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CHAPTER I INTRODUCTION

A cataract is a clouding of the eye's natural lens, which lies behind the iris and the pupil. The lens works much like a camera lens, focusing light into the retina at the back of the eye. The lens also adjusts the eye's focus, letting us see things clearly both up close and far away. Aging is the most common cause of cataract (esp. persons over 65-70 years) but many other factors can be involved, including trauma, toxins, systemic disease, and heredity. Age related cataract is a common cause of visual impairment. Cataract usually happens in both eyes, but traumatic cataract may happen in only one eye. The sexes are equally affected. Cataracts also run in families. The condition is estimated to have blinded more than 25 million people worldwide.

The crystalline lens is implicated as a causative element in producing several forms of glaucoma. Etiologically they represent a diversity in the presentation of the glaucomatous process. These conditions include glaucoma related to: lens dislocation (ectopia lentis), lens swelling (intumescent cataract), classical pupillary block, aqueous misdirection - ciliary block, phacoanaphylaxis, lens particle, and phacolytic glaucoma. In normal eye, there is a balance between the production and outflow of the aqueous. When it’s blocked, the intraocular pressure increased leads to the damage of optic nerve.The management of elevated intraocular pressure often requires altering the intraocular relationship of anatomic structures surrounding the lens or lens removal. In glaucoma there is a weakness in eye function caused of the visual field decreased and anatomical damage and the degeneration of the optic disc which can resulting blindness.

CHAPTER II LITERATURE REVIEW

Anatomy and Physiology of lens The crystalline lens focuses a clear image on the retina. The lens is suspended by thin filamentous zonules from the ciliary body between the iris anteriorly and the vitreous humor posteriorly. Contraction of the ciliary muscle permits focusing of the lens. The lens is enclosed in a capsule of transparent elastic basement membrane. The capsule encloses the cortex and the nucleus of the lens as well as a single anterior layer of cuboidal epithelium. The lens has no innervation or blood supply. Nourishment comes from the aqueous fluid and the vitreous. The normal lens continues to grow throughout life. The epithelial cells continue to produce new cortical lens fibers, yielding a slow increase in size, weight, and density over the years. The normal lens consists of 35% protein by mass. The percentage of insoluble protein increases as the lens ages and as a cataract develops. Definition of Cataract A cataract is any opacity or discoloration of the lens, whether a small, local opacity or the complete loss of transparency. Clinically, the term cataract is usually reserved for opacities that affect visual acuity because many normal lenses have small, visually opacities. A cataract is described in terms of the zones of the lens involved in the opacity. These zones of opacity may be subcapsular, cortical, or nuclear and may be anterior or posterior in location. In addition to of the nucleus and cortex, there may be a yellow or amber color change to the lens. A cataract also can be described in terms of its stage of development. A cataract with a clear cortex remaining is immature. A mature cataract has a totally opacified cortex.

Epidemiology

Age-related cataract is responsible for 48% of world blindness, which represents about 18 million people, according to the World Health Organization (WHO). In many countries surgical services are inadequate, and cataracts remain the leading cause of blindness. As populations age, the number of people with cataracts is growing. Cataracts are also an important cause of low vision in both developed and developing countries. Even where surgical services are available, low vision associated with cataracts may still

be prevalent, as a result of long waits for operations and barriers to surgical uptake, such as cost, lack of information and transportation problems. In the United States, age-related lenticular changes have been reported in 42% of those between the ages of 52 to 64, 60% of those between the ages 65 and 74, and 91% of those between the ages of 75 and 85.The increase in ultraviolet radiation resulting from depletion of the ozone layer is expected to increase the incidence of cataracts.

Classification of Cataract

  • 1. Congenital Cataract : Some babies are born with cataracts or develop them in childhood, often in both eyes. These cataracts may be so small that they do not affect vision. If they do, the lenses may need to be removed.

  • 2. Traumatic Cataracts : Cataracts can develop after an eye injury, sometimes years later.

  • 3. Secondary Cataracts :Cataracts can form after surgery for other eye problems, such as glaucoma. Cataracts also can develop in people who have other health problems, such as diabetes. Cataracts are sometimes linked to steroid use

  • 4. Senile Cataract.

5. Pathophysiology

The pathophysiology behind senile cataracts is complex and yet to be fully understood. In all probability, its pathogenesis is multifactorial involving complex interactions between various physiologic processes. As the lens ages, its weight and thickness increases while its accommodative power decreases. As the new cortical layers are added in a concentric pattern, the central nucleus is compressed and hardened in a process called nuclear sclerosis. Multiple mechanisms contribute to the progressive loss of transparency of the lens. The lens epithelium is believed to undergo age-related changes, particularly a decrease in lens epithelial cell density and an aberrant differentiation of lens fiber cells. Although the epithelium of cataractous lenses experiences a low rate of apoptotic death, which is unlikely to cause a significant decrease in cell density, the accumulation of small scale epithelial losses may consequently result in an alteration of lens fiber formation and homeostasis, ultimately leading to loss of lens transparency. Furthermore, as the lens ages, a reduction in the rate at which water and, perhaps, water-soluble low-molecular weight

metabolites can enter the cells of the lens nucleus via the epithelium and cortex occurs with a subsequent decrease in the rate of transport of water, nutrients, and antioxidants. Consequently, progressive oxidative damage to the lens with aging takes place, leading to senile cataract development. Various studies showing an increase in products of oxidation (eg, oxidized glutathione) and a decrease in antioxidant vitamins and the enzyme superoxide dismutase underscore the important role of oxidative processes in cataractogenesis. Another mechanism involved is the conversion of soluble low-molecular weight cytoplasmic lens proteins to soluble high molecular weight aggregates, insoluble phases, and insoluble membrane-protein matrices. The resulting protein changes cause abrupt fluctuations in the refractive index of the lens, scatter light rays, and reduce transparency. Other areas being investigated include the role of nutrition in cataract development, particularly the involvement of glucose and trace minerals and vitamins.

6.

Stage

In clinical, senile cataract devided to 4 stage:

1)

Insipient Cataracts

2)

In this stadium opacity start from marginal equator to anterior and posterior cortex. This opacity can arised poliopia because refraction index is not same in the all of lens. Immature Cataracts

3)

Opacity at a part of lens. In this stadium lens volume will increase and make osmotic pressure increase too. Subsequently, lens more convex and occure block pupil,finally can arise secunder glaucoma. Mature Catarcts

4)

Opacity can found in all of lens. This opacity can occure because there is calcium depotitions in the lens. Fluid in the lens will remove out so that lens will back at normal size, anterior chambers back at normal depth and there isn’t iris image at the opaque lens so shadow test is negative. Hipermature Cataracts Mass lens move out from the lens capsule so lens becomes small,yellow colored and dry. In the examination seen anterior chamber is deep and there is lens capsule fold. If cataract process continued accompanied with thicken capsule so cortex degeneration can

not move out and can seen like a milk pack accompanied nucleus that concentrate in basal lens cortex. This condition called Morgagni Cataract.

a.

Symptoms and Sign Symptoms

Many patients complain of blurred vision, which is usually worse when viewing distant objects. If the patient is unable to read small print, the surgeon might suspect that other pathology, such as macular degeneration, could be present. One must bear in mind that some elderly patients say that they cannot read when it is found that they can read small print if carefully tested. It is a curious fact that when the cataract is unilateral, the patient can claim that the loss of vision has been quite sudden. Elucidation of the history in these cases sometimes reveals that the visual loss was noted when washing and observing the face in the mirror. When one hand is lowered before the other, the unilateral visual loss is noticed for the first time and interpreted as a sudden event. The history in cataract cases might be further confused by a natural tendency for patients to project their symptoms into the spectacles, and several pairs might be obtained before the true cause of the problem is found. In order to understand the symptoms of cataract, it is essential to understand what is meant by index myopia. This simply refers to the change in refractive power of the lens, which occurs as a preliminary to cataract formation. Index myopia can also result from uncontrolled diabetes. If we imagine an elderly patient who requires reading glasses (for presbyopia) in the normal way but no glasses for viewing distant objects, the onset of index myopia will produce blurring of distance vision, but also the patient will discover to his or her surprise that it is possible to read again without glasses. In the same way, the hypermetropic patient will become less hypermetropic and find that it is possible to see again in the distance without glasses. The ageing fibres in the precataractous lens become more effective at converging light rays so that parallel rays of light are brought to a focus more anteriorly in the eye. A part from blurring of vision, the cataract patient often complains of monocular diplopia. Sometimes even a slight and subtle opacity in the posterior part of the lens can cause the patient to notice, for example, that car rear lights appear doubled, and this can be reproduced with the ophthalmoscope light. Monocular diplopia is suspect symptom, the suggestion being that if a patient continues to see double, even when one eye is closed,

then he or she might not be giving an accurate history. In actual practice nothing could be further from the truth and this is quite a common presenting feature of cataract. Glare is another common presenting symptom.

then he or she might not be giving an accurate history. In actual practice nothing could

Picture 2. Opaque areas in the lens can be seen clearly against the red reflex.

The patient complains that he or she cannot see so well in bright light and might even be wearing a pair of dark glasses. Glare is a photographic term but here it refers to a significant reduction in visual acuity when an extraneous light source is introduced. Light shining from the side is scattered in the cataractous lens and reduces the quality of the image on the retina. Glare becomes an important consideration when advising an elderly cataractous patient on fitness to drive. The visual acuity might be within the requirements laid down by law (seeing a number plate at 20.5 m) but only when the patient is tested in the absence of glare. A consideration of all these factors makes itrelatively easy to diagnose cataract even before examining the patient. To summarise, a typical patient might complain that the glasses have been inaccurately prescribed, that the vision is much worse in bright sunlight, that sometimes things look double and that there is difficulty in recognising people’s faces in the street rather than difficulty in reading. Patients with cataracts alone do not usually complain that things look distorted or that straight lines look bent, nor do they experience pain in the eye. Rarely, cataracts become hypermature; that is to say, the lens enlarges in the eye and this in turn can lead to secondary glaucoma and pain in the eye. Urgent surgery might be needed under these

circumstances. In its late stages, acataract matures and becomes white, so that exceptionally a patient might complain of a white spot in the middle of the pupil.

b. Signs

1)

Reduced Visual Acuity

A reduction in visual acuity can, of course, be an early sign of cataract formation but this

is not always the case. Some patients see surprisingly well through marked lens opacities, and the effect on visual acuity as measured by the Snellen test type depends as much on the position of the opacities in the lens as on the density of the opacities.

2) Findings of Ophthalmoscopy

The best way of picking up a cataract in its early stages is to view the pupil through the

ophthalmoscope from a distance of about 50 cm. In this way, the red reflex is clearly seen. The red reflex is simply the reflection of light from the fundus and it is viewed in exactly the

same manner that one might view a cat’s eyes in the headlamps of one’s car or the eyes of one’s friends in an illjudged flash photograph. In fact, such a flash photo could well show up an early cataract if an elderly relative were included in the photograph. When using the ophthalmoscope, the opacities in the lens are often seen as black spokes against the red

reflex. It is important to focus one’s eyes onto the plane of the patient’s pupil if the cataract is

to be well seen, and it is preferable to dilate the pupil beforehand or at least examine in a

darkened room. Typical age-related lens opacities are wedge shaped, pointing towards the centre of the pupil. At the same time, the central nucleus of the lens can take on a yellowish-

brown colour, the appearance being termed “lens sclerosis”, and ultimately, the lens can

become nearly black in some instances. After inspecting a cataract with the ophthalmoscope held at a distance from the eye, one must then approach closer and attempt to examine the fundus. Further useful information about the density of the cataract can be obtained in this way. It is generally true that if Cataract Opaque areas in the lens can be seen clearly against the red reflex. the observer can see in, the patient can see out. If there is an obvious discrepancy between the clarity of the fundus and the visual acuity of the patient, some other

pathology might be suspected. Sometimes the patient might not have performed too well on subjective testing and such an error should be apparent when the fundus is viewed. Some types of cataract can be misleading in this respect and this applies particularly to those seen in highly myopic patients. Here, there is sometimes a preponderance of nuclear sclerosis, which simply causes distortion of the fundus while the disc and macula can be seen quite clearly. 1

Management At the present time, there is no effective medical treatment for cataract in spite of a number of claims over the years. A recent report has suggested that oral aspirin can delay the progress of cataract in female diabetics. Although this might be expected to have some effect on theoretical grounds, any benefit is probably marginal. Occasionally, patients claim that their cataracts seem to have cleared, but such fluctuation in density of the lens opacities has not been demonstrated in a scientific manner. Cataracts associated with galactosaemia are thought to clear under the influence of prompt treatment of the underlying problem. Cataract is, therefore, essentially a surgical problem, and the management of a patient with cataract depends on deciding at what point the visual impairment of the patient justifies undergoing the risks of surgery. The cataractoperation itself has been practiced since pre-Christian times, and developments in recent years have made it safe and effective in a large proportion of cases. The operation entails removal of all the opaque lens fibres from within the lens capsule and replacing them with a clear plastic lens. Common Eye Diseases and their Management In the early part of the last century the technical side of cataract surgery necessitated waiting for the cataract to become “ripe”.Nowadays no such waiting is needed and it is theoretically possible to remove a clear lens. The decision to operate is based on whether the patient will see better afterwards. Modern cataract surgery can restore the vision in a remarkable way and patients often say that theyhave not seen so well for many years. Indeed, many patients have quite reasonable vision without glasses but this cannot be guaranteed and, because the plastic lens implant gives a fixed focus, glasses will inevitably be needed for some distances. Probably the worst thing that can happen after the operation is infection leading to endophthalmitis and loss of the sight of the eye. Although this only occurs in about one out of a thousand cases, the patient contemplating cataract surgery needs to be aware of the possibility. Before the operation, it is now a routine to measure the length of the eye and the corneal curvature.Knowing these two measurements, one can assess the strength of lensimplant that is needed. When deciding on thestrength of implant, it is necessary to considerthe other eye. The aim is usually to make the two eyes optically similar because patients find it difficult to tolerate two different eyes.

b. When To Operate

Even though the decision to operate on a cataract must be made by the ophthalmic surgeon, optometrists and the nonspecialist general practitioner need to understand the reasoning behind this decision. Elderly patients tend to forget what they have been told in the clinic and might not, for example, understand why cataract surgery is being delayed when macular degeneration is the main cause of visual loss. An operation is usually not required if the patient has not noticed any problem, although sometimes the patient can deny the problem through some unexpressed fear. The requirements of the patient need to be considered; those of the chairbound arthritic 80-year-old subject who can still read small print quite easily are different from the younger business person who needs to be able to see a car number plate at 20.5 m in order to drive. The visual acuity by itself is not always a reliable guide.Some patients who have marked glare might need surgery with a visual acuity of 6/9, whereas others with less visual demands might be quite happy with a vision of 6/12 or 6/18. Early surgery might be needed to keep a joiner or bus driver at work for which good binocular vision is needed.

  • b. The Cataract Operation

The definitive management for senile cataract is lens extraction. Over the years, various surgical techniques have evolved from the ancient method of couching to the present-day technique of phacoemulsification. Almost parallel is the evolution of the IOLs being used, which vary in ocular location, material, and manner of implantation. Depending on the integrity of the posterior lens capsule, the 2 main types of lens surgery are the intracapsular cataract extraction (ICCE) and the extracapsular cataract extraction (ECCE). Below is a general description of the 3 commonly used surgical procedures in cataract extraction, namely ICCE, standard ECCE, and phacoemulsification. Reading books on cataract surgeries for a more in-depth discussion of the topic, particularly with regard to technique and procedure, is also recommended. 4 1). Intracapsular cataract extraction Prior to the onset of more modern microsurgical instruments and better IOLs, ICCE was the preferred method for cataract removal. It involves extraction of the entire lens, including the posterior capsule. In performing this technique, there is no need to worry about subsequent development and management of capsular opacity. The

technique can be performed with less sophisticated equipment and in areas where operating microscopes and irrigating systems are not available. However, a number of disadvantages and postoperative complications accompany ICCE. The larger limbal incision, often 160°-180°, is associated with the following risks: delayed healing, delayed visual rehabilitation, significant against-the-rule astigmatism, iris incarceration, postoperative wound leaks, and vitreous incarceration. Corneal edema is a common intraoperative and immediate postoperative complication. Furthermore, endothelial cell loss is greater in ICCE than in ECCE. The same is true about the incidence of postoperative cystoid macular edema (CME) and retinal detachment. The broken integrity of the vitreous can lead to postoperative complications even after a seemingly uneventful operation. Finally, because the posterior capsule is not intact, the IOL to be implanted must either be placed in the anterior chamber or sutured to the posterior chamber. Both techniques are more difficult to perform than simply placing an IOL in the capsular bag and are associated with postoperative complications, the most notorious of which is pseudophakic bullous keratopathy. 5 Although the myriad of postoperative complications has led to the decline in popularity and use of ICCE, it still can be used in cases where zonular integrity is too severely impaired to allow successful lens removal and IOL implantation in ECCE. Furthermore, ICCE can be performed in remote areas where more sophisticated equipment is not available. ICCE is contraindicated absolutely in children and young adults with cataracts and cases with traumatic capsular rupture. Relative contraindications include high myopia, Marfan syndrome, morgagnian cataracts, and vitreous presenting in the anterior chamber.

  • 2. Extracapsular cataract extraction

In contrast to ICCE, ECCE involves the removal of the lens nucleus through an opening in the anterior capsule with retention of the integrity of the posterior capsule. ECCE possesses a number of advantages over ICCE, most of which are related to an intact posterior capsule, as follows:

A smaller incision is required in ECCE, and, as such, less trauma to the corneal endothelium is expected.

Short- and long-term complications of vitreous adherence to the cornea, iris, and incision are minimized or eliminated. A better anatomical placement of the IOL is achieved with an intact posterior capsule. An intact posterior capsule also (1) reduces the iris and vitreous mobility that occurs with saccadic movements (eg, endophthalmodonesis), (2) provides a barrier restricting the exchange of some molecules between the aqueous and the vitreous, and (3) reduces the incidence of CME, retinal detachment, and corneal edema. Conversely, an intact capsule prevents bacteria and other microorganisms inadvertently introduced into the anterior chamber during surgery from gaining access to the posterior vitreous cavity and causing endophthalmitis. Secondary IOL implantation, filtration surgery, corneal transplantation, and wound repairs are performed more easily with a higher degree of safety with an intact posterior capsule. The main requirement for a successful ECCE and posterior capsule IOL implantation is zonular integrity. As such, when zonular support is insufficient or appears suspect to allow a safe removal of the cataract via ECCE, ICCE or pars plana lensectomy should be considered.

3. Standard ECCE and phacoemulsification Standard ECCE and phacoemulsification are similar in that extraction of the lens nucleus is performed through an opening in the anterior capsule or anterior capsulotomy. Both techniques also require mechanisms to irrigate and aspirate fluid and cortical material during surgery. Finally, both procedures place the IOL in the posterior capsular bag that is more anatomical than the anteriorly placed IOL. Needless to say, significant differences exist between the 2 techniques. Removal of the lens nucleus in ECCE can be performed manually in standard ECCE or with an ultrasonically driven needle to fragment the nucleus of the cataract and then to aspirate the lens substrate through a needle port in a process termed phacoemulsification. The more modern of the 2 techniques, phacoemulsification offers the advantage of using smaller incisions, minimizing complications arising from improper wound closure, and affording more rapid wound healing and faster visual rehabilitation. Furthermore, it uses a relatively closed system during both phacoemulsification and aspiration with better control of intraocular pressure during surgery, providing safeguards against positive

vitreous pressure and choroidal hemorrhage. However, more sophisticated machines and instruments are required to perform phacoemulsification. Ultimately, the choice of which of the 2 procedures to use in cataract extraction depends on the patient, the type of cataract, the availability of the proper instruments, and the degree at which the surgeon is comfortable and proficient in performing standard ECCE or phacoemulsification

GLAUCOMA A condition of increased fluid pressure inside the eye so it make the compression of the retina and the optic nerve then make the nerve damage end. Glaucoma can cause partial vision loss, with blindness as a possible eventual outcome one of the leading causes of blindness, is estimated to affect 1 of every 50 adults. This is the diagram of pathophysiology of glaucoma.

vitreous pressure and choroidal hemorrhage. However, more sophisticated machines and instruments are required to perform phacoemulsification.

There are some risk factor of glaucoma:

Age

Family History

Drug consumption (steroid) Trauma

Severe Hypermethrophya

Other systemic disease (ex ; DM, Hypertension)

The classification may include:

1.

Open Angle Glaucoma

1. Open Angle Glaucoma
  • 2. Angle closure glaucoma

  • 3. Congenital Glaucoma

  • 4. Secondary glaucoma

Glaucoma can be divided roughly into two main categories, "open angle" and "closed angle" glaucoma.

Open Angle Glaucoma Primary open-angle glaucoma (POAG), the most common form of glaucoma, accounts for 6070% of all glaucomas and 9095% of primary glaucomas. POAG is a bilateral, chronic progressive condition that typically appears in individuals over 60 years of age.

Symptoms

  • a) asymptomatic (as moderately elevated IOP usually causes no symptoms but the IOP is

still high enough to cause glaucomatous optic neuropathy)

  • b) loss of part of their visual field cf tunnel vision

  • c) blindness in one or both eyes (advanced optic nerve damage)

Genetic factors are important and therefore the family history should be considered.

Signs

  • a) open angle

  • b) elevated IOP

  • c) glaucomatous optic nerve cupping

  • d) may have visual field loss

1. Open Angle Glaucoma 2. Angle closure glaucoma 3. Congenital Glaucoma 4. Secondary glaucoma Glaucoma can

Mild glaucomatous cupping

1. Open Angle Glaucoma 2. Angle closure glaucoma 3. Congenital Glaucoma 4. Secondary glaucoma Glaucoma can

Advanced glaucomatous cupping

The goal is to maintain IOP less than 21 mmHg and continued visual field loss should be

minimal. In fact, medications have been shown to control IOP in 6080% of patients over

a five-year period. Various treatmentmodalities include medical treatment, laser therapy,and surgery. Patients will initially start with topical ocular drug therapy. Prognosis : If discovered early and treated adequately, the prognosis for POAG is excellent. Closure Angle Glaucoma Less than 5% of all primary glaucomas. Requires immediate attention within hours to avoid dramatic vision loss. In primary the pathophysiology is a shallow ocular anterior chamber so the angle between the cornea and iris become narrow.This creates a situation where pupil dilation can physically occlude the trabecular meshwork. And secondary angle-closure glaucoma results from any type of blockage throughout this drainage pathway.

a five-year period. Various treatmentmodalities include medical treatment, laser therapy,and surgery. Patients will initially start with

figure. Primary close angle glaucoma

Diagnosis is determined by visualization of the angle by gonioscopy as well as provoking an IOP increase through mydriasis (dark room test) or by gravity (prone test).

Treatment of angle-closure glaucoma

Requires a rapid reduction in IOP to prevent a hypertensive event and ultimately preserve vision. For an acute hypertensive attack it can be given pilocarpine or secretory inhibitors (topical B- blockers, a2-agonists, CAIs). At IOPs greater than 60 mmHg, the iris becomes ischemic and may be unresponsive to pilocarpine even at high and frequent doses. An osmotic agent (oral glycerin, oral isosorbide, and intravenous Mannitol) is usually administered because of its rapid lowering of IOP. A peripheral iridectomy should be performed only when IOP is controlled.

Normal-Tension Glaucoma

Condition in which optic nerve damage and vision loss have occurred despite a normal pressure inside the eye (TIO< 21 mmHg). The patient has open, normal-appearing angles. In fact, the features of normal-tension glaucoma are similar to primary open-angle glaucoma.

The pathogenesis because of abnormal sensitivity to intraocular pressure caused by vascular or mechanically in the optical nerve

Others sign & symptoms:

Spasm of phertpheral vessel Chepalgia Hipotension at night Decrease of blood flow

Primary Congenital Glaucoma

Primary congenital glaucoma present at birth; however, but its manifestations may not be recognized until infancy or early childhood. The pathophysiology of primary congenital glaucoma is restricted to a developmental abnormality that affects the trabecular meshwork. Primary congenital glaucoma estimated to affect fewer than 0.05% of ophthalmic patients. The disease is bilateral in approximately 75% of cases.

Primary congenital glaucoma usually is diagnosed at birth or shortly thereafter, and most cases are diagnosed in the first year of life. Most cases are sporadic in occurrence and may be transmitted through an autosomal recessive pattern. Male patients are found to have a higher incidence of the disease, comprising approximately 65% of cases.

The triad of manifestations of primary congenital glaucoma are epiphora, photophobia , and blepharospasm. Blepharospasm is a spasm and closure of the eyelids.

Physically of congenital glaucoma there was:

Changes within the cornea, especially within the first few years of life, provide strong additional support for the diagnosis. Enlargement of the cornea The early presence of glaucoma may deepen the anterior chamber. Because of the frequent occurrence of iris abnormalities in many types of both primary and secondary childhood glaucomas, the iris and angles always should be studied carefully and with thorough gonioscopy.

The optic nerve head is usually abnormal. Variable cupping is present, usually annular in form, with nasalization of vessels and preservation of the well-vascularized rim. Pallor is first seen temporally when present at an advanced stage.

The Treatment of Congenital Glaucoma

Unlike adult glaucoma, the initial treatment for congenital glaucoma is often surgical. A

“drainage angle surgery” is often recommended for congenital glaucoma.

Secondary Glaucoma

Glaucoma can occur as the result of an eye injury, inflammation, tumor or in advanced cases of cataract or diabetes. It can also be caused by certain drugs such as steroids. This form of glaucoma may be mild or severe. The type of treatment will depend on whether it is open-angle or angle-closure glaucoma.

Pseudoexfoliative Glaucoma

This form of secondary open-angle glaucoma occurs when a flaky, dandruff-like material peels off the outer layer of the lens within the eye. The material collects in the angle between the cornea and iris and can clog the drainage system of the eye, causing eye pressure to rise.

Pseudoexfoliative Glaucoma is common in those of Scandinavian descent. Treatment usually includes medications or surgery.

Pigmentary Glaucoma

A form of secondary open-angle glaucoma, this occurs when the pigment granules in the back of the iris (the colored part of the eye) break into the clear fluid produced inside the eye. These tiny pigment granules flow toward the drainage canals in the eye and slowly clog them, causing eye pressure to rise. Treatment usually includes medications or surgery.

Traumatic Glaucoma

Injury to the eye may cause secondary open-angle glaucoma. This type of glaucoma can occur immediately after the injury or years later.

It can be caused by blunt injuries that “bruise” the eye (called blunt trauma) or by injuries that

penetrate the eye.

In addition, conditions such as severe nearsightedness, previous injury, infection, or prior surgery may make the eye more vulnerable to a serious eye injury.

Neovascular Glaucoma

The abnormal formation of new blood vessels on the iris and over the eye’s drainage channels can

cause a form of secondary open-angle glaucoma. Neovascular glaucoma is always associated with other abnormalities, most often diabetes. It never

occurs on its own. The new blood vessels block the eye’s fluid from exiting through the trabecular

meshwork (the eye’s drainage canals), causing an increase in eye pressure. This type of glaucoma is very difficult to treat.

Irido Corneal Endothelial Syndrome (ICE)

This rare form of glaucoma usually appears in only one eye, rather than both. Cells on the back surface of the cornea spread over the eye’s drainage tissue and across the surface of the iris, increasing eye pressure and damaging the optic nerve. These corneal cells also form adhesions that bind the iris to the cornea, further blocking the drainage channels.

Irido Corneal Endothelial Syndrome occurs more frequently in light-skinned females. Symptoms can include hazy vision upon awakening and the appearance of halos around lights. Treatment can include medications and filtering surgery. Laser therapy is not effective in these cases.

Absolute Glaucoma

Absolute glaucoma is the end stage of glaucoma (open angle/angle closure glaucoma). The clinical sign patien have total blindness. In absolute glaucoma, the cornea looks not clear, shallow of the chamber, athrofi of papil with excavation of glaucomatous, the eye become harder like a stone dan also painfull.

The treatment of absolute glaucoma can by given beta light into ciliary body for compres the

function of ciliary body or doing the nucleation because the eye doesn’t have function anymore so the eye can’t painfull anymore.

CHAPTER III

CASE REPORT

  • 1. Patient identity

Name

: Mrs. S

Sex

: female

Age

: 84 years old

Address

: Kuala Secapah

Job

: housewife

Religion

: Moslem

Patient was examined on January 21st, 2014

  • 2. Anamnesis Main complaint :

Red eye, watery, blindness. History of desease :

Patient complains blurry vision is affected in right eye. Blurry vision of the right eye since a few months ago, that become worse especially during this two weeks. Then, she told that her eye became redness until now. Not only

red, but also pain and watery. Now, patient have cloudy in her eye (right eye), so patient really can’t see anything from right eye. She also complaining the blurry vision at the left eye. Sometimes she had a headache. The manifestation of clinical from this patient : Headache (+), pain in the eyes (+), redness in the eye (+ right eye), itch feeling in the eyes (-), and traumatic history (-). Past clinical history :

Hypertension (-) Diabetes Mellitus (denied) because patient never did clinical check. Glasses wearing (-) Traumatic history (-) Family history

Hypertension (-)

Diabetes Mellitus (-)

Glasses wearing (-)

  • 3. General Physical assestment General condition Awareness

: Moderate : Compos mentis

Vital sign :

Blood Pressure

  • a. : 130/90 mmHg

  • b. RR

: 18/minute

  • c. Temperture

: 36,5˚C

  • 4. Ophthalmological status Visual acuity :

a.

OD

: 0

  • b. : 6/12

OS

  • c. Last glasses : the patient never use glasses

OD

 

OS

     

Ortho

Eye ball position

Ortho

     
Eye Movement

Eye Movement

Eye Movement

Movement(+), ptosis (-), lagoftalmos (-)

Palpebra

Movement (+), ptosis (-), lagoftalmos (-)

     

redness (+), discharge (-), degeneration plaque (-), foreign body (-), injection (-)

conjungtiva

redness (-), discharge (-), degeneration plaque (-), foreign body (-), injection (-)

     

ulcer (-) arcus senilis (+)

Cornea

ulcer (-) arcus senilis (+)

     
     

Not clear

Anterior chamber

clear, deep impression

     
     

Iris colour : brown, sinekia (-) Circular pupil, isochore

Iris/pupil

Iris colour : brown, sinekia (-) Circular pupil, isochore

     

Milky

Lense

Cloudy

     
     

-

Shadow test

+

     
     

-

Fundus

-

     

Shadow test : negatif (- right eye) , positive (+ left eye) Intra Ocular pressure (tonometry) : OD 26 mmHg, OS 15 mm Hg Funduscopy : - Visual field test: OD cannot be done, OS normal

  • 5. Resume A woman, 84 years old, came to ophthalmologist with the complain of blurry vision in right eye since a few months ago, and become worse during this two weeks. She told that her eye became redness until now. Not only red, but also pain and watery. Now, patient have cloudy in her eye (right eye), so patient really can’t see anything from right eye. She also complaining the blurry vision at the left eye. Sometimes she had a headache. The manifestation of clinical from this patient Headache (+), pain in the eyes (+), redness in the eye (+ right eye), watery (+), itch feeling in the eyes (-), and traumatic history (-). Visual acuity is “0” for OD, 6/12 for OS. Right lense seems milky. Left lense seems cloudy. Intraocular presure for OD 26mmHg, for OS 15 mmHg. Funduscopy cannot be done because of the lense opacity. Shadow test for left eye is positive. Confrontation test just be done at the left eye and the result is normal.

  • 6. Diagnosis

 

Diagnose :

a.

OD

: mature cataract with secondary glaucoma (absolute glaucoma)

b.

OS

: immature cataract (senilis)

DDx :

OD

: hipermature cataract with absolute galucoma

-

OS

:

  • 7. Plan for examination

a.

Slit lamp

 

b.

Perimetri

c.

Whole blood test and blood glucose

d.

Eye’s USG

 
  • 8. Treatment

 

a.

OD

i.

Pharmacological:

 
 

1.

Timolol

2.

Asetazolamide

 

ii.

Surgery : Extra Capsular Cataract Extraction

b.

OS

i.

Non-pharmacological

 
 

1.

Using eye protection

 

ii.

Surgery : Pachoemulsification + IOL

  • 9. Prognosis

a.

OD:

i.

Ad vitam

: bonam

ii.

Ad functionam

: malam

iii.

Ad sanactionam

: dubia ad malam

b.

OS :

i.

Ad vitam

: bonam

ii.

Ad functionam

: dubia ad bonam

iii.

Ad sanactionam

: dubia ad bonam

CHAPTER IV

DISCUSSION

A woman, 84 years old complained blurry vision clinic with complain redness, painfull, watery, even blindness in the right eye since a few months ago. The history before the eye became redness, patient had migrain at right part of head. The pain felt into her right eye. Then, she told that her eye became redness until now. Not only red, but also pain and watery. Now, patient have cloudy in her eye (right eye), so patient really can’t see anything from her right eye. There were no history of eye trauma. Visual acuity is 0 for OD, 6/12 for OS. Palpebra, conjunctiva, cornea and anterior chamber is inspected normally, while the right lens seems milky and the left eye seems blurry. No foreign body was found. Intra ocular pressure is 26 mmHg for OD, 15 mmHg for OS. Funduscopy cannot be done because of the lense opacity. Confrontation test for OD cannot be described, and for OS is normal, shadow test negative for right eye and positive for left eye. The abnormality found in physical examination is the opacity of the lens. We can get rid of inherited disorders because the patient is geriatric, and new phenomena arising in

recent years. In addition, the symptoms that arise in these patients as well as typical symptoms of cataract, like the the visual loss is slowly, and there is a cloud on the view that closes the view. Beside the opacity of left lense, the shadow test results is positive. In lens assesment found that at the right eye the lens is totally opaque, milky

appearance, funduscopy can’t be done cause the light can’t passes through the lens and it

indicated that is mature cataract at the right eye and for the left eye the lens looks cloudy and

shadow test is positive (+), show that it is an immature cataract at the left eye. These are some discussion about the clinical finding from the anamnesis and examination to the patient :

Blurred vision is caused by the opacity of the lense, that can cause disrupting the refraction media and finally, it can hampered the light to retinal

Vision slowly burred because of the progression of opacity in the lense (thickness of opacity influence the degree of vision lost)

VA : 0 for OD with good projection, 6/12 for OSopacity of OD is thicker than OSso OD must be treated firstly

Based on the examination, known that the visual acuity for right eye is 0. The patient can’t see at all, even with light perception.

There are some specific symptoms that can lead to diagnose the condition of the right eye. The IOP level for right eye is measure 26 mmHg. It indicated the raised of IOP greater than normal range. Raised IPO is determine by the balance between aqueous production inside the eye and aqueous drainage of the eye through the trabecular meshwork. The resistance to outflow through the trabecular meshwork gradually increase, causing the damage to the nerve. Pressure on the nerve fibres and chronic ischaemia at the optic nerve head cause damage to the retinal nerve fibres that leads to rapid loss of vision. Once optic nerve damage is occured, it cannot be repaired. It indicated that is absolute glaucoma at the right eye.

In mature cataract, there is degenerative lens capsule that cause the material out from the lens and enter the anterior chamber,stuck at the trabecular meshwork, block the drainage angle and cause the problem in excretion of aqueous humor. Type of glaucoma of this patient is absolute glaucoma indicated by the high level of IOP, visual acuity is 0, and the pain sensation inside the eye. So, the diagnosis of the right eye is absolute glaucoma e.c mature cataract

Treatment to this patient is to lower the IOP. Common medical therapy that used in this condition are combination of beta-blocker and carbonic anhidrase inhibitor, such as timolol 0,5 % and asetazolamide. Both of them action on the secretion system, that result the decrease in producing aqueous from ciliary body.

Definitive therapy for both eye is surgery. For the right eye should be treated by lens extraction. Medication that given to lower the IOP is aimed to controls the IPO and can minimize the symptoms. For the left eye with immature cataract the phacoemulsification is choosen as the therapy.

CHAPTER V CONCLUSION

The diagnosis of this patient is Mature Cataract with Secondary right eye. And for the right eye is immature cataract. The therapy for OD is doing the treatment of glaucoma and surgery for the lens extraction.

BIBLIOGRAPHY

  • 1. Cynthia AB, basic ophthalmology For Medical Studens and Primary Care Residents, Seventh Edition, electronic book. American Academy Of ophthalmology, 1999.

  • 2. Ilyas, S. Ilmu Penyakit Mata. Edisi 3. Jakarta. Balai Penerbit FKUI. 2007

  • 3. Galloway NR, Amoaku WMK, Galloway PH, Browing AC. Common Eye diseases and Their Management, electronic book. Springer-Verlag London, 2010

  • 4. Günter K. Krieglstein, MD and friends.Glaucoma. Springer-Verlag Berlin Heidelberg. Germany.2008

  • 5. Olver, J. and Cassidy, L., 2005. Ophthalmology at a Glance. Australia: Blackwell Publishing Company

  • 6. Vaughan D. G, Asbury, T. Eva, P.R. Oftalmologi umum. EGC. Jakarta. 2000