DISEASES OF LENS

BY: Dr. Ashok Kumar Meena

Head of Department
Department Of Ophthalmology
GMC, Kota
STRUCTURE OF LENS
• Cataract: development of any opacity in the lens or its capsule
• Its occur due to,
i) Formation of opaque lens fibers
ii) Opacification of the normally formed transparent lens fibres.

• Which leads to decrease in vision.

 CLASSIFICATION

Etiological classification Morphological Classification

Congenital and
development Acquired cataract
cataract
Acquired cataract
1. Age related (senile) cataract

2. Traumatic cataract

3. Complicated cataract

4. Cataract in systemic diseases.

 Metabolic cataract- Diabetic cataract- Galactosemic cataract- Hypocalcemic cataract
 Cataract due to error of copper metabolism
 Cataract in Lowe's syndrome.
 Cataract associated with skin disease (Syndermatotic catarct)
 Cataract in myotonic dystrophy
Cataract in neurofibromatosis type
 Cataract associated with osseous diseases
Cataract in Down's syndrome
 Cataract in Treacher Collins syndrome

5. Electric cataract

6. Radiational cataract

7. Toxic cataract, e.g .i. Corticosteroid-induced cataract

ii. Miotics-induced cataract.
iii. Copper (in chalcosis) and iron (in siderosis) induced
cataract
Morphological Classification
1. Capsular cataract.
It involves the capsule and never occurs alone:
i. Anterior capsular cataract, may rarely occur along with anterior
subcapsular cataract, especially in anterior polar cataract.
ii. Posterior capsular cataract, may sometimes occur along with
posterior subcapsular cataract, especially in posterior polar cataract.

2. Subcapsular cataract. It involves the superficial most part. of the

cortex (just below the capsule) and includes:
iii. Anterior subcapsular cataract
ii. Posterior subcapsular cataract
3. Cortical cataract. It involves the major part of the cortex.

4. Nuclear cataract. It involves the nucleus of the crystalline.

5. Polar cataract. It involves the capsule and superficial part of the

cortex in the polar region only and may be:
i. Anterior polar cataract
ii. Posterior polar cataracts
CONGENITAL CATARACT
ETIOLOGY
I. Idiopathic: About 33% cases are sporadic and of unknown etiology.

II. Hereditary: About one-third of all congenital cataracts are hereditary.

 Inherited cases without systemic disorders. In these cases, the mode of inheritance
is usually autosomal dominant.
 Inherited cases with systemic disorders include:
Chromosomal disorders (e.g. trisomy 21),
Skeletal disorders (e.g. Stickler syndrome),
 Central nervous system disorders (e.g. cerebro-oculo-facial syndrome),
 Renal system disorders (e.g. Lowe's syndrome).
Common familial cataracts include:
Cataracta pulverulenta,
Zonular cataract (also occurs as nonfamilial),
Coronary cataract and total soft cataract (may also occur due to rubella).
III. Maternal factors include:
1. Malnutrition
2. Infections – TORCH Infections
3. Drugs ingestion. e.g. thalidomide, corticosteroids.
4. Radiation.

IV. Foetal or infantile factors include:

5. Deficient oxygenation (anoxia) .
6. Birth trauma.
7. Metabolic disorders of the foetus or infant such as galactosemia,
galactokinase deficiency and neonatal hypoglycemia.
CLINICAL TYPES
A. Congenital capsular cataracts:
1. Anterior capsular cataract
2. Posterior capsular cataract

B. Congenital polar cataracts:

3. Anterior polar cataract
4. Posterior polar cataract.

C. Congenital nuclear cataracts

I. Cataracts involving embryonic nucleus
1. Cataracta pulverulenta
II. Cataracts involving foetal nucleus
1. Lamellar cataract
2. Sutural and axial cataracts
- Floriform cataract
- Coralliform cataract
- Spear-shaped cataract
- Anterior axial embryonic cataract
- Dendritic suture cataract
III. Cataract involving whole nucleus
3. Total congenital cataract
4. Congenital membranous cataract

D. Cataract involving adult nucleus and cortex

5. Coronary Cataract
6. Blue dot cataract
Lamellar or Zonular cataract
• Developmental cataract in which the opacity occupies a discrete zone
in the lens.
• It is the most common type of congenital cataract presenting with
visual impairment.
• Etiology:
Genetic pattern
Environmental:
• Vitamin D deficiency,
• Hypocalcemia
• Maternal rubella infection between 7th and 8th week of gestation.
LAMELLAR CATARACT SUTURAL CATARACT

POSTERIOR POLAR CATARACT TOTAL CONGENITAL CATARACT

MANAGEMENT OF CONGENITAL &
DEVELOPMENTAL CATARACT
CLINICO-INVESTIGATIVE WORKUP
Detailed history
Careful clinical evaluation
Basic assessment of vision
IOP Measurement
Fundus examination under dilatation
B-SCAN for posterior segement
A-SCAN to measure axial length
LABORATORY INVESTIGATIONS
TORCH evaluation

Urine test for reducing substance to r/o Galactosaemia

 Lowe's syndrome by urine chromatography for amino acids.

 Hyperglycaemia by blood sugar level.

 Hypocalcaemia by serum calcium and phosphate levels and X-ray skull.

Indications and timing of Paediatric Cataract
Surgery
 Partial cataracts and small central cataracts which are visually
insignificant can safely be ignored and observed.

Bilateral dense cataracts should be removed early (within 6 weeks of

birth) to prevent stimulus deprivation amblyopia.

 Unilateral dense cataract, should preferably, be removed as early as

possible (within days) after birth with optical correction in the first
few weeks.
 Surgical Procedures
Extracapsular cataract extraction technique involving anterior
capsulorrhexis and irrigation aspiration of the lens matter (lens
aspiration) or lensectomy.

Lens aspiration should be combined with primary posterior

capsulotomy in children below 6 years of age and also with anterior
vitrectomy in all children below 2 years of age.
Correction of Paediatric Aphakia
• Children above the age of 2 years can be corrected by implantation of
posterior chamber intraocular lens during surgery.

• Children below the age of 2 years should preferably be treated by

extended wear Contact lenses. Spectacles can be prescribed in
Bilateral cases. Later on Secondary IOL implantation may be
considered.
ACUIRED CATARACT
• Congenital and developmental cataracts occur due to disturbance in
the formation of the lens fibres, i.e., instead of clear, opaque lens
fibres are produced.

• In acquired cataract, opacification occurs due to degeneration of the

already formed normal fibres.
Course of events involved in occurrence of cortical
senile cataract
 STAGES OF MATURATION
• MATURATION OF CORTICAL SENILE CATARACT
1.STAGE OF LAMELLAR SEPARATION

2. STAGE OF INCIPIENT CATARACT

a)CORTICAL SENILE CATARACT
b)POSTERIOR SUBCAPSULAR SENILE CATARACT

3.IMMATURE SENILE CATARACT

4.MATURE SENILE CATARACT

5.HYPERMATURE SENILE CATARACT

a)MORGAGNIAN HYPERMATURE CATARACT
b)SCLEROTIC TYPE HYPERMATURE CATARACT
COMPLICATIONS
1. Phacoanaphylactic uveitis:
Lens proteins may leak into the anterior chamber in hypermature
cataract. These proteins may act as antigen and induce antigen-antibody
reaction.
2. Lens-induced glaucoma:
It may occur by different mechanisms:
i. Phacomorphic glaucoma is caused by intumescent (swollen and
cataractous) lens. It is a type of secondary angle closure glaucoma. It is
the most common type of lens induced glaucoma.
 ii. Phacolytic glaucoma. Lens proteins are leaked into the anterior
chamber in cases with Morgagnian type hypermature cataract. These
proteins are engulfed by the macrophages which clog the trabecular
meshwork leading to increase in IOP.

iii.Phacotopic glaucoma. Hypermature cataractous lens may

subluxate/dislocate and cause glaucoma by blocking the pupil or angle
of anterior chamber.

3. Subluxation or dislocation of lens.

It may occur due to degeneration of zonules in hypermature stage.
SYMPTOMS
• Blurred vision

• Increasing difficulty with vision at night

• Glare, especially at night

• Halos around lights

• Double vision in a single eye

• Black Spots infront of eyes

SIGNS
1. Visual acuity testing. - may range from 6/9 to just PL +.

2. Oblique illumination examination - It reveals

colour of the lens in pupillary area which varies
in different types of cataracts.

3. Test for iris shadow-

4. Distant direct ophthalmoscopic examination-

A reddish yellow fundal glow is observed in the absence of any opacity in
the media. Partial cataractous lens shows black shadow against the red glow
in the area of cataract. Complete cataractous lens does not even reveal red
glow
5. Slit-lamp examination - in a fully-dilated pupil to study complete
morphology of opacity (site, size, shape, colour pattern and hardness of
the nucleus).
MANAGEMENT OF CATARACT IN
ADULTS
A. NON-SURGICAL MEASURES
1. Treatment of cause of cataract:
• Adequate control of diabetes mellitus, when discovered.
• Removal of cataractogenic drugs such as corticosteroids,
phenothiazenes and strong miotics, may delay or prevent
cataractogenesis.
• Removal of irradiation (infrared or X-rays) may also delay or prevent
cataract formation.
• Early and adequate treatment of ocular diseases like uveitis may prevent
occurrence of complicated cataract.
2. Measures to improve vision in the presence of incipient and immature
cataract by prescription of refractive glasses.
B. SURGICAL MANAGEMENT
• Indications
1. Visual improvement.

2. Medical indications.
• Lens-induced glaucoma,
• Phacoanaphylactic endophthalmitis and
• Retinal diseases like diabetic retinopathy or retinal detachment, treatment of
which is being hampered by the presence of lens opacities.

3. Cosmetic indication.
Preoperative evaluation and workup
I. General medical examination of the patient to exclude the presence of
systemic diseases especially:
• Diabetes mellitus;
• Hypertension
• Cardiac problems
• Obstructive lung disorders and
• Any potential source of infection in the body such as septic gums,
urinary tract infection etc
II. Ocular examination.
1. Visual status assessment should include:
■Visual acuity should be noted unaided, best corrected and with pin
hole testing.
■Perception of light (PL) must be noted. Absence of PL indicates nil
visual prognosis.
■Projection of light rays (PR).

2. Pupils checked for:

■Light reactions and RAPD, and
■Ability of the pupils to dilate adequately before surgery .
3. Anterior segment evaluation by slit-lamp biomicroscopy is must before
cataract surgery.

4. Intraocular pressure (IOP) should be measured in each case.

5. Examination of lids, conjunctiva and lacrimal apparatus. Search for local

source of infection should be made by ruling out conjunctival infections,
meibomitis, blepharitis and lacrimal sac infection.

6. Fundus examination, wherever possible, should be carried out with special

attention on macula, to rule out other causes of decreased vision.

7. Keratometry and biometry to calculate power of intraocular lens (IOL) to

be implanted.
Preoperative medications and preparations
1. Consent, with detailed information about the procedure.

2. Scrub bath, care of hair and marking of the eye.

3. Preoperative antibiotics and disinfectants are required to prevent

postoperative endophthalmitis.

4. IOP lowering

5. Mydriasis
Types and choice of surgical techniques
I. Intracapsular cataract extraction (ICCE)

II. Extracapsular cataract extraction techniques:

Conventional extracapsular cataract extraction (ECCE),
Manual small incision cataract surgery (SICS),
Phacoemulsification.
INTRAOCULAR LENS IMPLANTATION
• Types of Intraocular Lenses
A. Based on the method of fixation in the eye-
1. Anterior chamber IOL (Angle supported IOLs)
2. Iris-supported lenses
3. Posterior chamber lenses
a. In the capsular bag fixation of PCIOL is the most ideal method.
b. In the ciliary sulcus fixation of PC-IOL is done in the absence of
intact capsular bag but with adequate capsular support.
c. Scleral fixation of PC-IOL is done in the absence of capsular support
INTRAOCULAR LENS
IMPLANTATION
TYPES OF INTRAOCULAR LENSES
B. Depending on the material of manufacturing:
1. Rigid IOLs.
2. Foldable IOLs,
3. Rollable IOLs are ultra-thin IOLs.

C. Based on the focussing ability the IOLs are of following types:

1. Unifocal IOLs
2. Multifocal IOLs
3. Accommodative IOLs
TYPES BASED ON THE FOCUSSING
ABILITY THE IOLS
SPECIAL IOLs
Calculation of IOL power (Biometry)
• ‘SRK (Sanders, Retzlaff and Kraff) formula’ .

• The formula is: P = A—2.5L–0.9K,

• where: P is the power of IOL,
A is a constant which is specific for each lens type.
L is the axial length of the eyeball in mm, which is determined
by A-scan ultrasonography.
K is average corneal curvature, which is determined by
keratometry
COMPLICATED CATARACT
1. Inflammatory conditions. :
Uveal inflammations (like iridocyclitis, parsplanitis, choroiditis),
Hypopyon corneal ulcer
Endophthalmitis.
2. Degenerative conditions :
Retinitis pigmentosa
Myopic chorioretinal degeneration.
3. Retinal detachment.
4. Glaucoma (primary or secondary)
5. Intraocular tumours
 SURGICAL STEPS OF MANUAL SICS

1. Superior Rectus (Bridal)

Suture : passed to fix the eye in
downward gaze.
2. Conjunctival flap and
exposure of sclera
3. Haemostasis
 SURGICAL STEPS OF MANUAL SICS
4. Sclerocorneal tunnel
incision.
i. External scleral incision.
ii. Sclerocorneal tunnel
iii. Internal corneal
incision.
5. Side-port entry
6. Anterior capsulotomy
7. Hydrodissection
 SURGICAL STEPS OF MANUAL SICS
8. Nuclear management
Prolapse of nucleus out of the capsular bag
into the anterior chamber
Delivery of the nucleus outside

Irrigating wire vectis method

Phacosandwitch technique,
Phacofracture technique, and
Fishhook technique.
 SURGICAL STEPS OF MANUAL SICS
9. Aspiration of cortex
10. IOL implantation.
11. Removal of viscoelastic material
12. Wound closure
 MERITS OF MANUAL SICS OVER
PHACOEMULSIFICATION
• Universal Applicability: All type of Cataract including Hard Cataract can be operated by
SICS
• Learning Curve : SICS is easier to learn as compared to Phacoemusification.
• Not Machine Dependent
• Less Surgical Complications
• Cost Effective
MERITS OF PHACOEMULSIFICATION
OVER SICS
• Topical Anaesthesia : Phaco can be done
• Small Incision : Phaco can be performed with smaller incision (1.8-
3.2mm)
• Less Corneal Complications
• Postoperative congestion is minimal : As Phaco is done with clear
corneal incision
• Visual Rehabilitation : quicker with Phaco as compared to SICS
• Post op Astigmatism is comparatively less.
 PHACOEMULSIFICATION
1. Clear corneal incision
self-sealing sclera corneal tunnel or clear corneal incision made with a 3 mm keratome.
2. Continuous curvilinear capsulorrhexis (CCC) of 4–6 mm is preferred over other methods of
anterior capsulotomy
3. Hydrodissection i.e., separation of capsule from the cortex by injecting fluid exactly between the
two
4. Nucleus is emulsified
5. Remaining cortical lens matter is aspirated
6. IOL implantation.
7. Removal of visco and wound closure
 MICROINCISION CATARACT
SURGERY
Performed through a microincision (<2 mm). These techniques offer almost no surgically induced
astigmatism.
1. Microincision coaxial phacoemulsification (COMICS)
• Stab 2 mm incision
2. Bimanual microphacoemulsification (BMICS)
• Separate hand piece for irrigation and phacoemulsification aspiration.
• The technique requires two limbal incisions of 1.2 × 1.4 mm made with a trapezoidal blade.
3. Phaconit
• Micro Phaco done with a Needle Incision Technique through an incision <1 mm in size.
 FEMTOSECOND LASER ASSISTED
CATARACT SURGERY(FLACS)
• Capsulorrhexis performend with FSL is more precise, accurate, controlled and centralised.
• Lens fragmentation with FSL
• Clear corneal incision fashioned with FSL
• Arcuate corneal incisions (Decrease astigmatism)
• Corneal incisions are opened up with fine iris repositor.
POSTOPERATIVE MANAGEMENT
AFTER CATARACT OPERATION
1. Patient is asked to lie quietly upon the back for about 2–3 hours.
2. Next morning bandage/eye patch is removed and eye is inspected for any
postoperative complication.
3. Antibiotic eyedrops are used for four times, 10-14 days.
4. Topical steroids (Prednisolone) eye drops 3 to 4 times a day are used for 6–
8 weeks.
5. Topical ketorolac or any other NSAID eye drops 2 to 3 times/ day are used
for 4 weeks.
6. Topical timolol (0.5%) eye drops twice daily are used for about 7–10 days.
7. Topical cycloplegic-mydriatic, e.g., homatropine eye drops may be used
OD for 10–14 days.
 COMPLICATIONS OF CATARACT
SURGERY AND THEIR MANAGEMENT
(A) Preoperative complications
(B) Operative complications
(C) Early postoperative complications
(D) Delayed (late) postoperative complications
(E) IOL related complications
 PREOPERATIVE COMPLICATIONS
1. Anxiety.
• Anxiolytic drugs such as diazepam 2 to 5 mg at bed time
2. Nausea and gastritis.
• Oral antacids
3. Irritative or allergic conjunctivitis
• Postponing the operation for 2 days
4. Corneal abrasion
• Patching with antibiotic ointment for a day and postponement of operation for 2
days is required.
 PREOPERATIVE COMPLICATIONS
5. Complications due to local anaesthesia
• Retrobulbar haemorrhage
• Immediate pressure bandage after instilling one drop of 2% pilocarpine and
postponement of operation for a week is advised.
• Oculocardiac reflex,
• Perforation of globe
• Sub conjunctival haemorrhage
• Spontaneous dislocation of lens
 OPERATIVE COMPLICATIONS
1. Superior rectus muscle laceration
2. Excessive bleeding
3. Incision related complications
In manual SICS and phacoemulsification
Button holing of anterior wall of tunnel
Premature entry into the anterior chamber
Scleral disinsertion
• 4. Injury to the cornea (Descemet’s detachment), iris and lens
• 5. Iris injury and iridodialysis (tear of iris from root)
 OPERATIVE COMPLICATIONS
6. Complications related to anterior capsulorrhexis
Escaping capsulorrhexis
Small capsulorrhexis
Very large capsulorrhexis
Eccentric capsulorrhexis
7. Posterior capsular rupture (PCR).
During forceful hydrodissection,
By direct injury with some instrument such as sinskey’s hook, chopper or
phacotip
During cortex aspiration (accidental PCR).
8. Zonular dehiscence
 OPERATIVE COMPLICATIONS
9. Vitreous loss:
Prevent vitreous loss
To decrease vitreous volume: Preoperative use of hyperosmotic agents like 20%
mannitol or oral glycerol is suggested.
To decrease aqueous volume:
o Preoperatively acetazolamide 500 mg orally.
o Adequate ocular massage carried out digitally after injecting local anaesthesia.
o Honan’s ball pressure
Better ocular akinesia and anaesthesia decrease the chances of pressure from eye
muscle.
 OPERATIVE COMPLICATIONS
Minimising the external pressure on eyeball by not using eye speculum, reducing
pull on bridle suture
Overall gentle handling during surgery.
Use of Flieringa ring to prevent collapse of sclera especially in highly myopic
patients decreases the incidence of vitreous loss.
When IOP is high in spite of all above measures and operation cannot be
postponed,
o A planned posteriorsclerotomy with drainage of vitreous from pars plana
will prevent rupture of the anterior hyaloid face and vitreous loss.
 OPERATIVE COMPLICATIONS
• Management of vitreous loss.
Once the vitreous loss has occurred, the aim should be to clear it from the anterior
chamber and incision site.
Partial anterior vitrectomy with the use of automated vitrectors.
A meticulously performed partial anterior
vitrectomy will reduce the incidence of postoperative problems like updrawn
pupil, iris prolapse and vitreous touch syndrome.
OPERATIVE COMPLICATIONS
10. Nucleus drop into the vitreous cavity.
Management. No attempt should be made to fish it out.
The case must be referred to vitreoretinal surgeon after a thorough anterior
vitrectomy and cortical clean up.
11. Posterior loss of lens fragments
Glaucoma
Chronic uveitis,
Chronic CME
Retinal detachment.
Management : Pars plana vitrectomy and removal of nuclear fragments.
OPERATIVE COMPLICATIONS
12. Expulsive choroidal haemorrhage.
Spontaneous gaping of the wound followed by expulsion of the lens, vitreous,
retina, uvea and finally a gush of bright red blood.
Drain subchoroidal blood by performing an equatorial sclerotomy.
If not controlled: Evisceration
 EARLY POSTOPERATIVE
COMPLICATIONS
1. Hyphaema.
• If the blood does not get absorbed in a week’s time, then a paracentesis should be
done to drain the blood.
2. Iris prolapse
• A small prolapse of less than 24 hours duration may be reposited back and wound
sutured.
• A large prolapse of long duration needs abscission and suturing of wound.
3. Striate keratopathy.
• Corneal oedema with Descemet’s folds
• Manage with hypertonic saline drops (5% sodium chloride) along with steroids.
 EARLY POSTOPERATIVE
COMPLICATIONS
• 4. Flat (shallow or nonformed) anterior chamber.
Wound leak:
• Pressure bandage and oral acetazolamide.
• Injection of air in the anterior chamber and resuturing of the leaking wound.
Ciliochoroidal detachment.
• Suprachoroidal drainage with injection of air in the anterior chamber.
 EARLY POSTOPERATIVE
COMPLICATIONS
Pupil block
• leads to formation of iris bombe and shallowing of AC.
• If the condition persists for 5–7 days, permanent peripheral anterior synechiae
(PAS) may be formed leading to secondary angle closure glaucoma
• Management:
• Mydriatic agent,
• hyperosmotic agents (e.g., 20% mannitol) and acetazolamide.
• Laser or surgical peripheral iridectomy .
 EARLY POSTOPERATIVE
COMPLICATIONS
5. Postoperative anterior uveitis
Management includes more aggressive use of topical steroids, cycloplegics and
NSAIDs.
6. Toxic anterior segment syndrome (TASS)
Postoperative sterile endophthalmitis may occur as toxic reaction to:
• Chemicals adherent to intraocular lens (IOL) or
• Chemicals adherent to instruments.
• Severe reaction mainly confined to the anterior segment.
 EARLY POSTOPERATIVE
COMPLICATIONS
7. Bacterial endophthalmitis.
• Symptoms and signs of bacterial endophthalmitis are generally present
between 48 and 72 hours after surgery.
• Ocular pain,
• Diminshed vision,
• Lid oedema,
• Conjunctival chemosis and marked circumciliary congestion,
• Corneal oedema,
• Exudates in pupillary area, Hypopyon
• Diminished or absent red pupillary glow.
 LATE POSTOPERATIVE
COMPLICATIONS
1. Cystoid macular oedema (CME).
• Collection of fluid in the form of cystic loculi in the Henle’s layer of macula
2. Delayed chronic postoperative endophthalmitis
3. Pseudophakic bullous keratopathy (PBK)
4. Retinal detachment (RD).
5. Epithelial ingrowth
6. Fibrous downgrowth
 LATE POSTOPERATIVE
COMPLICATIONS
7. After cataract.
• (i) Residual opaque lens matter may persist as after cataract.
• (ii) Proliferative type of after cataract may develop
The proliferative hyaline bands may sweep across the whole posterior capsule.
• Soemmering’s ring which refers to a thick ring of after cataract formed behind the
iris, enclosed between the two layers of capsule
• Elschnig’s pearls in which the vacuolated subcapsular epithelial cells are clustered
like soap bubbles along the posterior capsule
• Thin membranous after cataract and thickened posterior capsule are best treated
by YAG-laser capsulotomy or discission with cystitome or Zeigler’s knife.
• Dense membranous after cataract needs surgical membranectomy.
 LATE POSTOPERATIVE
COMPLICATIONS
• 8. Glaucoma-in-aphakia and pseudophakia
 IOL-RELATED COMPLICATIONS
• Complications like
• Cystoid macular oedema
• Corneal endothelial damage
• Uveitis
• Secondary Glaucoma are seen more frequently with IOL Implantation, especially
with anterior chamber and Iris supported IOLs.
• UGH syndrome refers to concurrent occurrence of uveitis, glaucoma and
hyphaema. It used to occur commonly with rigid anterior chamber IOLs
 IOL-RELATED COMPLICATIONS
2. Malpositions of IOL
Sunset syndrome (Inferior subluxation of IOL).
Sunrise syndrome (Superior subluxation of IOL).
Lost lens syndrome (Dislocation of an IOL into the vitreous cavity).
Windshield wiper syndrome.
(Small IOL is placed vertically in the sulcus. In this the superior loop moves to the
left and right, with movements of the head.)
3. Pupillary capture of the IOL
4. Toxic anterior segment syndrome (TASS).