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ACQUIRED CATARACT

Age-related cataract
Subcapsular cataract
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Figure 12.1 Age-related cataract. (a) Posterior subcapsular; (b) posterior subcapsular seen on
retroillumination; (c) nuclear; (d) early nuclear cannot be seen on retroillumination

Anterior subcapsular cataract lies directly under the lens capsule and is associated with fibrous
metaplasia of the lens epithelium. Posterior subcapsular opacity lies just in front of the posterior
capsule and manifests a vacuolated, granular, or plaque-like appearance on oblique slit-lamp
biomicroscopy (Fig. 12.1a) and appears black on retroillumination (Fig. 12.1b). Due to its location at
the nodal point of the eye, a posterior subcapsular opacity has a more profound effect on vision than
a comparable nuclear or cortical cataract. Near vision is frequently impaired more than distance
vision. Patients are particularly troubled under conditions of miosis, such as produced by headlights of
oncoming cars and bright sunlight.

Nuclear cataract
Nuclear cataract starts as an exaggeration of the normal ageing changes involving the lens nucleus. It
is often associated with myopia due to an increase in the refractive index of the nucleus and with
increased spherical aberration. Some elderly patients may consequently be able to read again without
spectacles ('second sight of the aged'). Nuclear sclerosis is characterized in its early stages by a
yellowish hue due to the deposition of urochrome pigment. This type of cataract is best assessed with
oblique slit-lamp biomicroscopy (Fig. 12.1c) and not by retroillumination (Fig. 12.1d). When advanced,
the nucleus appears brown (a brunescent cataract). Such cataracts are of hard consistency, which is
surgically relevant.

Cortical cataract
Cortical cataract may involve the anterior, posterior or equatorial cortex. The opacities start as clefts
(Fig. 12.2a) and vacuoles (Fig. 12.2b) between lens fibres due to hydration of the cortex. Subsequent
opacification results in typical cuneiform (wedge-shaped) or radial spoke-like opacities (Fig. 12.2c and
d) often initially in the inferonasal quadrant. Patients with cortical opacities frequently complain of
glare due to light scattering.
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Figure 12.2 Age-related cataract. (a) Cortical clefts; (b) cortical vacuoles seen on retroillumination;
(c) wedge-shaped cuneiform; (d) cuneiform seen on retroillumination; (e) Christmas tree; (f)
Christmas tree seen on retroillumination

Figure 12.3 Cataract maturity. (a) Mature; (b) hypermature with wrinkling of the anterior capsule; (c)
morgagnian with liquefaction of the cortex and inferior sinking of the nucleus; (d) total liquefaction
and absorption of the cortex with inferior sinking of the lens (Courtesy of P Gili - fig. d)

Christmas tree cataract


Christmas tree cataract, which is uncommon, is characterized by striking, polychromatic, needle-like
deposits in the deep cortex and nucleus (Fig. 12.2e and f) which may be solitary or associated with
other opacities.

Cataract maturity
1. Immature cataract is one in which the lens is partially opaque.
2. Mature cataract is one in which the lens is completely opaque (Fig. 12.3a).
3. Hypermature cataract has a shrunken and wrinkled anterior capsule due to leakage of water
out of the lens (Fig. 12.3b).
4. Morgagnian cataract is a hypermature cataract in which liquefaction of the cortex has
allowed the nucleus to sink inferiorly (Fig. 12.3c and d).

Cataract in systemic diseases


Diabetes mellitus
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Diabetes mellitus (see Chapter 24), in addition to causing cataract, can affect the refractive index of
the lens and also its amplitude of accommodation.

1. Classical diabetic cataract is rare. Hyperglycaemia is reflected in a high level of glucose in


the aqueous humour, which diffuses into the lens. Here glucose is metabolized by aldose
reductase into sorbitol, which then accumulates within the lens, resulting in secondary
osmotic overhydration of the lens substance. In mild degree, this may affect the refractive
index of the lens with consequent fluctuation of refraction pari-passu with the plasma glucose
level (hyperglycaemia resulting in myopia). Cortical fluid vacuoles develop and later evolve
into frank opacities. Classical diabetic cataract consists of snowflake cortical opacities (Fig.
12.4a) occurring in the young diabetic that may resolve spontaneously or mature within a few
days.
2. Age-related cataract occurs earlier in diabetes mellitus. Nuclear opacities are common and
tend to progress rapidly.
Figure 12.4 Cataract in systemic disease. (a) Diabetic snowflake; (b) stellate posterior subcapsular
in myotonic dystrophy seen on retroillumination; (c) shield-like anterior subcapsular in atopic
dermatitis; (d) advanced in atopic dermatitis (Courtesy of A Fielder - fig. a; L Merin - fig. b; S Tuft -
fig d)

Myotonic dystrophy
About 90% of patients with myotonic dystrophy (see Chapter 24) develop visually innocuous, fine
cortical iridescent opacities in the third decade. These evolve into a visually disabling stellate posterior
subcapsular cataract by the fifth decade (Fig. 12.4b). Occasionally cataract may antedate myotonia.

Atopic dermatitis
About 10% of patients with severe atopic dermatitis (see Chapter 24) develop cataracts in the second
to fourth decades. The opacities are often bilateral and may mature quickly. Shield-like dense anterior
subcapsular plaque which wrinkles the anterior capsule is characteristic (Fig. 12.4c and d). Posterior
subcapsular opacities resembling a complicated cataract may also occur.

Neurofibromatosis-2
Neurofibromatosis-2 (see Chapter 24) is associated with posterior subcapsular or posterior cortical
opacities.
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Figure 12.5 Secondary cataract. (a) Posterior polychromatic; (b) dense posterior subcapsular
plaque; (c) mild glaukomflecken; (d) severe glaukomflecken

Secondary cataract
A secondary (complicated) cataract develops as a result of some other primary ocular disease.

Chronic anterior uveitis


Chronic anterior uveitis is the most common cause of secondary cataract. The incidence is related to
the duration and activity of intraocular inflammation that results in prolonged breakdown of the blood-
aqueous or blood-vitreous barrier. The use of steroids, topically and systemically, is also important.
The earliest finding is a polychromatic lustre at the posterior pole of the lens (Fig. 12.5a) which may
not progress if the uveitis is arrested. If the inflammation persists, posterior (Fig. 12.5b) and anterior
opacities develop and may progress to maturity. Lens opacities appear to progress more rapidly in the
presence of posterior synechiae.

Acute congestive angle-closure


Acute congestive angle-closure may cause small, grey-white, anterior, subcapsular or capsular
opacities within the pupillary area (glaukomflecken - Fig. 12.5c and d). They represent focal infarcts of
the lens epithelium and are pathognomonic of past acute angle-closure glaucoma.

High myopia
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High (pathological) myopia is associated with posterior subcapsular lens opacities and early-onset
nuclear sclerosis, which may ironically increase the myopic refractive error. Simple myopia, however,
is not associated with such cataract formation.

Hereditary fundus dystrophies


Hereditary fundus dystrophies such as retinitis pigmentosa, Leber congenital amaurosis, gyrate
atrophy and Stickler syndrome may be associated with posterior subcapsular lens opacities (see
Chapter 18). Cataract surgery may occasionally improve visual acuity even in the presence of severe
retinal changes.

Printed from: Clinical Ophthalmology, 6th Edition (on 26 June 2007)


© 2007 Elsevier