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CataractOphthalmology|Fastbleep

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OphthalmologyArticles
Revision Notes
/ Biology Notes
/ Ophthalmology

Cataract
Written by: Tay Xue Chao, Brian Diaz from Manchester University,

Introduction
A cataract is opacity within the lens of the eye, and may affect either one or both eyes. The
opacity changes the transparency and refractive index of the lens, resulting in the blurring of a
persons vision. According to the World Health Organisation (WHO, 2007), cataracts account for
47.9% of blindness worldwide. The reported prevalence of childhood cataracts ranges from 115
per 10,000 children.

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TypesofCataract

Nuclear Cataract

This occurs at the centre of the lens, and

interferes with distance vision. It is the most
common type of cataract, and is usually the
result of advancing age.

Cortical Cataract

This begins at the outer rim of the lens, and

gradually works towards the centre of the
lens. It resembles the spokes of a wheel. It is
most commonly found in patients with
diabetes.

Subcapsular Cataract

This affects the back of the lens, causing

glare and blurring of vision. It is the most
rapidly progressing type of cataract. Risk
factors for the development of a
subcapsular cataract are use of steroids,
diabetes, and myopia.

Aetiology

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RiskFactors
The following are associated with acquired cataract in developed nations:

Age (above 60 years of age)

Smoking
Physical trauma
Alcohol consumption
Sunlight exposure
Low educational levels
Poor lifestyle habits inclusive of malnutrition and physical inactivity
Metabolic syndrome
Diabetes mellitus
Systemic corticosteroid use and possibly prolonged administration of high doses of
inhaled corticosteroids

Pathogenesis
The lens of the eye is composed of specialised cells arranged in a highly ordered and complex
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manner. These cells are stratified epithelia and have a very high content of cytoplasmic protein
the crystallins. These proteins, along with the complex structure, impart transparency to the
lens.

Unlike other epithelia, the lens does not shed nonviable cells. As such, it is particularly
susceptible to the degenerative effects of aging on cell structure. The exact pathogenetic
mechanisms of this are not known. It has, however been observed that most of the risk factors
identified are environmental stressors that lead to the formation of toxins or the impairment of
antioxidants.

ClinicalPresentation:SymptomsandSigns

Opacification of lens is painless, progressive, and highly variable

Often bilateral but asymmetrical
Common complaints include problems with night driving, reading road signs, and
reading fine print
"Myopic shift" (an increase in nearsightedness) happens prior to opacification of lens
Cataracts may present as immature (transmits red reflex), mature (does not transmit
red reflex), or hypermature (cortex of lens has liquefied and lens nucleus is mobile within
capsule)
Mature and hypermature cataracts can give rise to secondary glaucoma that is
associated with a red and painful eye (unlike many other glaucoma's)

With regards to the presentation of congenital cataracts:

Approximately onethird of congenital cataracts in children are inherited, one third are associated
with systemic diseases, and onethird are idiopathic or sporadic.

Parent's observation of cataract

Visual behaviour that deviates from normal
Asymmetry of red reflex identified on Bruckner testing (simultaneous red reflex test)
Leukocoria (white pupillary reflex)
Nystagmus
Strabismus (Squint)
Photophobia
Delayed development
Family history of hereditary cataracts
Genetic disorder associated with cataracts

Cataracts detected in infants and young children must be referred to a specialist as soon
as possible in order to allow for normal visual development and to prevent blindness.

DifferentialDiagnosis
Macular degeneration
Presbyopia
Retinal disease
Retinoblastoma (in children)

Diagnosis
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Slitlampexamination

The slit lamp is a binocular

microscope

Provides a three dimensional view of

the eye

A beam or "slit" of light is used as

opposed to diffuse light

Height and width can be adjusted

Anatomic features of the eye can be

accentuated

Provides greater magnification and

illumination than most handheld devices

Is used to diagnose a number of

traumatic and nontraumatic disorders,
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including cataract

Posteriorcapsularopacificationonretroilluminationwithslitlamp

Prevention

There is no proven therapy to prevent either cataract formation or its progression once it
has developed. However, the following have been observed to be of benefit in decreasing
risk:
Eating a healthy diet
Eating a diet rich in lutein and zeaxanthin
Smoking cessation
Postmenopausal oestrogen use (longer than 10 years)
Vitamin supplementation

Management

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Phacoemulsion

Most widely used

Most effective

Safest

The hard lens nucleus is liquefied by

an ultrasonic probe

Fragments are aspirated, along with

soft lens fibres

Replacement lens (folded) is placed

into empty capsular bag where it gradually
unfolds

The incision made through lens

capsule heals on its own

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Complicationsthatmayresultfromsurgery
Early complications

Late Complications

Rupture of posterior capsule (3%)

Trauma to iris
Prolapsed iris
Wound gape
Haemorrhage in anterior chamber
Rupture of lens capsule with loss of
vitreous
Vitreous haemorrhage
Choroidal haemorrhage
Postoperative endophthalmitis

Opacification of posterior capsule

(20%)
Cystoid macular oedema
Uveitis
Retinal detachment
Open and closed angle glaucoma
Agerelated macular degeneration

Postoperative thickening of the lens capsule frequently occurs over time causing gradual
deterioration of vision. This can be treated by splitting the capsule with a laser.

Prognosis
Postoperatively 95% of patients that have no other complications achieve a corrected acuity of
6/12.

The major risk factors that affect prognosis are diabetes and diabetic retinopathy. Diabetes
causes fluctuating blood glucose levels. Occasionally, high blood glucose levels cause
oedema and subsequent swelling of the lens. When the blood glucose diffuses, the swelling in
the lens also reduces. This repeated action causes cataracts.

In paediatric cataracts, visual acuities of 20/20 to 20/40 may be achieved if cataracts are
diagnosed and treated early.

Summary
Cataracts are lens opacities that can range in severity from unnoticed dots to total fogging of
vision. Cataracts are by far the commonest cause of preventable blindness worldwide.

Agerelated causes are most common, although there are also familial or congenital causes.
Gradual painless deterioration of vision is the most common symptom reported, with other
possible coexisting symptoms such as glare and problems with night driving dependent on the
type of cataract.

Early symptoms can be alleviated with spectacles, but to correct vision, surgery is required.
Surgery involves the insertion of an intraocular lens to replace the affected one. The exact
technique used is determined by the aetiology and density of the cataracts. Phacoemulsification
(a form of small incision surgery) is the most frequently used technique. Further investigations
such as blood glucose, serum calcium, and liver biochemistry should be considered in order to
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diagnose any possible underlying metabolic disorder.

It is also worth noting that cataracts may not always be bilateral, and hence, eyes may be
managed and treated individually according to the severity of the cataract within each eye.

Usefulresources
Websites:
http://www.cataractdoctor.com/
Videos:
http://www.careflash.com/video/cataracts (http://www.careflash.com/video/cataracts) (Cataracts
explained in lay terms)
http://www.rootatlas.com/wordpress/video/866/cartooncataractsurgeryvideo/
(http://www.rootatlas.com/wordpress/video/866/cartooncataractsurgeryvideo/)
(Cataract surgery, Phacoemulsification) My favourite!

References
Kumar and Clark Clinical Medicine 7th edition
UpToDate articles "Cataract", "Cataract in children", and "Slit lamp examination"
http://www.patient.co.uk/doctor/CataractsandCataractSurgery.htm
(http://www.patient.co.uk/doctor/CataractsandCataractSurgery.htm)

All images taken from: http://en.wikipedia.org/wiki/Cataract_surgery

(http://en.wikipedia.org/wiki/Cataract_surgery)

Skills
Eye Examination & Vision Assessment
Identifying and Treating Eye Emerge
Ocular History Taking
Using an Ophthalmoscope
Conditions
Agerelated Macular Degeneration
Allergic Eye Diseases
Blindness: Global Epidemiology
Cataract
Corneal Disorders
Cranial Nerve III, IV and VI Palsies
Eyelid, Orbital and Lacrimal Disorders
Glaucoma
Intraocular Tumours
Ocular Inflammation
Ophthalmic Infections
Ophthalmic Involvement in Systemic Disease
Retinal Detachment
Retinitis Pigmentosa
Retinoblastoma
Retinopathy
Squint
Presentations
Diplopia
Dry Eye
Eyelid Lumps, Bumps and Rashes
Floaters, Flashers and Halos
Foreign Body
Loss of Vision
Ocular Pain and Headaches
Ophthalmic Trauma
Optic Disc Swelling and Optic Atrophy
Orbital Swellings
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