CATARACT

Dr. T. Budi Sulistya, Sp.M

Dr. Anny Sulistiyowati, Sp.M
Dr. Sony Agung Santoso, Sp.M
Department of Ophthalmology
Faculty of Medicine Brawijaya University
Saiful Anwar Hospital

Biconvex
Avascular
Transparent
Thickness: 4 mm,
diameter 9 mm
Ant : aqueous humor
Post : vitreous
Position: suspensory
ligament (zonula)
zinn

PHYSIOLOGY
-Lens transparency : control water &
electrolyte

>
<

-Dehydrated
-K >>

-Amino Acid
-Na+
-Cl

HA &
Vitreous
HA &
Vitreous

BIOCHEMISTRY
65% water
35% Protein, mineral, glutathione,
Potassium, Ascorbic acid, etc.
Nutrition: Glucose HA
Ages : protein : water insoluble
Cataract

Hyperglicemic Osmotic Swelling

Opacification
Glutatione peroxidase
Catalase
Superoxide dismutatase

Peroxidatio
n
Opacificati
on

PATHOLOGY
Advance age
Trauma
Inflammation
Metabolic disorder
Corticosteroid
Radiation

Age Related Cataract

- Common
- Nuclear, Cortical, Posterior Sub
Capsular Cataract (PSC)

STAGES OF SENILE
CATARACT
Stadium INSIPIENT
Stadium IMMATURE
Stadium MATURE
Stadium HYPER MATURE

RISK FACTOR
Age
Diabetes mellitus
Drugs: corticosteroid, phenothiazine,
chlorpromazine
Ultraviolet radiation
Smoking
Alkohol

DIAGNOSIS &
EXAMINATION
1. Visual disturbance:
depends on: - opacity
- location
2. Glare
3. Altered contrast sensitivity
4. Diplopia

EXAMINATION
1. Visual acuity: natural, best corrected
2. Anterior segment
3. Pupilary dilatation
4. Funduscopic evaluation :
Examine with
ophthalmoscope
Black
spot over orange background (insipient
immature)
Negative (mature)

Additional test
1. Intraocular pressure
2. Keratometry and biometry
3. Retinometry
4. Ultrasonography
5. Blood pressure
6. Blood sugar
7. Hemostasis

MANAGEMEN
T
Non Surgical

1. Spectacle lens
2. Magnification / visual aids
3. Appropriate illumination

Surgical
Reduced visual funcion
Complication : Secondary
glaucoma

Indication of Surgery
1.Visual Impairment
Responsible for the patients disability
in desired activity (driving, reading,
occupational needs)

 Visual disability increases due to glare or

dim illumination
Patient complains of monocular diplopia or
polyopia
Visual disparity exists between two eyes

2. Other indications:
Lens induced diseases : phacomorphic
glaucoma, phacolytic glaucoma
Concomitant ocular disease that
requires clear media: required to
adequately diagnose diabetic
retinopathy

1. Stadium INSIPIENT
Visual acuity can be normal
Opacity starts as a line at lens edge
Wheel appearance
Central zone still
clear
May be stationer

2. Stadium IMMATURE

Lens absorbs water bulging glaucoma

VA: 5/6 - 1/60
Fundus reflex (+)
Opacity not
homogen
Iris shadow test (+)
Indication for
surgery (+)

3. Stadium MATURE

Visual acuity 1/60 - LP (+)

Homogen opacity
Fundus reflex (-)
Iris shadow test (-)
Obvious indication for surgery

4. Stadium HIPERMATURE
Degeneration of lens cortex and
capsule
Shrunken cataract : lens shrinks and thins due
to loss of water
Morgagnian Cataract : cortex softens and
liquefies nucleus sinks

Surgical Procedure
Extra Capsuler Cataract Extraction ECCE
Nuclear Expression/Extraction
Phacoemulsification
Intra Capsuler Cataract Extraction ICCE

EXTRA CAPSULAR
Extra capsular
Incision 8-10 mm corneo-scleral
Anterior capsulotomy
Nucleus Expressed from capsular bag
Residual cortex removed
Posterior capsule is intact
Large incision: suture >>
For all kinds of cataract
Manual Small Incisi Cataract Surgery
(MSICS)

Phacoemulsification
2 3 mm
Clear cornea
Capsulotomy: Continuous
Curvelinear
CCC
Ultrasonic
No sutures

Capsuloreksis

INTRA CAPSULAR
ICCE
Large incision
Lens & Capsule intoto
Higher risk of vitreous loss
For mature & hypermature cataract
Can not be done for congenital &
juvenile cat.

INTRAOCULAR LENS
More Physiological

More comfortable

PMMA, Silicone, Acrylic

Inside capsular bag
VA 6/6
Pseudophakia

COMPLICATIONS
Endophthalmi
tis

Bullous keratopaty
Dislocated IOL

Wound leak

Vitreous Lost

Iris prolapse

CME

Uveitis

RD

Increased IOP

Choroidal

Corneal
edema

hemorrhage

POST SURGICAL REHABILITATION

Patients complaint
VA
Anterior segment
Sign of inflammation
IOP
Wound healing.
Personal hygiene
Spectacle correction/reading

COMMUNITY OPHTHALMOLOGY
Blindness: 1.5 %, cataract 1 %
Handling: Dept of Health
NGO
Caused by: human resource
capacity
geographical factor
limited infrastructure
socio-economic status
ophthalmologist <<

Backlog Cataract
Cataract: 1 % = 210.000
Surgical capacity: 80.000/year
Backlog :

130.000/year

Affected by: unawareness community

high cost of surgery
ophthalmologist <<
reach surgical capacity
<<

 Community ophthalmology: elimination

cataract:
Promotion
Prevention
Cure
Rehabilitation
Ophthalmologist
General healthcare workers
Non healthcare