CATARACT

V.SREETEJA
PG-II nd year
Dept of Ophthalmology
 Contents

• Introduction

• Epidemiology

• Etiology

• Investigations

• Treatment
 Introduction
• The word Cataract comes from the Greek word meaning
“Waterfall”

• Until the mid 1700’s, it was thought that cataract was formed
by opaque material flowing, like a waterfall into the eye

• Cataract is caused by
– Degeneration or opacification of lens fibres
– Formation of aberrant lens fibres
– Deposition of materials in the lens
 Embryology of lens
Lens plate
• Cells of surface ectoderm that overlie optic vesicles become
columnar ,this area of thickened cells is called lens plate or
lens placode.
lens pit or fovea lentis is a small indentation inferior to center of
lens plate
• lens pit continue to invaginate ,the stalk of cells that connects
it to surface ectoderm consticts and eventually disappears
• The resultant sphere is called lens vesicle
EMBRYONIC NUCLEUS –
1 – 3 Months of GA
FETAL NUCLEUS –
3 months GA – Birth
INFANTILE NUCLEUS –
Birth to puberty
ADULT NUCLEUS –
Adults
 Anatomy of the lens
• Transparent biconvex structure
• Placed between iris & vitreous , suspended by zonule
of zinn from ciliary body
• Radius of curvature
Anterior 10mm
Posterior 6mm
• Diameter of lens 8.8 to 9.2mm
• Refractive index 1.37
• Dioptric power of lens 15-18D
• Thickness 4mm
• Weight at birth 65mg
at 80 yrs 258mg
• Accommodative power at birth --------14-16D
at 25 yrs------ 7-8D
at 50yrs------- 2D
12/1/2015 10
Function of lens
• Maintenance of transparency
• Refraction
• Accommodation
• Protection from U-V rays
• Loss of transparency, or opacification of lens is called
Cataract
 Epidemiology

• Cataract is the leading cause of blindness in the

world

• The prevalence of blindness in India is 14.9 per 1000.

sixty two percent of this blindness is due to cataract
alone

• Recent data from the World Health Organization

(WHO) shows that there is a 25% decrease in
blindness prevalence in India.
 Classification of Cataract

Etiological classification:
-Congenital and Developmental
-Acquired
1.Age related (senile)
2.Cataract associated with ocular diseases(complicated
or secondary)
3.Cataract associated with systemic diseases:
Diabetes, Hypoglycaemia, Hypoparathyroidism
4.Skin Diseases – Atopic Dermatitis
5.Traumatic Cataract :
Trauma
Electric Shock
Radiation
6. Drug induced cataract :
Corticosteroids, Anticholinesterases,
Chlorpromazine, Busulfan, Choroquine
 Morphological types of Developmental
cataract

Dense Blue Dot Cataract Sutural Cataract

Anterior Capsular Cataract Posterior Polar Cataract

Cataracta pulverulenta lamellar cataract

dense lamellar cataract

with with riders
 Secondary cataract

Complicated cataract posterior sub capsular

cataract

glaucoma flecken
 Cataract in systemic diseases

Snowflake cataract stellate cataract

shield cataract
 Traumatic cataract

Vossius’ ring Flower-shaped

Penetration
 Morphological classification

1. Capsular
2. Subcapsular
3. Cortical
4. Supranuclear
5. Nuclear
6. Polar
 Senile Cataract

Types:
1. Cortical Cataract: hydration followed by
coagulation of protein appears in cortex
2. Nuclear or Sclerotic Cataract: slow sclerosis of
nucleus.
 Stages of cortical cataract

• Stage of lamellar separation

• Incipient cataract
• Immature cataract –
intumescent
cuneiform
cupuliform
• Mature cataract
• Hypermature cataract – morgagnian cataract
Sclerotic or shrunken
Symptoms
• Blurring of vision
• Frequent change of
glasses due to rapid
change in refractive index
of the lens
• Painless, progressive,
gradual diminution of
vision
• Second sight or myopic
shift -nuclear cataract
• Monocular diplopia or polyopia
• Glare
• Colored haloes
• generalized reduction -Visual field
 Signs of senile cataract

• Lenticular opacity -grey or white opacity in lens

• Iris shadow in immature cataract

• No iris shadow in mature cataract

• Morgagnian Cataract- liquefied cortex- which is

milky and nucleus is seen as brown mass
 Morphological types

Nuclear Cataract Cortical Cataract

Mature Cataract Hypermature Morgagnian Cataract

 Management
• Cataract is the most treatable cause of decreased
vision

• Observation and Refraction – Early cataract

• When the glare, loss of contrast sensitivity or

polyopia are present
or
• When activities of daily living, such as driving,
reading, working, and self-care are affected

Surgery can be advised

 Pre-operative evaluation

• Detailed history

• Systemic examination

• Dental and ENT examination – to rule out any septic

foci

• Ocular examination
• Ocular examination
– Visual acuity testing

– Anterior Segment Examination :

• Lens Grading
• To rule out other anterior segment
diseases

– Dilated Fundus Examination: To

assess the posterior segment

– If fundus examination is not

possible – B-Scan
Ultrasonography
– Intraocular pressure measurement

– Examination of lacrimal apparatus and

Syringing

– Intraocular lens Power Calculation

• Keratometry
• A-Scan Biometry
 Anaesthesia

• Local anaesthesia
– Peribulbar or Retrobulbar Block
– Adjuvant Facial Block if needed
– Drugs used: 2% Xylocaine and 0.5% Bupivacaine in the
ratio of 2:1

• Topical anaesthesia

• General anaesthesia  children, psychiatric

patients
METHODS OF CATARACT SURGERY
• ICCE
• ECCE
 Surgical Techniques

• Intracapsular Cataract Extraction (ICCE)

– Entire lens is removed by rupturing the zonules
– Obsolete
– Indications: Dislocated lens
• Complications of ICCE:

– Intraocular lens cannot be placed

– Vitreous herniation into Anterior chamber can
occur
– Aphakic glasses –
• Magnified images
• Spherical aberrations
• Jack-in-the-box phenomenon
• Prismatic effect
• Reduced visual field
• Heavy spectacles
 ECCE- SURGERY OF CHOICE

• AGE- UPTO 30 Yrs – LENS ASPIRATION

LENSECTOMY
AFTER 30 Yrs -CONVENTIONAL ECCE
SICS
PHACOEMULSCIFICATION
• Extracapsular Cataract Extraction (ECCE)
– Part of anterior capsule, nucleus and cortex are
removed leaving behind the posterior capsular
bag

– So that intraocular lens can be placed

• Conventional ECCE

• Large incision (10-11mm) – needs suturing

• Time consuming procedure
• Longer wound healing time
 Extracapsular cataract extraction

1. Anterior 2. Completion of
capsulotomy incision

3. Expression of
nucleus

4. Cortical cleanup

5. Care not to aspirate

posterior capsule 6. Polishing of posterior
accidentally capsule, if appropriate
 7. Injection of 8. Grasping of
viscoelastic IOL and
substance coating with
viscoelastic
substance

9. Insertion of
inferior 10. Insertion of
haptic and optic superior
haptic

11. Placement 12. Dialling of

of haptics IOL into
into horizontal
capsular bag position
• Small Incision Cataract Surgery (SICS)
– Sutureless surgery
– Sclero-corneal tunnel is made
– 6-7mm incision – Post-operative astigmatism
 Phacoemulsification

1. Capsulorrhexis 2. Hydrodissection

3. Sculpting of nucleus
4. Cracking of nucleus

5. Emulsification of 6. Cortical cleanup and

each quadrant insertion of IOL
Femtosecond Laser cataract surgery

Incision with femtosecond laser

 complications

Pre operative complications:

Anxiety
Nausea and gastritis
Irritative /allergic conjunctivitis
Corneal abrasion
Due to local anesthesia:
Retrobulbar hemorrhage
Globe perforation
Oculocardiac reflex
Sub conjunctival hemorrhage
Intra-operative complications:
- Detachment of descemet’s membrane
– Iridodialysis
– Posterior capsular rupture
– Nucleus drop in to vitreous cavity
– Expulsive choroidal haemorrhage
Early post-operative complications:
• Hyphaema
• Iris prolapse
• Striate keratopathy
• Flat anterior chamber
• endophthalmitis
Late post-operative complications:
• Cystoid macular oedema
• Pseudophakic bullous keratopathy
• Retinal detachment
• After cataract
• Lens dislocation
Elschnigs pearls Soemmerings ring

dense posterior
c capsular opacity
 Summary
• Opacification of crystalline lens is called Cataract

• Causes diminution of vision, glare, reduced contrast sensitivity

• Treatment is only surgical removal of cataract and implantation of

intraocular lens

• Thorough pre-operative evaluation is necessary

• Advances in surgical technique and more sophisticated technology

have helped make surgery a safe and effective treatment for
cataracts