Approach to a Case of Cataract

1. Approachto a Case of Cataract SandeepSaxenaMS, FRCS (Edin), FRCS (Glasg) Professor, Ophthalmology, KGMU

2. Differential diagnosis Painless, progressive diminution of vision • Cataract • Primary open angle glaucoma • Diabetic retinopathy • Corneal dystrophies and degenerations • Age related macular degeneration • Retinitis pigmentosa

3. Cataract • Opacification of the human crystalline lens • Major cause of blindness worldwide • Classification- -Etiological -Morphological

4. Morphological classification • Capsular cataract -Anterior -Posterior • Subcapsular cataract -Anterior -Posterior • Cortical cataract • Nuclear cataract • Polar cataract

5. Etiological classification I. Congenital and Developmental cataract II. Acquired cataract • Senile cataract • Traumatic cataract (blunt, penetrating, radiation, electric shock, glass blowers, infra-red) • Complicated cataract (uveitis-induced) • Metabolic cataract (Diabetes - snowflake, Wilson’s disease-sunflower) • Drug induced cataract- corticosteroids, miotics • Cataract associated with syndromes

6. Congenital or Developmental cataract - Occur due to maternal infection or malnutrition, perinatal hypoxia – APH, or may be hereditary - Various morphological forms: • Blue dot • Sutural • Fusiform or spindle shaped • Embryonal nuclear • Zonular • Coronary • Anterior or posterior polar

7. Senile cataract • ‘Age-related cataract’ • By the age of 70 years, over 90% of the individuals develop senile cataract • Usually bilateral, but almost always asymmetrical

8. Symptoms • Gradual, painless progressive loss of vision • Discomfort / glare in daylight – nuclear cataract; better vision in daylight – cortical cataract • Uniocularpolyopia • Coloured halos • Black spots in front of eyes • ‘Second sight’

9. Signs • Iris shadow • Depth of anterior chamber • Pupillary reflex • Visual acuity • Plain mirror examination under mydriasis

11. Patient workup • Retinoscopy and best corrected visual acuity • Intraocular pressure • Slit lamp examination • Fundus evaluation – direct & indirect • Macular function tests • Ultrasonography • IOL power calculation

12. General investigations • Blood pressure • Blood sugar • Complete haemogram • HIV, Hepatitis B & C • Causes of straining • Foci of infection • Systemic examination

13. Management • An un-operated eye is more comfortable than an operated eye if visual diminution is mild. • Early cataract : -Refraction and glasses -Dark glasses or photochromatic glasses for nuclear cataract -Rule out other causes of visual diminution -If BCVA not to patient’s satisfaction, then operate.

14. Surgical techniques • Intracapsular cataract extraction (ICCE) • Extracapsular cataract extraction (ECCE) • Conventional ECCE • Small Incision Cataract Surgery • Phacoemulsification • Lens aspiration in paediatric (soft) cataract

15. Complications of cataract surgery • Intraoperative • Incision related complications • Posterior capsular rupture • Zonulardehisence • Vitreous loss • Nuclear drop • Posterior loss of lens fragments • Injury to the cornea, iris and lens • Expulsive choroidal haemorrhage

16. Early post operative complications • Hyphaema • Iris prolapse • Striate keratopathy • Postoperative anterior uveitis • Bacterial endophthalmitis • Late postoperative complications • Cystoid macular edema • Pseudophakicbullouskeraopathy • Retinal detachment • Delayed postoperative endophthalmitis • After cataract • Soemmering’s ring • Elschnig’s pearls

17. Intraocular Lenses Types Anterior chamber IOL Iris supported lens Posterior chamber IOL Rigid Foldable Calculation of IOL power SRK formula

18. Thank you