Lens Disease

Dr. Md. Emranul Islam Abir

FCPS
ICO (London)
MRCS opth (glasgow, uk)
FRCS opth (part 3, glasgow, uk)
fellow medical vitreo retina

Assistant professor
Eye specialist, phaco, laser and medical vitreo-retina specialist
• Some Cataract Terminology
– Phakic: When you have your natural lens
– Pseudophakic eye: When a cataract is
replaced with an artificial lens
– Aphakic eye: When a cataract is removed
but isn’t replaced.
Anatomy

• Equator
• Anterior capsule
• Posterior capsule
• Diameter:9-10mm
• Thickness:4-5mm
• Lens zonule
 Anatomy

• Capsule: integrity—maintain transparency

• Lens epi. — PCO
• Lens substance: lens fiber
– Nucleus
– Cortex
 Function
• Refraction
• Accommodation
• Protection: UV filtration !
• What is accommodation?
– The capability that eyes change refractive
condition in order to acquire clear near
sight.
 What is cataract?

• Any opacity of the lens and / or its capsule.

• A cataract is a natural clouding of the lens in eye.
• WHO: turbidity of lens + VA<0.5 eg 6/12
• Cataracts can form at different layers within
the lens.
 Cataract

• Cataract is the No. 1 eye disease that causing

blind.
• 46% blindness is caused by cataract

!
 How do you get a cataract?
• A cataract is an ocular condition associated with age.
• Not everyone will get a cataract.
• Rays of light from the sun are responsible for a cataract
forming.
• Rays must pass through the lens to reach the retina.
Not all of the light that enters the pupil will reach the
retina – some is absorbed by the lens. Over time, even
years, the amount of light rays your lens will have
absorbed will begin to add up, making it cloudy instead
of clear. This is a cataract.
 Etiology

• Any factors that change the intraocular

environment to affect lens metabolism.
– Such as: ageing, mechanical, chemical,
operation, inflammation, infections,
metabolic, drugs (eg steroids), trauma etc.
• Malformation
• Congenital factors
• May be induced by surgical procedure: lens
touch; gas; oil
Risk factors

• UV
• Diarrhea
• Malnutrition
• Diabetes
• Smoking
• Drinking alcohol
 Classification
• On etiology:
– Congenital
– Senile
– Complicated
• Uveitis, RD, RP, high
myopia.
– Metabolic
• DM, atopic dermatittis
– Drug induced or toxic
• Steroids, miotics,
chlorpromazine
– Traumatic
• mechanical,radiation,
electric shock
– After cataract
• On location:
– Cortical
– Nuclear
– Subcapsular
• On degree:
– Immature
– Intumescent
– Mature
– Hypermature
 Pathogenesis
• The common route that causing cataract
is the oxidation injury by peroxide free
radical.

• Apoptosis—hot spot of research

 Age -related cataract or senile
cataract
• Cataract that develops with aging process. It is the Most commonly
occurred.
• Classified according to:
• Morphological Classification
– Nuclear
– Cortical
– Subcapsular
– Christmas tree – uncommon
• Maturity classification
– Immature Cataract
– Mature Cataract
– Hypermature Cataract
 Nuclear cataract
• Most common type
• Age-related. Commonly over 50- 60 years.
• Sex - no predilection
• Occur in the center of the lens.
• In its early stages, as the lens changes the way it
focuses light, patient may become more
nearsighted or even experience a temporary
improvement in reading vision. Some people
actually stop needing their glasses.
• Unfortunately, this so-called 2nd sight
disappears as the lens gradually turns more
densely yellow & further clouds vision.
• As the cataract progresses, the lens may even
turn brown. Advanced discoloration can lead
to difficulty distinguishing between shades of
blue & purple.
 Cortical cataract
• Occur on the outer edge of the lens (cortex).
• Begins as whitish, wedge-shaped opacities or
streaks.
• It’s slowly progresses, the streaks extend to
the center and interfere with light passing
through the center of the lens.
• Problems with glare are common with this
type of cataract.
 Subcapsular cataract
• Occur just under the capsule of the lens
(posterior pole) & spreads to the periphery or
edges of the lens.
• Starts as a small, opaque area
• It usually forms near the back of the lens, right in
the path of light on its way to the retina.
• It’s interferes with reading vision
• Reduces vision in bright light
• Causes glare or halos around lights at night.
• It can be developed when:
– Part of the eye are chronically inflamed.
– Heavy use of some medications (steroids).
• Affects vision more than other types of
cataracts because the light converges at the
back of the lens.
• Anything constrict the pupils (bright light)
makes it very difficult for people with this type
of cataract to see.
• Dilating drops useful in this type by keeping
the pupils large and thus allow more light into
the eye.
 Subcapsular cataract
• Affecting vision early
 Immature Cataract
• Lens is partially opaque
• Two morphological forms are seen:
• Cuneiform Cataract:
– Wedge shaped opacities in the peripheral cortex and progress towards
the nucleus.
– Vision is worse in low ambient illumination when the pupil is dilated.
• Cupuliform Cataract:
– A disc or saucer shaped opacities beneath the posterior capsule.
– Vision is worse in bright ambient illumination when the pupil is
constricted.
• Lens appears grayish white in color.
• Iris shadow can be seen on the opacity with oblique illumination.
 Mature Cataract
• Lens is completely opaque.
• Vision reduced to just perception of light
• Iris shadow is not seen
• Lens appears pearly white
 Hypermature Cataract
• Shrunken and wrinkled anterior capsule due
to leakage of water out of the lense.
• This may take any of two forms:
– Liquefactive/Morgagnian Type
– Sclerotic Cataract
 Liquefactive/Morgagnian Type
• Cortex undergoes auto-lytic liquefaction and
turns uniformly milky white.
• The nucleus loses support and settles to the
bottom.
•
 Sclerotic Cataract
• The fluid from the cortex gets absorbed and
the lens becomes shrunken.
• There may be deposition of calcific material
on the lens capsule.
• Iridodonesis: Anterior chamber deepens and
iris becomes tremulous.
• The zonules become weak, increasing the risk
of subluxation / dislocation of lens.
 Iris A.C. Pupillary Visual
shadow Depth reflex acuity

•
Intumescent Present Shallow Greyish white FC to 6/18

Incipient Present Normal Greyish white FC to 6/18

Mature Absent Normal Pearly white HM to FC

close to face

Hypermature Absent Shallow Milky white HM +

Morgagnian
Hypermature Absent Normal or Milky HM +
Calcified deep chalky
 Classification

• Cortical

• Nuclear

• Subcapsular
 Cortical cataract
• 4 stages
Incipient stage: wedge turbidity
 Cortical cataract

• 4 stages
Intumescent stage (immature):
• iris projection

• Induce acute angle-closure

glaucoma
 Cortical cataract
• 4 stages
Mature stage
 Cortical cataract
• 4 stages
– Hypermature stage:
• Morgagni cataract
• Phacoanaphylactic uveitis
• Phacolytic glaucoma
 Congenital cataract
• Etiology:
– Hereditary
– Environmental:
• Virus infection
• Malnutrition
• Radiation
• Drug
• Systemic disease
• VD deficiency
 Congenital cataract

• Treatment

– observation
– Early operation
– Amblyopia
Treatment
 Complicated cataract

• Caused by other eye diseases

– Corneal ulcer
– Glaucoma
– Uveitis
– Retinal detachment
– Retinitis pigmentosa
– Intraocular tumor
– myopia
 Metabolic cataract

• Caused by systemic metabolic diseases

– Diabetic cataract

– Galactosemia cataract

– Hand-foot-twitch cataract
 Drug induced or toxic cataract
• Glucocorticosteroid cataract
• Chlorpromazine cataract
• Miotic cataract
• TNT cataract
• Metal: copper, iron, mercury, silver, zinc
 Traumatic cataract

• Contusive
• Penetrating
• Radiative
• Electric
 After cataract
• Now usually called PCO (posterior capsular
opacification)
• Adult: 30-50%
• Child: 100%
• Pathogenesis:
Proliferation, migration & metaplasia of lens epi.
 Cause:
• age related cataract

• Traumatic
−− Mechanical - blunt or penetrating
−− Irradiation - infrared - glass blowers
- ultraviolet light
- X ray
−− Electric shock
• Secondary (due to some systemic disease)
• −− systemic and metabolic - Diabetes mellitus
, hypothyroidism , hypoparathyroidism ,
galactosaemia , Hypocalcemia , Myotonic
dystrophy
• −− Dermatological - Atopic dermatitis
• Complicated (due to some other ocular
disease)
• --- Inflammatory - chronic anterior uveitis
• --- Degenerative - High myopia , Retinitis
Pigmentosa , Sticklers syndrome , long
standing retinal Detachment , Gyrate atrophy
• --- Glaukomflecken
• Toxic (due to drugs)
• −− Corticosteroids - topical/ systemic/ periocular
for a long time. Intermittent dose is preferable to
prevent cataract.
• −− Chlorpromazine
• −− Miotics (long-acting)
• −− Busulfan
• −− Amiodarone
• −− Gold
• Syndromes associate with cataract
• −− Down’s
• −− Lowe’s
• −− Treacher Collins
• −− Wilson’s disease
• −− Fabry’s disease
 Symptoms
• A cataract usually develops slowly, so:
– Causes no pain.
– Cloudiness may affect only a small part of the lens
– People may be unaware of any vision loss.
• Over time, however, as the cataract grows
larger, it:
– Clouds more the lens
– Distorts the light passing through the lens.
– Impairs vision
• Reduced visual acuity (near and distant object)
• Glare in sunshine or with street/car lights.
• Distortion of lines.
• Monocular diplopia or polyopia due to variation
of refraction by different parts of the lens.
• Rapid changes in refraction.
• Fixed spot in the visual field.
• Altered colours ( white objects appear yellowish)
• Not associated with pain, discharge or redness of
the eye
 Signs
• Reduced acuity.
• An abnormally dim red reflex is seen when the eye is
viewed with an ophthalmoscope.
• Black opacity in the red background with
ophthalmoscope.
• Reduced contrast sensitivity can be measured by the
ophthalmologist.
• Only sever dense cataracts causing severely impaired
vision cause a white pupil.
• After pupils have been dilated, slit lamp examination
shows the type of cataract.
 Gradual loss of vision
• Painless Progressive Loss of Vision
The common causes of painless progressive loss of vision are:

• •• Senile cataract
• •• Open angle glaucoma
• •• Presbyopia
• •• Degenerative myopia
• •• Retinitis pigmentosa
• •• Diabetic retinopathy
• •• Hypertensive retinopathy
• •• Age-related macular degeneration (ARMD)
• •• Vitamin A deficiency
• •• Papilledema [due to intracranial space-occupying lesions (SOL)].
 DD of leucocoria: (white papillary
reflex)
• Mature or advanced cataract / congenital
cataract
• Retinoblastoma
• Endophthalmitis
• Persistent hyperplastic primary vitreous
• Retrolental fibroplasias (ROP)
• Large coloboma of fundus
• Coat’s disease
• Retinal dysplasia
 PREOPERATIVE ASSESSMENT OF A
PATIENT WITH CATARACT
• A general medical review

• A history of cardiac, pulmonary, or cerebrovascular events,

especially recent. It is better to wait for cardiovascular stability as
determined by a physician.
• Congestive cardiac failure - Osmotic diuretics like mannitol are
generally contraindicated.
• Emphysema or chronic bronchitis and asthma require special
attention to optimize the airway patency for patient and surgeon
comfort.
• Systemic examination is done for diabetes mellitus, ischaemic heart
disease, systemic hypertension and gross focal sepsi affect the
course of surgery and the post-operative outcome.
• Thyroid .
• Genito-urinary problems (urinary tract infection) -
require treatment before surgery.
• Prostatism is not a contraindication.
• Parkinson’s disease and other involuntary movement
disorders involving the head, face and lids,
• communication disorders, and excessive fear or
anxiety.
• Orthopnoea
• or severe kyphosis or scoliosis , head tremor may make
optimal positioning of the patient on the operating
table difficult.
 Ocular examination with
• pencil torch, diffuse illumination and dark
room.
• Visual acuity.
• Slit lamp examination
• Ophthalmoscopic examination in a dilated
pupil ( Direct and Indirect ophthalmoscope)
• To exclude abnormality in the lids ,
conjunctiva , cornea , AC , iris , pupil , eyeball ,
lens , vitreous and retina
Examination of the eye is done carefully
• i. Pupillary reactions—The normal functions of optic
nerve and retina are assessed.
• ii. Visual acuity and projection of rays indicate retinal
function.
• iii. Intraocular pressure is recorded to rule out
glaucoma.
• iv. Patency of lacrimal apparatus is tested to exclude
chronic dacryocystitis.
• Fundus examination is done in both eyes to detect any
retinal diseases.
• 4. When fundus cannot be seen, the following tests are done to find out the
condition of posterior segment,
• I. Projection of light—This test is of utmost importance. The test is done in a dark
room with one eye covered. Patient is asked to look straight ahead. Light is thrown
from various directions and the patient points the correct direction.

• II. Macular function test

• i. Two point discrimination test—Patient looks through an opaque disc perforated
in the centre with two pinholes close together. If the central area of retina is good,
the patient appreciates the two lights.
• ii. Maddox rod test—Patient looks at a distant light through the Maddox rod. The
macular function is good if the red line is straight and unbroken.
Two point discrimination test
Maddox rod test
• iii. Entoptic view of the retina—
The eyes are closed and globe is firmly massaged through the lower lid
with a bare lighted bulb of a torch. The patient sees the vascular tree of
the retina on an orange background. Any blanks or scotomas are noted.
• iv. Foveal electroretinogram (ERG)—
It indicates the condition of fovea and macula.
• v. Ultrasonic investigation by B-scan—
Retinal detachment and vitreous pathology may be detected.
• vi. Laser interference fringes—
Postoperative visual acuity is assessed by focusing light beams from two
sources (helium—neon) which overlap equally posterior to the plane of
the lens.
• vii. Photo stress test—
The eye is exposed to bright light for 15 seconds and recovery time is
noted. In macular disease, recovery time is prolonged.
 General investigations prior to
surgery

• Blood pressure
• Blood sugar
• HIV, Hepatitis B & C
• Conjunctival swab for culture and sensitivity
test
• Operation should not be performed in presence of any pathogenic
organism. The value of conjunctival swab culture is doubtful, since
the conjunctival sac can harbor organisms during the period,
between the reporting time and day of operation.

• Most of the surgeons do not advise conjunctival swab culture, and

as a routine, advise to use antibiotic drops and ointment into the
conjunctival sac for a few days prior to operation.

• ECG
• Sac patency test
• Biometry - for calculating the power of intraocular lens.
 Indications for surgery
• 1• Visual improvement is by far the most common
indication for cataract surgery. Operation is indicated
when the opacity develops to a degree sufficient to
cause difficulty in performing essential daily
activities.
• 2• To prevent complications - in which a cataract is
adversely affecting the health of the eye, for example
phacolytic or phacomorphic glaucoma;
• 3• Clear lens exchange usually definitively addresses
primary angle closure, but less invasive options are
generally preferred
• 4• Clear lens exchange (replacement of the
healthy lens with an artificial implant) is an
option for the management of refractive error.
• 5• Cataract surgery to improve the clarity of
the ocular media may also be required in the
context of monitoring or treatment of fundus
pathology.
• 6• Cosmetic purpose
 Treatment
• Drug? NO USE
• Refraction for early cases.
• Operation: the only effective therapy
 Management

• Early cataract :
• Glasses:
• -Refraction and glasses
• -Dark glasses or photochromatic
glasses for nuclear cataract
• -Rule out other causes of visual
diminution
• Surgical removal: -If BCVA not to patient’s
satisfaction, then operate.
• Atropine
 Definite Treatment
• Surgical techniques
• An increasing variety of cataract extraction
methods are being employed depending on
the:
– Needs of the patient,
– Availability of the changing technology, and
– Training of the surgeon.
• Types:
• Intracapsular cataract extraction (ICCE)
• Extracapsular cataract extraction (ECCE)
– Conventional ECCE
– Small Incision Cataract Surgery
– Phacoemulsification
– Femto laser cataract surgery
– Lens aspiration in paediatric (soft) cataract
• Intraocular lens implantation with any of the
above techniques.
 Treatment
• IOL (intraocular lens) implantation
– AC and PC
– Hard and foldable
 Before IOL implantation was
developed
• Aphakic spectacles
• Contact lenses
 Aphakia
• A- absence
• Phakia – lens
• Literally, ‘aphakia’ means absence of the crystalline lens from the eyeball.
• Optically, it means absence of the crystalline lens from its normal
anatomical position in the pupillary area (patellar fossa).

Etiology
• Congenital: Rare
– „
Primary: It is resulting from failure of the development of the lens in fetal life.
– „
Secondary: The lens forms, but gets absorbed in utero due to some factors.
• Acquired
• „
. Post-operative (most common): Following
cataract surgery [needling, intracapsular cataract extraction (ICCE) or
extracapsular cataract extraction (ECCE)].
• „
. Post-traumatic: Following blunt or penetrating injury of the eye. It
includes subluxation or dislocation of the lens.
• .„Post-inflammatory: Following large
perforated corneal ulcer.
• „. Couching: An ancient surgery (still practised
by some quacks), where the lens is forcibly
dislocated into the vitreous by a needle via
limbus.
• Optics
The optical condition of the aphakic eye is
• Optical Defects
Acquired high hypermetropia: Crystalline lens contributes +15D
to +20D in the normal eye.
Astigmatism against the rule: Since, the cornea is flatter in
vertical meridian, and it is due to contracture or fibrosis of the
limbal scar. The amount of astigmatism is +1.0 to +3.0D initially, but
gradually diminishes.
Absence of accommodation.
Change in color vision: Due to increased entry of infrared or
ultraviolet rays into the eye, which are normally absorbed by the
crystalline lens.
 Clinical Features
History
• „. Blurred vision for distance and near.
• „. History of cataract operation in most cases.
Signs: Following a standard cataract surgery.
• „. Vision (unaided)—only finger counting at 2–3 ft. Patient
may have thick convex glasses, or if recently operated, using
dark glasses.
• „. Sutures may be visible at the upper limbus.
• „. Linear scar at the upper limbus.
• .„Anterior chamber: Deep (as the iris recedes back in
absence of the lens).
• „. Iris: (1) Iridodonesis or tremulousness of iris due to loss of
support from the lens. (2) Peripheral button-hole
iridectomy (PI) mark
• „. Pupil: Jet black reflex (due to loss of reflection of light rays
from the anterior surface of the lens).
• „. Absence of 3rd and 4th Purkinje images (in ICCE) and only
absence of 3rd image (in ECCE).
• „. Retinoscopy: Reveals high hypermetropia and
astigmatism.
• „
. Ophthalmoscopy: As in hypermetropic fundus with a
small optic disc.
 Complication of aphakia
• High hypermetropia
• Aphakic glaucoma
 Treatment
• Correction of aphakia:

– Frame glasses
– Contact lens
– IOL
– Laser
 TREATMENT OF APHAKIA
• 1. Correction by Spectacles
• Aphakia is treated by prescribing suitable spherical convex lens (+ 10 D
approximately) and convex cylindrical lens (+1 to +2D at 180°) 6 weeks after the
operation, i.e. when the corneo-scleral scar has healed completely and the
refraction has become stable.
• Advantages
• It is cheap, easy to handle and readily available.
• Disadvantages
• • They are heavy and give a cosmetically poor appearance.
• • There is 25% retinal image magnification hence it causes diplopia in unilateral
aphakia.
• • Spherical aberration can cause ‘pin-cushion’ effect. There may be chromatic
aberration. This leads to visual distortion.
• • There is ‘jack in the box’ ring scotoma and reduction in peripheral visual field.
• • Physical invonvenience and cosmetic deficiency are usually present.
• 2. Contact Lens
• Advantage
• There is minimum retinal image magnification therefore it is
specially useful in case of unilateral aphakia. It also looks good
cosmetically.
• Disadvantages
• • Daily cleaning and maintenance is essential.
• • Their insertion and removal is cumbersome.
• • Corneal epithelial oedema, erosion and vascularization may occur
due to hypoxia
• • Conjunctivitis, intolerance and foreign body sensation are
common complaints.
• • Loss, breakage and deterioration of the contact lens leads to
financial loss.
• 3. Intraocular Lens (IOL) Implant
• This is also known as ‘pseudophakia’. The modern trend is in favour
of posterior chamber IOL implantation as it offers best optical
rehabilitation following removal of a cataractous lens.
• Advantages
• There is minimum retinal image magnification and early return of
binocular vision. It also has cosmetic advantage.
• Complications
• • Pupillary block glaucoma may result in raised tension.
• • Dislocation of IOL may occur in the vitreous or anterior chamber.
Sunset phenomenon occurs when posterior chamber IOL dislocates
inferiorly.
• • Cystoid macular oedema, maculopathy and iridocyclitis.
• • Corneal endothelial dystrophy may occur with anterior chamber
• Biometry: The calculation of required IOL
power
• Keratometry (K) (corneal curvature)
• Axial length (AL) of eye (ultrasound)
• IOL power= A constant-2.5xAL-0.9K
• Eg: 118-2.5x 24-0.9x45=17.5 dioptres
IOL power
 Steps of SICS
• 1. Sclero-corneal tunnel incision—It consists of three components:
• • Extenral scleral incision: A 1/3 or 1/2 thickness external groove is
made 1.5 - 2 mm behind the limbus. It varies from 5.5 - 7 mm in
length depending on the size of the nucleus. It may be straight or
semi-circular in shape.
• • Sclero-corneal tunnel: It is made with a crescent knife. It usually
extends 1 - 1.5 mm into the clear cornea.
• • Internal corneal incision: It is made with a sharp 3.2 mm angled
keratome.
• 2. Side-port entry is made at 9 O’ clock position with a Stiletto or
MVR (micro vitreal retinal) blade.
• A valvular self sealing incision about 1 mm wide is made at the
limbus. This helps in aspiration of the sub-incisional cortex and
increasing the depth of anterior chamber.
• 3. Anterior capsulotomy—It can be either a ‘can-opener’, envelop shaped
or continuous circular capsulotomy (CCC). However, a large sized CCC is
preferred.
• 4. Hydrodissection is essential to separate cortico-nuclear mass from the
posterior capsule.
• 5. Removal of nucleus
• i. Prolapse of nucleus from the capsular bag into the anterior chamber is
done during hydrodissection and completed by rotating the nucleus with
Sinskey’s hook.
• ii. Delivery of nucleus through the corneo-scleral tunnel is done by
• • Irrigating wire vectis method. It is used most commonly
• • Phacofracture technique
• • Phaco-sandwitch technique
• • Fish hook
• • Visco expression.
• 6. Aspiration of the cortex is done by a two way
irrigation and aspiration cannula from the main incision
and side port entry.
• 7. A posterior chamber IOL is implanted in the capsular
bag after filling it with viscoelastic substance (OVD).
• 8. Viscoelastic substance is then removed thoroughly
from the anterior chamber and capsular bag with the
help of a two way irrigation aspiration cannula.
• 9. Wound closure—The anterior chamber is deepened
with balanced salt solution or Ringer’s lactate (through
side port entry). This results in self sealing the valvular
incision. The conjunctival flap is reposited
Difference between SICS and Phaco
 Advantages of Phacoemulsification
• 1. Intraoperatively, phacoemulsification allows excellent
control of each phase of the operation for cataract removal.
• 2. The small incision technique involving a self-sealing ‘no
stitch’ or ‘sutureless’ incision produces very secure and stable
wound. There is rapid wound healing and shorter
convalescence.
• 3. Removal of the nucleus occurs through a continuous
circular capsulotomy (CCC) with the closed chamber.
Aspiration of the cortex also occurs within a closed anterior
chamber, with low risks of damaging the endothelium, iris and
posterior chamber.
• 4. Phacoemulsification and small incision surgery are
compatible with small size implants, i.e. foldable lenses. There
is minimum or no astigmatism with early return of binocular
vision.
Disadvantages of Phacoemulsification
• 1. It is a difficult technique to master.
• 2. It requires expensive instrumentation.
Complications of cataract surgery
• Preoperative (anaesthesia related)
– Retrobulbar hemorrhage
– Improper akinesia
– Drug reactions
• Intraoperative
– Incision related complications - ragged incision , pre
mature entry , button hole deformity.
– Iridodialysis
– Posterior capsular rupture
– Zonular dehisence
– Vitreous loss , positive vitreous pressure
– Nuclear drop
– Posterior loss of lens fragments
– Injury to the cornea, iris and lens
– Expulsive supra choroidal haemorrhage
• Early post operative complications
– Hyphaema
– Wound leak shallow AC
– Iris prolapse
– Striate keratopathy and corneal oedema
– Retained lens matter
– Secondary glaucoma
– Postoperative anterior uveitis
– Wound infection , Bacterial endophthalmitis
• Intermediate and Late postoperative complications
– Astigmatism
– Corneal oedema / Pseudophakic bullous keraopathy
– Pigment over IOL
– Posterior synechiae and pupil / iris capture
– Updrawn pupil , iris prolapse
– Cystoid macular edema
– Retinal detachment
– Delayed postoperative endophthalmitis
– Malposition of IOL - sunset or sunrise syndrome
– UGH syndrome ( uveitis , glaucoma , hyphaema syndrome)
– After cataract
• Soemmering’s ring
• Elschnig’s pearls
 Paediatric cataract
• Treatment: is surgical
• Indications of Surgery
• About 50% of the opacities do not progress or
interfere with vision and can safely be ignored.
• If the opacity is partial with useful vision,
surgery should better not to be considered.
• All dense cataracts (unilateral or bilateral) and
partial cataracts with vision less than 6/18, are
to be operated as early as possible.
• Other modes of treatment
• •• Mydriatics: For axial cataract, and with
convex glasses to maintain near vision.
• •• Optical iridectomy for axial cataract and if
the opacity is stationary. It is obsolete now-a-
days.
• Timing of Surgery:
• Timing is important. Visually significant cataract
should be removed immediately. Because dense
cataract can cause stimulation deprivation
amblyopia.
• The requirement for urgent surgery is balanced
by the fact that the earlier this takes place,
particularly before 4 weeks of age, the higher the
chance of glaucoma developing during the
juvenile years.
• • Bilateral dense cataracts require surgery
between 4–10 weeks of age to prevent the
development of stimulus deprivation amblyopia.
If severity is asymmetrical, the eye with the more
dense opacity should be addressed first.
• • Bilateral partial cataracts may not require
surgery until later, or indeed at any stage. In cases
of doubt it may be prudent to defer surgery in
favour of careful monitoring. .
• • Unilateral dense cataract merits more urgent
surgery; there is no consensus regarding timing
except that 6 weeks is the latest point at which
elective surgery should be performed. Many
authorities would advocate surgery between 4
and 6 weeks, followed by aggressive anti-
amblyopia therapy, despite which results are
often disappointing. If the cataract is detected
after 16 weeks of age then the visual prognosis is
particularly poor
• • Partial unilateral cataract can usually be
observed or treated non-surgically with
pupillary dilatation and possibly part-time
contralateral occlusion.
• Anaesthia: G.A with low I.O.P
• Surgery: (Approach differs from adults)
• Incisions – limbal or pars plana)
• Lensectomy and anterior vitrectomy
• Anterior capsulonluxis, aspiration of cortical
matter and posterior capsulorhexis
• Phaco-aspiration and anterior vitrectomy
• Visual rehabilitation:
• Most important is prevent amblyopia in a child
• Spectacles – Not for unilateral cataract
• Contact lens- Soft silicon extended wear contact
lens
• good upto 2 years of age
•
• Intraocular lenses: P.C. IOL - good after 5 yrs. of
age
• Keratorefractive surgery – epikeratophakia
 Questions
• What is cataract?
• Classify cataract?
• Causes of cataract?
• Treatment of congenital cataract?
• Differentiate immature, mature and hypermature cataract.
• Evaluation before cataract surgery.
• Treatment of cataract.
• Most common cataract surgery.
• Advantage disadvantage of each surgery.
• Complication of cataract surgery.
• Endophthalmitis , panophthalmitis
• Advantage of IOL implantaion
• Disadvantage of aphakia.
• Type of IOL.
• What is aphakia? Sign , optical status ?
Cataract must be answered in exam in toto

If

Failed to do so….. then

Good luck and thank you