Ophtalmic Record

Examiners :
Catherine Maname Uli
Purnomo Hyaswicaksono
Ferry Kurniawan
Birgitta Wangsa
Chrestella Hartanuh
Aurelia Vania
Farrell Tanoto
Yuanita Budiman
I. Patient identity
Name
: Ms. S
Sex
: Female
Age
: 43 years old
Ethnic
: Javanese
Religion : Islam
Occupation : Ice cream seller
Address
: Muara Angke
II. History taking
Chief complaint: Patient feel her vision were blurred, both of her eyes since 4 year before
admission.
Additional complaint: Patient felt both of her eyes feel tired, dizzy, feeling tired easily,
photophobia (+), lacrimation (+), itchy.
History of present illness: Since 4 years before admission, patient feel her right eyes
started to blur, then her left eye. She said its so hard to
recognize other people. She also started to be afraid to greet
people she met and bumped them while walking.
Past occular history: Op. Cataract OD last month, history of using eye-glasses was denied.
General medical : diabetes was denied, allergy was denied, hypertension (+)
Familial medical history: no previous history of same complaint
no previous history of systemic disease
no previous history of malignancy
III. General status
General condition
Level of consciousness
Blood pressure
Heart rate
Respiratory rate
Temperature

: fatigue
: fully awake
: 140/90 mmHg
: 85
: 20
: 36oC

IV. Ophtalamic status

Periocular appearance
General condition
Eyeball position
Eyeball movement
Visual acquity
Supercillia
Cilia
Sup/Inf Margo Palpebra
Sup/Inf Tarsal
Conjunctiva
Bulbar conjunctiva
Cornea
-

Clearness
Edema
Infiltrate
Ulcer
Crust
Destruction

Anterior Chamber
Iris
Pupil

Lens
Palpebra

V.

Summary

Right eye
Normal
Well
Orthophoric
Can move to 8 directions
5/40
Full, symetric
Normal
Well-positioned
Hyperemic

Left eye
Normal
Well
Orthophoric
Can move to 8 directions
5/30 (S+2.5) 5/5
Full, symetric
Normal
Well-positioned
Hyperemic

Normal

Normal

Clear
-

Clear
-

Mild depth

Mild depth

Clear
Darkish brown

Clear
Darkish brown

Crypt (+)
Center

Crypt (+)
Center

Round

Round

3mm

3mm

Light reflex (+)/(+)

Light reflex (+)/(+)

Isochoric
Pseudophacia

Isochoric
Cloudy (posterior

Hyperemic +

subcapsular)
Hyperemic +

edema +

edema +

tenderness +

tenderness +

nodule -

nodule -

43 y.o. female came with complaint having blurry vision both of her eyes since 4 years
before admission. She also feel fatigue, photophobic, watery. History of trauma was
denied, and she hasnt taken any medication.
Few months before admission, she cant recognize other people face and started to
bump them while walking.
From the eye exam we found reduce visual acquity, and cloudy lens.
VI.

Clinical diagnosis
Pre-senile immature posterior subcapsular cataract

VII. Differential diagnosis

Pre-senile immature posterior polar cataract
Congenital posterior polar cataract
VIII. Treatment

IX.

ODS

: micro incision cataract extraction (PHACO)

Medication

: Troboson 1 drops/2 hour

Suggested examination
Slit lamp examination

X.

Prognosis
Quo ad vitam : bonam
Quo ad functionam : dubia ad bonam
Quo ad sanationam : dubia ad bonam

XI.

Complication
Rupture or atrophy of the optical nerve

XII. Discussion
Definition
Any opacity of the eye lens than can be caused by lens hydration, lens protein
denaturation, or both.
Classification
Based on patients ages, cataracts can be classified as:
1. Congenital cataract: cataract that happens before or soon after birth and the baby is
under one years old.
Congenital cataract can be divided into four types:
a. Zonular or lamellar
Most common type of congenital cataract. This type is characterized by white
opacities that surround the nucleus with alternating clear and white cortical
lamella like an onion skin. Lamellar cataract usually involves bilateral eyes.

b.

Polar
This type is characterized by small opacities of the lens capsule and adjacent
cortex on the anterior or posterior pole of the lens. This polar type usually has

c.

little efect on vision.

Nuclear
Nuclear type has opacity within embryonic/fetal nucleus that can be seen like

d.

coral flower.
Posterior lenticonus
This type is characterized by a posterior protrusion, usually opacified , in the

posterior capsule.
2. Juvenile cataract: cataract which happens after one years old and occurs in young
people under 20 years old. The opacity of lens in juvenile cataract occurs when lens
3.
4.

fibers is still developing, so it has soft consistency (soft cataract).

Pre-senile cataract: cataract which occurs until 50 years old.
Senile cataract: cataract which occurs after 50 years old.
Senile cataract is associated with the aging process in the lens. The changes include
increasing thickness of nucleus with the developing of cortex lens.
Stage of the senile cataract:
a. Incipient cataract: irregular opacity likes cogwheel-like spot. In this stage,
polyopia is common complaints because of the asimilarity of refraction index
b.

in all part of lens.

Immature cataract: thicker opacity but it hasnt involve all part of lens. In this
stage, hydration of cortex causes intumescence lens. Intumescence lens causes

c.

changes of refraction index which the eyes becomes myopic.

Mature cataract: all of lens protein is opaque. The lens fluid will come out

d.

from lens, so the size of lens will be normal again.

Hypermature cataract: later degeneration process will cause the lens become
liquid. This liquid may escape through the intact capsule, leaving a shrunken
lens with a wrinkled capsule. A hypermature cataract in which the lens nucleus
floats freely in the capsular bag is called a morgagnian cataract.

The Differences Between Senile Cataract Staging

Opacity
Lens fluid
Iris
Anteriorchamber
Shadow test

Incipient
mild
normal
normal

Immature
moderate
increased
being

Mature
severe
normal
normal

Hypermature
massive
decreased
tremulans

normal
negative

pushed
shallow
positive

normal
negatif

deep
Pseudopositive

Based on location of opacities, cataract can be classified as:

a.

Nuclear cataract
Nucleus of adult lens will increase and become sclerotic. This later white
nuclear will become yellow, brown, and black, and it is called

brunescence cataract (nigra cataract).

b. Cortical cataract
Early stage cortical cataract demonstrates water clefts and vacuoles,
which may change over time resulting in irreversible opacities. In a more
advanced stage, spoke-like or wedge-shaped peripheral opacities
progress circumferentially, initially sparing the clear central axis of the
lens. It can cause glare and often asymptomatic until central changes
c.

develop.
Posterior subcapsular cataract
Plaquelike opacity near the posterior aspect of the lens. Glare and
reduced vision under bright lighting are common complaints. This
cataract type classically occurs in patients <50 years. Posterior
subcapsular cataract is associated with ocular inflammation, steroid use,

diabetes, trauma, or radiation.

d. Posterior polar cataract
A posterior polar cataract is a round, discoid, opaque mass that is
composed of malformed and distorted lens fibers located in the central
posterior part of the lens. A posterior polar cataract consists of
dysplastic lens fibers, which, in ther migration posteriorly lens opacity
with the formation of a characteristic discoid posterior polar plaquelike
e.

cataract.
Anterior polar cataract
May present as a congenital (autosomal dominantly inherited) or
acquired cataract secondary to uveitis or trauma (associated with
anterior subcapsular opacities). Small anterior polar opacification
usually is sharply defined.

The Lens Opacities Classification System III (LOCS III) is a standard system
used for grading and comparison of cataract severity and type12. It was
derived from the LOCS II classification3, and it consist of three sets of
standardized photographs. The classification evaluates four features:
nuclear opalescence (NO), nuclear color (NC), cortical cataract (C),
posterior subcapsular cataract (P). Nuclear opalesecence (NO) and nuclear
color (NC) are graded on a decimal scale of 0.1 to 6.9, based on a set of six
standardized photographs. Cortical cataract (C) and posterior subcapsular
cataract (P) are graded on a decimal scale of 0.1 to 5.9, based on a set of
five standardized photographs each.

Figure 1

Etiology and Risk Factor

1. Congenital cataract:
- Idiopathic
- Familial, autosomal dominant
- Rubella: pearly white nuclear cataract
- Maternal diabetes mellitus, toxoplasmosis
2. Acquired cataract:
- Age-related cataract
- Traumatic cataract
Traumatic cataract is most commonly due to a foreign body injury to the lens
or blunt trauma to the eyeball. The lens becomes white soon after the entry of a
foreign body, since interruption of the lens capsule allows aqueous and
sometimes vitreous to penetrate into the lens structure.
- Complicated cataract
o Cataract secondary to intraocular disease
Cataract may develop as a direct effect of intraocular disease upon the
physiology of the lens, example: uveitis (posterior subcapsular cataract),
glaucoma (cataract vogt: anterior subkapsular pungtata cataract), retina
o

ablatio, and severe myopia.

Cataract associated with systemic disease
This cataract usually involve both of eyes although it may not appear in
the same time. The example of systemic disease that can cause cataract are
diabetes mellitus (white snowflake opacities in the anterior and posterior
subcapsular
hypocalcemia.

locations),

hypoparatyroidism,

myotonia

dystrophy,

- Drug-induced Cataract
Drugs that can induce lens opacities include steroids, miotics, antipsyhotics.
- After-Cataract (Secondary Cataract)
After-Cataract denotes opacification of posterior capsule following
extracapsular cataract extraction or phacoemulcification. This cataract type
thickening of posterior capsule caused by inflammatory cell proliferation in
residue cortex, giving the posterior capsule a "fish egg" appearance (Elschnig's
pearls).
Epidemiology
At least 300.000-400.000 new visually disabling cataract occur annually in the United
States. For the oldest age group, 75 years and older, the nuclear, cortical, and posterior
subcapsular cataracts were found in 65,5%, 27,7%, and 19,7% of the study population,
respectively.
In the Framingham Eye Study from 1973-1975, females had a higher than males in
both lens changes (63% vs 54,1%) and senile cataract (17,1% vs 13,2%).
Pathogenesis of pre-senile cataract
The term presenile cataract is used when the cataractous changes similar to senile
cataract occur before 50 years of age. Its common causes are:
1. Heredity. As mentioned above because of influence of heredity, the cataractous
2.

changes may occur at an earlier age in successive generations.1

Diabetes mellitus. Age-related cataract occurs earlier in diabetics. Nuclear

3.

cataract is more common and tends to progress rapidly.

Myotonic dystrophy is associated with posterior subcapsular type of presenile

4.

cataract.
Atopic dermatitis may be associated with pre- senile cataract (atopic cataract) in
10% of the cases.

Mechanism of loss of transparency

It is basically different in nuclear and cortical senile cataracts.
1.

Cortical senile cataract. Its main biochemical features are decreased levels of total
proteins, amino acids and potassium associated with increased concentration of
sodium and marked hydration of the lens, followed by coagulation of proteins. The
probable course of events leading to senile opacification of cortex is as shown in

2.

the Figure
Nuclear senile cataract. In it the usual degenerative changes are intensification of
the age- related nuclear sclerosis associated with dehydration and compaction of

the nucleus resulting in a hard cataract. It is accompanied by a significant increase

in water insoluble proteins. However, the total protein content and distribution of
cations remain normal. There may or may not be associated deposition of pigment
urochrome and/or melanin derived from the amino acids in the lens.

Figure 2
Clinical Manifestation
The thickening of the lens surface can be occurred without making any clinical signs or
symptoms, and also can be found in routine eye check up. The general signs and
symptoms of caratact are :

Photophobia
One of early symptoms that is felt by the patient. The degree of the photophobia

depends on the location of the lession and the cataract stage.

Unicolar polyopia (double vision)
Early manifestation. It is caused by the irreguler light deflection passing through

the lens.
Coloured halo
Caused by the dispersion of the white light into colour spectrums and the water

droplet on the lens.

Black spot in front of the eye
Blurry eye sight, distortion of the image can be acquired in the early stage
Declining visual acquity to loss of eye sight.
Can be various in any type of cataract. Painless, and progressive. Patient with
central thickening of the lens (kupuliform) often lose the vision in early stage.
Patient with periferal thickening of the lens comes with a late vision lost.

Diagnosis
History Taking
1.
2.

Patient data: name, address, sex, age/date of birth, race, occupational

Patient history:
a. Chief complaint: main problems and other problems
b. Present illness
- Time
- Severity
- Influences
- Constancy
- Laterality
- Clarification of certain complaints
- Documentation
c. Past ocular history:
- Glasses/contact lenses
- Ocular medication
- Ocular surgery
- Ocular trauma
- Ambliopia
d. General medication:
- Diabetes mellitus
- Hypertension
- Dermatologic
- Cardiac
- Gestational and birth history
e. Systemic disease
f. Alergies
g. Social history:
- Tobacco and alcohol
- Drug abuse
- Occupational
h. Family history:
- Glasses
- Heritable ocular conditions: corneal disease, glaucoma, cataract, retinal
-

disease
Diabetes mellitus
Thyroid disease
Malignancy

Physical Examination
a.

Complete ocular examination, including distance and near vision, pupilary

examination, and refraction

b.

A dilated slit-lamp examination using both direct and retroillumination techniques

c.

is required to view the cataract properly

Fundus examination, concentrating on the macula, is essential in ruling out other
causes of decrease vision

Supported Examination
a.
b.

B-scan Ultrasonography
If fundus is obscured to rule out detectable posterior segment disease
Keratometry readings and an A-scan Ultrasonography
Measurement of axial length are required for determining the power of the desired
intraocular lens. Corneal pachymetry or endothelial cell count is occasionaly
helpful if cornea guttata are present.

Treatment
Bilateral cataract
Cataract extraction is usually delayed until visual loss affects the patient's life.
This is an indication of the relative and will vary from patient to patient. This type
of cataract is important because cataracts can be associated with posterior subcapsular glare even though visual acuity was relatively good. It is important for
refractive patients carefully and record both near and far vision. To make
recommendations cataract extraction is important to know the lives of patients

and visual needs.

Unilateral cataract
Extraction is required if the patient has a desire to work requirements, binocular
vision, or if the cataract becomes hypermature. In some cases, contact lens or
plastic lens implant will cause the image size and the possibility of equality of
vision binoculars. Intraocular lens implant is ideally placed on the posterior
capsule.

Cataract Surgery
a.

ICCE is Intracapsular Cataract Extraction, all the component of the lens is

b.

removed, include the capsule. Usually perform when zonula zinn is damaged.
ECCE (ExtraCapsular Cataract Extraction): classic, SICS (Small Incision Cataract
Surgery), Micro incision with Phacoemulsification. ECCE is performed by
making an opening on anterior pole capsule, leaving a bowl-shape to put an Intra

Ocular Lens.
Phacoemulsification: is a method to remove the hard part of cataract by using an
ultrasound, then drain the remnant.

Prognosis
If there are no other eye diseases that accompany before surgery, which will have an
effect specifically on vision such as rupture or degeneration of optic nerve atrophy, a
standard ECCE or phaco-emulcification bring a very promising prognosis for vision in
which at least can see the 2 lines on the Snellen distance vision chart . The main cause
of visual morbidity is postoperative CME. A major risk factors that affect the visual
prognosis is the presence of diabetes mellitus and diabetic retinopathy.
However, according to research by Kumar et al. phaco-emulcification polar opacity in
the eye with the larger size has the risk of capsule rupture posterior.
References
1.

Ilyas S, Mailangkay HHB, Taim H, editor. Lensa Mata. Ilmu Penyakit Mata. Ed ke-2. CV

2.

Sagung Seto. 2010: 143.

Ilyas HS. Penglihatan Turun Perlahan Tanpa Mata Merah. Ilmu Penyakit Mata. Ed ke-3.

3.

Balai Penerbit FKUI. 2009: 200.

Ehlers JP, Shah CP, editor. Acquired Cataract. The Wills Eye Manual. Ed ke-4. Lippincott

4.

Williams & Wilkins. 2004: 368.

Eva PR, Whitcher JP, editor. Cataract. Vaughan & Asbury s General Opthalmology.
Lange. 2007.