Age related Cataract

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Age related Cataract

  1. 1. Age Related Cataract (Senile Cataract) Drug Induced Cataract Traumatic Cataract By Prof. Naimatullah Khan Kundi Head, Department of Ophthalmology Khyber Teaching Hospital Peshawar
  2. 2. AGE RELATED CATARACT (SENILE CATARACT)
  3. 3. Lens & Cataract (Pathology) Aging Chances Age related cataract (Senile Cataract)      Very common cause of visual impairment in older adults 50-70% between ages 60-75yrs Pathogenesis:      Multifactorial and not completely understood. As lens ages its wt. ↑ Thickness ↑ Accommodative power ↓ Lens Nucleus compressed and hardened (Nuclear Sclerosis) as new layers of cortical fibers as formed concentrically
  4. 4. Lens & Cataract (Pathology)  Lens proteins (Crystallines) – chemically modified and aggregate into high molecular wt. proteins The resulting proteins aggregates cause:  Abrupt fluctuations in refractive index  Scatter light rays  Reduce transparency   Chemical modification of nuclear lens proteins also produce pigmentation (yellow/brownish hue with advancing ages) ↓ concentration of glutathione and K+, ↑conc. of Na+ and Ca++, ↑ Hydration
  5. 5. Lens & Cataract (Pathology)  Types 1. Nuclear 2. Cortical 3. Subcapsular (Posterior)
  6. 6. Lens & Cataract (Pathology) Nuclear  In adults past middles ages some degree of nuclear sclerosis and yellowing is considered physiologically normal. This condition interferes minimally with visual function
  7. 7. Lens & Cataract (Pathology) Nuclear 2. Excessive sclerosis and yellowing (nuclear sclerosis) cause central opacity. Degree of scleroses, yellowing and opacifications evaluated with SL bio-microscope and examination of red reflex (Pupil dilated)
  8. 8. Lens & Cataract (Pathology) Nuclear (cont’d) 3. Progression slow 4. BL, (± asymmetric) 5. Visual impairment greater of distance vision than of near vision 6. ↑ refractive index and thus myopic shift in refraction (Lenticular myopia). This myopic shift transiently enables presbyopic individulas to read without spectacles (second sight)
  9. 9. Lens & Cataract (Pathology) Nuclear (cont’d) 7. Monocular diplopia:  Abrupt change in the refractive index between the sclerotic nucleus and the cortex 7. Progressive yellowing of the lens causes poor hue discrimination esp. at the blue end of the visible spectrum 8. Photopic retinal function may ↓ with advanced nuclear cataract
  10. 10. Lens & Cataract (Pathology) 10. In very advanced cases the nucleus becomes opaque and brown (brunescent)
  11. 11. Lens & Cataract (Pathology) 11. Histopathology:  Nucleus homogenous with loss of celluler laminations.
  12. 12. Lens & Cataract (Pathology) Cortical Cataract  1. Early changes:  2. 3. 4. Changes in ionic composition + hydration + cortical opacification BL, often Asymmetrical First visible signs of cortical cataract formation (SL bio-microscope) are vacuoles & water clefts in ant. And post. cortex Cuneiform opacities (cortical spokes): wedge shaped, form near the periphery the lens, with pointed ends oriented toward the center
  13. 13. Lens & Cataract (Pathology) 5. Cortical Cataract  The cortical spokes appear white when viewed with SL bio-microscope and dark shadows when viewed by retroillumination.
  14. 14. Lens & Cataract (Pathology) Cortical Cataract (cont’d)  6. Their effect on VA varies greatly, depending upon the location of the opacity relative to the visual axis 7. Common symptom:  Glare from intense focal light sources (e.g. Car head light) 8. Monocular diplopia may also result
  15. 15. Lens & Cataract (Pathology)  Cortical Cataract (cont’d) 9. Progression:  10. 11. vary, some times unchanged for prolonged periods, while others progress rapidly The wedge shaped opacities may enlarge and coalesce to form large cortical opacities. Intumscent Cataract:  As lens continues to take up water it may swell
  16. 16. Lens & Cataract (Pathology) 12. Mature Cataract:  When the entire lens from the capsule to the nucleus becomes white and pacified
  17. 17. Lens & Cataract (Pathology) 13. Hypermature Cataract:  when degenerated and liquefied cortical material leaks through the lens capsule, leaving capsule wrinkled and shrunken
  18. 18. Lens & Cataract (Pathology) 14. Morgagnian Cataract:  with further liquefaction of the cortex allows free movements of the nucleus within the capsular bag.
  19. 19. Morgagnian cataract
  20. 20. Lens & Cataract (Pathology) Cortical Cataract (cont’d) 15. Histopathology:  Hydropic swelling of the lens fibers  Globules (morgagnian) of eosinophilic material observed in slit-like spaces between lens fibers
  21. 21. Lens & Cataract (Pathology) Posterior Subcapsular (cupuliform) cataract (PSC) 1. PSCs often seen in patients younger than those presenting with nuclear/cortical cataracts 2. PSC located in the posterior cortical layer and is axial in location
  22. 22. Lens & Cataract (Pathology) Posterior Subcapsular (cupuliform) cataract (PSC) 3. First indication: subtle iridescent sheen in the posterior cortical layers (SLB exam) Later stages:  Granular opacities and  A plaque like opacities of posterior subcapsular cortex appear
  23. 23. Lens & Cataract (Pathology) Posterior Subcapsular (cupuliform) cataract (PSC)  Patient complains of  glare and  ↓ vision  PSC obscures more of the pupillary area when In bright light miosis is induced by:  Bright light  Accommodation  Miotics
  24. 24. Lens & Cataract (Pathology) Posterior Subcapsular (cupuliform) cataract (PSC) 5. 6. 7. Near VA tends to be decreased more than distance VA Some patients experience monocular diplopia Other causes of PSC: 1. 2. 3. 4. 5. Age related – main type Trauma Corticosteroids Inflammations Ionizing radiations
  25. 25. Lens & Cataract (Pathology) Posterior Subcapsular (cupuliform) cataract (PSC) 8. Histopathology 1. Posterior migration of lens epithelial cells in the posterior sub-capsular area, with aberrant enlargement 2. These swollen epithelial cells are called Wedl (Bladder) cells
  26. 26. DRUG INDUCED CATARACTS
  27. 27. Drug induced cataracts 1. Corticosteroids 2. Phenothiazines 3. Miotics 4. Amiodarone
  28. 28. Drug induced cataracts  Corticosteroids  Long term use of steroids cause PSCs  Occurrence related to: 1. Dose 2. Duration of treatment 3. Susceptibility to steroids (vary)
  29. 29. Drug induced cataracts  Corticosteroids (cont’d)  Cataract Formation:   Nasal spray   Systemic / Topical / Sub-conjunctival Eye lid dermatitis (steroids treatment) Histopathology:   Similar to senescent PSC changes Some steroid-induced PSCs in children may be reversible with cessation of the drug
  30. 30. Drug induced cataracts  Phenothiazines   Chloropromazine, Thioridazine Phenotiazines, a major group of Psycho-tropic medications, can cause pigmented deposits in the anterior lens epithelium in an axial configuration  Deposits appear to be affected by dose and duration  Visual changes associated with phenothiazine are usually insignificant
  31. 31. Drug induced cataracts  Miotics  Anticholinesterases (Ecothiophate, demacrium) pilocarpine, phospholine lodide  These can cause cataracts  Cataract dose and duration related   Cataract may progress to posterior cortical and nuclear First appears as small vacuoles within and posterior to the anterior lens capsule and epithelium (Best appreciated by retroillumiunation)
  32. 32. Drug induced cataracts  Miotics  Visually significant cataracts common in elderly patients (Topical anticholinesterase)  Progressive cataract not reported in children (Echothiophate for accommodative esotropia)
  33. 33. Drug induced cataracts  Amiodarone  Antiarrythmia medication has been reported to cause stellate anterior axial pigment deposition (Visually insignificant)
  34. 34. TRAUMATIC CATARACT
  35. 35. Traumatic Cataract Traumatic lens damage may be caused by:  1. Mechanical injury 2. Physical forces   Electrical current  3. Radiation Chemicals Osmotic influences (diabetes mellitus)
  36. 36. Traumatic Cataract Contusion (Blunt injury)   Vossius ring  Blunt trauma to eye can sometimes cause pigment from pupillary ruff to be imprinted on anterior lens surface in a ring shape  It is visually insignificant  It indicates previous trauma
  37. 37. Vossius ring due to blunt trauma
  38. 38. Traumatic Cataract  Contusion (Blunt injury)    Blunt, non perforating injury may cause lens opacification (acute event / late sequela) Cataract may involve a portion or entire lens Often the initial manifestation is a stellate / rosette-shaped opacification, axial in location (PSC)
  39. 39. Traumatic Cataract  Contusion (Blunt injury)  Rosette cataract may progress to opacification of entire lens  In some cases lens capsule may be ruptured by the force of blunt trauma, with subsequent hydration and rapid opacification of the lens
  40. 40. Traumatic Cataract Contusion (Blunt injury)   Perforating and penetrating injuries  Penetrating injury of lens often results in opacification of cortex at site of rupture, progressing rapidly to complete opacification  A small perforating injury of the lens capsule may heal, resulting in a small focal cortical cataract
  41. 41. Radiation-induced cataracts  Ionizing radiations    Lens is extremely sensitive to ionizing radiations Cataract clinically apparent after period of up to 20 yrs Latency related to:    Dose and Age of patient A young patient with more actively growing lens cells is more susceptible
  42. 42. Radiation-induced cataracts  Ionizing radiations (cont’d)  Clinically:   Punctate opacities within posterior capsule and feathery anterior subcapsular opacities that radiate towards the equator of the lens These may progress to complete opacification
  43. 43. Radiation-induced cataracts  Infra-red radiations (Glasses blower’s cataract)  Intense heat and infra-red radiations cause outer layer of the anterior capsule to peel off as a single layer (true   exfoliation) May be associated with cortical cataract Rarely seen today
  44. 44. Radiation-induced cataracts  Ultra-voilet radiations (UV)  Prolong exposure to UV radiations in the UVB range (Sun exposure) is associated with ↑ risk of:   Cortical PSCs (Epidemiologic Evidence)
  45. 45. Radiation-induced cataracts Micro-wave Radiations      Non-ionizing radiations with wavelength between IR and short waves on the electromagnetic spectrum No evidence of cataract by microwaves Biological effect – thermal Microwaves could theoretically cause cataract:  Dose levels would be so high as to induce hyperthermic brain damage
  46. 46. Chemical injuries  Alkalis and Acids  Alkalis injuries to ocular surface result in cataract  Alkalis compounds penetrate eye readly causing: 1. ↑ Aqueous pH 2. ↓ Aqueous Glucose 3. ↓ Aqueous Ascorbate  Cortical cataract: Acutely or delayed effect  Associated injuries: Damage to cornea, conjunctiva, iris etc.  Acids: Tends penetrate eye less easily than alkali  Acid injuries are less likely to result in cataract formation

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