JOHN CHRISTOPHER L.

LUCES
CLINICAL CLERK
WVSU-COM
GENERAL DATA
PATIENT: M. M.
56 YEARS OLD
FEMALE/ MARRIED
BOLILAO, MANDURRIAO, ILOILO COTY
CHIEF COMPLAINT

BLURRING OF VISION
OD<OS
HPI
3 MO PTC:
Patient started experiencing ear itchiness accompanied by blurry
of vision on the left eye
Occasional frontal headache was also experienced by the patient

2 MO PTC:
Same symptoms persisted
Patient also experienced blurring of vision on her right eye
She went back to the optometrist and there she was given new set
of glasses
HPI
FEW DAYS PTC:
Same symptoms persisted thus decided to sought
consult in this instituion
PAST MEDICAL HISTORY
(+) Hypertension (2015)- Amlodipine 10mg/tab OD
(+) DM (2016)- Metformin 5 mg/tab OD
(+) Gallstones

3 years ago: Nearsightedness

FAMILY HISTORY
(+) HYPERTENSION: father side
(+) DM: mother side
(+) OCULAR PROBLEM (unrecalled)- father
PERSONAL-SOCIAL HISTORY
Patient is a dressmaker
She is a non-alcoholic beverage drinker and non-
smoker
GENERAL SURVEY
AWAKE
AMBULATORY
NOT IN CARDIOPULMONARY DISTRESS
GCS 15 (E4V5M6)
RESPONSIVE, COHERENT, CONVERSANT
ORIENTED TO TIME, PLACE AND PERSON.
VITAL SIGNS
Normal Values
Temperature 37.1C 36.5-37.5C
Cardiac Rate 89 bpm 60-100 bpm
Respiratory Rate 18 cpm 12-20 cpm
SBP<120mmHg; DBP
Blood Pressure 120/80 mmHg
<80 mmHg
PHYSICAL EXAMINATION

HEENT AS, PC, PERRLA, NNVE, NCLAD

CHEST SCE, CBS, AP, NCRRR, (-) murmurs
ABDOMEN Soft, non-tender abdomen
EXTREMITIES Grossly Normal Extremities
GROSS EYE EXAMINATION

NO ACTIVE LESIONS ON THE OCULAR ADNEXA

PINK CONJUNCTIVA, WHITE SCLERA
NO APPARENT OPACITY
(-) SWELLING, ERYTHEMA, TENDERNESS OR MASS
PUPILLARY EXAMINATION

OD: 3 mm, BRTL, (+) direct & consensual PR

OS: 3 mm, BRTL, (+) direct & consensual PR
MOTILITY EXAM

Able to move the eye freely in 6 Able to move the eye freely in 6 cardinal
cardinal gazes gazes
FUNDOSCOPIC EXAMINATION

OD OS

(+) ROR (-) ROR

Fundoscopy
Slightly Hazy media Hazy media
VISUAL ACUITY
EYE EXAM OD OS

Visual Acuity 20/200 -2 CF- 4ft

Pin hole: 20/80

TONOMETRY

EYE EXAM OD OS

Tonometry 16 16
SLIT LAMP BIOMICROSCOPY

OD OS
POSTERIOR SUBSCAPULAR OPACIFICATION OF LENS
SUBSCAPULAR CATARACT OU
PLANS
FOR DILATED FUNDUSCOPY
ADVISED CATARACT SURGERY BUT STILL UNDECIDED
FOR FBS
TCB ONCE DECIDED
ANATOMY
 ANATOMY
Biconvex, avascular, transparent structure enclosed
by a capsule

Capsule is responsible for moulding the lens

substance during accommodation; lens capsule is
pliable

Capsule is thickest at equatorial zone and thinnest at

posterior pole of lens

Lens substance consist of the nucleus, the central

compacted core surrounded by the cortex.
CATARACT
Cataractous lenses are characterized by protein
aggregates that scatter light rays and reduce
transparency. Other protein alterations result in yellow
or brown discoloration. Additional findings may include
vesicles between lens fibers or migration and aberrant
enlargement of epithelial cells

Cataract is an ophthalmologic diagnosis. It is irrespective

of vision as long as there is opacity.
CATARACTS
AGE-RELATED CATARACT
PRESENILE CATARACT
TRAUMATIC CATARACT
DRUG INDUCED CATARACT
SECONDARY CATARACT
AGE-RELATED CATARACT

NOT HEREDITARY
COMMON CAUSE OF PREVENTABLE BLINDNESS
MEAN AGE: 65Y.O.
CLASSIFICATION ACCORDING TO MORPHOLOGY
1. SUBCAPSULAR CATARACT
ANTERIOR SUBCAPSULAR
- LIES DIRECTLY UNDER THE LENS CAPSULE

POSTERIOR SUBCAPSULAR
- LIES JUST IN FRONT OF THE POSTERIOR CAPSULE. MORE
COMMON THAN ANTERIOR AND MORE PROFOUND EFFECT ON
VISION THAN A COMPARABLE NUCLEAR OR CORTICAL CATARACT.
NEAR VISION MORE IMPAIRED THAN DISTANCE VISION.
 POSTERIOR SUBCAPSULAR CATARACT

AN OPACITY IN THE LENS POSITIONED JUST ANTERIOR TO THE POSTERIOR

LENS CAPSULE AND CHARACTERIZED BY THE POSTERIOR MIGRATION OF
LENS EPITHELIAL CELLS FROM THE LENS BOW.
INCIDENCE/PREVALENCE: POSTERIOR SUBCAPSULAR CATARACT MAY BE THE
MOST COMMON ABNORMALITY INVOLVING THE LENS EPITHELIUM

THE LENS IS COMPOSED LARGELY OF CRYSTALLINS WHICH AGGREGATE IN

CATARACT FORMATION. THERE ARE MANY ASSOCIATIONS WITH POSTERIOR
SUBCAPSULAR CATARACTS INCLUDING CHRONIC VITREAL INFLAMMATION,
IONIZING RADIATION, TRAUMA AND PROLONGED USE OF
CORTICOSTEROIDS.
 POSTERIOR SUBCAPSULAR CATARACT
CLINICAL FINDINGS:
Symptoms include complaints of glare at night with bright headlights or poor vision with accommodation.
Near vision may often be more affected than distance vision.
The earliest sign is a focal dot-like area on the posterior capsule or a reflective sheen.
With progression, translucent opacities appear (the swollen wedl cells) on the posterior capsule that have
been likened to a cloth of gold or fish eggs. Posterior capsular cataract is associated with cortical
degeneration and nuclear sclerosis.
CLASSIFICATION ACCORDING TO MORPHOLOGY

2. NUCLEAR CATARACT
- ASSOCIATED WITH MYOPIA.
MYOPIC SHIFT- NEAR VISION IS BETTER. PATIENT MAY FEEL THAT THEIR VISION IS RESTORED.
HOWEVER, THIS IS ONLY TEMPORARY. OVERTIME, THE LENS WILL GROW AND THICKEN
SECOND SIGHT OF THE AGED
YELLOWISH EARLY AND BRUNESCENT IN LATER STAGES. HARD IN CONSISTENCY.AND THE CATARACT WILL MATURE.
CLASSIFICATION ACCORDING TO MORPHOLOGY
3. CORTICAL CATARACT
MAY INVOLVE THE ANTERIOR, POSTERIOR, OR EQUATORIAL CORTEX.
START AS CLEFTS AND VACUOLES. TYPICAL CUNEIFORM (WEDGE-SHAPED) OR
RADIAL SPOKE LIKE OPACITIES. DOES NOT AFFECT VISION THAT MUCH.
4. CHRISTMAS TREE CATARACT
UNCOMMON. POLYCHROMATIC (GLOWS WHEN YOU CHECK ON
SLITLAMP EXAM), NEEDLE-LIKE DEPOSITS IN THE DEEP CORTEX AND NUCLEUS.
SHAPE IS SIMILAR TO CHRISTMAS TREE.
CLASSIFICATION ACCORDING TO MATURITY

1. IMMATURE CATARACT- lens is partially opaque

2. MATURE CATARACT- lens is completely opaque
3. HYPERMATURE CATARACT- shrunken and wrinkled anterior capsule; milky.
4. MORGAGNIAN CATARACT- a hypermature cataract in which total liquefaction
of cortex allows the nucleus to sink inferiorly
5. INDUMESCENT- if the lens takes up water.
PRESENILE CATARACT

MEAN AGE OF CATARACT DEVELOPMENT AT 65 Y.O. (ACCORDING TO

THE AMERICAN ACADEMY OF OPHTHALMOLOGY AND THE PHILIPPINE
BOARD OF OPHTHALMOLOGY). PRESENCE OF SYSTEMIC DISORDERS
MAY CAUSE EARLIER ONSET OF CATARACT FORMATION
PRESENILE CATARACT
1. DIABETES MELLITUS- ASIDE FROM CATARACT, CAN AFFECT REFRACTIVE INDEX OF LENS AND ITS
AMPLITUDE OF ACCOMMODATION. CAN AFFECT REFRACTIVE INDEX AND AFFECT, CAN AFFECT
AMPLITUDE OF ACCOMMODATION. CATARACT STARTS 50+ Y

A) CLASSICAL DIABETIC CATARACT- SORBITOL ACCUMULATES WITHIN THE LENS SNOWFLAKE CORTICAL
OPACITIES IN THE YOUNG DIABETIC.
B) AGE-RELATED CATARACT- OCCURS EARLIER IN DM PATIENTS NUCLEAR OPACITIES ARE COMMON AND
PROGRESS RAPIDLY
C) PREMATURE PRESBYOPIA- DUE TO REDUCED PLIABILITY OF LENS. EARLY LOSS OF ACCOMMODATION
OR ABILITY OF THE EYE TO ADJUST TO DISTANCE DUE TO AGING
PRESENILE CATARACT

2. MYOTONIC DYSTROPHY- VISUALLY INNOCUOUS, FINE CORTICAL. EVOLVES INTO VISUALLY

DISABLING STELLATE POSTERIOR SUBCAPSULAR. IRIDESCENT OPACITIES IN THE 3RD DECADE AND
CATARACT BY THE 5TH DECADE. DEVELOPS SLOWLY, TAKES ABOUT 2 DECADES FOR CATARACT TO
DEVELOP

3. ATOPIC DERMATITS- IN 10% OF PATIENTS WITH SEVERE DERMATITIS, CATARACT DEVELOP. A)

SHIELD-LIKEDENSE ANTERIOR SUBCAPSULAR PLAQUE B) POSTERIOR SUBCAPSULAR

4. NEUROFIBROMATOSIS TYPE 2- POSTERIOR SUBCAPSULAR OR POSTERIOR CORTICAL OPACITIES.

TRAUMATIC CATARACT

Trauma is the most common cause of unilateral cataract in

young individuals secondary to physical trauma due to their
active lifestyle and risk taking behaviors. Bilateral cataracts
are not as common but are possible depending on the
extent of injury
TRAUMATIC CATARACT

1. DIRECT PENETRATING
2. CONCUSSION
3. ELECTRIC SHOCK AND LIGHTNING
4. IONIZING RADIATION
5. INFRARED RADIATION
DRUG-INDUCED CATARACT
STEROIDS- SYSTEMIC, TOPICAL, (EVEN INHALED FORM) ARE CATARACTOGENIC. OPACITIES ARE
INITIALLY POSTERIOR SUBCAPSULAR THEN LATER AFFECT ANTERIOR SUBCAPSULAR REGION THEN
LATER BECOMES MATURE CATARACT
CHLORPROMAZINE- DOSE-RELATED AND IRREVERSIBLE
BUSULPHAN- USED IN TREATMENT OF CHRONIC MYELOCYTIC LEUKEMIA, MAY OCCASIONALLY
CAUSE LENS OPACITY
AMIODARONE- IN TREATMENT OF CARDIAC ARRHYTHMIAS, CAUSES INCONSEQUENTIAL
ANTERIOR SUBCAPSULAR OPACITIES
5. GOLD- IN TREATMENT OF RHEUMATOID ARTHRITIS, INNOCUOUS ANTERIOR CAPSULAR
OPACITIES IN 50% OF PTS OF >3YRS TREATMENT
SECONDARY CATARACT

1. CHRONIC ANTERIOR UVEITIS

2. ACUTE CONGESTIVE ANGLE CLOSURE GLAUCOMA
3. HIGH (PATHOLOGIC) MYOPIA
4. HEREDITARY FUNDUS DYSTROPHY
CONGENITAL CATARACTS

1. CATARACTS WITH NO SYSTEMIC ASSOCIATION

2. CATARACTS WITH SYSTEMIC ASSOCIATION
CATARACTS WITH SYSTEMIC ASSOCIATION
PRENATAL INFECTIONS
1. CONGENITAL RUBELLA
2. TOXOPLASMOSIS
3. CMV
4. HERPES SIMPLEX
5. VARICELLA
CATARACTS WITH SYSTEMIC ASSOCIATION

CHROMOSOMAL ABNORMALITIES
1. DOWN SYNDROME
2. PATAU SYNDROME (TRISOMY 11)
3. EDWARD SYNDROME (TRISOMY 18)
 CATARACT- PATHOPHYSIOLOGY
DEVELOPMENTAL METABOLIC EXPOSURE TRAUMA

Chemicals Foreign Body

Congenital Congenital
Radiation
Senile Acquired
Drugs

OPACITY OF LENS
BLOCKING THE PATHWAY OF LIGHT TOWARDS RETINA
MANAGEMENT

INDICATIONS FOR SURGERY

VISUAL IMPROVEMENT- BY FAR THE MOST COMMON INDICATION FOR CATARACT SURGERY. SURGERY IS
INDICATED ONLY IF AND WHEN CATARACT DEVELOPS TO A DEGREE SUFFICIENT TO CAUSEDIFFICULTY IN
PERFORMING DAILY ESSENTIAL ACTIVITIES
MEDICAL INDICATIONS- IN WHICH A CATARACT IS ADVERSELY AFFECTING THE HEALTH OF THE EYE
REMOVAL OF CATARACT

3. COSMETIC INDICATIONS RARE

CATARACT SURGERY
EXTRA-CAPSULAR CATARACT EXTRACTION (ECCE)
REQUIRES A RELATIVELY LARGE CIRCUMFERENTIAL LIMBAL INCISION(8-
10MM) THROUGH WHICH THE LENS IS EXTRACTED AND THE CORTICAL
MATERIAL ASPIRATED
INTACT POSTERIOR CAPSULE ACT AS HAMMOCK WHERE YOU PLACE
YOUR IOL
 CATARACT SURGERY
PHACOEMULSIFICATION (PHACO)
A SMALL HOLLOW NEEDLE, USUALLY TITANIUM, ATTACHED TO A HANDPIECE
CONTAINING A PIEZO-ELECTRICAL CRYSTAL, VIBRATES AT ULTRASONIC FREQUENCIES.
TIP IS APPLIED TO THE LENS NUCLEUS. CAVITATION OCCURS AT THETIP AS NUCLEUS IS
EMULSIFIED. AN IRRIGATING OR ASPIRATION SYSTEM REMOVES THE EMULSIFIED
MATERIAL FROM THE EYE.
IOL IS INSERTED (IF FOLDED) OR INJECTED THROUGH A MUCHSMALLER INCISION THAN
ECCE.
COMPLICATIONS
1. CORNEAL EDEMA. USUALLY TRANSIENT AND DUE TO INTRAOPERATIVE TRAUMA
2. IRIS PROLAPSE LEAKING INCISION, INADEQUATE SUTURING, PATIENT COUGHING OR STRAINING.

3. MALPOSITION OF IOL ALTHOUGH UNCOMMON, MALPOSITION MAY BE ASSOCIATED WITH BOTH OPTICAL
AND STRUCTURAL PROBLEMS. ANNOYING VISUAL ABERRATIONS INCLUDE GLARE,HALOES, AND MONOCULAR
DIPLOPIA IF THE EDGE OF THE IOL BECOMES DISPLACED INTO THE PUPIL.
4. RETINAL DETACHMENT. LATTICE DEGERATION, RETINAL BREAKS, HIGH MYOPIA, DISRUPTION OF POSTERIOR
CAPSULE, VITREOUS LOSS
5. CYSTOID MACULAR EDEMA (CME) RUPTURE OF POSTERIOR CAPSULE OR VITREOUS AND PROLAPSE.
SYMPTOMATIC CME IS RELATIVELY UNCOMMON FOLLOWING UNCOMPLICATED PHACOEMULSIFICATION AND
IN MOST CASES IT IS MILD AND TRANSIENT. IT OCCURS MORE OFTEN AFTER COMPLICATED SURGERY AND
HAS A PEAK INCIDENCE AT 610 WEEKS, ALTHOUGH THE INTERVAL MAY BE MUCH LONGER.