MANAGEMENT OF CATARACT BY DR. A. K. SALEH FAMMED AKTH

 Introduction  Epidemiology  Anatomy  Pathophysiology  Classification  Clinical features  Diagnosis and treatment  prevention OUT LINE

CATARACT

Introduction  Etymology; “cataracta” in Latin water fall ancient Greek “katarrhaktes ” dawn-rushing  Definition; a progressive, painless opacity of the natural crystalline lens of the eye leading to blurred or cloudy vision

Epidemiology  Is the leading cause of blindness world wide  Affecting over 20 million ppl  senile cataract is responsible for about 51% of blindness  prevalence increases with aging 70% at 80yrs  Cause of moderate to severe disability in 53.8 million ppl, 52.2 million of whom are in low and middle income countries  Congenital occurs 3 in 10,000 live birth  88% of pt cannot access health care services  F:M 1:2.2

Epidemiology Incidence of blindness secondary to cataract; Africa 0.5%, Asia 0.3%, Central & South America 0.15%, N. America, Europe & Oceania <0.05% Leading cause of blindness in Nigeria 1.3 million ppl 43% cause of blindness 45% cause of visual impairment 42 out of 1000 adults above 40 at risk 486,000 are in need of surgery Poor surgical outcome

Embryology

Gross Anatomy  Avascular biconcave transparent structure located between the anterior and posterior chamber of the eye suspended by zonule -susp. lig-ciliary body  Divides the eye into anterior and post. segments  Made up of Cortex and Nucleus in capsule  Width 10mm in dm, 3.5-4mm thickness  Surface- ant. 10mm,post.6mm  Wt 135ng-255ng btw (0-80) yrs

Crystalline Lens and the eye

Pathophysiology  Factors that plays role in maintaining the lens integrity i. avascularity of the lens therefore obtain nutrient from surrounding fluid i.e. aqueous and vitreous ii. Nature of lens protein iii. Lens membrane permeability iv. Lens interior is electronegative -64 to -78mv thus give selective electrochemical gradient v. Auto-oxidation and high conc. of Glutathione in the lens

Normal and Opaque lens

metabolism  Lens requires a continuous supply of energy for active transport of ions and AA for its maintenance  Metabolic activity is largely limited to the lens epithelium and cortex  Energy production i. mainly through anaerobic glycolysis 80% ii. HMP 15% iii. krebs < 5% iv. Sorbitol pathway is only important in diseased lens

Senile cataract

Classification of cataract  1. aetiology; a. Congenital cataract: i. genetic and metabolic diseases e.g. Downs syndrome, galactosemia etc ii. intrauterine infections e.g. TORCHS complex iii. Ocular anomalies e.g. aniridia b. Acquired: i. senile cataract ii. Traumatic e.g. penetrating injury, blunt injury, ionizing radiation, UV-b, electrocution, thunder strike iii. inflamations e.g. uveitis, angle closure glaucoma. iv. toxins e.g. steroids use

Congenital cataract

Traumatic cataract

Classification of cataract  2. base on maturity; i. immature ii. mature iii. hypermature iv. morgagnian  3. Anatomical location within the lens; i. cortical ii. Nuclear iii. Postr. Sub capsular  4. Base on complication; i. uncomplicated and ii. complicated

Risk factors  age,  metabolic dx,  UV light,  smoking,  alcohol,  drugs,  trauma,  Ionizing radiation,  high myopia,  Infections  inflammations,  Ocular anomalies,  Family hx.

Clinical features  Blurred/cloudy /foggy/vision  Sensitivity to light and glares  Halos  Difficulty in night vision  Difficulty in distinguishing colours  Myopic view  Hypermetropic view  diplopia  Decrease VA  White spots in the pupil  Opaque lens  Wheel spoke appearance  Blurred fundal view ELO  Nil further view if matured symptoms signs

Complication  Lens dislocation  Phacolytic glaucoma  Phacomorphic glaucoma  Phacoanaphylactic uveitis

Investigation  Base line; VA, Fundoscopy, E and U/Creatinine, Urinalysis, FBS, CXR, ECG  Diagnostic; IOP, Fundoscopy +-(dilatation), slit lamp biomicroscopy, B-Scan, retinoscopy, Biometry

Treatment  Education and counseling; i. FIFE ii. diagnosis iii. treatment options iv. cost implication v. source of support  Depends on; i. type and stage of cataract ii. pt needs and expectations iii. available resources iv. Co morbidity

Medical and surgical  Medical; i. controlling the precipitating factors ii. Refraction iii. Brighter illumination of reading/environ iv. Avoidance of obstacle v. Sun glasses to reduce glare vi. higher spectacles vii. Pupillary dilatation

surgical Definitive treatment; Success (97-98%) in 1 st world poor outcome in Nigeria children early surgery Types;  ICCE  ECCE  MSICS  PHACOEMULSIFICATION

ICCE

ECCE+IOL

MSICE (manual small incision cataract surgery)

phacoemulcification

Post operative complication  Early; i. hypaema ii. uveal prolapse iii. keratopathy iv. Anterior uveitis v. end ophthalmitis vi. Pan ophthalmitis  Late; i. haemorhage into AC and PC ii. supr rectus muscle laceration iii. Postr capsular rupture iv. Second cataract v. lens dislodge vi. retinal detachment vii. Corneal/macular oedema viii. lacrimation

Prevention  Primary; i. routine eye examination ii. avoidance of risk factors/life style modification iii. Antioxidants iv. Lutein, zeaxanthin and carotenoid v. Sun glasses etc  Secondary; early detection and prevention  Treatment and rehabilitation

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References [1] Quillen DA (July 1999). “Common causes of vision loss in elderly patients”. Am Fam Physician 60 (1): 99–108. PMID [2] Courtney P (1992). “The National Cataract Surgery Survey: I. Method and descriptive features”. Eye (Lond) 6 (Pt 5): 487–92. doi: /eye PMID [3] Allen D, Vasavada A (2006). “Cataract and surgery for cataract”. BMJ 333 (7559): 128–32. doi: /bmj PMC PMID [4] “Posterior Supcapsular Cataract”. Digital Reference of Ophthalmology. Edward S. Harkness Eye Institute, Department of Ophthalmology of Columbia University Retrieved 2 April [5] Emmett T. Cunningham, Paul Riordan-Eva. Vaughan & Asbury’s general ophthalmology. (18th ed. ed.). McGraw-Hill Medical. ISBN

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