Approach to a Case of Cataract Sandeep Saxena MS, FRCS (Edin), FRCS (Glasg) Professor, Ophthalmology, KGMU

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

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

Morphological classification Capsular cataract -Anterior -Posterior Subcapsular cataract -Anterior -Posterior Cortical cataract Nuclear cataract Polar cataract

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

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

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

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

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

Iris shadow A.C. Depth Pupillary reflex Visual acuity Intumescent PresentShallowGreyish whiteFC to 6/18 Incipient PresentNormalGreyish whiteFC to 6/18 Mature AbsentNormalPearly whiteHM to FC close to face Hypermature Morgagnian AbsentShallowMilky whiteHM + Hypermature Calcified AbsentNormal or deep Milky chalky HM +

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

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

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.

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

Complications of cataract surgery Intraoperative – Incision related complications – Posterior capsular rupture – Zonular dehisence – Vitreous loss – Nuclear drop – Posterior loss of lens fragments – Injury to the cornea, iris and lens – Expulsive choroidal haemorrhage

Early post operative complications – Hyphaema – Iris prolapse – Striate keratopathy – Postoperative anterior uveitis – Bacterial endophthalmitis Late postoperative complications – Cystoid macular edema – Pseudophakic bullous keraopathy – Retinal detachment – Delayed postoperative endophthalmitis – After cataract Soemmering’s ring Elschnig’s pearls

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

Thank you