CATARACTS: A Leading

Cause of Preventable
Blindness
Neda Karimi, M.D.
Represented by
Dr.R.Handoko Pratomo,SpM

Epidemiology

Cataracts are the leading cause of

blindness in the world
More than 1.3 million cataract
procedures are performed in the
U.S. each year
Visual disability associated with
cataracts account for 8 million
physician office visits each year

Cataract is the leading cause of

blindness in those 40 years or
older in the United States

History

The earliest reference to cataracts can

be found in Hindu writings from the 5th
century BC
The word Cataract comes from the
Greek word meaning Waterfall
Until the mid 1700s, it was thought that
cataract was formed by opaque material
flowing, like a waterfall into the eye

Lens

The human lens is

a naturally clear
structure located
behind the iris
and supported by
the zonules
The lens is
avascular-It does
not have a
vascular supply

Structure

The basic lens

consists of a
central nucleus
surrounded by the
cortex contained
within the lens
capsule

Optics

When light passes

through the pupil, it
is focused by the
lens to produce clear,
sharp images on the
retina, the lightsensitive membrane
on the back of the
eye that functions
like the film of a
camera

Optics

When this
arrangement is
disturbed in any
way, the
transparency is lost
This results in
scattering of light,
blurring, and
blocking of the
image

Structure

The lens is made mostly of water and protein

fibers
The protein fibers are arranged in a precise
manner that makes the lens clear and allows
light to pass through without interference
With aging, the composition of the lens
undergoes changes and the structure of the
protein fibers breaks down
Some of the fibers begin to clump together,
clouding areas of the lens, and leading to the
loss of transparency

This loss of
transparency, or
opacity formation
is called Cataract

Clouding of the lens is a normal part of

aging
About half of Americans older than 65
have some degree of clouding of the
lens
According to one study, after age 75,
39% of men, and 46% percent of
women in the U.S. have visually
significant cataracts

Cataracts produce a gradual,

painless, progressive loss of vision,
and many patients are unaware of
vision problems
Generally do not cause pain, or
abnormal tearing
But as the clouding progresses, the
cataract eventually interferes with
your vision

Commonly affect distance vision

Cause problems with glare
In the early stages, stronger
lighting and eyeglasses can help
deal with the vision problems
If impaired vision jeopardizes your
normal lifestyle, you might need
surgery

Patients often
describe trying to
look through a
fogged-up window
Clouded vision
can make it more
difficult to drive a
car, read, or see
details

Symptoms

Blurred vision
Increasing difficulty with vision at night
Glare, especially at night
Halos around lights
The need for brighter light for reading
Double vision in a single eye
Fading or yellowing of colors

Due to increase of
yellow-brown
pigment in the
lens, color
perception also is
affected

These may also be symptoms of

other eye conditions, therefore it is
important to see your
ophthalmologist annually, or if
there is a persistent change in
vision

Pain, redness, discharge, or

irritation in the eye are usually not
signs or symptoms of a cataract,
but may be signs and symptoms of
other eye disorders

Hypermature Cataract

A cataract isn't
dangerous to the eye
unless the cataract
becomes completely
white, a condition
known as an overripe
(hypermature) cataract
This can cause
inflammation, eye pain
and headache
A hypermature
cataract is extremely
rare and needs
removal

Types of Cataract

The lens consists of

three layers
The outer layer is a
thin, clear membrane
It surrounds a soft,
clear material (cortex)
The hard center of the
lens is the nucleus
A cataract can form in
any part of the lens

Nuclear Cataract

Occurs in the center of the lens

In its early stages, the patient may
become more nearsighted or even
experience a temporary improvement in
reading vision
This so-called second sight disappears
as the lens gradually turns yellow and
begins to cloud the vision
Seeing in dim light and driving at night
may be especially troublesome

Cortical Cataract

Begins as whitish, wedge-shaped streaks

on the outer edge of the lens cortex
As it slowly progresses, the streaks
extend to the center and interfere with
light passing through the nucleus
Both distance and near vision can be
impaired
Patients also have problems with glare
and loss of contrast

Subcapsular Cataract

Starts as a small, opaque area just under

the capsule shell, usually at the back of the
lens, right in the path of light on its way to
the retina

This type of cataract may occur in both

eyes but tends to be more advanced in one
eye than the other

Often interferes with reading vision,

reduces your vision in bright light and
causes glare or halos around lights at night

Etiology

Why age-related changes happen to the

lens is not known
One possibility is damage caused by
unstable molecules known as free
radicals
Smoking and exposure to UV light are two
sources of free radicals
General wear and tear on the lens over
the years also may cause the changes in
protein fibers

Etiology

Age-related changes in the lens are not the only

cause of cataracts
Some infants are born with cataracts or develop
them during childhood
Such cataracts may be the result of the mother
having contracted rubella during pregnancy
Metabolic disorders

Congenital Cataracts

Responsible for nearly 10% of all visual

loss in children worldwide
Approximately 0.03% of newborns have
some form of congenital cataract
Most are not associated with additional
developmental problems
Around one fifth of these patients have a
family history of congenital cataract but
in up to half of all cases there is no family
history

In the case of a newborn infant, a

cataract causes the immature visual
system to be deprived of the stimulation
needed for normal development
If left untreated, permanent visual loss
may occur
Unilateral cataracts are more likely to
cause visual loss because of the
competition between the two eyes

If the cataract is small there may be only

slight blurring of vision with near normal
visual development
If the cataract is larger, or located more
posteriorly, it can effect visual
development
In some cases this can lead to permanent
amblyopia (lazy eye)
Without adequate stimulation central
vision can be permanently effected

Outcome is very much dependent on

the type of cataract
Some congenital cataracts impair
visual development only to a small
degree and may never require surgery
If the cataract is only in one eye, there
is a strong tendency for the child to
prefer the healthy eye

The eye affected by the cataract rarely

achieves normal vision, therefore removal of
the cataract is indicated

Etiology of Pediatric
Cataracts

Hereditary

Genetic and Metabolic Diseases

Autosomal dominant form most common

Down syndrome
Marfans syndrome
Myotonic Dystrophy

Maternal Infections

Rubella, Syphilis, Toxoplasmosis, Varicella

Ocular Anomalies

Toxic

Aniridia-Absence of iris at birth

Corticosteroids, Radiation

Trauma

Risk Factors In Adults

Exposure to sunlight (UV light)

Smoking
Diabetes
Trauma (blunt or penetrating)
Family history of cataracts
Corticosteroid therapy
Radiation exposure
Electrical injury
Myotonic dystrophy
Uveitis- Ocular inflammation

Risk Factors

Everyone is at risk of developing

cataracts simply because age is
the single greatest risk factor
By age 65 about half of all
Americans have developed some
degree of lens clouding

Cataracts develop sooner in diabetic

patients than in non-diabetic
patients
This is caused by shifts in the
glucose, electrolyte, and water
balance within the lens
Fluctuating vision and rapid shift to
near sightedness are symptoms of
diabetes

Clinical Findings

The most
common objective
finding associated
with cataracts is
decreased visual
acuity
This is measured
with an office wall
chart or nearvision card

Visual Acuity

Acuity refers to the sharpness of vision or

how clearly you see an object
In this test, your eye doctor checks to see
how well you read letters from across the
room
Eyes are tested one at a time, while the
other eye is covered.
Using the chart with progressively smaller
letters from top to bottom, to determine
the level of vision

Refraction

This is performed
by your doctor to
see if the decrease
in vision is simply
due for need for
new glasses, or if
there is another
process at work
that accounts for
the decrease in
visual acuity

Slit Lamp Exam (SLE)

SLE allows the

ophthalmologist to see
the structures of the
eye under magnification
The microscope is called
a slit lamp because it
uses an intense slit of
light to illuminate your
cornea, iris, and lens
These structures are
viewed in small sections
to detect any small
abnormalities

Dilated Exam

Dilating drops are placed

in the eyes to dilate the
pupils wide and provide
a better view to the back
of the eyes
It allows the
ophthalmologist to
examine the lens for
signs of a cataract and, if
needed, determine how
dense the clouding is

Dilated Exam

It also allows for

examination of the
retina and the
optic nerve.
Dilating drops
usually keep your
pupils open for a
few hours before
their effect
gradually wears off

When pupils are dilated, patients

will have difficulty focusing on
close objects
With your pupils open this wide,
sunglasses are helpful on a sunny
day, and you may need a driver to
drive you home

Other Causes of painless

Vision Loss

Cataract
Retinal detachment
Macular degeneration
Diabetes mellitus
Glaucoma
Retinal artery occlusion

Retinal detachment is often accompanied

by floaters, flashes of light, and loss of
peripheral vision, which is often described
as a gray curtain or shade covering all or
part of the visual field
Risk factors include a history of previous
ocular trauma, nearsightedness, retinal
detachment in the fellow eye, or a family
history of retinal detachment

Macular degeneration usually

causes a slow, progressive loss of
central vision
Symptoms of acute vision loss and
distortion result from leakage from
abnormal subretinal vessels
Patients should be referred to a
retina specialist immediately

Diabetic retinopathy may also contribute

to vision loss
Findings include dot-and-blot
hemorrhages, microaneurysms, dilated
and tortuous vessels, and
neovascularization of the disk and retina
Cataracts often obscure the fundus,
making assessment of diabetic
retinopathy difficult

Open-angle glaucoma produces slow,

painless visual field loss that usually
begins peripherally
Optic nerve damage and subsequent
loss of peripheral vision occur at normal
as well as elevated intraocular pressures
With progressive optic nerve damage
and visual field loss, central vision is the
last to be affected

Cataracts are the most treatable cause

of decreased vision in the United
States
For most patients, observation and
frequent eyeglass prescription changes
are sufficient
When activities of daily living, such as
driving, reading, working, and self-care
are affected surgery should be
discussed

Cataract Surgery should be

considered when changes in
eyeglasses no longer help, quality
of life is jeopardized, and cataract
removal is likely to have an impact
on vision

Treatment

Make sure that eyeglasses or

contact lenses are the most
accurate prescription possible
Improve the lighting in your home
with more or brighter lamps
When outside during the day, wear
sunglasses to reduce glare
Limit night driving

Think about how the cataract affects your

daily life

Can you see to do your job and drive safely

Do you have problems reading or watching
television?
Is it difficult to cook, shop, climb stairs or take
medications?
How active are you? Does lack of vision affect
your level of independence?
Are you afraid you'll trip or fall or bump into
something?

Sometimes a cataract should be

removed even if it doesn't cause
major problems with vision

If it is preventing the treatment of

another eye problem, such as agerelated macular degeneration,
diabetic retinopathy or retinal
detachment

If you have cataracts in both eyes

and decide to have surgery, your
eye doctor typically removes the
cataract in one eye at a time
This allows time for the first eye to
heal before the second eye surgery

Cataract surgery is the most common

operation performed on patients over 65
years of age
More than 95% of patients have improved
vision after surgery
Benefits include improvement in uncorrected
and best-corrected visual acuity, improved
binocularity, depth perception, and
increased peripheral vision to enhance
patients' ability to drive, read, work, and
manage their own medications

Advances in surgical technique and more

sophisticated technology have helped make
surgery a safe and effective treatment for
cataracts
Prior to surgery, your eye doctor measures
the size and shape of your eye to determine
the proper lens implant power
This measurement is made with a painless
ultrasound test

Cataract surgery is
typically an outpatient
procedure that takes
less than an hour
Most people are awake
and need only local
anesthesia
On rare occasions some
people may need
general anesthesia if
they have difficulty
laying flat or have
claustrophobia

Two things happen

during cataract
surgery the
clouded lens is
removed, and a clear
artificial lens is
implanted

Phacoemulsification

During
phacoemulsificati
on, phaco for
short, the surgeon
makes a small
incision, where
the cornea meets
the conjunctiva

The surgeon then

uses the probe,
which vibrates
with ultrasound
waves, to break
up (emulsify) the
cataract and
suction out the
fragments

Once the cataract is

removed, a clear
artificial lens is
implanted to replace
the original clouded
lens
This lens implant is
made of plastic,
acrylic or silicone and
becomes a permanent
part of the eye

Some IOLs are rigid

plastic and implanted
through an incision
that requires several
stitches (sutures) to
close
However, many IOLs
are flexible, allowing a
smaller incision that
requires no stitches

Patients usually go home the same day

Patients are seen in the office the next day,
the following week, and then again after a
month so that he or she can check the healing
progress
It's normal to feel mild discomfort for a couple
of days after surgery
You may wear an eye patch or protective
shield the day of surgery
Your doctor may prescribe medications to
prevent infection and control eye pressure

Post-op Course

Patients are usually examined 1

day, 1 week and then one month
after the surgery date

Complications of Surgery

Vitreous Loss- 3.1%

Vitreous Hemorrhage-0.3%
Uveitis-1.8%
Increased Eye Pressure- 1.2%
Retinal Detachment- 0.7%
Endophthalmitis- 0.13%

Post Operative Period

Contact your doctor immediately if you

experience any of the following signs or
symptoms after cataract surgery:

Vision loss
Pain that persists despite the use of overthe-counter pain medications
A definite increase in eye redness
Light flashes or multiple spots (floaters) in
front of the eye
Nausea, vomiting or excessive coughing

Posterior Subcapsular
Opacity

This condition occurs

when the back of the
lens capsule
eventually becomes
cloudy and blurs
vision
PCO can develop
months or years after
cataract surgery
Occurs approx. 20%
percent of the time

Treatment for PCO is simple and quick

Laser capsulotomy is a quick, painless
outpatient procedure that usually
takes less than five minutes
Capsulotomy means "cutting into the
capsule" and YAG is an abbreviation of
yttrium-aluminum-garnet, the type of
laser used for the procedure

YAG Laser Capsulotomy

A technique in
which a laser
beam is used to
make a small
opening in the
clouded capsule
to let light pass
through

Post YAG

Afterward, patients typically stay in the

doctor's office for about an hour to make
sure the eye pressure is not elevated
In some people, particularly those who have
glaucoma or are extremely nearsighted, YAG
laser surgery can raise eye pressure
Other complications are rare but can include
swelling of the macula and a detached retina

Most cataracts occur with age and

can't be avoided altogether
Regular eye exams remain the key
to early detection
You can take steps to help slow or
prevent the development of
cataracts

Do not smoke

Eat a balanced diet

Smoking produces free radicals, increasing

your risk of cataracts.
Include plenty of fruits and vegetables.

Ultraviolet light protection since UV light

may contribute to the development of
cataracts
Diabetes Control

New Frontiers

Researchers are continuing to

explore new ways to prevent and
treat cataracts, such as developing
medications that would reduce or
eliminate the need for surgery
Until then, cataract surgery is the
method to restore vision