Lens and Cataract

Cesar Matthew Madria

School of Medicine
St. Paul University Philippines

Outline

Anatomy of the Lens

Physiology of symptoms in Lens disorders

Cataract
-

mature
immature
hypermature
intumescent
morgagnian

A. Age-related Cataract
B. Childhood Cataract
> Congenital
> Acquired
C. Traumatic Cataract
D. Cataract associated with Systemic Disease
E. Drug-induced Cataract
F. After Cataract
Cataract Surgery
1. ICCE
2. ECC
3. Phacoemulsification

Lens and its Attributes

Appearance: crystalline structure, biconvex, and covered

by lens capsule

Location: posterior to Iris and is supported by zonular fibers

arising from the ciliary body. (These fibers insert onto the
equatorial region of the lens capsule.)

Function: its shape, elasticity and transparency allow light

to properly pass and create a normal visual experience.
ciliary muscle contracts -> zonular tension relaxes -> more spherical
ciliary muscle relaxes -> zonular tension tenses -> more flattened

Avascular its source of nutrient is from aqueous humor

Metabolism: anaerobic

Physiology of Symptoms

Symptoms associated with lens disorders are primarily visual.

1.

Presbyopic symptoms: diminished ability to perform near tasks.

2.

Blurred vision for near and distant view: usually not accompanied with pain

3.

Aphakic refractive state: complete dislocation of the lens from the visual axis

Cataract
is any opacity in the lens.

Cause:
1.

Aging

2.

Trauma

3.

Drug

4.

Systemic disease

5.

Smoking

6.

Heredity

Cataract Maturity

Mature is one in which ALL of the lens proteins is opaque.

Immature has SOME transparent protein.

Intumescent if lens take up water.

Hypermature cortical proteins have become liquid.

Generally speaking, the decrease in visual acuity is directly proportionate to the

density of the cataract.

Cataract Maturity

Mature is one in which ALL of the lens proteins is opaque.

Cataract Maturity

Hypermature cortical proteins have become liquid with fluid passage from
the lens

Cataract Maturity

Morgagnian Cataract when further liquefaction of the cortex allows free

movement of the nucleus within the capsular bag.

Age-Related Cataract

Cataract by location

A.

Nuclear Cataract

B. Cortical Cataracts
C. Posterior subcapsular cataracts

Age-Related Cataract

Cataract by location

A.

Nuclear Cataract due to normal condensation process in the lens

nucleus after middle age.
>Earliest symptom Myopic shift
>bilateral but may be asymmetric
> best assessed with oblique slit lamp biomicroscopy
> in early stages, it is colored yellow due to urochrome deposition

Age-Related Cataract
B. Cortical Cataracts opacities in the
lens cortex.
> Bilateral and asymmetric
> First signs are vacuoles and
water clefts
> Cortical spokes/cuneiform
opacities form near the periphery of
the lens, edge pointing towards the
center.

Age-Related Cataract
C. Posterior subcapsular cataracts
located in the cortex near the central
posterior capsule.
- Typically causes early visual symptoms
due to its location.
- Lens epithelial cell migrate from lens
equator to visual axis of inner surface of
posterior capsule

Summary of Age-Related Cataract

Location

Laterality

Causes

Symptoms

Nuclear

Lens Nucleus

Bilateral

Old age, smoking

diabetes

1. Good near visual

acuity
2. Less glaring

Cortical

Lens cortex

Bilateral

Diabetes, Hyperkalemia, 1. Visual acuity

hypernatremia, UV light
insignificantly
exposure
affected
2. Less glaring

Posterior
Subcapsular

Cortex near the

central posterior
capsule

Unilateral/Bilateral Female, Steroid use,

diabetes

1. Good distant
visual acuity
2. Increased Glaring

Childhood Cataract
Onset

Laterality

Causes

Treatment

Congenital Cataract

Present at birth or
appear shortly
thereafter

Unilateral/bilateral

1/3 hereditary
1/3 metabolic,
infectious, variety
of syndromes
1/3 undetermined
causes

Mechanical
irrigation-aspiration
with posterior and
anterior vitreous
removal

Acquired cataract

Later in life

Unilateral/bilateral

Trauma
Uveitis
Diabetes
Drugs

Mechanical
irrigation-aspiration
with posterior and
anterior vitreous
removal

Traumatic Cataract
Most

commonly due to a foreign body injury

to the lens or blunt trauma to the eyeball.

Once

lens capsule is interrupted, it allows

aqueous and sometimes vitreous to
penetrate the lens structure -> lens
becomes white

Traumatic cataract

Vossius Ring with blunt injury pigment from pupillary ruff is imprinted onto
anterior lens capsule

Soemmerings ring doughnut of residual equatorial cortex

Complete cortical cataract

Focal cortical cataract

Infrared radiation / glassblower cataract cataract formed

due to overexposure to heat

Cataracts associated with systemic

disease

Diabetes Milletus

Hypocalcemia

Galactosemia

Downs syndrome

Myotonic dystrophy

Cataracts associated with

systemic disease

Diabetes Milletus

Snow-flake appearance

Cataracts associated with systemic

disease

Inability to convert galactose to glucose

Accumulation of galactitol

Cataracts associated with systemic

disease

Hypocalcemia

Common in patients without

parathyroid glands

Sodium correlated to be causing

cataract.

Cataracts associated with systemic

disease

Wilson Disease

- An inherited disease
related to disorder in
copper metabolism

Sunflower cataract

Cataracts associated with systemic

disease
Myotonic

dystrophy

characterized by
delayed relaxation of
contracted muscles,
ptosis, cardiac
conduction defects,
and prominent frontal
balding in affected
male patients.
Christmas tree Cataract

Drug-induced Cataract

Corticosteroids taken over a long period of time

Phenothiazines

Amiodarone

Strong miotic drop (phospholine iodide)

Drug-induced Cataract

Corticosteroid

Can cause Posterior Subcapsular Cataract

Due to 2 mechanisms:
1. Alters Na-K pump of Lens
2. hastens crystalin conformational
change
> Triamcinolone acetonide

Dense central opacity, thinner periphery

with pseudopodia-like fringes

Drug-induced Cataract
Phenothiazine

accelerate any predisposition to lens

opacification from solar radiation because of
their ability to form photosensitive products.

Dust-like appearance until stellate in

appearance

> Chlorpromazine

Pigmented deposits on anterior lens

capsule

Drug-induced Cataract

Miotics:Chronic use of long-acting

cholinesterase inhibitors

can produce anterior subcapsular

vacuoles. Continued use of these strong
miotics may cause posterior
subcapsular and nuclear changes.

The mechanism of cataract formation

remains unclear.

Echothiophate iodide, demecarium

bromide

After-cataract (Secondary Membrane)

Opacification of the posterior capsule after ECCE.

Persistent subcapsular lens epithelium regeneration
fish egg appearance
continuous proliferation

multiple layer formation

myofibroblast differentiation

frank opacification

tiny wrinkles in posterior capsule

Cataract Surgery

Intracapsular Cataract Extraction (ICCE)

Involves the extraction of the entire lens, including the posterior capsule.

Extracapsular Cataract Extraction (ECCE)

Involves the removal of the lens nucleus through an opening in the anterior
capsule with retention of the integrity of the posterior capsule.

Phacoemulsification

ECCE

Intraocular lens implantation is part of the procedure

1.

Incision is made at the limbus or peripheral cornea

2.

Opening is made in the anterior capsule

3.

Nucleus and cortex of the lens are removed.

4.

Intraocular lens is then placed in the empty capsular bag

In nuclear removal it is removed intact with a wider incision

In cortical removal done by manual or automated aspiration

Phacoemulsification

It utilizes a handheld ultrasonic vibrator to disintegrate the hard nucleus such

that the nuclear material and cortex can be aspirated through an incision of
3mm.

NON SURGICAL
MANAGEMENT

TREATMENT OF THE CAUSE OF CATARACT

Adequate

control of diabetes mellitus,

Removal

of cataractogenic drugs such as

corticosteroids, phenothiazenes and strong miotics

Removal of irradiation (infrared or X-rays)

Early and adequate treatment of ocular diseases like
uveitis

MEASURES TO DELAY PROGRESSION

Commercially

available preparations containing iodide

salts of calcium and potassium are being prescribed in
abundance in early stages of cataract

Vit

E and aspirin also delays the process of

cataractogenesis

SURGICAL MANAGEMENT

INDICATIONS
a)

Visual improvement

b)

Medical indications:
-Lens induced glaucoma
-Phacoanaphylactic endophthalmitis
-Retinal diseases like diabetic retinopathy or
retinal detachment

PRE-OP MEDICATIONS AND PREPERATIONS

1.

TOPICAL ANTIBIOTICS - Tobramycin and Gentamicin QID for 3days

before surgery

2.

PREPARATION OF THE EYE TO BE OPERATED

3.

CONSENT

4.

SCRUB BATH AND CARE OF HAIR

5.

DRUGS TO LOWER IOP - Acetazolamide 500mg stat 2hrs before

surgery and Glycerol 60ml mixed with water 1hr before surgery

6.

DRUGS TO SUSTAIN DILATED PUPIL - AntiProstaglandin eye

drops(Indomethacin)

ANAESTHESIA
Cataract extraction can be performed under gen or local
anaesthesia. Local is preferred.

SURGICAL TECHNIQUE FOR

CATARACT EXTRACTION

INTRACAPSULAR CATARACT EXTRACTION

The entire cataractous lens along with the intact capsule is

removed.

Therefore weak and degenerated zonules are a pre-requisite for

this method. Because of this reason, this technique cannot be
employed in younger patients where zonules are strong.

ICCE can be performed between 40-50 years of age by use of the

enzyme alphachymotrypsin (which will dissolve the zonules).

Beyond 50 years of age usually there is no need of this enzyme.

INDICATION
- Subluxated and dislocated lens

SURGICAL STEPS OF ICCE TECHNIQUE:

i.

Superior rectus (bridle) suture

ii.

Conjunctival flap

iii.

Partial thickness groove/gutter

iv.

Corneoscleral section

v.

Iridectomy

vi.

Methods of lens delivery

Indian smith method

Cryoextraction

Capsule forceps method

Irisophake method

Wire vectis method

vii.

Formation of Anterior Chamber

viii.

Implantation of anterior chamber IOL(ACIOL)

ix.

Closure of incision- 5-7 interrupted sutures

x.

Conjunctival flap repositioned

xi.

Subconjunctival injection-dexamethasone 0.25ml and

gentamicin 0.5ml given

xii.

Patching of the eye

A. Passing of superior rectus

suture
B. Fornix based conjunctival
flap
C. Partial thickness groove
D.Completion of
corneoscleral section
E. Peripheral iridectomy
F. Cryolens extraction
G.Insertion of Kelman
multiflex IOL in anterior
chamber
H.Insertion of Kelman
multiflex IOL in anterior
chamber
I. Corneo-scleral suturing

EXTRACAPSULAR CATARACT EXTRACTION

Major

portion of anterior capsule with epithelium,

nucleus and cortex are removed; leaving behind intact
posterior capsule.

Indications:

Presently, it is the surgery of choice for all

types of adulthood as well as childhood cataracts
unless contraindicated.

Contraindications

- Subluxated and dislocated lens

Types of extracapsular cataract extraction

a) Conventional Extracapsular Cataract
(ECCE)

Extraction

b) Manual Small Incision Cataract Surgery

c) Phacoemulsification

(SICS),

CONVENTIONAL ECCE
i.

Superior rectus (bridle) suture

ii.

Conjunctival flap (fornix based)

iii.

Partial thickness groove/gutter

iv.

Corneoscleral section.

v.

Injection of viscoelastic substance in anterior

chamber - 2% MethylCellulose or 1% Sodium Hyaluronate
(Maintains anterior chamber and protects endothelium)

vi. Anterior

capsulotomy.

Can-opener's
Linear

capsulotomy (Envelope technique)

Continuous

vii.Removal

technique

circular capsulorrhexis (CCC)

of anterior capsule

viii.Completion

of corneoscleral section

ix. Hydrodissection (ie., seperation of capsule from cortex by

injecting fluid between the two) - Balanced salt solution injected

under peripheral part of ant capsule to separate corticonuclear mass
from the capsule

x.

Removal of nucleus
After hydrodissection the nucleus can be removed by any of the
following techniques:
Pressure
Irrigating

and counter-pressure method

wire vectis technique

xi.

Aspiration of the cortex

xii.

Implantation of IOL

xiii.Closure

of the incision - 3-5 interrupted sutures

xiv.

Removal of viscoelastic substance

xv.

Conjunctival flap is reposited and secured

xvi.

Subconjunctival injection

xvii.

Patching of eye

A. Anterior capsulotomy Can

Opener's technique
B. Removal of anterior
capsule
C. Completion of corneoscleral section
D. Removal of nucleus
(pressure and counterpressure method)
E. Aspiration of cortex
F. Insertion of inferior haptic
of posterior chamber IOL
G.Insertion of superior
haptic of PCIOL
H. Dialing of the IOL
I. Corneo-scleral suturing

MANUAL SMALL INCISION CATARACT SURGERY

1.

Superior rectus suture

2.

Conjunctival flap and exposure of sclera

3.

Haemostasis

4.

Sclero corneal tunnel incision:

External scleral incision - 5.5mm to 7.5mm
Sclero corneal tunnel - 1-1.5mm
Internal corneal incision

5.

Side port entry

6. Anterior

capsulotomy - can be can-openers,envelope or

continuous circular capsulorrhexis (CCC)

7. Hydrodissection
8. Nuclear

management

a)prolapse of nucleus into ant chamber

b)delivery of nucleus through corneoscleral
9. Aspiration
10.IOL

of cortex

implantation

11.Removal
12.Wound

of viscoelastic material

closure

tunnel

A. Superior rectus bridle suture

B. Conjunctival flap and exposure of sclera
C, D & E. External Scleral incisions (straight, frown
shaped, and chevron,
respectively) part of tunnel incision
F. Sclero-corneal tunnel with crescent knife
G. nternal corneal incision
H. Side port entry
I. Anterior capsulotomy
J. Hydrodissection
K. Prolapse of nucleus into anterior chamber
L. Nucleus delivery with irrigating
wire vectis
M. Aspiration of cortex
N. Insertion of inferior haptic of posterior chamber
IOL
O. Insertion of
superior haptic of PCIOL
P. Dialing of the IOL
Q. Reposition and anchoring of conjunctival flap.

PHACOEMULSIFICATION
1.

Corneoscleral incision-very small 3mm

2.

Continuous curvilinear capsulorrhexis of 4-6mm

3.

Hydrodissection

4.

Nucleus is emulsified and aspirated

5.

Remaining cortical lens matter is aspirated

6.

IOL Implantation

7.

Removal of viscoelastic material

8.

Wound closure

A.
B.
C.
D & E.
F.

Continuous curvilinear capsulorrhexis

Hydrodissection;
Hydrodelineation
Nucleus emulsification by divide and conquer technique
Aspiration of cortex.

Thank you