LENS AND CATARACT

PGI Kathleen Anne Luneta

RT, 55 y.o., Male

FILIPINO SAN MATEO, ISABELA

LOSS OF VISION, LEFT EYE BLURRING OF VISION, RIGHT EYE

CHIEF COMPLAINTS

2 YEARS PTC

(+) BLURRING OF VISION, LEFT EYE No other signs and symptoms noted No medications taken No consult done

1 YEAR PTC

(+) PROGRESSION OF THE BLURRING OF VISION ON THE LEFT EYE (+) BLURRING OF VISION , RIGHT EYE No other signs and symptoms noted No medications taken No consult done

2 MONTHS PTC

(+) TOTAL LOSS OF VISION, LEFT EYE Prompted consult Subsequently referred to our institution

Past Ocular History, PMH, FH

unremarkable

Personal/Social History

Smoker consuming 1 pack/ day Non alcohol beverage drinker

Date

Visual Acuity
OD: counting fingers OS: hand movements

EOM

Pupils

Ext. Exam
Opacity, OS

Visual Field Exam

4/11

U/R

3-4 mm, OU (+) direct and consensual light reflex (-) marcus gunn reflex

4/18 ECCE with PCIOL, OS ECCE without PCIOL, OS Dx: S/P ECCE, OS; APHAKIA 4/19 Post op Day 1 4/21 Post op Day 3 counting fingers at 2 feet, OU U/R OD: 3mm (+) direct & cons (-) MG OS Non reactive Reddish sclera, OS

counting fingers at 2 feet, OU

U/R

1 mm OU (+) direct and consensual light reflex (-) marcus gunn reflex

Reddish sclera, OS

4/25 Post op day 7

counting fingers at 2 feet, OU

U/R

2mm OU (+) direct and consensual light reflex (-) marcus gunn reflex

Reddish sclera, OS

4/27

counting fingers at 2 feet, OU

U/R

2mm OU (+) direct and consensual light reflex (-) marcus gunn reflex

Reddish sclera, OS

4/30 ACIOL Implantation; anterior vitrectomy Dx: S/P ACIOL Implantation

Date

Tono

Fundoscopy

Assessment

Plan

4/11

OD: 10 OS: 10

OD CDR: 0.3-0.4 AVR:2:3, (-) hges

OS No view Poor dilatation

MATURE CATARAT WITH PSC, OD MORGAGNIAN CATARACT, OS

Phaco with PCIOL, OD ECCE with PCIOL, OS Meds: Levofloxacin, PF, NaCl

4/18 ECCE with PCIOL, OS ECCE without PCIOL, OS Dx: S/P ECCE, OS; APHAKIA 4/19 OD: soft OS: soft --S/P ECCE, OS; APHAKIA Increase PF to q1 Cont Levo, NaCl Follow up after 1 week -do-

4/21

OD: 14 OS: 16 --

--

--

S/P ECCE, OS; APHAKIA

4/25

--

--

S/P ECCE, OS; APHAKIA

Cont Levo and PF q2, OS For IOL Implantation For Phaco with PCIOL, OD Schedule for ACIOL Implant Con Levofloxacin q2

4/27

OD: 10 OS: 16

--

--

S/P ECCE, OS; APHAKIA Leaking wound, OS

4/30 ACIOL Implantation; anterior vitrectomy Dx: S/P ACIOL Implantation

Date

Visual Acuity
OD: counting fingers OS: 10/200 (snellens) OD: counting fingers OS: 20/200 (snellens) 20/80 -2 (PH) counting fingers at 2 feet, OU

EOM

Pupils

Ext. Exam
---

Visual Field Exam

--

5/1

U/R

--

5/7

U/R

OD: 2-3mm (+) direct & cons (-) MG

OS Non reactive

Reddish sclera, OS

5/14

U/R

1 mm OU (+) direct and consensual light reflex (-) marcus gunn reflex

Reddish sclera, OS

Date

Tono

Fundoscopy

Assessment

Plan

5/1

--

--

--

S/P ECCE with ACIOL, OS

Prednisolone acetate q2, OS Moxifloxacin q2, OS d/c NaCl Follow up after 1 week Contiinue Prednisolone acetate q2, OS Moxifloxacin q2, OS Follow up after 1 week Shift to Vigadexa 4x/day, OS Follow up after 1 week

5/7

OD: 14 OS: 6

--

--

S/P ECCE with ACIOL, OS MATURE SENILE CATARACT, OD

5/14

OD: 14 OS: 14

--

--

S/P ECCE with ACIOL, OS MATURE SENILE CATARACT, OD

LENS: Anatomy

Biconvex Avascular Colorless Transparent 4mm thick; 9mm in diameter Behind the iris Suspended by the zonules Anterior: aqueous Posterior: vitreous

LENS: Basic Function

REFRACTION
To

focus light rays to retina 1/3 of refracting power

ACCOMMODATION
the

process by which the eye increases optical power to maintain a clear image (focus) on an object as it draws near As the lens ages, accommodation decreases

ABNORMAL LENS: chief complaint

Blurred vision without pain Glare Dull perception of colors Second Sight Phenomenon

ABNORMAL LENS: causes

Opacification Dislocation
Sublaxated

- partial Laxated - complete

CATARAC T

CATARACT

clouding/opacity that develops in the lens of the or in its envelope (lens capsule) Characterized by:
Lens

edema Protein alteration Necrosis Disruption of normal lens fibers

CLASSIFICATION by morphology

NUCLEAR
At

area of nucleus Myopia Second sight of the aged Nuclear sclerosis

CLASSIFICATION by morphology

CORTICAL
Anterior

or posterior area of the cortex typical cuneiform or radial spoke-like opacities

CLASSIFICATION by morphology

SUBCAPSULAR
ANTERIOR
Lies

directly under the lens capsule Associated with fibrous metaplasia of the lens epithelium
POSTERIOR
Lies

in front of the posterior capsule Vacuolated, granular, or plaque-like material Black on retroillumination Has a more profound effect on vision Near vision is more impaired Miosis

CLASSIFICATION: stage of development

IMMATURE
Early

insipient stage Lens is partially opaque Vision is not yet affceted

MATURE
Lens

is completely opaque

CLASSIFICATION: stage of development

HYPERMATURE
Shrunken

and wrinkled anterior capsule Leakage of water out of the lens

MORGAGNIAN

CATARACT liquefaction of the cortex has allowed the nucleus to sink inferiorly

CLASSIFICATION according to age

Congenital Infantile liquefaction Juvenile Pre-senile Senile

CLASSIFICATION: congenital

Bilateral Associated with maternal infections

most common Toxoplasmosis Cytomegalic inclusion disease Varicella
RUBELLA

May cause nystagmus

CLASSIFICATION: etiology

AGE RELATED
Most

common Affects the elderly Progressive blurring of vision

TOXIC
Secondary
Miotics Chlorpromazine Busulphan

to medicaitons
most common

CORTICOSTEROIDS

CLASSIFICATION: etiology

TRAUMATIC
PENETRATING

FOREIGN BODY most

common Concussion Exposure to heat Irradaition Electric shock

Traumatic Cataract

Most common cause of unilateral cataract

Penetrating

trauma Blunt trauma Electric shock and lightning strike Infrared radiation Ionizing radiation

Secondary Cataract

Chronic anterior uveitis most common Acute congestive angle-closure High myopia Hereditary fundus syndromes
Retinitis

pigmentosa Leber congenital amaurosis Gyrate atrophy Stickler syndrome

Cataract associated with systemic diseases

METABOLIC DISEASES
Mellitus most common Myotonic dystrophy Atopic dermatitis Neurofibromatosis type 2 Lowe syndrome Down syndrome, Edwards syndrome, Cri du chat syndrome Farby disease Mannosidosis Hypoparathyroidism, Pseudohypoparathyroidism,
Diabetes

DIAGNOSIS OF ABNORMAL LENS

GROSS EXAM / SLIT LAMP BIOMICROSCOPE

Lens

opacity is noticed Iridodonesis Phacodonesis

FUNDOSCOPY
Poor

red-orange reflex

Cataract surgery

Indications:
improvement most common Prevent complications (secondary uveitis, glaucoma) Cosmetic Presence of congenital cataract which can cause amblyopia Maintaining posterior segment visualization in svere diabetic retinopathy
Visual

Techniques

INTRACAPSULAR CATARACT EXTRACTION

Removal

of the complete lens Bring lens out as a whole

EXTRACAPSULAR CATARACT EXTRACTION

Removal

of the lens material except the peripheral and the posterior portion of the capsule Thru manual extraction or phacoemulsification

Operative Complications

Rupture of the posterior lens capsule Posterior loss of lens fragments Posterior dislocation of IOL Suprarachnoidal hemorrhage

Rupture of the posterior lens capsule

Accompanied by:
Vitreous

loss Posterior migration of lens material Expulsive hemorrhage

Rupture of the posterior lens capsule

Sequelae to vitreous loss if inappropriately managed:

Chronic

cystoid macular edema Retinal detachment Endophthalmitis Updrawn pupil Uveitis Vitreous touch Viterous wick syndrome Glaucoma Posterior dislocation of IOL

Rupture of the posterior lens capsule

Signs:
Sudden

deepening or shallowing of the anterior chamber momentary pupil dilatation The nucleus falls away and cannot be approached by the phaco tip vitreous aspirated by the phaco tip often manifests with marked slowing of lens material aspiration The torn capsule or the vitreous gel may be directly visible

Rupture of the posterior lens capsule

Management:
Depends

on the magnitude of the tear Size and type of any residual lens material Presence or absence of vitreous prolapse

Surgical complications

Uveitis Glaucoma Infection Retinal detachment Hyphemia Dislocated intraocular lens After surgery cataract
opacification of the posterior lens Proliferation and migration of lens epithelial cells Treatment: laser capsulotomy

THANK YOU!!! :D