Approach to a

Case of Cataract
Sandeep Saxena MS, FRCS (Edin), FRCS (Glasg)
Professor, Ophthalmology, KGMU
 Differential diagnosis
Painless, progressive diminution of vision

• Cataract
• Primary open angle glaucoma
• Diabetic retinopathy
• Corneal dystrophies and degenerations
• Age related macular degeneration
• Retinitis pigmentosa
 Cataract
• Opacification of the human crystalline lens
• Major cause of blindness worldwide

• Classification-
-Etiological
-Morphological
 Morphological classification
• Capsular cataract
-Anterior
-Posterior
• Subcapsular cataract
-Anterior
-Posterior
• Cortical cataract
• Nuclear cataract
• Polar cataract
 Etiological classification
I. Congenital and Developmental cataract
II. Acquired cataract
• Senile cataract
• Traumatic cataract (blunt, penetrating, radiation,
electric shock, glass blowers, infra-red)
• Complicated cataract (uveitis-induced)
• Metabolic cataract (Diabetes - snowflake, Wilson’s
disease-sunflower)
• Drug induced cataract- corticosteroids, miotics
• Cataract associated with syndromes
• Congenital or Developmental cataract
- Occur due to maternal infection or malnutrition,
perinatal hypoxia – APH, or may be hereditary

- Various morphological forms:

– Blue dot
– Sutural
– Fusiform or spindle shaped
– Embryonal nuclear
– Zonular
– Coronary
– Anterior or posterior polar
 Senile cataract
• ‘Age-related cataract’
• By the age of 70 years, over 90% of the
individuals develop senile cataract
• Usually bilateral, but almost always
asymmetrical
 Symptoms
• Gradual, painless progressive loss of vision
• Discomfort / glare in daylight – nuclear
cataract; better vision in daylight – cortical
cataract
• Uniocular polyopia
• Coloured halos
• Black spots in front of eyes
• ‘Second sight’
 Signs
• Iris shadow
• Depth of anterior chamber
• Pupillary reflex
• Visual acuity
• Plain mirror examination under mydriasis
 Iris A.C. Pupillary Visual
shadow Depth reflex acuity

Intumescent Present Shallow Greyish white FC to 6/18

Incipient Present Normal Greyish white FC to 6/18

Mature Absent Normal Pearly white HM to FC

close to face

Hypermature Absent Shallow Milky white HM +

Morgagnian
Hypermature Absent Normal or Milky HM +
Calcified deep chalky
 Patient workup
• Retinoscopy and best corrected visual acuity
• Intraocular pressure
• Slit lamp examination
• Fundus evaluation – direct & indirect
• Macular function tests
• Ultrasonography
• IOL power calculation
 General investigations
• Blood pressure
• Blood sugar
• Complete haemogram
• HIV, Hepatitis B & C
• Causes of straining
• Foci of infection
• Systemic examination
 Management
• An un-operated eye is more comfortable than an
operated eye if visual diminution is mild.
• Early cataract :
-Refraction and glasses
-Dark glasses or photochromatic glasses for
nuclear cataract
-Rule out other causes of visual diminution
-If BCVA not to patient’s satisfaction, then
operate.
 Surgical techniques

• Intracapsular cataract extraction (ICCE)

• Extracapsular cataract extraction (ECCE)
– Conventional ECCE
– Small Incision Cataract Surgery
– Phacoemulsification
– Lens aspiration in paediatric (soft) cataract
 Complications of cataract surgery
• Intraoperative
– Incision related complications
– Posterior capsular rupture
– Zonular dehisence
– Vitreous loss
– Nuclear drop
– Posterior loss of lens fragments
– Injury to the cornea, iris and lens
– Expulsive choroidal haemorrhage
• Early post operative complications
– Hyphaema
– Iris prolapse
– Striate keratopathy
– Postoperative anterior uveitis
– Bacterial endophthalmitis

• Late postoperative complications

– Cystoid macular edema
– Pseudophakic bullous keraopathy
– Retinal detachment
– Delayed postoperative endophthalmitis
– After cataract
• Soemmering’s ring
• Elschnig’s pearls
 Intraocular Lenses
Types
• Anterior chamber IOL
• Iris supported lens
• Posterior chamber IOL
• Rigid
• Foldable

Calculation of IOL power

• SRK formula
Thank you