Cataract

: Problem not yet solved

Lecturer : dr. Werlinson Tobing,SpM

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No part of this work may be reproduced, including photocopied, without wriCen permission of Universitas Pelita Harapan .
 Learning ObjecHve
•  Understand the main cause of visual impairment and
blindness
•  Explain types of cataract
•  Explain the clinical manifestaHon of cataract
•  Perform ophthalmology examinaHon
•  Able to diagnose cataract
•  Explain the management of cataract

 Global blindness
1998 - 2020
90
80
70
60
50
Million 40
blind 30 x2
20
10
0
1998 2020
 Global Causes of Blindness

1995 2010
Oncho.,
1 Child Bl,
Other
28 4 Und., 21

Glauc.,
14 Cataract Cataract
42 % DR, AMD, 5
1 51 %

Tra, 3
Tra., Glauc,
15 CO, 4 8

URE, 3
 What is a cataract?

– OpacificaHon of human crystalline lens
– FuncHonally, it includes the cases which
interferes with vision
The Lens
 Morphological classificaHon
–  Subcapsular cataract
•  Anterior subcapsular cataract
•  Posterior subcapsular cataract
–  Nuclear cataract involves the nucleus of lens.
•  Yellow to brown voloraHon
–  CorHcal cataract
•  wedge shaped or radial spoke-like opaciHes.
–  Polar cataract
 Subcapsular cataract
Anterior Posterior
 Nuclear cataract
Progression

•  Exaggeration of normal nuclear •  Increasing nuclear opacification

ageing change
•  Causes increasing myopia •  Initially yellow then brown
ClassificaHon according to maturity
–  An immature cataract
•  Intumescent cataract
–  A mature cataract
–  A hypermature cataract
•  A morgagnian cataract
Classification according to maturity

Immature Mature

Hypermature Morgagnian
 EHological classificaHon
–  Congenital and developmental cataract
–  Acquired cataract
•  Senile cataract
•  TraumaHc cataract
•  Complicated (secondary) cataract . eg, uveiHs, pathological myopia,
glaucoma, reHnal detachment, reHniHs pigmentosa etc,
•  Metabolic cataract . Eg, Diabetes, hypocalcaemia, Wilson’s disease,
Lowe’s syndrome
 EHological classificaHon
–  Acquired cataract
•  Electric cataract
•  RadiaHonal cataract
•  Drug induced cataract eg, corHcosteroid, copper, iron,
Chlorpromazine, Busulphan, Allopurinol, Amiodarone,
etc,
•  Cataract associated with skin diseases . Eg, atopic
dermaHHs, scleroderma, etc,
•  Cataract with miscellaneous syndromes . Eg, Dystrophica
myotonica, Down’s syndrome etc,
 AGE RELATED (SENILE) CATARACT
–  Common and bilateral above the age of 50 years.
–  Male: Female::1:1
–  EHology
•  Hereditary : Incidence, age of onset and maturaHon
•  Ultravoilet radiaHon : More exposure to UV-rays = early maturaHon.
•  Dietary factors : Poor diatery factors eg, lack of certain aminoacids,
Vitamines (Vitamin E, Vitamin C, riboflavin) and essenHal minerals.
•  DehydraHonal crisis : Prior episode of severe dehydraHon due to
diarrhea and cholera.
 Mechanism of loss of transparency
–  CorHcal cataract
•  DenaturaHon and coagulaHon of lens proteins.
•  Decrease level of aminoacids and protein systhesis
•  Increased hydraHon brought by decrease in potassium due to
reversal of Na/K pump mechanism.
–  Nuclear cataract:
•  DegeneraHve changes occurring as nuclear sclerosis
•  Increase in water insoluble proteins,
•  compacHon of nucleus resulHng in a hard cataract.
•  Disturbance of lamellar arrangement in fibres
 Symptoms
–  Painless progressive visual loss
–  Glare
–  Reduced color percepHon
–  Color haloes
–  Uniocular diplopia
–  Based on the locaHon and density
 Sign
–  OpacificaHon of the normally clear lens seen through the
pupil
–  IndisHnct on reHna examinaHon
–  Red reflex may be dim
–  No afferent pupillary defect
–  Myopic shii
 Assessment
–  Assess visual acuity and review report on refracHon.
•  Surgery is indicated when cataract develops to a degree sufficient to
cause difficulty in performing daily essenHal acHviHes.
–  Perform cover test
–  Test pupillary response.
–  Examine cornea to rule out any opaciHes
–  Examine ocular adnexa
–  Performed dilated fundus examinaHon if necessary
–  Perform intraocular pressure test
Visual acuity

Don’t forget
- Finger counHng
- Hand movement
- Light percepHon
 Cover Test
•  To detect phoria or
tropia
•  To detect bilateral or
unilateral diplopia
 Pupilary respons
•  Direct
•  Consensual
•  RAPD/ Swing light reflex
 Anterior segment exam
•  Use LOUPE
•  Use penlight
•  Consist of : inspecHon, AC depth, shadow test.
Shadow test
Funduscopy
 Type of cataract surgery
–  Extracapsular cataract extracHon (ECCE).
•  Requires a relaHvely large circumferenHal limbal incision (8-10mm)
through which the lens nucleus is extracted and the corHcal maCer
aspirated, leaving behind an intact posterior capsule.
•  The IOL is then inserted.
•  It is the universal procedure of operaHon in cataract.
•  Posterior IOL can be transplanted aier ECCE.
 Type of cataract surgery
–  Intracapsular cataract extracHon (ICCE) .
•  The enHre cataractous lens along with the intact capsule is removed
in this procedure.
•  Weak and degenerated zonules are a pre-requisite for this method.
•  This is the surgery of choice only in markedly subluxated and
dislocated lens.
•  This technique of surgery has been largely replaced by ECCE
nowadays.
 Type of cataract surgery
–  PhacoemulsificaHon:
•  A small hollow needle containing a piezo-electric crystal vibrates
longitudinally at ultrasonic frequencies
•  The Hp is applied to the lens nucleus; cavitaHon occurs at the Hp as
the nucleus is emulsified;
•  an irrigaHon and aspiraHon system removes this emulsified material
from the eye.
•  The IOL is then injected through a much smaller incision than in ECCE.
•  Safe: avoid compression of eye, results in liCle postoperaHve
asHgmaHsm and early stabilizaHon of refracHon, and eliminate post-
operaHve wound related problem
 Barriers ahead
•  low demand because of fear of surgery
•  low demand from poor people because of high cost of surgery
•  low demand because of poor visual results
•  lack of eye surgeons (1240;2012;ICO)

CSR Indonesia : 450/1.000.000 (2011: Depkes)

Thank you
 Reference
•  Duane’ s basic of ophthalmology
•  Cataract and refracHve surgery. BriHsh Medical Journal
•  Vaughan General Ophthalmology