CATARACT

Sagun N. Joshi, MD
Asst. Professor
 Embryo Genesis & Basic Anatomy
Develops from surface ectoderm
Critical period 1st Trimester eg. Rubella
Lens fiber form throughout life
Capsule, epithelium, cortex, nucleus
Suspended by zonules from ciliary body.
 What is a cataract?
Definition
Opacificationof human crystaline lens - white frothy
appearance of rapids (cataract).
Classification:
Congenital (Developmental)
Acquired
 Symptoms
Progressive visual loss
Glare
Reduced color perception
Based on the location and density
 Critical Sign
Opacification of the normally clear lens seen
through the pupil
Differential diagnosis of leukocoria
 Other Signs
Indistincton funduscopic examination
Red reflex may be dim
No afferent pupillary defect
 Types of Cataracts
Nuclear
Posterior sub-capsular
Cortical
Note:
A mature cataract - obscures the view of the posterior
lens and posterior segment of eye
 Etiology
Age related
Trauma
Toxic (Steroids, anticholinesterases, antipsychotics, anti-
arhythmic
Intraocular inflammation (e.g., uveitis)
Radiation eg. Ionizing, infrared, ultraviolet
Intraocular tumor (malignant melanoma)
Degenerative ocular disease (e.g., retinitis pigmentosa)
 Etiology
Systemic disease
Diabetes snow flake
Hypocalcemia iridescent, white, small and cortical
Wilsons disease: sunflower cataract, corneal Kayser-
Fleischer ring
Myotonic dystrophy: Christmas-tree cataract behind
the anterior capsule
Others (eg., Downs syndrome, atopic dermatitis)
 Etiology
Chemical injury alkali
Nutritional disease riboflavin, Vit. C, E and
carotene
 Work-up
Determine the etiology
cataract is responsible for the decreased vision
Whether surgical removal would improve vision

History:
Medications? Systemic diseases? Trauma? Ocular
disease or poor vision in youth or young adulthood
(before the cataract)?
 Work-up
Visual acuity
Complete ocular examination
Pupillary reflex
Fundus examination
Macular function test
IOP measurement
Other ocular pathology
Syringing

Contd
 Work-up
B-scan ultrasound
The potential acuity meter or laser interferometry
When surgery is planned, keratometry reading
A-scan ultrasound measurement of axial length
Power of the desired intraocular lens
Corneal endothelium
 Systemic Evaluation
Cardiovascular
Respiratory
To prepare for surgery
Genitourinary
Others
 Investigations
Blood pressure
Blood sugar
Complete blood picture
Urine examination
Conjunctival swab for C/S
 Treatment
Performed for the following reasons:
Improve visual function
As surgical therapy of ocular disease
To facilitate management of ocular disease

Correct any refractive error if declines surgery

A trial of mydriasis (scopolamine 0.25% daily) if
the patient opts not to have the cataract removed
 Congenital Cataract
Presentation
Fundus reflex (leukocoria), nystagmus, visually
inattentive
Presence of squint
 Congenital Cataract
Critical sign
Opacity of the lens
Other signs
Strabismus, nystagmus, blunted red reflex
Monocular cataract, eye is often smaller
No afferent pupillary defect
 Congenital Cataract
Types of Cataracts
Polar (anterior or posterior)
Zonular (lamellar) in a concentric zone around the
nucleus and bilateral
Lenticular (lens nucleus)
Sutural (Y-shaped inverted Y-shaped
Capsular
 Congenital Cataract
Etiology
Idiopathic
Galactosemia (galactokinase deficiency). Galactose-1-
phosphate uridyl transferase, mental retardation,
symptomatic cirrhosis along with cataracts, oil-droplet
opacity
PHPV (unilateral), slightly smaller, plaque of
fibrovascular tissue behind the lens, elongated ciliary
process, angle-closure glaucoma
 Congenital Cataract
Etiology
Rubella (salt-and-pepper chorioretinitis, iritis, smaller
involved eye, glaucoma. Hearing defects, heart abnormalities,
dental anomalies
Lowes syndrome (oculocerebrorenal syndrome), Opaque lens,
congenital glaucoma, renal disease, mental retardation. X-linked
recessive. Patients mothers small white opacities within their
lens cortices
Others Hereditary, chromosomal disorders, systemic
syndromes, intrauterine infections (TORCH), trauma, drugs,
metabolic abnormalities.
 Congenital Cataract
Differential diagnosis
Leukicoria
 Congenital Cataract
Work-up
History: maternal illness, drug ingestion. Systemic or ocular
disease, radiation, family history
Visual assessment of each eye, using illiterate Es pictures, small
toys light
Ocular examination: determine the visual significance of the
cataract, evaluate size and location, whether the retina can be
seen with a direct ophthalmoscope, portable slit lamp,
retinoscopic reflex check for signs of associated glaucoma- large
corneal diameter, corneal edema, breaks in Descemets
membrane; retina for pathology
 Congenital Cataract
Work-up:
Note
Cycloplegic refraction
B-Scan ultrasonography
Red blood cell (RBC) galactokinase activity, RBC
galactose-1-phosphate-uridyltransferase activity
 Congenital Cataract
Work-up:
Other tests as suggested by the systemic or ocular examination:
Blood: calcium phosphorus levels (hypocalcemia,
hypoparathyroidism), glucose levels (hypoglycemia, diabetes
mellitus)
Urine: sodium nitroprusside (homocystinuria), blood and
protein quantitation (Alports syndrome), amino acid content
(Lowes syndrome), copper (Wilsons disease)
Antibody titers (rubella, other infectious agents, TORCH)
Note: the chance that one of these condition is present in a healthy
child is small.
 Congenital Cataract
Treatment
Referral to a pediatrician to correct any underlying disorder
Treat associated ocular diseases (glaucoma)
Amblyopia in children younger than 9-11 years of age
Cataract extraction, usually within days to weeks of discovery
under following circumstances:
Vision is obstructed, the eyes visual development is at risk
The lens is responsible for intraocular disease
Cataract progression threatens the health of the eye

Note: Unlike adult cataracts, significant delay in treating

congenital cataracts may lead to irreversible amblyopia.
 Congenital Cataract
Treatment
A mydriatic agent (phenylephrine 2.5% tid or
homatropine 2% tid) temporizing measure, allowing
peripheral light rays, pass around the lens opacity
 Congenital Cataract
Follow-up
Infants that do not undergo surgery are followed
closely for cataract progression and amblyopia
Note:
Children with rubella must be isolated from pregnant
women
 Why Should You Know
About Cataract ?
Commonest cause of blindness
It is a curable blindness
Take part in preoperative evaluation and post
operative follow up
Indicator of underlying diseases
Overcome barrier to surgery
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