17/8/2017 Senile Cataract (Age-Related Cataract) Workup: Laboratory Studies, Imaging Studies, Other Tests

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Senile Cataract (Age-Related

Cataract) Workup
Updated: May 09, 2017
Author: Vicente Victor D Ocampo, Jr, MD; Chief Editor: Andrew A Dahl, MD, FACS more...

WORKUP

Laboratory Studies
Diagnosis of senile cataract is made basically after a thorough history and physical examination
are performed. Laboratory tests are requested as part of the preoperative screening process to
detect coexisting diseases (eg, diabetes mellitus, hypertension, cardiac anomalies). Studies have
shown that thrombocytopenia may lead to increased perioperative bleeding and, as such, should
be properly detected and managed before surgery, especially if synechiolysis, a retrobulbar block,
or an adjunctive procedure such as microincisional glaucoma surgery (MIGS) or pars plana
vitrectomy is anticipated. Additional risk factors for accentuated perioperative bleeding should also
be assessed, including the use of oral NSAIDs, anticoagulant prescription medications, or omega-3
supplements containing vitamin E (eg, fish oil).

Imaging Studies
Ocular imaging studies (eg, ultrasonography, CT scanning, MRI) are requested when a posterior
pole pathology is suspected and an adequate view of the back of the eye is obscured by an
extremely dense or hypermature cataract. This is helpful in planning out the surgical management
and in providing a more guarded postoperative prognosis for the visual recovery of the patient.

Other Tests
Additional patient-specific tests can be performed when coexisting ocular diseases are suspected,
especially in identifying the etiology of preoperative visual loss. Aside from the routine visual acuity
testing, testing for brightness acuity and contrast sensitivity and confrontation visual field testing
can be performed to assess visual function. Patients with a history of glaucoma, optic nerve
disease, or retinal abnormality should undergo an automated visual field test to document the
degree of preoperative field loss.

In patients suspected of having a macular problem, the following tests may be performed to
evaluate macular function: Maddox rod test, photostress recovery test, blue-light entoptoscopy,
Purkinje entoptic phenomenon, and visual-evoked response and electroretinography (VER-ERG).
Above all, macular optical coherence tomography (OCT) should prove to be the most informative.

In patients with dense cataracts that preclude adequate visualization of the fundus, a Maddox rod
test can be used to grossly evaluate macular function with detection of a large scotoma,
represented as a loss of the red line, a sign suggestive of a macular pathology.

While the photostress recovery test is a semiquantitative estimate of macular function, both blue-
light entoptoscopy and Purkinje entoptic phenomenon are subjective means of evaluating macular
integrity. The most objective method of measuring macular function is VER-ERG. A simple color

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17/8/2017 Senile Cataract (Age-Related Cataract) Workup: Laboratory Studies, Imaging Studies, Other Tests

vision test with a large Ishihara chart or muscle light illuminated color-coded glaucoma medication
caps can also qualitatively predict intact macular function.

Several measurements should be taken preoperatively, particularly in an anticipated cataract

extraction with intraocular lens (IOL) implantation.

Careful refraction must be performed on both eyes in selecting the IOL style, power, optics (spheric
or aspheric), and premium features best suited to the individual eye. The power of the IOL on the
operated eye must be compatible with the refractive error of the fellow eye to avoid complications
(eg, postoperative anisometropia), while also anticipating future surgeries. Ocular dominance is
also important since many patients tolerate a small degree of monovision with a small add or
additional IOL plus power in the nondominant eye, often called mini-monovision.

An accurate biometry also should be performed to calculate for the IOL power to be used.

Corneal integrity, specifically the endothelial layer, must be assessed very well via pachymetry, slit
lamp 40x high-magnification endothelial specular illumination, and specular microscopy to predict
postoperative corneal morbidities (eg, corneal edema, corneal decompensation) and to weigh the
risks versus the benefits of performing cataract extraction. A preoperative discussion of endothelial
transplantation, however brief, is wise in the context of even minimal detected endothelial
pathology.

Histologic Findings
Nuclear cataracts are characterized by homogeneity of the lens nucleus with loss of cellular
laminations. Cortical cataracts typically manifest with hydropic swelling of the lens fibers with
globules of eosinophilic material (morgagnian globules) seen in slit-like spaces between lens
fibers. Finally, a posterior subcapsular cataract is associated with posterior migration of the lens
epithelial cells in the posterior subcapsular area, with aberrant enlargement of the epithelial cells
(Wedl or bladder cells).

Costello et al examined senile cataracts using electron microscopy to highlight differences in the
cellular architecture of the various forms of age-related lens changes. [22] Comparisons were made
between a typical nuclear cataract with a central opacity and a transparent rim, and a more
advanced or mature, completely opaque nuclear cataract. The former was described as having no
obvious cell disruption, cellular debris, or changes that could readily account for the central opacity.
The fiber cells had intact uniformly stained cytoplasms with well-defined plasma membrane
borders and gap junctions. The mature cataract exhibited various types of cell disruption in the
perimeter but not in the core of the nucleus in the form of globules, vacuoles, multilamellar
membranes, and clusters of highly undulating membranes.

Staging
Clinical staging of senile cataract is based largely on the visual acuity of the patient. A patient who
cannot read better than 20/200 on the visual acuity chart is said to have a mature cataract. If the
patient can distinguish letters on lines better than 20/200, then the cataract is described as being
immature. An incipient cataract is found in a patient who can still read at 20/20 but possesses a
lens opacity as confirmed by slit lamp examination. Patients with incipient cataract who report
symptoms can be ordained with the synonymous diagnosis of dysfunctional lens syndrome.

Treatment & Management

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