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Ophthalmology
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Diseases of the Lens

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Atul K Shankar

31

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ESSAY
What is Senile Cataract? Describe the stages, clinical features,
complications and management of Senile Cataract.
Senile Cataract, also known as ‘Age-related cataract’ is the commonest type of acquired
cataract. It affects persons of either sex equally, above the age of 50 years. This condition is usually
bilateral, but almost always one eye is affected earlier than the other.

STAGES OF SENILE CATARACT

Maturation of Cortical Type of Senile Cataract:

- Stage of Lamellar Separation

o earliest sign is formation of vacuoles and water clefts in the anterior and posterior
cortex
o leads to demarcation of cortical fibres owing to their separation by fluid
o this phenomenon is demonstrated by slit-lamp examination only
- Stage of Incipient Cataract
o early detectable opacities with clear areas between them are seen
o two distinct types are recognised as
 Cuneiform senile cortical cataract
 characterised by wedge-shaped opacities with clear areas in between
 Cupuliform senile cortical cataract
 Saucer-shaped opacity develops below the capsule usually in the
central part of posterior cortex, which extends outwards.
- Immature Senile Cataract
o opacification progresses further
o cuneiform or cupuliform patterns can be recognised till the advanced stage of ISC,
when opacification becomes more diffuse and irregular
o lens appears greyish white, but clear cortex is still present and so iris shadow is
visible
o in some patients, lens may become swollen due to continued hydration –
INTUMESCENT CATARACT
- Mature Senile Cataract
o opacification becomes complete
o lens becomes pearly white in colour
o such a cataract is also labelled as ripe cataract
- Hypermature Senile Cataract
o Morgagnian Hypermature Cataract
 whole cortex liquefies and the lens is converted into a bag of milky fluid
 small brownish nucleus settles at the bottom, altering its position with change in
the position of the head
 sometimes, calcium deposits may be seen on the lens capsule
o Sclerotic Type Hypermature Cataract
 cortex becomes disintegrated and the lens becomes shrunken due to
leakage of water
 Anterior capsule is wrinkled and thickened due to proliferation of anterior
cells and dense white capsule cataract may be formed.
CLINICAL FEATURES OF SENILE CATARACT

- Symptoms
o Glare
o Uniocular diplopia or polyopia
o Coloured halos around the light
o Poor colour discrimination
o Black spots in front of eyes
o Image blur, and misty vision
o Deterioration of vision
- Signs
o Visual acuity may range from 6/9 to PL+
o Test for iris shadow
o Colour of Lens
 Nuclear cataract – amber, brown, black or reddish
 Immature senile cataract – greyish white
 Mature senile cataract – pearly white
 Morgagnian Hypermature Senile Cataract – milky white
 Sclerotic HMSC – dirty white with hyper white spots
o Distant direct ophthalmoscopic examination

COMPLICATIONS OF SENILE CATARACT

- Phacoanaphylactic Uveitis
o Lens proteins may leak into the anterior chamber in Hypermature cataract
o proteins act as an antigen and induces an antigen-antibody reaction
 leading to phacoanaphylactic Uveitis
- Lens Induced Glaucoma
o Phacomorphic Glaucoma
 caused by intumescent lens
 type of secondary angle closure glaucoma
 most common type of lens induced glaucoma
o Phacolytic Glaucoma
 lens proteins are leaked into the anterior chamber in cases with Morgagnian
Hypermature cataract
 proteins are engulfed by the macrophages
 swollen macrophages clog the trabecular network, leading to an increase in IOP
o Phacotopic Glaucoma
 Hypermature cataractous lens may subluxate and cause glaucoma by blocking
the pupil or angle of anterior chamber
- Subluxation of Lens
o occurs due to degeneration of zonules in hyperamature stage
MANAGEMENT OF SENILE CATARACT

- Non-surgical Measures
o Treatment of Cause of Cataract
 Adequate control of Diabetes Mellitus
 Removal of cataractogenic drugs
 Removal of irradiation
 Early and inadequate treatment of ocular diseases
o Measures to delay progression
 Topical preparations containing iodide salts of calcium and potassium
 Role of vitamin E and aspirin in delay cataractogenesis
o Measures to improve vision in the presence of incipient and immature cataract
 prescription of glasses
 Arrangement of illumination
 Dark goggles
 Mydriatics
 Describe the complications of cataract surgery and its
management.
PRE-OPERATIVE COMPLICATIONS

- Anxiety
o some patients may develop anxiety, on the eve of operation due to fear and
apprehension of operation
o anxiolytic drugs such as alprazolam at bed time usually alleviates these symptoms
- Irritative or Allergic Conjunctivitis
o may occur in patients due to preoperative topical antibiotic drops
o postponing the surgery for 2 days along with withdrawal of such drugs is
required
- Complications due to Local Anaesthesia
o Retrobulbar Haemorrhage
 due to retrobulbar block
 immediate pressure bandage after instilling one drop of 2% pilocarpine and
postponement of surgery for 1 week is advised.
o Oculocardiac reflex
 manifests as bradycardia or cardiac arrhythmia
 due to retrobulbar/peribulbar block
 IV injection of atropine is useful
o Perforation of Globe
 prevented by gentle injection with blunt tipped needle
 further peribulbar anaesthesia may be preferred over retrobulbar block
o Subconjunctival Haemorrhage
 minor complication observed frequently
 does not need much attention
o Spontaneous Dislocation of Lens
 reported during vitreous ocular massage after retrobulbar block
 operation should be postponed and further management is similar to that of
posterior dislocation of lens

OPERATIVE COMPLICATIONS

- Superior Rectus Muscle Laceration

o may occur while applying the bridle suture in conventional ECCE and SICS
o usually no treatment is required
- Excessive bleeding
o may be encountered during the preparation of conjunctival flap or during sclera
incision in SICS and ECCE
o bleeding vessels may be gently cauterised
- Incision related Complications
o irregular incision
 may lead to defective coaptation of wound
 may occur due to blunt cutting instruments
o Button Holing of Anterior wall of Tunnel
 due to superficial dissection of sclera flap
 to remedy, abandon the dissection and re-enter at a deeper plane
 o Premature entry into Anterior Chamber
 due to deep dissection
 dissection in that area should be stopped
 a new dissection is started at a lesser depth at the other end of the
tunnel
o Scleral Disinsertion
 occurs due to very deep groove incision
 complete separation of inferior sclera from the sclera superior to
the incision occurs
 needs to be managed by radial sutures
- Injury to the Cornea, iris and Lens
o may occur when the anterior chamber is entered with a sharp tipped instrument
o gentle handling reduces the incidence of such injuries
- Iris Injury and Iridodialysis
o tear of iris may occur inadvertently during intraocular manipulation
- Complications related to the anterior capsulorrhexis
o Escaping Capsulorrhexis
 capsulorrhexis moves peripherally
 may extend to the equator or posterior capsule
o Small Capsulorrhexis
 predisposes to posterior capsular tear and nuclear drop during
hydrodissection
 also predisposes to occurrence of zonular dehiscence
 should be enlarged by 2 or 3 relaxing incisions
o Very Large Capsulorrhexis
 may cause problems for in the bag placement of intraocular lens
o Eccentric capsulorrhexis
 can lead to intraocular lens decentration at a later stage
- Posterior Capsular Rupture
o dreaded complication during cataract extraction
o can occur during
 forceful hydrodissection
 by direct injury with some instrument such as Sinskey’s hook, chopper or
phacotip
 cortical aspiration (accidental PCR)
- Zonular Dehiscence
o may occur in all techniques of ECCE
o especially common during nucleus prolapse into the anterior chamber in manual
SICS
- Vitreal Prolapse and Loss
o most serious complication which may occur following rupture of posterior capsule
o measures to prevent this loss include
 decrease vitreous volume
 decrease aqueous volume
 decrease orbital volume
 better ocular akinesia and anaesthesia
 Minimising external pressure
 - Nucleus drop into the vitreous cavity
o occurs more frequently with phacoemulsification
o dreadful complication which occurs due to sudden and large PCR
o management includes referral to a vitreoretinal surgeon after a thorough
anterior vitrectomy and cortical clean up
- Posterior loss of Lens fragments into the vitreous cavity
o potentially serious
o may result in glaucoma, chronic Uveitis, chronic CME and even retinal
detachment
o surgical management includes performing pars plana vitrectomy and removal
of nuclear fragments
- Expulsive Choroidal Haemorrhage
o occurs in hypertensive patients and those with atherosclerotic changes
o may occur during operation or during immediate postoperative period
o characterised by spontaneous gaping of the wound, during ICCE and
conventional ECCE
 followed by expulsion of lens, vitreous, retina, uvea and gush of
bright red blood
o surgeon should attempt to drain the subchoroidal blood by performing an
equatorial sclerotomy
 most of the time, the eye is lost

EARLY POST-OPERATIVE COMPLICATIONS

- Hyphaema
o collection of blood in the anterior chamber
o most hyphaemas absorb spontaneously
 treatment is unnecessary
o in cases that are associated with high IOP
 IOP should be lowered with Acetazolamide and hyperosmotic
agents
o if blood is not absorbed in a week, paracentesis should be done to drain the
blood.
- Iris Prolapse
o usually caused by inadequate suturing after ICCE and conventional ECCE
o small prolapse may be repositioned and wound is sutured
o large prolapse needs abscission and wound suturing
- Striate keratopathy
o characterised by mild corneal oedema with Descemet’s folds
o due to endothelial damage during surgery
o disappears spontaneously within a week
o moderate to severe cases may be treated by instillation of hypertonic saline
drops along with steroids
- Flat anterior chamber
o rare complications
o due to wound leak, ciliochondral detachment or pupil block
 - Post-operative anterior Uveitis
o induced by instrumental trauma, undue handling of uveal tissue or reaction
to residual cortex
o management includes more aggressive use of topical steroid, cycloplegics and
NSAIDs
o rarely systemic steroids may be required in cases with severe fibrinous reaction
- Toxic anterior segment syndrome
- Bacterial Endophthalmitis
o one of the most dreaded complication with an incidence of 0.1% to 0.5%
o principal sources of infection are contaminated solutions, instruments,
surgeon’s hands, patients own conjunctival flora
o signs and symptoms include ocular pain, diminished vision, lid oedema,
conjunctival chemosis, marked circumciliary congestion, corneal oedema,
exudates in pupillary area, hypopon and diminished or absent red
pupillary glow
o management requires emergency attention

LATE POST-OPERATIVE COMPLICATIONS

- Cystoid Macular Oedema

o collection of fluid in the form of cystic loculi in the Henle’s layer of macula
o in most cases it is clinically insignificant and doesn’t produce any visual
disturbances
o in few cases, significant CME typically produces visual diminution within 2-3
months after cataract extraction
o on fundoscopy, it produces a honey-comb appearance
o on fluorescein angiography, it depicts a ‘typical flower petal pattern’ due to
leakage of dye from perifoveal capillaries
o this is managed by anterior vitrectomy along with steroids and anti-
prostaglandins
- Delayed Chronic Post-operative Endophthalmitis
o caused when an organism of low virulence becomes trapped within the capsular
bag
o it has an onset ranging from 4 weeks to years
o typically follows an uneventful cataract extraction
o fungal Endophthalmitis may occur rarely, characterised by puff-ball vitreous
exudates
o treated by pars plana vitrectomy and anti-fungal drugs administered
intravitreally and orally
- Pseudophakic Bullous Keratopathy
o continuation of Postoperative corneal oedema
o produced by surgical or chemical insult to a healthy or compromised corneal
endothelium
o common indication of penetrating keratoplasty
- Retinal Detachment
o incidence is higher in aphakic patients as compared to phakics
o more common after ICCE than after ECCE and IOL implantation
 - Epithelial Ingrowth
o rarely conjunctival epithelial cells may invade the anterior chamber through a
defect in the incision
o this abnormal epithelial membrane grows slowly and lines the back of the cornea
and trabecular meshwork leading to intractable glaucoma
- Fibrous downgrowth into the anterior chamber
o may occur occasionally when the cataract wound apposition is not perfect
o it may cause secondary glaucoma, disorganisation of anterior segment and
ultimately phthisis bulbi
- After cataract
o known as secondary cataract
o most common postoperative complication
o opacity which persists or develops after extracapsular lens extraction
o Clinical Types
 Tenures Posterior Capsule Opacification
 Dense membranous after cataract
 Soemmering’s rings
 refers to a thick ring of after cataract formed behind the iris,
enclosed between the 2 layers of capsule
 Elschnig’s pearls
 vacuolated subcapsular epithelial cells are clustered like soap bubbles
along the posterior capsule
o treatment is as follows
 YAG-laser capsulotomy and Surgical membranectomy

IOL-RELATED COMPLICATIONS

- Complications like CME, corneal epithelial damage, Uveitis and Secondary

glaucoma
o seen more frequently with IOL implantation especially with anterior chamber
and iris supported IOLs
o UGH syndrome refers to concurrent occurrence of Uveitis, glaucoma and
hyphaema
o it is used to occur commonly with rigid anterior chamber IOLs
- Malpositions of IOL
o may be in the form of decentration, subluxation and dislocation
o examples include
 Sunset Syndrome – inferior subluxation of IOL
 Sunrise Syndrome – superior subluxation of IOL
 Windshield Wiper Syndrome
 results when a very small IOL is placed vertically in the sulcus
 in this the superior loop moves to the left and right, with movements of
the head
- Pupillary Capture of the IOL
o occurs following postoperative iritis or proliferation of the remains of lens
- Toxic Anterior Segment Syndrome (TASS)
o uveal inflammation excited by either ethylene gas used for sterilising IOLs
o characterised by violent inflammation
SHORT NOTES
Zonular Cataract
- zonular cataract is a type of hypocalcemic, or tetanic, cataract
- may be associated with parathyroid tetany, which may occur due to atrophy or
inadvertent removal of parathyroid glands
- characterised by a thin, opacified lamella deep in the infantile cortex
- typically seen in infants with hypocalcemia

Traumatic Cataract
- occurs mainly due to imbibitions of aqueous and partly due to direct mechanical
effects of the injury on lens fibres
- it may assume any of the following shapes
o Discrete subepithelial opacities are of most common occurrence
o Early rosette cataract
 it is the most typical form of concussion cataract
 appears as feathery lines of opacities along the star-shaped suture
lines
o Late Rosette Cataract
 it develops in the posterior cortex 1-2 years after the injury
 its sutural extensions are shorter and more compact than the early
rosette cataract
o Traumatic Zonular Cataract
 it may also occur in some cases, though it is rare
o Diffuse Concussion Cataract
 it is of frequent occurrence
o Early Maturation of Senile Cataract
 may follow blunt trauma

Morgagnian Hypermature Cataract

- form of Hypermature senile cataract
- in some patients, after maturity the whole cortex liquefies and the lens is converted
into a bag of milky fluid
- the small brownish nucleus settles at the bottom, altering its position with change in the
position of the head
- sometimes in this stage, calcium deposits may also be seen on the lens capsule

Nuclear Cataract
- progressive nuclear sclerotic process renders the lens inelastic and hard
o this decreases the ability to accommodate and obstructs the light rays
- changes begins centrally and spread slowly peripherally almost up to the capsule when it
becomes mature
- nucleus becomes diffusely cloudy or tinted due to deposition of pigments
- in practice the most commonly observed pigmented nuclear cataracts are amber, brown
and black and rarely reddish in colour
 Complicated Cataract
Complicated cataract refers to opacification of the lens secondary to some other intraocular
disease

- Etiology
o lens depends for it nutrition on intraocular fluids
o any condition in which the ocular circulation is disturbed or in which
inflammatory toxins are formed, will disturb nutrition of the lens
 results in development of complicated cataract
o some important ocular conditions that give rise to complicated cataract are
 Inflammatory Conditions – iridocyclitis, pars planitis, choroiditis
 Degenerative Conditions – retinitis pigmentosa
 Retinal detachment
 Glaucoma
 Intraocular tumours
- Clinical Features
o starts as a posterior subcapsular cortical cataract
o opacity is irregular in outline and variable in density
o the opacities have
 Breadcrumb appearance
 Polychromatic luster – iridescent coloured particles (Rainbow
cataract)
 Diffuse yellow haze is seen in the adjoining cortex
 slowly the opacity spreads in the rest of the cortex
 deposition of calcium is common in the later stages
- Drug-induced Cataracts
o examples of drug induced cataracts include
 Corticosteroid Induced Cataract
 Miotics-induced cataract
 Other drug induced cataracts
 amiodarone, chlorpromazine, busulphan, gold and Allopurinol

Intumescent Cataract
- progression of immature senile cataract
- the lens may become swollen due to continued hydration
- this condition is known as Intumescent Cataract
- Intumescence may persist even in the next stage of maturation
- due to the swollen lens, the anterior chamber becomes shallow
 Phacoemulsification
- procedure of choice for extracapsular cataract extraction surgery, along with
foldable posterior chamber intraocular lens implantation
- differs from conventional ECCE and manual SICS
- METHOD
o CLEAR CORNEAL INCISION
 very small (2.8-3mm)
 provides sutureless surgery as the cornea will heal on its own
o CONTINUOUS CURVILINEAR CAPSULORRHEXIS
 4-6 mm
 preferred over anterior capsulotomy methods
o HYDRODISSECTION
 separation of capsule from the cortex by injecting fluid between them
 facilitates nucleus rotation and manipulation during phacoemulsification
 some surgeons also perform a Hydrodelineation by injecting the fluid
between the nucleus and epinuclear lens substance
o NUCLEUS IS EMULSIFIED
 and aspirated by phacoemulsifier
 acts through a hollow 1mm titanium needle
 this needle vibrates by piezoelectric crystal in its longitudinal axis at an
ultrasonic speed
o REMAINING CORTICAL LENS IS ASPIRATED
 aided by an irrigation-aspiration technique
o IOL IMPLANTATION
 foldable IOL implantation with the help of an injector
 phacoprofile rigid IOL can also be implanted after enlarging the incision
o NEXT STEPS
 removal of viscoelastic substance
 wound closure

Congenital Cataracts
- occur due to some disturbance in the normal growth of the lens
- when the disturbance occurs before birth, it is considered a congenital cataract
- the opacity is limited to either embryonic or foetal nucleus
- etiology may be idiopathic, hereditary, maternal (malnutrition, infection, drugs,
radiation), foetal (deficient oxygenation, trauma, metabolic disorders, malnutrition)
- Clinical Types
o Congenital Capsular Cataract – anterior and posterior types
o Polar Cataracts – anterior and posterior types
o Congenital Nuclear Cataracts
 Cataracta pulverulenta
 Lamellar cataract
 Sutural and axial cataracts – floriform, coralliform, spear-shaped, anterior axial
embryonic, dentritic suture
 Total nuclear cataract
o Generalised cataracts – coronary cataracts, blue dot cataract, total congenital cataract,
congenital membranous cataract