Post on 02-Mar-2015
Cataract
Yesi Putri ari Hartiningrum
I11107031
Definition
an abnormal progressive condition of the lens of the eye, characterized by loss of transparency.
A yellow, brown, or white opacity can be observed within the lens, behind the pupil.
Etiology
Physical
Chemical
Predisposition of other disease
Genetic and development disorder
Viral infection in fetal growth
Aging
Signs and symptoms
Reduced visual acuity (near and distant objects)
• Glare and halo in sunshine or with street or car lights
• Distortion of lines
• Monocular diplopia
• Altered colours (white objects appear yellowish).
• Not associated with pain, discharge or redness of the eye
• Inability to fix visual on a target
Classification
Classified by etiology Classified by opacities Classified by location of opacity within lens
structure Classified by maturity
Classification by etiology
Age-related cataract Congenital cataract Secondary cataract Traumatic cataract
A. Age-related cataract It is acquired lens opacity occurring old age in the absence of a
local or systemic disease.
The general features : Always bilateral (one eye precedes the other). Progressive to maturity and hypermaturity. Hard nucleus. No local or systemic disease can be found.
Clasification : Cortical Senile Cataract Senile Nuclear Cataract Subcapsular Senile Cataract
B. Congenital cataract Hereditary Congenital Cataracts Cataract from Transplacental Infection in the First Trimester of
Pregnancy Without systemic association : isolated hereditary cataracts Systemic association : metabolic(galactosemia, galaktokinase
deficiency), prenatal infection,chromosomal abnormalities, skeletal syndrom
Classification : Lamellar or zonular cataract Opacities are located in one layer
of lens fibers, of ten as “riders” only in the equatorial region Nuclear cataract The lamellar cataract in which initially only the
outer layer of the embryonic nucleus is affected. Coronary cataract Fine radial opacities in the equatorial region. Cerulean cataract Fine round or club-shaped blue peripheral
lens opacities.
C. Secondary cataract Drug-induced cataract (e.g. corticosteroids) Diabetic cataract atypical radial snowflake pattern of
cortical opacities (snowflake cataract) Galactosemic cataract Deep posterior cortical opacity
begins after birth Dialysis cataract swelling of the cortex of the lens Tetany cataract The opacity lies within a broad zone
inferior to the anterior lens capsule and consists of a series of gray punctate lesions
Dermatogenous cataract (e.g. chronic neurodermatitis, scleroderma, etc) anterior crest-shape d thickening of the protruding center of the capsule
D. Traumatic cataract
Blunt trauma (capsule usually intact) Penetrating trauma (capsular rupture & leakage of
lens material)
Classification by opacities(Lens Opacities Classification System III)
Classification by location of opacity within lens structure
Anterior & Posterior cortical cataract Anterior & Posterior polar cataract Anterior & Posterior subcapsular cataract Nuclear cataract posterior capsular opacification
(PCO)
Cortical cataract : Develops in the outer shell of the lens as spokes and wedges and
commonly causes increasing glare sensitivity.
Commonly process due to increased water/ fluid content inside the lens.
A history of diabetes or previous heart attack, and a blood factor
(fibrinogen) associated with vascular conditions appeared to increase
the risk
Tend to be hyperopia
Subcapsular Cataract :
Starts as a small, opaque area just under the capsule shell, usually at
the back of the lens
This type of cataract may occur in both eyes but tends to be more
advanced in one eye than the other
Often interferes with reading vision, reduces your vision in bright light
and causes glare or halos around lights at night
Posterior subcapsular cataract : Develops at the back of the lens, often in the visual axis, and so affects
vision rapidly and severely
The majority of people needing cataract surgery have some posterior
subcapsular cataract present at that time
Nuclear cataract : Develops in the nucleus or centre of the lens, due to hardening
process.
As it increases, there is an associated yellow or brown discolouration of
the lens.
smoking, heavy alcohol consumption, sunlight exposure and diabetes
increased the risk of nuclear cataract.
Produce myopia
(A, bipolar; B, pyramidal; C, axial; D, subcapsular (cupuliform); E, nuclear; F, coronary; G, snowflake; H, cuneiform)
Classification by maturity Intumescent The lens becomes swollen by absorbing
water. Immature Scattered opacities are separated by clear
zones. Mature Cortex and nucleus become totally opaque. Hyper-mature Cataract Mature cataract, which has
become smaller and has a wrinkled capsule as a result of leakage of water out of lens.
Morgagnian Cataract A Hyper-mature cataract, in which total liquefaction of cortex allows the nucleus to sink inferiorly.
Insipien Cataract :
Intumescent Cataract :
Immature Cataract :
Mature Cataract :
Hyper-mature Cataract :
Morgagnian Cataract :
Examinations Visual acuity : Checking vision of both eyes unaided and aided with
glasses and pin-hole vision to know the improvement as well as to get the general idea about the macular function of the eyes. This will help in prognostic evaluation of visual recovery after cataract surgery.
Slit-lamp examination : To know the type of cataract along with its opacity, morphology and etiology or any associated ocular pathology.
Direct and indirect ophthalmoscopy (Brückner’s test): : Dense opacity (cataract will prevent retinal evaluation), Under a light source or ophthalmoscope (set to 10 diopters), opacities will appear black in the re d pupil
Prevention
wearing ultraviolet-protecting sunglasses Regular intake of antioxidants (such as
vitamin A, C and E) antioxidant N-acetylcarnosine
Treatment
Improving the vision for a while : using new glasses, strong bifocals, magnification,
appropriate lighting
Cataract surgery extracapsular cataract extraction (ECCE) intracapsular cataract extraction (ICCE) Small Incission Cataract Surgery (SICS) Phacoemulsification
extracapsular cataract extraction (ECCE)
only the cortex and nucleus of the lens are removed ( extracapsular extraction); the posterior capsule and zonule suspension remain intact. This provides a stable base for implantation of the posterior chamber intraocular lens.
ECCE is a conventional technique that :
ECCE requires an incision of 10-12mm
The doctor removes the clouded lens in one piece.
Multiple stitches are required.
He implants a non-foldable lens.
This not only provides support of placement of IOL but also
prevents vitreous from bulging forwards and acts as a barrier
between anterior and posterior segment
All this results in decreasing the incidence of complications :
Vitreous loss, corneal edema, endophthalmitis, cystoid macular
edema, aphakic glaucoma, etc.
intracapsular cataract extraction (ICCE)
The lens is removed as one single piece i.e., the nucleus and the
cortex are removed within the capsule of the lens after breaking
the zonules. The entire lens is frozen in its capsule with a cryophake and
removed from the eye through a large superior corneal incision
There is no support left for posterior chamber IOL, therefore,
only anterior chamber IOL (ACL) can be implanted which has
risk of adverse corneal complications.
There is no barrier left between anterior and posterior
segment, which increases the incidence of other
complications e.g., vitreous loss, aphakic glaucoma, cystoid
macular edema, endophthalmitis, etc
Small Incission Cataract Surgery (SICS)
The difference with ECCE is by the size of the incission (Incission ± 5-7 mm)
Do not need suture
Phacoemulsification
It is an advancement in the method of doing ECCE.
The nucleus is converted into pulp or emulsified using high
frequency (40,000 MHz) sound waves, and then is sucked out
of the eye through a small (3.2 mm) incision or micro incision
(less than 1.5 mm).
A special foldable IOL is then inserted into the posterior
chamber through the same incision.
Diabetic Retinopathy
Diabetic Retinopathy
Is a progressive ophthalmic condition that is associated with diabetes and can have devastating consequences
It is a leading cause of blindness in adults of working age and is characterised by capillary leakage, capillary vessel occlusion and subsequent new vessel formation.
Retinopathy will develop within 5 years of diagnosis of diabetes in approximately: 25% of people with Type 1 diabetes 40% of people with Type 2 diabetes who are taking insulin 24% of people with Type 2 diabetes who are not taking
insulin
Classification
Non-proliferative diabetic retinopathy (NPDR) Proliferative diabetic retinopathy (PDR) Diabetic maculopathy
Non-proliferative diabetic retinopathy (NPDR) Capillaries develop leaks and later become occluded.
Do not have much effect on vision when they occur in the peripheral retina
The retinal changes : Mycroaneurysms Intra-retinal hemorrhages Venous bleeding Excessive hemorrhages Cotton-wool spot (nerve fiber infaction with soft exudates) hard yellow exudates with well defined edges macular edema
Proliferative diabetic retinopathy (PDR)
Typified by the growth of new vessels on the retina or into the vitreous cavity and thought to result from the ischaemic diabetic retina producing vasoproliferative factors that cause the growth of abnormal new vessels.
The retinal changes : Pra-retinal neovascularization Vitreous hemorrhages Tractional retinal detachment Rubeosis iridis (neovascularization of the iris that can occlude
the angle of anterior chamber)
Diabetic maculopathy When diabetic retinopathy causes vessel leakage and ischaemia
in the macula area
occurs more commonly in type II diabetics
Classification : Focal focal leakage from a microaneurysm or dilated
capillaries and surrounding exudates are seen (Figure 21.5). Diffuse oedema diffuse leakage from dilated capillaries at the
posterior pole of the eye. Retinal oedema is diffuse and can be associated with microaneurysms and few haemorrhages but exudates are absent (Figure 21.6).
Ischaemic maculopathy by closure of the perifoveal and surrounding vascular network. In addition to diffuse oedema, several dark haemorrhages might be present (Figure 21.7a).
Focal maculopathyDiffuse oedema maculopathy
Ischaemic maculopathy
Symptoms
Asymptomatic for a long time The late stages with macular involvement or
vitreous hemorrhage will the patient notice visual impairment or suddenly go blind
Treatments
Control of diabetes Proliferative diabetic retinopathy scatter
photocoagulation macular edema focal laser treatment
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