Cataract associated with Cataract associated with systemic diseases and systemic diseases and

management of Cataractmanagement of Cataract

Complicated CataractComplicated Cataract

Cataract associated with ocular diseases:Cataract associated with ocular diseases:Complicated Cataract : is due to Complicated Cataract : is due to

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

Complicated CataractComplicated Cataract

Cataract has characteristic Cataract has characteristic breadcrumb appearance and rainbow breadcrumb appearance and rainbow display of colours (polychromatic display of colours (polychromatic lustre). lustre).

Vision is usually affected even in Vision is usually affected even in early stages as opacity is near the early stages as opacity is near the nodal point of the eye. nodal point of the eye.

Complicated CataractComplicated Cataract

Prognosis depends on the causative Prognosis depends on the causative condition.condition.

All cases of cataract without obvious All cases of cataract without obvious cause should be carefully looked for cause should be carefully looked for keratic precipitates or evidences of keratic precipitates or evidences of pars planitis.pars planitis.

Cataract associated with Cataract associated with systemic disease systemic disease

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

Diabetic CataractDiabetic Cataract

The lens rapidly becomes The lens rapidly becomes cataractous with dense, white cataractous with dense, white anterior and posterior subcapsular anterior and posterior subcapsular cortical cataract resembling cortical cataract resembling snowstorm “snowflake Cataract”.snowstorm “snowflake Cataract”.

If diabetes is controlled If diabetes is controlled appropriately, the rapid progression appropriately, the rapid progression to mature cataract may be arrested.to mature cataract may be arrested.

Cataract associated with Cataract associated with systemic diseasesystemic disease

Parathyroid TetanyParathyroid Tetany Myotonic DystrophyMyotonic Dystrophy GalactosaemiaGalactosaemia Down SyndromeDown Syndrome Atopic CataractAtopic Cataract

Objective Examination Objective Examination

The state of the nucleus (grading of The state of the nucleus (grading of nuclear sclerosis)nuclear sclerosis)

The state of the cortexThe state of the cortex The presence or absence of signs of The presence or absence of signs of

inflammationinflammation Pupillary glow by transilluminationPupillary glow by transillumination B- Scan ultrasonographyB- Scan ultrasonography

Functional TestsFunctional Tests

Pupillary reactionPupillary reaction Projection of lightProjection of light Macular function test – two pinholes Macular function test – two pinholes

test and Maddox rod testtest and Maddox rod test Entoptic view of the retina : Auto-Entoptic view of the retina : Auto-

ophthalmoscopy ophthalmoscopy Electro-retinographic record, Electro-retinographic record,

particularly of macula.particularly of macula.

Pre-operative evaluation Pre-operative evaluation

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

Pre-operative evaluationPre-operative evaluation

Systemic examination to exclude Systemic examination to exclude hypertension, cardiovascular hypertension, cardiovascular disorder, cerebro-vascular disease, disorder, cerebro-vascular disease, chronic obstructive air way disorder chronic obstructive air way disorder etc. If any disorder is present, it etc. If any disorder is present, it should be adequately controlled should be adequately controlled before surgerybefore surgery

ENT and Dental checkup to exclude ENT and Dental checkup to exclude septic focusseptic focus

Treatment of cataractTreatment of cataract

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

Treatment of cataractTreatment of cataract

Surgical Treatment:Surgical Treatment:

Indication for surgery:Indication for surgery:

1. Cataract – when routine work becomes 1. Cataract – when routine work becomes difficult due to reduced vision (attributable difficult due to reduced vision (attributable to cataract)to cataract)

2. Subluxated or dislocated lens2. Subluxated or dislocated lens

3. Lens induced complications like 3. Lens induced complications like phacolytic uveitis / glaucoma, phacolytic uveitis / glaucoma, phacoanaphylactic endophthalmitis, phacoanaphylactic endophthalmitis, phacomorphic glaucoma.phacomorphic glaucoma.

Treatment of cataractTreatment of cataract

Surgical Treatment: Surgical Treatment:

OptionsOptions

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

Surgical Treatment of Surgical Treatment of CataractCataract

II. Extracapsular Cataract Extraction II. Extracapsular Cataract Extraction (ECCE): (ECCE):

Methods –Methods –

1. Conventional ECCE1. Conventional ECCE

2. ECCE by small incision cataract surgery 2. ECCE by small incision cataract surgery (SICS)(SICS)

3. Lensectomy3. Lensectomy

4. Phacoemulsification 4. Phacoemulsification

Steps of ECCESteps of ECCE

1.1. Anaesthesia Anaesthesia

a. General Anaesthesia : In children, a. General Anaesthesia : In children, psychiatric patients, senile dementia psychiatric patients, senile dementia

b. Local anaesthesia: Retrobulbar b. Local anaesthesia: Retrobulbar block, peribulbar block, along with or block, peribulbar block, along with or without facial block , topical without facial block , topical anaesthesiaanaesthesia

Steps of ECCESteps of ECCE

2. Cleaning of lids with 5% betadine 2. Cleaning of lids with 5% betadine solution and instillation of betadine solution and instillation of betadine solution in conjunctival sac solution in conjunctival sac

3. Draping3. Draping

4. Superior Rectus suture in case of 4. Superior Rectus suture in case of conventional ECCE and SICSconventional ECCE and SICS

5. Conjunctival flap in case of SICS5. Conjunctival flap in case of SICS

Steps of ECCESteps of ECCE

6. Scleral tunnel incision or Corneo-6. Scleral tunnel incision or Corneo-scleral section or corneal or corneal scleral section or corneal or corneal tunnel incisiontunnel incision

7. Anterior chamber entry7. Anterior chamber entry8. Injection of ocular viscosurgical 8. Injection of ocular viscosurgical

device (OVD) in anterior chamber device (OVD) in anterior chamber (HPMC or Sodium Hyaluronate) (HPMC or Sodium Hyaluronate)

9. Capsulotomy ( can opener or 9. Capsulotomy ( can opener or continuous curvilinear capsulorrhexis, continuous curvilinear capsulorrhexis, CCC)CCC)

Steps of ECCESteps of ECCE

10. Hydrodissection and Hydrodelineation10. Hydrodissection and Hydrodelineation11. Nucleus delivery (in conventional 11. Nucleus delivery (in conventional

ECCE and SICS) / Phacoemulsification of ECCE and SICS) / Phacoemulsification of nucleus (in phacoemulsification, nucleus (in phacoemulsification, machine , through titanium needle machine , through titanium needle provides energy for emulsification of provides energy for emulsification of nucleus, needle vibrates at an speed of nucleus, needle vibrates at an speed of 20,000 Hz and pulverizes the nucleus) 20,000 Hz and pulverizes the nucleus)

Steps of ECCESteps of ECCE

12. Cortical clean up by aspiration and 12. Cortical clean up by aspiration and irrigation (BSS or Ringer lactate is irrigation (BSS or Ringer lactate is used as irrigating fluid)used as irrigating fluid)

13. Filling of lens capsule (capsular 13. Filling of lens capsule (capsular bag) with OVDbag) with OVD

14. Insertion of posterior chamber IOL 14. Insertion of posterior chamber IOL (in the bag, in case of complications (in the bag, in case of complications in the ciliary sulcus) in the ciliary sulcus)

Steps of ECCESteps of ECCE

15. Removal of OVD from anterior 15. Removal of OVD from anterior chamberchamber

16. Closure of wound of entry 16. Closure of wound of entry (corneoscleral wound requires (corneoscleral wound requires sutures 10-0 silk or nylon), phaco sutures 10-0 silk or nylon), phaco and SICS incisions are self sealing. and SICS incisions are self sealing.

Complications of Cataract Complications of Cataract SurgerySurgery

I.I. Due to local anesthesia: Due to local anesthesia: Retrobulbar haemorrhage, globe Retrobulbar haemorrhage, globe perforataion, oculocardiac reflex perforataion, oculocardiac reflex etc. etc.

II.II. Intra-operative complications : Intra-operative complications : detachment of descemet’s detachment of descemet’s membrane, damage to corneal membrane, damage to corneal endothelium, zonular dialysis, endothelium, zonular dialysis, posterior capsular rupture posterior capsular rupture

Complications of cataract Complications of cataract Surgery Surgery

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

Complications of Cataract Complications of Cataract SurgerySurgery

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