(2) According to the age (Surgical classification) SoftHard Below 25 Y.O.After 25 Y.O. (3) According to the site CapsularNuclearCortical
* Congenital Cataract * N.B.: - C ongenital Cataract: = Lens opacity present at birth. - Infantile Cataract: = Lens opacity that develop during the 1 st year of life. - These 2 terms are fused together & some physicians prefer the term developmental cataract.
1- Anterior Polar Cataract Etiology: * Congenital - B ilateral. - Occurring at the time of the lens vesicle separation from surface ectoderm resulting in delayed formation ant. Chamber with contact between ant. Pole & cornea. * Acquired - U nilateral. - Due to small central perforation of corneal ulcer.
Clinical Picture: * Symptoms (By parents) - W hite dot at the center of the pupil * Signs - S mall white opacity in the center of the pupil at the ant. pole of the lens. - No marked visual affection (as it is far from the nodal point).
2- Posterior Polar Cataract Etiology: - Persistence of hyaloid artery. Clinical Picture: * Symptoms: U sually no symptoms. * Signs: - Disc shaped opacity at the post. Pole. - Marked visual affection due to it is near to nodal point.
3- polar Cataract Etiology: 1) Hereditary. 2) Malnutrition of the mother during pregnancy. Clinical Picture: * Symptoms: - White colour of the pupil. - Child doesn’t see well.
* Signs: 1) Diffuse illumination: - C entral disc opacity with clear lens around it. - There may be linear extensions. 2) Slit lamb examination: - O pacity arranged in one or many concentric zones. - l ens substance outside & inside the affected zones are clear. 3) Red Reflex: - D im central. - Bright peripheral
4- Coronary Cataract Developmental Cataract. Appears at puberty due to defect in the growth of lens fibers at childhood. Appear clinically as a corona of oval opacities near the periphery.
5- Punctate Cataract Developmental Cataract. Multiple small bluish dots scattered all over the lens. 6- Total Cataract The lens is opaque. Etiology: Infection of the mother in the first 3 months of pregnancy by Rubella virus.
Complications of congenital cataract: Occurs only if the opacity affects the vision: - Unilateral cataract: Squinting of the eye. - Bilateral cataract: Nystagmus.
Management of a case of congenital Cataract Evaluation Indication of surgery Surgical techniques Correction of Aphakia
(1) Evaluation: A - The Eyes: - unilateral versus Bilateral. - Density. - Morphology. - Visual functions. Q) How can you test visual acuity during infancy? - B y special tests as Preferential looking. B- The patient: -E-Examined by Pediatrician for any congenital anomaly. C- Parents: -M-May gives clue to the etiology.
(2) Indications of surgery: A) Bilateral advanced cataract: s urgery at once. B) Bilateral & fundus can be seen: d on’t require surgery. C- Bilateral & fundus seen only by indirect ophthalmoscope: - Good near vision: P ostpone surgery. - Poor near vision: S urgery at once.
(3) Surgical techniques: Old Operations: 1 - Needling operation. 2- Needling & curette op. * Complications of old operations: - d ense after cataract. - Secondary iritis. - Secondary glaucoma. - Delayed unexplained retinal detachment.
(4) Correction of Aphakia 1 - Contact lens. 2- Epikeratophakia. Q) Why we don’t do ICCE??? - P resence of strong zonules & strong hyaloid capsular ligament.
Acquired Cataract 1- Senile Cataract: Def. - B ilateral progressive lens opacity affecting the old people not suffering from local or general diseases. Etiology: U nknown But theories: 1- Disturbance of lens capsule permeability. 2- Disturbance in lens metabolism. 3- Ultraviolet rays. 4- Endocrinal disturbance. 5- Hereditary.
Classification: - Cortical: M ost common type. - Nuclear. - Cortico-nuclear. Pathology : -H-Hydration. -C-Coagulation of lens proteins.
Senile Cortical Cataract C/P: - Symptoms – 1) gradual painless diminution of vision. 2) Fixed black spots. 3) Diminution of vision at night??. 4) Uniocular diplopia or polyopia. 5) Index myopia??. 6) Change in colour value.
- Signs - hypermatureMatureImmature The lens is not totally opaque Lens loses water & shrinks (Typical ) The whole cortex become opaque in front & behind the nucleus. Intumescent.Incipient. Pathology The opacity inc. associated with breakdown of lens proteins. Opacity begins as sectors from the periphery of the cortex in front & behind the nucleus Lens show: - Thickened caps. - White dots of Ca. - Yellow dots of cholesterol. Uniformly grayish white. Fluid vacuolesOpacities grey against black background Oblique illumination +ve-ve+ve Iris shadow DeepNormalShallowNormal Ant. Cham. Absent.AbsentSeen with difficultyBlack sectors against red background R. Reflex. H.M. Marked decrease.Slightly dec. especially at night. V.A May be raised.NormalMay be raisedNormal Tension
N.B. 1. Secondary glaucoma in intumescent cataract due to Phacomorphic glaucoma. 2. Secondary glaucoma due to hypermature cataract is called phacolytic glaoucoma. 3. Morgagnian cataract: one of hypermature stage. If present = Atypical hypermature. 4. Incipient cataract & senile nuclear sclerosis = Grey pupil. Differentiated by red reflex.
Complications 1. Sec. glaucoma. 2. Subluxation or dislocation of the lens due to degenerations of the zonules. 3. Sec. uveitis. 4. Endophthalmitis phacoanaphylactica.
Senile Nuclear Cataract Senile nuclear sclerosis: - P hysiological process. - Old lens fibers becomes compressed towards the center with loss water. So nucleus increase in size & volume but remains transparent.
Senile nuclear cataract - P athological senile nuclear sclerosis in which the transparency is affected. oSoSymptoms: 1 ) Gradual diminution of vision. 2) Defective vision at day “Photopic vision” 3) Index myopia.
S Signs: oDoDo not the stages of cortical cataract. o Red reflex: red ring around opacity. oDoDue to deposition of melanin formed tyrosine, Lens may have a color: o 1- Black: Cataract nigra. o 2- Brown: Cataracta Brunescence.
- Differential Diagnosis: 1- Gradual painless diminution of vision: 1ry optic atrophyO.A. glaucomaSenile cataractCharacter > 35 Y.O. Males more. Of the cause. > 50 Y.O. Equal Field lose >50 Y.O. Equal. Fixed black spots. (1) History: 1- Age: 2- Sex: 3- Other symptoms: Normal. Absent with dilated pupil. Normal White disc. shallow cup Peripheral contraction Normal Normal outflow. Normal Present Normal Glauc. Disc cupping. Glauc. Field defects. Raised. Impaired outflow Grayish Present Abnormal Normal Normal outflow (2) Signs: 1- Pupil color: 2- D. Light reflex: 3- Red reflex: 4- Fundus: 5- field: 6- Tension: 7- Tomography: 2- Incipient from senile nuclear sclerosis: By R. reflex.
Treatment II.C.C.E with or without I.O.L implantation. EE.C.C.E // // // // // PPhaco-emulsification with or without I.O.L implantation.
Traumatic Cataract Lens opacity as a result of ocular trauma. According to the type of trauma Sharp trauma Small but high speed F.B Large but low speed F.B Linear opacity Cloudy swollen with rupture capsule Blunt trauma Usually cause post. Cortical rosette shaped Cat.
Complications : - - Iritis. - 2ry glaucoma Treatment: 11- Medical: Immediately after trauma, * Rest * Atropine * Cortisone. 22- Surgical : Later, * If light projection is good, indicating good retinal function.
NN.B.1 : I n Blunt trauma we may find Vossius ring “ Brown ring on the ant. Lens capsule cue to impress of the pupillary border or the iris on the lens. NN.B.2 : Electrical trauma: - D ue to passage of high electric current through the body. - May occur within days or after years. - Pathology: C hange in lens capsule p ermeability. - Morphology: S ubcapsular vacuoles causing opacity.
Complicated Cataract Lens opacity due to local disease in the eye. EEtiology: - C onjunctiva. - Cornea: Sever corneal ulcer. - Sclera: Acute scleritis. - Uveal tract: Iridocyclitis. - Lens: Subluxation & dislocation. - Glaucoma. - Retina: R.D., R.P. & retinoblastoma.
Pathology: - I nterference with lens nutrition. - Effect of toxins present in aqueous or vitreous. N.B. Why lens opacity is usually posterior cortical?? oToThin posterior capsule. oNoNo protective subcaosular epithelium.
TTypes: 1 ) Anterior segment. 2) Posterior segment. -I-In both types: W hen the whole lens become opaque, it may be difficult to differentiate from senile cataract. TTreatment: 1) Cataract operation. 2) According to the cause.
Pathological Cataract Lens opacity due to systemic disease. 1) Diabetic Cataract: a- True: - Y oung patient with uncontrolled D.M. - Milky white dots under ant. & post. capsule. - Soon, the whole lens become opaque. b- False: T he same as senile but earlier. * Treatment : C ataract extraction after control of diabetes.
2) Hypoparathyroid Cataract: - L ow serum calcium which is important for lens metabolism. - Subcapsular opacities “Malformation of new lens fibers”. - Treatment: E.C.C.E & I.O.L. 3) Ankylostoma Cataract: Due to: - A nemia “Malnutrition of the lens”. - Ankylostoma toxins.
Deficiency cataract - Interfere with normal lens nutrition or metabolism. a- Galactosaemia. b- Mannosidosis. c- Fabry’s disease. d- Deficiency of vit. C or D. Occupational cataract - G lass blowers cataract.
Radiation Cataract X -rays & Gamma rays -P-Pathology: * Injury to the lens fibers directly. * Injury to the cilliary body: A bnormal aqueous Disturbance of lens nutrition Opacity in posterior cortex. Toxic cataract - Anterior subcapsular: M iotics, Gold. -P-Posterior subcapsular: C orticosteroids “ topically or systematically”.