Acquired Acquired CataractCataract

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Classification of Classification of CataractCataract

1.1. DevelopmentalDevelopmental

2.2. Age related (senile)Age related (senile)

3.3. Cataract associated with ocular Cataract associated with ocular diseasesdiseases

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Classification of CataractClassification of Cataract

4. Cataract associated with systemic 4. Cataract associated with systemic diseases (pre-senile): diseases (pre-senile):

Diabetes, Hypoglycaemia, Diabetes, Hypoglycaemia, Hypoparathyroidism, Myotonic Hypoparathyroidism, Myotonic Dystrophy, Galactosaemia, Alport Dystrophy, Galactosaemia, Alport Syndrome, Lowe Syndrome, Stickler Syndrome, Lowe Syndrome, Stickler Syndrome, Down SyndromeSyndrome, Down Syndrome

Skin Diseases – Atopic Dermatitis, Skin Diseases – Atopic Dermatitis, IchthyosisIchthyosis

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Classification of Classification of CataractCataract

5. Traumatic Cataract : Trauma 5. Traumatic Cataract : Trauma (Blunt / Perforating) , Electric (Blunt / Perforating) , Electric Shock, RadiationShock, Radiation

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Classification of Classification of CataractCataract

6. Drug induced cataract : 6. Drug induced cataract :

Corticosteroids, Anticholinesterases, Corticosteroids, Anticholinesterases, Chlorpromazine, Busulfan, Choroquine, Chlorpromazine, Busulfan, Choroquine, Amiodrone, Cigarette smoker, Copper, Amiodrone, Cigarette smoker, Copper, Iron, Gold, Naphthalene, Lactose, Iron, Gold, Naphthalene, Lactose, Galactose, Selenite, Thallium, Galactose, Selenite, Thallium, Dinitrophenol, ParadichlorobenzeneDinitrophenol, Paradichlorobenzene

Deficiency – of amino-acids or Riboflavin Deficiency – of amino-acids or Riboflavin (B2) (B2)

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Etiopathogenesis of Etiopathogenesis of CataractCataract

Caused by degeneration and Caused by degeneration and opacification of existing lens fibres, opacification of existing lens fibres, formation of aberrant fibres or formation of aberrant fibres or deposition of other material in their deposition of other material in their place.place.

Loss of transparency occurs because Loss of transparency occurs because of abnormalities of lens protein and of abnormalities of lens protein and consequent disorganization of the consequent disorganization of the lens fibreslens fibres

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Etiopathogenesis of Etiopathogenesis of CataractCataract

Any factor that disturbs the critical intra Any factor that disturbs the critical intra and extra cellular equilibrium of water and and extra cellular equilibrium of water and electrolytes or deranges the colloid system electrolytes or deranges the colloid system within the fibres causing opacification. within the fibres causing opacification.

Fibrous metaplasia of lens fibres occurs in Fibrous metaplasia of lens fibres occurs in complicated cataract. complicated cataract.

Epithelial cell necrosis occurring in angle Epithelial cell necrosis occurring in angle closure glaucoma leads to focal opacification closure glaucoma leads to focal opacification of the lens epithelium (Glaucomflecken)of the lens epithelium (Glaucomflecken)

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Etiopathogenesis of Etiopathogenesis of CataractCataract

Abnormal products of metabolism, Abnormal products of metabolism, drugs or metals can be deposited in drugs or metals can be deposited in storage diseases (Febry), metabolic storage diseases (Febry), metabolic diseases (Wilson) and toxic reactions diseases (Wilson) and toxic reactions (Siderosis) (Siderosis)

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Etiopathogenesis of Etiopathogenesis of CataractCataract

Three biochemical factors are Three biochemical factors are evident in cataract formation:evident in cataract formation:1. 1. HydrationHydration: seen particularly in : seen particularly in rapidly developing forms. Actual fluid rapidly developing forms. Actual fluid droplets collect under the capsule droplets collect under the capsule forming lacunae between fibres, the forming lacunae between fibres, the entire tissue may swell (intumescent) entire tissue may swell (intumescent) and becomes opaque, this process is and becomes opaque, this process is reversible in early stage, as in reversible in early stage, as in juvenile insulin dependent diabetes.juvenile insulin dependent diabetes.

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Etiopathogenesis of Etiopathogenesis of CataractCataract

Hydration may be due to osmotic Hydration may be due to osmotic changes in the lens or due to changes in the lens or due to changes in the semi-permeability of changes in the semi-permeability of the capsule. the capsule.

In traumatic cataract, rupture of In traumatic cataract, rupture of capsule gives rise to lens swelling. capsule gives rise to lens swelling.

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Etiopathogenesis of Etiopathogenesis of CataractCataract

2. 2. Denaturation of lens proteinsDenaturation of lens proteins - If - If the proteins are denatured with an the proteins are denatured with an increase in insoluble protein, a increase in insoluble protein, a dense opacity is produced. This dense opacity is produced. This stage is irreversible and opacity do stage is irreversible and opacity do not clear, this change is seen in not clear, this change is seen in young lens or the cortex of the adult young lens or the cortex of the adult nucleus where metabolism is active nucleus where metabolism is active (soft cataract). (soft cataract).

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Etiopathogenesis of Etiopathogenesis of CataractCataract

3. 3. SclerosisSclerosis: Inactive fibres of the : Inactive fibres of the nucleus suffer from degenerative nucleus suffer from degenerative change of slow sclerosis (hard change of slow sclerosis (hard cataract).cataract).

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Etiological theories of Etiological theories of CataractCataract

Etiological TheoriesEtiological Theories

1.1. Biological Biological

a. An expression of senilitya. An expression of senility

b. Geneticb. Genetic

2. Immunological2. Immunological

3. Functional, due to strain of 3. Functional, due to strain of excessive accommodative strain excessive accommodative strain

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Etiological theories of Etiological theories of Cataract… contdCataract… contd

4. Local Disturbances 4. Local Disturbances

a. Nutritional supplya. Nutritional supply

b. Of the chemistry of lens due to b. Of the chemistry of lens due to disturbances of permeability disturbances of permeability

c. Radiational damage due to c. Radiational damage due to sunlight sunlight

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Etiological theories of Etiological theories of Cataract… contdCataract… contd

5. General metabolic disturbances 5. General metabolic disturbances

a. changes in blood chemistrya. changes in blood chemistry

b. toxic statesb. toxic states

c. conditions of deficiencyc. conditions of deficiency

d. endocrine disturbancesd. endocrine disturbances

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Experimental CataractExperimental Cataract

Can be produced by: Can be produced by:

1. Mechanical injury – concussion, rupture 1. Mechanical injury – concussion, rupture of capsuleof capsule

2. Physical causes – Osmotic influences, 2. Physical causes – Osmotic influences, cold and heat, acidity, electricity currentcold and heat, acidity, electricity current

3. Radiational Cataract – Micro-wave, 3. Radiational Cataract – Micro-wave, thermal, UV and ionizing radiationthermal, UV and ionizing radiation

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Experimental Cataract… Experimental Cataract… contdcontd

4.4. Decrease in semi-permeability of Decrease in semi-permeability of capsulecapsule

5.5. Interference with nutrient supply, Interference with nutrient supply, anoxia and asphyxiaanoxia and asphyxia

6.6. Sugar Cataract – Galactose, xylose, Sugar Cataract – Galactose, xylose, glucose glucose

7.7. Deficiency cataract- lack of proteins, Deficiency cataract- lack of proteins, specific amino acids and vitamins specific amino acids and vitamins

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Experimental CataractExperimental Cataract

8. A low calcium / phosphate ratio in the 8. A low calcium / phosphate ratio in the blood – parathyroidectomy and tetanyblood – parathyroidectomy and tetany

9. Endocrine Cataract9. Endocrine Cataract

10. Toxic cataract – Naphthaline, 10. Toxic cataract – Naphthaline, dinitrophenol, paradichlorbenzene, dinitrophenol, paradichlorbenzene, thallium, cobalt, anti-mitotic agents, thallium, cobalt, anti-mitotic agents, enzyme inhibitors, cataractogenic drugsenzyme inhibitors, cataractogenic drugs

11. Due to systemic infections 11. Due to systemic infections

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Age Related Age Related

(Senile) Cataract(Senile) Cataract

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Age Related Senile Age Related Senile CataractCataract

Age related cataract is universal in Age related cataract is universal in persons over 70 years of age. Both persons over 70 years of age. Both sexes are involved equally.sexes are involved equally.

There is considerable genetic There is considerable genetic influence.influence.

Average age of onset of cataract is Average age of onset of cataract is approximately 10 years earlier in approximately 10 years earlier in tropical countries.tropical countries.

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Senile CataractSenile Cataract

Types:Types:

1.1. Cortical CataractCortical Cataract: Wherein : Wherein classical sign of hydration followed classical sign of hydration followed by coagulation of protein appears by coagulation of protein appears in cortexin cortex

2.2. Nuclear or Sclerotic CataractNuclear or Sclerotic Cataract: : Here the essential feature is slow Here the essential feature is slow necrosis of nucleus.necrosis of nucleus.

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Cortical CataractCortical Cataract There is demarcation of cortical fibres There is demarcation of cortical fibres

due to their separation by fluid due to their separation by fluid ((Lamellar SeparationLamellar Separation) these changes ) these changes can be seen by slit lamp , changes are can be seen by slit lamp , changes are not visible by Ophthalmoscope. not visible by Ophthalmoscope. Increased refractive index of cortex Increased refractive index of cortex gives a grey appearance to the pupil as gives a grey appearance to the pupil as against the blackness seen in the young. against the blackness seen in the young. The greyness is due to increase in The greyness is due to increase in reflection and scattering of light (and reflection and scattering of light (and not due to cataractous changes) not due to cataractous changes)

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Cortical Cataract… contdCortical Cataract… contd

Next stage is Next stage is incipient cataractincipient cataract: : Wedge shaped spokes of opacities with Wedge shaped spokes of opacities with clear areasclear areas in between them appear in in between them appear in peripheral lens and are common in lower peripheral lens and are common in lower nasal quadrant (nasal quadrant (Cuneiform opacitiesCuneiform opacities) . ) . These opacities lies in the cortex in front These opacities lies in the cortex in front and behind the nucleus. There is sectorial and behind the nucleus. There is sectorial alteration in refractive indices of the lens alteration in refractive indices of the lens fibres, producing irregularities in fibres, producing irregularities in refraction. Patient experience visual refraction. Patient experience visual deterioration and polyopia. deterioration and polyopia.

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Cortical Cataract…contdCortical Cataract…contd

Cupuliform CataractCupuliform Cataract: consisting of : consisting of dense aggregation of opacities just dense aggregation of opacities just beneath the capsule in posterior beneath the capsule in posterior cortex. It is difficult to see with cortex. It is difficult to see with ophthalmoscope but can be detected ophthalmoscope but can be detected as a dark shadow on distant direct as a dark shadow on distant direct ophthalmoscopy. Being near the ophthalmoscopy. Being near the nodal point of the eye the vision is nodal point of the eye the vision is diminished considerably. diminished considerably.

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Cortical Cataract…contdCortical Cataract…contd

Perinuclear Punctate CataractPerinuclear Punctate Cataract: : Appears in elderly people often in Appears in elderly people often in association with a coronary cataract. association with a coronary cataract. Onset is recognized by a thickening and Onset is recognized by a thickening and intensification of the appearance of the intensification of the appearance of the anterior and posterior bands of the anterior and posterior bands of the adult nucleus, multiple small opaque adult nucleus, multiple small opaque dots with large plaques are seen in the dots with large plaques are seen in the deeper layers forming concentric lines deeper layers forming concentric lines and cloudy patches. and cloudy patches.

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Cortical Cataract…contdCortical Cataract…contd Incipient cataract stage is followed by Incipient cataract stage is followed by

diffuse and irregular opacification of diffuse and irregular opacification of deeper layer of cortex which becomes deeper layer of cortex which becomes cloudy and eventually uniform white cloudy and eventually uniform white and opaque. Progressive hydration of and opaque. Progressive hydration of cortex may cause swelling of the lens, cortex may cause swelling of the lens, making the anterior chamber shallow making the anterior chamber shallow ((intumescent cataractintumescent cataract) eventually ) eventually entire cortex becomes opaque, swelling entire cortex becomes opaque, swelling subside and cataract is termed as subside and cataract is termed as maturemature. .

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Cortical Cataract …Cortical Cataract …contdcontd

In the mean time the nucleus suffers In the mean time the nucleus suffers progressive sclerosis. If the process progressive sclerosis. If the process is allowed to go uninterruptedly, the is allowed to go uninterruptedly, the stage of hypermaturity sets in. stage of hypermaturity sets in.

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Hypermature CataractHypermature Cataract

Types of hypermature cataract: Types of hypermature cataract:

a. a. Hypermature shrunken Hypermature shrunken cataract-cataract- when cortex disintegrate when cortex disintegrate and transform into pultaceous mass. and transform into pultaceous mass. The lens become inspissated and The lens become inspissated and shrunken, the anterior capsule shrunken, the anterior capsule become thickened. A dense white become thickened. A dense white capsular cataract (sometimes with capsular cataract (sometimes with capsular calcification) capsular calcification)

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Hypermature CataractHypermature Cataract

b. b. Morgagnian Hypermature Morgagnian Hypermature CataractCataract: Following maturity, : Following maturity, sometimes cortex becomes fluid and sometimes cortex becomes fluid and nucleus sink into the bottom. The nucleus sink into the bottom. The liquefied cortex become milky and liquefied cortex become milky and nucleus is seen as brown mass, nucleus is seen as brown mass, visible as semicircular line in visible as semicircular line in pupillary area altering its position pupillary area altering its position with change in position of the head. with change in position of the head.

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Senile Nuclear SclerosisSenile Nuclear Sclerosis

The normal tendency of central The normal tendency of central nuclear fibres to become sclerosed is nuclear fibres to become sclerosed is intensified. The cortical fibres intensified. The cortical fibres remain transparent. This type of remain transparent. This type of cataract tends to develop earlier cataract tends to develop earlier than cortical type, usually in fifth than cortical type, usually in fifth decade. It typically blur the distant decade. It typically blur the distant vision more than near vision. vision more than near vision.

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Senile Nuclear SclerosisSenile Nuclear Sclerosis

With time nucleus becomes diffusely With time nucleus becomes diffusely cloudy. Cloudiness spread towards the cloudy. Cloudiness spread towards the cortex. Occasionally nucleus becomes cortex. Occasionally nucleus becomes tinted dark brown, dusty red or even tinted dark brown, dusty red or even black due to deposition of yellow black due to deposition of yellow pigmented protein derived from the pigmented protein derived from the amino acid tryptophan. The brown amino acid tryptophan. The brown cataract is called cataract brunescens, cataract is called cataract brunescens, and black cataract is termed as and black cataract is termed as cataracta nigracataracta nigra

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Symptoms of CataractSymptoms of Cataract

1. Blurring of vision1. Blurring of vision2. Frequent change of glasses due to 2. Frequent change of glasses due to

rapid change in refractive index of the rapid change in refractive index of the lens lens

3. Painless, progressive, gradual 3. Painless, progressive, gradual diminution of vision due to reduction diminution of vision due to reduction in transparency of the lensin transparency of the lens

4. Second sight or myopic shift in case 4. Second sight or myopic shift in case of nuclear cataract causing index of nuclear cataract causing index myopia, improving near vision. myopia, improving near vision.

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Symptoms of CataractSymptoms of Cataract

5. Loss or marked diminution of vision 5. Loss or marked diminution of vision in bright sunlight or bright light in bright sunlight or bright light beam in central posterior sub-beam in central posterior sub-capsular cataract.capsular cataract.

6. Monocular diplopia or polyopia in 6. Monocular diplopia or polyopia in presence of cortical spoke opacities presence of cortical spoke opacities

7. Glare in posterior sub-capsular 7. Glare in posterior sub-capsular cortical cataract due to increased cortical cataract due to increased scattering of lightscattering of light

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Symptoms of CataractSymptoms of Cataract

8. Colored haloes around the light as 8. Colored haloes around the light as seen in cortical cataract due to seen in cortical cataract due to irregular refractive index in different irregular refractive index in different parts of the lens. parts of the lens.

9. Color shift , reds are accentuated9. Color shift , reds are accentuated

10. Visual field loss, generalized 10. Visual field loss, generalized reduction in sensitivity due to loss of reduction in sensitivity due to loss of transparency transparency

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Signs of senile cataractSigns of senile cataract

Positive findingsPositive findings

1.1. Diminution of visionDiminution of vision

2.2. Anterior chamber is shallow in Anterior chamber is shallow in cases of intumescent cataract and cases of intumescent cataract and deep in cases of hypermature deep in cases of hypermature (shrunken) cataract(shrunken) cataract

3.3. Tremulousness of iris in cases of Tremulousness of iris in cases of hypermature shrunken cataracthypermature shrunken cataract

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Signs of senile cataractSigns of senile cataract

4. Lenticular opacity , grey or white 4. Lenticular opacity , grey or white opacity in lens. Iris shadow in opacity in lens. Iris shadow in immature cataract. No iris shadow in immature cataract. No iris shadow in mature cataractmature cataract

5. Morgagnian Cataract- is characterized 5. Morgagnian Cataract- is characterized by liquefied cortex, which is milky and by liquefied cortex, which is milky and nucleus is seen as brown mass, seen as nucleus is seen as brown mass, seen as semicircular line, altering its position semicircular line, altering its position with change in position of headwith change in position of head

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Signs of senile cataractSigns of senile cataract

6. Distant direct ophthalmoscopy will 6. Distant direct ophthalmoscopy will reveal black shadow against red reveal black shadow against red background in cases of immature background in cases of immature cataract.cataract.

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Complications of Complications of CataractCataract

Secondary glaucoma during Secondary glaucoma during intumescent stage by causing angle intumescent stage by causing angle closure and phacolytic glaucoma closure and phacolytic glaucoma and lens induced uveitis in and lens induced uveitis in hypermature cataract hypermature cataract

Anaphylactic irritation by the Anaphylactic irritation by the products of hypermaturityproducts of hypermaturity

Subluxation and dislocation of Subluxation and dislocation of hypermature cataract hypermature cataract

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Differential Diagnosis of Differential Diagnosis of painless gradual diminution painless gradual diminution

of visionof vision Chronic open angle glaucomaChronic open angle glaucoma Macular degenerationMacular degeneration Optic atrophyOptic atrophy Corneal dystrophyCorneal dystrophy Retinopathy associated with Retinopathy associated with

systemic disorders (hypertension or systemic disorders (hypertension or diabetes) diabetes)