Approach to a case of adult cataract.pptx

an overall approach to a case of adult cataract

1. Presenter : Dr. Laxmi Dhawal 1 st year MD Ophthalmology Resident , LEIRC Approach to a case of adult cataract

2. LAYOUT Introduction Causes Cataract & Its Type Approach History Examination Pre-operative investigation and measurements 2

3. INTRODUCTION Cataract refers to the development of any opacity in the lens or its capsule. Congenital or developmental cataract: disturbance in the formation of lens fibers. Acquired cataract : multifactorial cause 3

4. causes Age related cataract /senile cataract (most common) Drugs Traumatic Metabolic diseases Effect of Nutrition, alcohol Cataract associated with uveitis Hyperbaric oxygen therapy Pseudo-exfoliation syndrome Atopic dermatitis 4

5. Age related cataract/senile cataract commonest type of acquired cataract affecting persons > 50 years occurring equal in both genders. Presenile cataract : occurs below < 50 years. 5

6. Types 6

7. Cortical cataract Are usually bilateral and asymmetrical, Glare: common symptom Monocular diplopia May progress slowly or rapidly 1 st Sign: vacuoles and water clefts in anterior or posterior cortex Wedge shaped opacity: cortical spokes or cuneiform opacities, 7

8. Pathophysiology Sample Footer Text 8 Fig : Flow chart depicting probable course of events involved in occurrence of cortical senile cataract

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10. Stages of maturation of cortical cataract Stage of lamellar separation : earliest senile change is demarcation of cortical fibres owing to their separation by fluids. Reversible changes. 10

11. 11 Stage of incipient cataract : 2 different forms can be seen. Cuneiform and cupuliform . Immature senile cataract Mature senile cataract 5. Hypermature senile cataract

12. Mature cataract 12

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14. Nuclear cataract Occur due to degenerative changes & age related nuclear sclerosis associated with dehydration & compaction of nucleus. Total protein content & distribution of cation remains normal Significant increase in water soluble protein. Slowly progressive, usually bilateral, asymmetrical 14

15. Early stage: progressive hardening – increase refractive index of the lens- myopic shift- second sight Later- hyperopic shift Occasionally monocular diplopia Poor color discrimination Brunescent nuclear cataract: in advanced cases 15

16. Posterior subcapsular cataract Often occurs in younger patients , Located in posterior cortical layer, Associated with posterior migration of lens epithelial cells from lens equator to visual axis on inner surface of posterior cortex, Enlargement of migrated epithelial cells: Wedl (bladder) cell, Visually significant only when they become axial, 16

17. iridescent sheen: 1 st indication of PSCC Later stage: granular and plaque like opacities Symptoms: glare and poor vision under bright light Near vision reduced more than distance vision Monocular vision 17

18. Drug induced cataract Steroids: PSCC Phenothiazines: pigment deposits in anterior lens epithelium Miotics: subcapsular cataract, posterior cortical, nuclear cataract Amiodarone: stellate pigment deposit in anterior cortical axis Statins: NS 18

19. Traumatic cataract May be caused by mechanical or physical forces like radiation, chemicals and electric current, Blunt nonperforating injury: Stellate or rosette shaped cataract: that involves posterior lens capsule, 19 blunt trauma showing a flower-shaped opacity

20. Penetrating trauma (black arrow indicates corneal penetration site and white arrow indicates a cut in the anterior capsule) 20 Perforating or penetrating injury: Opacification of the cortex at the site of rupture – progress rapidly to complete opacification

21. Radiation: Ionizing radiation: first clinical sign-punctate opacities within posterior capsule and feathery anterior subcapsular opacities that radiate toward the equator of the lens. Infrared radiation: true exfoliation of lens capsule , glassblower’s cataract Ultraviolet radiation 21

22. IONIZING RADIATION CATARACT 22

23. Electrical injury: initially lens vacuoles appear later linear opacities in anterior subcapsular cortex, Chemical injury: mainly with alkali - CC 23

24. 24 Sunflower cataract(Wilson disease) Snowflake cataract(diabetes) Oil droplet cataract(galactosemia) Christmas tree , Christmas tree on retro-illumination Metabolic cataract

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26. Infrared radiation (glassblower’s cataract) Posterior Subcapsular Cataract Spokes Assuming A Stellate Morphology In Myotonic Dystrophy 26

27. HISTORY Patients profile Age : young patient age Old patient Occupation : Eg - glass blowers or glass workers , driver ,office workers , student , housewife , pilot 27

28. Decreased Visual Acuity Unilateral or bilateral Duration & Onset Progression Association with pain , trauma Discomfort/glare in day light Near vision loss --- common in PSCC Diplopia : monocular diplopia---cortical diplopia Altered colour discrimination----brown cataract 28

29. PARSONS’ DISEASES OF THE EYE 23 RD EDITION 29

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31. GENERAL HISTORY History Of Joint Pain And Stiffness History Of Recurrent Epistaxis, Frequent Gum Bleed History Of Urinary Incontinence History Of Shortness Of BreatH History of DM , hypertension , IHD 31

32. Ocular history Eye discharge, ocular redness Trauma, glaucoma, optic nerve abnormalities, retinal disease. History suggestive of amblyopia History of previous ocular procedures/surgeries : Eyelid surgeries, conjunctival repairs, refractive surgeries, keratoplasty, trabeculectomy, vitreoretinal surgery , intravitreal injections 32

33. History of Cataract surgery in the fellow eye: any complication Family history of cataract, cataract surgery Possible chemical dependencies like nicotine and illicit drugs, alcohol use that may affect postoperative recovery. History of radiation exposure / Radiation therapy ( Dose of 15GY shown to be associated with 50% risk ) 33

34. Drug history Anticoagulants Antiplatelets Alfa-1 adrenergic antagonists Herbal medication: saw palmetto Systemic steroids Immunosuppressive agents History of allergy. 34

35. Examination Measurement of visual function: Visual acuity testing Refraction Contrast Sensitivity Glare testing Visual field testing 35

36. Measurement of IOP Gonioscopy Blood pressure 36

37. General examination Extensive supraclavicular fat Kyphosis Ankylosing spondylitis Obesity Head tremor 37

38. Ocular examination Any abnormalities of the external eye and ocular adnexa Presence of enophthalmos or prominent brow Evaluate Ocular alignment, Movement of extraocular muscles, Eyelid Entropion Ectropion Eyelid closure abnormalities Blepharitis 38

39. Lacrimal system Tear film abnormalities ROPLAS test (Regurgitation on pressure over lacrimal sac) 39

40. conjunctiva Vascularization or scarring from previous inflammation, injury or ocular surgery Symblepharon or shortening of the fornices presence of a filtering bleb conjunctivitis 40

41. sclera Scleral thinning, Scleritis 41

42. cornea Corneal opacities Keratitis Scarring consistent with herpetic eye disease Corneal dystrophy and degenerations Endothelial guttate Descement membrane irregularity Corneal thickness Pterygium Pannus Previous signs of refractive surgery 42

43. Anterior chamber Shallow AC May Indicate Anatomically Narrow Angles Nanophthalmos Short Axial Length Intumescent Lens Weak Lens Zonules 43

44. Iris and pupil Iris: Iridodonesis , Iris Coloboma, Iris Sphincter Tear, Exfoliation At Margin Of Undilated Pupil, Rubeiosis Iridis Pupil: Posterior Synechiae, RAPD, size of pupil, adequate dilatation 44

45. Lens In dilated pupil, Evaluate cataract density staging, types of cataract, Evaluate position of lens and integrity of zonular fibers, Lens coloboma, Clue to systemic associations. 45

46. Lens Opacities Classification Systems (LOCS): 46

47. Fundus evaluation Media Macula Optic Nerve Retinal vessels Retinal periphery 47

48. Evaluation with opaque media 1.Projection of Rays (PR) 2.Two light discrimination test 3.Color perception 48

49. 4. Entoptic visualization, 5. Blue field entoptoscopy , 6. Photostress recovery test. 7. Maddox Rod Test 49

50. 8 . B-scan Ultrasonography: B-scan ultrasonography is useful in assessing the posterior segment of the eye to rule out an associated Retinal detachment, Choroidal detachment, other pathological conditions : vitreous hemorrhage, tumor within the eye, abnormality of optic nerve, staphyloma 50

51. 9 . Optical coherence tomography macula 10. Visual Evoked Potential 11. Electroretinography 12. Electro-oculogram 8/21/2024 Sample Footer Text 51

52. Special tests: Laser interferometry, Potential acuity meter, 52

53. Potential Acuity Meter: Consists of slitlamp attachment that can project an entire letter Visual Acuity Chart onto the macula Emits 0.1mm beam of light through relatively clear area of cataract Test is performed with dilated pupil Beam is directed through the clearer areas of cataract and patient reads the chart (small line should be read if macula is normal) This test is easier to perform than Laser Interferometry 53

54. Pre-operative Investigations: Serology test, Random blood sugar 54

55. Pre-operative measurements Biometry: Optical biometry, A-scan ultrasonography (to record and compare the axial lengths of the two eyes) IOL power calculation 55

56. Corneal Topography, Corneal pachymetry, Specular microscopy (These all tests done according to the availability of instruments and surgeon’s preferences Better if done in all) 56

57. summary The following questions need to be addressed before subjecting patient to cataract surgery :- What is the functional impact of the cataract? What are the morphological characteristics of the cataract? Is surgery indicated either to improve the patient’s quality of life or to aid in the management of other ocular conditions? 57

58. What are the patient’s expectations regarding the refractive results of surgery? Does the patient have ocular or systemic comorbidities that might affect the decision to proceed with surgery or alter the management plan? What are the possible barriers to obtaining informed consent or to ensuring good postoperative care? 58

59. Bibliography AAO-BSCS Lens and cataract , 2023-2024 kanski’s clinical ophthalmology , ninth edition Parson’s diseases of the eye 23 rd edition 59

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