Approach to a Case of Cataract

Sandeep Saxena MS, FRCS (Edin), FRCS (Glasg)

Professor, Ophthalmology, KGMU

Differential diagnosis Painless, progressive diminution of vision

• Cataract• Primary open angle glaucoma• Diabetic retinopathy• Corneal dystrophies and degenerations• Age related macular degeneration• Retinitis pigmentosa

Cataract

• Opacification of the human crystalline lens• Major cause of blindness worldwide

• Classification- -Etiological -Morphological

Morphological classification• Capsular cataract -Anterior -Posterior• Subcapsular cataract -Anterior -Posterior• Cortical cataract• Nuclear cataract• Polar cataract

Etiological classificationI. Congenital and Developmental cataractII. Acquired cataract• Senile cataract• Traumatic cataract (blunt, penetrating, radiation,

electric shock, glass blowers, infra-red)• Complicated cataract (uveitis-induced)• Metabolic cataract (Diabetes - snowflake,

Wilson’s disease-sunflower)• Drug induced cataract- corticosteroids, miotics• Cataract associated with syndromes

• Congenital or Developmental cataract - Occur due to maternal infection or malnutrition,

perinatal hypoxia – APH, or may be hereditary - Various morphological forms:

– Blue dot– Sutural– Fusiform or spindle shaped– Embryonal nuclear– Zonular– Coronary– Anterior or posterior polar

Senile cataract

• ‘Age-related cataract’• By the age of 70 years, over 90% of the

individuals develop senile cataract• Usually bilateral, but almost always

asymmetrical

Symptoms• Gradual, painless progressive loss of vision• Discomfort / glare in daylight – nuclear

cataract; better vision in daylight – cortical cataract

• Uniocular polyopia• Coloured halos• Black spots in front of eyes• ‘Second sight’

Signs

• Iris shadow• Depth of anterior chamber• Pupillary reflex• Visual acuity• Plain mirror examination under mydriasis

Iris shadow

A.C.Depth

Pupillary reflex

Visual acuity

Intumescent Present Shallow Greyish white FC to 6/18

Incipient Present Normal Greyish white FC to 6/18

Mature Absent Normal Pearly white HM to FC close to face

Hypermature Morgagnian

Absent Shallow Milky white HM +

Hypermature Calcified

Absent Normal or deep

Milkychalky

HM +

Patient workup

• Retinoscopy and best corrected visual acuity• Intraocular pressure• Slit lamp examination• Fundus evaluation – direct & indirect• Macular function tests• Ultrasonography• IOL power calculation

General investigations

• Blood pressure• Blood sugar• Complete haemogram• HIV, Hepatitis B & C• Causes of straining• Foci of infection• Systemic examination

Management

• An un-operated eye is more comfortable than an operated eye if visual diminution is mild.

• Early cataract : -Refraction and glasses -Dark glasses or photochromatic glasses for

nuclear cataract -Rule out other causes of visual diminution -If BCVA not to patient’s satisfaction, then

operate.

Surgical techniques

• Intracapsular cataract extraction (ICCE)• Extracapsular cataract extraction (ECCE)

– Conventional ECCE– Small Incision Cataract Surgery– Phacoemulsification– Lens aspiration in paediatric (soft) cataract

Complications of cataract surgery• Intraoperative

– Incision related complications– Posterior capsular rupture– Zonular dehisence– Vitreous loss– Nuclear drop– Posterior loss of lens fragments– Injury to the cornea, iris and lens– Expulsive choroidal haemorrhage

• Early post operative complications– Hyphaema– Iris prolapse– Striate keratopathy– Postoperative anterior uveitis– Bacterial endophthalmitis

• Late postoperative complications– Cystoid macular edema– Pseudophakic bullous keraopathy– Retinal detachment– Delayed postoperative endophthalmitis– After cataract

• Soemmering’s ring• Elschnig’s pearls

Intraocular Lenses Types• Anterior chamber IOL• Iris supported lens• Posterior chamber IOL

• Rigid• Foldable

Calculation of IOL power• SRK formula

Thank you