WHAT IS CATARACT?

 Any opacity in the lens or its capsule which leads to decrease in

vision ,whether developmental or acquired is called a cataract
CLASSIFICATION OF CATARACT
A. Etiological classification

Congenital
and Acquired
developmental cataract
cataract
B.MORHOLOGICAL CLASSIFICATION

Capsular Subcapsular
cataract Polar
• Anterior Cortical Nuclear
• Anterior • posterior •Anterior
• posterior •posterior
Congenital and developmental cataract
 Developmental cataract may be present at birth
(congenital) or it may develop later.

 Has tendency to affect particular zone which was being formed

when the disturbance occurred.
Various morphological forms:

1. Punctate cataract
2. Lamellar cataract
3. Fusiform cataract
4. Nuclear cataract
5. Coronary cataract
6. Anterior and posterior polar cataract
 PUNCTATE CATARACT : most
common type
 Small opaque dots multiple and
scattered all over the lens .
 When they appear as tiny blue dots by
oblique illumination known as
cataracta coerulea or blue dot cataract.
 When crowded in the y-sutures
termed sutural and anterior axial
embryonic cataract .
 Another variant cataracta centralis
pulverulenta , with a central
spheroidal or biconvex opacity
consisting of powdery fine white dots
within embryonic and fetal nucleus.
 Non-progressive and has no visual
significance
 LAMELLAR CATARACT : 50% of all
visually significant congenital cataracts .
 Development is affected at zone around the
embryonic or fetal nucleus.
 Opacity is sharply demarcated and area of
the lens within and around the opaque zone
is clear although linear opacities like spokes
of a wheel called riders which run outwards
towards the equator.
 Bilateral
 NUCLEAR CATARACT :
 development of lens affected at very
early stage central (embryonal)
remains opaque .
 Progressive type of congenital cataract
is associated with rubella in the
mother if contracted in second or
third month of pregnancy .
 The lens nucleus is found to be
necrotic and whole lens becomes
opaque .
 CORONARY CATARACT :
developmental cataract occurring
around puberty
 Situated in the deep layers of
cortex and most superficial layers
of adolescent nucleus .
 Appears as a corona of club shaped
opacities near the periphery of
lens.
 Non-progressive .
 ANTERIOR POLAR CATARACT :
this may be developmental owing
to delayed formation of anterior
chamber .
 More commonly it is acquired .
 Sometimes white plaque forms in
lens capsule which projects in
anterior chamber like pyramid
called anterior pyramidal cataract.
 Reduplicated cataract .
 Opacities are not progressive.
POSTERIOR POLAR CATARACT: due to persistence of posterior part of
vascular sheath of lens.
 Sometimes particularly in cases with persistent hyaloid artery, the lens is
deeply invaded by fibrous tissue and a total cataract is formed.
ACQUIRED CATARACT
 Age related or Senile cataract
 Traumatic cataract
 Complicated cataract
 Metabolic cataract
 Electric cataract
 Radiational cataract
 Toxic cataract
 Cataract associated with skin diseases
 Drug induced cataract
 Cataract associated with osseous diseases
 Cataract associated with miscellaneous syndromes:
dystophica myotonica, down syndrome, lowe’s syndrome,
treacher Collin’s syndrome
Senile cataract
 Most commonest type
 Affecting persons usually above 50 years of age
 Usually bilateral but almost always one eye is affected earlier then the
other
 Morphologically, occurs in 2 forms-
1. cortical
2. nuclear
Maturation of cortical cataract
 Nuclear cataract
 Grade II
Grade I

Grade III GradeIV

Traumatic cataract
 Blunt non-penetrating injury or concussion
may cause lens opacification as an acute
event or late sequel
Vossius ring
 Lens may show following changes
1. Vossius ring- circular ring of brown
pigments seen on anterior capsule
2. Early rosette- feathery lines of opacities
along star shaped suture lines
3. Late rosette- develops in posterior cortex
1-2 years after injury
Early Rosette Late Rosette
Traumatic cataract
 Perforating or penetrating injuries may cause

1. Perforation of lens capsule leading to free floating lens particles in

anterior chamber
2. Opacification of cortex at site of rupture
3. Stationary focal cortical cataract
Complicated cataract
 Opacification of lens secondary to some other
intraocular diseases
 Seen in-
1. Inflammatory conditions -chronic uveitis,
hypopyon corneal ulcer, Endopthalmitis
2. Degenerative conditions- RP, retinal
dystrophies, myopic chorio-retinal
degeneration Poly chromatic lustre/
3. Retinal detachment Bread crumb appearance
4. Glaucoma (primary or secondary)
5. Intraocular tumours
Cataract associated with systemic diseases
 Diabetic cataract:

 Snowflake cataract or snow

storm cataract
Myotonic dystrophy
Galactosemia

oil droplet cataract

Down syndrome
 Punctate subcapsular cataracts
Atopic cataract
Cataract due to toxic agents
 Drug induced
 Cigarette smoker
 Copper
 Iron
 Gold
 DRUG INDUCED CATARACT

CHLORPROMAZINE STEROID
INDUCED- pigments deposits on anterior INDUCED-posterior subcapsular
capsule cataract

ELECTRIC CATARACT

•Other drugs-
•Amiodarone •Chloroquine
•Busulphan •Miotics
Sunflower cataract : copper
Cataract grading systems
 Grading of nuclear hardness
(Emery Little Classification)
• Grade I-greyish nucleus
• Grade II- yellowish white
• Grade III- amber
• Grade IV- brown
 (cataracta Brunescens)
• Grade V-dense brown or black
 (cataracta Nigra)
 LOCS I classification for cataract

 Grading-
 Grade zero- absence of lens
opacities
 Grade 1-early opacification
 Grade 2- definite cataract
LOCS II classification for cataract
Nuclear Standard Description

N0 clear nucleus

NI early degree of nuclear opacification

NII moderately advanced nuclear

opacification

NIII advanced nuclear opacification and

browning
C0 clear lens devoid of aggregated dots,
flecks, vacuoles and waterclefts

Ctr minimal degree of cortical opacification

and/or minispoke formation

CI more extensive opacification with small

minispokes

CII cortical spoking that obscures more than

2 full quadrants

CIII opacification that obscures about 50% of

the intrapupillary zone

CIV advanced opacification filling about 90%

of the intrapupillary zone
Posterior Subcapsular Description
Standard

P0 Clear posterior capsule

PI Cataract filling less than 30% of the area of the posterior

capsule

PII about 30% opacification of the area of the posterior

capsule

PIII about 50% opacification of the area of the posterior

capsule
LOCS III classification for cataract
Clinical features of
Cataract
 Reduced visual acuity
 Loss of contrast sensitivity
 Glare
 Second sight /myopic shift
 Monocular diplopia / polyopia
 Frequent change of glasses
 Coloured haloes
 Altered colour perception
 Generalized depression of sensitivity on Visual field
analysis
Symptom Pathogenesis Type of cataract

Coloured halos around light Irregularity in refractive index of Cortical cataract

different part of lens

Second sight/ myopic shift Change in refractive index of lens Nuclear cataract
causing index myopia

Colour shift(become more obvious Blue end of spectrum is more Nuclear cataract
after surgery) absorbed by cataractous lens

Visual field loss Generalised reduction in sensitivity All types

due to loss of transparency
Symptom Pathogenesis Type of cataract

Frequent changes of glasses Rapid change in refractive index of Cortical or nuclear

lens

Gradual, painless, progressive Reduction in transparency of lens All types

diminution of vision

Loss of ability to see objects in Loss of contrast sensitivity, which is Posterior subcapsular cataract
bright light, blinded with light of greater at higher spatial frequency:
oncoming headlamps when driving constriction of pupil leading to cut
at night off peripheral vision

Monocular diplopia or polyopia Cortical spokes opacities in Cortical cataract

conjunction with water clefts that
from radial wedges containing fluid
of lower refractive index than the
surrounding

Glare Increased scattering of light Cortical and PSC

Preoperative assessment
 Ocular history
 Systemic history
 Ocular examination
 Ocular investigations
 Lab investigations
Ocular history
 h/o of trauma, amblyopia, glaucoma, optic nerve abnormalities, or
retinal disease
 h/o previous ocular surgeries
 If the patient has had cataract surgery in the fellow eye, it is
important to obtain information about the operative and
postoperative course.
Systemic history
 h/o of systemic diseases especially diabetes mellitus,
ischemic heart disease, chronic obstructive pulmonary
disease, bleeding disorders
 Systemic alpha blockers(tamsulosin)- floppy iris syndrome
 Antiplatelets and anticoagulants
 h/o of long term use of steroids
 Any h/o drug allergy to sulfonamides and antibiotics
Ocular examnation
 Visual acuity for distance and near
 Head posture and Ocular movements to be checked
 Cover and uncover test to be done to look for strabismus
 Ocular adenexa- to look for blepharitis, ectropion, entropion,
lagophthalmos
 Conjunctiva-congestion,scarring,symbleharon
 Cornea- to look for any opacity and prominent arcus senilis
 Any deposits over corneal endothelium-uveitis or glaucoma

 Anterior chamber examination and gonioscopy to rule out any angle

pathologies

 Pupil- reacting promptly to light or not

 Direct and indirect light reflexes to be checked
 Presence of RAPD- implies pathology in optic nerve
 Dilatation to mydriatics to be noted
Macular functions tests
 Two point discrimination test
 Maddox red test
 Color perception
 Entoptic visualization
 Blue light entoptoscopy
 Measurement of IOP
 conjunctival swab for cultural sensitivity
 Oro dental check up to exclude septic foci
 Fundus evaluation : ophthalmoscopy and fundus evaluation with
opaque media
 Retinal functions tests : PR must be present in all 4 quadrants
Electro-Retinogram
Electro-Oculogram
Visual evoked potential
Pre-operative measurement
 Biometry : keratometry and A-scan ultrasonography
(IOL MASTER)
 B-scan ultrasonography
 Corneal topography: specially POST LASIK PATIENTS ( PENTACAM
SHOULD BE DONE)
 Corneal pachymetry
 Specular microscopy: FOR CORNEAL ENDOTHELIAL CELL
COUNT
Systemic investigations
 Clinical: Blood pressure
 Lab tests: complete hemogram
RBS/FBS
Bleeding and clotting time
Urine routine microscopy
X-ray chest and ECG
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