OPHTHALMOLOGY

DISEASES OF THE CRYSTALLINE LENS

OVERVIEW
1. Anatomy
2. Embryology
3. Biochemistry
4. Physiology
5. Diseases
 S/Sx
 Biochem & pathophysiology
 Classification
 Management
 Complication EMBRYOLOGY
Anatomy of Lens
LENS
 Biconvex structure
 4-5 mm, in thickness
 9-10mm in diameter
 Function: Accommodation
 Lacks innervation
 Capsule
 Membrane on Lens surface
 Fine filaments aligned parallel to the
surface
 ALC thicker PLC

 Epithelium
o Lies beneath anterior and equatorial
capsule
o Change from tall  cuboidal to fibers
 Zonules
o Collagen attached to the lens equator
 OPHTHALMOLOGY
Embryonicstage Structure Abberration a. MIP : Main Intrinsic
/ AOG Polypeptide
4mm / 25 days Lens plate Aphakia a. Albuminoids

5 mm / 27 days Lens pit Ectopia lentis

  Lens opacification due to 
7 mm / 29 days Lens vesicle Spherophakia increased levels of insoluble
micro /  proteins
macro-phakia PHYSIOLOGY OF LENS
9 mm / 30 days Lens vesicle Dislocated Main Function:
 (lens: /subluxated – Accommodation
intraocular)  lens – 2nd refracting medium 
8 mos. AOG Tunica vascula Cong.  Reading Near/Accommodation
Lenti shyaloid Cataract; – Ciliary muscle contract
arteries mittendorf – Zonules relax
(atrophies) spots – Lens becomes thicker
Biochemistry – Parallel lines of light are
 focused in front of retina
A. Water : 65% by weight
 Transparency  of the lens:
1. Intracellular – bound to the fibers
• Sparsely cellular, with cell
2. Extra-cellular – free water
nuclei crowded at the equator
B. Proteins : 30-35% by weight
• Composed of fibers from
1. Water Soluble : 86%
equator uniformly arranged in
2. Water Insoluble:
concentric manner toward
A. Minerals: 
the center
Lens:
• Just a layer of epithelial cell
• Na : 20 mM
beneath the anterior capsule
• K   : 120 mM  
• Avascular
             Aqueous humour:
• Relatively dehydrated
 Na : 150 mM
Diseases
 K   :     5 mM
Aphakia
 Congenital absence of lens
*Calcium level is very low (0.1µm)
 S/Sx: deep anterior chamber, iridodonesis,
corneal scar, iris coloboma, no
 Lens Transport:
accommodation
– Na out of lens
 Tx: + 10 lens, IOL, contact lens
– Accumulates K, amino acid and
ascorbic acid
 Lens synthesizes:
– Inositol
– Glutathione
LENS PROTEIN
Water Soluble
a. Alpha Crystalline : 32%
– Largest Ectopia Lentis
– Fxn: transformation of epith  Lens dislocates either into vitreous cavity or
to fibers anterior chamber
b. Beta Crystalline: 55%  Seen in Marfans and Weill-Marchesani
– Most abundant syndrome
c. Gamma Crystalline  Homocystinuria
-   Smallest 
Water insoluble
 OPHTHALMOLOGY
Hypermatur Intumescent Trauma / post
e cataract lens surgery

Lens Iris lens Lens material

material diaphragm reaction
leaks pushed
 ingested by forward
phagocytes

 Hypermature cataract
causing Phacolytic Glaucoma
Subluxated lens  Intumescent lens with secondary glaucoma
 Lens is in the vitreous but dislocated (Phacomorphic)
superiorly or inferiorly

Microphakia
 Smaller than normal
 Tend to be spherical
o (spherophakia): weill- marchesani
syndrome

Phacolytic Glaucoma

Lenticonus
 Cone protrusion at anterior pole of lens
 Lentiglobus

CATARACT
*Any imbalance in the biochemistry of the lens
composition causes CATARACT
• Most common cause of 
Lentiglobus
   blindness in the Philippines (44.4%)
 Cone protrusion at posterior pole of lens
• Any opacity in the crystalline
lens with visual impairment
• Gradual and progressive 
• Symptoms: 
– PAINLESS,PROGRESSIVE,
    BLURRING of vision
Cataract Induced Secondary Glaucoma

Phacolytic Phacomorphic Phacoanaphylactic

Glaucoma Glaucoma Glaucoma
Open angle Angle closure Open angle
GL
Clinical Manifestation of cataract
• Sign
 OPHTHALMOLOGY
– Lens opacity 7. Infectious
• Symptoms 1. Toxoplasmosis
– PAINLESS,PROGRESSIVE, 2. Herpes Virus
    BLURRING of vision 3. Rubella
– Fixed scotoma Location of cataract opacity
– Monocular diplopia
– Induced myopia
– Color desensitization:
– BLUE OR YELLOW
Pathophysiology of Cataract 
A. Increase Hydration (normally relatively
dehydrated)
B. pH: acidification
 ↑ lactic acid; ↓ascorbic acid
 Normal lens pH 5.6 - 6.3
(Alkalosis)
B. Insoluble Proteins > Soluble proteins
 Normal: soluble proteins > insoluble Anterior polar
proteins
C. Minerals
↑Ca = ↑H20
↑ Na = ↓K
Classification of cataract
1. Age of onset
a) Congenital
Anterior subcapsular
b) Infantile
c) Juvenile
d) Adult
e) Senile
2. Location of opacity
a) Anterior polar
b) Anterior subcapsular Nuclear
c) Nuclear
d) Lamellar 
e) Cortical (peripheral and posterior)
3. Maturity
a) Immaturity
i. Insipient
ii. Intumescent Posterior Subscapular cataract
b) Mature
c) Hyper-mature
4. Etiology
1. Age related ( aging / senile)
2. Traumatic
3. Metabolic
4. Toxic
5. Radiation
Posterior  Polar cataract
6. Secondary
1. Inflammatory
2. Glaucoma
 OPHTHALMOLOGY
– Surgical
• ICCE
• ECCE with PC or ACIOL
• Phacoemulsification with
PCIOL
ECCE vs Phaco
Cortical cataract
Surgical Complication:
• Endophthalmitis / Panophthalmitis

ECCE Phaco
Incision Big ( 10-15 mm) Small 2-5 mm
Maturity Suture + -
Duration 40 min – 90 min 6 – 25 min
Visual outcome Fair – good Better
Restriction of More Less
activities
Complications Many Few
Recovery period Weeks – months Days
Bleeding +  -/+
• Flat anterior chamber
• Corneal edema
• Hemorrhage
• Glaucoma
• No intra-ocular lens
• Retinal detachment
• Choroidal effusion
• Macular edema

Management of Cataract
• Medical
     - No management has been
proven to delay prevent or
reverse cataract
- Anti-cataract Eyedrops trial
(less than 10% chance for
immature)
- Utilize low vision aids:
magnifiers, loupes, camera

• Surgical intervention indication:

– Desire or need of patient
– Bilateral significant cataract
– Secondary glaucoma
– Secondary uveitis
– Lens dislocation
– Anesthesia
• General
• Sedation
• Local / retrobulbar inj.
• Intra-cameral
• topical