Seminar 3 - Cataract
Transcript of Seminar 3 - Cataract
8/8/2019 Seminar 3 - Cataract
http://slidepdf.com/reader/full/seminar-3-cataract 1/56
YIP
FARADIANAROIHAN
ARIF
TASNIM
29th March 2010
1
8/8/2019 Seminar 3 - Cataract
http://slidepdf.com/reader/full/seminar-3-cataract 2/56
Mr AS68 yrs old
C/o: blurring of vision
What to ask next?????
What is your differential diagnosis???
2
8/8/2019 Seminar 3 - Cataract
http://slidepdf.com/reader/full/seminar-3-cataract 3/56
Glaucoma
Cataract
Diabetic/hypertensive retinopathy
Mononeuritic multiplex CRVO (central retina vein occlusion)/CRAO
Corneal injury
Retinal detachment
Uveitis
TIA
Trauma
3
8/8/2019 Seminar 3 - Cataract
http://slidepdf.com/reader/full/seminar-3-cataract 4/56
•Noticed blurring of vision since September last year
•Blurring of both vision simultaneously
•Slowly started as blurring of edges of objects but has now
his vision is limited to just shadows (he sees things as mere
shadows)•Also complains of seeing rainbow flashes upon sudden
head movements and getting up after sitting for a long time
•No pain, no headache
History of presenting illness
4
8/8/2019 Seminar 3 - Cataract
http://slidepdf.com/reader/full/seminar-3-cataract 5/56
Past Med
-Newly diagnosed hypertension
Drug HX/ Occular Hx
-Tried „Permata Hijrah‟ for his blurring of vision for
two months but stopped because it did not improve
his vision-Has not had any eye ops
Family hx
-Unremarkable
5
8/8/2019 Seminar 3 - Cataract
http://slidepdf.com/reader/full/seminar-3-cataract 6/56
Refractive error
Cataract
Glaucoma (primary open angle)
Retinal disease diabetic retinopathy
Age related macular degeneration
Tumours and inflammation: intraocular
tumor, tumor of optic nerve
6
8/8/2019 Seminar 3 - Cataract
http://slidepdf.com/reader/full/seminar-3-cataract 7/56
All normal
Right eye post operative
Red eye reflex not symmetrical both sideReduced red reflex on left eye
Reduced diameter of red reflex on right eye
7
8/8/2019 Seminar 3 - Cataract
http://slidepdf.com/reader/full/seminar-3-cataract 8/568
8/8/2019 Seminar 3 - Cataract
http://slidepdf.com/reader/full/seminar-3-cataract 9/56
Congenital cataract
Senile cataractComplicated cataract (Diabetic cataract &
parathyroid tetany)
Cataract due to radiant / heat energy
Traumatic cataract
9
8/8/2019 Seminar 3 - Cataract
http://slidepdf.com/reader/full/seminar-3-cataract 10/56
Pathogenesis
Heredity (genetic mutation)
Maternal (malnutrition & infection)
Foetal ( oxygenation), metabolic disorder(galactosaemia), trisomy 21
Idiopathic
10
8/8/2019 Seminar 3 - Cataract
http://slidepdf.com/reader/full/seminar-3-cataract 11/56
• Symptoms
– Visual impairment
– Nystagmus
• Signs
– White reflex (leucocoria)
– Ophthalmoscopic examination (black opacity
against red background)
– Systemic congenital heart disease
11
8/8/2019 Seminar 3 - Cataract
http://slidepdf.com/reader/full/seminar-3-cataract 12/5612
8/8/2019 Seminar 3 - Cataract
http://slidepdf.com/reader/full/seminar-3-cataract 13/56
Pathogenesis
History of “anticipation”
Sunlight exposure
Old age (“age related cataract”) Diabetes
Atopic dermatitis
Myotonic dystrophy
13
8/8/2019 Seminar 3 - Cataract
http://slidepdf.com/reader/full/seminar-3-cataract 14/56
• Degeneration & opacification of lens
(hydration, denaturation & coagulation of
proteins)
•
Formation of aberrant lens• Fibrous metaplasia of lens fibres
• Abnormal product of metabolism, drugs or
metals
• Slow sclerosis of the central nucleus fibres(senile nuclear cataract) – brown pigment
14
8/8/2019 Seminar 3 - Cataract
http://slidepdf.com/reader/full/seminar-3-cataract 15/56
Symptoms
Frequent changes of glasses Diminished visual acuity
Glare
Coloured halos
Monocular diplopia / polyopia “myopic shift” & Colour shift (senile nuclear
cataract)
15
8/8/2019 Seminar 3 - Cataract
http://slidepdf.com/reader/full/seminar-3-cataract 16/56
Signs
Slit lamp examination (yellow layer in theposterior cortex, lost of fundus details)
Ophthalmoscopic examination (dark shadow)
Blackened pupillary reflex (senile nuclear
cataract)
16
8/8/2019 Seminar 3 - Cataract
http://slidepdf.com/reader/full/seminar-3-cataract 17/5617
8/8/2019 Seminar 3 - Cataract
http://slidepdf.com/reader/full/seminar-3-cataract 18/56
Pathogenesis
Disturbance of nutrients in the lens (inflammatory
/ degenerative disease)
Diabetic cataract
Excess glucose sorbitol (sugar alcohol) osmotic
imbalance at lens
Parathyroid tetany
Deficiency of parathyroid hormone
18
8/8/2019 Seminar 3 - Cataract
http://slidepdf.com/reader/full/seminar-3-cataract 19/56
• Symptoms
– Impaired vision
• Signs
– Anterior segment (opacification of cortex)
– Posterior segment ( posterior cortical cataract)
– Ophthlamoscopic examination (vaguely defined,
dark area seen in the posterior cortex)
– Slit lamp examination (irregular borders of
opacity, breadcrumb‟s appearance, rainbow
display, snow flakes, crystalline flakes)
19
8/8/2019 Seminar 3 - Cataract
http://slidepdf.com/reader/full/seminar-3-cataract 20/56
8/8/2019 Seminar 3 - Cataract
http://slidepdf.com/reader/full/seminar-3-cataract 21/56
Pathogenesis
Heat (infrared) Irradiation (X-ray)
Electric (passage of powerful current)
Ultrasonic radiation (heat & concussion)
21
8/8/2019 Seminar 3 - Cataract
http://slidepdf.com/reader/full/seminar-3-cataract 22/56
Pathogenesis
Concussion
Perforating corneal injuries
• Signs
- Rosette-shaped‟ cataract (posterior cortex / anterior
cortex)
22
8/8/2019 Seminar 3 - Cataract
http://slidepdf.com/reader/full/seminar-3-cataract 23/56
23
8/8/2019 Seminar 3 - Cataract
http://slidepdf.com/reader/full/seminar-3-cataract 24/56
Early
Glare
Frequent changes of glasses
Black spot
Uniocular diplopia / polyopia
Coloured halo
Colour value changes
Late
Impaired central vision
24
8/8/2019 Seminar 3 - Cataract
http://slidepdf.com/reader/full/seminar-3-cataract 25/56
25
8/8/2019 Seminar 3 - Cataract
http://slidepdf.com/reader/full/seminar-3-cataract 26/56
Cataracts may be classified according to
1. age of onset
2. morphology
3. grade
4. maturity of cataract
26
8/8/2019 Seminar 3 - Cataract
http://slidepdf.com/reader/full/seminar-3-cataract 27/56
CONGENITAL ACQUIRED
Chromosomal
Down, Edward, Turner
syndromes
Early embryonic [transplacental]
damage
Rubella
Mumps
Hepatitis
Toxoplasmosis
Age related cataract
Most common cause
Secondary cataract
Cataract form after eye surgery for other eye
problem eg. Glaucoma
cataract in patient with other health problem
such as diabetes
cataract due to use of steroids
Traumatic cataract
Cataract forms after trauma or exposed to
alkaline chemicals may form immediately or years after trauma
Radiation cataract
over exposure of ultraviolet sunlight or other
radiation
27
8/8/2019 Seminar 3 - Cataract
http://slidepdf.com/reader/full/seminar-3-cataract 28/56
28
Congenital Presenile Senile
-inherited inautosomal dominant
fashion [1/3]
-birth trauma or
maternal infection
during pregnancy
-galactosaemia
[common metabolic
cause of congenital or
infantile cataract]
Systemic diseases-diabetes mellitus
-corticosteroid therapy
-atopy
-galactosaemia
-hypocalcaemia
-dystrophia myotonica
Ocular factors
-blunt or perforating trauma
-high myopia
-recurrent uveitis
-topical steroid use-ionising irradiation
-excessive ultraviolet light
exposure
-infrared irradiation
- age-related
8/8/2019 Seminar 3 - Cataract
http://slidepdf.com/reader/full/seminar-3-cataract 29/56
29
8/8/2019 Seminar 3 - Cataract
http://slidepdf.com/reader/full/seminar-3-cataract 30/56
Classification of Cataract Morphology
Fibre-based Sutural Congenital sutural
Concussion
Storage disorder
Deposition
Non-sutural LamellarNuclear
Cortical
Non-fibre based Subscapular
LamellarCoronary
Blue dot
Christmas tree
30
Type Picture Cause Properties
8/8/2019 Seminar 3 - Cataract
http://slidepdf.com/reader/full/seminar-3-cataract 31/56
Type Picture Cause Properties
Sutural Congenital non-progressive
Concussion often flower-shaped [lens fibre
separation and fluid entry]; anterior andposterior
Storage
disorder
usually starts posteriorly
Deposition usually starts anteriorly
Nuclear Congenital non-progressive, limited to embryonic
nucleus or more extensive
Age-related increased white scatter (light scattering)
and brunescence (brown chromophores)
Lamellar Congenital /
infantile
Localized to a particular lamella (layer)
with or without extensions
- inherited, rubella, diabetes,
hypocalcaemia
Y
31
8/8/2019 Seminar 3 - Cataract
http://slidepdf.com/reader/full/seminar-3-cataract 32/56
Type Picture Cause Properties
Coronary Sporadic Round opacities in the deep cortex
forming a “crown” -occasionally inherited
Cortical Age-related Spoke-like opacities in the superficial
cortex, spreading along fibres at an
unpredictable rate
Subcapsular Age-related/ presenile
granular material just beneath capsule,posterior (more common and visually
significant) or anterior
- diabetes, corticosteroids, uveitis,
radiation
32
8/8/2019 Seminar 3 - Cataract
http://slidepdf.com/reader/full/seminar-3-cataract 33/56
Type Picture Cause Properties
Polar Congenital anteriorwith abnormalities of capsule ± anterior
segment
posterior
with abnormalities of capsule ± posterior
segment
Diffuse Congenital focal blue dot opacities are common and
visually significant
Age-related christmas tree cataracts are highly
reflective crystalline opacities
. . . . .
. . . . .
. . . . .
. . . . .. . .
33
8/8/2019 Seminar 3 - Cataract
http://slidepdf.com/reader/full/seminar-3-cataract 34/56
Grading system is designed to quantify the degree of opacification.
These vary from simple assessment by direct ophtalmoscopy
to the Lens Opacities Classification System II [LOSCII], where
slit lamp examination is compared to a standard set of photographs [separate set for nuclear, cortical, and posterior
subcapsular].
It involves grading 4 features of the cataract:
- nuclear color (NC)
- nuclear opalescence (N)- cortical cataract (C)
- posterior subcapsular (P)
34
8/8/2019 Seminar 3 - Cataract
http://slidepdf.com/reader/full/seminar-3-cataract 35/56
The clinical appearance ofA – cortical cataractB – nuclear cataractC – posterior subcapsular
cataract
The spoke opacities aresilhouetted against the red reflexin A.
A B
C
35
8/8/2019 Seminar 3 - Cataract
http://slidepdf.com/reader/full/seminar-3-cataract 36/56
Maturity Description
Immature opacification is incomplete
Mature opacification is total
Hypermature lysis of cortex results in shrinkage,
seen clinically as wrinkling of the
capsule
Morgagnian liquefaction of cortex allows the harder
nucleus to drop inferiorly [but still
within the capsule]
36
8/8/2019 Seminar 3 - Cataract
http://slidepdf.com/reader/full/seminar-3-cataract 37/56
8/8/2019 Seminar 3 - Cataract
http://slidepdf.com/reader/full/seminar-3-cataract 38/56
38
8/8/2019 Seminar 3 - Cataract
http://slidepdf.com/reader/full/seminar-3-cataract 39/56
• improve visual function depends on degree of impairment and visual needs of individual,
most patients with a vision of 6/18 or worse
in both eyes because of lens opacities
benefit from cataract surgery• diabetic retinopathy
• cataract prevents adequate retinal
examination or laser treatment
• lens induced glaucoma
• uveitis
39
8/8/2019 Seminar 3 - Cataract
http://slidepdf.com/reader/full/seminar-3-cataract 40/56
• Choice of anaesthesia
• Incision: via cornea or anterior sclera
• Technique of cataract removal
• Correction of aphakia: by intraocular lens
implantation, contact lens or aphakicspectacles
• There are 2 types:
–
Phacoemulsification – ECCE (Extracapsular cataract extraction)
– Intracapsular method
40
8/8/2019 Seminar 3 - Cataract
http://slidepdf.com/reader/full/seminar-3-cataract 41/56
Phacoemulsification methodA very small tunnel incision (about 3mm
wide) is made in the eye and a circular hole
(diameter about 5 mm) is made in the
anterior capsule of the lens.
41
8/8/2019 Seminar 3 - Cataract
http://slidepdf.com/reader/full/seminar-3-cataract 42/56
A fine ultrasonic probe is then used to liquefy
the hard lens nucleus (phacoemulsification)
through this hole.
42
8/8/2019 Seminar 3 - Cataract
http://slidepdf.com/reader/full/seminar-3-cataract 43/56
• A folded replacement lens is then inserted into the
empty lens capsular bag and allowed to unfold.
• A high viscosity gel substance (viscoelastic) often is
used to protect the delicate endothelial cells thatline the posterior surface of the cornea during the
operation.
• This is then washed out at the end of the
procedure.
43
8/8/2019 Seminar 3 - Cataract
http://slidepdf.com/reader/full/seminar-3-cataract 44/56
Sutures often are not required as the tunnel
incision is self sealing.
These advances in technique have considerably
improved the speed of recovery and visual
rehabilitation after cataract surgery.
44
8/8/2019 Seminar 3 - Cataract
http://slidepdf.com/reader/full/seminar-3-cataract 45/56
Break Up and Remove the Cataract Lens
45
8/8/2019 Seminar 3 - Cataract
http://slidepdf.com/reader/full/seminar-3-cataract 46/56
Extracapuslar cataract extraction (ECCE)method
• conventional method may be indicated for patients
with very hard cataracts or other situations inwhich phacoemulsification is problematic
• An incision is made in the eye (about 10 mm in
length) and the anterior capsule is cut open with
the tip of a sharp needle.
• The large nucleus is then expressed whole and the
remaining soft lens fibres aspirated
•
A non-folding lens is then inserted into the emptylens capsular bag and the incision closed with fine
sutures.
46
8/8/2019 Seminar 3 - Cataract
http://slidepdf.com/reader/full/seminar-3-cataract 47/56
Intracapsular method
• In this method, the entire lens isremoved within its capsule, usuallywith a cryoprobe, after the suspensory
ligaments of the lens have beendissolved by the enzyme chymotrypsin.
• As there is no remaining lens capsule,the vitreous gel in the eye can moveforward and block the flow of aqueousthrough the pupil.
• A hole cut in the iris (iridectomy)allows the aqueous to bypass the pupil.This method is now usually used only inspecial situations.
• The procedure has a relatively high
rate of complications due to the largeincision required and pressure placedon the vitreous body
47
8/8/2019 Seminar 3 - Cataract
http://slidepdf.com/reader/full/seminar-3-cataract 48/56
80% achieve 6/12 vision or better following
surgery
Failure to improve usually due to pre-existing
disease
48
8/8/2019 Seminar 3 - Cataract
http://slidepdf.com/reader/full/seminar-3-cataract 49/56
49
8/8/2019 Seminar 3 - Cataract
http://slidepdf.com/reader/full/seminar-3-cataract 50/56
Corneal edema Elevated IOP
• water content of the corneaincreases causing thecornea to swell and losetransparency.
• Sx:Poor vision and haloes("star bursts" around lights)
• Tx: usually self limiting andimproves with anti-inflamattory eye drops
occur when the visco-
elastic is left in the eye,or is not adequately
aspirated prior to wound
closure.
The visco-elastic particleswould block the
trabecular meshwork and
raise the IOP.
Tx: control with topicaltreatment
50
8/8/2019 Seminar 3 - Cataract
http://slidepdf.com/reader/full/seminar-3-cataract 51/56
Wound leak Iris prolapse
• are complication due topoor wound constructionas well as poor surgicaltechnique in closure
(loose sutures.)• If severe and persistent ,
need to return to theaterand suture wound closed
Iris tissue may prolapsethrough the surgicalwound. This is usually
due to poor surgicalclosure.
Assess vitality of extruded iris and suturewound closed
51
8/8/2019 Seminar 3 - Cataract
http://slidepdf.com/reader/full/seminar-3-cataract 52/56
8/8/2019 Seminar 3 - Cataract
http://slidepdf.com/reader/full/seminar-3-cataract 53/56
Late-complication
1. Posteriorcapsule
opacification
2. Cytoidmacularedema
3. Cornealdecompesation
4. Retinaldetachment
53
8/8/2019 Seminar 3 - Cataract
http://slidepdf.com/reader/full/seminar-3-cataract 54/56
Posterior capsule ossification Cystoid macular oedema
• “ secondary cataract “
• clouding of the 'posteriorcapsule', the thin membranethat surrounded thecataractous lens prior to its
removal.• Sx: reduced vission, monocular
diplopia
• Tx: YAG posterior capsulotomy
• painless condition in which
swelling or thickening occursof the central retina (macula)
• Sx: usually associated withblurred or distorted vision.
• Tx: anti-inflammatory eyedrops or injections of steroidsto the back of the eye
54
8/8/2019 Seminar 3 - Cataract
http://slidepdf.com/reader/full/seminar-3-cataract 55/56
Retinal detachment
• condition that occurs whenfluid seeps through a tear inthe retina.
• The seepage causes theretina to detach from theback of the eye.
•
Occurs mainly in eyes withposterior capsular rupture,vitreous loss, and eyes withperipheral retinaldegenerations like latticedegeneration.
• Sx: flashes of light or darkspots In the field of vision
• Tx: surgical
55
8/8/2019 Seminar 3 - Cataract
http://slidepdf.com/reader/full/seminar-3-cataract 56/56
Steroid drops (to reduce inflammation)
Antibiotic drops (to prevent infection)
Non-pharmacology advice:
- to avoid very strenuous exertion and oculartrauma ( eg: heavy lifting )
- wear dark glasses
- prevent your eyes from coming into contact
with water and soap