Lens and Cataract
Cesar Matthew Madria
School of Medicine
St. Paul University Philippines
Outline
Anatomy of the Lens
Physiology of symptoms in Lens disorders
Cataract
-
mature
immature
hypermature
intumescent
morgagnian
A. Age-related Cataract
B. Childhood Cataract
> Congenital
> Acquired
C. Traumatic Cataract
D. Cataract associated with Systemic Disease
E. Drug-induced Cataract
F. After Cataract
Cataract Surgery
1. ICCE
2. ECC
3. Phacoemulsification
Lens and its Attributes
Appearance: crystalline structure, biconvex, and covered
by lens capsule
Location: posterior to Iris and is supported by zonular fibers
arising from the ciliary body. (These fibers insert onto the
equatorial region of the lens capsule.)
Function: its shape, elasticity and transparency allow light
to properly pass and create a normal visual experience.
ciliary muscle contracts -> zonular tension relaxes -> more spherical
ciliary muscle relaxes -> zonular tension tenses -> more flattened
Avascular its source of nutrient is from aqueous humor
Metabolism: anaerobic
Physiology of Symptoms
Symptoms associated with lens disorders are primarily visual.
1.
Presbyopic symptoms: diminished ability to perform near tasks.
2.
Blurred vision for near and distant view: usually not accompanied with pain
3.
Aphakic refractive state: complete dislocation of the lens from the visual axis
Cataract
is any opacity in the lens.
Cause:
1.
Aging
2.
Trauma
3.
Drug
4.
Systemic disease
5.
Smoking
6.
Heredity
Cataract Maturity
Mature is one in which ALL of the lens proteins is opaque.
Immature has SOME transparent protein.
Intumescent if lens take up water.
Hypermature cortical proteins have become liquid.
Generally speaking, the decrease in visual acuity is directly proportionate to the
density of the cataract.
Cataract Maturity
Mature is one in which ALL of the lens proteins is opaque.
Cataract Maturity
Hypermature cortical proteins have become liquid with fluid passage from
the lens
Cataract Maturity
Morgagnian Cataract when further liquefaction of the cortex allows free
movement of the nucleus within the capsular bag.
Age-Related Cataract
Cataract by location
A.
Nuclear Cataract
B. Cortical Cataracts
C. Posterior subcapsular cataracts
Age-Related Cataract
Cataract by location
A.
Nuclear Cataract due to normal condensation process in the lens
nucleus after middle age.
>Earliest symptom Myopic shift
>bilateral but may be asymmetric
> best assessed with oblique slit lamp biomicroscopy
> in early stages, it is colored yellow due to urochrome deposition
Age-Related Cataract
B. Cortical Cataracts opacities in the
lens cortex.
> Bilateral and asymmetric
> First signs are vacuoles and
water clefts
> Cortical spokes/cuneiform
opacities form near the periphery of
the lens, edge pointing towards the
center.
Age-Related Cataract
C. Posterior subcapsular cataracts
located in the cortex near the central
posterior capsule.
- Typically causes early visual symptoms
due to its location.
- Lens epithelial cell migrate from lens
equator to visual axis of inner surface of
posterior capsule
Summary of Age-Related Cataract
Location
Laterality
Causes
Symptoms
Nuclear
Lens Nucleus
Bilateral
Old age, smoking
diabetes
1. Good near visual
acuity
2. Less glaring
Cortical
Lens cortex
Bilateral
Diabetes, Hyperkalemia, 1. Visual acuity
hypernatremia, UV light
insignificantly
exposure
affected
2. Less glaring
Posterior
Subcapsular
Cortex near the
central posterior
capsule
Unilateral/Bilateral Female, Steroid use,
diabetes
1. Good distant
visual acuity
2. Increased Glaring
Childhood Cataract
Onset
Laterality
Causes
Treatment
Congenital Cataract
Present at birth or
appear shortly
thereafter
Unilateral/bilateral
1/3 hereditary
1/3 metabolic,
infectious, variety
of syndromes
1/3 undetermined
causes
Mechanical
irrigation-aspiration
with posterior and
anterior vitreous
removal
Acquired cataract
Later in life
Unilateral/bilateral
Trauma
Uveitis
Diabetes
Drugs
Mechanical
irrigation-aspiration
with posterior and
anterior vitreous
removal
Traumatic Cataract
Most
commonly due to a foreign body injury
to the lens or blunt trauma to the eyeball.
Once
lens capsule is interrupted, it allows
aqueous and sometimes vitreous to
penetrate the lens structure -> lens
becomes white
Traumatic cataract
Vossius Ring with blunt injury pigment from pupillary ruff is imprinted onto
anterior lens capsule
Soemmerings ring doughnut of residual equatorial cortex
Complete cortical cataract
Focal cortical cataract
Infrared radiation / glassblower cataract cataract formed
due to overexposure to heat
Cataracts associated with systemic
disease
Diabetes Milletus
Hypocalcemia
Galactosemia
Downs syndrome
Myotonic dystrophy
Cataracts associated with
systemic disease
Diabetes Milletus
Snow-flake appearance
Cataracts associated with systemic
disease
Inability to convert galactose to glucose
Accumulation of galactitol
Cataracts associated with systemic
disease
Hypocalcemia
Common in patients without
parathyroid glands
Sodium correlated to be causing
cataract.
Cataracts associated with systemic
disease
Wilson Disease
- An inherited disease
related to disorder in
copper metabolism
Sunflower cataract
Cataracts associated with systemic
disease
Myotonic
dystrophy
characterized by
delayed relaxation of
contracted muscles,
ptosis, cardiac
conduction defects,
and prominent frontal
balding in affected
male patients.
Christmas tree Cataract
Drug-induced Cataract
Corticosteroids taken over a long period of time
Phenothiazines
Amiodarone
Strong miotic drop (phospholine iodide)
Drug-induced Cataract
Corticosteroid
Can cause Posterior Subcapsular Cataract
Due to 2 mechanisms:
1. Alters Na-K pump of Lens
2. hastens crystalin conformational
change
> Triamcinolone acetonide
Dense central opacity, thinner periphery
with pseudopodia-like fringes
Drug-induced Cataract
Phenothiazine
accelerate any predisposition to lens
opacification from solar radiation because of
their ability to form photosensitive products.
Dust-like appearance until stellate in
appearance
> Chlorpromazine
Pigmented deposits on anterior lens
capsule
Drug-induced Cataract
Miotics:Chronic use of long-acting
cholinesterase inhibitors
can produce anterior subcapsular
vacuoles. Continued use of these strong
miotics may cause posterior
subcapsular and nuclear changes.
The mechanism of cataract formation
remains unclear.
Echothiophate iodide, demecarium
bromide
After-cataract (Secondary Membrane)
Opacification of the posterior capsule after ECCE.
Persistent subcapsular lens epithelium regeneration
fish egg appearance
continuous proliferation
multiple layer formation
myofibroblast differentiation
frank opacification
tiny wrinkles in posterior capsule
Cataract Surgery
Intracapsular Cataract Extraction (ICCE)
Involves the extraction of the entire lens, including the posterior capsule.
Extracapsular Cataract Extraction (ECCE)
Involves the removal of the lens nucleus through an opening in the anterior
capsule with retention of the integrity of the posterior capsule.
Phacoemulsification
ECCE
Intraocular lens implantation is part of the procedure
1.
Incision is made at the limbus or peripheral cornea
2.
Opening is made in the anterior capsule
3.
Nucleus and cortex of the lens are removed.
4.
Intraocular lens is then placed in the empty capsular bag
In nuclear removal it is removed intact with a wider incision
In cortical removal done by manual or automated aspiration
Phacoemulsification
It utilizes a handheld ultrasonic vibrator to disintegrate the hard nucleus such
that the nuclear material and cortex can be aspirated through an incision of
3mm.
NON SURGICAL
MANAGEMENT
TREATMENT OF THE CAUSE OF CATARACT
Adequate
control of diabetes mellitus,
Removal
of cataractogenic drugs such as
corticosteroids, phenothiazenes and strong miotics
Removal of irradiation (infrared or X-rays)
Early and adequate treatment of ocular diseases like
uveitis
MEASURES TO DELAY PROGRESSION
Commercially
available preparations containing iodide
salts of calcium and potassium are being prescribed in
abundance in early stages of cataract
Vit
E and aspirin also delays the process of
cataractogenesis
SURGICAL MANAGEMENT
INDICATIONS
a)
Visual improvement
b)
Medical indications:
-Lens induced glaucoma
-Phacoanaphylactic endophthalmitis
-Retinal diseases like diabetic retinopathy or
retinal detachment
PRE-OP MEDICATIONS AND PREPERATIONS
1.
TOPICAL ANTIBIOTICS - Tobramycin and Gentamicin QID for 3days
before surgery
2.
PREPARATION OF THE EYE TO BE OPERATED
3.
CONSENT
4.
SCRUB BATH AND CARE OF HAIR
5.
DRUGS TO LOWER IOP - Acetazolamide 500mg stat 2hrs before
surgery and Glycerol 60ml mixed with water 1hr before surgery
6.
DRUGS TO SUSTAIN DILATED PUPIL - AntiProstaglandin eye
drops(Indomethacin)
ANAESTHESIA
Cataract extraction can be performed under gen or local
anaesthesia. Local is preferred.
SURGICAL TECHNIQUE FOR
CATARACT EXTRACTION
INTRACAPSULAR CATARACT EXTRACTION
The entire cataractous lens along with the intact capsule is
removed.
Therefore weak and degenerated zonules are a pre-requisite for
this method. Because of this reason, this technique cannot be
employed in younger patients where zonules are strong.
ICCE can be performed between 40-50 years of age by use of the
enzyme alphachymotrypsin (which will dissolve the zonules).
Beyond 50 years of age usually there is no need of this enzyme.
INDICATION
- Subluxated and dislocated lens
SURGICAL STEPS OF ICCE TECHNIQUE:
i.
Superior rectus (bridle) suture
ii.
Conjunctival flap
iii.
Partial thickness groove/gutter
iv.
Corneoscleral section
v.
Iridectomy
vi.
Methods of lens delivery
Indian smith method
Cryoextraction
Capsule forceps method
Irisophake method
Wire vectis method
vii.
Formation of Anterior Chamber
viii.
Implantation of anterior chamber IOL(ACIOL)
ix.
Closure of incision- 5-7 interrupted sutures
x.
Conjunctival flap repositioned
xi.
Subconjunctival injection-dexamethasone 0.25ml and
gentamicin 0.5ml given
xii.
Patching of the eye
A. Passing of superior rectus
suture
B. Fornix based conjunctival
flap
C. Partial thickness groove
D.Completion of
corneoscleral section
E. Peripheral iridectomy
F. Cryolens extraction
G.Insertion of Kelman
multiflex IOL in anterior
chamber
H.Insertion of Kelman
multiflex IOL in anterior
chamber
I. Corneo-scleral suturing
EXTRACAPSULAR CATARACT EXTRACTION
Major
portion of anterior capsule with epithelium,
nucleus and cortex are removed; leaving behind intact
posterior capsule.
Indications:
Presently, it is the surgery of choice for all
types of adulthood as well as childhood cataracts
unless contraindicated.
Contraindications
- Subluxated and dislocated lens
Types of extracapsular cataract extraction
a) Conventional Extracapsular Cataract
(ECCE)
Extraction
b) Manual Small Incision Cataract Surgery
c) Phacoemulsification
(SICS),
CONVENTIONAL ECCE
i.
Superior rectus (bridle) suture
ii.
Conjunctival flap (fornix based)
iii.
Partial thickness groove/gutter
iv.
Corneoscleral section.
v.
Injection of viscoelastic substance in anterior
chamber - 2% MethylCellulose or 1% Sodium Hyaluronate
(Maintains anterior chamber and protects endothelium)
vi. Anterior
capsulotomy.
Can-opener's
Linear
capsulotomy (Envelope technique)
Continuous
vii.Removal
technique
circular capsulorrhexis (CCC)
of anterior capsule
viii.Completion
of corneoscleral section
ix. Hydrodissection (ie., seperation of capsule from cortex by
injecting fluid between the two) - Balanced salt solution injected
under peripheral part of ant capsule to separate corticonuclear mass
from the capsule
x.
Removal of nucleus
After hydrodissection the nucleus can be removed by any of the
following techniques:
Pressure
Irrigating
and counter-pressure method
wire vectis technique
xi.
Aspiration of the cortex
xii.
Implantation of IOL
xiii.Closure
of the incision - 3-5 interrupted sutures
xiv.
Removal of viscoelastic substance
xv.
Conjunctival flap is reposited and secured
xvi.
Subconjunctival injection
xvii.
Patching of eye
A. Anterior capsulotomy Can
Opener's technique
B. Removal of anterior
capsule
C. Completion of corneoscleral section
D. Removal of nucleus
(pressure and counterpressure method)
E. Aspiration of cortex
F. Insertion of inferior haptic
of posterior chamber IOL
G.Insertion of superior
haptic of PCIOL
H. Dialing of the IOL
I. Corneo-scleral suturing
MANUAL SMALL INCISION CATARACT SURGERY
1.
Superior rectus suture
2.
Conjunctival flap and exposure of sclera
3.
Haemostasis
4.
Sclero corneal tunnel incision:
External scleral incision - 5.5mm to 7.5mm
Sclero corneal tunnel - 1-1.5mm
Internal corneal incision
5.
Side port entry
6. Anterior
capsulotomy - can be can-openers,envelope or
continuous circular capsulorrhexis (CCC)
7. Hydrodissection
8. Nuclear
management
a)prolapse of nucleus into ant chamber
b)delivery of nucleus through corneoscleral
9. Aspiration
10.IOL
of cortex
implantation
11.Removal
12.Wound
of viscoelastic material
closure
tunnel
A. Superior rectus bridle suture
B. Conjunctival flap and exposure of sclera
C, D & E. External Scleral incisions (straight, frown
shaped, and chevron,
respectively) part of tunnel incision
F. Sclero-corneal tunnel with crescent knife
G. nternal corneal incision
H. Side port entry
I. Anterior capsulotomy
J. Hydrodissection
K. Prolapse of nucleus into anterior chamber
L. Nucleus delivery with irrigating
wire vectis
M. Aspiration of cortex
N. Insertion of inferior haptic of posterior chamber
IOL
O. Insertion of
superior haptic of PCIOL
P. Dialing of the IOL
Q. Reposition and anchoring of conjunctival flap.
PHACOEMULSIFICATION
1.
Corneoscleral incision-very small 3mm
2.
Continuous curvilinear capsulorrhexis of 4-6mm
3.
Hydrodissection
4.
Nucleus is emulsified and aspirated
5.
Remaining cortical lens matter is aspirated
6.
IOL Implantation
7.
Removal of viscoelastic material
8.
Wound closure
A.
B.
C.
D & E.
F.
Continuous curvilinear capsulorrhexis
Hydrodissection;
Hydrodelineation
Nucleus emulsification by divide and conquer technique
Aspiration of cortex.
Thank you
