CHAPTER I INTRODUCTION

Cataract is an eye disease that is very known to the public at this time. Cataract comes from the Greek word Katarrakhies, English word cataract and Latin word cataracta which means waterfall. Likely due to cataract patients seemed to see something like covered by a waterfall in front of his eyes.

Cataract is the opacification of the lens. Majority of cataracts are not visible to ordinary observers until it is quite solid and cause blindness. However, cataracts at the earliest stages of development can be seen through a maximal dilated pupil with an ophthalmoscope, magnifying glass. The majority of cases are bilateral, although the pace of development in each eye is seldom the same. Traumatic cataract, congenital cataract and other types of catarat are more rare. Age is the most common cause of cataracts. Besides, cataracts can also be caused due to congenital, hereditary, and is also associated with systemic diseases, metabolic, other ocular disease, trauma, radiation, maternal infections, electrical trauma and drug usage.

The majority of cataracts are not visible to the ordinary observer until it is quite solid (mature or hipermatur) and causes blindness. In the earliest stages of the development of cataracts, it can be detected from a maximally dilated pupil with an ophthalmoscope, loupe or slitlamp. In congenital cataracts, the main abnormality occurs in the lens nucleus (fetal nucleus or embryonic nucleus), depending on the time of caractogenik stimulus or in the anterior or posterior pole of the lens when the disorder is located on the lens capsule. In cataracts due to age, especially disorders of the nucleus (nucleus sclerosis), cortex (coronary or cuneiform opacities), or posterior subkapsul area.

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CHAPTER II LITERATURE REVIEW

2.1 Anatomy and physiology of the lens

2.1.1. Anatomy of the Lens

The lens is a biconvex structure, avascular, colorless and transparent. The thickness is 4 mm and it is 9 mm in diameter. Lens is hanged behind iris by zonula (zonula Zinnii) that is connected to ciliary body. Aquaeus humor is located anterior to the lens whereas viterus humor is located posteriorly. Lens capsule is a semipermeable membrane that can be bypassed by water and electrolytes. On the front there is a layer of subcapsular epithelium. Lens nucleus is harder than its cortex. Accordance with age, subepithelial lamellar fibers are continuously produced and the lens gradually becomes less elastic.

The lens consists of sixty-five percent water, thirty-five percent protein, and a few minerals normally found in other body tissues. There is higher potassium content in the lens than in most other tissues. Ascorbic acid and glutathione present in the oxidized and reduced forms. There are no pain fibers, blood vessels or nerves in lens.

Figure 1 : Anatomy of Human Lens

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2.1.2. Physiology of Lens

The main function of the lens is to focus light rays onto the retina. To focus light coming from distant, ciliary muscles relax, making zonula fibers tense and lenses to minimize the anteroposterior diameter to the smallest size, refractive power of the lens is reduced so that the light beam parallel or focused onto the retina. To focus light from near objects, ciliary muscles contract so that the zonula tense is reduced. Elastic lens capsule which then affects the lens becomes more spherical accompanied by an increase in refractive power.

The physiologic cooperation between ciliary body, zonula and lense to focus the object close to the retina is known as accommodation. Along with age, the ability of the lens refraction decreases slowly. In addition there is also a function of refraction, which is a part of the eyeball optics to focus the light to yellow spots, lenses accounted +18.0 - diopters.

2.1.3 Normal Lens Metabolism

Transparency of the lens is maintained by a balance of water and cations (sodium and potassium). Both cations from the aqueous and vitreous humor. Potassium levels in the anterior part of the lens is higher in comparison to the posterior. And sodium levels in the posterior greater. K ions move to the posterior and exit into the aqueous humor, from the outside Ion diffusion of Na entry and move to the anterior portion of K ions to replace the pump and out through the active Na-K-ATPase, whereas calcium levels were maintained in the by Ca-ATPase.

Glikolsis lens through anaerobic metabolism (95%) and HMP-shunt (5%). HMP shunt pathway produces NADPH for fatty acid biosynthesis and ribose, as well as to the activity of glutathione reductase and aldose reductase. Aldose reduktse is an enzyme that converts glucose into sorbitol, and sorbitol converted into fructose by the enzyme sorbitol dehydrogenase. Disorder is clouding the lens, distortion, dislocation, and geometric anomalies. Patients who experience these disorders will suffer painless blurring of vision.

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2.2.Cataract

2.2.1. Definition

A cataract is a cloudiness in the situation where there is fiber or material in the lens or the lens capsule is also a pathological condition in which the lens becomes cloudy due to lens hydration fluid lens or lens protein denaturation. Cataracts cause the patient could not see clearly because of the cloudy lens is difficult light reaching the retina and will produce a blurred shadow on the retina.

Cataracts caused by hydration (addition of liquid lens), the lens protein denaturation, the process of aging (degenerative). Cataracts are not uncommon in young people, newborn babies as congenital defects, viral infections (rubella) during the growth of the fetus, with the growth of genetic eye disease, injury to the lens of the eye, retinal stretch and excessive exposure to ultraviolet light. Oxidative damage by free radicals, diabetes mellitus, smoking, alcohol and drugs, and steroid glaucoma (high eye pressure), may lead to the risk of cataracts.

2.2.2 Epidemiology

Studies in the United States identify cataracts in about 10% of people, and this incidence increases to around 50% for those aged between 65 to 74 years, and up to about 70% for those aged over 75 years. Serduto and Hiller stated that cataracts are found more often in women than men. In another study by Nishikori and Yamomoto, male and female ratio is 1:8 with a predominance of female patients over the age of 65 years and underwent surgery katarak.4, 5

Similarly, in Indonesia, cataract is the leading cause of vision loss. It is known that the prevalence of blindness in Indonesia ranges from 1.2% of the population and cataract was ranked first with the highest percentage of 0.7%. Based on several studies of cataract is more common in women than men, with most blacks.

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2.2.3. Classification of Cataract Cataracts can be classified in the following categories: a. cataract development (developmental) b. Congenital cataract: juvenile cataract, cataract senil c. Complicated cataract d. traumatic cataract The cause of the lens opacities can: 1. primer, based on the basic metabolic disorders and developmental lens. 2. secondary, due to lens surgery. 3. local and general complications Based on the patient's age, cataracts can be divided into: 1. Congenital cataracts, cataract seen in under a year of age 2. Juvenile cataracts, cataract seen in over a year of age and under 40 years 3. Cataracts pre senil, ie cataracts after the age of 30-40 years 4. Cataracts senil, namely cataracts that occur in more than 40 years of age During development, the primary cataract is divided into: 1. Insipient stage 2. Immature stage 3. Mature stage 4. Hypermature stage (cataract Morgagni)

a) Insipien Stage Where nascent cataract due to the degeneration of the lens. Opacification of the lensshaped patches of irregular opacities. Patients complain of visual disturbances such as seeing double with one eye. At this stage of the degeneration process has not been absorbed into the lens of the eye fluid so it will be visible to the anterior chamber depth is normal, sliced in a regular position is accompanied by mild opacities in the lens. Patients have impaired visual acuity.

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a) Immature Stage Where at this stage the lens begins to absorb liquid degenerative eye to the lens so that the lens becomes convex. At this stage the swelling of the lens is called a cataract intumesen. At this stage there is miopisasi result of the convex lens, so that the patient claimed not to Deutsch sunglasses while reading closely. Due to the swollen lens, iris pushed forward, shallow chamber and chamber angle will narrow or closed. At the immature cataract vision began gradually becoming less, Hali is covered by a vision due to media opacities thickened lens. At this stage can occur secondary glaucoma. In the shadow of iris test inspection or test will be visible shadow Shadow iris on the lens. Iris shadow test positive.

b) Mature Stage An advanced lens degeneration process. At this stage occurs around the lens opacities. Pressure in the fluid within the lens is a state of balance with the eye fluid so that the size of the lens will be normal again. On examination of the iris seen in the normal, normal anterior chamber, anterior chamber angle normal open, and iris shadow test negative. Severely decreased visual acuity and can only stay positive light projection.

c) Hypermature stage At this stage of the process further degeneration and cortical lens so that the lens can melt lens nucleus immersed in the cortex of the lens (cataract Morgagni). At this stage of degeneration also occurs so that the lens capsule or cortical lens material lenses thaw out and into the anterior chamber. In stage hipermatur will look smaller lens than normal, which will result in trimulans iris, and anterior chamber open. In the shadow of iris visible test positive even though the entire lens was cloudy so at this stage is called the shadow test iris pseudopositif. Iris shadow formed on the anterior lens capsule that has been cloudy with a lens that has been shrinking. As a result of the material out of the lens capsule, then there will be a reaction in the form of network uvea uveitis.

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2.3.4 JUVENILE CATARACT

Cataracts are flabby and there is on young people, who began the formation at less than 9 years of age and more than 3 months. Juvenile cataract is usually a continuation of congenital cataracts.

Juvenile cataracts usually is a complication of systemic or metabolic disease and other diseases such as: 1. metabolic cataracts a.) and diabetic cataract galaktosemik (sugar) b.) Cataracts hypocalcemic (tetanik) c.) Cataracts nutritional deficiency d.) Cataracts aminoaciduria (including Lowe syndrome and homocystinuria) e.) Wilson Disease f.) Cataract associated with other metabolic abnormalities 2. Myotonic muscular dystrophy (aged 20-30 years) 3. Traumatic cataract 4. Complicated cataract a) Congenital and hereditary abnormalities - Cyclopia, koloboma, microphthalmia, aniridia, persistent hialoid vessels, heterochromia iridis b) Cataracts are degenerative (with myopia and vitreoretinal dystrophy) - Wagner and retinitis pigmentosa, and neoplasms c) Cataracts anoxic d) Toxic (systemic or topical corticosteroids, ergot, naftalein, dinitrophenol, triparanol (MER-29), antikholinesterase, chlorpromazine, myotic,

chlorpromazine, busulfan, iron) e) Other congenital abnormalities, certain syndromes, accompanied by skin disorders (sindermatik), bone (disostosis craniofacial, osteogenesis inperfekta, khondrodistrofia kalsifikans kongenita pungtata), and chromosome f) Radiation cataracts

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Examination and Diagnosis:

Anamnesis: o Progressive decrease in visual acuity (the main symptom of cataract) o Eyes do not feel pain, itchy or red o General description of the other symptoms of cataract, such as: a) Foggy, smoky, closed vision movies b) Changes in color vision c) Disorders night driving, headlights blinding eye d) Lights and the sun is very disturbing e) Frequently requested change eye glass prescription f) Double vision

Clinical examination: Examination of visual acuity and by looking through the lens of the flashlight hand, magnifying glass, slit lamp and ophthalmoscope preferably with dilated pupils. By irradiation angle (45 degrees from the axis of the eye) can be assessed opacification of the lens. Examination using a slit lamp is not only intended to see any cloudiness in the lens, but also to see the other ocular structures such as the conjunctiva, cornea, iris, and other anterior segment.

Treatment: Treatment for cataracts is surgery. Surgery is performed if the patient can not see well with glasses help to do daily task. Some patients may feel better eyesight just by changing his glasses, wearing stronger bifocus glasses or using a magnifying lens. If cataracts do not disturb usually do not need surgery.

Indication for surgery: - Social Indications: patients complain of vision problems in doing routine work - Medical Indications: if there are complications such as glaucoma - Optic Indications: visual acuity with count fingers from a distance of 3 m showed visual acuity 3/60

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Preparation for cataract surgery: Usually surgery is prepared to issue a cloudy lens and put a clear artificial lens permanently. Pre-surgical medical examination required public bodies to determine if any abnormalities are an obstacle to be removed surgically. This examination will provide further information surgical plan.

The examination includes things like: - Blood Sugar, Hemoglobin, leukocytes, bleeding time, clotting time - Blood pressure, Electrocardiography - History of drug allergy -Routine medical examination - Intraocular pressure - Anel Test - Ultrasonography: to measure the length of the eyeball. - Retinometry: Prior to surgery to know functions of the retina - Keratometry: measure the curvature of the cornea to determine the strength of the lens to be planted

Anesthetic technique used: 1. Local In the cataract surgery techniques commonly used anesthetic is a local anesthetic. As is done with local anesthesia techniques: a. Topical anesthesia b. Sub conjunctiva (commonly used) c. Retrobulbaer d. Parabulbaer

2. General General anesthesia is used in patients who are not cooperative, infants and children

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Complications of Operation: Complications can be minimized if the pre-treatment and post-operative surgery performed in accordance with procedures. The complications that can occur include: endophthalmitis (intraocular infection), iris prolapse

Cataract surgery consists of removal of the lens and replacing it with an artificial lens. a) Removal of the lens 1. Intracapsular Cataract Extraction (ICCE) Type of surgery that is rarely done. It is performed by removing the entire lens with the capsule, through the superior limbus incision 140 to 160 degrees. This surgery can be performed on zonula Zinni or degenerates who have brittle and easily broken. At this extraction will not occur secondary cataracts.

2. Extracapsular Cataract Extraction (ECCE) This extraction is a lens cataract surgery in which the lens performed evisceration by breaking or tearing the anterior lens capsule so that future lenses and lens cortex can exit through the rips. This type of surgery since a few years ago have become cataract surgery is most often performed as an intact posterior capsule, the intraocular lens can be inserted into the posterior camera. The incidence of postoperative complications occur if the smaller posterior capsule intact.

3. Phacoemulsification Phacoemulsification with irrigation or aspiration (or both) is extracapsular technique that uses vibration - ultrasonic vibrations to remove nuclei and limbic cortex through a small incision (2-5 mm), making it easier for postoperative wound healing.

b) Planting new lens Patients who have undergone cataract surgery usually will get an artificial lens in view of lenses that have been removed. This artificial lens is a plastic strip called an intraocular lens, usually inserted into the lens capsule inside the eye.

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Cataract surgery is commonly performed and generally safe. After surgery are rare infections or bleeding in the eye that can lead to serious vision problems. To prevent infection, reduce inflammation and accelerate healing, for several weeks after surgery was given eye drops or ointment. To protect the eyes from injury, patients should wear glasses or protective goggles made of metal until the surgical wound is completely healed.

Complication Glaucoma is said to be a complication of cataract. This can arise due to glaucoma or swelling intumesenensi lens. If the cataract is emerging with the complications of glaucoma surgery is indicated extraction of the lens. Additionally Chronic Uveitis occurring after cataract surgery have been reported. It is associated with the presence of pathogenic bacteria including Propionibacterium acnes and Staphylococcus epidermidis.

Prognosis Visual prognosis for pediatric patients who require surgery is not as good as senile cataract. Presence of amblyopia and sometimes the optic nerve or retinal anomalies limit the level of achievement of the vision in this patient group. Prognosis for improvement of vision acuity after cataract surgery on the worst and best of unilateral congenital cataract congenital bilateral incomplete on the progressive slow.

Prevention Cataracts generally coincided with increasing age that can not be prevented. Regular eye examination is necessary to determine the presence of cataracts. The 60-yearold's eyes should be checked every year. At this time the speed of the development of cataracts can be maintained by: - Smoking cessation - A healthy diet, increase the consumption of fruits and vegetables - Eye protection from sunlight, because UV rays cause cataracts on eye - Maintain a healthy body state such as keeping diabetes and other diseases in control

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REFERRENCE

Cunningham E, Riordan-Eva P, 2011. Vaughan & Asburys General Ophthalmology, 18th Edition, Lange McGrawhill Profesional Publication.

E.Ahmed, 2004. A Textbook of Ophthalmology,2nd Edition. PHI Learning Pvt.Ltd

Krieglstein G.K, 2007. Essential in Ophthalmology. Springer Berlin Heidelberg New York Publication.

Mansjoer, Arif, 2000, Kapita Selekta Kedokteran Jilid 2 Ed. III, media Aeuscualpius, Jakarta Myron Y, Duker J.S, 2008. Ophthalmology, 3rd Edition. Mosby Elsevier Publishing.

Olver J, Cassidy L. Ophthalmology at A Glance. Hongkong: SNP Best-set Typesetter Ltd; 2005. Tasman W, Jaeger E.A, 2001. Clinical Ophthalmology, 2nd Edition. Lippincott Williams & Wilkins Publishing.

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