MANAGEMENT OF CATARACT

Pre-operative Evaluation

Indications for Surgery

*General medical exam should be done
1. Cover test
for misalignments and amblyopia

not based on a specific acuity level but on the quality of life of patient
Surgery- definitive treatment for cataracts
1. VISUAL IMPROVEMENT
by far the most common indication for cataract surgery
surgery is indicated only if and when cataract develops to
to cause difficulty in performing daily essential activities

a degree sufficient

2. MEDICAL INDICATIONS
in which a cataract is adversely affecting the health of the eye
ex. Phacolytic or phacomorphic glaucoma --- both lens induced
Phacolytic - pupillary block, hence, acqueous cannot drain to anterior chamber
inc intraocular pressure (normal: 10-20)
TX: give eye drops like carbonic anhyrase inhibitors to dec. of intraocular
pressure removal of cataract
3. COSMETIC INDICATIONS rare

2. Pupillary Responses
presence of RAPD implies an additional pathology which may influence visual outcome
Marcus-Gunn pupil swinging flashlight test
3. Ocular adnexa
dacryocystitis, blepharitis, chronic conjunctivitis, lagophthalmos, entropion, ectropion, tear film abnormalities may predispose
to endophthalmitis
could not operate since youll be creating an opening, thus, inc risk for bacterial infection
1-2days prior, preparation for OR, give antibiotics
any infection (as mentioned above), no operation
4. Cornea
wide arcus senilis, stromal opacities, gutata
Arcus senilis - Normal part of eye due to aging, periphery of cornea, white color, deposits of lipid
Eyes with decreased endothelial cell counts (e.g. substantial cornea guttata) have increased vulnerability to postoperative
decompensation secondary to operative trauma
5. Anterior Segment
shallow AC, pseudoexfoliation, poorly dilating pupil, poor ROR
A shallow anterior chamber can render cataract surgery difficult.
ARMD aged related macular degeneration
Macula area of most acute central vision
6. Lens
The type of cataract is important
Nuclear cataracts tend to be harder and may require more power for phacoemulsification, while cortical opacities tend to
be softer.
Pseudoexfoliation indicates a likelihood of weak zonules (look for phakodonesis), a fragile capsule and poor mydriasis
7. Intraocular Pressure
Any Glaucoma or Ocular Hypertension must be noted
8. Fundus
recognition of fundal pathology like Age related macular degeneration (ARMD), which may affect the visual outcome.
Ultrasonography may be required, principally to exclude retinal detachment and staphyloma, in
eyes with very dense opacity that precludes fundoscopy.

BIOMETRY

surgical removal of lens subtracts about 20D from the refracting

power of the eye
modern cataract surgery involves the implantation of an intraocular lens(IOL)
biometry affords calculation of the lens power most likely to
result in emmetropia
Emmetropia perfect vision
Biometry facilitates calculation of the lens power likely to result
in the desired postoperative refractive outcome; in its basic form
this involves the measurement of two ocular parameters,
keratometry and axial (anteroposterior) length

ANESTHESIA

Local or general; local more common.

The vast majority of cataract surgery is performed
under local anaesthesia (LA) although general
anaesthesia is required in some circumstances such
as children and many young adults, very anxious
patients, some patients with learning difficulties,
epilepsy, dementia and those with a head tremor.
1. Retrobulbar Block
is given in the muscle cone behind the globe using a 1.5inch
needle; MC
2. Peribulbar Block
Given through skin or conjunctiva with a 1 inch needle; MC
The anaesthetic is injected beyond the equator of
the globe. Penetration of the globe is a very
severe, though extremely rare, complication, and
for this reason peribulbar is avoided.
3. Parabulbar Block (Sub-Telon)
Passing a blunt cannula through a conjunctival incision
Sub-Tenon block involves inserting a blunt-tipped
cannula through an incision in the conjunctiva and
Tenon capsule 5 mm from the limbus infero-nasally, and
passing it through the sub-Tenon space. Chemosis and
subconjunctival hemorrhage are common but
penetration of the globe is extremely rare.
It involves drops or gel (proxymetacaine 0.5%,
tetracaine 1% drops, lidocaine 2% gel) which can be
augmented with intracameral preservative-free
lidocaine 0.2%1%, usually during hydrodissection.
4. Topical
Intracameral anesthesia initial surface anesthesia with
drops or gel and intracameral injection of preservative-free
anesthesia

INTRAOCULAR LENS

Intraocular lenses (IOL)- are inert to prevent allergic

reactions in the eye
consist of:
a. optic the central refracting element; the lens iself
b. haptics
sit in contract with the ocular structures; zonules.
Haptics are the arms or loops which sit in contact with
the ocular structures (capsular bag, ciliary sulcus or
anterior chamber angle) for stable optimal positioning
(centration) of the optic.
Positioning
ideal is in the bag with optimal concentration
Designs
numerous and continuous to evolve
Rigid IOLs
Mde
entirely
from
PMMA
(polymethylmethacrylate); one piece to facilitate
maximal stability
They cannot be folded or injected so require an incision
larger than the diameter of the optic, typically 5 mm,
for insertion. For economic reasons, they continue to be
widely used in developing countries.

Foldable (Flexible) IOLs

used in phacoemulsification since the
procedure
uses small incision
a. silicone
b. acrylic
c. hydrogel
d. collamer
For insertion they may be folded in half with
special forceps or loaded into an injector
delivery system, then unfolded or unrolled
inside the eye.

CATARACT SURGERY
EXTRA-CAPSULAR CATARACT EXTRACTION
requires a relatively large circumferential limbal incision(8-10mm) through which the lens is extracted and the
cortical material aspirated
intact posterior capsule act as hammock where you place your IOL
Technique:
1. Preparation- Anesthetic, antiseptics, careful draping
2. Incision
3. Continuous curvilinear capsulorhexis
4. Hydrodissection- performed to separate the nucleus and cortex from the capsule so that the nucleus can be
more easily and safely rotated.
5. Four quadrant ('divide and conquer) technique for removal of the nucleus is a very widely used, safe
technique.
6. Nuclear phaco chop takes greater experience, but has the advantage of generally requiring lower total phaco
energy.
7. Cortical clean up- fragments are engaged by vacuum, pulled centrally and aspirated
8. Insertion of IOL
9. Completion

PHACOEMULSIFICATION (PHACO)
a small hollow needle, usually titanium, attached to a handpiece containing a
piezo-electrical crystal, vibrates at ultrasonic frequencies.
Tip is applied to the lens nucleus.
Cavitation occurs at thetip as nucleus is emulsified
An irrigating or aspiration system removes the emulsified material from the
eye.
IOL is inserted (if folded) or injected through a much smaller incision than ECCE.
- ROR is now clear, no more cataract, posterior capsule intact, pupil is now
miotic (miostat given for enhanced constriction) Dilated insert clean
up cortical material inject miostat

SURGICAL COMPLICATIONS
OPERATIVE COMPLICATIONS
Rupture of posterior capsule
May be accompanied by vitreous loss, posterior migration of lens
material; rarely expulsive hemorrhage
Signs:
Sudden deepening or shallowing of the anterior
chamber and momentary pupillary dilatation.
The nucleus falls away and cannot be approached by
the phaco tip.
Vitreous aspirated into the phaco tip often manifests
with a marked slowing of lens material aspiration.
The torn capsule or vitreous gel may be directly
visible.
Posterior loss of lens fragments
Into the vitreous cavity after zonular dehiscence or posterior capsule
rupture.
Acute postoperative endophthalmitis
in about 1:1000 cases
Staph epidermidis and aureus, Pseudomonas
source often cannot be pinpointed, patients own bacterial flora most
often implicated
Contaminated solutions and instruments, environmental flora.
Uncommon but dangerous.
Prophylaxis
Instillation of 5% povidone-iodine
Scrupulous preparation of the surgical site,
Treatment of pre-existing infections
Prophylactic antibiotics (Fluoroquinolones from 1
hour to 3 days prior to surgery)
Early resuturing of leaking wounds
About 90% of isolates are Gram-positive and 10% Gramnegative. In order of frequency they include:
Coagulase-negative Staphylococci (S. epidermidis)

POSTOPERATIVE CAPSULAR COMPLICATIONS

Posterior Capsular Opacification (PCO)
secondary cataract
visually significant PCO is the most common
late complication of uncomplicated cataract
surgery
Posterior capsule is often left as it acts as a
hammock for the intraocular lens
Before it was classified as a secondary
cataract which can be confusing. It is not the
cataract that that recurs but the posterior
capsule which was left after surgery that
becomes opacified
also impair contrast sensitivity, glare, or
monocular diplopia
Treatment: ND YAG Laser
It can occur as early as several weeks after
surgery and is accompanied by prominent
subcapsular fibrosis.
Anterior Capsular Opacification (ACO)
less common but occurs earlier than PCO

MISCELLANEOUS POSTOPERATIVE COMPLICATIONS

Corneal Edema
Usually transient and due to intraoperative trauma
Iris Prolapse
Leaking incision, inadequate suturing, patient coughing or
straining.
Malposition of IOL
Although uncommon, malposition may be associated with
both optical and structural problems. Annoying visual
aberrations include glare,haloes, and monocular diplopia
if the edge of the IOL becomes displaced into the pupil.
Retinal Detachment.
Lattice degeration, retinal breaks, high myopia, disruption
of posterior capsule, vitreous loss, YAG laser especially if
done within a year from cataract surgery
Cystoid Macular Edema (CME)
rupture of posterior capsule or vitreous prolapse
Symptomatic CME is relatively uncommon following
uncomplicated phacoemulsification and in most cases it is
mild and transient. It occurs
more often after complicated surgery and has a peak
incidence at 610 weeks, although the interval may be
much longer.

Other Gram-positive organisms (S. aureus and

Streptococcus spp.)
Gram-negative organisms (Pseudomonas spp.
And Proteus spp.)

Symptoms are pain and visual loss.

Signs:
Eyelid swelling, chemosis, conjunctival injection
and discharge.
A relative afferent pupillary defect
Corneal haze
Fibrinous exudate and hypopyon
Vitritis with an impaired view of the fundus
Severe vitreous inflammation and debris
Elschnig pearls (bladder cells, Wedl cells) are
caused by the proliferation and migration of
residual equatorial epithelial cells along the
posterior capsule at the site of apposition
between the remnants of the anterior capsule
and the posterior capsule.
Capsular fibrosis due to fibrous metaplasia of
epithelial cells.

CONGENITAL CATARACT
Congenital lens opacities are common and often visually insignificant. A partial opacification or one out of the visual axis or not dense enough
to interfere significantly with light transmission requires no treatment other than observation for progression. Dense central congenital
cataracts require surgery
Congenital cataracts that cause significant visual loss must be detected early, preferably in the newborn nursery by the pediatrician or family
physician. Large, dense white cataracts may present as leukocoria (white pupil), noticeable by the parents, but many dense cataracts cannot
be seen by the parents. Unilateral infantile cataracts that are dense, central, and larger than 2 mm in diameter will cause permanent
deprivation amblyopia if not treated within the first 2 months of life and thus require surgical management on an urgent basis. Even then
there must be careful attention to avoidance of amblyopia related to postoperative anisometropia. Symmetric (equally dense) bilateral
cataracts may require less urgent management, although bilateral deprivation amblyopia can result from unwarranted delay. When surgery is
undertaken, there must be as short an interval as is reasonably possible between surgery on the two eyes
Childhood cataracts are divided into two groups: congenital (infantile) cataracts, which are present at birth or appear shortly thereafter, and
acquired cataracts, which occur later and are usually related to a specific cause. Either type may be unilateral or bilateral
Acquired Cataracts do not require the same urgent care (aimed at preventing amblyopia) as infantile cataracts because the children are older
and the visual system more mature. Surgical assessment is based on the location, size, and density of the cataract, but a period of observation
along with subjective visual acuity testing can be part of the decision-making process. Because unilateral cataracts in children will not produce
any symptoms or signs parents would routinely notice, screening programs are important for case finding.
Congenital cataracts occur in about 3 in 10 000 live births. Two-thirds of cases are bilateral. The most common cause is genetic mutation,
usually autosomal dominant (AD), other causes include chromosomal abnormalities, metabolic disorders and intrauterine infections
CATARACTS WITH NO SYSTEMIC ASSOCIATION
ISOLATED HEREDITARY
ZONULAR CATARACTS
CATARACTS
a. Nuclear
About 25% of cases
Opacities are confined
AD but may be AR or Xto fetal nuclei of lens
linked
b. Lamellar
Sandwiched
between
clear nucleus and cortex

METABOLIC

CATARACTS WITH SYSTEMIC ASSOCIATION

PRENATAL INFECTIONS

1. Galactosemia
absence
of
the
enzyme
galactose-1-phosphate
uridyltransferase with severe galactose utilization
impairment
failure to thrive, lethargy, vomiting, diarrhea
Cataract: central oil droplet opacity
Galactosaemia is an AR condition characterized by severe
impairment of galactose utilization caused by absence of
the enzyme galactose-1-phosphate uridyl transferase
(GPUT).
Cataract, characterized by a central oil droplet opacity ,
develops within the first few days or weeks of life in a large
percentage of patients. The exclusion of galactose (in milk
products) from the diet will prevent the progression of

1. Congenital Rubella
associated with cataract in 15%
of cases
uni or bilateral cataracts
usually present at birth of
weeks or months after
nuclear or diffuse opacity
Cataract occurs in about 15%
of cases. After the gestational
age of 6 weeks, the virus is
incapable of crossing the lens
capsule so that the lens is
immune.

CHROMOSOMAL ABNORMALITIES
1.

Down Syndrome
Cataract
of
various
morphology in 5% of
cases often in late
chilldhood.
2. Others
Patau(Trisomy 11) and
Edward
Syndrome
(Trisomy 18)

cataract and may reverse early lens changes

2. Galactokinase Deficiency
involves the first enzyme in the galactose metabolism
pathway
absent systemic features
Cataract: lamellar opacities

1.

2.
3.

4.
5.

2. Other intrauterine infection

associated with neonatal Cataracts
Toxoplasmosis, CMV, Herpes Simplex,
Varicella

3. Lowe (Oculocerebrorenal) Syndrome

inborn error of amino acid metabolism
mental handicap, Fanconi syndrome of renal tubules,
muscular hypotonic, frontal prominence and sunken eyes
cataract:
is universal, the lens is small, thin and disc-like
(microphakia)
may be capsular, lamellar, nuclear or total
X-linked
Systemic features include psychomotor retardation,
Fanconi syndrome of the proximal renal tubules, muscular
hypotonia, frontal prominence, chubby cheeks and sunken
eyes
MANAGEMENT
Ocular Examination
Systemic Investigation
1. Serologic Tests
formal estimate of visual acuity cannot be obtained in the
TORCH and Varicella Zoster Antibody titers
neonate.
Density
2. Urine
potential impact on visual function
Urinalysis for reducing substance after drinking
milk (galactosemia) and chromatography for amino
appearance of ROR and the quality of the fundus view on
acids (Lowe Syndrome)
direct and indirect ophthalmoscopy
3. Other Investigations
high-quality portable slit lamps if available
Fasting blood sugar, serum calcium and
Morphology of the opacity
phosphorus, RBC, GPUT and galactokinase levels
Associated ocularpathology which may involve:
4. Referal to pediatrician
the anterior segment (corneal clouding, microphthalmos,
glaucoma, persistent fetal vasculature) or
the posterior segment (chorioretinitis, Leber amaurosis,
rubella retinopathy, foveal or optic nerve hypoplasia)
Other indicators of visual impairment.
Special Tests
Forced choice preferential looking and visually evoked
potentials

1.

2.

3.

4.

Timing of Surgery
Bilateral Dense Cataracts
early surgery (by 6weeks of age) to prevent stimulus
deprivation amblyopia
if asymmetric, denser cataract operated on first
Bilateral Partial Cataracts
surgery not required until later;
monitoring of lens opacity and visual function essential
Unilateral Dense Cataracts
Urgent surgery (within days) followed by aggressive
anti-amblyopia therapy
Partial Unilateral Cataracts
Observed or treated non surgically

LENS COLOBOMA

Notching (segmental agenesis) at inferior

equator

ANOMALIES OF THE LENS SHAPE

POSTERIOR LENTICONUS
ANTERIOR LENTICONUS

Round or conical bulge of posterior zone into

the vitreous

Projection of anterior portion of lens in the AC

LENTIGLOBUS

Hemispherical deformity of lens

a rare congenital anomaly showing a prominent
spheroid elevation on the posterior surface of the
lens