Beruflich Dokumente
Kultur Dokumente
Cataract
Course period: 4th Semester
Department of Ophthalmology
Faculty of Medicine Brawijaya University
Dr. Saiful Anwar Hospital Malang
2013
1. Contributors
Ophthalmology staffs at the Department of Ophthalmology, Faculty of Medicine
Brawijaya University/ Dr. Saiful Anwar Hospital.
2. Competency area
This module is relevant for competence level 3 of the Indonesian Doctor
Competencies.
3. Competency component
4. Learning objectives
At the end of Teaching Learning process, the student should be able to :
-
5. Lecture Description
This module is a part of lecture block designed for 5 th semester small group
discussion. This module will facilitate students understanding of general aspects
of cataract disease and its management.
Introduction
Cataract is one of the most common eye disorder that causes significant
visual impairment. By definition, cataract is opacity of the lens. However, to be
clinically significant, the opacity should be in a certain degree to cause decrease
of visual function. In Indonesia, cataract is estimated to be responsible for 0.78%
of blindness in the community. Cataract is widely distributed in community
throughout rural areas. Primary healthcare providers are suitable pioneer case
finders in the referral system. Basic examinations for screening and post surgical
rehabilitation can also be done by medical doctors in these settings. Through this
module we will explore several aspects of cataract relevant for general
practitioners competency.
Physiology
The lens is avascular and contains no nerve fibers. Control of water and
electrolyte balance is an important mechanism and critical to maintain lens
transparency. The lens is dehydrated and contains higher levels of potassium
ions (K+) and amino acids than the surrounding aqueous and vitreus. Conversely,
the lens contains lower levels of sodium ions (Na +) and chloride ions (Cl -) than
the surrounding environment. The cation balance between the inside and outside
of the lens is the result of both the permeability of the lens cell membranes and
the activity of the sodium pump located within the cell membranes of the
epithelium and lens fiber. The mechanism by which the lens controls the state of
water and ions is termed the pump-leak theory. According to this theory,
potassium and amino acids are actively transported into the anterior lens via the
epithelium and then diffuse out with concentration gradient through the back of
the lens. Conversely, sodium flows through the back of the lens with the
concentration gradient and then is actively exchanged for potassium by the
epithelium. Active transport is energy dependant and critical in preserving
physiological condition of the lens.
Accommodation is another important feature of lens physiology. It is the
mechanism by which the eye changes focus from distance to near images. This
ability is produced by cillary muscle contraction which alters the tension of the
zonules and changes the shape of the lens. When cilliary muscle relaxes, the
zonular tension increases and the lens becomes less spherical, decreasing its
5
dioptric power. On the other hand, when cillary muscle contracts, the zonular
tension is reduced and the power of the lens increases. The capacity of
accommodation diminishes with increasing age.
Biochemistry
The human lens is composed of 35% protein and 65% water. With
increasing age, more part of the proteins becomes water insoluble and scatter
lights. The excess of insoluble proteins can make the lens less transparent and
become cataractous.
Energy production in the lens is dependant on glucose metabolism obtained from
the aqueous humor. Most of these glucose will enter the anaerobic metabolism
and only a small part of them undergoes aerobic metabolism in the lens.
Hyperglycemic state can increase glucose and its metabolites in the lens, which
will increase the osmotic pressure and draw water into the lens. This may result
in swelling of lens fiber and opacification of the lens.
The lens is equipped with several enzymes that protect against free
radical damage. These include glutathione peroxidase, catalase, and superoxide
dismutase. These enzyme are valuable in preventing peroxidation of lens fiber
which has been suggested as a factor contributing to lens opacification.
Pathology
Cataracts may occur as a result of aging or secondary to hereditary
factors, trauma, inflammation, metabolic or nutritional disorders, or radiation.
Congenital cataract are found since birth. Cataracts found in young persons are
termed juvenile cataract.
Age-related cataracts are the most common. The three common types of
cataract are nuclear, cortical, and posterior subcapsular (PSC). According to the
level of opacity, cataractous lens can be grossly classified as immature
cataract when the opacity is not homogen, and mature cataract when the lens
opacity is total and homogen.
The mechanism of cataract formation is multifactorial and, therefore,
difficult to study. Oxidation of membrane lipids, structural or enzymatic proteins,
or DNA by peroxides or free radicals induced by UV light maybe early initiating
events that lead to loss of transparency in both the nuclear and cortical lens
tissue. In cortical cataract, electrolyte imbalance leads to overhydration of the
lens, causing liquefaction of the lens fibers. Clinically, cortical cataract formation
6
Certain
medications
have
been
found
to
be
associated
with
Evaluation of the lens with pupillary dilatation (using pupillary dilating eye
drops such as Tropicamide / Mydriatyl). Iris shadow test can be useful in
determining lens opacities.
Funduscopic evaluation.
Inquiry about systemic condition and other illness should be obtained. Blood
pressure, blood sugar level, and hemostasis function is a routine requirement
when surgery is to be planned.
Management
The mainstay of cataract management is surgery. However, nonsurgical
management is sometimes useful in the early stages of cataract.
Non-Surgical Management
During early cataract development, visual improvement may be achieved
through a number of means including:
changes in spectacle lens prescription
magnification or other visual aids
appropriate illumination
Antioxidants supplements might have some beneficial effect for holding up
cataract development and are currently under investigation. No eye drops are
currently available as an effective treatment for cataract. Although pupillary
dilating agents may give some visual improvement for centrally located
cataracts, they are not recommended for treatment.
Surgical Management
The presence of a cataract does not itself indicate a need for surgery. Cataract
surgery may be indicated when the cataract reduces visual function to a level
that interferes with everyday activities of the patient and the patient desires
surgical intervention to improve vision. Most cataract surgery are elective. In
cases with accompanying complication, such as secondary glaucoma, the
surgery can be urgent.
cataract
by
extracapsular
cataract
extraction
(ECCE),
using
either
extraction
although
ICCE
is
still
used
under
certain
special
circumstances. Uncomplicated cataract surgery are usually done in less than one
hour and the patient may not need to be hospitalized. The following brief
descriptions show the nature as well as special indications and risks of each
surgical procedure.
Extracapsular cataract extraction by nuclear expression /extraction.
An incision of 8-10 mm is created at the corneo-scleral margin (limbal region).
Following the opening incision and anterior capsulotomy, the nucleus is
expressed from the capsular bag and removed in one piece through the incision.
The residual cortex is removed by irrigation and aspiration. This procedure
requires a larger incision, usually necessitating several sutures to close the
wound. Modification of this procedure utilize a small incision (6-8 mm) through
a scleral tunnel that can self seal without suture or a single suture.
Extracapsular cataract extraction by phacoemulsification.
An incision of 2-3 mm is created at the peripheral cornea. After the opening
incision and anterior capsulotomy, an ultrasonic probe emulsifies the hard
nucleus, enabling the surgeon to remove the lens material using a suction
device. This procedure maintains the normal depth of the anterior chamber. The
incision may be closed without sutures.
10
tasks until the wound is completely healed. Personal hygiene, especially on the
operated eye should be concerned. Topical eye drops of antibiotics and
antiinflamation are usually given for a few weeks. Spectacle correction or reading
adds can be prescribed after the visual function is stable.
12
References
American Academy of Ophthalmology Staff. Basic And Clinical Science Course:
Lens and Cataract.
San Fransisco: American Academy of Ophthalmology. 2008-2009
Kanski JJ, Clinical Ophthalmology, A Systematic Approach. 6 th ed. Edinburgh:
ButterworthHeinemann. 2007
Vaughan D, Asbury T, Riordan-Eva P. General Ophthalmology. 15 th ed. Stamford:
Prentice Hall. 1999
13
Willson
F,
Gurland
JE,
Hamed
LM,
Johnes
KJ,
Wilhelmus
KR.
Practical
Module Task
Answer the questions below after discussing with your group and reading the
suggested references
1. Mention alterations of the lens that can cause visual disturbance. (Two)
14
6. What should you look for when evaluating the post surgical cataract patient?
15
16