YIP

FARADIANA
ROIHAN
ARIF
TASNIM

29th March 2010

1
Mr AS
68 yrs old

C/o: blurring of vision

What to ask next?????

What is your differential diagnosis???

2
 Glaucoma
 Cataract
 Diabetic/hypertensive retinopathy
 Mononeuritic multiplex
 CRVO (central retina vein occlusion)/CRAO
 Corneal injury
 Retinal detachment
 Uveitis
 TIA
 Trauma

3
 History of presenting illness

•Noticed blurring of vision since September last year

•Blurring of both vision simultaneously
•Slowly started as blurring of edges of objects but has now
his vision is limited to just shadows (he sees things as mere
shadows)
•Also complains of seeing rainbow flashes upon sudden
head movements and getting up after sitting for a long time
•No pain, no headache

4
Past Med
-Newly diagnosed hypertension

Drug HX/ Occular Hx

-Tried „Permata Hijrah‟ for his blurring of vision for
two months but stopped because it did not improve
his vision
-Has not had any eye ops

Family hx
-Unremarkable

5
 Refractive error
 Cataract
 Glaucoma (primary open angle)
 Retinal disease diabetic retinopathy
 Age related macular degeneration
 Tumours and inflammation: intraocular
tumor, tumor of optic nerve

6
 Allnormal
 Right eye post operative
 Red eye reflex not symmetrical both side
 Reduced red reflex on left eye
 Reduced diameter of red reflex on right eye

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8
 Congenital cataract
 Senile cataract
 Complicated cataract (Diabetic cataract &
parathyroid tetany)
 Cataract due to radiant / heat energy
 Traumatic cataract

9
 Pathogenesis
 Heredity (genetic mutation)
 Maternal (malnutrition & infection)
 Foetal ( oxygenation), metabolic disorder
(galactosaemia), trisomy 21
 Idiopathic

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• Symptoms
– Visual impairment
– Nystagmus

• Signs
– White reflex (leucocoria)
– Ophthalmoscopic examination (black opacity
against red background)
– Systemic  congenital heart disease

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12
 Pathogenesis
 History of “anticipation”
 Sunlight exposure
 Old age (“age related cataract”)
 Diabetes
 Atopic dermatitis
 Myotonic dystrophy

13
• Degeneration & opacification of lens
(hydration, denaturation & coagulation of
proteins)
• Formation of aberrant lens
• Fibrous metaplasia of lens fibres
• Abnormal product of metabolism, drugs or
metals
• Slow sclerosis of the central nucleus fibres
(senile nuclear cataract) – brown pigment

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 Symptoms
 Frequent changes of glasses
 Diminished visual acuity
 Glare
 Coloured halos
 Monocular diplopia / polyopia
 “myopic shift” & Colour shift (senile nuclear
cataract)

15
 Signs
 Slit lamp examination (yellow layer in the
posterior cortex, lost of fundus details)
 Ophthalmoscopic examination (dark shadow)
 Blackened pupillary reflex (senile nuclear
cataract)

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17
 Pathogenesis
Disturbance of nutrients in the lens (inflammatory
/ degenerative disease)

 Diabetic cataract
 Excess glucose  sorbitol (sugar alcohol)  osmotic
imbalance at lens
 Parathyroid tetany
 Deficiency of parathyroid hormone

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• Symptoms
– Impaired vision

• Signs
– Anterior segment (opacification of cortex)
– Posterior segment ( posterior cortical cataract)
– Ophthlamoscopic examination (vaguely defined,
dark area seen in the posterior cortex)
– Slit lamp examination (irregular borders of
opacity, breadcrumb‟s appearance, rainbow
display, snow flakes, crystalline flakes)

19
20
 Pathogenesis
 Heat (infrared)
 Irradiation (X-ray)
 Electric (passage of powerful current)
 Ultrasonic radiation (heat & concussion)

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 Pathogenesis
 Concussion
 Perforating corneal injuries

• Signs
- Rosette-shaped‟ cataract (posterior cortex / anterior
cortex)

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 Early
 Glare
 Frequent changes of glasses
 Black spot
 Uniocular diplopia / polyopia
 Coloured halo
 Colour value changes

 Late
 Impaired central vision

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25
Cataracts may be classified according to

1. age of onset
2. morphology
3. grade
4. maturity of cataract

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 CONGENITAL ACQUIRED

 Chromosomal  Age related cataract

 Most common cause
 Down, Edward, Turner
 Secondary cataract
syndromes  Cataract form after eye surgery for other eye
problem eg. Glaucoma
 cataract in patient with other health problem
 Early embryonic [transplacental] such as diabetes
 cataract due to use of steroids
damage
 Traumatic cataract
 Rubella  Cataract forms after trauma or exposed to
 Mumps alkaline chemicals
 may form immediately or years after trauma
 Hepatitis
 Radiation cataract
 Toxoplasmosis  over exposure of ultraviolet sunlight or other
radiation

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Congenital Presenile Senile

-inherited in Systemic diseases - age-related

autosomal dominant -diabetes mellitus
fashion [1/3] -corticosteroid therapy
-atopy
-birth trauma or -galactosaemia
maternal infection -hypocalcaemia
during pregnancy -dystrophia myotonica

-galactosaemia Ocular factors

[common metabolic -blunt or perforating trauma
cause of congenital or -high myopia
infantile cataract] -recurrent uveitis
-topical steroid use
-ionising irradiation
-excessive ultraviolet light
exposure
-infrared irradiation

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29
Classification of Cataract Morphology
Fibre-based Sutural Congenital sutural
Concussion
Storage disorder
Deposition

Non-sutural Lamellar
Nuclear
Cortical

Non-fibre based Subscapular

Lamellar
Coronary
Blue dot
Christmas tree

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Type Picture Cause Properties

Sutural Congenital non-progressive

Concussion often flower-shaped [lens fibre
separation and fluid entry]; anterior and
posterior
Y Storage usually starts posteriorly
disorder
Deposition usually starts anteriorly

Nuclear Congenital non-progressive, limited to embryonic

nucleus or more extensive

Age-related increased white scatter (light scattering)

and brunescence (brown chromophores)

Lamellar Congenital / Localized to a particular lamella (layer)

infantile with or without extensions
- inherited, rubella, diabetes,
hypocalcaemia

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Type Picture Cause Properties

Coronary Sporadic Round opacities in the deep cortex

forming a “crown”
-occasionally inherited

Cortical Age-related Spoke-like opacities in the superficial

cortex, spreading along fibres at an
unpredictable rate

Subcapsular Age-related granular material just beneath capsule,

/ presenile posterior (more common and visually
significant) or anterior
- diabetes, corticosteroids, uveitis,
radiation

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Type Picture Cause Properties

Polar Congenital anterior

with abnormalities of capsule ± anterior
segment

posterior
with abnormalities of capsule ± posterior
segment

Diffuse Congenital focal blue dot opacities are common and

..... visually significant
.....
.....
..... Age-related christmas tree cataracts are highly
... reflective crystalline opacities

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 Grading system is designed to quantify the degree of
opacification.
 These vary from simple assessment by direct ophtalmoscopy
to the Lens Opacities Classification System II [LOSCII], where
slit lamp examination is compared to a standard set of
photographs [separate set for nuclear, cortical, and posterior
subcapsular].
 It involves grading 4 features of the cataract:
- nuclear color (NC)
- nuclear opalescence (N)
- cortical cataract (C)
- posterior subcapsular (P)

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A B

C The clinical appearance of

A – cortical cataract
B – nuclear cataract
C – posterior subcapsular
cataract

The spoke opacities are

silhouetted against the red reflex
in A.

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Maturity Description

Immature opacification is incomplete

Mature opacification is total

Hypermature lysis of cortex results in shrinkage,

seen clinically as wrinkling of the
capsule
Morgagnian liquefaction of cortex allows the harder
nucleus to drop inferiorly [but still
within the capsule]

36
 Hypermature
cataract

Mature age-related cataract

viewed through a dilated
pupil

37
38
• improve visual function depends on degree of
impairment and visual needs of individual,
most patients with a vision of 6/18 or worse
in both eyes because of lens opacities
benefit from cataract surgery
• diabetic retinopathy
• cataract prevents adequate retinal
examination or laser treatment
• lens induced glaucoma
• uveitis

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• Choice of anaesthesia
• Incision: via cornea or anterior sclera
• Technique of cataract removal
• Correction of aphakia: by intraocular lens
implantation, contact lens or aphakic
spectacles

• There are 2 types:

– Phacoemulsification
– ECCE (Extracapsular cataract extraction)
– Intracapsular method

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Phacoemulsification method
 A very small tunnel incision (about 3mm
wide) is made in the eye and a circular hole
(diameter about 5 mm) is made in the
anterior capsule of the lens.

41
A fine ultrasonic probe is then used to liquefy
the hard lens nucleus (phacoemulsification)
through this hole.

42
• A folded replacement lens is then inserted into the
empty lens capsular bag and allowed to unfold.
• A high viscosity gel substance (viscoelastic) often is
used to protect the delicate endothelial cells that
line the posterior surface of the cornea during the
operation.
• This is then washed out at the end of the
procedure.

43
 Sutures often are not required as the tunnel
incision is self sealing.
 These advances in technique have considerably
improved the speed of recovery and visual
rehabilitation after cataract surgery.

44
Break Up and Remove the Cataract Lens
45
Extracapuslar cataract extraction (ECCE)method

• conventional method may be indicated for patients

with very hard cataracts or other situations in
which phacoemulsification is problematic
• An incision is made in the eye (about 10 mm in
length) and the anterior capsule is cut open with
the tip of a sharp needle.
• The large nucleus is then expressed whole and the
remaining soft lens fibres aspirated
• A non-folding lens is then inserted into the empty
lens capsular bag and the incision closed with fine
sutures.

46
 Intracapsular method
• In this method, the entire lens is
removed within its capsule, usually
with a cryoprobe, after the suspensory
ligaments of the lens have been
dissolved by the enzyme chymotrypsin.
• As there is no remaining lens capsule,
the vitreous gel in the eye can move
forward and block the flow of aqueous
through the pupil.
• A hole cut in the iris (iridectomy)
allows the aqueous to bypass the pupil.
This method is now usually used only in
special situations.
• The procedure has a relatively high
rate of complications due to the large
incision required and pressure placed
on the vitreous body

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 80% achieve 6/12 vision or better following
surgery
 Failure to improve usually due to pre-existing
disease

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49
 Corneal edema
• water content of the cornea
increases causing the
cornea to swell and lose
transparency.
• Sx:Poor vision and haloes
("star bursts" around lights)
• Tx: usually self limiting and
improves with anti-
inflamattory eye drops
Elevated IOP
occur when the visco-

elastic is left in the eye,
or is not adequately
aspirated prior to wound
closure.
 The visco-elastic particles
would block the
trabecular meshwork and
raise the IOP.
 Tx: control with topical
treatment
50
 Wound leak Iris prolapse

• are complication due to

poor wound construction  Iris tissue may prolapse
as well as poor surgical through the surgical
technique in closure wound. This is usually
(loose sutures.) due to poor surgical
closure.
• If severe and persistent ,
need to return to theater  Assess vitality of
and suture wound closed extruded iris and suture
wound closed
51
 Endophtalmitis

• intra-ocular
bacterial infection which
occurs in 1/1000 cases, with
crippling visual complications
in more than 50% of the
cases, depending on the
etiologic organism
• These include Staph.
epidermidis, Staph. aureus,
Pseudomonas, and Proteus. The hallmark findings: posterior
• Ix: AC tap and vitreous biopsy and anterior chamber
inflammation and Hypopyon
• Treatment : topical, intra-
vitreal, peri-ocular, and
systemic antibiotics together
with steroid therapy when
indicated.

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 1. Posterior
capsule
opacification

Late- 2. Cytoid
4. Retinal
macular
detachment complication edema

3. Corneal
decompesation

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 Posterior capsule ossification Cystoid macular oedema

• painless condition in which

swelling or thickening occurs
of the central retina (macula)
• Sx: usually associated with
blurred or distorted vision.
• Tx: anti-inflammatory eye
drops or injections of steroids
• “ secondary cataract “ to the back of the eye
• clouding of the 'posterior
capsule', the thin membrane
that surrounded the
cataractous lens prior to its
removal.
• Sx: reduced vission, monocular
diplopia
• Tx: YAG posterior capsulotomy

54
 Retinal detachment

• condition that occurs when

fluid seeps through a tear in
the retina.
• The seepage causes the
retina to detach from the
back of the eye.
• Occurs mainly in eyes with
posterior capsular rupture,
vitreous loss, and eyes with
peripheral retinal
degenerations like lattice
degeneration.
• Sx: flashes of light or dark
spots In the field of vision
• Tx: surgical

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 Steroid drops (to reduce inflammation)
 Antibiotic drops (to prevent infection)
 Non-pharmacology advice:
- to avoid very strenuous exertion and ocular
trauma ( eg: heavy lifting )
- wear dark glasses
- prevent your eyes from coming into contact
with water and soap

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