Cataract management
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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.
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Cataract management
- 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