Complicated cataract, Cataract associated with systemic diseases and management of Cataract

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Complicated cataract, Cataract associated with
systemic diseases and management of Cataract

• Copy of power point presentation of lecture taken
  for Junior final year MBBS students by
• Dr Sanjay Shrivastava,
• Prof of Ophthalmology
• Gandhi Medical College
• Bhopal (M.P.) India

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Complicated Cataract

• Cataract associated with ocular diseases
• Complicated Cataract is due to disturbance of
  the nutrition of lens due to inflammatory or
  degenerative disease of anterior and /or
  posterior segment of the eye like iridocyclitis,
  cilitis, pars planitis, choroiditis, myopic
  degeneration, retinitis pigmentosa, retinal
  detachment, other retinal pigmentory dystrophies
  etc.

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Complicated Cataract

• A non-descript opacity develops in cortex which
  usually progresses and mature.
• In inflammatory or degenerative condition of
  posterior segment, opacification usually starts
  in the posterior part of the cortex in the axial
  region (posterior cortical cataract or posterior
  subcapsular cataract)

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Complicated Cataract

• Cataract has characteristic breadcrumb appearance
  and rainbow display of colours (polychromatic
  lustre). Cataract may remain stationary in
  posterior cortex or progress to involve the whole
  posterior cortex and entire lens. Cataract is
  usually soft and uniform in appearance.
• Vision is usually affected even in early stages
  as opacity is near the nodal point of the eye.

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Complicated Cataract

• Prognosis depends on the causative condition.
• All cases of cataract without obvious cause
  should be carefully looked for keratic
  precipitates or evidences of pars planitis.

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Cataract associated with systemic disease

• Diabetic Cataract
• Early onset of senile cataract and cataract
  develops rapidly.
• True diabetic cataract is rare condition,
  occurring typically in young people with acute
  diabetes (with gross imbalance of water balance
  of the body). Fluid droplets (vacuoles) appear
  under the anterior and posterior subcapsular
  cortex, manifesting as myopia, producing diffuse
  opacity. These changes are reversible.

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Diabetic Cataract

• The lens rapidly becomes cataractous with dense,
  white anterior and posterior subcapsular cortical
  cataract resembling snowstorm snowflake
  Cataract.
• If diabetes is controlled appropriately, the
  rapid progression to mature cataract may be
  arrested.

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Cataract associated with systemic disease

• Parathyroid Tetany
• Myotonic Dystrophy
• Galactosaemia
• Down Syndrome
• Atopic Cataract

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Objective Examination

• The state of the nucleus (grading of nuclear
  sclerosis)
• The state of the cortex
• The presence or absence of signs of inflammation
• Pupillary glow by transillumination
• B- Scan ultrasonography

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Functional Tests

• Pupillary reaction
• Projection of light
• Macular function test two pinholes test and
  Maddox rod test
• Entoptic view of the retina Auto-ophthalmoscopy
  
• Electro-retinographic record, particularly of
  macula.

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Pre-operative evaluation

• Thorough ocular examination to exclude any ocular
  disease like abnormalities of lids, lacrimal sac,
  conjunctiva (including conjunctival infections),
  cornea, uveal inflammation, glaucoma, posterior
  segment inflammatory/ degenerative condition etc.

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Pre-operative evaluation

• Systemic examination to exclude hypertension,
  cardiovascular disorder, cerebro-vascular
  disease, chronic obstructive air way disorder
  etc. If any disorder is present, it should be
  adequately controlled before surgery
• ENT and Dental checkup to exclude septic focus

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Treatment of cataract

• Medical treatment No medical treatment is
  effective once the lens opacity has developed.

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Treatment of cataract

• Surgical Treatment
• Indication for surgery
• 1. Cataract when routine work becomes
  difficult due to reduced vision (attributable to
  cataract)
• 2. Subluxated or dislocated lens
• 3. Lens induced complications like phacolytic
  uveitis / glaucoma, phacoanaphylactic
  endophthalmitis, phacomorphic glaucoma.

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Treatment of cataract

• Surgical Treatment
• Options
• I. Intracapsular lens extraction (ICCE) Method
  of intracapsular cataract extraction (ICCE), now
  becoming obsolete, by which the entire lens
  including the capsule is removed by rupturing
  zonular ligaments.

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Surgical Treatment of Cataract

• II. Extracapsular Cataract Extraction (ECCE)
• Methods
• 1. Conventional ECCE
• 2. ECCE by small incision cataract surgery
  (SICS)
• 3. Lensectomy
• 4. Phacoemulsification

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Steps of ECCE

• Anaesthesia
• a. General Anaesthesia In children,
  psychiatric patients, senile dementia
• b. Local anaesthesia Retrobulbar block,
  peribulbar block, along with or without facial
  block , topical anaesthesia

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Steps of ECCE

• 2. Cleaning of lids with 5 betadine solution and
  instillation of betadine solution in conjunctival
  sac
• 3. Draping
• 4. Superior Rectus suture in case of conventional
  ECCE and SICS
• 5. Conjunctival flap in case of SICS

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Steps of ECCE

• 6. Scleral tunnel incision or Corneo-scleral
  section or corneal or corneal tunnel incision
• 7. Anterior chamber entry
• 8. Injection of ocular viscosurgical device (OVD)
  in anterior chamber (HPMC or Sodium Hyaluronate)
• 9. Capsulotomy ( can opener or continuous
  curvilinear capsulorrhexis, CCC)

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Steps of ECCE

• 10. Hydrodissection and Hydrodelineation
• 11. Nucleus delivery (in conventional ECCE and
  SICS) / Phacoemulsification of nucleus (in
  phacoemulsification, machine , through titanium
  needle provides energy for emulsification of
  nucleus, needle vibrates at an speed of 20,000 Hz
  and pulverizes the nucleus)

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Steps of ECCE

• 12. Cortical clean up by aspiration and
  irrigation (BSS or Ringer lactate is used as
  irrigating fluid)
• 13. Filling of lens capsule (capsular bag) with
  OVD
• 14. Insertion of posterior chamber IOL (in the
  bag, in case of complications in the ciliary
  sulcus)

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Steps of ECCE

• 15. Removal of OVD from anterior chamber
• 16. Closure of wound of entry (corneoscleral
  wound requires sutures 10-0 silk or nylon), phaco
  and SICS incisions are self sealing.

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Complications of Cataract Surgery

• Due to local anesthesia Retrobulbar haemorrhage,
  globe perforataion, oculocardiac reflex etc.
• Intra-operative complications detachment of
  descemets membrane, damage to corneal
  endothelium, zonular dialysis, posterior capsular
  rupture

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Complications of cataract Surgery

• III. Early post-operative complications wound
  leak and complications related to it (iris
  prolapse, flat anterior chamber), secondary
  glaucoma, postoperative infection, lens matter
  induced uveitis etc.

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Complications of Cataract Surgery

• IV. Late post-operative complications cystoid
  macular edema, posterior capsular opacification,
  corneal endothelial decompensation causing
  corneal edema, retinal detachment, displacement
  of IOL etc.