cataract

By Dr Banumathi Gurusamy, HPP

Cataract

By Dr Banumathi Gurusamy

Hospital Pulau Pinang

By Dr Banumathi Gurusamy, HPP

Definition

Opacity on or within the lens due to loss of transparency due to :

1. Hydration of lens fibres.

2. Denaturation of lens protein.

By Dr Banumathi Gurusamy, HPP

Anatomy

By Dr Banumathi Gurusamy, HPP

Anatomy

Developed from surface ectoderm.Biconvex, avascular transparent structure suspended by zonules behind the iris.Partscentral nucleus, cortex, anterior and posterior capsule.Composition: 65% water., 35% protein and traces of minerals.

By Dr Banumathi Gurusamy, HPP

Anatomy

By Dr Banumathi Gurusamy, HPP

Function

Acts as refractory surface.

Helps in the act of accomodation.

By Dr Banumathi Gurusamy, HPP

Classification (Aetiological)

1. Senile2. Traumatic:

Penetrating injuriesBlunt injuriesInfrared radiationIonising radiation

By Dr Banumathi Gurusamy, HPP

Classification (Aetiological)

3. Metabolic:

Diabetes Mellitus

Galactosemia

Hypocalcemia

Wilson’s disease

Galactokinase Deficiency

By Dr Banumathi Gurusamy, HPP

Classification (Aetiological)

4. Toxic:

Corticosteroids

Chlorpromazine

Miotics

5. Secondary (complicated)

Anterior Uveitis

High myopia

Chronic vitreo retinal disorders

By Dr Banumathi Gurusamy, HPP

Classification (Aetiological)

6. Congenital & DevelopmentalHereditaryMaternal Prenatal Infections as Rubella/ Toxoplasmosis.Maternal drug ingestionInborn errors of metabolism

7. Presenile CataractDystrophia myotonicaAtopic Dermatitis

By Dr Banumathi Gurusamy, HPP

Classification according to the stage of maturity

ImmatureMatureIntumuscent (swollen lens) Leads to Phacomorphic glaucoma Hypermature Leads to subluxation/ dislocation of lens and phacolytic glaucoma.Morgagnian cataract

By Dr Banumathi Gurusamy, HPP

Nuclear cataract

• Exaggeration of normal nuclear ageing change• Causes increasing myopia

• Increasing nuclear opacification

• Initially yellow then brown

Progression

By Dr Banumathi Gurusamy, HPP

Cortical cataract

Initially vacuoles and clefts Progressive radial spoke-like opacities

Progression

By Dr Banumathi Gurusamy, HPP

Classification according to maturity

Immature Mature

Hypermature Morgagnian

By Dr Banumathi Gurusamy, HPP

Other causes of cataract - diabetesJuvenile

• White punctate or snowflake posterior or anterior opacities

• May mature within few days

Adult

• Cortical and subcapsular opacities

• May progress more quickly than in non-diabetics

By Dr Banumathi Gurusamy, HPP

Causes of traumatic cataract

Penetration

Concussion

‘Vossius’ ring from imprinting of iris pigment Flower-shaped

• Ionizing radiation

• Electric shock

• Lightning

Other causes

By Dr Banumathi Gurusamy, HPP

DrugsChlorpromazine

• Long-acting mioticsOther drugs

• Amiodarone• Busulphan

- initially posterior subcapsularSystemic or topical steroids

- central, anterior capsular granules

By Dr Banumathi Gurusamy, HPP

Secondary (complicated) cataract

• Chronic anterior uveitis• High myopia

Posterior subcapsular

• Hereditary fundus dystrophies• Central, anterior subcapsular opacities

Glaukomflecken

• Follows acute angle- closure glaucoma

By Dr Banumathi Gurusamy, HPP

Symptoms

Progressive decrease in visual acuity for near and distant.Glare in bright light and sun light. difficulty in driving.Uniocular diplopia or polyopia. Fixed dark spots in field of vision.Nuclear sclerosis making the patient short sighted (good near vision).aka myopic shift

By Dr Banumathi Gurusamy, HPP

Signs

Reduction in visual acuity.

Diminished red reflex on ophthalmoscopy.

Opacity covering the pupillary area.

Slit lamp examination details and location of cataract.

By Dr Banumathi Gurusamy, HPP

Treatment: Surgical

Indications:Decreased visual acuity which causes disturbance in his or her daily work.Lens induced glaucomaPhacomorphic/ PhacolyticTo permit photocoagulation.If cataract blocks the posterior segment for posterior segment surgery.Cosmetic to obtain black pupil.

By Dr Banumathi Gurusamy, HPP

Management In Children

Unilateral should be removed as early as possible to avoid amblyopia.Bilateral dense cataracts immediate surgery.Bilateral immature cataract if fundus details seen, op can be postponed until lens becomes more denser.Vision should be corrected with contact lens or intraoular lens.

By Dr Banumathi Gurusamy, HPP

Surgical techniques (1/3)

Intracapsular cataract extraction with IOL (ICCE).

The entire lens is removed using cryo probe.

Anterior chamber IOL.

This method is for subluxated cataractous lens.

By Dr Banumathi Gurusamy, HPP

Surgical techniques (2/3)

Extracapsular cataract extraction with IOL. (ECCE)

1. Open the anterior capsule.

2. Nucleus expression.

3. Aspiration of lens cortex.

4. Posterior chamber IOL implant.

5. Incision size is about 10 mm.

By Dr Banumathi Gurusamy, HPP

ECCE

By Dr Banumathi Gurusamy, HPP

ECCE with IOL

By Dr Banumathi Gurusamy, HPP

ECCEStep 1- Incision

By Dr Banumathi Gurusamy, HPP

ECCE

Step 2- Anterior capsulotomy

By Dr Banumathi Gurusamy, HPP

ECCE

Step 3- Deepening the wound

By Dr Banumathi Gurusamy, HPP

ECCE

Step 4- Nucleus expression

By Dr Banumathi Gurusamy, HPP

ECCEStep 5- Cortex aspiration

By Dr Banumathi Gurusamy, HPP

ECCEStep 6- IOL insertion

By Dr Banumathi Gurusamy, HPP

ECCE

Step 7- Suture

By Dr Banumathi Gurusamy, HPP

ECCE

Complete suture

By Dr Banumathi Gurusamy, HPP

Surgical techniques (3/3)

Phacoemulsification (sophisticated form of ECCE) with IOL:

1. Open the anterior capsule2. Using the ultrasonic power nucleus is

fragmented and removed. 3. Aspiration of lens cortex.4. Posterior chamber IOL implant.5. Incision size 3mm only.

By Dr Banumathi Gurusamy, HPP

Phaco

By Dr Banumathi Gurusamy, HPP

PhacoStep 1- Incision

By Dr Banumathi Gurusamy, HPP

Phaco

Step 2- ccc- Anterior capsulorhexis

By Dr Banumathi Gurusamy, HPP

Phaco Step 3- Nucleofractis

By Dr Banumathi Gurusamy, HPP

PhacoStep 4- Fragments removal

By Dr Banumathi Gurusamy, HPP

Phaco Step 5- Aspiration of cortex

By Dr Banumathi Gurusamy, HPP

Phaco

Step 6- IOL Insertion

By Dr Banumathi Gurusamy, HPP

PhacoComplete

By Dr Banumathi Gurusamy, HPP

ECCE Vs Phaco

By Dr Banumathi Gurusamy, HPP

Advantages of Phaco

Small incision.

Fewer wound problems.

Less astigmatism.

More rapid physical rehabilitation.

By Dr Banumathi Gurusamy, HPP

Disadvantages of Phaco

Machine dependent.

Larger learning curve.

Expensive equipment.

Difficult with hard nucleus.

By Dr Banumathi Gurusamy, HPP

Intraocular lenses

Optical advantage of its natural counterpart when it is placed in the eye.IOL power is calculated by measuring the curvature of cornea and length of the eye (measured by ultrasonography).Types of IOL:posterior chamber IOL :

rigid PMMA. foldable silicone/acrylic.

anterior chamber IOL.

By Dr Banumathi Gurusamy, HPP

By Dr Banumathi Gurusamy, HPP

Optical Correction (1/3)

If no IOL correction should be made with aphakic glasses or contact lenses.Problems with aphakic glasses:

1. Thick and heavy2. The corrected image is 30% larger than

that seen with the normal eye with increased distortion hence image cannot be fused with that from the unoperated eye.

By Dr Banumathi Gurusamy, HPP

Optical correction (2/3)

3. Objects are perceived closer than they are. Eg: pouring tea into one’s lap rather than into the cup.

4. Corrective glasses are maximally effective only when the patient looks through the optical centre.

5. The field of vision is restricted and there is blind area all round within this field.

By Dr Banumathi Gurusamy, HPP

Optical Correction (3/3)

Contact lenses:

Size of image is only 10% larger than the image in the unoperated eye

Disadvantages:

most of the patients are elderly with inadequate tearfilm, so difficult to use CL.

difficulty in handling/ risk of infection.

By Dr Banumathi Gurusamy, HPP

Post op management

Steroid drops to reduce inflamation.

Antibiotic drops to treat infection.

Relative contra indications for IOL:

1. Intraocular inflamation.

2. Severe diabetic retinopathy.

By Dr Banumathi Gurusamy, HPP

Complications of Cataract Surgery (1/4)

During surgery:1. Posterior capsule rupture with vitreous

loss will lead to:Updrawn pupil Vitreous touch syndrome with sec. Glaucoma/ pupillary block glaucoma.UveitisChronic cystoid macular oedemaRetinal detachment

By Dr Banumathi Gurusamy, HPP

Complications of cataract surgery (2/4)

2. In phaco emulcification nucleus can drop into the vitreous when the posterior capsule ruptures.

3. Expulsive chroidal haemorrhage (caused by rupture of choroidal vessels).EXTREMELY RARE

By Dr Banumathi Gurusamy, HPP

Complications of cataract surgery (3/4)

Early Post op. complications:

1. Wound leak .

2. Hyphaema.

3. Iris prolapse.

4. Uveitis

5. Increase IOP.

6. Bacterial endophthalmitis.

By Dr Banumathi Gurusamy, HPP

Complications of cataract surgery (4/4)

Late complications:

1. Chronic cystoid macular oedema.

2. Posterior capsule opacity. (Elschnig’s pearls) To be treated with YAG laser capsulotomy.

3. Retinal detachment.

4. Displacement of IOL pupillary capture/ sunset syndrome.

By Dr Banumathi Gurusamy, HPP

Thank You