Cataracts

A cataract is a lens opacity or cloudiness.

Cataracts rank only behind arthritis and heart disease as a leading cause of
disability in older adults.
Cataract is the leading cause of blindness in the world

Pathophysiology
Cataracts can develop in one or both eyes at any age for a variety of
causes.
Visual impairment normally progresses at the same rate in both eyes over
many years or in a matter of months.
The three most common types of senile (age-related) cataracts are
defined by their location in the lens:
 Nuclear
 Cortical
 Posterior subcapsular
The extent of visual impairment depends on the size, density, and location
in the lens. More than one type can be present in one eye.

A nuclear cataract is associated with myopia (ie, nearsightedness), which

worsens when the cataract progresses. If dense, the cataract severely blurs
vision.
 Periodic changes in prescription eyeglasses help manage this problem

A cortical cataract involves anterior, posterior, or equatorial cortex of the

lens.
 A cataract in the equator or periphery of the cortex does not interfere
with the passage of light through the center of the lens and has little effect
on vision.
 Vision is worse in very bright light
Posterior subcapsular cataracts occur in front of the posterior capsule.
 This type typically develops in younger people and, in some cases, is
associated with prolonged corticosteroid use, inflammation, or trauma.
 Near vision is diminished, and the eye is increasingly sensitive to glare
from bright light (E.g., sunlight, headlights).

Risk factor for cataract formation

Aging  Loss of lens transparency
 Clumping or aggregation of
lens protein (which leads to
light scattering)
 Accumulation of a yellow-
brown pigment due to the
breakdown of lens protein
 Decreased oxygen uptake •
Increase in sodium and
calcium
 Decrease in levels of vitamin
C, protein, and glutathione
(an antioxidant)
Associated Ocular Conditions  Retinitis pigmentosa
 Myopia
 Retinal detachment and
retinal surgery
 Infection (E.g., herpes
zoster, uveitis)
Toxic Factors  Corticosteroids, especially at
high doses and in long-term
use
 Alkaline chemical eye burns,
poisoning
 Cigarette smoking
 Calcium, copper, iron, gold,
silver, and mercury, which
tend to deposit in the
pupillary area of the lens
Nutritional Factors  Reduced levels of
antioxidants
 Poor nutrition
 Obesity
Physical Factors  Dehydration associated with
chronic diarrhea, use of
purgatives in anorexia
 nervosa, and use of
hyperbaric oxygenation
 Blunt trauma, perforation of
the lens with a sharp object
or foreign body, electric
shock
 Ultraviolet radiation in
sunlight and x-ray
Systemic Diseases and  Diabetes mellitus
Syndromes  Down syndrome
 Disorders related to lipid
metabolism
 Renal disorders
 Musculoskeletal disorders

Clinical Manifestations
 Painless
 Blurry vision
 The patient perceives that surroundings are dimmer, as if glasses need
cleaning
 Light scattering is common
 Individual experiences reduced contrast sensitivity
 Sensitivity to glare
 Reduced visual acuity
Other effects include: Myopic shift, astigmatism, monocular diplopia (ie,
double vision), color shift (ie, the aging lens becomes progressively more
absorbent at the blue end of the spectrum), brunescens (ie, color values shift
to yellow-brown), and reduced light transmission
Assessment and Diagnostic Findings
Decreased visual acuity is directly proportionate to cataract density.
The Snellen visual acuity test, ophthalmoscopy, and slitlamp
biomicroscopic examination are used to establish the degree of cataract
formation.
 Visual acuity is an imperfect measure of visual impairment

Medical Management
No nonsurgical treatment cures cataract
 In the early stages of cataract development, glasses, contact lenses,
strong bifocals, or magnifying lenses may improve vision.
 Reducing glare with proper light and appropriate lighting can facilitate
reading.
 Mydriatics can be used as short-term treatment to dilate the pupil and
allow more light to reach the retina, although this increases glare

Surgical management
In general, if reduced vision from cataract does not interfere with normal
activities, surgery may not be needed.
 Surgery is performed on an outpatient basis and usually takes less
than 1 hour, with the patient being discharged in 30 minutes or less
afterward

 Topical anesthesia, such as lidocaine gel applied to the surface of the

eye, eliminates the hazards of regional anesthesia, such as ocular
perforation, retrobulbar hemorrhage, optic injuries, diplopia, and ptosis,
and is ideal for patients receiving anticoagulants.

Intracapsular Cataract Extraction (ICCE)

 The entire lens (nucleus, cortex, and capsule) is removed, and fine
sutures close the incision.
 Not frequently performed today; however, it is indicated when there is a
need to remove the entire lens, such as with a subluxated cataract
(partially or completely dislocated lens).
Extracapsular cataract extraction (ECCE) achieves the intactness of
smaller incisional wounds (less trauma to the eye) and maintenance of the
posterior capsule of the lens, reducing postoperative complications,
particularly aphakic retinal detachment and cystoid macular edema.
 In ECCE, a portion of the anterior capsule is removed, allowing
extraction of the lens nucleus and cortex. The posterior capsule and
zonular support are left intact.
 An intact zonular-capsular diaphragm provides the needed safe anchor
for the posterior chamber intraocular lens (IOL). After the pupil has
 been dilated and the surgeon has made a small incision on the upper
edge of the cornea, a viscoelastic substance (clear gel) is injected into
the space between the cornea and the lens.
 This prevents the space from collapsing and facilitates insertion of
the IOL.
Phacoemulsification
 This method of extracapsular surgery uses an ultrasonic device that
liquefies the nucleus and cortex, which are then suctioned out through a
tube.
 The posterior capsule is left intact
 Because the incision is even smaller than the standard ECCE, the wound
heals more rapidly, and there is early stabilization of refractive error and
less astigmatism
Lens Replacement
 After removal of the crystalline lens, the patient is referred to as aphakic
(ie, without lens). The lens, which focuses light on the retina, must be
replaced for the patient to see clearly.
There are three lens replacement options:
1. Aphakic eyeglasses
2. Contact lenses
3. IOL implants
Aphakic glasses are effective but heavy
 Objects are magnified by 25%, making them appear closer than they
actually are.
 Objects are magnified unequally, creating distortion
 Peripheral vision is also limited, and binocular vision (ie, ability of both
eyes to focus on one object and fuse the two images into one) is
impossible if the other eye is phakic (normal)
Contact lenses provide patients with almost normal vision, but because
contact lenses need to be removed occasionally, the patient also needs a
pair of aphakic glasses
 Contact lenses are not advised for patients who have difficulty
inserting, removing, and cleaning them. Frequent handling and
improper disinfection increase the risk for infection
IOL
 Insertion of IOLs during cataract surgery is the usual approach to lens
replacement.
 After ICCE, the surgeon implants an anterior chamber IOL in front of
the iris.
 Posterior chamber lenses, generally used in ECCE, are implanted
behind the iris.
 IOL implantation is contraindicated in patients with recurrent uveitis,
proliferative diabetic retinopathy, neovascular glaucoma, or rubeosis
iridis