CATARACT

It is an opacity of the lens of the eye that may cause blurred or distorted vision, glare problems, or, in
advanced cases, blindness. It is characterized by lens edema, protein alteration, necrosis and disruption of
normal lens fibers. It occurs frequently with increasing age and may be a normal part of aging. However, poor
nutrition, metabolic insults, excessive exposure to sunlight or other sources of radiation, trauma and certain
medications such as cortisone can speed their development. The lens of the eye has a unique structure that
renders it vulnerable to insults due to aging or other causes. It is composed of specialized cells arranged in a
highly ordered and complex manner, which contain a high content of cytoplasmic protein. These proteins, the
crystallins, along with the complex structure, impart transparency to the lens. Unlike other epithelia, the lens
cannot shed its nonviable cells; these cells are compressed into the center of the lens over time and begin to
lose their transparency. The development of cataract is a painless, progressive process. It usually presents
with bilateral symptoms and complain of difficulty with night driving or reading road signs or fine print. In many
patients there is an increase in nearsightedness before there is opacity of the lens that degrades vision.
“Myopic shift” is caused by an increase in refractive power of a lens that is gradually becoming cataractous and
can continue as opacity develops.

Classification of Cataract
 Nuclear
o Dulls colors and white significantly; progresses very slowly
 Cortical
Morphology
o Does not degrade vision very much, may appear suddenly after trauma or
other insult but tend to progress slowly
 Subcapsular
 Immature
o Early, insipient stage; swelling stage of the lens
o Has some transparent regions
 Mature
o Totally opaque
Stage of Development o Best time to operate (Phacoemulsification)
 Hypermature
o Mature cataract with possible leakage of proteins out of lens
o Shrunken lens with a wrinkled capsule
o Morgagnian: with liquefaction of the cortex; lens nucleus falls freely in the
capsular bag
 Congenital
o Most are bilateral
o Associated with maternal infection (TORCH)
Age of Onset o May cause nystagmus which is a bad prognosis
o *Acquired childhood cataracts are not as urgent as congenital
 Juvenile: can be drug induced, or traumatic
 Senile: usually this age group is seen with cataract
Etiology  Age related
o Most common; affects the elderly
o Progressive blurring of vision
o Types
 Cortical cataracts: Changes in hydration creating clefts
 Coronary cortical cataract: Club shaped peripheral opacities with clear
central lens; slowly progressive
 Cuneiform cortical cataract: Peripheral spicules and central clear lens;
slowly progressive
 Nuclear sclerotic cataract: Diffuse opacity; principally affects the nucleus,
slowly progressive
 Posterior subcapsular cataract: Plaque of granular opacities; rapidly
 progressive; causes earlier visual symptoms like glare and reduced
vision
 Distance and near vision are affected equally
 Toxic: Secondary to medications; corticosteroids
 Traumatic: Penetrating foreign body, concussion, heat, irradiation, electric
shock
 Systemic Diseases: Metabolic diseases such as DM (Punctate dot cataract;
Spokes wheel pattern opacity); Hypocalcemia, Galactossemia, Galactokinase
deficiency

Posterior Capsule Opacification

 Proliferation and migration of lens epithelial cells; Elschnig’s pearls or a fish egg appearance of the
capsule due to regeneration of lens fibers
 Treatment: Laser capsulotomy (YAG laser: non-invasive, creates an optical window in the posterior
capsule)

ECCE & Phacoemulsification

Extracapsular Cataract Extraction Phacoemulsification
Steps Lens cortex is aspirated from the eye  Anesthesia
and the lens capsule is left behind to  Prepping, draping, microscope’s setup
support an intraocular lens. A rigid  Incision
plastic lens is inserted through the  Capsulorhexis
same incision and placed on or in the  Nuclear disassembly
capsule behind the iris.  Cortical cleanup
 Implantation of IOL
 Closure of incision
Removal technique Lens is removed in 1 piece Ultrasound vibrations break apart the
cataract, fragments it into tiny pieces, then
removed using a suction device, leaving
the back portion of the lens capsule intact
Incision size 10 mm 3 mm
Lens type Hard plastic lens implant Soft, foldable lens implant
Stitches Yes multiple stitches required Usually no stitches, or single stitch only
Features Traditional, old-type procedure Modern procedure
Slower healing and visual recovery Shorter surgery time
Increase in the risk of post-operative Less trauma to the eye
astigmatism Little discomfort during and after surgery
Dramatically reduced healing time and
faster visual recovery, usually 2-3 weeks
Reduced risk of post-operative
astigmatism
ERRORS OF REFRACTION
 Emmetropia: Absence of refractive error; focus of the subject is on the retina (one focal point)
 Ametropia: Presence of refractive error; an optical defect that prevents light rays from being brought to
a single focus on the retina

Features Management
Myopia Near sightedness Concave lens
Light rays focus in front or before the retina
High degrees of myopia (>6 diopters) results in greater
susceptibility of degenerative retinal changes
Hyperopia Far sightedness Convex lens
Eye focuses the image behind the retina
Degree of hyperopia decreases with age as presbyopia
increases with age
May cause amblyopia or lazy eye
Presbyopia Loss of accommodation associated with aging Convex lens / Plus lens
Loss of the lens’ power to accommodate Progressive lens
There is loss of choroidal elasticity, loss of ciliary muscles,
sclerosis of lens
Astigmatism Eye produces an image with multiple focal points or lines Cylindrical lens
Football shaped eye

Correction of Refractive errors

 Spectacle lenses: safest method of refractive correction
 Contact lenses
o Hard & Gas-permeable: Changes the curvature of anterior surface of the eye
o Soft: Adapts to shape of the cornea
 Refractive Surgery
o Astigmatic Keratotomy: microsurgical procedure
o Photorefractive Keratectomy: excimer laser used to reduce myopia and astigmatism; very
painful
o Laser in Situ Kerato Mileusis (LASIK)
 Shortening the A-P diameter
 Performed under a protective layer of tissue; there is less surface area to heal, less risk
of corneal haze; less post-op discomfort and meds; rapid recovering
o Intraocular lens: implant intraocular lens; preferred method for aphakia
o Clear lens extraction for myopia

References:
Riordan-Eva, P., & Augsburger, J. (2018). Vaughan & Asbury’s General Ophthalmology (19th Ed). New York
Lange Medical Books: McGraw-Hill
Jacobs, D. S., Cataract in adults. In: UpToDate (2020)