CCATARACTATARACT

HistoryHistory

CataractCataract (Greek: 1000 BC)(Greek: 1000 BC)

Waterfall or flowing down Waterfall or flowing down

An inspissated humor which had seeped from the An inspissated humor which had seeped from the

brain into the space between the cornea and irisbrain into the space between the cornea and iris

HistoryHistory

CouchingCouching Push the cataract away from the visual line Push the cataract away from the visual line

(2300BC – 17th century)(2300BC – 17th century)

ECCEECCE Jacques Daviel Jacques Daviel (1747) (1747) : reported 115 surgeries with : reported 115 surgeries with

100 successes 100 successes (1753)(1753)

ICCEICCE Sharp Sharp (1753)(1753) & George de la Faye & George de la Faye (1752)(1752)

Cataract problemCataract problem

What is blindness?What is blindness?

WHO classification of visual impairmentWHO classification of visual impairment

C r i t e r i a S n e l l e n NormalNormal 6/6 to 6/186/6 to 6/18

Visual impairmentVisual impairment <6/18 to 6/60<6/18 to 6/60

Severe visual impairmentSevere visual impairment <6/60 to 3/60<6/60 to 3/60

Blind < 3/60

How many are blind?How many are blind?

Total blindness Total blindness (2000)(2000) 50 million blind individuals50 million blind individuals 110 million visually impaired 110 million visually impaired

Prevalence of blindness :Prevalence of blindness : 0.25% in 0.25% in goodgood economy & health service countries economy & health service countries 0.50% in 0.50% in reasonablereasonable economy & health service countries economy & health service countries 0.75% in 0.75% in poorpoor economy & health service countries economy & health service countries 1%+ in 1%+ in very poorvery poor economy & health service countries economy & health service countries

Global blindnessGlobal blindness

28 3138

50

70

0

10

20

30

40

50

60

70

80

1975 1984 1990 2000 2020

Mill

ion

Joseph Mallord Joseph Mallord William TurnerWilliam Turner1775 – 18511775 – 1851

CataractCataract

Joseph Mallord William TurnerJoseph Mallord William Turner1775 – 18511775 – 1851

Severe cataractSevere cataract

Claude MonetClaude Monet1840 – 19261840 – 1926

After a cataract operation he was shocked by the blueness of his worldAfter a cataract operation he was shocked by the blueness of his world

Why are people blind?Why are people blind?

Etiology Etiology (2000)(2000) CataractCataract : 25.0 Millions: 25.0 Millions (50%)(50%) GlaucomaGlaucoma : 8.0 “ : 8.0 “ (16%)(16%) Corneal scar / trachoma Corneal scar / trachoma : 5.0 “: 5.0 “ (10%)(10%) Diabetic retinopathy Diabetic retinopathy : 3.0 “: 3.0 “ ( 6%)( 6%) ARMDARMD : 2.0 “: 2.0 “ ( 4%)( 4%) Refractive errorsRefractive errors : 2.0 “: 2.0 “ ( 4%)( 4%) Vit. A deficiencyVit. A deficiency : 0.5 “: 0.5 “ TraumaTrauma : 1.0 “: 1.0 “ Childhood blindnessChildhood blindness : 1.0 “: 1.0 “ OthersOthers : 1.5 “: 1.5 “

Distribution?Distribution?

25%

25%

20%

20%

10%

Rest of Asia India Africa China America & Europe

Cataract surgeryCataract surgery

USA : 2 million annuallyUSA : 2 million annually

Indonesia : 60,000 cases annuallyIndonesia : 60,000 cases annually New cases : 210,000 / yearNew cases : 210,000 / year Back log : 150,000 cases / yearBack log : 150,000 cases / year

United StatesUnited States IndiaIndiaPopulationPopulation 240 million240 million 800 million800 million

Cataract prevalenceCataract prevalence

52-64 y.o52-64 y.o

65-7465-74

75-8475-84

55

1818

4646

2929

4343

8282

Blindness attributeBlindness attribute 9 %9 % 55%55%

OphthalmologistsOphthalmologists 11,00011,000 3,5003,500

Cataract surgeries / yearCataract surgeries / year 1,500,0001,500,000 1,000,0001,000,000

Chatterjee et al. Br J Ophthalmol 1982; 66

Dept of Ophthalmology - Dept of Ophthalmology - UIUI

Cataract surgery Jan – Dec 2001Cataract surgery Jan – Dec 2001 ECCEECCE : 73: 73 ECCE IOLECCE IOL : 560: 560 ICCE IOLICCE IOL : 6: 6 PhacoPhaco : 16: 16 Phaco IOLPhaco IOL : 564: 564

Cataract cases = 1219Cataract cases = 1219

Total ALL surgeries 2001 = 1600Total ALL surgeries 2001 = 1600

Ratio : Social / Private = 768 / 832Ratio : Social / Private = 768 / 832

Normal lensNormal lens

StructureStructure 90% protein 90% protein divided into 2 large classes divided into 2 large classes

Soluble proteins Soluble proteins (80%)(80%) Hydrophilic proteins : Hydrophilic proteins : -, -, -, -, - crystallins - crystallins

Insoluble proteins Insoluble proteins (20%)(20%) Membrane, cytoskeletal proteinsMembrane, cytoskeletal proteins

Transparency :Transparency : Regularity / uniform packing of crystallinsRegularity / uniform packing of crystallins

Pathogenesis of Pathogenesis of cataractscataracts

Many factors involvedMany factors involved Two fundamental processesTwo fundamental processes

Cortex : imbalance in electrolytes Cortex : imbalance in electrolytes overhydration overhydration of lens of lens liquefaction of the lens fibers liquefaction of the lens fibers

Nucleus : modification of lens protein Nucleus : modification of lens protein protein protein aggregationaggregation

Those changes cause light scattered within Those changes cause light scattered within the lens and reducing transparencythe lens and reducing transparency

Cortical cataractsCortical cataracts

Involves changes in electrolyte and water Involves changes in electrolyte and water balance : osmotic type of cataractbalance : osmotic type of cataractNormal lensNormal lens Low sodium & high potassium contentLow sodium & high potassium content Proper balance by cation pump in lens Proper balance by cation pump in lens

epitheliumepithelium

Cortical cataract Cortical cataract Membrane permeability to sodium ion Membrane permeability to sodium ion

increase increase High sodium & low potassium, High sodium & low potassium,

Nuclear cataractsNuclear cataracts

Physical chemical changes of the lens Physical chemical changes of the lens structure protein (crystallin)structure protein (crystallin) OxidationOxidation Ultraviolet-induced oxidationUltraviolet-induced oxidation Proteolysis, glycation, deamidation, Proteolysis, glycation, deamidation,

racemization, transpeptidation, aggregationracemization, transpeptidation, aggregation

DiagnosisDiagnosis

Visual acuityVisual acuity

IOPIOP

Iris / pupilIris / pupil

CorneaCornea

LensLens

DiagnosisDiagnosis

Cataract is easy Cataract is easy to diagnose to diagnose when pupil is when pupil is dilateddilated

Intraocular Intraocular pressure (IOP)?pressure (IOP)?

Sumatera SelatanSumatera Selatan

Prevalensi angka kebutaan sebesar 1,5 Prevalensi angka kebutaan sebesar 1,5 (berdasar survey kesehatan indera 1993-(berdasar survey kesehatan indera 1993-1996) 1996)

Jumlah penduduk Sumatera Selatan Jumlah penduduk Sumatera Selatan 6.486.015 jiwa ( thn. 2003 ) 6.486.015 jiwa ( thn. 2003 )

Angka kebutaan 1,5% : 97290 jiwa Angka kebutaan 1,5% : 97290 jiwa penderita penderita

Analisis situasiAnalisis situasiEpidemiologiEpidemiologi Prevalensi katarak 0.78% dari jumlah Prevalensi katarak 0.78% dari jumlah

pendudukpenduduk1.7 juta dari 210 juta penduduk1.7 juta dari 210 juta penduduk

Insidens 0.1% per tahunInsidens 0.1% per tahun210,000 kasus baru kebutaan katarak / tahun210,000 kasus baru kebutaan katarak / tahun

Sumatera SelatanSumatera Selatan: 50.590 : 50.590 dari dari 6.486.015 6.486.015 pendudukpenduduk

Insidens 0.1% per tahunInsidens 0.1% per tahun6.486 kasus baru kebutaan katarak / tahun6.486 kasus baru kebutaan katarak / tahun

Analisis situasiAnalisis situasi

Jumlah dokter mata 2002Jumlah dokter mata 2002 800 dokter ( 25 )800 dokter ( 25 ) 200 resident (25 )200 resident (25 )

Rata-rata operasi katarak 70,000 / thRata-rata operasi katarak 70,000 / th Setara dengan 2 kasus / minggu / Sp.MSetara dengan 2 kasus / minggu / Sp.M

Insidens 210,000 / th ( 6.486 )Insidens 210,000 / th ( 6.486 )

Cataract backlog 140,000 / th ( 4.000)Cataract backlog 140,000 / th ( 4.000)

Analisis situasiAnalisis situasi

Dimana kita sekarang ?Dimana kita sekarang ?

Perlu data demografiPerlu data demografi

Jumlah penderita katarak di daerah masing-Jumlah penderita katarak di daerah masing-masingmasing

Proporsi pendudukProporsi penduduk Berapa persen usia > 50 thBerapa persen usia > 50 th

Persentase penderita buta hurufPersentase penderita buta huruf Indikator sosial ekonomiIndikator sosial ekonomi

Berapa jumlah operasi katarak / tahun untuk :Berapa jumlah operasi katarak / tahun untuk : Mengatasi insidensMengatasi insidens Mengatasi prevalensMengatasi prevalens

Data infrastrukturData infrastruktur

Jumlah rumah sakitJumlah rumah sakit

Jumlah dokter spesialis mataJumlah dokter spesialis mata

Jumlah puskesmasJumlah puskesmas

Jumlah dokter umum, refraksionis, Jumlah dokter umum, refraksionis, perawat mahir mataperawat mahir mata

TargetTarget

80% dokter mata melakukan operasi80% dokter mata melakukan operasi 12 operasi / minggu12 operasi / minggu

25% kenaikan CSR (cataract surgical rate) 25% kenaikan CSR (cataract surgical rate) / tahun sejak tahun 2005/ tahun sejak tahun 2005 CSR = jumlah operasi / 1 juta pendudukCSR = jumlah operasi / 1 juta penduduk

Alternatif Alternatif penanggulanganpenanggulangan

Penyuluhan memanfaatkan kaderPenyuluhan memanfaatkan kader

Advokasi kepada PemdaAdvokasi kepada Pemda

Pendekatan kepada pengusahaPendekatan kepada pengusaha

Thank Thank youyou

One blind person – a tragedy.One blind person – a tragedy.Ten blind persons – a disaster.Ten blind persons – a disaster.

One million blind persons – a One million blind persons – a statistic.statistic.

ReferencesReferences1.1. Apple DJ, Ram J, et al. Elimination of cataract blindness : a global Apple DJ, Ram J, et al. Elimination of cataract blindness : a global

perspective entering the new millennium. Surv Ophthalmoloy 2000; 45 perspective entering the new millennium. Surv Ophthalmoloy 2000; 45 (supl.1); (supl.1);

2.2. Adelman RA, Brauner BA, et al. Cataract formation after initial Adelman RA, Brauner BA, et al. Cataract formation after initial trabeculectomy in young patients. Ophthalmology 2003: 110;625trabeculectomy in young patients. Ophthalmology 2003: 110;625

3.3. Oyster CW. The human eye structure and function.Massachusetts : Oyster CW. The human eye structure and function.Massachusetts : Sinauer Associate Inc. 1999Sinauer Associate Inc. 1999

4.4. Kwitko ML, Kelman CD. The history of modern cataract surgery. Kwitko ML, Kelman CD. The history of modern cataract surgery. Netherlands : Kugler publications, 1998.Netherlands : Kugler publications, 1998.

5.5. Jaffe NS, Jaffe MS, Jaffe GF. Cataract surgery and its complications. 6th Jaffe NS, Jaffe MS, Jaffe GF. Cataract surgery and its complications. 6th Ed. St. Louis : Mosby, 1997Ed. St. Louis : Mosby, 1997

6.6. Steinert RF, Fine HI, Gimbel HV, Lindstrom RL. Cataract surgery : Steinert RF, Fine HI, Gimbel HV, Lindstrom RL. Cataract surgery : technique, complications & management. Philadelphia : WB Saunder, technique, complications & management. Philadelphia : WB Saunder, 19951995

7.7. Lu LW, Fine IH. Phacoemulsification in difficult and challenging cases. Lu LW, Fine IH. Phacoemulsification in difficult and challenging cases. New York : Thieme, 1999New York : Thieme, 1999