Cataract

Edwin Dermody Sirait

I11109069

Defintion

Opacities Crystalline lens of the eye.

Extensive opacities of the lens will interfere light
passing through the crystalline lens cause
distortion of, or considerable reduction in light
rays falling on retina.

Epidemiology
In 2006, WHO estimated that the number of
visul impaired people worldwide was 314
million. Which 45 million among them was
blindness.
Age releted cataract was 48% causes of
blindness in world wide. Which 58% of
cases happen in Africa and South east asia
region.

Anatomy of the lens

Risk Factor
Genetics
Nutrition, health, diabetics
Antioxidants
Sunlight and irradiation
Age, education

Patofisiology

The transparncy of the lens is dependent on

the regular organization of the lens cells
and intracellular lens proteins.

Metabolic Disturbance and

Osmotic Regulation Failure
The lens maintains ion differentials between
intra- and extracellular fluids (high
potassium and low sodium internally; low
potassium and high sodium externally) via
the action of the sodium-potassium ATPase
pump.
Pump inactivation causes increased
intracellular osmolality, which with
membrane leakiness results in localized
water accumulation and light scatter.

Calpains

Calpains are a group of intracellular cysteine

proteases, which are activated by Ca 2+.
Calpains can contribute to cataract in two ways.
First, a lack of calpains can lead to pathologically
elevated levels of damaged proteins, reduced
optical performance, and cause cataract.
Second, excessive stimulation of calpain activity
by Ca2+ can also lead to unregulated proteolysis
and cataract.
Calpain inhibitors could therefore be useful in
the nonsurgical treatment of cataract.

Oxidation
Oxidation is a key feature in the pathogenesis of
most cataracts and low oxygen levels (O2) are
important for maintaining a clear lens.
There is a steep oxygen gradient from the outer
part of the lens to the center. Mitochondria in the
lens cortex remove most of the oxygen, thus
keeping nuclear O2 levels low.
However, in older people mitochondrial function
diminishes and superoxide production by the
mitochondria increases resulting in increased
nuclear oxygen and superoxide levels.

Defensive Mechanisms

Primary defenses are provided by antioxidant

enzymes and antioxidants such as ascorbate,
glutathione, tocopherols, and carotenoids,
which maintain lens proteins in the reduced
state.
Secondary defenses include proteolytic and
repair processes, which degrade and eliminate
damaged proteins, UV filters, and other
molecules such as glutathione reductase and
free radical scavenging systems.
Failure of these protective mechanisms, a
shortage of antioxidants, and increased free
radicals result in cell membrane and protein
damage.

Other Factors
Crystallins may have a number of
functions.
Decreased crystallin levels cause
proteins to precipitate, which leads
to cataract formation.

Causes of cataract
Age
Trauma
Systemic disorder
Ocular disease and cataract
Toxic cause

Classification
Age-related diseases:
a. Congenital
b. Juvenile
c. Senile
Complication
Diabetic
Secondary

Congenital Cataract
A cataract present at birth or in aged less
than 1 year.
It can affect one eye, which is known as
'unilateral cataract' or both eyes, which is
known as 'bilateral cataracts'.
Most children with cataract in only one eye
usually have good vision in the other.

To know the exact cause of congenital

cataract it needs a prenatal history of
infection (example: rubella) during the first
tri-semester of pregnancy and medicine
used during pregnancy.
Cataract with positive urine reduction test
might be cause by galactosemia
Almost 50% of congenital cataract is
sporadic and have an unknown cause

Symptoms of Congenital
Cataract
Gray or white cloudiness of the pupil (which
is normally black)
Infant doesn't seem to be able to see (if
cataracts are in both eyes)
"Red eye" glow of the pupil is missing in
photos, or is different between the two eyes
Unusual rapid eye movements (nystagmus)

Treatment
Surgical may be present if the fundus reflex
is not shown
Surgical acts for congenital cataract are
lens incision, linear extraction, and
extraction with aspiration

Juvenile Cataract
A mature cataract with a poorly developed
nucleus in a child or young adult, it
developed by the age less than 9 years and
more than 3 months. (usually its a
continuation of congenital cataract)
A juvenile cataract cause by manifestation
of systemic or metabolic disorder

Senile Cataract

Senile cataract is one that forms as a

result of the ageing process and one
most commonly found in the elderly. The
word senile comes from the Latin word
for "old" and has nothing to do with
mental faculties or behavior.

Clinical Stages

a.
b.
c.
d.

There are four clinical stages in the senile

cataract:
Insipient cataract
Intumescent cataract
Mature cataract
Hypermature cataract

Insipient Cataract
-

Cloudiness starting from the edge of the

equator, grilled-shaped head to anterior
and posterior (cortical cataract)
Vacuole starting to seen inside the
cortex
In the posterior sub capsular cataract
cloudiness starting to seen in the
anterior part, where the cleave is form
between the lens fiber and cortex which
contain morgagni
This cloudiness can lead to polioplia
where the refraction index is not the
same in all of the part of the lens

Intumesent Cataract

Cloudiness start and acommpanying

by swollen of the lens, where the
degenerative lens absorbed water
The swollen pushing the iris and
make the eye chamber became
shallow than normal
Intumescent cataract usually have a
rapid progress which can lead to
lenticular miophy, where this
condition can cause cortex hydration
until the lens have a convex shape
and the refraction level will increase
than normal (known as miopisation)

Immature cataract

Only part of the cloudiness found in the lens

(not affected all the part),
The volume of the degenerative lens will
increase due to the osmotic pressures rise
In a convex lens condition, the difficulties in
pupil will cause secondary glaucoma

Mature cataract

The cloudiness already covered the

masses of the lens, which caused by
calcium ions deposition
If there is no surgical procedure during
intumescent or immature cataract,
then the liquid will came out of the
lens bring out the cloudiness all over
the lens, which in prolonged condition
will cause the calcification of the lens
The anterior eye chamber will be in
the same normal depth
The iris reflection test will be negative,
since the cloudiness cover up the iris

Hypermature cataract

A continuation of degenerative stage of

cataract , will result in hard, soft, or
melting
The degenerative lens mass will be out of
the lens capsule and the lens will be
shrink, yellow and dry.
Sometime the shrink process will
continue and make the zonular of zinn
got loosen.
If the cataract process continue,
accompanied by thick capsule, the
degenerative cortex will shown like a box
of milk-shape with a drowning heavy
nucleus inside the cortex lens (condition
knows as Morgagni cataract)

insipen

immature

Mature

Hypermatu
re

opacities

Mild

moderate

All of the
lense

massive

Lense fluid

Normal

increase

normal

Decrease

Iris

Normal

Pushed

Normal

Tremulans

Anterior
chamber

Normal

Pushed

Normal

Deep

Angle

Normal

Narrow

Normal

open

Shadow test

negative

positive

negative

pseudopos

glaucoma

Uveitis+gal
ucoma

Complicated cataract

Treatments been used for Senile Cataract

Iodium liquid tear-drops, topical meds,

iontophoresis,
Calcium cysteine,
Immunization in purpose to fix the lens
metabolic disorder
Lentokalin and cataractolysin made from
fish lens and high dose of vitamin
Recent treatment is surgical procedure
(with several condition; glaukoma, uveitis,
or the visual acuity is decreasing gradually
and disturb the daily activities)

Complication cataract
Cataract cause by other eyes diseases
manifestation like inflammation, or the
degenerative processes such as, retinal
detachment, retinitis pigmentosa,
glaucoma, okular ischemic, and etc
Other than eye diseases, it can caused by
systemic endocrine disease

Diabetic Cataract

a.

b.

c.

The cataract in diabetic happen in 3 forms:

Patient with heavy dehydration, acidosis,
hyperglycemia the lens will shown a linecloudiness result from a folding lens
Old and uncontrollable patient with diabetic
juvenile, where the cataract happen in both eyes
at the same time in 48 hours (snow-flake shape
or sub-capsular plate)
Mature diabetic patient, where the histological
and biochemical views are the same withy nondiabetic cataract patient

Secondary Cataract
Result from the fibroses made from
the remain of the lens , the result will
came up two days after Extra
Capsular Cataract Extraction.

Surgical Processes
Two types of surgical processes for cataract:
a. Extra Capsular Cataract Extraction
Surgical procedure to the cataract lens where the
action is to do the incision or tearing the lens in
order to pulling out the contain of the lens
Phacoemulsification. It utilizes a handheld
ultrasonic vibrator to disintegrate the hard nucleus
such that the nuclear material and cortex can be
aspirated through an incision of approximately 3
mm.
b. Intra Capsular Cataract Extraction
Surgical procedure where the lens is being pulled
out with the capsule

1. Anterior
capsulotomy

3. Expression of
nucleus

5. Care not to aspirate

posterior capsule
accidentally

2. Completion of
incision

4. Cortical cleanup

6. Polishing of
posterior
capsule, if
appropriate

7. Injection
of
viscoelastic
substance

9. Insertion of
inferior
haptic and
optic

1. Placement of haptics
into capsular bag
and not into ciliary
sulcus

8. Grasping of IOL and

coating with
viscoelastic
substance

10. Insertion of superio

haptic

12. Dialling of IOL into

horizontal position

1. Capsulorrhexis

3. Sculpting of nucleus

5. Emulsification of
each quadrant

2. Hydrodissection

4. Cracking of nucleus

6. Cortical cleanup and

insertion of IOL