Management of Cataract for undergraduate MBBS Students. Covers the basics of diagnosis of cataract, evaluation of a case of cataract and various modalities of treatment of cataract. Also encompasses salient points for PGMEE.

1. Management of Cataract
Dr. Abhishek Onkar

2. Symptom Pathogenesis Type of cataract
Frequent change of glasses Rapid change in µ of lens Cortical/nuclear
↓ VA (Gradual, painless,
progressive
↓ transparency of lens All types → ← ↑
Second sight/myopic shift ↑ µ of nucleus → index myopia Nuclear
↓ ability to see in bright sunlight,
blinded by light from headlights
while driving at night
Loss of contrast sensitivity which is
greater at higher spatial
frequencies; constriction of pupil
cuts off peripheral vision from non-
cataractous area
PSC
Monocular diplopia/ polyopia Cortical spokes with water clefts of
↓ µ than surrounding lens
Cortical cataract( spoke/cuneiform)
Glare ↑ scattering of light Cortical/ PSC
Coloured haloes around light Irregularities of µ Cortical
Colour shift (more obvious after
surgery)
Blue specta absorbed more by
cataractous lens
Nuclear
Visual field loss Generalized ↓ in sensitivity d/t loss
of lens transparency
All types

3. Signs
• Iris shadow
• Depth of anterior chamber
• Pupillary reflex
• Visual acuity
• Plain mirror examination under mydriasis

5. Iris
shadow
A.C.
Depth
Pupillary
reflex
Visual
acuity
Intumescent Present Shallow Greyish white FC to 6/18
Incipient Present Normal Greyish white FC to 6/18
Mature Absent Normal Pearly white HM to FC
close to face
Hypermature
Morgagnian
Absent Shallow Milky white HM +
Hypermature
Calcified
Absent Normal or
deep
Milky
chalky
HM +

6. Differential diagnosis
Painless, progressive diminution of vision
• Cataract
• Primary open angle glaucoma
• Diabetic retinopathy
• Age related macular degeneration
• Corneal dystrophies and degenerations
• Retinitis pigmentosa
• Refractive errors

7. Management
• An un-operated eye is more comfortable than an operated eye if
visual diminution is mild.
• Early cataract :
-Refraction and glasses
-Dark glasses or photochromatic glasses for nuclear cataract
-Rule out other causes of visual diminution
-If BCVA not to patient’s satisfaction, then operate.

8. Patient workup
• Retinoscopy and best corrected visual acuity
• Intraocular pressure
• Slit lamp examination
• DDO
• Fundus evaluation – direct & indirect
• Macular function tests
• Ultrasonography
• IOL power calculation

9. • Complete Ocular Examination including adnexa
• IOP
• Syringing
• Tear film evaluation
• Keratometry
• Axial length measurement: A-scan
• IOL power calculation

10. SRK Formula: Sanders, Retzlaff and Kraff
P = A – 0.9 K – 2.5 AL

11. General investigations
• Blood pressure
• Blood sugar
• Complete haemogram
• HIV, Hepatitis B & C
• Causes of straining
• Foci of infection
• Systemic examination

12. Evolution of cataract surgery

15. ICCE
• TRAUMATIC SUBLUXTED LENS

16. ECCE: Steps in short
• 1. +/-Bridle traction suture
• 2. Peritomy (Conj opening)
• 3. Partial thickness corneoscleral wound and AC Entering
• 4. Can-opener capsulotomy
• 5. Extend corneoscleral wound and Lens extraction
• 6. remove cortex +/- suture
• 7. IOL implantation and close wound

17. Phacoemulsification : Steps in short
• 1. Capsulorhexis
• 2. Corneal/ scleral incision
• 3. Hydrodissection and hydrodelineation
• 4. Phacoemulsification- Divide and Conquer
• 5. Cortex removal/ capsule polishing
• 6. IOL implantation

20. Potential Postoperative Complications
• Corneal edema
• Descemet's membrane detachment
• Induced astigmatism
• Corneal melting
• Conjunctival ballooning
• Epithelial downgrowth
• Toxic anterior segment syndrome (TASS)
• Flat chamber
• Elevated intraocular pressure
• Intraoperative floppy iris syndrome (IFIS)
• Iridodialysis
• Cyclodialysis
• Ciliary block glaucoma
• Chronic postoperative uveitis
• Macular infarction
• Retinal detachment
• Retained lens material
• Capsular rupture/PCR
• Vitreous prolapse
• Dropped nucleus
• IOL complications (decentration and dislocation, pupillary
capture, capsular block syndrome, uveitis-glaucoma-
hyphema syndrome, pseudophakic bullous keratopathy,
incorrect IOL power, IOL glare, IOL opacification)
• Anterior capsular fibrosis and phimosis
• Posterior capsular opacification
• Hemorrhage (retrobulbar hemorrhage, suprachoroidal
effusion, expulsive suprachoroidal hemorrhage, hyphema)
• Endophthalmitis
• Cystoid macular edema
• Uretts Zavala syndrome
• Retinal light toxicity