JUVENILE CATARACTSubheading goes here

OUTLINEINTRODUCTIONLITERATURE REVIEWCASE REPORTDISCUSSIONCONCLUSION

INTRODUCTIONCataract is opacity of the lens which occur because of lens hidration, lens protein denaturation, or both. Cataract remain the leading cause of blindness

LITERATURE REVIEW

Anatomy Shape a biconvex lens and capable of changing shape colorlesstransparentavascularsize 4mm thick and 9mm in diameter position behind the iris and the pupilIn front of the vitreoussuspended by suspensary ligament

Lens

Anatomystructurecapsule:an elastic transparent basement membrane admit water and electrolytes pass through the lens fibers are enveloped in it epithelium : this single cell layer located anteriorly and extending to the equator fibers:continuously produced by epthelium the nucleus:old fibers ,harder at the centre the cortex: new fibers,softer, at the periphery With age,the lens gradually becomes larger, harder and less elastic

Physiologycompositionwater -64% The water content of the lens decreases with age. protein -35% the highest protein content in any body tissue soluble proteininsoluble protein:With age, the percent of it increases

1%- A trace of minerals are present (Potassium, Ascorbic acid and Glutathione) The lens has complex metabolic process. It`s nourishment comes from aqueous humor.When there are changes of aqueous or capsule or metabolism,the transparent lens becomes opaque.

Physiology Functionone of important refractive mediasfocus light rays upon the retinafilter a part of ultraviolet rays ,it is beneficial to the retina

CataractCataract transparent lens becomes opaque

CataractEpidemiologyCataract is a common ocular disease and one of the main causes of blindness.It is estimated that 30 to 45 million people in the world are blind,with cataract accounting for as much as 45% of this blindness.The prevalence of cataract varies widely with striking regional differences.It is more common in areas where people eyes expose to sunlight greatly.The prevalence rises with age and is higher in females.WHO defines blindness as best corrected visual acuity less than 20/400(0.05) or visual field restricted to 10or less.

EtiologyThe actual cause of cataracts is unknown juvenile and in cases that are found usually familial , so it is very important to know the patient's family history in detail.Cataracts can be found in the absence of eye or systemic disorders ( senile cataract , juvenile cataracts , cataract hereditary ) or congenital abnormalities of the eye .Cataracts are caused by various factors :PhysicalChemistryDisease predisposingGenetic and developmental disordersViral infections future growth of the fetusAge

Juvenile cataract is usually a complication of systemic or metabolic disease and other diseases such as1. Cataracts metabolic diabetic cataract and galaktosemik cataract hypocalcemic ( tetany ) cataract nutritional deficiency cataract aminoaciduria2. Muscle : myotonic dystrophy3. Traumatic Cataract4. Complicated Cataract Congenital and hereditary disorders ( microphthalmia , aniridia , and others ) degenerative cataract ( with myopia and vitreoretinal dystrophy ) cataract anoxic toxic ( systemic or topical corticosteroids , ergot , and others ) radiation cataract other congenital abnormalities , specific syndrome , accompanied by abnormalities of the skin, bones and chromosomes .

DiagnosisCataracts diagnosed by history, physical examination , and investigations are complete . Complaint that brought the patient comes , among others :Blur visionGlare visionSensitive toward contrastMiopisasi Diurnal Variation VisionDistortionHaloDiplopia monokuler Change of colour perceptionBlack spot

Several checks are needed to see signs of cataracts-visual acuity test-oblique illumination-Direct Opthalmoscope examination-Iris shadow test-Slit lamp examination

Management of cataractMedical managementNo medical treatment has been proven conclusively to delay,prevent,or reverse the development of cataractIndication for surgeryThe most common indication for cataract surgery is the patient`s desire for improved visual function. When visual acuity impairment interferes with the patient`s normal activities,the surgery of cataract well be performed.

Lens surgeryMicrosurgical techniques is employed for all cataract surgery.There are 3 principal types of lens extractionIntracapsular cataract extraction(ICCE)It involves complete removal of the lens within its capsule. through a larger (12mm length) superior limbal incisionThe larger incision may increase the risk of wound-related problems.

Lens surgeryExtracapsular cataract extraction(ECCE)It involves removal of the lens nucleus and cortex through an opening in the anterior capsule, leaving the posterior capsule in place.A superior limbal incision is made,it is shorter than ICCEThe anterior portion of the capsule is ruptured and removedThe nucleus is extracted The cortex is either irrigated or aspirated from the eye leaving the posterior capsule behind.

ECCE and IOL

IOL

Lens surgeryPhacoemulsification(Phaco)It is a relatively new technique.In recent years, it has become popular.It is a method of extracting the nucleus through a small incision(3mm).The nucleus is extracted by ultrasonic vibration.This technique results in a lower incidence of wound-related complications, faster healing, and more rapid visual rehabilitation than procedures requiring larger incisions.

Phaco

ICCE vs ECCE vs PhacoTYPE ADVANTAGES DISADVANTAGES ICCE Removes all lens Larger incision material, no posterior Cystoid macular edema capsular opacity Vitreous complications Endophthalmodonesis Increased incidence of RDECCE Smaller incision Posterior capsule opacity No vitreous complications Less endophthalmodonesis Less CME,RD Allows implants pcIOLPhaco Smallest incision Demanding technique Less induced astigmatism Complications while learning Fastest technique

CASE REPORT

PATIENT IDENTITYName: Si Luh Nyoman Puspa JuniartiMR: 15020708Age: 7 y.oSex: FemaleAddress: Br Kutaraga, Bongkasa, Abiansemal, BadungReligion: HinduDate of exam: 15th April 2015 at 11.00 AM

ANAMNESISCHIEF COMPLAINT: blurry vision

PRESENT ILLNESS:Patient refered from RSUD Badung to Eye Clinic Sanglah Hospital with chief complaint of blurry vision on her right eye since 3 months ago. The blurry vision appear insidiously, the right eye was getting blurred like seeing a cloud and it was getting worse since 3 days ago. The right eye became clouded and disturbed the vision. Patient denied history of recently trauma, redness on the eyes, watery eyes, pain, and fever.

HISTORY OF MEDICATION:Patient used Insto eye drop to relieve the blurry vision but it didnt improve.

PAST HISTORY:Patient complained redness on the eye about 1 year ago but it relieved by using Insto eye drop. Trauma and allergic history were denied. History f fever, cough, and sneezing were also denied.

FAMILY HISTORY:None of family members had the same symptoms as the patient did. Any history of systemic disease, asthma, drug or food allergy were also denied.

SOCIAL HISTORY :Patient was a Elementary School student. Patient read, write, and count well. Patient had some problems on study because of the blurry vision.

PHYSICAL EXAMINATIONPRESENT STATUS:Consciousness: compos mentisBlood pressure: 110/70 mmHgPulse rate: 80x/minuteRespiration: 20x/minuteTemperature axilla: 36o C

LOCAL STATUS:

Oculi Dextra (OD)Oculi Sinistra (OS)Visus 0,5/606/12 PH 6/7,5Supra ciliaMadarosisSikatriks Tidak adaTidak adaTidak adaTidak adaPalpebra superiorEdemaHiperemiEnteropionEkteropionBenjolanTidak adaTidak adaTidak adaTidak adaTidak adaTidak adaTidak adaTidak adaTidak adaTidak adaPalpebra inferiorEdemaHiperemiEnteropionEkteropionBenjolanTidak adaTidak adaTidak adaTidak adaTidak adaTidak adaTidak adaTidak adaTidak adaTidak adaPungtum lakrimalisPungsiBenjolanTidak dilakukanTidak adaTidak dilakukanTidak ada

Konjungtiva tarsal superiorHiperemiFolikelSikatriksBenjolanSekret Papil Tidak adaTidak adaTidak adaTidak adaTidak adaTidak adaTidak adaTidak adaTidak adaTidak adaTidak adaTidak adaKonjungtiva tarsal inferiorHiperemiFolikelSikatriksBenjolanTidak adaTidak adaTidak adaTidak adaTidak adaTidak adaTidak adaTidak adaKonjungtiva bulbiKemosisHiperemiKonjungtivaSilierPerdarahan subkonjungtivaPterigiumPingueculaeTidak adaTidak adaTidak ada

Tidak adaTidak adaTidak adaTidak adaTidak adaTidak ada

Tidak adaTidak adaTidak ada

SkleraWarnaPigmentasiTenangTidak adaTenangTidak adaKorneaOdemInfiltratUlkusSikatriksKeratik presifitatTidak adaTidak adaTidak adaTidak adaTidak adaTidak adaTidak adaTidak adaTidak adaTidak adaKamera okuli anteriorKejernihanKedalamanJernihDangkalJernihDalamIrisWarnaKolobomaSinekia anteriorSinekia posteriorCoklatTidak adaTidak adaAda, jam 5-6CoklatTidak adaTidak adaTidak adaPupil BentukRegularitasRefleks cahaya langsungRefleks cahaya konsensualOvalIregulerAdaAdaBulatRegulerAdaAda

LensaKejernihanDislokasi/subluksasiKeruhTidak adaJernihTidak ada

SUMMARYPatient female, 7 y.o, came with chief complaint of blurry vision on her right eye since 3 months ago and getting worse since 3 days ago. The right eye became clouded and disturbed the vision. Patient complained redness on the eye about 1 year ago but it relieved by using Insto eye drop. Trauma and other systemic disease were denied. Patient was a Elementary School student.

ODPemeriksaan MataOS0,5/60Visus6/12 PH 6/7,5Ortophoria KedudukanOrtophoriaPergerakanHiperemi (-), Edema (-), spasme (-)Palpebra Hiperemi (-), Edema (-), spasme (-)Hiperemi (-) jaringan fibrovaskular (-) KonjungtivaHiperemi (-), jaringan fibrovaskular (-) Jernih, Edema(-), infiltrate (-)KorneaJernih, Edema (-), infiltrate (-)DangkalCOA DalamIrregular, sinekia posterior jam 5-6IrisBulat, regularSentral, oval, reflek cahaya (+), 5 mmPupilSentral, round, reflek cahaya (+), 5 mmKeruhLensaJernihSulit dievaluasiVitreusJernihSulit dievaluasiFunduskopiRefleks (+), papil N II bulat, batas tegas, CD ratio 0,3; a/v 2/3; retina baik, reflex macula (-)11NCT16,5

ULTRASONOGRAPHY (15th April 2015)Conclusion: vitreous opacity

DIAGNOSISDIFFERENTIAL DIAGNOSIS:OD Juvenile CataractOD Uveitis PosteriorOD Vitreous Opacity

WORKING DIAGNOSIS:OD Juvenile Cataract

MANAGEMENT AND PROGNOSISSupporting examination:Laboratory: CBC, BSN, BTCTThorak photo

Therapy:OD Pro lens mass aspiration and IOL insertion with general anesthesia

Prognosis:Ad vitam: dubia ad bonamAd fungsionam: dubia ad bonamAd sanasionam: dubia ad bonam

DISCUSSION

CASETHEORYFrom anamnesis obtained complaint of blurry vision. On physical examination found lens opacity. Cataract diagnosis based on anamnesis, physical examination, and supporting examination. The subjective findings such as cloudy vision, lens discoloration, myopic shift, poor night vision, glare and halos, and double vision. The lens opacity could be partly or whole part, the iris shadow positive or negative, and any spot of red reflex on fundus reflex. Patient diagnosed as OD juvenile cataract. According to age, cataract divides into congenital, juvenile, and senile cataract. Juvenile cataract cause decreasing of vision gradually and lens opacity formed between age of 36 months 9 years when lens fibers are developed so that the consistency of lens is soft and milky-like. Juvenile cataract is usually the continuation of congenital cataract

CASETHEORYPatient had history of redness of the eye about 1 year ago. On physical examination found posterior sinechia on 5-6 oclock. We suspect this patient had uveitis. On eye ultrasonography found vitreous opacity. In case of unilateral cataract usually realted to local disease such as glaucoma, uveitis, local or systemic steroid use, high myopia, retina ablation, retinitis pigmentous, and intraocular tumor. Uveitis is a chronic inflammation on choroid, cilliary body, or iris. The symptoms such as pain, photophobia, and blurry vision. Usually the type of cataract in children is subcapsular. Posterior sinechia sometimes found in this patient with necrosis on capsule area and lens opacity. No history of familial cataract and other risk factors related to patient disease. Mostly cataract appears in late age as the consequences of exposure to environment. But in case of juvenile cataract, the related risk factor including hereditary, uv radiation, and increase of blood glucose.

CASETHEORYIn this patient planned to OD Pro lens mass aspiration and IOL insertion with general anesthesia. Some cataracts dont alter the vision and dont need surgical intervention. If the cataract disturbs the vision, we can consider surgical therapy to extract the lens. In this patient lens mass aspiration surgery with IOL fixation was performedPatient who are considered for IOL fixation must be at least 8 months to 11 years of age. Best results are observed in patients above 1 years old.

ConclusionHave been reported cases , female patients aged 7 years , complained of blurred right eye since 3 months ago and was advancing since 3 days ago with the growing white white round is in the eye and impair vision . The patient never complained red eyes about 1 year ago and improved with eye drops.From the results of a careful history and examination has been carried out , the working diagnosis OD obtained Cataract Juvenil . Patients will be given in the form of handling pro OD + IOL lens mass aspiration with general anesthesia . This patient prognosis ad vitam : bonam dubious ad , ad fungsionam : bonam dubious ad , ad sanationam : dubious ad bonam

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