Cataract

It is a clouding or opaqueness of the crystalline

lens which leads gradual painless blurring and
eventual loss of vision
A cause of blindness and is conventionally
treated with surgery
Vision loss occurs because opacification of
the lens obstructs light from passing and
being focused on the retina
3rd leading cause of preventable blindness
 Due to etiological factors

Decrease in the function of active Altered oxidative

transport of pump mechanism of lens reactions

Reversal of sodium /potassium Decreased level of

ratio amino acids

Hydration of lens Decreased synthesis of

fibers proteins in lens fibers

Denaturation of lens proteins

Opacification of cortical lens fibers

Causes

Aging
Loss of lens transparency
Decreased oxygen uptake
Denaturation of proteins in lens
Accumulation of a yellow brown pigment
due to the break down of lens protein
Trauma
Blunt trauma causes swelling, thickening
and whitening of the lens fibers
Swelling resolves but white color remains
Or
Capsule can be damaged and allows water
from other parts to enter the lens,
obstructing light from reaching the retina
Associated ocular conditions

Retinitis pigmentosa – degenerative

disorder caused by abnormalities of the
photoreceptors
Myopia
Retinal detachment and retinal surgery
Infection
Toxic factors
Corticosteroids
Chemical eye burns or poisoning
Cigarette smoking

Nutritional factors
Reduced levels of antioxidants – antioxidants
helps to prevent oxidative changes in proteins
and fat
Poor nutrition
Obesity
Physical factors

Perforation of lens with sharp object or

foreign body
Electric shock
Ultraviolet radiation

Risk factors – age, ultraviolet light exposure,

high dose of radiation exposure, drug effects,
trauma
Systemic diseases and syndromes

Diabetes mellitus
Down syndrome
Renal disorders
Musculoskeletal disorders
Classification
Age related cataracts Based on the area of
(senile cataract) lens
Congenital cataract Nuclear, cortical and
Secondary cataract posterior subcapsular
Traumatic cataracts
Based on the
characteristics
Partial or complete
Stationary or
progressive
Hard or soft
Nuclear cataract
 Central opacity in the lens
 It is associated with myopia

Cortical cataract
 Cortical cataract involves the anterior, posterior or equatorial
(peripheral) cortex of the lens
 People with highest levels of sunlight exposure have twice the
risk
Posterior subcapsular cataract
 Posterior subcapsular cataract occur in front of the posterior
capsule.
 Typically develop in younger people
 Associated with prolonged corticosteroid use, diabetic and
ocular trauma
Signs and symptoms
Painless, blurry vision
Reduced visual acuity
Myopic shift – return of ability to read without
glasses
Astigmatism - optical defect in which vision is
blurred due to the inability of the optics of the
eye to focus a point object into a sharp focused
image on the retina
Visible opaqueness
Diplopia
Abnormal color perception, glare (due
to light scatter caused by lens opacities
and significantly worse at night and in
bright light when th pupil dilates )
Brunescence – color shift from yellow
to brown
Reduced light transmission
Color of pupil will be yellowish, gray or
white
Develop in both eyes
Diagnostic findings
Visual acuity measurements
Snellen visual acuity test
Ophthalmoscopy
Slit lamp microscopic examination
Blood test
Visual field perimetry
A – scan ultrasound
Prevention

Avoid the risk factors – UV rays, x

rays, smoking
Wear sunglasses
Regular intake of antioxidants
(vitamins A,C AND E) would protect
against risks
Prevent accidents
Treat underlying disorders properly
Management
Non surgical treatment will not cure cataract
Surgery is performed as outpatient basis
usually takes less than 1 hour and
discharged in 30 minutes
Topical and intra ocular anesthesia – 1%
lidocaine gel is used
Patient can communicate and cooperate
during surgery
IV moderate sedation – to minimize anxiety
When both eyes have cataracts – one eye is
treated first, after several weeks the other
cataracts is been managed.

This will help one eye to heal properly and

the doctor can check the surgical procedure
is effective or not

The doctor can also check the presence of

any complications due to surgery.
 Phacoemulsification
Most widely used cataract surgery
Through a very small incision in the surface of the
eye
An ultrasound probe is then inserted
This uses ultrasonic vibrations to dissolve
(phacoemulsify) the clouded lens
These tiny fragmented pieces are then suctioned
out through the same ultrasound probe
Once the cataract is removed, an artificial lens is
placed into the thin capsular bag
 Steps of phacoemulsification
Anesthesia

Exposure of the eyeball using a lid speculum

Entry into the eye through a minimal incision

Viscoelastic injection to stabilize the anterior chamber

Capsulorhexis -Ultrasonic destruction or emulsification

and aspiration of the fragments

Implantation of the intra ocular lens

Viscoelastic removal

Wound sealing
Extra capsular cataract extraction
ECCE
Only uses in very advanced cataracts where the lens
is too dense to dissolve into fragments
This technique requires a larger incision so that the
cataract can be removed in one piece without being
fragmented inside the eye
The posterior capsule is left intact.
An artificial lens is place in the same capsular bag
An eye patch after the surgery is needed.
Intracapsular cataract extraction
ICCE
This surgical technique requires an even
larger wound than extracapsular surgery

In this the entire lens and the surrounding

capsule is removed

Intra ocular lens is placed in front of the iris.

Lens replacement
After removal of the crystalline lens, the
patient is referred to as aphakic (without lens)
Three lens replacement options – aphakic eye
glasses, contact lens, and IOL implants
IOL -It is permanently placed, no maintenance
or handling and neither felt by the patient nor
noticed by others
Made of silicone or acrylic material
Monofocal lens – commonly implanted
lenses
They have equal power in all regions of the
lens and can provide high quality distance
vision
It have sharpest focus at only one distance
Usually a pair of spectacles is need for
better quality
Toric lens – it have more power in one
specific region in the lens

Multifocal lens – latest advancements

It have variety of regions with different power

that allows individuals to see at a variety of
distances, including distance and near

 BUT They can cause more glare than

monofocal or toric lenses
Preoperative care
Eye examination by surgeon to confirm the
presence of cataract and to determine the
patient is suitable candidate for surgery

Eyes should have normal pressure. If

increased pressure is there it should be
controlled with medication before surgery

In some cases a combined cataract –

glaucoma procedure (phaco trabeculectomy)
can be planned
Pupil should be adequately dilated
Retinal detachment should be ruled
NPO – 6- 8 HOURS BEFORE in selected cases
Pre operative antibiotic eye drops
NSAIDS eye drops
Mydriatics – phenylephrine HCL acid
Every 10 min for four doses atleast 1 hour
before surgery
 cycloplegics (paralyses the ciliary muscles thus
losing the accommodation of lens) -
tropicamide, atropine, cyclopentolate HCL
Post operative care
Discharged within few hours
Eye patch should be done – the dressing is
removed a day after surgery
Position the patient on back or up operated side to
prevent pressure in operated eye
Eye protective shields should be provided for 2-3
weeks for avoiding accidental injury
Proper follow up – 4-5 visit in a period of 5 to 6
weeks
Tell the patient to avoid situation that IOP can
increases (sneezing, coughing, vomiting, straining,
or sudden bending)
Instruct the patient
Avoid touching the operative eye
Take care to prevent soap or water from entering the
operative eye during face or hair washing
Avoid heavy lifting
Exercise in moderation
Wash hands before instilling eye medications
Wear sunglasses to prevent bright lights
Wait 2 -3 min between administration of different eye
medications (antibiotics and corticosteroids)
Administer eye ointments last
Avoid smoking, driving
Complications of cataract surgery
Immediate preoperative complications
Retrobulbar hemorrhage – can result due to
anesthesia injection
Effects – increased IOP, lid tightness, and
subconjunctival hemorrhage
Management
Canthotomy – slitting of canthus to reduce the
IOP
Puncture of anterior chamber
Intraoperative complications
Rupture of posterior capsule and
Suprachoroidal hemorrhage
Management is vitrectomy
 Post operative complications
Early
Acute bacterial endophthalmitis – antibiotic therapy
Toxic anterior segment syndrome (TASS) – non
infectious inflammation caused by toxic agent used
to sterilize surgical instruments
Late
Suture related problems
Malposition of IOL
Opacification of posterior capsule