WHAT IS CATARACT?
Any opacity in the lens or its capsule which leads to decrease in
vision ,whether developmental or acquired is called a cataract
CLASSIFICATION OF CATARACT
A. Etiological classification
Congenital
and Acquired
developmental cataract
cataract
[Link] CLASSIFICATION
Capsular Subcapsular
cataract Polar
• Anterior Cortical Nuclear
• Anterior • posterior •Anterior
• posterior •posterior
Congenital and developmental cataract
Developmental cataract may be present at birth
(congenital) or it may develop later.
Has tendency to affect particular zone which was being formed
when the disturbance occurred.
Various morphological forms:
1. Punctate cataract
2. Lamellar cataract
3. Fusiform cataract
4. Nuclear cataract
5. Coronary cataract
6. Anterior and posterior polar cataract
PUNCTATE CATARACT : most
common type
Small opaque dots multiple and
scattered all over the lens .
When they appear as tiny blue dots by
oblique illumination known as
cataracta coerulea or blue dot cataract.
When crowded in the y-sutures
termed sutural and anterior axial
embryonic cataract .
Another variant cataracta centralis
pulverulenta , with a central
spheroidal or biconvex opacity
consisting of powdery fine white dots
within embryonic and fetal nucleus.
Non-progressive and has no visual
significance
LAMELLAR CATARACT : 50% of all
visually significant congenital cataracts .
Development is affected at zone around the
embryonic or fetal nucleus.
Opacity is sharply demarcated and area of
the lens within and around the opaque zone
is clear although linear opacities like spokes
of a wheel called riders which run outwards
towards the equator.
Bilateral
NUCLEAR CATARACT :
development of lens affected at very
early stage central (embryonal)
remains opaque .
Progressive type of congenital cataract
is associated with rubella in the
mother if contracted in second or
third month of pregnancy .
The lens nucleus is found to be
necrotic and whole lens becomes
opaque .
CORONARY CATARACT :
developmental cataract occurring
around puberty
Situated in the deep layers of
cortex and most superficial layers
of adolescent nucleus .
Appears as a corona of club shaped
opacities near the periphery of
lens.
Non-progressive .
ANTERIOR POLAR CATARACT :
this may be developmental owing
to delayed formation of anterior
chamber .
More commonly it is acquired .
Sometimes white plaque forms in
lens capsule which projects in
anterior chamber like pyramid
called anterior pyramidal cataract.
Reduplicated cataract .
Opacities are not progressive.
POSTERIOR POLAR CATARACT: due to persistence of posterior part of
vascular sheath of lens.
Sometimes particularly in cases with persistent hyaloid artery, the lens is
deeply invaded by fibrous tissue and a total cataract is formed.
ACQUIRED CATARACT
Age related or Senile cataract
Traumatic cataract
Complicated cataract
Metabolic cataract
Electric cataract
Radiational cataract
Toxic cataract
Cataract associated with skin diseases
Drug induced cataract
Cataract associated with osseous diseases
Cataract associated with miscellaneous syndromes:
dystophica myotonica, down syndrome, lowe’s syndrome,
treacher Collin’s syndrome
Senile cataract
Most commonest type
Affecting persons usually above 50 years of age
Usually bilateral but almost always one eye is affected earlier then the
other
Morphologically, occurs in 2 forms-
1. cortical
2. nuclear
Maturation of cortical cataract
Nuclear cataract
Grade II
Grade I
Grade III GradeIV
Traumatic cataract
Blunt non-penetrating injury or concussion
may cause lens opacification as an acute
event or late sequel
Vossius ring
Lens may show following changes
1. Vossius ring- circular ring of brown
pigments seen on anterior capsule
2. Early rosette- feathery lines of opacities
along star shaped suture lines
3. Late rosette- develops in posterior cortex
1-2 years after injury
Early Rosette Late Rosette
Traumatic cataract
Perforating or penetrating injuries may cause
1. Perforation of lens capsule leading to free floating lens particles in
anterior chamber
2. Opacification of cortex at site of rupture
3. Stationary focal cortical cataract
Complicated cataract
Opacification of lens secondary to some other
intraocular diseases
Seen in-
1. Inflammatory conditions -chronic uveitis,
hypopyon corneal ulcer, Endopthalmitis
2. Degenerative conditions- RP, retinal
dystrophies, myopic chorio-retinal
degeneration Poly chromatic lustre/
3. Retinal detachment Bread crumb appearance
4. Glaucoma (primary or secondary)
5. Intraocular tumours
Cataract associated with systemic diseases
Diabetic cataract:
Snowflake cataract or snow
storm cataract
Myotonic dystrophy
Galactosemia
oil droplet cataract
Down syndrome
Punctate subcapsular cataracts
Atopic cataract
Cataract due to toxic agents
Drug induced
Cigarette smoker
Copper
Iron
Gold
DRUG INDUCED CATARACT
CHLORPROMAZINE STEROID
INDUCED- pigments deposits on anterior INDUCED-posterior subcapsular
capsule cataract
ELECTRIC CATARACT
•Other drugs-
•Amiodarone •Chloroquine
•Busulphan •Miotics
Sunflower cataract : copper
Cataract grading systems
Grading of nuclear hardness
(Emery Little Classification)
• Grade I-greyish nucleus
• Grade II- yellowish white
• Grade III- amber
• Grade IV- brown
(cataracta Brunescens)
• Grade V-dense brown or black
(cataracta Nigra)
LOCS I classification for cataract
Grading-
Grade zero- absence of lens
opacities
Grade 1-early opacification
Grade 2- definite cataract
LOCS II classification for cataract
Nuclear Standard Description
N0 clear nucleus
NI early degree of nuclear opacification
NII moderately advanced nuclear
opacification
NIII advanced nuclear opacification and
browning
C0 clear lens devoid of aggregated dots,
flecks, vacuoles and waterclefts
Ctr minimal degree of cortical opacification
and/or minispoke formation
CI more extensive opacification with small
minispokes
CII cortical spoking that obscures more than
2 full quadrants
CIII opacification that obscures about 50% of
the intrapupillary zone
CIV advanced opacification filling about 90%
of the intrapupillary zone
Posterior Subcapsular Description
Standard
P0 Clear posterior capsule
PI Cataract filling less than 30% of the area of the posterior
capsule
PII about 30% opacification of the area of the posterior
capsule
PIII about 50% opacification of the area of the posterior
capsule
LOCS III classification for cataract
Clinical features of
Cataract
Reduced visual acuity
Loss of contrast sensitivity
Glare
Second sight /myopic shift
Monocular diplopia / polyopia
Frequent change of glasses
Coloured haloes
Altered colour perception
Generalized depression of sensitivity on Visual field
analysis
Symptom Pathogenesis Type of cataract
Coloured halos around light Irregularity in refractive index of Cortical cataract
different part of lens
Second sight/ myopic shift Change in refractive index of lens Nuclear cataract
causing index myopia
Colour shift(become more obvious Blue end of spectrum is more Nuclear cataract
after surgery) absorbed by cataractous lens
Visual field loss Generalised reduction in sensitivity All types
due to loss of transparency
Symptom Pathogenesis Type of cataract
Frequent changes of glasses Rapid change in refractive index of Cortical or nuclear
lens
Gradual, painless, progressive Reduction in transparency of lens All types
diminution of vision
Loss of ability to see objects in Loss of contrast sensitivity, which is Posterior subcapsular cataract
bright light, blinded with light of greater at higher spatial frequency:
oncoming headlamps when driving constriction of pupil leading to cut
at night off peripheral vision
Monocular diplopia or polyopia Cortical spokes opacities in Cortical cataract
conjunction with water clefts that
from radial wedges containing fluid
of lower refractive index than the
surrounding
Glare Increased scattering of light Cortical and PSC
Preoperative assessment
Ocular history
Systemic history
Ocular examination
Ocular investigations
Lab investigations
Ocular history
h/o of trauma, amblyopia, glaucoma, optic nerve abnormalities, or
retinal disease
h/o previous ocular surgeries
If the patient has had cataract surgery in the fellow eye, it is
important to obtain information about the operative and
postoperative course.
Systemic history
h/o of systemic diseases especially diabetes mellitus,
ischemic heart disease, chronic obstructive pulmonary
disease, bleeding disorders
Systemic alpha blockers(tamsulosin)- floppy iris syndrome
Antiplatelets and anticoagulants
h/o of long term use of steroids
Any h/o drug allergy to sulfonamides and antibiotics
Ocular examnation
Visual acuity for distance and near
Head posture and Ocular movements to be checked
Cover and uncover test to be done to look for strabismus
Ocular adenexa- to look for blepharitis, ectropion, entropion,
lagophthalmos
Conjunctiva-congestion,scarring,symbleharon
Cornea- to look for any opacity and prominent arcus senilis
Any deposits over corneal endothelium-uveitis or glaucoma
Anterior chamber examination and gonioscopy to rule out any angle
pathologies
Pupil- reacting promptly to light or not
Direct and indirect light reflexes to be checked
Presence of RAPD- implies pathology in optic nerve
Dilatation to mydriatics to be noted
Macular functions tests
Two point discrimination test
Maddox red test
Color perception
Entoptic visualization
Blue light entoptoscopy
Measurement of IOP
conjunctival swab for cultural sensitivity
Oro dental check up to exclude septic foci
Fundus evaluation : ophthalmoscopy and fundus evaluation with
opaque media
Retinal functions tests : PR must be present in all 4 quadrants
Electro-Retinogram
Electro-Oculogram
Visual evoked potential
Pre-operative measurement
Biometry : keratometry and A-scan ultrasonography
(IOL MASTER)
B-scan ultrasonography
Corneal topography: specially POST LASIK PATIENTS ( PENTACAM
SHOULD BE DONE)
Corneal pachymetry
Specular microscopy: FOR CORNEAL ENDOTHELIAL CELL
COUNT
Systemic investigations
Clinical: Blood pressure
Lab tests: complete hemogram
RBS/FBS
Bleeding and clotting time
Urine routine microscopy
X-ray chest and ECG
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