Acquired cataract

1. Acquired CataractAcquired Cataract

2. 2
Classification of CataractClassification of Cataract
1.1.DevelopmentalDevelopmental
2.2.Age related (senile)Age related (senile)
3.3.Cataract associated with ocular diseasesCataract associated with ocular diseases

3. 3
Classification of CataractClassification of Cataract
4. Cataract associated with systemic diseases 4. Cataract associated with systemic diseases
(pre-senile): (pre-senile):
Diabetes, Hypoglycaemia, Hypoparathyroidism, Diabetes, Hypoglycaemia, Hypoparathyroidism,
Myotonic Dystrophy, Galactosaemia, Alport Myotonic Dystrophy, Galactosaemia, Alport
Syndrome, Lowe Syndrome, Stickler Syndrome, Syndrome, Lowe Syndrome, Stickler Syndrome,
Down SyndromeDown Syndrome
Skin Diseases – Atopic Dermatitis, IchthyosisSkin Diseases – Atopic Dermatitis, Ichthyosis

4. 4
Classification of CataractClassification of Cataract
5. Traumatic Cataract : Trauma (Blunt / 5. Traumatic Cataract : Trauma (Blunt /
Perforating) , Electric Shock, RadiationPerforating) , Electric Shock, Radiation

5. 5
Classification of CataractClassification of Cataract
6. Drug induced cataract : 6. Drug induced cataract :
Corticosteroids, Anticholinesterases, Chlorpromazine, Corticosteroids, Anticholinesterases, Chlorpromazine,
Busulfan, Choroquine, Amiodrone, Cigarette smoker, Busulfan, Choroquine, Amiodrone, Cigarette smoker,
Copper, Iron, Gold, Naphthalene, Lactose, Copper, Iron, Gold, Naphthalene, Lactose,
Galactose, Selenite, Thallium, Dinitrophenol, Galactose, Selenite, Thallium, Dinitrophenol,
ParadichlorobenzeneParadichlorobenzene
Deficiency – of amino-acids or Riboflavin (B2) Deficiency – of amino-acids or Riboflavin (B2)

6. 6
Etiopathogenesis of CataractEtiopathogenesis of Cataract
Caused by degeneration and opacification of Caused by degeneration and opacification of
existing lens fibres, formation of aberrant fibres existing lens fibres, formation of aberrant fibres
or deposition of other material in their place.or deposition of other material in their place.
Loss of transparency occurs because of Loss of transparency occurs because of
abnormalities of lens protein and consequent abnormalities of lens protein and consequent
disorganization of the lens fibresdisorganization of the lens fibres

7. 7
Etiopathogenesis of CataractEtiopathogenesis of Cataract
Any factor that disturbs the critical intra and extra Any factor that disturbs the critical intra and extra
cellular equilibrium of water and electrolytes or cellular equilibrium of water and electrolytes or
deranges the colloid system within the fibres causing deranges the colloid system within the fibres causing
opacification. opacification.
Fibrous metaplasia of lens fibres occurs in complicated Fibrous metaplasia of lens fibres occurs in complicated
cataract. cataract.
Epithelial cell necrosis occurring in angle closure Epithelial cell necrosis occurring in angle closure
glaucoma leads to focal opacification of the lens glaucoma leads to focal opacification of the lens
epithelium (Glaucomflecken)epithelium (Glaucomflecken)

8. 8
Etiopathogenesis of CataractEtiopathogenesis of Cataract
Abnormal products of metabolism, drugs or Abnormal products of metabolism, drugs or
metals can be deposited in storage diseases metals can be deposited in storage diseases
(Febry), metabolic diseases (Wilson) and toxic (Febry), metabolic diseases (Wilson) and toxic
reactions (Siderosis) reactions (Siderosis)

9. 9
Etiopathogenesis of CataractEtiopathogenesis of Cataract
Three biochemical factors are evident in cataract Three biochemical factors are evident in cataract
formation:formation:
1. 1. HydrationHydration: seen particularly in rapidly : seen particularly in rapidly
developing forms. Actual fluid droplets collect developing forms. Actual fluid droplets collect
under the capsule forming lacunae between under the capsule forming lacunae between
fibres, the entire tissue may swell (intumescent) fibres, the entire tissue may swell (intumescent)
and becomes opaque, this process is reversible and becomes opaque, this process is reversible
in early stage, as in juvenile insulin dependent in early stage, as in juvenile insulin dependent
diabetes.diabetes.

10. 10
Etiopathogenesis of CataractEtiopathogenesis of Cataract
Hydration may be due to osmotic changes in the Hydration may be due to osmotic changes in the
lens or due to changes in the semi-permeability lens or due to changes in the semi-permeability
of the capsule. of the capsule.
In traumatic cataract, rupture of capsule gives In traumatic cataract, rupture of capsule gives
rise to lens swelling. rise to lens swelling.

11. 11
Etiopathogenesis of CataractEtiopathogenesis of Cataract
2. 2. Denaturation of lens proteinsDenaturation of lens proteins - If the proteins - If the proteins
are denatured with an increase in insoluble are denatured with an increase in insoluble
protein, a dense opacity is produced. This stage protein, a dense opacity is produced. This stage
is irreversible and opacity do not clear, this is irreversible and opacity do not clear, this
change is seen in young lens or the cortex of the change is seen in young lens or the cortex of the
adult nucleus where metabolism is active (soft adult nucleus where metabolism is active (soft
cataract). cataract).

12. 12
Etiopathogenesis of CataractEtiopathogenesis of Cataract
3. 3. SclerosisSclerosis: Inactive fibres of the nucleus suffer : Inactive fibres of the nucleus suffer
from degenerative change of slow sclerosis (hard from degenerative change of slow sclerosis (hard
cataract).cataract).

13. 13
Etiological theories of CataractEtiological theories of Cataract
Etiological TheoriesEtiological Theories
1.1.Biological Biological
a. An expression of senilitya. An expression of senility
b. Geneticb. Genetic
2. Immunological2. Immunological
3. Functional, due to strain of excessive 3. Functional, due to strain of excessive
accommodative strain accommodative strain

14. 14
Etiological theories of Cataract… contdEtiological theories of Cataract… contd
4. Local Disturbances 4. Local Disturbances
a. Nutritional supplya. Nutritional supply
b. Of the chemistry of lens due to disturbances b. Of the chemistry of lens due to disturbances
of permeability of permeability
c. Radiational damage due to sunlight c. Radiational damage due to sunlight

15. 15
Etiological theories of Cataract… contdEtiological theories of Cataract… contd
5. General metabolic disturbances 5. General metabolic disturbances
a. changes in blood chemistrya. changes in blood chemistry
b. toxic statesb. toxic states
c. conditions of deficiencyc. conditions of deficiency
d. endocrine disturbancesd. endocrine disturbances

16. 16
Experimental CataractExperimental Cataract
Can be produced by: Can be produced by:
1. Mechanical injury – concussion, rupture of capsule1. Mechanical injury – concussion, rupture of capsule
2. Physical causes – Osmotic influences, cold and heat, 2. Physical causes – Osmotic influences, cold and heat,
acidity, electricity currentacidity, electricity current
3. Radiational Cataract – Micro-wave, thermal, UV and 3. Radiational Cataract – Micro-wave, thermal, UV and
ionizing radiationionizing radiation

17. 17
Experimental Cataract… contdExperimental Cataract… contd
4.4.Decrease in semi-permeability of capsuleDecrease in semi-permeability of capsule
5.5.Interference with nutrient supply, anoxia and Interference with nutrient supply, anoxia and
asphyxiaasphyxia
6.6.Sugar Cataract – Galactose, xylose, glucose Sugar Cataract – Galactose, xylose, glucose
7.7.Deficiency cataract- lack of proteins, specific Deficiency cataract- lack of proteins, specific
amino acids and vitamins amino acids and vitamins

18. 18
Experimental CataractExperimental Cataract
8. A low calcium / phosphate ratio in the blood – 8. A low calcium / phosphate ratio in the blood –
parathyroidectomy and tetanyparathyroidectomy and tetany
9. Endocrine Cataract9. Endocrine Cataract
10. Toxic cataract – Naphthaline, dinitrophenol, 10. Toxic cataract – Naphthaline, dinitrophenol,
paradichlorbenzene, thallium, cobalt, anti-paradichlorbenzene, thallium, cobalt, anti-
mitotic agents, enzyme inhibitors, cataractogenic mitotic agents, enzyme inhibitors, cataractogenic
drugsdrugs
11. Due to systemic infections 11. Due to systemic infections

19. 19
Age Related Age Related
(Senile) Cataract(Senile) Cataract

20. 20
Age Related Senile CataractAge Related Senile Cataract
Age related cataract is universal in persons over Age related cataract is universal in persons over
70 years of age. Both sexes are involved equally.70 years of age. Both sexes are involved equally.
There is considerable genetic influence.There is considerable genetic influence.
Average age of onset of cataract is Average age of onset of cataract is
approximately 10 years earlier in tropical approximately 10 years earlier in tropical
countries.countries.

21. 21
Senile CataractSenile Cataract
Types:Types:
1.1.Cortical CataractCortical Cataract: Wherein classical sign of : Wherein classical sign of
hydration followed by coagulation of protein hydration followed by coagulation of protein
appears in cortexappears in cortex
2.2.Nuclear or Sclerotic CataractNuclear or Sclerotic Cataract: Here the : Here the
essential feature is slow necrosis of nucleus.essential feature is slow necrosis of nucleus.

22. 22
Cortical CataractCortical Cataract
There is demarcation of cortical fibres due to There is demarcation of cortical fibres due to
their separation by fluid (their separation by fluid (Lamellar SeparationLamellar Separation) )
these changes can be seen by slit lamp , changes these changes can be seen by slit lamp , changes
are not visible by Ophthalmoscope. Increased are not visible by Ophthalmoscope. Increased
refractive index of cortex gives a grey refractive index of cortex gives a grey
appearance to the pupil as against the blackness appearance to the pupil as against the blackness
seen in the young. The greyness is due to seen in the young. The greyness is due to
increase in reflection and scattering of light (and increase in reflection and scattering of light (and
not due to cataractous changes) not due to cataractous changes)

23. 23
Cortical Cataract… contdCortical Cataract… contd

Next stage is Next stage is incipient cataractincipient cataract: Wedge shaped : Wedge shaped
spokes of opacities with clear areasspokes of opacities with clear areas in between them in between them
appear in peripheral lens and are common in lower appear in peripheral lens and are common in lower
nasal quadrant (nasal quadrant (Cuneiform opacitiesCuneiform opacities) . These opacities ) . These opacities
lies in the cortex in front and behind the nucleus. There lies in the cortex in front and behind the nucleus. There
is sectorial alteration in refractive indices of the lens is sectorial alteration in refractive indices of the lens
fibres, producing irregularities in refraction. Patient fibres, producing irregularities in refraction. Patient
experience visual deterioration and polyopia. experience visual deterioration and polyopia.

24. 24
Cortical Cataract…contdCortical Cataract…contd
Cupuliform CataractCupuliform Cataract: consisting of dense : consisting of dense
aggregation of opacities just beneath the capsule aggregation of opacities just beneath the capsule
in posterior cortex. It is difficult to see with in posterior cortex. It is difficult to see with
ophthalmoscope but can be detected as a dark ophthalmoscope but can be detected as a dark
shadow on distant direct ophthalmoscopy. Being shadow on distant direct ophthalmoscopy. Being
near the nodal point of the eye the vision is near the nodal point of the eye the vision is
diminished considerably. diminished considerably.

25. 25
Cortical Cataract…contdCortical Cataract…contd
Perinuclear Punctate CataractPerinuclear Punctate Cataract: Appears in : Appears in
elderly people often in association with a elderly people often in association with a
coronary cataract. Onset is recognized by a coronary cataract. Onset is recognized by a
thickening and intensification of the appearance thickening and intensification of the appearance
of the anterior and posterior bands of the adult of the anterior and posterior bands of the adult
nucleus, multiple small opaque dots with large nucleus, multiple small opaque dots with large
plaques are seen in the deeper layers forming plaques are seen in the deeper layers forming
concentric lines and cloudy patches. concentric lines and cloudy patches.

26. 26
Cortical Cataract…contdCortical Cataract…contd
Incipient cataract stage is followed by diffuse Incipient cataract stage is followed by diffuse
and irregular opacification of deeper layer of and irregular opacification of deeper layer of
cortex which becomes cloudy and eventually cortex which becomes cloudy and eventually
uniform white and opaque. Progressive uniform white and opaque. Progressive
hydration of cortex may cause swelling of the hydration of cortex may cause swelling of the
lens, making the anterior chamber shallow lens, making the anterior chamber shallow
((intumescent cataractintumescent cataract) eventually entire cortex ) eventually entire cortex
becomes opaque, swelling subside and cataract is becomes opaque, swelling subside and cataract is
termed as termed as maturemature. .

27. 27
Cortical Cataract …contdCortical Cataract …contd
In the mean time the nucleus suffers progressive In the mean time the nucleus suffers progressive
sclerosis. If the process is allowed to go sclerosis. If the process is allowed to go
uninterruptedly, the stage of hypermaturity sets uninterruptedly, the stage of hypermaturity sets
in. in.

28. 28
Hypermature CataractHypermature Cataract
Types of hypermature cataract: Types of hypermature cataract:
a. a. Hypermature shrunken cataract-Hypermature shrunken cataract- when when
cortex disintegrate and transform into cortex disintegrate and transform into
pultaceous mass. The lens become inspissated pultaceous mass. The lens become inspissated
and shrunken, the anterior capsule become and shrunken, the anterior capsule become
thickened. A dense white capsular cataract thickened. A dense white capsular cataract
(sometimes with capsular calcification) (sometimes with capsular calcification)

29. 29
Hypermature CataractHypermature Cataract
b. b. Morgagnian Hypermature CataractMorgagnian Hypermature Cataract: :
Following maturity, sometimes cortex becomes Following maturity, sometimes cortex becomes
fluid and nucleus sink into the bottom. The fluid and nucleus sink into the bottom. The
liquefied cortex become milky and nucleus is liquefied cortex become milky and nucleus is
seen as brown mass, visible as semicircular line seen as brown mass, visible as semicircular line
in pupillary area altering its position with change in pupillary area altering its position with change
in position of the head. in position of the head.

30. 30
Senile Nuclear SclerosisSenile Nuclear Sclerosis
The normal tendency of central nuclear fibres to The normal tendency of central nuclear fibres to
become sclerosed is intensified. The cortical become sclerosed is intensified. The cortical
fibres remain transparent. This type of cataract fibres remain transparent. This type of cataract
tends to develop earlier than cortical type, tends to develop earlier than cortical type,
usually in fifth decade. It typically blur the usually in fifth decade. It typically blur the
distant vision more than near vision. distant vision more than near vision.

31. 31
Senile Nuclear SclerosisSenile Nuclear Sclerosis
With time nucleus becomes diffusely cloudy. With time nucleus becomes diffusely cloudy.
Cloudiness spread towards the cortex. Cloudiness spread towards the cortex.
Occasionally nucleus becomes tinted dark Occasionally nucleus becomes tinted dark
brown, dusty red or even black due to brown, dusty red or even black due to
deposition of yellow pigmented protein derived deposition of yellow pigmented protein derived
from the amino acid tryptophan. The brown from the amino acid tryptophan. The brown
cataract is called cataract brunescens, and black cataract is called cataract brunescens, and black
cataract is termed as cataracta nigracataract is termed as cataracta nigra

32. 32
Symptoms of CataractSymptoms of Cataract
1. Blurring of vision1. Blurring of vision
2. Frequent change of glasses due to rapid change 2. Frequent change of glasses due to rapid change
in refractive index of the lens in refractive index of the lens
3. Painless, progressive, gradual diminution of 3. Painless, progressive, gradual diminution of
vision due to reduction in transparency of the vision due to reduction in transparency of the
lenslens
4. Second sight or myopic shift in case of nuclear 4. Second sight or myopic shift in case of nuclear
cataract causing index myopia, improving near cataract causing index myopia, improving near
vision. vision.

33. 33
Symptoms of CataractSymptoms of Cataract
5. Loss or marked diminution of vision in bright 5. Loss or marked diminution of vision in bright
sunlight or bright light beam in central posterior sunlight or bright light beam in central posterior
sub-capsular cataract.sub-capsular cataract.
6. Monocular diplopia or polyopia in presence of 6. Monocular diplopia or polyopia in presence of
cortical spoke opacities cortical spoke opacities
7. Glare in posterior sub-capsular cortical cataract 7. Glare in posterior sub-capsular cortical cataract
due to increased scattering of lightdue to increased scattering of light

34. 34
Symptoms of CataractSymptoms of Cataract
8. Colored haloes around the light as seen in 8. Colored haloes around the light as seen in
cortical cataract due to irregular refractive index cortical cataract due to irregular refractive index
in different parts of the lens. in different parts of the lens.
9. Color shift , reds are accentuated9. Color shift , reds are accentuated
10. Visual field loss, generalized reduction in 10. Visual field loss, generalized reduction in
sensitivity due to loss of transparency sensitivity due to loss of transparency

35. 35
Signs of senile cataractSigns of senile cataract
Positive findingsPositive findings
1.1.Diminution of visionDiminution of vision
2.2.Anterior chamber is shallow in cases of Anterior chamber is shallow in cases of
intumescent cataract and deep in cases of intumescent cataract and deep in cases of
hypermature (shrunken) cataracthypermature (shrunken) cataract
3.3.Tremulousness of iris in cases of hypermature Tremulousness of iris in cases of hypermature
shrunken cataractshrunken cataract

36. 36
Signs of senile cataractSigns of senile cataract
4. Lenticular opacity , grey or white opacity in lens. 4. Lenticular opacity , grey or white opacity in lens.
Iris shadow in immature cataract. No iris Iris shadow in immature cataract. No iris
shadow in mature cataractshadow in mature cataract
5. Morgagnian Cataract- is characterized by 5. Morgagnian Cataract- is characterized by
liquefied cortex, which is milky and nucleus is liquefied cortex, which is milky and nucleus is
seen as brown mass, seen as semicircular line, seen as brown mass, seen as semicircular line,
altering its position with change in position of altering its position with change in position of
headhead

37. 37
Signs of senile cataractSigns of senile cataract
6. Distant direct ophthalmoscopy will reveal black 6. Distant direct ophthalmoscopy will reveal black
shadow against red background in cases of shadow against red background in cases of
immature cataract.immature cataract.

38. 38
Complications of CataractComplications of Cataract
Secondary glaucoma during intumescent stage Secondary glaucoma during intumescent stage
by causing angle closure and phacolytic by causing angle closure and phacolytic
glaucoma and lens induced uveitis in glaucoma and lens induced uveitis in
hypermature cataract hypermature cataract
Anaphylactic irritation by the products of Anaphylactic irritation by the products of
hypermaturityhypermaturity
Subluxation and dislocation of hypermature Subluxation and dislocation of hypermature
cataract cataract

39. 39
Differential Diagnosis of painless Differential Diagnosis of painless
gradual diminution of visiongradual diminution of vision
Chronic open angle glaucomaChronic open angle glaucoma
Macular degenerationMacular degeneration
Optic atrophyOptic atrophy
Corneal dystrophyCorneal dystrophy
Retinopathy associated with systemic disorders Retinopathy associated with systemic disorders
(hypertension or diabetes) (hypertension or diabetes)