Lens and Cataract

Cataract and Refractive Surgery Subspecialty Service

Department of Ophthalmology
Medicine Faculty 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

Ciliary Body

Sclera

Lens

Cornea

Anterior Chamber
Posterior Chamber

Retina

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
Capsular

1.

Congenital (Anterior Polar & Posterior Polar)

Acquired

Subcapsular

2.

Posterior subcapsular (Cupuliform)

Anterior subcapsular

Nuclear

3.

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 :

2.

Failure of active pump mechanism

Increased leakage across posterior or
anterior capsule
Increased Osmotic Pressure

Sclerosis

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

Progression
Stage of Lamellar Separation

1.

Hydration

Stage of Incipient Cataract

2.

Early opacities appear

Symptom e.g., glare, appear

Immature Cataract

3.

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

Immature

Mature

Hypermature

Vision

6/9 - FC

HM - PL

HM FC

Anterior
Chamber

Normal (shadow
in intumescent)

Normal (shallow
in intumescent)

Normal to deep

Color of Lens

Grayish white

Pearly white

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

Iris shadow

Seen

Not seen

Not seen

No red glow
seen

No red glow
seen

Distant Direct
Black patches
Ophthalmoscopy againts red glow

Complication of Cataract
1.

Lens Induced Glaucoma

1.
2.
3.

2.
3.

Phacomorphic Galucoma
Phacolytic Glaucoma
Phacotopic Glaucoma

Lens Induced Uveitis

Subluxation or Dislocation of Lens

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

1.
2.
3.
4.
5.
6.
7.
8.
9.

Biometry

Indications for Cataract Surgery

Optical indications
Medical indication

1.
2.

3.

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

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

2.

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

ICCE

The lens is removed in toto

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

ICCE

Lens removal

Nucleus removed out

of the capsule and
cortex sucked out

Lens removed as
single piece within its
capsule

Posterior capsule &

zonules

Intact

Removed

Incision

Smaller (8 mm)

Larger (10 mm)

Peripheral iridectomy

Not performed

Required to avoid
pupillary block glaucoma

Sophisticated
equipment

Required

Not required

Time taken

More

Less

ECCE vs. ICCE

ECCE

ICCE

IOL Implantation

Posterior chamber

Anterior chamber

Expertise required

Difficult technique

Easier to learn

Cost

More

Less

Complications which Posterior Capsular

are increased
Opacification (PCO)

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

Vitreous prolapse &

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

ECCE vs. ICCE

ECCE

ICCE

Complications
which are
decreased

All the complications PCO

mentioned for ICCE

Indications

A routine procedure
for all forms of
cataract (except
where contraindicated

1.
2.
3.
4.
5.

Contraindications

1.
2.

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

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

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
Eye is cleaned routinely
The eye is examined :

1.
2.

3.

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

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