CHAPTER I

INTRODUCTION

The crystalline lens is a remarkable structure that in its normal state functions to
bring images into focus on the retina. Symptoms associated with lens disorders are
primarily visual. The lens is best examined with the pupil dilated. A magnified view
of the lens can be obtained with a slitlamp or by using the direct ophthalmoscope with
a high plus (+10) setting. 1
The lens is a vital refractive element of the human eyes. 2 Presbyopic symptoms
are due to decreased accommodative ability with age and result in diminished ability
to perform near tasks. Loss of lens transparency results in blurred vision (without
pain) for both near and distance. If the lens is partially dislocated (subluxation) due to
congenital, developmental, or acquired causes, visual blur can be due to a change in
refractive error. In 2002, the World Health Organization estimated that lens pathology
(cataract) was the most common cause of blindness worldwide, affecting over 17
million people across the globe. Senile cataract is a vision-impairing

disease

characterized by gradual, progressive thickening of the lens. It is one of the leading

causes of blindness in the world today. 1,2
In Indonesia cataract becomes the first rank that cause blindness. Of course
blindness will reduce productivity and cause many impairment to the patient. Cataract
surgery is available in Indonesia but low vision associated with cataracts may still be
prevalent, as a result of long waits for operations and barriers to surgical uptake, such
as cost, lack of information and transportation problems.

CHAPTER II
LITERATURE REVIEW

2.1 Anatomy of the Lens

The lens is located behind the iris and pupil in the anterior compartment of the
eye. The anterior surface is in contact with the aqueous on the corneal side; the
posterior surface is in contact with the vitreous. The anterior pole of the lens and
the front of the cornea are separated by approximately 3.5mm.2
The lens is held in place by the zonular fibers (suspensory ligaments), which run
between the lens and the ciliary body. These zonular fibers, which originate from
the region of the ciliary epithelium, are a series of fibrillin-rich fibers that
converge in a circular zone on the lens. Both an anterior and a posterior sheet
meet the capsule 12mm from the equator and are embedded into the outer part
of the capsule (12m deep). It also is thought that a series of fibers meets the
capsule at the equator. 2

Fig. 1 Gross anatomy of the adult human lens

2.2 Cataract
A. Definition
The crystalline lens is a remarkable structure that in its normal state functions to
bring images into focus on the retina. Because the lens is avascular and has no
innervation, it must derive nutrients from the aqueous humor. 1
A cataract is present when the transparency of the lens is reduced to the point
that the patients vision is impaired. The term cataract comes from the Greek
word katarraktes (downrushing; waterfall).3 A cataract

is any opacity or

discoloration of the lens, whether a small, local opacity or the complete loss of
transparency. These zones of opacity may be subcapsular, cortical, or nuclear
and may be anterior or posterior in location. In addition to of the nucleus and
cortex, there may be a yellow or amber color change to the lens. 4
A senile cataract, occurring in the elderly, is characterized by an initial
opacity in the lens, subsequent swelling of the lens and final shrinkage with
complete loss of transparency.

Fig. 2 Normal lens and lens with cataract

B. Epidemiology

Age-related cataract is a common cause of visual impairment and responsible for

48% of world blindness, which represents about 18 million people, according
to the World Health Organization (WHO). In 2002, the World Health
Organization calculated that the number of visually impaired people worldwide
was in excess of 161 million. Cataract is the leading cause, accounting for 47.8%
of all cases. Over the next 20 years it is estimated that the worlds population
will increase by about one third, this growth occurring predominantly in
developing countries. During the same period, the number of people over the age
of 65 years will more than double. 2 The Beaver Dam Eye Study reported that
38.8% of men and 45.9% of women older than 74 years had visually significant
cataracts.5
Developing countries also face other challenges such as poor uptake of services
because of a lack of patient information, misinformation from traditional healers,
superstition, poor quality of services, monetary costs, distance to services, and
the need for an escort. Even where facilities are available, there is often a lack of
surgeons, instruments, and other equipment (exacerbated by poor maintenance),
and a shortage of consumables and medications. Developing intraocular lens
manufacturing facilities in these countries (such as the Fred Hollows Foundation
in Eritrea and Nepal), will reduce costs and improve access to surgery. 2
C. Etiology
The etiology of cataract that are :
1

Old age (commonest)

Associated with other ocular and systemic diseases (diabetes, uveitis, previous
ocular surgery)

Associated with systemic medication (steroids, phenothiazines)

Trauma and intraocular foreign bodies

Ionizing radiation (X-ray, UV)

Congenital (dominant, sporadic or part of a syndrome, abnormal galactose

metabolism, hypoglycaemia)

Associated with inherited abnormality (myotonic dystrophy, Marfan's

syndrome, Lowe's syndrome, rubella, high myopia)
D. Classification
The following is a classification of the various types of cataracts.

a) Time of occurrence
Classification of cataract according to time of occurence
1) Acquired cataract

Senile cataract (< 50 years old)

Cataract with systemic disease

Bilateral cataracts may occur in association with the following systemic
disorders: diabetes mellitus, hypocalcemia (of any cause), myotonic
dystrophy, atopic dermatitis, galactosemia, and Lowe's, Werner's, and Down's
syndromes. 1

Secondary and complicated cataracts

Cataract may develop as a direct effect of intraocular disease upon the
physiology of the lens (eg, severe recurrent uveitis). The cataract usually
begins in the posterior subcapsular area and eventually involves the entire
lens structure. Intraocular diseases commonly associated with the
development of cataracts are chronic or recurrent uveitis, glaucoma, retinitis
pigmentosa, and retinal detachment. These cataracts are usually unilateral.
The visual prognosis is not as good as in ordinary age-related cataract.1

Postoperative cataract
After-cataract denotes opacification of the posterior capsule following
extracapsular cataract extraction. Persistent subcapsular lens epithelium may
favor regeneration of lens fibers, giving the posterior capsule a "fish egg"

appearance (Elschnig's pearls). The proliferating epithelium may produce

multiple layers, leading to frank opacification. These cells may also undergo
myofibroblastic differentiation. Their contraction produces numerous tiny
wrinkles in the posterior capsule, resulting in visual distortion. All of these
factors may lead to reduced visual acuity following extracapsular cataract
extraction. 1

Traumatic Cataract
Traumatic cataract is most commonly due to a foreign body injury to the lens
or blunt trauma to the eyeball. Air rifle pellets and fireworks are a frequent
cause; less-frequent causes include arrows, rocks, contusions, overexposure
to heat ("glassblower's cataract"), and ionizing radiation. Most traumatic
cataracts are preventable. In industry, the best safety measure is a good pair
of safety goggles. 1

Toxic cataract
Corticosteroids administered over a long period of time, either systemically
or in drop form, can cause lens opacities. Other drugs associated with
cataract include phenothiazines, amiodarone, and strong miotic drops such as
phospholine iodide. 1
2) Congenital cataract 6

Hereditary cataract

Cataract due to early embryonic (transplasental) damage

b) Morphology
Nuclear
The normal condensation process in the lens nucleus results in nuclear
sclerosis after middle age.1
Subcapsular
Posterior subcapsular cataracts are located in the cortex near the central
posterior capsule. They tend to cause visual symptoms earlier in their

development owing to involvement of the visual axis. Common symptoms

include glare and reduced vision under bright lighting conditions. This lens
opacity can result also from trauma, corticosteroid use (topical or systemic),
inflammation, or exposure to ionizing radiation. 1
Kortical
Cortical cataracts are opacities in the lens cortex. Changes in the hydration of
lens fibers create clefts in a radial pattern around the equatorial region. They
also tend to be bilateral, but they are often asymmetric. Visual function is
variably affected, depending on how near the opacities are to the visual axis.1
c) Maturity
Insipien : An incomplete cataract where the lens is only slightly opaque and
the cortex is clear, usually at the anterior or posterior cortex.
Immature : More opaque, still with transparent part of the lens.
Mature : The lens is diffusely white, complete opacification of the cortex. A
yellow lens nucleus is often faintly discernible.
Hypermature : A mature cataract progresses to the point of complete
liquification of the cortex. 6
E. Pathogenesis
The pathogenesis of cataracts is not completely understood. However,
cataractous lenses are characterized by protein aggregates that scatter light rays
and reduce transparency. Other protein alterations result in yellow or brown
discoloration. Additional findings may include vesicles between lens fibers or
migration and aberrant enlargement of epithelial cells. Factors thought to
contribute to cataract formation include oxidative damage (from free radical
reactions), ultraviolet light damage, and malnutrition. 1
The pathophysiology behind senile cataracts is complex and yet to be fully
understood. In all probability, its pathogenesis is multifactorial involving

complex interactions between various physiologic processes. As the lens

ages, its weight and thickness increases while its accommodative

power

decreases. As the new cortical layers are added in a concentric pattern, the
central nucleus is compressed and hardened in a process called nuclear
sclerosis. Multiple mechanisms contribute

to the progressive

loss of

transparency of the lens. The lens epithelium is believed to undergo agerelated changes, particularly a decrease in lens epithelial cell density and an
aberrant differentiation
cataractous

of lens fiber cells. Although the epithelium

lenses experiences

of

a low rate of apoptotic death, which is

unlikely to cause a significant decrease in cell density, the accumulation of

small scale epithelial losses may consequently result in an alteration of lens
fiber formation and homeostasis,

ultimately leading to loss of lens

transparency. Furthermore, as the lens ages, a reduction in the rate at which

water and, perhaps, water-soluble low- molecular weight metabolites can
enter the cells of the lens nucleus via the epithelium and cortex occurs with
a subsequent

decrease in the rate of transport of water, nutrients, and

antioxidants. Consequently, progressive oxidative damage to the lens with

aging takes place, leading to senile cataract development.
7

F. Clinical
History
Careful history taking is essential in determining the progression and functional
impairment in vision resulting from the cataract and in identifying other possible
causes for the lens opacity. A patient with senile cataract often presents with a
history of gradual progressive deterioration and disturbance in vision. Such
visual aberrations are varied depending on the type of cataract present in the
patient. 7

Decreased visual acuity : Decreased visual acuity is the most common

complaint of patients with senile cataract. The cataract is considered
clinically relevant if visual acuity is affected significantly. Furthermore,
different types of cataracts produce different effects on visual acuity. For
example, a mild degree of posterior subcapsular cataract can produce a
severe reduction in visual acuity with near acuity affected more than distance
vision, presumably as a result of accommodative miosis. However, nuclear
sclerotic cataracts often are associated with decreased distance acuity and
good near vision. A cortical cataract generally is not clinically relevant until
late in its progression when cortical spokes compromise the visual axis.
However, instances exist when a solitary cortical spoke occasionally results
in significant involvement of the visual axis. 7

Glare : Increased glare is another common complaint of patients with senile

cataracts. This complaint may include an entire spectrum from a decrease in
contrast sensitivity in brightly lit environments or disabling glare during the
day to glare with oncoming headlights at night. Such visual disturbances are
prominent particularly with posterior subcapsular cataracts and, to a lesser
degree, with cortical cataracts. It is associated less frequently with nuclear

sclerosis. Many patients may tolerate moderate levels of glare without much
difficulty, and, as such, glare by itself does not require surgical management.
Myopic shift : The progression of cataracts may frequently increase the
diopteric power of the lens resulting in a mild- to-moderate degree of myopia
or myopic shift. Consequently, presbyopic patients report an increase in their
near vision and less need for reading glasses as they experience the so-called
second sight. However, such occurrence is temporary, and, as the optical
quality of the lens deteriorates, the second sight is eventually lost.Typically,
myopic shift and second sight are not seen in cortical and posterior
subcapsular cataracts. Furthermore, asymmetric development of the lensinduced myopia may result in significant symptomatic anisometropia that
may require surgical management.
Monocular diplopia : At times, the nuclear changes are concentrated in the
inner layers of the lens, resulting in a refractile area in the center of the lens,
which often is seen best within the red reflex by retinoscopy or direct
ophthalmoscopy. Such a phenomenon may lead to monocular diplopia that is
not corrected with spectacles, prisms, or contact lenses.
Physical
After a thorough history is taken, careful physical examination

must be

performed. The entire body habitus is checked for abnormalities that may point
out systemic illnesses that affect the eye and cataract development.
A complete ocular examination must be performed beginning with visual
acuity for both near and far distances. When the patient complains of glare,
visual acuity should be tested in a brightly lit room. Contrast sensitivity also
must be checked, especially if the history points to a possible problem. 7
Examination of the ocular adnexa and intraocular structures may provide
clues to the patient's disease and eventual visual prognosis.

 A very important test is the swinging flashlight test which detects for a
Marcus Gunn pupil or a relative afferent pupillary defect (RAPD) indicative
of optic nerve lesions or diffuse macular involvement. A patient with RAPD
and a cataract is expected to have a very guarded visual prognosis after
cataract extraction. A patient with long-standing ptosis since childhood may
have occlusion amblyopia, which may account more for the decreased visual
acuity rather than the cataract. Similarly, checking for problems in ocular
motility at all directions of gaze is important to rule out any other causes for
the patient's visual symptoms.
Slit lamp examination should not only concentrate on evaluating the lens
opacity but the other ocular structures as well (eg, conjunctiva, cornea, iris,
anterior chamber). Corneal thickness and the presence of corneal opacities,
such as corneal guttata, must be checked carefully. Appearance of the lens
must be noted meticulously before and after pupillary dilation. The visual
significance of oil droplet nuclear cataracts and small posterior subcapsular
cataracts is evaluated best with a normal-sized pupil to determine if the
visual axis is obscured. However, exfoliation syndrome is appreciated with
the pupil dilated, revealing exfoliative material on the anterior lens capsule.
After dilation, nuclear size and brunescence as indicators of cataract density
can be determined prior to phacoemulsification surgery. The lens position
and integrity of the zonular fibers also should be checked because lens
subluxation may indicate previous eye trauma, metabolic disorders, or
hypermature cataracts.
The importance of direct and indirect ophthalmoscopy in evaluating the
integrity of the posterior pole must be underscored. Optic nerve and retinal
problems may account for the visual disturbance experienced by the patient.
Furthermore, the prognosis after lens extraction is affected significantly by

detection of pathologies in the posterior pole preoperatively (eg, macular

edema, age-related macular degeneration).
G.Treatment
Cataract surgery has undergone dramatic change during the past 30 years with
the introduction of the operating microscope and microsurgical instruments, the
development of intraocular lenses, and alterations in techniques for local
anesthesia.

Further

refinements

continue

to

occur,

with

automated

instrumentation and modifications of intraocular lenses allowing surgery through

small incisions. 1
a) Intracapsular cataract extraction
Consisting of removal of the entire lens together with its capsule, is rarely
performed today. The incidence of postoperative retinal detachment and
cystoid macular edema is significantly higher than after extracapsular
surgery, but intracapsular surgery is still a useful procedure, particularly
when facilities for extracapsular surgery are not available.

Fig 3. Intracapsular cataract extraction

b) Extracapsular cataract extraction

The generally preferred method of cataract surgery in adults and older

children preserves the posterior portion of the lens capsule and thus is
known as extracapsular cataract extraction. Intraocular lens implantation is
part of this procedure. An incision is made at the limbus or in the peripheral
cornea, either superiorly or temporally. An opening is formed in the anterior
capsule, and the nucleus and cortex of the lens are removed. The intraocular
lens is then placed in the empty "capsular bag," supported by the intact
posterior capsule. In the nuclear expression form of extracapsular cataract
extraction, the nucleus is removed intact, but this requires a relatively large
incision. The cortex is removed by manual or automated aspiration.
c) The technique of phacoemulsification is now the most common form of
extracapsular cataract extraction. 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 approximately 3 mm. This same incision
size is then adequate for insertion of foldable intraocular lenses. If a rigid
intraocular lens is used, the wound needs to be extended to approximately 5
mm. The advantages of small-incision surgery are more controlled operating
conditions, avoidance of suturing, rapid wound healing with lesser degrees
of corneal distortion, and reduced postoperative intraocular inflammation all
contributing to more rapid visual rehabilitation. The phacoemulsification
technique does, however, entail a higher risk of posterior displacement of
nuclear material through a posterior capsular tear, which generally
necessitates complex vitreoretinal surgery.

Fig 4 Phacoemulsification surgery

d) Neodymium:YAG laser
After all forms of extracapsular cataract surgery, there may be secondary
opacification of the posterior capsule that requires discission using the
neodymium:YAG laser.
H.Prognosis
In the absence of any other accompanying ocular disease prior to surgery, which
would affect significantly the visual outcome, such as macular degeneration or
optic

nerve atrophy, a

successful uncomplicated standard ECCE

or

phacoemulsification carries a very promising visual prognosis of gaining at least

2 lines in the Snellen distance vision chart. The main cause of visual morbidity

postoperatively is CME. A major risk factor affecting visual prognosis is the

presence of diabetes mellitus and diabetic retinopathy.

CHAPTER III
CASE

1. Patient identity
Name

: Mr. AH

Sex

: Male

Age

: 63 years old

Address

: Jl. Adi Sucipto Gg. Transmigrasi

Ethnic

: Melayu

Religion

: Moslem

Patient was examined on May 18st, 2015

2. Anamnesis
a. Main complaint: blurred vision in both eyes.
b. History of disease :
Patient came to hospital with major complaint of blurred vision in
his right eye. This complaint is getting worsened since the last 8 months.
Blurred vision is felt continuously throughout the day, especially when
viewing a far object. Patients also complain of glare when he saw light
during day time. red eye (-), pain (-), watery eyes (-), itching (-), out dirt
tear (-), diplopia (-), photopsia (-). The patient confessed that he had gone
to the primary care clinics to treat this complain and was given eye drops,
but it wasnt helping too much and his complaint is getting worsened.
The patient was then complained his left eye also began to blur
since six months ago, which distrubed his daily activity. Therefore, the
patient comes to seek medical help in Universitas Tanjungura Hospital on
May 18, 2015.
c. Past clinical history:
Hypertension (+)
Diabetes mellitus was denied
16

 He also disclaim about another eyes disease, systemic disease and

another disease because he never did a medical check up.
d. Family history : He diclaim that his family didnt have same complaint
with him and didnt have another disease.
3. General Physical Assessment
General condition

: Good

Awareness

: Compos mentis

Vital Signs:
Heart Rate

: 64x/minute

Respiration freq.

: 20x/minute

Blood Pressure

: 140/90 mmHg

Temperature

:-

4. Ophthalmological Status
Visual acuity:
a. OD
b. OS

: 1/300
: 1/300

OD

OS

Right Eye

Left Eye

Ortho

Eye Ball Position

Ortho

Ptosis (-), Lagostalmus(-)

Palpebra

Ptosis
Lagostalmus(-)

Normal, injeksi (-)

Conjungtiva

Normal, injeksi (-)

Clear

Cornea

Clear

(-),

17

Iris Colour: Brown

Iris

Isocor

Iris Colour: Brown

Isocor

Pupil

Light reflex (+)

Light reflex (+)

Opacity

Lens

Opacity

Positive (-)

Shadow Test

Positive (-)

Eye ball movement

OS
+

OD
+
+

Intraocular pressure (tonometry) : -

5. Resume
A man, 63 years old, complained about his right eye that had blur vision
about 8 month ago and his left eye also had blur vision about 6 month ago,
and his vision was worsen day by day. He had no complain about pain, red
eyes, itchy, and discarge in his eyes. And he disclaimed about history of
trauma in his eyes.
He had hypertension. Visual acuity both of his eyes is 1/300. The lens both of
eyes are opacity. Funduscopy was inappreciable.

6. Diagnose
Working Diagnose:
Senile mature catarct ODS

18

 Hypertension grade I
Differential Diagnose:
Leucoria ODS
7. Plan for examination
-

Slit Lamp

Blood Sugar Level

Blood Pressure

8. Treatment:
-

ECCE and an Intraocular Lens (IOL)

Consult to interna, BP goal target before surgery is <140/90mmHg

Education for control blood pressure

9. Prognosis
Ad vitam

: Bonam

Ad functionam

: Dubia ad bonam

Ad sanactionam : Dubia ad bonam

19

CHAPTER IV
DISCUSSION

CHAPTER V
CONCLUSION

20

REFERENCES

21