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OPHTHA - 1.07a - Lens and Cataract-2 PDF
OPHTHA - 1.07a - Lens and Cataract-2 PDF
Composed of:
1. Capsule (D)
2. Zonular fibers
EMBRYOLOGY
From 3B 2017
Derived from the surface ectroderm arising from the lens plate (2-wk)
Thickening invaginates to form lens vesicle, becomes separated from
the original surface ectoderm
o Cells of anterior wall become the subcapsular epithelium (single
layer)
o Cells of posterior wall become the elongated primary lens fiber
(embryonic nucleus) (no epithelium)
Posterior layer of the lens vesicle stop dividing and begins to elongate
filling in the cavity of the vesicle to constitute the central region known as
“central dark interval”
Day Development
22 Optic Groove
25 Optic Vesicles
26 Optic Cup
27 Lens Placode
29 Lens Pit
30 Lens Vesicle
40 Primary lens fiber obliterate lumen
7 weeks Secondary lens fiber
8 weeks Sutures recognizable
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OPHTHALMOLOGY
Lens
CONGENITAL APHAKIA
absence of the lens of the eye
o Primary – lens plate fails to form
o Secondary – developing lens spontaneous absorbed
II. PATHOLOGY
MICROSPHEROPHAKIA
CONGENITAL DISEASES lens is smaller and spherical in shape
o Seen as part of Weil-Marchesani and can cause pupillary block
LENTICONUS
Cone-shaped deformation of anterior or posterior lens surfaces
o Anterior - bilateral, associated with Alport syndrome
o Posterior - unilateral, most common
DEVELOPMENTAL CATARACT
ECTOPIA LENTIS
Subluxated lens – partially displaced
Displaced lens – completely displaced
Trauma is the most common cause
LENS COLOBOMA
Indentation or defect in the lens equator
Failure of the embryonic fissure to close
o Primary
o Secondary - lack of zonular development
Accompanying conditions:
o Lenticular astigmatism
o Coloboma of the iris and ciliary body
Management: corrective lens
MARFAN’S SYNDROME
Tall, chest wall deformities, cardiac abnormalities
Superotemporal subluxation
dislocation : superiorly
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OPHTHALMOLOGY
Lens
HOMOCYSTINURIA DRUG-INDUCED LENS CHANGE
Inborn error in Methionine metabolism Corticosteroids
Inferonasally subluxated Phenothiazines
dislocation : inferiorly Miotics
Amiodarone
AGE RELATED CATARACTS Statins
Increase in weight and thickness
Decrease in accommodation TRAUMA
Decrease glutathione and potassium Contusion
Increase sodium and calcium Perforating and Penetrating injury
Radiation
NUCLEAR SCLEROSIS Chemical injuries
Myopic refractive shift which patients notice as an improvement in their Metallosis
near vision Electrical injury
Decrease in distance vision, difficulty with night driving, monocular
diplopia and loss of color discrimination ability
METABOLIC CATARACT
DIABETES MELLITUS
Snow-flake
Abrupt, bilateral, widespread subcapsular changes
Young with uncontrolled diabetes mellitus
CORTICAL CATARACT
Minimal symptoms of decrease in visual acuity
Glare and Night vision difficulties and monocular diplopia
Early stage demonstrates water clefts and vacuoles
In a more advanced stage, spoke-like or wedge-shaped peripheral
opacities
GALACTOSEMIA
Oil droplet appearance
AR, 75% bilateral
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OPHTHALMOLOGY
Lens
PSEUDOEXFOLIATION SYNDROME Slit-Lamp o Filtering bleb
Basement membrane-like fibrinogranular white material Examination o Chemical Injury
Expected findings: o Corneal guttae
o Poorly dilating pupil o Anterior chamber depth
o Capsular fragility o Iridodonesis
o Zonular weakness o Exfoliations
o Open angle glaucoma o Phacodonesis
Fundus o Macular degeneration
Evaluation o Diabetic retinopathy
o Macular holes
o Optic nerve pallor
Special Tests o Potential Acuity Estimation
o Test of Macular Function
Maddox Rod
Photostress recovery time
Blue light entoptoscopy
Purkinje’s entoptic phenomenon
Electroretinogram
Visual Evoked Response
LENS-INDUCED GLAUCOMA
Phacoanaphylactic glaucoma PREOPERATIVE MEASUREMENTS
Phacolytic glaucoma
Refraction Desired post-op refractions
Lens particle glaucoma
Phacomorphic glaucoma Biometry (A-Scan) Intra-Ocular Lens (IOL) power
Corneal topography Map the surface curvature of the cornea
Reduce post-op astigmatism
Epidemiology
Corneal pachymetry Measure corneal thickness
Leading cause of blindness and visual impairment throughout the world
17 million (47.8%) of the 37 million blind individuals (2002 WHO) Specular microscopy Prevent Pseudophakic bullous
Projected to reach 40 million in 2020 keratopathy (PBK)
Endothelial cell count: determine the
number of cells per square millimeter of
III. PREOPERATIVE EVALUATION corneal endothelium
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OPHTHALMOLOGY
Lens
Rise time – rate at which vacuum builds once aspiration port is
MODERN EXTRACAPSULAR CATARACT EXTRACTION occluded. Directly related to aspiration flow rate
Surge – occurs after occlusion with high vacuum is broken. Fluid
Required the complete removal of cortical lens from AC enters phaco tip. AC depth may suddenly shallow.
Development of instrumentation Vacuum – suction force exerted on fluid in aspiration line of the eye.
o System of irrigation and aspiration The “holding force” for the material occluding phaco tip
o Balanced salt solution Venting – process by which vacuum is equalized to atmospheric
o Cystitome (23-27 needles) levels to minimize surge
Irrigation – maintains anterior chamber depth and cools phaco
Advantages over ICCE Disadvantage
probe
Less trauma to Cannot be used for Aspiration – the withdrawal of fluid and les material from the eye
endothelium cataracts with weak
Less astigmatism zonular support
More secure wound V. COMPLICATIONS
Less vitreous loss
Corneal edema
Better IOL placement
PC Rent and Vitreous Loss
Reduced Elevated IOPs
CME/RD/Corneal edema Induced Astigmatism
Incision Leak
PHACOEMULSIFICATION Retained Lens material
Cystoid Macular Edema
Developed in 1967 by Charles Kelman Endophthalmitis
Also a form of ECCE DM Tear
Ultrasonic emulsification of the lens Corneal Melting
Resulted in lower incidence of wound related complications, faster Epithelial Downgrowth
healing and more rapid visual rehabilitation Toxic Solutions
Problem Conjunctival Ballooning
o Size of IOL Shallow or Flat anterior chamber
o Proximity of the needle to the epithelium IFIS (Intraoperative Floppy Iris Syndrome)
Foldable IOLs Capsular opacity and contraction
o Thomas Mazzoco Hemorrhage
o In 1980, implanted the first foldable IOL made of silicone Malignant glaucoma
Ocular Viscoelastic Device (OVD) Chronic Uveitis
IOL related
Cohesive Dispersive Retinal Detachment
Iridodialysis/Cyclodialysis
Adhere to themselves Little tendency for self-
adherence CORNEAL EDEMA
High molecular weight Low molecular weight Causes:
High surface tension Low surface tension (good o Mechanical trauma
coating ability) o Prolonged phaco time
Easily aspirated Not easily aspirated o Inflammation
Maintain AC during Tamponade vitreous in capsular o IOP elevation
capsulorrhexis rent
Healon Viscoat
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OPHTHALMOLOGY
Lens
Irvinne Gass Syndrome Acute
More common in ICLE (Intra-capsular lens extraction) o <6 weeks (S. epidermidis, S. aureus, Streptococcus sp., gram
Peak incidence occurs 6-10 weeks post-op negative organisms)
Management: Topical NSAID Chronic
o >6 weeks (Propionibacterium acnes, coagulase negative,
Staphyloccocus, Fungi)
Differential diagnosis: Toxic Anterior Segment Syndrome
o Diagnosis of exclusion
o Onset is within 24 hours
ENDOPHTHALMITIS
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