Lens and Cataract

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
 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
Nucleus (from without inwards) :

• Adults
• Adolescent
• Infantile
• Fetal (contains anterior & posterior Y-
sutures)
• Embryonic
 Physiology
• Functions :
1. Refraction of light (+18 D)
2. Accomodation : ability to increase refractive
power in order to focus near objects.
 Optics
• +18 D refraction. And in accomodation this
power increases
• 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
 Cataract

Definition
– Any opacity of the lens
or loss of transparancy
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. Fabry’s Disease
7. Lowe’s Syndrome
8. Wilson’s Disease (Sunflower Cataract)
9. Hypocalcaemia
4. Toxic
1. Corticosteroids
2. Chlorpromazine
3. Miotics
4. Busulphan
5. Gold
6. Amiodarone
5. Complicated
– Anterior uveitis
– Hereditary Retinal & Vitreoretinal Disoders
– High Myopia
– Glaucomflecken
– Intraocular Neoplasia

6. Maternal Infection
1. Rubella
2. Toxoplasmosis
3. Cytomegalovirus
7. Maternal Drug Ingestion
– Thalidomide
– Corticosteroid

8. Presenile Cataract
– Myotonic Dystrophy
– Atopic Dermatitis (Syndermatotic Cataract)
– GPUT & Enzyme Deficiencies
9. Syndromes with Cataract
– Down’s Syndrome
– Werner’s Syndrome
– Rothmund’s Syndrome
– Lowe’s 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