Ophtalmic Record

Examiners :

Catherine Maname Uli

Purnomo Hyaswicaksono

Ferry Kurniawan

Birgitta Wangsa

Chrestella Hartanuh

Aurelia Vania

Farrell Tanoto

Yuanita Budiman

I. Patient identity

Name : Ms. S

Sex : Female

Age : 43 years old

Ethnic : Javanese

Religion : Islam

Occupation : Ice cream seller

Address : Muara Angke

II. History taking

Chief complaint: Patient feel her vision were blurred, both of her eyes since 4 year before

admission.

Additional complaint: Patient felt both of her eyes feel tired, dizzy, feeling tired easily,

photophobia (+), lacrimation (+), itchy.

History of present illness: Since 4 years before admission, patient feel her right eyes

started to blur, then her left eye. She said its so hard to

recognize other people. She also started to be afraid to greet

people she met and bumped them while walking.

Past occular history: Op. Cataract OD last month, history of using eye-glasses was denied.

General medical : diabetes was denied, allergy was denied, hypertension (+)

Familial medical history: no previous history of same complaint

no previous history of systemic disease

no previous history of malignancy

III. General status

General condition : fatigue

Level of consciousness : fully awake

Blood pressure : 140/90 mmHg

Heart rate : 85

Respiratory rate : 20

Temperature : 36oC

IV. Ophtalamic status

Right eye Left eye

Periocular appearance Normal Normal

General condition Well Well

Eyeball position Orthophoric Orthophoric

Eyeball movement Can move to 8 directions Can move to 8 directions

Visual acquity 5/40 5/30 (S+2.5) 5/5

Supercillia Full, symetric Full, symetric

Cilia Normal Normal

Sup/Inf Margo Palpebra Well-positioned Well-positioned

Sup/Inf Tarsal

Conjunctiva

Hyperemic Hyperemic

Bulbar conjunctiva Normal Normal

Cornea

- Clearness

- Edema

- Infiltrate

- Ulcer

- Crust

- Destruction

Clear

-

-

-

-

-

Clear

-

-

-

-

-

Anterior Chamber Mild depth

Clear

Mild depth

Clear

Iris Darkish brown

Crypt (+)

Darkish brown

Crypt (+)

Pupil Center

Round

3mm

Light reflex (+)/(+)

Isochoric

Center

Round

3mm

Light reflex (+)/(+)

Isochoric

Lens Pseudophacia Cloudy (posterior

subcapsular)

Palpebra Hyperemic +

edema +

tenderness +

nodule -

Hyperemic +

edema +

tenderness +

nodule -

V. Summary

43 y.o. female came with complaint having blurry vision both of her eyes since 4 years

before admission. She also feel fatigue, photophobic, watery. History of trauma was

denied, and she hasn’t taken any medication.

Few months before admission, she can’t recognize other people face and started to

bump them while walking.

From the eye exam we found reduce visual acquity, and cloudy lens.

VI. Clinical diagnosis

Pre-senile immature posterior subcapsular cataract

VII. Differential diagnosis

Pre-senile immature posterior polar cataract

Congenital posterior polar cataract

VIII. Treatment

ODS : micro incision cataract extraction (PHACO)

Medication : Troboson 1 drops/2 hour

IX. Suggested examination

Slit lamp examination

X. Prognosis

Quo ad vitam : bonam

Quo ad functionam : dubia ad bonam

Quo ad sanationam : dubia ad bonam

XI. Complication

Rupture or atrophy of the optical nerve

XII. Discussion

Definition

Any opacity of the eye lens than can be caused by lens hydration, lens protein

denaturation, or both.

Classification

Based on patients’ ages, cataracts can be classified as:

1. Congenital cataract: cataract that happens before or soon after birth and the baby is

under one years old.

Congenital cataract can be divided into four types:

a. Zonular or lamellar

Most common type of congenital cataract. This type is characterized by white

opacities that surround the nucleus with alternating clear and white cortical

lamella like an onion skin. Lamellar cataract usually involves bilateral eyes.

b. Polar

This type is characterized by small opacities of the lens capsule and adjacent

cortex on the anterior or posterior pole of the lens. This polar type usually has

little efect on vision.

c. Nuclear

Nuclear type has opacity within embryonic/fetal nucleus that can be seen like

coral flower.

d. Posterior lenticonus

This type is characterized by a posterior protrusion, usually opacified , in the

posterior capsule.

2. Juvenile cataract: cataract which happens after one years old and occurs in young

people under 20 years old. The opacity of lens in juvenile cataract occurs when lens

fibers is still developing, so it has soft consistency (soft cataract).

3. Pre-senile cataract: cataract which occurs until 50 years old.

4. Senile cataract: cataract which occurs after 50 years old.

Senile cataract is associated with the aging process in the lens. The changes include

increasing thickness of nucleus with the developing of cortex lens.

Stage of the senile cataract:

a. Incipient cataract: irregular opacity likes cogwheel-like spot. In this stage,

polyopia is common complaints because of the asimilarity of refraction index

in all part of lens.

b. Immature cataract: thicker opacity but it hasn’t involve all part of lens. In this

stage, hydration of cortex causes intumescence lens. Intumescence lens causes

changes of refraction index which the eyes becomes myopic.

c. Mature cataract: all of lens protein is opaque. The lens fluid will come out

from lens, so the size of lens will be normal again.

d. Hypermature cataract: later degeneration process will cause the lens become

liquid. This liquid may escape through the intact capsule, leaving a shrunken

lens with a wrinkled capsule. A hypermature cataract in which the lens nucleus

floats freely in the capsular bag is called a morgagnian cataract.

The Differences Between Senile Cataract Staging

Incipient Immature Mature Hypermature

Opacity mild moderate severe massive

Lens fluid normal increased normal decreased

Iris normal “being

pushed”

normal tremulans

Anteriorchamber normal shallow normal deep

Shadow test negative positive negatif Pseudopositive

Based on location of opacities, cataract can be classified as:

a. Nuclear cataract

Nucleus of adult lens will increase and become sclerotic. This later white nuclear will

become yellow, brown, and black, and it is called brunescence cataract (nigra cataract).

b. Cortical cataract

Early stage cortical cataract demonstrates water clefts and vacuoles, which may change

over time resulting in irreversible opacities. In a more advanced stage, spoke-like or

wedge-shaped peripheral opacities progress circumferentially, initially sparing the clear

central axis of the lens. It can cause glare and often asymptomatic until central changes

develop.

c. Posterior subcapsular cataract

Plaquelike opacity near the posterior aspect of the lens. Glare and reduced vision under

bright lighting are common complaints. This cataract type classically occurs in patients

<50 years. Posterior subcapsular cataract is associated with ocular inflammation, steroid

use, diabetes, trauma, or radiation.

d. Posterior polar cataract

A posterior polar cataract is a round, discoid, opaque mass that is composed of

malformed and distorted lens fibers located in the central posterior part of the lens. A

posterior polar cataract consists of dysplastic lens fibers, which, in ther migration

posteriorly lens opacity with the formation of a characteristic discoid posterior polar

plaquelike cataract.

e. Anterior polar cataract

May present as a congenital (autosomal dominantly inherited) or acquired cataract

secondary to uveitis or trauma (associated with anterior subcapsular opacities). Small

anterior polar opacification usually is sharply defined.

The Lens Opacities Classification System III (LOCS III) is a standard system used for grading

and comparison of cataract severity and type1–2. It was derived from the LOCS II

classification3, and it consist of three sets of standardized photographs. The classification

evaluates four features: nuclear opalescence (NO), nuclear color (NC), cortical cataract (C),

posterior subcapsular cataract (P). Nuclear opalesecence (NO) and nuclear color (NC) are

graded on a decimal scale of 0.1 to 6.9, based on a set of six standardized photographs.

Cortical cataract (C) and posterior subcapsular cataract (P) are graded on a decimal scale of

0.1 to 5.9, based on a set of five standardized photographs each.

Figure 1

Etiology and Risk Factor

1. Congenital cataract:

- Idiopathic

- Familial, autosomal dominant

- Rubella: pearly white nuclear cataract

- Maternal diabetes mellitus, toxoplasmosis

2. Acquired cataract:

- Age-related cataract

- Traumatic cataract

Traumatic cataract is most commonly due to a foreign body injury to the lens

or blunt trauma to the eyeball. The lens becomes white soon after the entry of a

foreign body, since interruption of the lens capsule allows aqueous and

sometimes vitreous to penetrate into the lens structure.

- Complicated cataract

o Cataract secondary to intraocular disease

Cataract may develop as a direct effect of intraocular disease upon the

physiology of the lens, example: uveitis (posterior subcapsular cataract),

glaucoma (cataract vogt: anterior subkapsular pungtata cataract), retina

ablatio, and severe myopia.

o Cataract associated with systemic disease

This cataract usually involve both of eyes although it may not appear in

the same time. The example of systemic disease that can cause cataract are

diabetes mellitus (white snowflake opacities in the anterior and posterior

subcapsular locations), hypoparatyroidism, myotonia dystrophy,

hypocalcemia.

- Drug-induced Cataract

Drugs that can induce lens opacities include steroids, miotics, antipsyhotics.

- After-Cataract (Secondary Cataract)

After-Cataract denotes opacification of posterior capsule following

extracapsular cataract extraction or phacoemulcification. This cataract type

thickening of posterior capsule caused by inflammatory cell proliferation in

residue cortex, giving the posterior capsule a "fish egg" appearance (Elschnig's

pearls).

Epidemiology

At least 300.000-400.000 new visually disabling cataract occur annually in the United

States. For the oldest age group, 75 years and older, the nuclear, cortical, and posterior

subcapsular cataracts were found in 65,5%, 27,7%, and 19,7% of the study population,

respectively.

In the Framingham Eye Study from 1973-1975, females had a higher than males in

both lens changes (63% vs 54,1%) and senile cataract (17,1% vs 13,2%).

Pathogenesis of pre-senile cataract

The term presenile cataract is used when the cataractous changes similar to senile

cataract occur before 50 years of age. Its common causes are:

1. Heredity. As mentioned above because of influence of heredity, the cataractous

changes may occur at an earlier age in successive generations.1

2. Diabetes mellitus. Age-related cataract occurs earlier in diabetics. Nuclear

cataract is more common and tends to progress rapidly.

3. Myotonic dystrophy is associated with posterior subcapsular type of presenile

cataract.

4. Atopic dermatitis may be associated with pre- senile cataract (atopic cataract) in

10% of the cases.

Mechanism of loss of transparency

It is basically different in nuclear and cortical senile cataracts.

1. Cortical senile cataract. Its main biochemical features are decreased levels of total

proteins, amino acids and potassium associated with increased concentration of

sodium and marked hydration of the lens, followed by coagulation of proteins. The

probable course of events leading to senile opacification of cortex is as shown in

the Figure

2. Nuclear senile cataract. In it the usual degenerative changes are intensification of

the age- related nuclear sclerosis associated with dehydration and compaction of

the nucleus resulting in a hard cataract. It is accompanied by a significant increase

in water insoluble proteins. However, the total protein content and distribution of

cations remain normal. There may or may not be associated deposition of pigment

urochrome and/or melanin derived from the amino acids in the lens.

Figure 2

Clinical Manifestation

The thickening of the lens surface can be occurred without making any clinical signs or

symptoms, and also can be found in routine eye check up. The general signs and

symptoms of caratact are :

Photophobia

One of early symptoms that is felt by the patient. The degree of the photophobia

depends on the location of the lession and the cataract stage.

Unicolar polyopia (double vision)

Early manifestation. It is caused by the irreguler light deflection passing through

the lens.

Coloured halo

Caused by the dispersion of the white light into colour spectrums and the water

droplet on the lens.

Black spot in front of the eye

Blurry eye sight, distortion of the image can be acquired in the early stage

Declining visual acquity to loss of eye sight.

Can be various in any type of cataract. Painless, and progressive. Patient with

central thickening of the lens (kupuliform) often lose the vision in early stage.

Patient with periferal thickening of the lens comes with a late vision lost.

Diagnosis

History Taking

1. Patient data: name, address, sex, age/date of birth, race, occupational

2. Patient history:

a. Chief complaint: main problems and other problems

b. Present illness

- Time

- Severity

- Influences

- Constancy

- Laterality

- Clarification of certain complaints

- Documentation

c. Past ocular history:

- Glasses/contact lenses

- Ocular medication

- Ocular surgery

- Ocular trauma

- Ambliopia

d. General medication:

- Diabetes mellitus

- Hypertension

- Dermatologic

- Cardiac

- Gestational and birth history

e. Systemic disease

f. Alergies

g. Social history:

- Tobacco and alcohol

- Drug abuse

- Occupational

h. Family history:

- Glasses

- Heritable ocular conditions: corneal disease, glaucoma, cataract, retinal

disease

- Diabetes mellitus

- Thyroid disease

- Malignancy

Physical Examination

a. Complete ocular examination, including distance and near vision, pupilary

examination, and refraction

b. A dilated slit-lamp examination using both direct and retroillumination techniques

is required to view the cataract properly

c. Fundus examination, concentrating on the macula, is essential in ruling out other

causes of decrease vision

Supported Examination

a. B-scan Ultrasonography

If fundus is obscured to rule out detectable posterior segment disease

b. Keratometry readings and an A-scan Ultrasonography

Measurement of axial length are required for determining the power of the desired

intraocular lens. Corneal pachymetry or endothelial cell count is occasionaly

helpful if cornea guttata are present.

Treatment

Bilateral cataract

Cataract extraction is usually delayed until visual loss affects the patient's life.

This is an indication of the relative and will vary from patient to patient. This type

of cataract is important because cataracts can be associated with posterior sub-

capsular glare even though visual acuity was relatively good. It is important for

refractive patients carefully and record both near and far vision. To make

recommendations cataract extraction is important to know the lives of patients

and visual needs.

Unilateral cataract

Extraction is required if the patient has a desire to work requirements, binocular

vision, or if the cataract becomes hypermature. In some cases, contact lens or

plastic lens implant will cause the image size and the possibility of equality of

vision binoculars. Intraocular lens implant is ideally placed on the posterior

capsule.

Cataract Surgery

a. ICCE is Intracapsular Cataract Extraction, all the component of the lens is

removed, include the capsule. Usually perform when zonula zinn is damaged.

b. ECCE (ExtraCapsular Cataract Extraction): classic, SICS (Small Incision Cataract

Surgery), Micro incision with Phacoemulsification. ECCE is performed by

making an opening on anterior pole capsule, leaving a bowl-shape to put an Intra

Ocular Lens.

Phacoemulsification: is a method to remove the hard part of cataract by using an

ultrasound, then drain the remnant.

Prognosis

If there are no other eye diseases that accompany before surgery, which will have an

effect specifically on vision such as rupture or degeneration of optic nerve atrophy, a

standard ECCE or phaco-emulcification bring a very promising prognosis for vision in

which at least can see the 2 lines on the Snellen distance vision chart . The main cause

of visual morbidity is postoperative CME. A major risk factors that affect the visual

prognosis is the presence of diabetes mellitus and diabetic retinopathy.

However, according to research by Kumar et al. phaco-emulcification polar opacity in

the eye with the larger size has the risk of capsule rupture posterior.

References

1. Ilyas S, Mailangkay HHB, Taim H, editor. Lensa Mata. Ilmu Penyakit Mata. Ed ke-2. CV

Sagung Seto. 2010: 143.

2. Ilyas HS. Penglihatan Turun Perlahan Tanpa Mata Merah. Ilmu Penyakit Mata. Ed ke-3.

Balai Penerbit FKUI. 2009: 200.

3. Ehlers JP, Shah CP, editor. Acquired Cataract. The Wills Eye Manual. Ed ke-4.

Lippincott Williams & Wilkins. 2004: 368.

4. Eva PR, Whitcher JP, editor. Cataract. Vaughan & Asbury ‘s General Opthalmology.

Lange. 2007.