CATARACT

Dr. T. Budi Sulistya, Sp.M

Dr. Anny Sulistiyowati, Sp.M
Dr. Sony Agung Santoso, Sp.M

Department of Ophthalmology
Faculty of Medicine Brawijaya University
Saiful Anwar Hospital
ANATOMY Of EYE & LENS
• Biconvex
• Avascular
• Transparent
• Thickness: 4 mm,
diameter 9 mm
• Ant : aqueous humor
• Post : vitreous
• Position: suspensory
ligament (zonula) zinn
 PHYSIOLOGY
-Lens transparency : control water & electrolyte
-Dehydrated
-K >>
-Amino Acid
> HA & Vitreous

-Na+
-Cl -
< HA & Vitreous
BIOCHEMISTRY

• 65% water
• 35% Protein, mineral, glutathione,
Potassium, Ascorbic acid, etc.
• Nutrition: Glucose  HA
• Ages  : protein : water insoluble Cataract
Hyperglicemic  Osmotic   Swelling
Opacification

Glutatione peroxidase
Catalase Peroxidation
Superoxide dismutatase

Opacification
 PATHOLOGY

• Advance age
• Trauma
• Inflammation
• Metabolic disorder
• Corticosteroid
• Radiation
Age Related Cataract
- Common
- Nuclear, Cortical, Posterior Sub
Capsular Cataract (PSC)
STAGES OF SENILE CATARACT

• Stadium INSIPIENT

• Stadium IMMATURE

• Stadium MATURE

• Stadium HYPER MATURE

RISK FACTOR
• Age
• Diabetes mellitus
• Drugs: corticosteroid, phenothiazine,
chlorpromazine
• Ultraviolet radiation
• Smoking
• Alkohol
DIAGNOSIS & EXAMINATION

1. Visual disturbance:
depends on: - opacity
- location

2. Glare

3. Altered contrast sensitivity

4. Diplopia
EXAMINATION
1. Visual acuity: natural, best corrected
2. Anterior segment
3. Pupilary dilatation
4. Funduscopic evaluation :
– Examine with ophthalmoscope
– Black spot over orange background (insipient –
immature)
– Negative (mature)
Additional test

1. Intraocular pressure
2. Keratometry and biometry
3. Retinometry
4. Ultrasonography
5. Blood pressure
6. Blood sugar
7. Hemostasis
MANAGEMENT
Non Surgical
1. Spectacle lens
2. Magnification / visual aids
3. Appropriate illumination

Surgical
Reduced visual funcion
Complication : Secondary glaucoma
 Indication of Surgery

1. Visual Impairment

• Responsible for the patient’s disability in

desired activity (driving, reading,
occupational needs)
• Visual disability increases due to glare or dim
illumination

• Patient complains of monocular diplopia or

polyopia

• Visual disparity exists between two eyes

2. Other indications:
 Lens induced diseases : phacomorphic
glaucoma, phacolytic glaucoma

 Concomitant ocular disease that requires

clear media: required to adequately
diagnose diabetic retinopathy
1. Stadium INSIPIENT

 Visual acuity can be normal

 Opacity starts as a line at lens edge
 Wheel appearance
 Central zone still
clear
 May be stationer
2. Stadium IMMATURE

Lens absorbs water  bulging  glaucoma

• VA: 5/6 - 1/60

• Fundus reflex (+)
• Opacity not homogen
• Iris shadow test (+)
• Indication for surgery
(+)
3. Stadium MATURE

• Visual acuity 1/60 - LP (+)

• Homogen opacity
• Fundus reflex (-)
• Iris shadow test (-)
• Obvious indication for surgery
4. Stadium HIPERMATURE
Degeneration of lens cortex and capsule

Shrunken cataract : lens shrinks and thins due to

loss of water
Morgagnian Cataract : cortex softens and liquefies 
nucleus sinks
 Surgical Procedure

• Extra Capsuler Cataract Extraction ECCE

Nuclear Expression/Extraction

Phacoemulsification

• Intra Capsuler Cataract Extraction ICCE

 EXTRA CAPSULAR

Extra capsular
 Incision 8-10 mm corneo-scleral
 Anterior capsulotomy
 Nucleus Expressed from capsular bag
Residual cortex removed
 Posterior capsule is intact
Large incision: suture >>
 For all kinds of cataract
 Manual Small Incisi Cataract Surgery (MSICS)
Phacoemulsification

• 2 – 3 mm

• Clear cornea

• Capsulotomy: Continuous Curvelinear

Capsuloreksis CCC

• Ultrasonic

• No sutures
 INTRA CAPSULAR

• ICCE
• Large incision
• Lens & Capsule intoto
• Higher risk of vitreous loss
• For mature & hypermature cataract
• Can not be done for congenital & juvenile cat.
 INTRAOCULAR LENS

• More Physiological

More comfortable

• PMMA, Silicone, Acrylic

• Inside capsular bag
• VA 6/6
• Pseudophakia
COMPLICATIONS
• Endophthalmitis • Bullous keratopaty

• Wound leak • Dislocated IOL

• Iris prolapse • Vitreous Lost

• Uveitis • CME

• Increased IOP • RD

• Corneal edema • Choroidal hemorrhage

POST SURGICAL REHABILITATION

• Patients complaint
• VA
• Anterior segment
• Sign of inflammation
• IOP
• Wound healing.
• Personal hygiene
• Spectacle correction/reading
COMMUNITY OPHTHALMOLOGY

• Blindness: 1.5 %, cataract 1 %

• Handling: Dept of Health
NGO
• Caused by: human resource capacity
geographical factor
limited infrastructure
socio-economic status
ophthalmologist <<
 Backlog Cataract

• Cataract: 1 % = 210.000
• Surgical capacity: 80.000/year
• Backlog : 130.000/year
• Affected by: unawareness community
high cost of surgery
ophthalmologist <<
reach surgical capacity <<
• Community ophthalmology: elimination cataract:
Promotion
Prevention
Cure
Rehabilitation
Ophthalmologist
General healthcare workers
Non healthcare