CATARACT CASE PRESENTATION

By MBBS Gang
PATIENT PARTICULARS
▸ Name: Mrs X
▸ Age: 65 years
▸ Gender: Female
▸ Occupation: Homemaker
▸ Upper class by Modified Kuppuswamy Classification [Importance of
demographic data]
▸ Residency: Whitefield, Bangalore [for documentation purposes, endemic
diseases]
▸ Date of examination: 22.2.2020

CHIEF COMPLAINTS
▸ Diminution of vision in both eyes since the last 8 months, right eye more than left
eye.
[D/D for progressive painless diminution of vision – Presbyopia, Myopia,
Hypermetropia (R.E) ; Pterygium of Higher Grade, Corneal Degeneration, Corneal
Opacity (if H/O trauma), Primary Open Angle Glaucoma, Keratoconus via
astigmatism, Hypertensive Retinopathy, Retinitis Pigmentosa, ARMD, CRVO]

HISTORY OF PRESENTING ILLNESS

▸ Patient was apparently alright 8 months back, when she noticed diminution
of vision in both eyes, right eye more than the left eye. It was insidious in onset
and gradually progressed to the current state. It was not associated with pain.
▸ Diminution of vision was same for both distance and near vision and was more
in bright light. (D/D of diminution of vision with & w/o pain, acute & progressive, in
bright light [posterior subcapsular cataract] & in dim light [nuclear cataract])
▸No aggravating or relieving factors (seen in painful cases) [Diurnal variation seen
in Glaucoma, Posterior Sub-capsular Cataract more dimness in Bright Light, Cortical
Cataract better vision during day, not much variation seen in Nuclear Cataract;
Cuneiform and Cupuliform Cataract in Bright and Dim Light]
▸ It was associated with glare.
▸ She also mentioned that initially she was able to differentiate colors well, but
now she finds colors dull.
▸ It was not associated with Redness (d/d of red eye), Watering (r/o dacrocystitis),
Discharge, Headache (r/o lens induced glaucoma), Double Vision, Coloured halos
(On seeing white light) [Coloured halos, Polyopia seen in Incipient Stage /early
stages of Immature cataract, helps in Staging cataract] [(d/d- mucopurulent
conjunctivitis [halo disappear after washing mucopurulent discharge], acute
congestive glaucoma - halo intact, corneal oedema, cataract- broken halos), black
spots, Frequent changing of glasses.

OCULAR HISTORY
▸ She uses glasses since the last 20 years. (Presbyopia; if she needs glasses after
Cataract Sx, IOL used is monofocal and cataract was not nuclear)
▸ No history of ocular surgeries (Previous cataract surgery in one eye can hint at
cataract in the other eye)
▸ No history of trauma (Blunt Ocular trauma leads to cataract, lens goes into
vitreous)
▸ No history of using eye drops in the past (R/O steroid eyedrop can cause both
cataract and glaucoma, Pilocarpine eyedrop)
▸ No history of squint, lazy eye (amblyopia) (in such case vision will not improve
with cataract surgery, but still go ahead with Sx to prevent complications of
Hypermature cataract like Painful Blind Eye, treat vitreous hemorrhage of retina if
present and so on) or any other significant past ocular history .

PAST HISTORY
▸ Patient is a known diabetic (DM Premature cataract, Post OP delayed wound
healing, Diabetic retinopathy) since the last 15 years and hypertensive [HTN
Retinopathy (Keith-Wagener-Barker classification), Glaucoma, Choroidal
Hemorrhage, Central Retinal Vein Occlusion] (Precaution of lignocaine/adrenaline
use in peribulbar anaesthesia) since the last 10 years and is on medication for the
same.
▸ No history of Asthma, COPD (long term steroid cause cataract, raised IOP
Complicate Cataract Sx), Ischemic heart disease (Retrobulbar Haemorrhage if
antiplatelet drug used).

FAMILY HISTORY
▸ No significant family history (Congenital cataract in infant, POAG in adult)

PERSONAL HISTORY
▸ Mixed diet, predominantly non vegetarian.
▸ Normal Appetite
▸ Regular Bowel and Bladder Movements (Tamsulosin should be stopped before
OT, to prevent intraoperative floppy iris syndrome)
▸ Normal Sleep (Inflammatory/pain condition in eye hampers sleep)
▸ No ill habits (Smoking causes nuclear cataract, glaucoma, HTN retinopathy,
ARMD, Pterygium, Thyroid eye ds)

GENERAL PHYSICAL EXAMINATION

▸ Patient was examined under adequate light.
▸ She was well oriented to time place and person.
▸ Height: 153 cm
▸ Weight : 65kg
▸ BMI : 27.7Kg/m
▸ Vitals:
Temperature: 98F/ afebrile to touch
Pulse: 82 beats per minute
Blood Pressure: 140/ 80 mm Hg; Right Arm Sitting Position
Respiratory Rate: 16 per minute
No Pallor, Icterus, Cyanosis, Clubbing, Lymphadenopathy, Edema.
(Lymphadenopathy in viral/ Gonococcal/ Chlamydial (preauricular & submandibular
LN) conjunctivitis, Paranoid ocular glandular syndrome, )
OCULAR EXAMINATION
▸ Head Posture Straight and erect.
▸ Both sides of the face are symmetric in appearance
▸ Ocular Symmetry: Symmetrical (Facial asymmetry- CN7 Palsy, U/L CN3 palsy,
hHrner, Strug weber syndrome)
▸ Ocular Posture: Both eyes are aligned (Hirschberg Corneal Reflex Test)
straight – Orthotropic

Right eye Left eye

Visual acuity (Bedside) Counting fingers >6 m Counting fingers >6 m
Ideally check by
Snellen’s and Jaegar’s
chart optotypes with
and w/o glasses - 6/60
Projection of rays (PR) Accurate in all Accurate in all
quadrant quadrant
Perception of light (PL) Present (can count Present (can count
fingers) fingers)
Pinhole No improvement No improvement
Near vision (know Not checked Not checked
second sightedness in
nuclear cataract- index
myopia improve !!)
Eyebrows Normal Normal
Eyelids (r/o blepharitis, Normal Normal
entropion/extropion,
dystriciasis)
Eyeball Normal Normal
Eyelashs Normal Normal
Conjunctiva (r/o Normal Normal
circumcorneal
congestion vs
superficial conjunctival
congestion)
Cornea Normal in size (Know Normal in size
the normal dimensions Shape
!!) Transparency
Shape Regular surface
Transparency Sheen
Regular surface
 Sheen (normal tear Arcus senilis under
film, what is sheen!!) torchlight
Arcus senilis under
torchlight (Difficult to
do tunnel during Sx)
Purkinje images (1st & seen seen
2nd )
Corneal Sensations Intact Intact (Both sided
corneal blink on
touching with cotton, if
absent in opposite
side- U/L CN7 palsy)
Sclera Normal Normal
Anterior chamber Normal depth (shallow Normal depth and clear
AC intumescent content
cataract

Deep AC Zonular

dehiscence,
Aphakia/pseudophakia)
clear content (R/O
Hyphema, hypopyon)
Iris Dark Brown in color Dark Brown in color
(r/o uveitic cataract, Normal pattern
Fuchs Uveitis
Syndrome / Fuchs
Heterochromic
Iridocyclitis)
Normal pattern
Pupil 3mm round and 3mm round and
circular circular
Reactive to light
(intactness of anterior
visual pathway- good
post op vision
development)
Direct reflex Present briskly reactive Present briskly reactive
Indirect reflex Present briskly reactive Present briskly reactive
Near reflex (Know the present Present
steps!!)
Lens Greyish white opacity Greyish white opacity
seen (pearly white seen
mature cataract, Iris shadow seen
 milky white
hypermature
cataract/sclerotic
cataract)
Iris shadow seen (know
iris shadow!!)
Purkinje images (3rd & seen seen
4th )
Ocular Movements Free and full in all Free and full in all
[Duction, Version, directions (Know all directions
Vergences] the names of direction
!!)
Lacrimal apparatus
Punctum (check both) Normal Normal
Skin over lacrimal sac Normal Normal
(Scar in previous DCR,
Swelling in
inflammation/mucocele)
ROPLAS Negative Negative
Digital Tonometry Firm and Fluctuant Firm and Fluctuant
(complications of (Normal) (Normal)
Cataract Sx due to high
IOP!! )

SYSTEMIC EXAMINATION
▸CVS: S1, S2 heard, no murmurs
▸RS: Decreased breath sound on both side
▸CNS: No focal neurological deficit

SUMMARY
▸ Mrs X, 65 yr old homemaker, came with complaint of painless diminution of
vision in both eyes since the last 8 months, Right eye more than left eye. It was
same
for near and distance vision and was associated with glare. On examination,
the patient was found to have a grayish-white opacity in pupillary area in the right
and left
pupillary area and iris shadow was present.
PROVISIONAL DIAGNOSIS
▸ Right eye Senile Immature Cataract & Left eye Senile Immature Cataract
(Posterior subcapsular cataract- reduced vision in bright light/hemarlopia) (iris
shadow absent, greyish white opacity- immature cataract) (4th Purkinje absent in
mature cataract) (senile> 45 yr, presenile <45 yr) [Also know LOCS Grading of
Cataract]
[Investigations: Visual acuity, pinhole, slit lamp (grading of cataract), retinal
function tests- 2 point discrimination test and others, macular test- color vision,
amsler gris test, syringing test-r/o lacrimal infection, fundus examination- Diabetic
retinopathy, HTN, IOP measurement, systemic- sugar, pressure, ANC, serology,
USG A scan & B scan
Surgery- Know the types briefly!! Operate on worst eye first!!
Calculate IOL Power!!--> Biometry & its formulae
Pre OT steps!!- topical NSAIDS
Types of ocular anaesthesia and drugs!!
Anaesthesia Complications, Ocular Spaces
Argentinian flag sign after femtosecond laser-assisted capsulotomy in intumescent
cataract
Techniques of nucleus delivery in Manual SICS (Anterior chamber maintainer
technique, Micro-vectis technique, Phaco-fracture technique, Phaco-sandwich
technique, Fish hook technique, Ruit's technique)
Post OP Complications!!
D/D of glare (cataract- at night in posterior subcapsular, nebular opacity, ARMD
Drusen at day time)
Expulsive choroidal hemorrhage if BP is high, so control BP before Sx
Moderate NPDR- progress after Cataract Sx
Post OP management!!- antibiotic-steroid drop,
Dislocation of IOL!!- sunrise/sunset/windshield wiper syndrome
Uveitis- delay OT, 3 months of absent Aq cells- go for Sx
Dark glass after OT for 1 week- to reduce photophobia due to iridocyclitis, to give
rest