Cataract, Types, Management, Treatment

1. By Kevin J Ambadan
MANAGEMENT OF
CATARACT

2. NON SURGICAL
MANAGEMENT

3. TREATMENT OF THE CAUSE OF CATARACT
• Adequate control of diabetes mellitus,
• Removal of cataractogenic drugs such as
corticosteroids, phenothiazenes and
strong miotics
• Removal of irradiation (infrared or X-rays)
• Early and adequate treatment of ocular
diseases like uveitis

4. MEASURES TO DELAY PROGRESSION
• Commercially available preparations
containing iodide salts of calcium and
potassium are being prescribed in
abundance in early stages of cataract
• Vit E and aspirin also delays the process
of cataractogenesis

5. MEASURES TO IMPROVE CATARACT IN THE
PRESENCE OF INCIPIENT AND IMMATURE
CATARACT
• Refraction should be corrected at frequent
intervals
• Arrangement of illumination-patients with
peripheral opacities brilliant illumination
• Use of dark goggles in patients with central
opacities
• Mydriatics- 5%phenyephrine or 1%
tropicamide b.i.d in affected eye

6. SURGICAL
MANAGEMENT

7. INDICATIONS
a) Visual improvement
b) Medical indications:
-Lens induced glaucoma
-Phacoanaphylactic endophthalmitis
-Retinal diseases like diabetic retinopathy or
retinal detachment
c) Cosmetic indication-to obtain black
pupil

8. PREOPERATIVE
EVALUATION

9. I. GENERAL MEDICAL EXAMINATION OF
THE PATIENT
II. OCULAR EXAMINATION
The following information is essential before
the patient is considered for surgery:
A. RETINAL FUNCTION TESTS
i. Light Perception
ii. Test for Marcus Gunn pupillary
response
iii. Projection of rays - Test for function of
peripheral retina

10. iv. Two light discrimination test - Macular
function
v. Maddox rod test
vi. Colour perception-macular function
and optic nerve
vii. Entoptic visualisation-retinal function
viii. Laser interferometry
ix. Objective tests for evaluating retina-
ultrasonic evaluation, ERG, EOG, VER
and indirect ophthalmoscopy

11. III. SEARCH FOR LOCAL SOURCE OF
INFECTION - to rule out conjunctival infection
or lacrimal sac infection
IV. ANTERIOR SEGMENT EVALUATION
V. IOP MEASURMENT - raised IOP needs priority
management

12. PRE-OP MEDICATIONS AND PREPERATIONS
1. TOPICAL ANTIBIOTICS - Tobramycin and
Gentamicin QID for 3days before surgery
2. PREPARATION OF THE EYE TO BE OPERATED
3. CONSENT
4. SCRUB BATH AND CARE OF HAIR
5. DRUGS TO LOWER IOP - Acetazolamide
500mg stat 2hrs before surgery and Glycerol
60ml mixed with water 1hr before surgery
6. DRUGS TO SUSTAIN DILATED PUPIL -
AntiProstaglandin eye drops(Indomethacin)

13. ANAESTHESIA
Cataract extraction can be performed
under gen or local anaesthesia. Local is
preferred.

14. SURGICAL TECHNIQUE
FOR CATARACT
EXTRACTION

15. INTRACAPSULAR CATARACT EXTRACTION
• The entire cataractous lens along with the intact
capsule is removed.
• Therefore weak and degenerated zonules are a
pre-requisite for this method. Because of this
reason, this technique cannot be employed in
younger patients where zonules are strong.
• ICCE can be performed between 40-50 years of
age by use of the enzyme alphachymotrypsin
(which will dissolve the zonules).
• Beyond 50 years of age usually there is no need of
this enzyme.

16. INDICATION
- Subluxated and dislocated lens
SURGICAL STEPS OF ICCE TECHNIQUE:
i. Superior rectus (bridle) suture
ii. Conjunctival flap
iii. Partial thickness groove/gutter
iv. Corneoscleral section
v. Iridectomy

17. vi. Methods of lens delivery
• Indian smith method
• Cryoextraction
• Capsule forceps method
• Irisophake method
• Wire vectis method
vii. Formation of Anterior Chamber
viii. Implantation of anterior chamber IOL(ACIOL)
ix. Closure of incision- 5-7 interrupted sutures
x. Conjunctival flap reposited
xi. Subconjunctival injection-dexamethasone
0.25ml and gentamicin 0.5ml given
xii. Patching of the eye

18. A. Passing of superior rectus
suture
B. Fornix based conjunctival
flap
C. Partial thickness groove
D. Completion of
corneoscleral section
E. Peripheral iridectomy
F. Cryolens extraction
G. Insertion of Kelman
multiflex IOL in anterior
chamber
H. Insertion of Kelman
multiflex IOL in anterior
chamber
I. Corneo-scleral suturing

19. EXTRACAPSULAR CATARACT EXTRACTION
• Major portion of anterior capsule with
epithelium, nucleus and cortex are
removed; leaving behind intact posterior
capsule.
• Indications: Presently, it is the surgery of
choice for all types of adulthood as well
as childhood cataracts unless
contraindicated.
• Contraindications - Subluxated and
dislocated lens

20. TYPES OF EXTRACAPSULAR CATARACT
EXTRACTION
a) Conventional Extracapsular Cataract
Extraction (ECCE)
b) Manual Small Incision Cataract Surgery
(SICS),
c) Phacoemulsification

21. CONVENTIONAL ECCE
i. Superior rectus (bridle) suture
ii. Conjunctival flap (fornix based)
iii. Partial thickness groove/gutter
iv. Corneoscleral section.
v. Injection of viscoelastic substance in
anterior chamber - 2% MethylCellulose or
1% Sodium Hyaluronate (Maintains anterior
chamber and protects endothelium)

22. vi.Anterior capsulotomy.
• Can-opener's technique
• Linear capsulotomy (Envelope technique)
• Continuous circular capsulorrhexis (CCC)
vii.Removal of anterior capsule
viii.Completion of corneoscleral section
ix.Hydrodissection (ie., seperation of capsule from
cortex by injecting fluid between the two) -
Balanced salt solution injected under peripheral
part of ant capsule to separate corticonuclear
mass from the capsule

23. x. Removal of nucleus
After hydrodissection the nucleus can be
removed by any of the following techniques:
• Pressure and counter-pressure method
• Irrigating wire vectis technique
xi. Aspiration of the cortex
xii. Implantation of IOL
xiii.Closure of the incision - 3-5 interrupted sutures
xiv. Removal of viscoelastic substance
xv. Conjunctival flap is reposited and secured
xvi. Subconjunctival injection
xvii. Patching of eye

24. A. Anterior capsulotomy Can
Opener's technique
B. Removal of anterior capsule
C. Completion of corneo-scleral
section
D. Removal of nucleus (pressure
and counter-pressure method)
E. Aspiration of cortex
F. Insertion of inferior haptic of
posterior chamber IOL
G. Insertion of superior haptic of
PCIOL
H. Dialing of the IOL
I. Corneo-scleral suturing

25. MANUAL SMALL INCISION CATARACT
SURGERY
1. Superior rectus suture
2. Conjunctival flap and exposure of sclera
3. Haemostasis
4. Sclero corneal tunnel incision:
External scleral incision - 5.5mm to 7.5mm
Sclero corneal tunnel - 1-1.5mm
Internal corneal incision
5. Side port entry

26. 6.Anterior capsulotomy - can be can-
openers,envelope or continuous circular
capsulorrhexis (CCC)
7.Hydrodissection
8.Nuclear management
a)prolapse of nucleus into ant chamber
b)delivery of nucleus through corneoscleral
tunnel
9.Aspiration of cortex
10.IOL implantation
11.Removal of viscoelastic material
12.Wound closure

27. A. Superior rectus bridle suture
B. Conjunctival flap and exposure of sclera
C, D & E. External Scleral incisions (straight,
frown shaped, and chevron,
respectively) part of tunnel incision
F. Sclero-corneal tunnel with crescent knife
G. nternal corneal incision
H. Side port entry
I. Anterior capsulotomy-Large CCC
J. Hydrodissection
K. Prolapse of nucleus into anterior chamber
L. Nucleus delivery with irrigating
wire vectis
M. Aspiration of cortex
N. Insertion of inferior haptic of posterior
chamber IOL
O. Insertion of
superior haptic of PCIOL
P. Dialing of the IOL
Q. Reposition and anchoring of conjunctival flap.

28. PHACOEMULSIFICATION
1. Corneoscleral incision-very small 3mm
2. Continuous curvilinear capsulorrhexis of
4-6mm
3. Hydrodissection
4. Nucleus is emulsified and aspirated
5. Remaining cortical lens matter is
aspirated
6. IOL Implantation
7. Removal of viscoelastic material
8. Wound closure

29. A. Continuous curvilinear capsulorrhexis
B. Hydrodissection;
C. Hydrodelineation
D & E. Nucleus emulsification by divide and conquer technique
F. Aspiration of cortex.

30. SURGICAL TECHNIQUE FOR ECCE FOR
CHILDHOOD CATARACT
Surgical techniques employed for childhood
cataract are essentially of two types:
• Irrigation and aspiration of lens
matter
• Lensectomy
1. Irrigation and aspiration of lens matter
i. Conventional ECCE technique
ii. Corneo-scleral tunnel techniques which
include :
• Manual SICS technique
• Phaco-aspiration technique

31. SURGICAL STEPS OF IRRIGATION AND
ASPIRATION OF LENS MATTER BY
CORNEOSCLERAL TUNNEL INCISION
1-5. Initial steps upto making of side port entry are
same as SICS
6. Anterior capsulorhexis of about 5mm size
7. Irrigation and aspiration of lens matter
8. Posterior capsulorhexis of about 3-4 mm size is
recommended in children to avoid posterior capsule
opacification
9. Anterior vitrectomy
10. Implantation of IOL after inflating capsular bag
with viscoelastic substance-heparin or flourine
coated PMMA IOL preferred in children.
11. Removal of viscoelastic substance is done
12. Wound closure.

32. LENSECTOMY
In this operation most of the lens including anterior
and posterior capsule along with anterior vitreous
are removed with the help of a vitreous cutter,
infusion and suction machine .
Childhood cataracts, both
congenital/developmental and acquired, being
soft are easily dealt with this procedure especially
in very young children (less than 2 years of age) in
which primary IOL implantation is not planned.
Lensectomy in children is performed under general
anaesthesia

33. INTRAOCULAR LENS IMPLANTATION
Presently, intraocular lens (IOL) implantation is the method
of choice for correcting aphakia.
Types of intraocular lenses:
The commonly used material for their manufacture of
lens is polymethylmethacrylate (PMMA).
The major classes of IOLs based on the method of fixation in
the eye are as follows:
1. Anterior chamber IOL
• Lie entirely in front of the iris and are supported in
the angle of anterior chamber.
• ACIOL can be inserted after ICCE or ECCE.
• Not very popular due to comparatively higher
incidence of bullous keratopathy.
• When indicated, ‘Kelman multiflex’ type of ACIOL
is used commonly.

34. 2. Iris-supported lenses
• These lenses are fixed on the iris with the help of sutures, loops or
claws.
• High incidence of postoperative complications.
• Example of iris supported lens is Singh and Worst’s iris claw lens .
3. Posterior chamber lenses
• PCIOLs rest entirely behind the iris . They may be supported by the
ciliary sulcus or the capsular bag. Commonly used model of
PCIOLs is modified C-loop .
• Depending on the material of manufacturing, three types of
PCIOLs are available:
i. Rigid IOLs -made entirely from PMMA.
ii. Foldable IOLs-made of silicone, acrylic, hydrogel and
collamer.
iii. Rollable IOLs are ultra thin IOLs-These are made of hydrogel.

35. Kelman multiflex Singh & Worst's iris claw lens Posterior chamber IOL
(an anterior chamber IOL) (modified C-loop type)

36. Thank you