Management of cataract

eye

1. Cataract associated with Cataract associated with
systemic diseases and systemic diseases and
management of Cataractmanagement of Cataract

2. Complicated CataractComplicated Cataract
Cataract associated with ocular diseases:Cataract associated with ocular diseases:
Complicated Cataract : is due to disturbance Complicated Cataract : is due to disturbance
of the nutrition of lens due to inflammatory of the nutrition of lens due to inflammatory
or degenerative disease of anterior and /or or degenerative disease of anterior and /or
posterior segment of the eye like posterior segment of the eye like
iridocyclitis, cilitis, pars planitis, choroiditis, iridocyclitis, cilitis, pars planitis, choroiditis,
myopic degeneration, retinitis pigmentosa, myopic degeneration, retinitis pigmentosa,
retinal detachment, other retinal retinal detachment, other retinal
pigmentory dystrophies etc. pigmentory dystrophies etc.

3. Complicated CataractComplicated Cataract
Cataract has characteristic breadcrumb Cataract has characteristic breadcrumb
appearance and rainbow display of appearance and rainbow display of
colours (polychromatic lustre). colours (polychromatic lustre).
Vision is usually affected even in early Vision is usually affected even in early
stages as opacity is near the nodal point stages as opacity is near the nodal point
of the eye. of the eye.

4. Complicated CataractComplicated Cataract
Prognosis depends on the causative Prognosis depends on the causative
condition.condition.
All cases of cataract without obvious All cases of cataract without obvious
cause should be carefully looked for cause should be carefully looked for
keratic precipitates or evidences of pars keratic precipitates or evidences of pars
planitis.planitis.

5. Cataract associated with systemic Cataract associated with systemic
disease disease
Diabetic Cataract:Diabetic Cataract:
Early onset of senile cataract and cataract Early onset of senile cataract and cataract
develops rapidly. develops rapidly.
True diabetic cataract is rare condition, occurring True diabetic cataract is rare condition, occurring
typically in young people with acute diabetes typically in young people with acute diabetes
(with gross imbalance of water balance of the (with gross imbalance of water balance of the
body). Fluid droplets (vacuoles) appear under body). Fluid droplets (vacuoles) appear under
the anterior and posterior subcapsular cortex, the anterior and posterior subcapsular cortex,
manifesting as myopia, producing diffuse manifesting as myopia, producing diffuse
opacity. These changes are reversible. opacity. These changes are reversible.

6. Diabetic CataractDiabetic Cataract
The lens rapidly becomes cataractous with The lens rapidly becomes cataractous with
dense, white anterior and posterior dense, white anterior and posterior
subcapsular cortical cataract resembling subcapsular cortical cataract resembling
snowstorm “snowflake Cataract”.snowstorm “snowflake Cataract”.
If diabetes is controlled appropriately, the If diabetes is controlled appropriately, the
rapid progression to mature cataract may rapid progression to mature cataract may
be arrested.be arrested.

7. Cataract associated with systemic Cataract associated with systemic
diseasedisease
Parathyroid TetanyParathyroid Tetany
Myotonic DystrophyMyotonic Dystrophy
GalactosaemiaGalactosaemia
Down SyndromeDown Syndrome
Atopic CataractAtopic Cataract

8. Objective Examination Objective Examination
The state of the nucleus (grading of The state of the nucleus (grading of
nuclear sclerosis)nuclear sclerosis)
The state of the cortexThe state of the cortex
The presence or absence of signs of The presence or absence of signs of
inflammationinflammation
Pupillary glow by transilluminationPupillary glow by transillumination
B- Scan ultrasonographyB- Scan ultrasonography

9. Functional TestsFunctional Tests
Pupillary reactionPupillary reaction
Projection of lightProjection of light
Macular function test – two pinholes test Macular function test – two pinholes test
and Maddox rod testand Maddox rod test
Entoptic view of the retina : Auto-Entoptic view of the retina : Auto-
ophthalmoscopy ophthalmoscopy
Electro-retinographic record, particularly of Electro-retinographic record, particularly of
macula.macula.

10. Pre-operative evaluation Pre-operative evaluation
Thorough ocular examination to exclude Thorough ocular examination to exclude
any ocular disease like abnormalities of any ocular disease like abnormalities of
lids, lacrimal sac, conjunctiva (including lids, lacrimal sac, conjunctiva (including
conjunctival infections), cornea, uveal conjunctival infections), cornea, uveal
inflammation, glaucoma, posterior inflammation, glaucoma, posterior
segment inflammatory/ degenerative segment inflammatory/ degenerative
condition etc.condition etc.

11. Pre-operative evaluationPre-operative evaluation
Systemic examination to exclude Systemic examination to exclude
hypertension, cardiovascular disorder, hypertension, cardiovascular disorder,
cerebro-vascular disease, chronic cerebro-vascular disease, chronic
obstructive air way disorder etc. If any obstructive air way disorder etc. If any
disorder is present, it should be disorder is present, it should be
adequately controlled before surgeryadequately controlled before surgery
ENT and Dental checkup to exclude septic ENT and Dental checkup to exclude septic
focusfocus

12. Treatment of cataractTreatment of cataract
Medical treatment: No medical treatment Medical treatment: No medical treatment
is effective once the lens opacity has is effective once the lens opacity has
developed. developed.

13. Treatment of cataractTreatment of cataract
Surgical Treatment:Surgical Treatment:
Indication for surgery:Indication for surgery:
1. Cataract – when routine work becomes 1. Cataract – when routine work becomes
difficult due to reduced vision (attributable to difficult due to reduced vision (attributable to
cataract)cataract)
2. Subluxated or dislocated lens2. Subluxated or dislocated lens
3. Lens induced complications like phacolytic 3. Lens induced complications like phacolytic
uveitis / glaucoma, phacoanaphylactic uveitis / glaucoma, phacoanaphylactic
endophthalmitis, phacomorphic glaucoma.endophthalmitis, phacomorphic glaucoma.

14. Treatment of cataractTreatment of cataract
Surgical Treatment: Surgical Treatment:
OptionsOptions
I. Intracapsular lens extraction (ICCE): I. Intracapsular lens extraction (ICCE):
Method of intracapsular cataract extraction Method of intracapsular cataract extraction
(ICCE), now becoming obsolete, by which (ICCE), now becoming obsolete, by which
the entire lens including the capsule is the entire lens including the capsule is
removed by rupturing zonular ligaments.removed by rupturing zonular ligaments.

15. Surgical Treatment of CataractSurgical Treatment of Cataract
II. Extracapsular Cataract Extraction (ECCE): II. Extracapsular Cataract Extraction (ECCE):
Methods –Methods –
1. Conventional ECCE1. Conventional ECCE
2. ECCE by small incision cataract surgery 2. ECCE by small incision cataract surgery
(SICS)(SICS)
3. Lensectomy3. Lensectomy
4. Phacoemulsification 4. Phacoemulsification

16. Steps of ECCESteps of ECCE
1.1.Anaesthesia Anaesthesia
a. General Anaesthesia : In children, a. General Anaesthesia : In children,
psychiatric patients, senile dementia psychiatric patients, senile dementia
b. Local anaesthesia: Retrobulbar block, b. Local anaesthesia: Retrobulbar block,
peribulbar block, along with or without peribulbar block, along with or without
facial block , topical anaesthesiafacial block , topical anaesthesia

17. Steps of ECCESteps of ECCE
2. Cleaning of lids with 5% betadine solution 2. Cleaning of lids with 5% betadine solution
and instillation of betadine solution in and instillation of betadine solution in
conjunctival sac conjunctival sac
3. Draping3. Draping
4. Superior Rectus suture in case of 4. Superior Rectus suture in case of
conventional ECCE and SICSconventional ECCE and SICS
5. Conjunctival flap in case of SICS5. Conjunctival flap in case of SICS

18. Steps of ECCESteps of ECCE
6. Scleral tunnel incision or Corneo-scleral 6. Scleral tunnel incision or Corneo-scleral
section or corneal or corneal tunnel section or corneal or corneal tunnel
incisionincision
7. Anterior chamber entry7. Anterior chamber entry
8. Injection of ocular viscosurgical device 8. Injection of ocular viscosurgical device
(OVD) in anterior chamber (HPMC or (OVD) in anterior chamber (HPMC or
Sodium Hyaluronate) Sodium Hyaluronate)
9. Capsulotomy ( can opener or continuous 9. Capsulotomy ( can opener or continuous
curvilinear capsulorrhexis, CCC)curvilinear capsulorrhexis, CCC)

19. Steps of ECCESteps of ECCE
10. Hydrodissection and Hydrodelineation10. Hydrodissection and Hydrodelineation
11. Nucleus delivery (in conventional ECCE 11. Nucleus delivery (in conventional ECCE
and SICS) / Phacoemulsification of and SICS) / Phacoemulsification of
nucleus (in phacoemulsification, machine , nucleus (in phacoemulsification, machine ,
through titanium needle provides energy through titanium needle provides energy
for emulsification of nucleus, needle for emulsification of nucleus, needle
vibrates at an speed of 20,000 Hz and vibrates at an speed of 20,000 Hz and
pulverizes the nucleus) pulverizes the nucleus)

20. Steps of ECCESteps of ECCE
12. Cortical clean up by aspiration and 12. Cortical clean up by aspiration and
irrigation (BSS or Ringer lactate is used as irrigation (BSS or Ringer lactate is used as
irrigating fluid)irrigating fluid)
13. Filling of lens capsule (capsular bag) 13. Filling of lens capsule (capsular bag)
with OVDwith OVD
14. Insertion of posterior chamber IOL (in 14. Insertion of posterior chamber IOL (in
the bag, in case of complications in the the bag, in case of complications in the
ciliary sulcus) ciliary sulcus)

21. Steps of ECCESteps of ECCE
15. Removal of OVD from anterior chamber15. Removal of OVD from anterior chamber
16. Closure of wound of entry (corneoscleral 16. Closure of wound of entry (corneoscleral
wound requires sutures 10-0 silk or nylon), wound requires sutures 10-0 silk or nylon),
phaco and SICS incisions are self sealing. phaco and SICS incisions are self sealing.

22. Complications of Cataract SurgeryComplications of Cataract Surgery
I.I.Due to local anesthesia: Retrobulbar Due to local anesthesia: Retrobulbar
haemorrhage, globe perforataion, haemorrhage, globe perforataion,
oculocardiac reflex etc. oculocardiac reflex etc.
II.II.Intra-operative complications : Intra-operative complications :
detachment of descemet’s membrane, detachment of descemet’s membrane,
damage to corneal endothelium, damage to corneal endothelium,
zonular dialysis, posterior capsular zonular dialysis, posterior capsular
rupture rupture

23. Complications of cataract Surgery Complications of cataract Surgery
III. Early post-operative complications: III. Early post-operative complications:
wound leak and complications related to it wound leak and complications related to it
(iris prolapse, flat anterior chamber), (iris prolapse, flat anterior chamber),
secondary glaucoma, postoperative secondary glaucoma, postoperative
infection, lens matter induced uveitis etc.infection, lens matter induced uveitis etc.

24. Complications of Cataract SurgeryComplications of Cataract Surgery
IV. Late post-operative complications: IV. Late post-operative complications:
cystoid macular edema, posterior capsular cystoid macular edema, posterior capsular
opacification, corneal endothelial opacification, corneal endothelial
decompensation causing corneal edema, decompensation causing corneal edema,
retinal detachment, displacement of IOL retinal detachment, displacement of IOL
etc. etc.