Cataract and Refractive Surgery

Subspecialty Service
Department of Ophthalmology
Faculty of Medicine Padjadjaran
LENS AND
University

CATARACT
Anatomy
Anatomy
Lies behind the iris
Concavity in the anterior face of vitreus
called the Patellar Fossa
Suspended from the cilliary processes by
Zonules
In young patients (<35 years) lens is
adherent to vitreus by Ligament of
Weigert
Layers (from without
inwards) :
Lens capsule (thinnest at posterior
pole)
Epithelium (missing from posterior
surface)
Cortex
Epinuclear Cortex
Nucleus
Physiology
Functions :
1. Refraction of light (+18 D)
2. Accomodation : ability to increase
refractive power in order to focus near
objects
Cataract

Definition
Any opacity of the
lens or loss of
transparency of the
lens that causes
diminution or
impairment of vision
Classification

Etiological
Morphological
Stage of Maturity
Chronological
Etiological classification
1. Senile
2. Traumatic
1. Penetrating
2. Concussion (Rosette Cataract)
3. Infrared irradiation
4. Electrocution
5. Ionizing Radiation
3. Metabolic
1. Diabetes (Snow Storm Cataract)
2. Hypoglycaemia
3. Galactosemia (Oil drop cataract)
4. Galactokinase Deficiency
5. Mannosidosis
6. Fabrys Disease
7. Lowes Syndrome
8. Wilsons Disease (Sunflower Cataract)
9. Hypocalcaemia
4. Toxic
1. Corticosteroids
2. Chlorpromazine
3. Miotics
4. Busulphan
5. Gold
6. Amiodarone
5. Complicated
1. Anterior uveitis
2. Hereditary Retinal & Vitreoretinal Disorders
3. High Myopia
4. Glaucomflecken
5. Intraocular Neoplasia

6. Maternal Infection
6. Rubella
7. Toxoplasmosis
8. Cytomegalovirus
7. Maternal Drug Ingestion
Thalidomide
Corticosteroid

8. Presenile Cataract
Myotonic Dystrophy
Atopic Dermatitis (Syndermatotic
Cataract)
GPUT & Enzyme Deficiencies
9. Syndromes with Cataract
Downs Syndrome
Werners Syndrome
Rothmunds Syndrome
Lowes Syndrome

10. Hereditary

11. Secondary Cataract

Posterior Capsular Opacification (PCO)
Morphological Classification

1. Capsular
Congenital (Anterior Polar & Posterior
Polar)
Acquired

2. Subcapsular
Posterior subcapsular (Cupuliform)
Anterior subcapsular

3. Nuclear
Congenital (Discoid, etc)
Senile
4. Cortical
Congenital (Coronary, Coralliform, etc)
Senile (Cuneiform)
5. Lamelar or Zonular
6. Sutural
7. Others
Blue Dot (Cataracta caerulea)
Membranous
Cataracta Pulveranta Centralis
Reduplicated Cataract
Stage of Maturity

1. Immature
2. Mature
3. Intumescent
4. Hypermature
5. Morgagnian
Chronological

1. Congenital : since birth

2. Infantile : first year of life
3. Juvenile : 1 to 13 years of life
4. Presenile : 13 to 35 years of
life
5. Senile
Pathogenesis
Two main pathogenetic processes are :
1. Hydration :
Failure of active pump mechanism
Increased leakage across posterior or
anterior capsule
Increased Osmotic Pressure
2. Sclerosis
Senile Cataract

Global
38 million people are

blind
41% because of cataract
Progression

1. Stage of Lamellar Separation

Hydration
2. Stage of Incipient Cataract
Early opacities appear
Symptom e.g., glare, appear
3. Immature Cataract
Diminution of vision
Lens appears grayish white in
color
Iris shadow can be seen
Progression
4. Intumescent Cataract
The lens imbibes lot of fluid and becomes
swollen
Anterior chamber becomes shallow
Angle of anterior chamber may close :
Phacomorphic glaucoma

5. Mature Cataract
Entire cortex becomes opaque
Vision reduced to just perception
of light
Iris shadow is not seen
Lens appears pearly white
Progression

6. Hypermature Cataract
This may take any of two form :
Liquefactive or Morgagnian type : milky
white
Sclerotic Cataract with iridodenesis
Vision improves to about finger
counting at 1 meter
Clinical Presentation

Symptoms
1. Glare
2. Image Blur
3. Diurnal Variation of Vision
4. Distortion (Metamorphopsia)
5. Diplopia/Polyopia
6. Altered Color Perception
7. Black Spots
8. Behavioral Changes
Clinical Presentation
Signs
1. Visual Acuity : vision is diminished
proportionate to the degree of cataract
(immature from 6/9 to finger counting
close to face; mature perception of light
or hand movements)
2. Leukocoria : white pupil
3. Iris shadow in immature cataract
4. Distant Direct Ophthalmoscopy (DDO) :
red reflexes depends on degree of
cataract
Differentiating Various Stages of Cataract

Features Immature Mature Hypermature

Vision 6/9 - FC HM - PL HM FC
Anterior Normal (shadow Normal (shallow Normal to deep
Chamber in intumescent) in intumescent)

Color of Lens Grayish white Pearly white Milky white(with

browm crescent of
nucleus) or chalky
white

Iris shadow Seen Not seen Not seen

Distant Direct Black patches No red glow No red glow

Ophthalmoscopy againts red glow seen seen
 Complication of Cataract

1. Lens Induced Glaucoma

1. Phacomorphic Galucoma
2. Phacolytic Glaucoma
3. Phacotopic Glaucoma
2. Lens Induced Uveitis
3. Subluxation or Dislocation
of Lens
Investigation
1. Visual Acuity
2. Pupillary Reflexes
3. Intraocular Pressure
4. Fundus Examination
5. Blood Pressure
6. General Investigation
7. Macular Function Test
8. Ultrasonography (USG B-Scan)
9. Intraocular Lens Power Calculation
Biometry
Indications for Cataract
Surgery
1. Optical indications
2. Medical indication
Hypermature cataract
Lens induced glaucoma
Lens induced uveitis
Dislocated/subluxated lens
Intra-lenticular foreign body
Diabetic Retinopathy to give
Laser Photocoagulation
Retinal Detachment
3. Cosmetic indication
Surgery for Cataract
Choice of Operation :
1. Extra-capsular cataract extraction with
Posterior Chamber Lens Implantation
(ECCE with PCL)
2. Intra-capsular cataract extraction
(ICCE)
3. Pars plana lensectomy
4. Phacoemulsification with Foldable
Intra-ocular Lens (IOL)
Intra-ocular lens (IOL) types :
1. Posterior chamber lens (PCL)
2. Anterior chamber lens (ACL)
Principles of Various
Techniques
1. ECCE
The nucles and the cortex is removed out
of the capsule leaving behind intact
posterior capsule, peripheral part of the
anterior capsule and the zonules
2. ICCE
The lens is removed in toto
3. Pars Plana Lensectomy
A special techniques used in very young
children
The lens and anterior part of vitreous is
nibled out using an instrument called
Vitrectomy Probe or Vitreous irrigation
Suction Cutting (VISC)
4. Phacoemulsification
It is essentially an advancement in the
methode of doing ECCE
The nucleus is converted into pulp or
emulsified using high frequency (40.000
MHz) sound waves and then sucked out of
the eye through a small (3.2) incision
A special foldable IOL is then inserted
Is the choice of the operation for cataract
ECCE vs. ICCE

ECCE ICCE
Lens removal Nucleus removed out Lens removed as
of the capsule and single piece within its
cortex sucked out capsule

Posterior capsule & Intact Removed

zonules
Incision Smaller (8 mm) Larger (10 mm)
Peripheral iridectomy Not performed Required to avoid
pupillary block glaucoma

Sophisticated Required Not required

equipment
Time taken More Less
ECCE vs. ICCE

ECCE ICCE
IOL Implantation Posterior chamber Anterior chamber
Expertise required Difficult technique Easier to learn
Cost More Less
Complications which Posterior Capsular 1. Vitreous prolapse &
are increased loss
Opacification (PCO)
2. CME
3. Endophthalmitis
4. Aphakic Glaucoma
5. Fibrous &
endothelial ingrowth
6. Neovasc. Glaucoma
in PDR
 ECCE vs. ICCE
ECCE ICCE
Complications All the complications PCO
which are mentioned for ICCE
decreased
Indications A routine procedure 1. Dislocated Lens
for all forms of 2. Subluxated Lens (>1/3
cataract (except zonules broken)
where contra- 3. Chronic Lens Induced
indicated Uveitis
4. Hypermature Shrunken
Cataract
5. Intraocular foreign body

Contraindications 1. Dislocated lens Young patient (<35 years)

2. Subluxated lens
(>1/3 zonules
broken)
Preoperative Preparation
1. Patient preferably admitted to the
hospital on previous evening (however,
surgery can also be done on OPD basis)
2. Informed consent is taken
3. The eye-lashes are trimmed carefully
4. Antibiotic drops are instilled every 6
hourly
5. Pupils are dillated
6. Other medications e.g., antiglaucoma
drugs, antihypertensives, etc
Anesthesia

1. Topical anesthesia
2. Retrobulbar anesthesia
3. Peribulbar anesthesia
4. Subtenon anesthesia
5. General anesthesia
Postoperative Care

1. Eye is cleaned routinely

2. The eye is examined :
Visual acuity
Apposisition of the wound
Corneal clarity
Anterior chamber depth
Pupil
IOL
Posterior capsule
Intra-ocular pressure (IOP)
3. Topical antibiotic-steroid eye drops every
4-6 hourly (4-6 weeks)
Complication of Cataract
Surgery

These can be grouped as :

1. Intraoperative
2. Postoperative :
Early
Late
Intraoperative
Complications
1. Damage to corneal endothelium
2. Rupture of posterior capsule
3. Vitreous prolapse and loss
4. Hyphaema
5. Expulsive hemmorrhage
6. Dislocation of nucleus into vitreous
 Posoperative Complications

Early
1. Corneal edema
2. Wound leak
3. Iris prolapse
4. Shallow or flat anterior
chamber
5. Hyphaema
6. Hypotony
7. Glaucoma
8. Decentered or displaced IOL
9. Endophthalmitis
Late
1. Posterior Capsular
Opacification (PCO)
2. Cystoid Macular Edema
(CME)
3. Vitreous touch syndrome
4. UGH syndrome
5. Bullous Keratopathy
6. Glaucoma
Visual Rehabilitation After Cataract
Surgery (Aphakia)

1. Absolute high
hypermetropia
2. Astigmatism
3. Loss of accomodation
4. Altered Color Perception
5. More of UV rays reach the
retina
Rehabilitation

Three methods are mainly used to

tackle the problems of aphakia :
1. Intraocular Lens (IOL)
2. Spectacles
3. Contact Lens
Aphakic Spectcles

Physical and Optical Problems :

1. The glasses are heavy and
great physical discomfort
2. Magnification : diplopia
3. Roving Ring Scotoma
4. Jack in the box Phenomenon
5. Pin Cushion Effect
6. Spherical Aberations
7. Chromatic Aberation
Pediatric Cataract

Main problems
1. Visual Assesment
2. Vision Deprivation Amblyopia
3. Postoperative Inflammation and
Fibrosis
4. PCO
5. IOL Power Calculation
 Dislocation of Lens

Congenital
1. Familial
2. Ectopia lentis
3. Marfan Syndrome
4. Weil Marchesani Syndrome
5. Homocystinuria
6. Hyperlisinemia
7. Aniridia
Acquired
1. Hypermature
cataract
2. Trauma
3. Chronic uveitis
4. Intraocular tumor
5. High myopia
6. Buphthalmos
Treatment

1. Spectacles
2. ECCE : only 1/3 zonules are broken
3. ICCE : more than 1/3 zonules are
broken
4. Pars Plana Surgery
Miscellaneous Condition of
Lens

1. Lenticonus
2. Lens Coloboma
3. PCO
Thank You
Topics of Study
1. Cataract
Causes of Cataract
Global/National distribution & population
characteristics of Cataract
Diagnosis of Cataract. Distinction between
immature, mature and hypermature
Appropriate referral of cataract patient
Outline of surgical management
Visual rehabilitation of Aphakia
Outline of cataract management in young
age
Topics of Study
2. Congenital Abnormalities of Lens
Ectopia Lentis (Subluxation & Dislocation)
Lenticonus
 Crystalline Lens

Embryology
Derived from surface Ectoderm

Ectoderm invaginates and breaks as two

layers structure
Basement membrane of epithelium forms the

lens capsule
Posterior epithelium cells form the embryonic

nucleus
Anterior epithelium continues to regenerate

and develop lens fibers

Nucleus (from without inwards) :

Adults
Adolescent
Infantile
Fetal (contains anterior & posterior Y-
sutures)
Embryonic
Optics
+18 D refraction
In accomodation this power
Accomodation : contraction of ciliary
muscles results in laxity of zonules, which
leads to increase convexity of lens due to
its inherent elasticity
Iris controls the amount of light that
enters the eye by varying the size of pupil
and covers the peripher of the lens
thereby cutting the optical (spherical)
aberrations from it