Management of Adult Cataract

Prof. Naimatullah Khan KundiHead, Department of Ophthalmology

Khyber Teaching HospitalPeshawar

Management of Adult Cataract

Medical Management

Indications for surgery

Pre-operative measurements

Pre-operative evaluation and

information

Management of adult cataract Evaluation

1. Each individual’s situation may vary 2. Information and examination about the

patient:

Does the lens opacity correspond to the degree of

visual impairment? Does the patient’s reduced ability to function

warrant surgery? Is the eye sufficiently healthy to expect improved

visual function? Is the lens opacity 2ndry to a systemic or ocular

condition?

Cataract Medical Management

Some approaches may be temporarily effective

until cataract progression causes additional

symptoms

Refraction

Illumination and spectacle add

Pupillary dilation

Optical aids

Cataract Medical Management

Refraction

Improvement of distant and near vision with glasses

can the functional visual impairment in many

patients

Increased ambient illumination and increased

spectacle add are also helpful.

Cataract Medical Management Pupillary dilation

Pupillary dilation may improve visual function (axial cataracts allowing light to pass through peripheral portions of the lens)

Optical aids

Some patients with limited visual function from

cataract may be assisted with optical aids when

surgical management is not appropriate Hand held monoculars (2.5x, 4x) High add spectacles Magnifiers Telescopic loups for reading and close work

Indications for Surgery

Patient’s desire

Visual requirements

Significant cataract

Monocular cataract

Complications

Diagnosis and management of other ocular

diseases

Indications for Surgery

Patient’s desire for improved visual function

Visual requirements:

Many governmental agencies and industries

have minimum standards of visual function for

such tasks as: Driving Flying Operating complex equipments

A patient whose BCVA does not meet these

visual requirements may need to consider

surgery

Indications for Surgery

Significant cataract:

A patient with visually significant cataracts is a

candidate for surgery

Monocular cataract:

Common indications in these situations

include: Loss off stereopsis peripheral vision Bothersome glare Symptomatic anisometropia

Indications for Surgery

Complications:

Phacolytic glaucoma

Phacomorphic glaucoma

Phacoantigenic uveitis

Anterior dislocated lens in to AC

Indications for Surgery

Diagnosis and management of other ocular

diseases:

Dense cataract that obscures the view of the

fundus and impedes the diagnosis or

management of other ocular diseases:

Diabetic retinopathy

Retinal detachment

Glaucoma

Pre-operative measurements

1. Refraction

2. Biometry

3. Corneal Pachymetry

4. Specular Microscopy

5. B-Scan ultrasonography

Pre-operative measurements

Refraction

Careful refraction on both eyes

Useful in planning the IOL power necessary to

obtain the desired postoperative refraction

If fellow eye has a cataract, it may be

preferable to plan the implant power to

achieve emmetropia postoperatively

Pre-operative measurements

Refraction (cont’d)

If fellow eye has clear lens and a high

refractive error that requires spectacles

correction, obtaining a similar refractive

result in the operated eye will avoid

problems with postoperative anisometropia

Contact lens wearing in the phakic eye can

avoid the problems

Pre-operative measurements

Biometry Keratometry:

To determine corneal curvature and power

A-scan Ultrasonography:

To determine axial length of the eye

These are performed to calculate the

appropriate IOL implant power

Pre-operative measurements

Corneal Pachymetry

Measurement of corneal thickness

Useful in assessing the function of corneal

endothelium

When quantitative evaluation of corneal

endothelial cell density may be limited in

patients with significant corneal guttata

Pre-operative measurements

Corneal Pachymetry (cont’d) Types:

1. Ultrasonic

2. Optical

Ultrasonic pachymeter more accurate and reliable

Central corneal thickness > 600µm may be consistent with corneal edema and endothelial dysfunction Likelihood of postoperative clinical

corneal edema

Pre-operative measurements

Specular Microscopy

Determine the number of corneal endothelial

cells/mm2

Normal counts > 2400 cells/mm2

Cell count < 1000 cells/mm2 abnormal

Cataract surgery causes some loss of

endothelial cells

Pre-operative measurements

Specular Microscopy (cont’d)

If preoperative endothelial cells counts low,

risk of postoperative corneal

decompensation

Endothelial cell morphology, including

enlargement and irregularity provides

additional information about the cornea to

withstand stress

Pre-operative measurements

B-scan Ultrasonography

When retinal view impossible, US of posterior segment

useful

This test can help determine the preoperative status of

the posterior segment with regard to the potential for:

1. Retinal Detachment

2. Vitreous Opacities

3. Posterior Pole Tumors

4. Posterior Staphyloma