EVALUATION OF

LENS OPACITY
ARAVIND KUMAR
 CONTENTS
•Introduction: Vision 2020
•The Crystalline Lens
•Cataract
•Evaluation of Cataract
•Lens Opacity: Āyurvedic View
•Conclusion
 THE
CRYSTALLINE LENS
 EMBRYOLOGY
• 25th day of gestation: formation of optic vesicle from
diencephalon
• Placode – columnar ectoderm cells at 27th day
• Lens pit – indentation of lens placode at 29th day
• Lens vesicle – single layer of ectoderm cells attached to
basement membrane
• Primary lens fibers – elongated cells in the posterior layer of
lens vesicle
• Secondary lens fibers – elongated and proliferated epithelial
cells near the equator
• Sutures – pattern of elongated and interdigitated cells with the
fibers on the opposite side of the lens
 ANATOMY
• Bi-convex structure
• Between iris and vitreous in patellar fossa
• 5-10mm in diameter
• Thickness
• 3.5mm at birth
• 5mm at old age
• Weight: 135mg at 0-9 years to 250mg at 40-80 years
• Anterior and Posterior Surfaces
• Refractive Index: 1.39; total power: 15-16D
 ANATOMY – CONTD.
• Capsule – thin, transparent, hyaline material surrounding
the lens
• Anterior epithelium – single layer of cuboidal cells that lies
deep to epithelium
• Lens fibers – elongation of epithelial cells
• Cortex – youngest lens fibers
• Nucleus – oldest lens fibers
 ANATOMY – CONTD.
NUCLEUS CORRESPONDS T0 POSITION/ORIGIN
EMBRYONIC First 3 Months of Gestation Primary lens fibers caused
by elongation of cells of
posterior wall of lens
FETAL 3 months of gestation till Fibers surround fetal
birth nucleus
INFANTILE Birth till Puberty Fibers surround infantile
nucleus
ADULT Puberty till death Fibers surround infantile
nucleus
 TRANSPARENCY

PHYSIOLOGY METABOLISM

ACCOMMODATION
 Sparsicity
of the Single
Auto- cells
oxidation layer of
epithelial
cells

Pump Close
mechanism Transparency alignment
of lens of
fibers of the Lens individual
cells

Uniform
index of
refraction Semi-permeable
character of lens
Avascularity capsule
• Metabolism
• Requires a constant supply of ATP
• Soluble and insoluble proteins
• Water-soluble proteins – a-crystallin, b-crystallin, g-crystallin
• Water-insoluble proteins – albuminoid fraction
• Generation of energy
• Anerobic glycolysis
• Hexose-monophosphate shunt
• Krebs cycle
• Low sodium and water content using Na-K-ATP pump
• Accommodation
• Changes focus from distant to near vision
• Action of ciliary muscle on the zonular fibers
• Gradually loses its ability to change shape with age
• After 40, nucleus cannot bulge anteriorly and change its
anterior curvature
• Presbyopia
CATARACT
 ETYMOLOGY AND DEFINITION
• From the Greek Katarracktes and the Latin Cataracta, which
means “waterfall”
• Normal lens – crystalline structure
• Opacity, either congenital or acquired
• Causes:
• Degeneration and opacification of lens fibers already formed
• Formation of aberrant lens fibers
• Deposition of other material in its place
 Congenital/Developmental

Etiological Classification

Acquired
 Anterior
CAPSULAR
Posterior

Anterior
SUBCAPSULAR
Posterior
MORPHOLOGY CORTICAL

SUPRANUCLEAR

NUCLEAR
Anterior
POLAR
Posterior
 Congenital Cataract

Sutural and
Capsular Polar Nuclear Lamellar Generalized
Axial

Anterior Anterior Floriform Blue-dot

Posterior Posterior Coralliform Coronary

Spear-
Total
shaped

Anterior axial
Membranous
embryonic
 Senile
Miscellaneous
Traumatic
syndromes

Osseus
disease Acquired Metabolic

Cataract
Dermatologic Electric

Toxic Radiation
 Heredity Malnutrition

Infections
Maternal
factors Drugs

Radiation

Deficient
oxygenation
Congenital
Metabolic
disorders

Fetal factors Other congenital

anomalies

Idiopathic Birth trauma

Malnutrition
 Acquired
Cataract

Senile Pre-senile Metabolic Complicated Radiation Electric Syndermatotic

Diabetes
Heredity Heredity Inflammation
mellitus

Dietary Diabetes
Galactosemia Degenerative
factors mellitus

Atopic Retinal
Dehydration Hypocalcemia
dermatitis detachment

Myotonic Wilson’s
Smoking Glaucoma
dystrophy disease

Intraocular
tumors
 EVALUATION OF
CATARACT
(INCLUDING EVALUATION PRIOR TO
CATARACT SURGERY)
 DEMOGRAPHIC DATA
• Name and Address
• Rural areas and Hot, dry climate – higher incidence
• Age
• At birth – Congenital Cataract
• Birth to Puberty – Developmental Cataract
• Puberty to 50 years – Pre-senile Cataract
• After 50 years – Senile (Age-related) Cataract
• Occupation – Heat Cataract in Glass Factory workers
• Socioeconomic Status – More risk in low status
 PRESENTING COMPLAINT
• Gradually Progressive Diminished Vision
• White-colored pupillary reflexes (leukocoria) –
Congenital Cataract; seen by parents
• Early stages
• Glare – Diffraction of Light by opacity
• Colored Haloes – presence of water droplets, which causes
change in refractive index
• Uniocular Polyopia – irregular refraction of the lens due to
variable refractive index
 HISTORY OF PRESENTING
COMPLAINT
CATARACT POSITION LOSS OF VISION,
etc.
CUPULIFORM CENTRAL OPACITY EARLY;
Day blindness
CUNEIFORM PERIPHERAL OPACITY LATE;
Diminution of Vision at
Night
NUCLEAR SCLEROSIS LENS NUCLEUS DISTANT VISION
 HISTORY OF PRESENTING
COMPLAINT – CONTD.
• “Second Sight” – Nuclear Cataract
• Due to Index Myopia
• Other complications
• Redness
• Watering Uveitis, Glaucoma, Acute
• Pain Dacryocystitis, Conjunctivitis
• Discharge
 HISTORY OF PRESENTING
COMPLAINT – CONTD.
• Spectacles (Glasses)
• For near vision – Presbyopia
• Trauma
• Vossius Ring
• Rosette Cataract
• Dislocation of Lens
• Subluxation of Lens
• Concussion Cataract
 HISTORY OF PAST ILLNESS
• Diabetes Mellitus – Pre-senile Cataract
• “Snowstorm Cataract”
• Other Conditions
• Hypertension
• COPD
• Asthma
• Ischemic Heart Disease
• Tuberculosis
• Anterior Uveitis – Complicated Cataract
 TREATMENT HISTORY
• Usage of Topical Eyedrops
• Prolonged Steroid Usage – Posterior
Subcapsular Cataract
• Prolonged use of Miotics (demecardium
chloride, echothiophate) – Anterior
Subcapsular Cataract
• Usage of Chlorpromazine, Bisulfan, and
Amiodarone
• Surgery
• After ECCE – “After-Cataract”
 PERSONAL HISTORY
• Diet
• Deficiency of Proteins, Amino acids, and essential elements
• Dehydration crisis – diarrhea, cholera, etc.
• Deficiency of Vitamin E, C, and Riboflavin
• Bowel
• Appetite
• Micturition
• Sleep
 OBSTETRIC AND
MATERNAL HISTORY
• Malnutrition – Familial Zonular Cataract
• Infections
• TORCH
• Rubella = 50%
• Drug intake
• Thalidomide, Corticosteroids
• Birth Trauma
• Deficient Oxygenation – Placental Hemorrhage
• Association with Other Anomalies
• Down’s Syndrome, Lowe’s Disease, Myotonica Dystropica
 GENERAL HEALTH, ETC.
• Control of Systemic Diseases
• Diabetes, Hypertension, Surgery-complicating Ailments
• Knowledge about Medications
• Especially a-1A Blockers
• Ocular History
• Inflammatory conditions, Trauma, etc.
• Social History
• Impact on person’s lifestyle and work
 VISUAL FUNCTIONS
• Visual Acuity
• Both Distant and Near
• Refraction
• Determine the IOL power to get the optimal postoperative
refraction
• Brightness Acuity
• Visual acuity in a well-lit room
• Contrast Sensitivity
• Testing of Visual Field
• HFA, Automated Perimetry
 VISUAL FUNCTIONS – CONTD
Growth Effect on Effect Induced
Cataract Glare
Rate Distance on Near Myopia
CORTICAL Moderate Mild Mild Mild None

NUCLEAR Mild Mild Moderate None Moderate

PSC Rapid Marked Mild Moderate None

 EXTERNAL EXAMINATION
• Body habitus and abnormality of the external eye and
adnexa
• Conditions that impact surgical approach
• Ankylosing spondylosis, Kyphosis, Obesity, Head Tremor
• Ocular conditions
• Entropion, Ectropion, Blepharitis, Acne rosacea, Tear Film
Abnormalities, Exposure Keratitis, Nasolacrimal Infection
• Motility
• Tropia from disruption of fusion – Diplopia post surgery
• Amblyopia – Limited improvement
• Pupils
• Limited – optic nerve dysfunction in RAPD
• Small pupils – examination after full dilatation
 SLIT-LAMP EXAMINATION
• Conjunctiva
• Scarring and Filtered Bleb
• Symblepharon or shortening of fornices – systemic pathology
• Vascularization – compromised healing and limited surgical
exposure
• Cornea
• Specular Reflection – Endothelial cell count and morphology
• Descemet’s membrane irregularities with corneal guttata – limit
visual acuity following surgery
• Contact lens wear, history of corneal dystrophy, arcus, pannus,
and stromal opacity – limit surgical view into AC
 SLIT-LAMP EXAMINATION
– CONTD.
• Anterior Chamber
• KPs – Uveitis
• Gonioscopy – Angle abnormalities and ACIOL implant
• Iris
• Iridodonesis and Exfoliation at margin of undilated pupil –
weakened or absent zonular attachments to lens
• Synechiae after dilation
• Poorly-dilating pupil – radial iridotomy, scleral iridotomy, posterior
synechiolysis, etc. for adequate exposure
 SLIT-LAMP EXAMINATION
– CONTD.
• Crystalline Lens
• Before and After Dilatation of the Pupil
• Nuclear Density, Exfoliation syndrome, Distortions of the
Retinoscopic Reflex
• Clarity of the opacity to asses contribution to visual defect
• Position of Lens and Integrity of Zonular Fibers
• Iris Shadow – D/D between ISC and MSC
 GRADING OF NUCLEAR CATARACT
Grade of Description of
Color of Nucleus
Hardness Hardness
White/Greenish
I Soft
Yellow
II Soft-Medium Yellowish

III Medium-Hard Amber

IV Hard Brownish

V Ultra-Hard Blackish
 EXAMINATION OF THE
POSTERIOR SEGMENT
• Both direct and indirect ophthalmoscopy
• Early macular degeneration – Limit rehabilitation after
operation
• Diabetic patients – edema, retinal ischemia, PDR, NPDR
• Optic Nerve Head (Disc) – Cupping, Pallor, Other
Abnormalities
• Other Techniques
• B-scan USG – useful in dense opacity
LABORATORY INVESTIGATIONS
• TORCH test – Intrauterine Infections
• Urine Test – Galactosemia
• Urine Chromatography for Amino Acids – Lowe’s disease
• Blood Glucose – Hyperglycemia
• Hypocalcemia – Serum Ca and KO43 levels, X-Ray Skull
 Mature Senile Cataract Leukocoria

White Reflex in Pupillary Area White Reflex in Pupillary Area

Normal Size of Pupil Pupil is Semi-Dilated

Fourth Purkinje Image absent Fourth Purkinje Image present

Cataractous lens Transparent lens with White Reflex

USG normal USG: Opacity in Vitreous Cavity

 Retinoblastoma

Retinopathy of
Prematurity
Persistent Hyperplastic
Primary Vitreous
Other Conditions of Inflammatory Deposits
Leukocoria on Vitreous

Choroidal Coloboma

Toxocara
Endophthalmitis
Exudative retinopathy of
Coats
Immature Senile Cataract Nuclear Sclerosis
Painless, Progressive Loss of Painless, Progressive Loss of
Vision Vision

Greyish Color of Lens Greyish Color of Lens

Black Spots against Red Glow No Black Spots Against Red Glow

Cataractous Cortex on SLE Clear Lens on SLE

No Improved VA on Pinhole Improved VA on Pinhole

Examination Nuclear ISC MSC HMSC (M) HMSC (S)

Visual Acuity 6/9-PL+ 6/9-FC+ HM-PL+ PL+ PL+

Pearly white Milky white,

Color of Lens Grey, Amber Greyish White with sinking Hyper-white Dirty White
brown nucleus Spots

Iris Shadow Seen Seen Not Seen Not Seen Not Seen

Multiple Dark
Distant Direct Central Dark
Areas in No Red Glow No Red Glow No Red Glow
Ophthalmoscopy Area
periphery
Shrunken Les
Complete Milky White,
Slit-Lamp Nuclear Cataractous with Thickened
Cataractous Sunken Brown
Examination Opacity changes Anterior
Cortex Nucleus
Capsule
 INDICATIONS OF CATARACT
SURGERY
• Congenital Cataract
• Bilateral dense opacities (within 6 weeks of birth)– prevent
stimulus deprivation amblyopia
• Unilateral dense cataract – within six days
• Acquired Cataract
• Visual improvement – most common indication
• Cosmetic indication – obtain a black pupil
• Medical indication
 LENS OPACITY:
ĀYURVEDIC VIEW
• Pat + Klacha pratyaya
• Layer, veil, covering, especially of the eye
Patala Composition
Prathama Tejas + Jala
Dvitiya Pisita (Mamsa)
Trtiya Medas
Caturtha Asthi
• Different opinions regarding Patala
• Dalhana reverses Susruta’s view
• Layers of Cornea – Vagbhata’s description of Kshataja Sukla
• Layers of Lens
• Layers of Retina
• Prathama Patalagata Dosha – Avyakta Darsana
• Dvitiya Patalagata Dosha vis-à-vis Opacity
• Distant objects as nearby and vice versa (Vagbhata, Susruta) –
Polyopia due to irregular refraction/Accommodative
disturbances
• Bahudha bahudhasthite (Vagbhata) – Polyopia
• Inability to find the eye of a needle (Susruta) – Accommodative
disturbances
• Trtiya Patalagata Dosha (Kaca acc. to Vagbhata)
• Drishtirhiye ca ta kramat/Anucailavrtopamam (Vagbhata) –
progressive diminution of vision
• Yatha varnam ca rajyeta (Vagbhata) – different colors seen in
nuclear cataract
• Caturtha Patala (Linganasa)
• Timira
• 1st and 2nd patala acc. to Vagbhata; 1st, 2nd, and 3rd patala acc. to
Susruta
• Vataja Timira, etc. laksana
• Seeing the moon, sun, lamp, etc. as many – Polyopia in early
stage of cataract
• Red color of linganasa – grade III of nuclear opacity
• Pittaja Timira, etc. laksana
• Seeing the rainbow, sun, etc. as though surrounded by color –
haloes
• Yellow organ of vision in Pittaja linganasa – Nuclear opacity
Grade I
• Kaphaja Timira, etc. lakshana
• White color of the lens – mature cataract
• Linganasa Upadrava
• Avartaki, Sarkara, Rajimati, Chinnamsuka, Candriki, Chatraki
• Indications for Linganasa Vyadhana
• Kaphaja
• No upadrava
• Complete loss of vision
• Not shaped like half moon, sweat drop or pearl
• Uneven, thin in the center, not fixed
• Contraindications for Linganasa Vyadhana
• Contraindications for siravyadha
• Trshna, Dushta pinasa, Kasa, Agnimandya, Bhaya, Chardi, Siro,
Karna, Nasa, Netraroga
 CONCLUSION
• Leading cause of preventable blindness worldwide
• Can be prevented through various means
• Surgery can restore eyesight in many cases
• Mainstay of cataract treatment
• Tamomayam jayata ekarupam (Vagbhata)
THANK YOU!