CASE REPORT

Cataract Senilis Mature OS

Mentor :
Prof. Dr. dr. Harry H.B. Mailangkay, Sp.M (K)

Composed by :
Matilda Susanto (2011-061-145)
Marcella Haryanto (2011-061-146)
Pauline Octaviani (2011-061-147)
Daniel (2011-061-148)

KEPANITERAAN KLINIK ILMU PENYAKIT MATA

FAKULTAS KEDOKTERAN UNIKA ATMA JAYA
JAKARTA
PERIODE 29 APRIL – 1 JUNI 2013
 Patient Identity
• Name : Mrs. A
• Age : 45 years
• Sex : Female
• Occupation : Factory worker
• Religion : Moslem
• Address : Muara Baru
 Autoanamnesa (May 10th 2013)
Chief Complaint : Blurred vision on the left eye since 10 months
ago.
History of Present Illness :
• Patient came to Hospital with blurred vision on the left eye
since 10 months ago. Patient felt her vision become worsen in
each day. But, she did not have a red eye, watery eye,
discharge, itchy or pain when exposed with light.
• She had already came to hospital with the same complaint a
month ago. At that time, the patient still could count finger at
1 meter distance with her left eye and she was suggested to
do cataract operation. Three days later, the patient came to
hospital to do medical check-up that necessarily for the
operation. Her vision was already worsening, she only see the
hand's movement.
 History of Past Illness
• Patient has pre-diabetes melitus that was
known after she was doing medical check-up
to internist.
• History of allergy, asthma, cardiovascular
disease, pulmonary disease, trauma, and
history of surgery was denied
 General Examination
• General condition : Well
• Consciousness : Compos Mentis
• Blood pressure : 130/80 mmHg
• Pulse : 76 times/minute
• Respiratory rate : 20 times/minute
 Ophthalmic Status
Right eye Left eye
Periocular appearance Quiet Quiet
General condition Well Well
Eyeball position Normal Normal
Eyeball movement Normal Normal

Right eye Left eye

Visual acuity 5/20 1/300

Supercillia Normal Normal

Cillia Normal Normal

Sup/inf margo palpebra Normal, pressure pain (-) Normal, pressure pain (-)

Sup/inf tarsal conjunctiva Normal Normal

Sup/inf fornix conjunctiva Normal Normal

Bulbar conjunctiva Conjunctiva injection (-), cilliar Conjunctiva injection (-), cilliar
 Ophthalmic Status
Right eye Left eye

Cornea Clear Clear

COA Deep Deep

Iris Brown, crypt good Brown, crypt good

Pupil central, round, isocor, d = central, round, isocor, d =

3 mm, direct reflex / 3 mm, direct reflex /
Indirect reflex +/+ Indirect reflex +/+

Lens Shadow test -, clear Shadow test -, cloudy

Fundus Reflex -
+
 Summary
• Female, 45 years old, came with progressively decrease visual
acuity since 10 months ago. She did not have a red eye,
watery eye, discharge, itchy or pain when exposed to light.
Patient has pre-diabetes mellitus that was known after she
was doing medical check-up to internist. Result from general
examination in normal range. Examination for eye :
• - Visual acuity : OD 5/20, OS 1/300
• - Cornea : clear in both eyes
• - COA : Deep in both eyes
• - Lens : Cloudy and shadow test (-)in left eye
• - Fundus Reflex : Negative in left eye
Working Diagnosis
• Cataract Senilis Mature OS

Suggested Work Ups

• Biometry, tonometry, keratometry

Treatment
• Pro operasi OS SICS PCIOL
• Prognosis
• Quo ad vitam : ad bonam
• Quo ad functionam : dubia ad bonam
• Quo ad sanationam : dubia ad bonam
CATARACT
 Definition
• Cataract derives from the Latin cataracta meaning
"waterfall" and the Greek kataraktes and
katarrhaktes, as rapidly running water turns white 
the similar appearance of mature ocular opacities
• A cataract is a clouding that develops in the
crystalline lens of the eye, varying in degree from
slight to complete opacity and obstructing the
passage of light.
• Cataracts progress slowly to cause vision loss and
are potentially blinding if untreated.
• Affects both the eyes, but almost always one eye is
affected earlier than the other.
 Anatomy of Lens
• The lens is mostly made of water and protein. The
protein is arranged in a precise way that keeps the
lens clear and lets light pass through it.
 Epidemiology
• As a person ages, the chance of developing a
senile cataract increases.
• Cross-sectional studies place the prevalence of
cataracts at 50% in individuals aged 65-74
years, the prevalence increases to about 70%
for those over 75.
 Epidemiology
• 2002, National Eye Institute and Prevent
Blindness America  cataracts affect nearly
20.5 million Americans age 40 and older. By
age 80, > ½ of all Americans have cataracts.
• 2010, National Eye Institute data, females had
a higher prevalence than males in cataract
 Etiology
• Aging is the most common cause of cataract,
but many other factors can be involved.
Cataracts can result from genetic, metabolic,
nutritional or environmental insults, or they
may be secondary to other ocular or systemic
diseases such as diabetes or retinal
degenerative diseases.
Causes of cataracts
● Ageing
● Inheritance
● Metabolic disorders, e.g. Lowe’s syndrome,
hypocalcaemia
● Diabetes
● Toxicity, e.g. drug-induced (steroids, amiodarone),
chemical, metal ions
● Nutrition
● Trauma
● Radiation
● Eye disease, e.g. glaucoma, uveitis, post-vitrectomy
● Systemic disease, e.g. atopy, renal failure
 Age-related Cataract
• is any opacification of the lens that occurs
after 50 years, nearly half of all blindness
worldwide
• three distinct diseases (nuclear, cortical, and
posterior subcapsular cataracts)  different
regions of the lens, have different risk factors,
and involve different pathologic mechanisms
 Risk Factor
• General : age, genetics, lower socioeconomic, poor nutrition
• Evironmental :
– Nuclear : smoking, poorer nutrition, and living in a warmer climate
– Cortical : higher sunlight exposure and diabetes
– Posterior subcapsular : diabetes, use of immunosuppressive and
intraocular steroids, and therapeutic radiation to the head.
• Anatomical :
– Lens thickness : Thinner lens  cortical; denser lens  nuclear
– Vitreous gels stability : more liquefied vitreous  nuclear
 Nuclear Cataract
• opacities occur in the central region of the lens
• Opacification of the nucleus  associated with
increased light scattering, caused by the aggregation
or condensation of lens proteins, and increased
coloration (brunescent / brown)
• Common in western population

• Theory of opacification process in nuclear cataract :

– reduced glutathione and an increase in the oxidized form
– Exposure to excess oxygen
 Cortical Cataract
• Cortical opacities  associated with gross
disruption of the structure of fiber cells, local
proteolysis, and protein precipitation.
• Usually begin in small foci near the lens
equator  toward the optic axis 
circumferentially to adjacent fiber cells.
• Common in Asian populations
 Posterior subcapsular cataract
• less than 10% of age-related cataracts
• epithelial cells that fail to differentiate
properly into fiber cells, carried to the
posterior pole of the lens  form a plaque in
optic axis that scatters light that degrade
vision.
 Scheimpflug &
Retroilluminati
on images of
cataracts
• A : normal older
human lens
• B : lenses with cortical
cataract (cuneiformis)
• C : nuclear cataract
• D : posterior
subcapsular cataract
(cupulliformis)
 Maturation of the cortical type of
senile cataract
1. Stage of lamellar separation.
• The earliest senile change is demarcation of cortical fibres
owing to their separation by fluidcan be demonstrated by
slit-lamp examination only  reversible.
2. Incipient Cataract
• The opacity was shaped irregularly  wedge-shaped.
located in the anterior or the posterior cortex
 can only be seen when the pupil is dilated
 complaints of polyopia because of the different refraction
index on the surface of the lens.
• Shadow test (+)
 Maturation of the cortical type of
senile cataract
3. Immature Cataract
• On the later stage, the opacity will become thicker,
but still haven’t involve the whole lens.
• On this stage, a hydration of cortex  water flow
into the lens, thus making the lens more convex.
cause a change in refraction index slight myopia.
• As the convexity progress, the lens will bulge upfront
and pushing the iris forward  may block the pupil.
development of glaucoma
• Shadow test (+)
 Maturation of the cortical type of
senile cataract
4. Mature Cataract
• The water that were inside the cortex will be drained
out of the lens alongside with the other disintegrated
materials the lens will return to normal.
• Iris will no bulge and the narrow angle of the anterior
chamber caused by the convexity return to normal.
• The lens will be white all over the whole lens
because the opacity has involved whole of the lens.
• Shadow test (-)
 Maturation of the cortical type of
senile cataract
5. Hypermature Cataract
• Degeneration of the lens has reached such a stage where the
cortex of the lens is liquefied and drained out of the lens.
• The lens will shrink and has a yellowish discoloration.
• As the liquefaction progresses, the nucleus of the lens will be
floating in the liquefied cortex material  the nucleus will
change place according to the eye movement
• Because the lens is shrinking, the anterior chamber will
become deeper.
• Shadow test  pseudopositive results.
• Complication : drained out of the lens might cause an
inflammation  hypersensitivity reactiona phacotoxic
uveitis or phacolytic glaucoma
 General Classification of Cataract
Cataract congenital Cataract that are visible under age 1 years old.

Cataract Bilateral
lamelar/zonular Seen immediately after the baby is born. Picture ad gray discs in the
outer nuclear layer of the cortex.

Cataract polaris Persistent of the vascular sheath lens. Located in the posterior lens
posterior

Cataract polaris In the embryonic development, cornea has not entirely let go of the
anterior lens. The cloudy of the COA could be shaped like a pyramid

Cataract nuclearis The cataract looks like a sponge in the lens nucleus.

Cataract juvenile Cataract that occurs after the age of 1 year. Cloudy that occurs during
fiber development. Often called soft cataract.
 General Classification of Cataract
Cataract traumatic Occurs due to trauma to the eye

Due to blunt force Ussually capsule still intact

Due to sharp force Lens capsule is rupture and leak

Cataract senilis Occurs after 50 years

Cataract nuclear Cataract that affects the central part of the lens. The nucleus of lens
become sclerotic. Originally develop drom yellowish white to brown
and finally to blackish (cataract nigra)

Cataract cortical Cataract that affects the peripheral part of the lens. Because of
absorption of water, the lense become convex and miopisasi developed.
The vision is improve at early disease.

Cataract cupulliform The cloudy in the posterior cortex. Glare +

 Sign and Symptom of Cataract
• Decrease in clarity of vision, clouded, blurred or
dim bision
• Increase sign difficulty with vision at night
• sensitivity to light and glare
• seeing 'halos' around light
• Double vision
• require frequent changes in
patient's eyeglass or contact
lense prescriptions
• loss of contrast sensitivity,
so that shadows and color
vision are less vivid. 2,3
 Examination
• no sign of
inflammation
• shadow test +
• Fundus reflex -
• Dilatation of pupil
for retina
examination.
 Slit Lamp Examination
Grade of hardness Description of hardness Colour of nucleus

Grade I Soft White or greenish yellow

Grade II Soft-medium Yellowish

Grade III Medium-hard Amber

Grade IV Hard Brownish

Grade V Ultrahard (rock hard) Blackish

 Treatment
• The only effective treatment for cataract is removing
the clouded lens
• if surgery is suggested
• Up until now, there is no eveidence to suggest that
changing diet, taking vitamins can cure cataract. But,
there some things to minimize the progress of
cataract such as:
– Eye glasses or sunglasses to reduce the exposure from
ultraviolet
– aldose reductase inhibitor to slowing down the
conversion of glucose becomes sorbitol - antioxsidan
vitamin C and E
• Cataract surgery involves removing the clouded lens and replacing it
with a plastic lens implant.

• Measurements for the size, shape and power of this lens, eye
health and general health is checked carefully. This is usually done
by a machine which measures the length of the eye ball and its
shape. The examination:

– Tonometry
• A standard test to measure fluid pressure inside the eye
– Biometry
• To measure the length of the eye (axial length) using A-scan.
• To calculte the power of the replacement lens
For an accurate IOL power calculation: namely the axial
length of the eye, the refractive properties of the cornea
(power of the cornea) and the predicted position of the IOL
after surgery.
– Keratometry
• To measure the curve of cornea and reflection of the
anterior surface of the cornea
• Helps determine a proper corrective prescription, the
degree of correction, and whether concave or convex
lenses are required to restore vision to an acceptable
level.
 Surgical technique
1. Intracapsular cataract Extraction (ICCE)
– larger wond than extracapsular surgery
– it involves removal the entire lens and the surrounding capsule
together includes posterior capsule.
– The entire lens is frozen in its capsule with cryophake
– Now, this methode has not been use frequently because of the
complication that can happen like, astigmatism, glaucoma, uveitis,
endofthalmitis and bleeding.

2. Ekstracapsular cataract Extraction (ECCE)

– This procedure is used mainly for very advanced catarcts where the lens is
too dense to dissolve into fragments (phacoemulsify).
– This techique require a larger incicions (12mm)
– Tearing the anterior capsule and left the posterior capsule.
– Requires a various number of suture to close the larger wound and visual
recovery is often slower.
– Complication that can arise from this technique is the occurrence of
secondary cataract.
 Hence, arise a new technique of ECCE that uses small incision, which small incision
or sutureless ectracapsular cataract extraction (SECCE)
– a small incision in the lining sklerocorneal 6-8mm and a little trauma from the
corneal endothelia
– Make it easier for placement of the IOL if the posterior capsule is still intact

3. Phacoemulsification
– The extraction of lens with
incision of 2.5 mm in limbus-
corneal.
– Uses ultrasound probe to
mechanically tear the lens and
absorb it. In some cases,
– stitches will not be necessary

• The advantage of this surgery is:

– Small incision
– Minimal anesthesia
– Rapid healing
– There is no need for
hospitalization and patients can
return to daily activities
Anasthesia that often used is:
• Local anasthesia
– Sub-tenon anestthesia – Topical anasthesia
• Using the tip of blunt needle inserted • Dripped on the
directly into subtenon layer the cular surface of the
opening layer between konjunctivav eye before the
and capsule tendon in konjuctiva operation begin.
fornix.
The thing that needs to be done and avoid for the first week
to ten days after operation:

– Avoid harsh cough

– Take care of eyes's hygiene carefully
using soft cotton.
– Wear a blindfold
– Do not bend while wearing a shoe
string
– Do not rub the eyes
– Wearing eye shield when sleeping to
avoid rubbing the eye
– Avoid swimming to avoid contact with
dirty water
– Do not straining too hard.
 Cataract & Diabetes
• Cataract in one of the early complications that is
often found in patients with diabetes.
– develops in an earlier age & more progressive faster.
• Patients with DM  2-5 x risk of developing a
cataract
• Risk of the cataract happens in patients aged less
than 40 years 15 -25 x.
• Eventhough the impairment was only in the fasting
plasma glucose (prediabetic stage) predisposing
factor of the development of the cortical cataract.
 Cataract & Diabetes
• 3 molecular mechanisms non-enzymatic glycation of lens
proteins, oxidative stress & activated polyol pathway.
• Diabetes is associated with two types of cataracts:
1. Senile cataract in diabetics appears at an early age and progresses
rapidly.
2. True diabetic cataract. It is also called ‘snow flake cataract’ or ‘snow-
storm cataract’.
– It is a rare condition.
– Hyperglycemia is reflected in a high level of glucose in the aqueous
humor  diffuses into the lens  is metabolized by aldose reductase
into sorbitol
• accumulates within the lens, resulting in secondary osmotic overhydration
of the lens substanceresulting myopia.
– Cortical fluid vacuoles develop & evolve into frank opacities.
• young diabetic that may resolve spontaneously or mature within a few
days.
 Prevention Cataract-DM
• Despite the fact that a wide variety of agents,
including inhibitors of glycation (Aspirin,
Ibuprofen, Aminoguanidine and Pyruvate),
antioxidants (Vitamin C, Vitamin E,
Carotenoids, Trolox and Hydroxytoluene) and
aldose reductase inhibitors (Zenarestat,
Eplarestat, Imirestat, Ponalrestat, Zopolrestat)
 in animal models, it would be premature to
recommend them in humans.
 Prognosis
• More than 98% of cataract surgeries are
successful, without surgical complications
• more than 95% of patients have improved
vision promising visual prognosis of gaining at
least 2 lines in the Snellen distance vision
chart.
• People whose vision fails to improve often
have underlying eye disorders, such as age-
related macular degeneration, diabetic
retinopathy and other eye conditions.
 Prognosis
• <10 in 100 people have any complications
during surgery. And patient unlikely to get
serious problems that make their sight much
worse. Serious problems only happen to 1 in
1,000 people.
• Some problems can happen months or even
years after the operation. Cataracts can't grow
back, but sometimes the tissue around the
new lens turns cloudy. This happens to about
20 in 100 people. It can be treated with laser
surgery.
 Complication
• Complications are generally classified as
intraoperative or postoperative.
• The effect of a complication varies widely
from delay in visual recovery or protracted
ocular discomfort to devastating visual
consequences and even loss of the eye.
• Complication of cataract surgery can occur at
any stage of the proedure.
 Intraoperative Complication
• Bleeding  Choroidal haemorrhage
• Bruise or “Black Eye”
• Wound or Incision Leak
• Rupture of the Posterior Capsule
• Loss of capsular integrity and zonular support
• Vitreous loss
• Iris and corneal trauma
 Postoperative complications
•Early (1–3 days):
● wound leak
● conjunctival chemosis
● corneal abrasion
● corneal wound burn
● hyphaema
● corneal oedema
● raised intraocular pressure (IOP)
● intraocular lens (IOL) haptic prolapse
 Postoperative complications
•Intermediate (1–2 weeks)
● corneal oedema
● Descemet detachment
● suture irritation
● preservative or drug allergy
● retained lens matter
● endophthalmitis
● ametropia
● posterior vitreous detachment (PVD)
 Postoperative complications
•Late (3–4 weeks):
● posterior capsular opacification (PCO)
● cystoid macular oedema (CMO)
● endophthalmitis
● persistent uveitis
● induced astigmatism
 Postoperative complications
•Delayed (after 1 month):
● IOL decentration
● glare effect
● PCO
● low-grade endophthalmitis
● recurrent uveitis
● diplopia
●corneal endothelial damage
● glare effect
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