mansukhani, sujata to marcial, karmi margarette. this 30 year old male sought consult because of...
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Mansukhani, Sujata To Marcial, Karmi Margarette
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This 30 year old male sought consult because of blurring of vision of the left eye. Visual acuity was light perception on the involved eye. This condition has been present since childhood.
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OutlineWhat is your diagnosis?What diagnostic test would you do to help
you decide on your management?What is your treatment plan?What will be the visual outcome of this
patient after your surgical management?
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Question # 1
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SALIENT FEATURESPatient presented with:
LEUKOCORIAUNILATERAL, PAINLESS BLURRING OF
VISIONCondition is congenital or “present since birth”
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Patient Retinopathy of
prematurity
Retinal Detachment
Coloboma Cataract
UnilateralGradual, Painless Blurring of Vision present since birthLight perception on affected eyeLeukocoria
occurs in premature, low-birth-weight infants maintained on oxygen therapy
risk factors: trauma and surgery, vitreous detachment, high myopia, retinal breaks or tears, retinal vascular disease, and history of detachment in the other eyeflashes of light, floaters, curtain-like decrease in vision
Congenitalcaused by incomplete closure of the fetal fissureDegree of visual loss related to area affected (iris, retina, choroid, or optic nerve head)
May be: age-related childhood cataract (congenital or acquired) traumatic drug-inducedUnilateral or bilateralPainlessleukocoriaGlare or star bursts
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Question # 2
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History and PEthorough history careful physical examination must be
performedentire body habitus is checked for
abnormalities that may point out systemic illnesses
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Ocular ExaminationVisual acuity for both
near and far distances (Snellen’s Chart)
Glare- brightly lit room
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Swinging Flashlight Testdetects for a Marcus Gunn
pupil or a relative afferent pupillary defect (RAPD)
indicative of optic nerve lesions or diffuse macular involvement.
RAPD + Cataract= very guarded visual prognosis after cataract extraction
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Ocular Motilitylong-standing ptosis since
childhood may have occlusion amblyopia decreased visual acuity
rather than the cataract Checking all directions- to
rule out any other causes for the patient's visual symptoms
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Slit Lamp Examinationshould not only
concentrate on evaluating the lens opacity but the other ocular structures as well (eg, conjunctiva, cornea, iris, anterior chamber)
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Corneal thickness and the presence of corneal opacities
lens noted meticulously before and after pupillary dilation
Nuclear size and Brunescence as indicators of cataract density can be determined prior to phacoemulsification surgery.
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lens position and integrity of the zonular fibers also should be checked lens subluxation may indicate previous eye
trauma, metabolic disorders, or hypermature cataracts.
Dilated fundus examination is recommended as part of the ocular examination for both unilateral cataract cases and bilateral cataract cases.
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Question # 3
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Early cataracts may be managed with the following measures:Stronger eyeglasses or contact lensesUse of a magnifying glass during readingStrong lightingMedication that dilates the pupil. (This may
help some people with capsular cataracts, although glare can be a problem with this treatment.)
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Indications for SurgeryThe Snellen eye test reports 20/40 or worse,
with a cataract being responsible for vision loss that cannot be corrected by glasses.
Performing everyday activities has become difficult to perform to the point that independence is threatened, or the patient is at risk for accident or injury.
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Three basic types of surgeryExtracapsular cataract extractionIntracapsular cataract extractionPhacoemulsification
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Surgery to remove cataracts is generally an outpatient procedure. A local anesthetic is used and the procedure lasts about an hour.
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Question # 4
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A comprehensive study reported in Archives of Ophthalmology (1994)95.5 percent of healthy eyes achieved 20/40
uncorrected vision or better outcomes following cataract surgery
Of the more than 17,000 eyes evaluated, fewer than 2 percent had sight-threatening complications.
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Sight-threatening complications
• associated with individuals who are much older or who already have poor underlying health affecting how their eyes heal.
• cataracts are far more advanced or "hardened" at the time of surgery, making them difficult to remove
• Glaucoma• Retinal detachment• Endophthalmitis• Secondary cataract
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A Swedish study published in the British Journal of Ophthalmology (1999)Younger people undergoing cataract surgery
reported the highest satisfaction levels.
Less satisfactory outcome when other eye problems were present
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British Journal of Ophthalmology (2000)people in their 6Os undergoing cataract
surgery were 4.6 percent more likely to achieve 20/40 uncorrected vision or better than people in their 80s