Lens and Cataract

Cataract and Refractive Surgery Subspecialty Service Department of Ophthalmology Faculty of Medicine Padjadjaran University

Topics of Study
1.

Cataract
Causes of Cataract Global/National distribution & population characteristics of Cataract Diagnosis of Cataract. Distinction between immature, mature and hypermature Appropriate referral of cataract patient Outline of surgical management Visual rehabilitation of Aphakia Outline of cataract management in young age

Topics of Study
2. Congenital Abnormalities of Lens
Ectopia Lentis (Subluxation & Dislocation) Lenticonus

Crystalline Lens
Embryology Derived from surface Ectoderm Ectoderm invaginates and breaks as two layers structure Basement membrane of epithelium forms the lens capsule Posterior epithelium cells form the embryonic nucleus Anterior epithelium continues to regenerate and develop lens fibers

Anatomy

Lies behind the iris Concavity in the anterior face of vitreus called the Patellar Fossa Suspended from the cilliary processes by Zonules In young patients (<35 years) lens is adherent to vitreus by Ligament of Weigert

Layers (from without inwards) :

Lens capsule (thinnest at posterior pole) Epithelium (missing from posterior surface) Cortex Epinuclear Cortex Nucleus

Nucleus (from without inwards) :

Adults Adolescent Infantile Fetal (contains anterior & posterior Ysutures) Embryonic

Physiology

Functions :
1. 2.

Refraction of light (+18 D) Accomodation : ability to increase refractive power in order to focus near objects.

Optics

+18 D refraction. And in accomodation this power increases Accomodation : contraction of ciliary muscles results in laxity of zonules, which leads to increase convexity of lens due to its inherent elasticity Iris controls the amount of light that enters the eye by varying the size of pupil and covers the peripher of the lens thereby cutting the optical (spherical) aberrations from it

Cataract
Definition

Any opacity of the lens or loss of transparancy of the lens that causes diminution or impairment of vision

Classification

Etiological Morphological Stage of Maturity Chronological

Etiological classification
1. 2.

Senile Traumatic
1. 2. 3. 4. 5.

Penetrating Concussion (Rosette Cataract) Infrared irradiation Electrocution Ionizing Radiation

3.

Metabolic
1.
2. 3. 4. 5. 6. 7.

8.
9.

Diabetes (Snow Storm Cataract) Hypoglycaemia Galactosemia (Oil drop cataract) Galactokinase Deficiency Mannosidosis Fabrys Disease Lowes Syndrome Wilsons Disease (Sunflower Cataract) Hypocalcaemia

4. Toxic
1. 2. 3. 4. 5. 6.

Corticosteroids Chlorpromazine Miotics Busulphan Gold Amiodarone

5. Complicated

Anterior uveitis Hereditary Retinal & Vitreoretinal Disoders High Myopia Glaucomflecken Intraocular Neoplasia

6. Maternal Infection
1.
2. 3.

Rubella Toxoplasmosis Cytomegalovirus

7. Maternal Drug Ingestion

Thalidomide Corticosteroid

8. Presenile Cataract

Myotonic Dystrophy Atopic Dermatitis (Syndermatotic Cataract) GPUT & Enzyme Deficiencies

9. Syndromes with Cataract

Downs Syndrome Werners Syndrome Rothmunds Syndrome Lowes Syndrome

10. Hereditary 11. Secondary Cataract

Posterior Capsular Opacification (PCO)

Morphological Classification
1.

Capsular
Congenital (Anterior Polar & Posterior Polar) Acquired

2.

Subcapsular
Posterior subcapsular (Cupuliform) Anterior subcapsular

3.

Nuclear
Congenital (Discoid, etc) Senile

4. Cortical

Congenital (Coronary, Coralliform, etc) Senile (Cuneiform)

5. Lamelar or Zonular 6. Sutural 7. Others

Blue Dot (Cataracta caerulea) Membranous Cataracta Pulveranta Centralis Reduplicated Cataract

Stage of Maturity
1.
2. 3. 4. 5.

Immature Mature Intumescent Hypermature Morgagnian

Chronological
1.
2. 3. 4. 5.

Congenital : since birth Infantile : first year of life Juvenile : 1 to 13 years of life Presenile : 13 to 35 years of life Senile

Pathogenesis
Two main pathogenetic processes are :
1.

Hydration :

Failure of active pump mechanism Increased leakage across posterior or anterior capsule Increased Osmotic Pressure

2.

Sclerosis

Senile Cataract Global 38 million people are blind 41% because of cataract

Progression
1.

Stage of Lamellar Separation

Hydration

2.

Stage of Incipient Cataract

Early opacities appear Symptom e.g., glare, appear

3.

Immature Cataract

Diminution of vision Lens appears grayish white in color Iris shadow can be seen

Progression
4. Intumescent Cataract

The lens imbibes lot of fluid and becomes swollen Anterior chamber becomes shallow Angle of anterior chamber may close : Phacomorphic glaucoma

5. Mature Cataract

Entire cortex becomes opaque Vision reduced to just perception of light Iris shadow is not seen Lens appears pearly white

Progression

6. Hypermature Cataract
This may take any of two form : Liquefactive or Morgagnian type : milky white Sclerotic Cataract with iridodenesis Vision improves to about finger counting at 1 meter

Clinical Presentation
Symptoms 1. Glare 2. Image Blur 3. Diurnal Variation of Vision 4. Distortion (Metamorphopsia) 5. Diplopia/Polyopia 6. Altered Color Perception 7. Black Spots 8. Behavioral Changes

Clinical Presentation
Signs 1. Visual Acuity : vision is diminished proportionate to the degree of cataract (immature from 6/9 to finger counting close to face; mature perception of light or hand movements) 2. Leukocoria : white pupil 3. Iris shadow in immature cataract 4. Distant Direct Ophthalmoscopy (DDO) : red reflexes depends on degree of cataract

Differentiating Various Stages of Cataract

Features Vision Anterior Chamber Color of Lens Immature 6/9 - FC
Normal (shadow in intumescent)

Mature HM - PL
Normal (shallow in intumescent)

Hypermature HM FC Normal to deep

Milky white(with browm crescent of nucleus) or chalky white

Grayish white

Pearly white

Iris shadow

Seen

Not seen
No red glow seen

Not seen
No red glow seen

Distant Direct Black patches Ophthalmoscopy againts red glow

Complication of Cataract
1.

Lens Induced Glaucoma

1. 2.

3.

Phacomorphic Galucoma Phacolytic Glaucoma Phacotopic Glaucoma

2. 3.

Lens Induced Uveitis Subluxation or Dislocation of Lens

Investigation
1.

2.
3. 4.

5.
6. 7.

8.
9.

Visual Acuity Pupillary Reflexes Intraocular Pressure Fundus Examination Blood Pressure General Investigation Macular Function Test Ultrasonography (USG B-Scan) Intraocular Lens Power Calculation
Biometry

Indications for Cataract Surgery

1. 2.

Optical indications Medical indication

Hypermature cataract Lens induced glaucoma Lens induced uveitis Dislocated/subluxated lens Intra-lenticular foreign body Diabetic Retinopathy to give Laser Photocoagulation Retinal Detachment

3.

Cosmetic indication

Surgery for Cataract

Choice of Operation : 1. Extra-capsular cataract extraction with Posterior Chamber Lens Implantation (ECCE with PCL) 2. Intra-capsular cataract extraction (ICCE) 3. Pars plana lensectomy 4. Phacoemulsification with Foldable Intraocular Lens (IOL)

Intra-ocular lens (IOL) types :

1. 2.

Posterior chamber lens (PCL) Anterior chamber lens (ACL)

Principles of Various Techniques

1.

ECCE

The nucles and the cortex is removed out of the capsule leaving behind intact posterior capsule, peripheral part of the anterior capsule and the zonules The lens is removed in toto

2.

ICCE

3. Pars Plana Lensectomy

A special techniques used in very young children The lens and anterior part of vitreous is nibled out using an instrument called Vitrectomy Probe or Vitreous irrigation Suction Cutting (VISC)

4. Phacoemulsification

It is essentially an advancement in the methode of doing ECCE The nucleus is converted into pulp or emulsified using high frequency (40.000 MHz) sound waves and then sucked out of the eye through a small (3.2) incision A special foldable IOL is then inserted Is the choice of the operation for cataract

ECCE vs. ICCE

ECCE
Lens removal
Nucleus removed out of the capsule and cortex sucked out

ICCE
Lens removed as single piece within its capsule

Posterior capsule & zonules Incision

Peripheral iridectomy

Intact Smaller (8 mm) Not performed Required More

Removed Larger (10 mm)

Required to avoid pupillary block glaucoma

Sophisticated equipment Time taken

Not required Less

ECCE vs. ICCE

ECCE
IOL Implantation Expertise required Cost Posterior chamber Difficult technique More

ICCE
Anterior chamber Easier to learn Less
1.

Complications which Posterior Capsular are increased Opacification (PCO)

2. 3. 4. 5.

6.

Vitreous prolapse & loss CME Endophthalmitis Aphakic Glaucoma Fibrous & endothelial ingrowth Neovasc. Glaucoma in PDR

ECCE vs. ICCE

ECCE Complications which are decreased Indications ICCE
All the complications PCO mentioned for ICCE A routine procedure for all forms of cataract (except where contraindicated
1. 2.

3.

4.

5.

Dislocated Lens Subluxated Lens (>1/3 zonules broken) Chronic Lens Induced Uveitis Hypermature Shrunken Cataract Intraocular foreign body

Contraindications

1. 2.

Dislocated lens Subluxated lens (>1/3 zonules broken)

Young patient (<35 years)

Preoperative Preparation
1.

2. 3. 4. 5. 6.

Patient preferably admitted to the hospital on previous evening (however, surgery can also be done on OPD basis) Informed consent is taken The eye-lashes are trimmed carefully Antibiotic drops are instilled every 6 hourly Pupils are dillated Other medications e.g., antiglaucoma drugs, antihypertensives, etc

Anesthesia
1.
2. 3. 4. 5.

Topical anesthesia Retrobulbar anesthesia Peribulbar anesthesia Subtenon anesthesia General anesthesia

Postoperative Care
1. 2.

Eye is cleaned routinely The eye is examined :

Visual acuity Apposisition of the wound Corneal clarity Anterior chamber depth Pupil IOL Posterior capsule Intra-ocular pressure (IOP)

3.

Topical antibiotic-steroid eye drops every 4-6 hourly (4-6 weeks)

Complication of Cataract Surgery

These can be grouped as : 1. Intraoperative 2. Postoperative :

Early Late

Intraoperative Complications
1.
2. 3. 4. 5.

6.

Damage to corneal endothelium Rupture of posterior capsule Vitreous prolapse and loss Hyphaema Expulsive hemmorrhage Dislocation of nucleus into vitreous

Posoperative Complications
Early
1. 2. 3.

4.
5. 6. 7. 8. 9.

Corneal edema Wound leak Iris prolapse Shallow or flat anterior chamber Hyphaema Hypotony Glaucoma Decentered or displaced IOL Endophthalmitis

Late
1.

2.

3. 4. 5. 6.

Posterior Capsular Opacification (PCO) Cystoid Macular Edema (CME) Vitreous touch syndrome UGH syndrome Bullous Keratopathy Glaucoma

Visual Rehabilitation After Cataract Surgery (Aphakia)

1.

2.

3.
4. 5.

Absolute high hypermetropia Astigmatism Loss of accomodation Altered Color Perception More of UV rays reach the retina

Rehabilitation
Three methods are mainly used to tackle the problems of aphakia : 1. Intraocular Lens (IOL) 2. Spectacles 3. Contact Lens

Aphakic Spectcles
Physical and Optical Problems : 1. The glasses are heavy and great physical discomfort 2. Magnification : diplopia 3. Roving Ring Scotoma 4. Jack in the box Phenomenon 5. Pin Cushion Effect 6. Spherical Aberations 7. Chromatic Aberation

Pediatric Cataract
Main problems 1. Visual Assesment 2. Vision Deprivation Amblyopia 3. Postoperative Inflammation and Fibrosis 4. PCO 5. IOL Power Calculation

Dislocation of Lens
Congenital
1. 2. 3. 4. 5.

6.
7.

Familial Ectopia lentis Marfan Syndrome Weil Marchesani Syndrome Homocystinuria Hyperlisinemia Aniridia

Acquired
1. 2. 3. 4. 5.

6.

Hypermature cataract Trauma Chronic uveitis Intraocular tumor High myopia Buphthalmos

Treatment
1.
2. 3.

4.

Spectacles ECCE : only 1/3 zonules are broken ICCE : more than 1/3 zonules are broken Pars Plana Surgery

Miscellaneous Condition of Lens

1. 2. 3.

Lenticonus Lens Coloboma PCO