OPHTHALMOLOGY

Lens and Cataract

Stelson L. Sia, MD | 27 Sept 18
S1T7a
OUTLINE 3. Lens epithelium (C)
4. Cortex (E)
TOPIC OUTLINE III. Pre-Operative Evaluation 5. Nucleus (N)
IV. Cataract Surgery
I. Lens V. Complications
CAPSULE
a. Anatomy a. Corneal Edema
b. Embryology b. Cystoid Macular
 Elastic, transparent basement membrane (Collagen type IV)
II. Pathology Edema
 Contains the lens substance and capable of molding the lens during
a. Congenital Diseases c. Cystic rent with
accommodation
b. Developmental Vitreous Loss
 Zonular lamellae: outer layer of the capsule that serves as attachment
Diseases d. Elevated IOP
for the zonular fibers
c. Drug-induced e. Induced
d. Metabolic  Thickest: anterior and posterior pre-equatorial zones
Astigmatism
f. Retained Lens  Thinnest: region of the central posterior pole (2-4µm)
Material
g. Endophthalmitis ZONULAR FIBERS

 Origin: basal laminae of nonpigmented epithelium of:

o Pars plana
I. LENS o Pars plicata
 Inserts:
o 1.5 anterior to the equator
ANATOMY
o 1.25 posterior to the equator
 Transparent, biconvex crystalline structure
 Avascular and no innervation after fetal development LENS EPITHELIUM
o Must derive nutrients from aqueous humor
 Simple cuboidal epithelium
 Positioned just posterior to the iris and anterior to the vitreous
 Located just behind the anterior capsule
 Suspended by the Zonules of Zinn (zonular fibers arising from the ciliary
body)  Metabolically active
 Index of refraction: 1.4 centrally and 1.36 peripherally  Mitotic cells occurring greatest in a ring around the anterior lens
(germinative zone)
 Contributes 1/3 to the total refractive power of the eye (18-20 diopters);
o Epithelial cells near the lens equator divide throughout life and
cornea - 40 diopters
continually differentiate into new lens fibers
o Total refractory power of the eye: 60 diopters
 Functions:
o Maintain its own clarity
o Refract light
o Provide accommodation
 Optical axis – imaginary line connecting the anterior and posterior poles
 Meridian – line on the surface passing from one pole to another
 Equator – the greatest circumference

NUCLEUS AND CORTEX

Birth Adult
 Older lens fibers are compressed into a central nucleus
Equator 6.4 mm 9 mm o Embryonic lens nuclei
 Younger, less compact fibers around the nucleus make up the cortex
AP 3.5 mm 5 mm  Sutures
o Formed by the arrangement of interdigitations of:
Weight 90 mg 255 mg  Apical cell processes (anterior suture)
 Basal cell processes (posterior suture)

 Composed of:
1. Capsule (D)
2. Zonular fibers

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 OPHTHALMOLOGY
Lens

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”

 The band consisting of preequatorial and equatorial cells is called

germinal zone
 Cells in the germinal zone divides constantly. The newly formed cells
are forced into the transitional zone where they elongate and
differentiate to form the fiber mass of the lens
 The secondary fibers arise from the cells at the equator and grow to
surround the embryonic cells
o Secondary lens fibers (fetal nucleus) - equatorial epithelial cells
elongate
 The continuous laying down of fibers from the equatorial cells forms
distinct layers referred to as the embryonal, infantile, juvenile, and adult
zones from the inside out
o “pinakamatandang cells ay nasa loob”

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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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

POSTERIOR SUBCAPSULAR CATARACT

 Glare and decreased visual acuity especially during bright sunlight
 Granular opacities in the posterior pole of cortex adjacent to the
posterior capsule
 Age-related or occur as a complication of inflammation, steroids,
vitreoretinal surgery, trauma, irradiation and DM WILSON’S DISEASE

 AR, hepatolenticular degeneration

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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

Primary Objective: To determine whether the lens opacity is the

principal reason for the decline in vision IV. CATARACT SURGERY
 Indications o Patient’s desire for improved vision
o Loss of stereopsis COUCHING
o Diminished peripheral vision  Sharp needle placed posterior to corneoscleral junction
o Disabling glare  Blunt needle used to wiggle the lens free of the zonular fibers
o Symptomatic anisometropia  Lens displaced into vitreous cavity
o Dense cataract that obscure view of fundus
 Clinical o Decreased visual acuity INTRACAPSULAR CATARACT EXTRACTION
History: o Altered contrast sensitivity
 Removal of both the lens and the thin capsule that surround
o Mononuclear diplopia or polypia
the lens
 General o Co-morbidities  Early ICCE: Extracted via limbal incision with the thumb
Health o Medications  Smith-Indian Operation: Extracted using muscle hooks
 Pertinent o Trauma  Verhoeff/Kalt Toothless forceps
Ocular History o Inflammation  Erysiphakes: suction cup-like device
o Glaucoma  Krwawicz: cryoprobe
o Retinal Problems
 Measurements o Visual acuity Advantages Disadvantages
of Visual o Refraction  Entire lens removed  Delayed healing/ visual
Function: o Brightness acuity  Less sophisticated rehabilitation
o Contrast sensitivity and visual field testing instruments  Astigmatism
 External o Enophthalmos  For luxated cataract  Vitreous/iris incarceration
Examination o Dry eye syndrome  Post-op wound leaks
o Ocular alignment  Cystoid macular edema
o Relative Afferent Pupillary Defect (CME)/retinal detachment
o Pupil size (RD) more common

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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

 Cavitation – formation of vacuoles in a liquid by a swiftly moving

solid body. Collapse of vacuole  released energy  crushed lens
material
 Chatter – to cut unevenly with rapidly intermittent vibration
 Stroke – sudden action producing impact
 Frequency – strokes per second (27000 – 60000Hz)
 Load – in ultrasonics, occurs when tip encounters nuclear material
 Piezoelectric – transducer which transforms electrical energy to
mechanical energy
 Power – ability of phaco-needle to vibrate and cavitate adjacent
lens material
 Tuning – used to match optimum driving frequency of ultrasonic
board with the frequency of phaco handpiece
 Ultrasonic – frequencies above human audibility (>20000 vibrations
per second)
 Aspiration flow rate – rate at which fluid flows from eye. Attracting
force of handpiece
 Followability – ability of fluidic system to attract lens material
 Occlusion – obstruction of aspiration port (necessary to create
vacuum)
CYSTOID MACULAR EDEMA

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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

CAPSULAR RENT WITH VITREOUS LOSS

 Signs  Endophthalmitis Vitrectomy Study
o Sudden deepening of AC o Randomized into 2 groups
o Momentary pupillary dilation  VIT – underwent PPV (Pars plana vitrectomy)
o Decreased mobility of nuclear pipe  TAP – underwent vitreous tap/biopsy
o Vitreous is aspirated into the phaco tip o Both groups received
 Management  Intravitreal amikacin and vancomycin
o Inject viscoelastic before removing phaco tip  Subconjunctival vancomycin and dexamethasone
o Lower bottle height o Results:
o Lower settings  VA better than LP – visual results are the same for both
o Anterior Vitrectomy groups
 LP – PPV is beneficial
 IV antibiotics not beneficial
ELEVATED IOP
 Retained viscoelastic material is a common cause
 If persistent, look for the other cause
REFERENCES
INDUCED ASTIGMATISM
 Post ECCE, up to 2D of WTR astigmatism will usually resolve Batch 2019 Trans
 Removal of Sutures 6-8 weeks post op
 Removal of too many/early sutures may result in significant Batch 2017 Trans
flattening or wound leak
Lecture notes
RETAINED LENS MATERIAL
 More common in phaco than ECCE
 Degree of inflammation varies on:
o Size of lens fragment
o Type of lens material
o Time elapsed since surgery
 Cortical material is better tolerated and more likely to resorb than
nuclear material
 Does not necessarily require reoperation
 Control inflammation and IOP

ENDOPHTHALMITIS

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