developmental cat

8/12/2019 Developmental Cat

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Congenital / DevelopmentalCataract

Copy of power point presentation of lecture

taken for junior final year by

Dr Sanjay ShrivastavaProfessor of Ophthalmology

Gandhi medical College, Bhopal (M.P.)


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18 June 2014 Dr Sanjay Shrivastava 2

Classification of Cataract

1. Developmental

2. Age related (senile)

3. Cataract associated with ocular diseases4. Cataract associated with systemic

diseases (pre-senile)

5. Traumatic Cataract6. Drug induced cataract


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Developmental Cataract

When cataract is present at birth it is called

congenital.

Types

1. Punctate: most common manifestation, in itsminute form it is of universal occurrence.

Multiple small opaque spots are seen scattered

all over the lens. Types:

a. Blue dot appearing as tiny blue dots in

oblique illumination.


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Punctate Cataract

b. Sutural when opaque spots are

crowded in the Y sutures

c. Central Pulverulent Cataract

Autosomal dominant inherited, non-

progressive, central spheroidal or

biconvex opacity consisting of fine white

powdery dots within embryonic or fetalnucleus.


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Developmental Cataract.. Types

2. Zonular Cataract: accounts for approximately

50% of all visually significant congenital

cataracts.

Etiology May have a genetic origin with astrong hereditary tendency of autosomal

dominant type. They may have an

environmental origin, due to malnutrition at late

intra-uterine or early infantile life and Vitamin Ddeficiency. Patient may have Rickets and

defective enamel of permanent teeth.


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Zonular Cataract

Zone around embryonic nucleus, usually area offetal nucleus is affected and opacified. Its extentdepends on the duration of the inhibiting factor.Sharply demarked opacity, area within andaround opacity is clear; with linear opacitiesresembling spokes of a wheel (riders) runningtowards equator.

Such cataracts are usually bilateral formed justbefore or shortly after birth, may be sufficient indiameter to fill the pupillary area and vision isaffected.


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Developmental Cataract- types

3. Fusiform CataractSpindle shaped,

axial or coralliform. There is antero-

posterior spindle shaped opacity

sometimes with offshoots giving anappearance of coral.

Discoid Cataract is disc shaped opacity in

posterior cortex behind nucleus.


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Nuclear Cataract

Other congenital deformities like,

congenital heart disease (PDA),

microphthalmos, micrencephaly, mental

retardation, deafness and dentalanomalies may be associated.

If the lens matter remains in eye during

surgery, it is followed by a chronicinflammatory endophthalmitis.


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Nuclear Cataract

Prevention of rubella by administration of MMR

vaccine or rubella vaccine to pre-pubertal girls or

women planning to have child may be

considered to prevent this condition. Medical termination of pregnancy may be

considered if evidence of rubella infection is

confirmed during 2ndor 3rdmonth of pregnancy

to prevent birth of a child with multiple congenitalanomalies.


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Developmental Cataract - Types

5. Coronary Cataract: It is a developmentalcataract, similar to zonular cataract,occurring around puberty. Situated in deep

layer of the cortex and the most superficiallayers of adolescent nucleus. Appears ascorona of club shaped opacities atperiphery, hidden by iris. Axial area and

periphery of lens remains clear. Vision isusually not affected. These opacities arenon-progressive.


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Developmental Cataract - Types

6. Anterior Capsular (polar) Cataract: may be dueto delayed development of anterior chamber(congenital cataract) or due to contact of anteriorlens capsule and posterior surface of corneadue to perforation of ulcer, as in case ofophthalmia neonatorum.

Types Anterior Polar, Pyramidal Cataract andReduplication cataract

Usually these opacities are non-progressive andrarely interfere with vision.


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Developmental Cataract Types

7. Posterior Capsular (Polar) Cataract: Is

due to persistence of the posterior part of

vascular sheath of the lens. In minimal

degree it is common and usually isinsignificant.

Sometimes in cases of persistent hyaloid

artery, the lens is deeply invaded byfibrous tissue and a total cataract forms.


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Etiology of Developmental Cataract

Usually unknown

Maternal (and infantile) malnutrition

Maternal Viral (rubella) infection

Placental Haemorrhage causing deficient

oxygenation

Hypocalcaemia

Chromosomal abnormality (Down syndrome) Metabolic disorders (galactosaemia)


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Symptoms of Developmental

Cataract

Informant usually parents

History of white spot in pupillary area

Child is usually brought with history ofdiminution of vision / does not recognizeobjects and parents

Unsteady eyes

Deviation of eye Associated symptoms of systemic

disease, if present


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Signs

Diminished vision (at times it is difficult toestablish in very young children)

Lenticular opacity

Nystagmus

Deviation of eye, usually convergentsquint

There may be other ocular and systemicabnormalities in cases of rubella nuclearcataract


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Management of Developmental

CataractI. Investigations:

1. Detailed history

2. Detailed clinical examination- visual status,

intra-ocular tension, fundus examination, Bscan ultrasonography to exclude posterior

segment abnormality like growth/

retinoblastoma, A scan to determine axial

length of the eye, retinoscopy and cover test

to exclude squint.


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Cataract

B. Urine analysis:

For reducing substance for

galactosaemia

For amino acids (to exclude Lowe

syndrome in suspected cases)


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Cataract

B. Treatment

1. Timing of surgery

a. Bilateral Dense cataract

by 6weeks

b. Bilateral partial if vision is not

significantly affected, surgery may bedelayed up to the age of 2 years or up to

puberty


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Cataract

c. Uniocular dense cataract- urgent

surgery within days

d. Partial Uniocular cataract- if vision is

not significantly affected, surgery may be

delayed up to the age of 2 years or up to

puberty


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Cataract2. Treatment options

* No treatment if vision is not affectedsignificantly

* Mydriatics- if opacity is central and visionimproves with mydriatics

* In cases in Rubella Cataract operation maybe delayed till 1-2 years of age. But early

surgery may be indicated if cataract is total,squint and nystagmus is developing.


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Cataract* Uniocular cataract if vision is affected

then early surgery, preferably within first sixweeks of birth with immediate fitting of contactlens.

* Fixation develops between 2-4 months ofage, therefore any cataract interfering with visionshould be dealt before this age, and the earliestpossible time is preferred

* Medical/ Paediatric fitness for anaesthesiashould be obtained.


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Cataract

3. Operative procedure

a. Aspiration and irrigation (ECCE)

b. Lensectomy (Pars plana or anteriorroute)

c. Aspiration and irrigation (ECCE) with

primary posterior capsulotomy with partial

anterior vitrectomy


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Cataract

4. Post-operative visual rehabilitation:

a. Posterior Chamber IOL (PMMA or

acrylic polymer foldable lens) in patients

who are more than two years in age,

Uniocular cataract where contact lens

fitting is not possible/ practical.

b. Contact lens after surgery for

uniocular cataract at very young age.


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Cataract

c. Aphakic Spect- In bilateral cataract

operated cases below the age of two

years. These cases are implanted

posterior chamber IOL as secondaryprocedure at later age.

d. Occlusion therapy for treatment of

amblyopia / prevention of amblyopia.


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Post-operative complications

Posterior capsular opacification

Secondary membrane formation

Proliferation of lens epithelium(Sommerring ring)

Glaucoma

Retinal detachment

developmental cat

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