Cataract

By

Dr.Tarek Badr El Din

FRCS , M.D.

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 Tarek Badr

= Define the Problem:

Cataractous patient complaining of diminusion of vision

= D.D. ( Classification ) :

A- Congenital .

B- Acquired : 1- age related

2- systemic dis.
3- secondary (complicated )

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 Tarek Badr

1- Age related :
= According to shape : - Cortical
- Nuclear
- PSC
- Christmas tree……Polychromatic…..Chronic AU

= According to maturity : - Immature

- Mature
- Hypermature
- Morgagnian

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 Tarek Badr

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 Tarek Badr

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 Tarek Badr

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 Tarek Badr

2- Systemic diseases :

a - Diabetes mellitus :

- Accelerate age related cataract

- Snow flakes cortical opacities….young diabetics…..resolve or mature

within few days ( acute onset cataract ) .

b – Atopic dermatitis :…………… Shield – like ant. Subcap. cataract

c – Myotonic dystrophy : …………PSC (Christmas tree)

d – NF 2 : ………………………….PSC

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 Tarek Badr

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 Tarek Badr

3 – Secondary (complicated ) cataract :

a – CAU : most common..….PSC….Polychromatic

b – High myopia : …………..PSC

c - RP : ……………………. PSC , also Leber , Gyrae & Stickler .

d – ACG : …………………. Glaucomflecken ( ant. Subcap. Cat )

e – Traumatic & steroid induced………………PSC

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 Tarek Badr

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 Tarek Badr

= Outline risk factors :

Coversion into glaucoma ( Lens induced glaucoma )

- Phacomorphic glaucoma ………at any………...

- Phacolytic glaucoma…………...only with ……

- disloacated lens in AC ……….Weak zonules…………

- Incarcerated lens in pupil……Microspherophakia….M & W

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 Tarek Badr

Management :

History

- Age….+++ 50 except if congenital

- C/O….Hazziness

- G.H…..Systemic dis…….

- O.H…..operations…procedures…medications….trauma…diplopia

& glare…nodal point

- Perinatal…STORCH….Trauma….Phototherapy
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 Tarek Badr

Examination

- BCVA

- SL ( Guttata – PEX – RI – Subluxation ) & Pupil

- Tension

- Fundus

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 Tarek Badr

Investigations

= Biometry & B – scan : if……………………………...

= Topography : if …………………………

= Specular microscopy : if ……………….

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 Tarek Badr

Treatment

Surgery…..

= ICCE

= ECCE…..conventional or small incision

= Phacoemulsification

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 Tarek Badr

Complications

= Pre-op…..Difficult dilatation

= Intra-op…………………….

= Post- op….Acute postoperative endophthalmitis.

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 Tarek Badr

Difficult dilatation

= Pre-operative : Mydriacyl 1% , Cyclopentolate 1% , PE 10%.....sponge

Mydricaine subconjunctival ( atropine – adrenaline – procaine ) .

= Intra-operative: Adrenaline ( intracameral or added to solution), Mechanical

by viscoelastic injection , Iris retractors , dilating ring ( Malyugin ) , multiple small

sphincterotomies , manual iris retraction .

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 Tarek Badr

Acute postoperative endophthalmitis

= Organism : 90 % +ve , 10 % -ve

Staph.epidermidis…..staph.aureus…..strept…..proteus…..pseudomonas
= C/P :
- History….C/o: PDR
- Exam. : - Ciliary inj. , chemosis , discharge
- RAPD
- Corneal haze
- Hypopyon , fibrinous exudate
- Vitritis
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- Loss of red reflex
 Tarek Badr

D.D.

Sterile reaction : (TASS)

= Retained lens matter…………………………………………..Q

= Toxic reaction to OVD or irrigating solutions…………………Q

= Prolonged or complicated surgery……………………………..Q

= Post-operative uveitis

= Vitreous hemorrhage

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 Tarek Badr
Investigations

= B-scan .

= Aqueous sample….0.1 – 0.2 ml…..Insulin syringe (28 – 32 G ).

= Vitreous sample…0.2 – 0.4 ml….23 G needle or disposable vitrector .

…………..Conj. Swab if – ve cultures

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 Tarek Badr

TTT
= Intravitreal Abs…………..

= Topical fortified Abs……..

= Systemic Abs……………..moxifloxacin 400 mg once for 10 days

= Periocular or subconj. Abs………….. Vancomycin 50 mg….Ceftazidime 125 mg

= Topical steroids…….dexa. 0.1 %

= Systemic steroids……………….

= Periocular steroids……………..

= Intravitreal……………………..controversial

= Mydriatic +/- Aq.supressants

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 Tarek Badr

Subsequent TTT

= Improvement………continue

= Worsening…………Repeat intravitreal Abs after 48h……reculture…..Vitrectomy

N.B: Prognosis of endophthalmitis depend on Virulence of organism and Early

intervention.

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 Ectopia lentis Tarek Badr

= Def. : Malpositioned lens either subluxated or dislocated

= Causes :

A – Aquired : - Trauma
– PEX
– Hypermature cat.
- Large globe ( Buph. , high myopia )
- Ch.uveitis as cylitis or ant. Uveal tumors

B – Hereditary : = Without systemic : - Familial

- Ectopia lentis et pupillae
- Aniridia

= With systemic : - Marfan………ST

- Weill – Marchesani………….Inferior
- Homocystinuria………………IN
- Others as hyperlysinemia , sulphite oxidase --- ,
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Stickler & ED-6
 Tarek Badr

= Treatment :

A ) Spectacles : astigmatic or ametropic correction .

B ) Surgical removal : - Refractory ametropia

- Meridional amblyopia
- Lens induced glaucoma or uveitis
- Cataract
- Endothelial touch

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 Congenital cataract Tarek Badr

Work up
A- History :

- OCD of complaint ( usually leukocoria by parents ) .

- Systemic problems with the child ( as determined by pediatrician ) .
- Trauma .
- Family history of congenital cataract .
- Perinatal history : fever & skin rash of mother during pregnancy and
birth trauma .

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 Tarek Badr

B- Examination :…..EUA.

- Refraction under cycloplegia. N.B. evaluation of vision is important and the

poor prognostic factors include eccentric fixation , nystagmus &strabismus .
- Corneal diameters & Anterior segment examination : after excluding other
causes of leukocoria , the most important point is to determine Density and
Laterality of catarct also shape of cataract may give clue to aetiology e.g. oil
droplet and membranous and lastly detect any associated anomalies as
corneal clouding , microphthalmos and PHPV.
- IOP .
- Gonioscopy .
- Fundus : search for associated signs as rubella retinopathy , chorioretinitis &
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macular or ON hypoplasia.
 Tarek Badr
C-Investigations :

a- Ocular :
= B-scan if fundus can not be seen & Biometry if operation .
= ERG & Pattern VEP : to evaluate vision in an infant or child .

b- Systemic :
In coordination with pediatrician especially if bilateral cataract , dystrophic features
or suggestive history .
= Serology : for STORCH.
= Urine analysis : - Reducing substances after drinking milk …Galactosemia.
- Amino acids … Lowe syndrome.

= others : - FBS …..hypoglycemia & hyperglycemia .

- Serum Calcium & Phosphorus ….hypoparathyroidism(hypocalcemia & hyperphosphatemia)
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- GPUT & Galactokinase …..Galactosemia .
 Tarek Badr

D-Treatment & Follow up :

Timing of surgery depends on age , laterality and density:

= If visually insignificant whether unilateral or bilateral…..Follow up ( vision –
density of cataract ) & guard against amblyopia .

= If visually significant :….Surgery .

- Unilateral dense …..Urgent surgery (within days) followed by
aggressive anti-amblyopia ttt…..poor prognosis. N.B. if detected after 16
weeks ,no need for surgery as amblyopia is refractory .

- Bilateral dense …..Early surgery ( 4-6 weeks age ).

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 Tarek Badr

Surgery:

= CCC – Lensectomy ( I/A ) – Posterior CCC – Limited anterior

vitrectomy – IOL implantation ( if preferred by surgeon ) .

= Postoperative visual rehabilitation :

* --- 2 years : C.L.
* +++ 2 years : - unilateral : IOL .
- Bilateral : Glasses .
, Most suregeons prefer IOL implantation & may aim at some hypermetropia
corrected by glasses or C.L.

N.B. Follow up is important including anti-amblyopic ttt by occlusion or penalization .

### TTT of any systemic problems by pediatrician .

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 Tarek Badr

N.B. Complications of surgery in congenital cataract :

1- PCO : Universal …( Posterior ccc + anterior vit. )

2- secondary membranes : across the pupil : - thin membrane …YAG .
- thick membrane…surgical removal .
3- Sommering ring ( proliferation of lens epith. From equator to be encapsulated
between anterior and posterior capsules …..universal & visually insignificant.
4- Glaucoma : - angle closure : immediately post op. , in microphthalmos …pup. Block
- open angle : years later …F.up.

5- RD : Uncommon .

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 Tarek Badr

MCQ

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 Cataract

= Polychromatic cataract:

- Chronic AU.

- Christmas tree cataract → Age related or Myotonia dystrophy.

= Rays:

- UV rays → BCC, SCC, pterygium & cataract.

- IR rays → true exfoliation (welder & glass blower).

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THANK YOU

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