
age of 45 years grouped for having cortical
cataract or not. Both histograms are divid- 0
ed for myopes, emmetropes, and hyper-
opes and the percentage of cases with or
without cortical cataract within each re-
fractive group are given. Median (M) is
shown as dashed line.
as cutoff because definitions in the literature vary be-
tween < –5 and < –8 dpt according to a report from WHO
[32] with most common values around –6 dpt.
Even after excluding cases with high myopia, we had a
large proportion, 55%, of myopes, 25% emmetropes, and
20% hyperopes in our cohort (Fig. 5). This compares to a
proportion of 38% myopes, 46% emmetropes, and 17%
hyperopes, aged 40–59 years in a general population in
the USA [33]. Other studies of the general population for
the same age range but defining myopia as < –0.5 dpt find
proportions of myopes of 25, 43 or 44% [34–36]. This dif-
ference is probably explained by our cohort of patients
scheduled for cataract surgery, which considers only 50–
70% of the general aged population [37]. Furthermore,
most cataract patients are operated to remove nuclear
lens opacities which are known to be related to more my-
opic eyes [38].
Based on the analysis of the current article, we found
that myopes have considerably less cortical cataracts
(37%) as compared to emmetropes (82%) and hyperopes
(85%) (Fig. 6). This corresponds well with earlier popula-
tion-based studies. A meta-analysis which combined 12
studies with 38,000 cases showed that myopia is associ-
ated with nuclear cataract, but not with cortical cataract
[38]. One major population-based, cross-sectional study
from this meta-analysis (The Singapore Indian Eye Study
Cortical Cataract and Refractive Error
Cortical cataract n = 115
M = –0.52 dpt
37% 82% 85%
No cortical cataract n = 84
M = –2.79 dpt
63% 18% 15%
–6 –4 –2 0 2 4
Refractive error at 45 years, dpt
with 3,400 cases) differentiated between hyperopia, em-
metropia, mild myopia, moderate myopia, and high my-
opia and found a higher risk for nuclear cataract with my-
opia as compared with hyperopia and a higher risk of cor-
tical cataract with hyperopia as compared with myopia
[39]. A cross-sectional study of 3,650 people showed that
a history of wearing distance glasses was associated with
the presence of nuclear cataract, but not with cortical cat-
aract. A weak association was found between cortical cat-
aract and hyperopia [40].
A comparative study of refraction before cataract sur-
gery in India revealed that eyes with cortical cataract had
a mean refraction of +2.75 and with nuclear cataract
–3.75 dpt [15]. Our results showed the same tendency,
but with less difference between groups; we found for
pure cortical cataracts a median refractive error of –0.23
dpt and for pure nuclear cataracts it was –2.69 dpt. A pos-
sible reason for this might be the different age of the cata-
ract patients, in the study from India between 30 and 45
years and in our present study it was between 50–90 years
with a median of 71 years.
Early cortical cataracts begin near the lens equator, be-
hind the iris and are therefore seldom detected in vivo.
Studies in postmortem lenses, where the entire lens can
be seen, show that segmental or annular cortical cataracts
have a low prevalence of 11% at the age between 31 and
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45 years which increases to 45% in the age group 61–75
years and remains rather stable in older age groups with
48% between 76–90 years [10, 21]. This shows that corti-
cal cataracts develop at the time of the onset of presbyopia
and – in contrast to nuclear cataracts – do not gradually
increase with aging [11].
Cataracts are generally considered a multifactorial dis-
ease and largely caused by lifelong accumulation of oxida-
tive stress, influenced by environmental and genetic fac-
tors, life style, exposure to ultraviolet radiation, diet and
other systemic diseases [10, 41]. The mechanical force
acting on the lens during accommodation may induce di-
rectly morphological damage to the lens fibers leading to
cortical cataract or they may make the zones of shear
stress inside the lens more vulnerable to environmental
factors, like ultraviolet radiation, and in this way lead to
cortical cataract [15].
In summary, emmetropes and hyperopes tend to de-
velop more cortical cataract than myopes. These cortical
cataracts might be caused by shear stress inside the crys-
talline lens due to accommodation efforts at the time of
onset of presbyopia.
Acknowledgments
Dr. F.G. Rauscher is supported by a grant from the German
Federal Ministry of Education and Research: i:DSem – Integrative
data semantics in systems medicine (grant number 031L0026).
Statement of Ethics
Ethics committee approval was not required for this retrospec-
tive observational study. The work was carried out in accordance
with the Code of Ethics of the World Medical Association (Decla-
ration of Helsinki).
Disclosure Statement
The authors have no conflicts of interest to declare.
Author Contributions
R.M. designed the study, acquired data, analyzed data, inter-
preted data, wrote the manuscript, revised the manuscript; L.P.-A.
acquired data, revised the manuscript; F.G.R. interpreted data, re-
vised the manuscript; R.I.B. revised the manuscript, obtained
funding.

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