STUDENTS MODULE

Cataract
Course period: 4th Semester

Department of Ophthalmology
Faculty of Medicine Brawijaya University
Dr. Saiful Anwar Hospital Malang
2013

Course period: 4th Semester

Course Content / Topic: Cataract

1. Contributors
Ophthalmology staffs at the Department of Ophthalmology, Faculty of Medicine
Brawijaya University/ Dr. Saiful Anwar Hospital.

2. Competency area
This module is relevant for competence level 3 of the Indonesian Doctor
Competencies.

3. Competency component

To understand the basic anatomy, physiology, and biochemistry of the lens.

To understand the pathology and epidemiology of cataract disease in

Indonesia

To understand the clinical evaluation and management of cataract patient

4. Learning objectives
At the end of Teaching Learning process, the student should be able to :
-

Understand the anatomy, physiology, and biochemistry of the lens in

relation to cataract

Describe the pathological entities of cataract and its risk factors

Understand the clinical features of cataract and its diagnosis

Understand the principles of cataract management including indication for

surgery, types of surgical procedures, post surgical care, and rehabilitation
of visual function

Understand the role of General Practitioners in the eradication of cataract

blindness

5. Lecture Description

This module is a part of lecture block designed for 5 th semester small group
discussion. This module will facilitate students understanding of general aspects
of cataract disease and its management.

Introduction
Cataract is one of the most common eye disorder that causes significant
visual impairment. By definition, cataract is opacity of the lens. However, to be
clinically significant, the opacity should be in a certain degree to cause decrease
of visual function. In Indonesia, cataract is estimated to be responsible for 0.78%
of blindness in the community. Cataract is widely distributed in community
throughout rural areas. Primary healthcare providers are suitable pioneer case
finders in the referral system. Basic examinations for screening and post surgical
rehabilitation can also be done by medical doctors in these settings. Through this
module we will explore several aspects of cataract relevant for general
practitioners competency.

Anatomy of the lens

The lens is a transparent biconvex structure in the eye which lies in the
visual axis. It is located behind the iris and in front of the vitreous body,
suspended by ligaments called the zonule of Zinn. The central part of the lens
can be seen through the pupil. In the adult eye, the lens is about 4 mm thick and
9 mm in diameter. The lens is composed of cortex and nucleus, covered by a
semipermeable membrane known as the capsule. Zonular fibers are attached to
this capsule at the equatorial zone. Behind the anterior side of the capsule lies a
single layer epithelial cells. The epithelial cells performs regular metabolic
activity and mitosis. At the equatorial zone the epithelial cells differentiate into
lens fibers. The main function of the lens is to refract light and to provide
accommodation. To maintain these functions, the lens also has to keep its own
clarity. The refractive power of the lens is about 20 diopters which is obtained
from its curve and its refractive index difference from aqueous humor and
vitreus.

Picture 1. Illustration of the human lens (adapted from BCSC.AAO-2008/2009:

Lens and cataract)

Physiology
The lens is avascular and contains no nerve fibers. Control of water and
electrolyte balance is an important mechanism and critical to maintain lens
transparency. The lens is dehydrated and contains higher levels of potassium
ions (K+) and amino acids than the surrounding aqueous and vitreus. Conversely,
the lens contains lower levels of sodium ions (Na +) and chloride ions (Cl -) than
the surrounding environment. The cation balance between the inside and outside
of the lens is the result of both the permeability of the lens cell membranes and
the activity of the sodium pump located within the cell membranes of the
epithelium and lens fiber. The mechanism by which the lens controls the state of
water and ions is termed the pump-leak theory. According to this theory,
potassium and amino acids are actively transported into the anterior lens via the
epithelium and then diffuse out with concentration gradient through the back of
the lens. Conversely, sodium flows through the back of the lens with the
concentration gradient and then is actively exchanged for potassium by the
epithelium. Active transport is energy dependant and critical in preserving
physiological condition of the lens.
Accommodation is another important feature of lens physiology. It is the
mechanism by which the eye changes focus from distance to near images. This
ability is produced by cillary muscle contraction which alters the tension of the
zonules and changes the shape of the lens. When cilliary muscle relaxes, the
zonular tension increases and the lens becomes less spherical, decreasing its
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dioptric power. On the other hand, when cillary muscle contracts, the zonular
tension is reduced and the power of the lens increases. The capacity of
accommodation diminishes with increasing age.

Biochemistry
The human lens is composed of 35% protein and 65% water. With
increasing age, more part of the proteins becomes water insoluble and scatter
lights. The excess of insoluble proteins can make the lens less transparent and
become cataractous.
Energy production in the lens is dependant on glucose metabolism obtained from
the aqueous humor. Most of these glucose will enter the anaerobic metabolism
and only a small part of them undergoes aerobic metabolism in the lens.
Hyperglycemic state can increase glucose and its metabolites in the lens, which
will increase the osmotic pressure and draw water into the lens. This may result
in swelling of lens fiber and opacification of the lens.
The lens is equipped with several enzymes that protect against free
radical damage. These include glutathione peroxidase, catalase, and superoxide
dismutase. These enzyme are valuable in preventing peroxidation of lens fiber
which has been suggested as a factor contributing to lens opacification.

Pathology
Cataracts may occur as a result of aging or secondary to hereditary
factors, trauma, inflammation, metabolic or nutritional disorders, or radiation.
Congenital cataract are found since birth. Cataracts found in young persons are
termed juvenile cataract.
Age-related cataracts are the most common. The three common types of
cataract are nuclear, cortical, and posterior subcapsular (PSC). According to the
level of opacity, cataractous lens can be grossly classified as immature
cataract when the opacity is not homogen, and mature cataract when the lens
opacity is total and homogen.
The mechanism of cataract formation is multifactorial and, therefore,
difficult to study. Oxidation of membrane lipids, structural or enzymatic proteins,
or DNA by peroxides or free radicals induced by UV light maybe early initiating
events that lead to loss of transparency in both the nuclear and cortical lens
tissue. In cortical cataract, electrolyte imbalance leads to overhydration of the
lens, causing liquefaction of the lens fibers. Clinically, cortical cataract formation
6

is manifested by the formation of vacuoles, clefts, wedges, or lamellar

separations that can be seen with the slit lamp. Nuclear cataracts usually occur
secondary to deamidation of the lens proteins by oxidation, proteolysis, and
glycation. The proteins aggregate into high-molecular-weight (HMW) particles
that scatter light. Colored products formed from amino acid residues in this
process (urochrome)may be present. The increasing optical density of the
nucleus may cause index myopia that results in myopic shift of the refractive
error. In addition, the central region of the lens acquires a murky, yellowish to
brunescent appearance that is visible in optic section with the slit lamp. Agerelated PSCs are created by loss of lens fiber nuclei and replacement epithelial
cells that aberrantly migrate toward the posterior pole. These epithelial cells
cluster, form balloon cells, and interdigitate with adjacent lens fibers and the
deeper cortical fibers, breaking them down.

Picture 2. Lens with cataract (adapted from BCSC.AAO-2008/2009: Lens and

cataract)
Risk factors for the development of cataract include:
Age. Prevalence of cataract increases in the aged people.
Diabetes mellitus. Persons with diabetes mellitus are at higher risk for
cataracts, and persons with diabetes who have cataracts have a higher morbidity
than those without cataracts.
Drugs.

Certain

medications

have

been

found

to

be

associated

with

cataractogenesis and vision loss. There is an association between corticosteroids

and posterior subcapsular cataracts. Drugs such as phenothiazine or other
thiazines and chlorpromazine have been associated with the induction of
cataract formation.

Ultraviolet radiation. Studies have shown that there is an increased chance of

cataract formation with unprotected exposure to ultraviolet (UV) radiation.
Persons with higher occupational exposure to UV light are at greater risk for
cataract than those with lower occupational exposure rates.
Smoking. An association between smoking and increased nuclear opacities has
been reported.
Alcohol. Several studies have shown increased cataract formation in patients
with higher alcohol consumption compared with patients who have lower or no
alcohol consumption.

Diagnosis and examination

Cataract patient can suffer decrease of visual acuity, glare, altered
contrast sensitivity, and diplopia. Reduction of visual acuity is gradual and
painless. The glare can be mild but can also be disabling, particularly during
daylight or from car headlights. Contrast sensitivity is measured by specially
designed card and can provide a more comprehensive measure of visual
deterioration.
Examination
A flashlight is practical and valuable aid for examining the eye. Patient with
suspected cataract should be assessed for:
-

Visual acuity, natural and best corrected.

Anterior segment evaluation, including the eyelids, conjunctiva, cornea,

anterior chamber, iris, and pupil.

Evaluation of the lens with pupillary dilatation (using pupillary dilating eye
drops such as Tropicamide / Mydriatyl). Iris shadow test can be useful in
determining lens opacities.

Funduscopic evaluation.

Additional tests include:

-

Intraocular pressure evaluation.

Keratometry and biometry, (to estimate intraocular lens power).

Potential acuity testing (e.g. retinometry).

Posterior segment ultrasonography A/B scan.

Inquiry about systemic condition and other illness should be obtained. Blood
pressure, blood sugar level, and hemostasis function is a routine requirement
when surgery is to be planned.

Management
The mainstay of cataract management is surgery. However, nonsurgical
management is sometimes useful in the early stages of cataract.
Non-Surgical Management
During early cataract development, visual improvement may be achieved
through a number of means including:
changes in spectacle lens prescription
magnification or other visual aids
appropriate illumination
Antioxidants supplements might have some beneficial effect for holding up
cataract development and are currently under investigation. No eye drops are
currently available as an effective treatment for cataract. Although pupillary
dilating agents may give some visual improvement for centrally located
cataracts, they are not recommended for treatment.
Surgical Management
The presence of a cataract does not itself indicate a need for surgery. Cataract
surgery may be indicated when the cataract reduces visual function to a level
that interferes with everyday activities of the patient and the patient desires
surgical intervention to improve vision. Most cataract surgery are elective. In
cases with accompanying complication, such as secondary glaucoma, the
surgery can be urgent.

Indications for surgery

The following specific indications for cataract surgery are suggested:
1. The visual impairment produced by the cataract is responsible for the patients
disability in carrying out needed or desired activities (driving, reading,
occupational needs), which can be accompanied by the following symptoms:
visual disability increases due to glare or dim illumination
patient complains of monocular diplopia or polyopia
visual disparity exists between the two eyes
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2. Other indications for cataract removal

Lens-induced disease: phacomorphic glaucoma, phacolytic glaucoma, and
other lens-induced
disease may require cataract surgery and the need for extraction may be
urgent.
Concomitant ocular disease that requires clear media: cataract extraction may
be required to
adequately diagnose other ocular conditions such as diabetic retinopathy.
Surgical Procedures
Under most circumstances, the standard of care in cataract surgery is removal of
the

cataract

by

extracapsular

cataract

extraction

(ECCE),

using

either

phacoemulsification (PE) or nuclear expression/ extraction. ECCE has replaced

intracapsular cataract extraction (ICCE) as the standard of care for primary
cataract

extraction

although

ICCE

is

still

used

under

certain

special

circumstances. Uncomplicated cataract surgery are usually done in less than one
hour and the patient may not need to be hospitalized. The following brief
descriptions show the nature as well as special indications and risks of each
surgical procedure.
Extracapsular cataract extraction by nuclear expression /extraction.
An incision of 8-10 mm is created at the corneo-scleral margin (limbal region).
Following the opening incision and anterior capsulotomy, the nucleus is
expressed from the capsular bag and removed in one piece through the incision.
The residual cortex is removed by irrigation and aspiration. This procedure
requires a larger incision, usually necessitating several sutures to close the
wound. Modification of this procedure utilize a small incision (6-8 mm) through
a scleral tunnel that can self seal without suture or a single suture.
Extracapsular cataract extraction by phacoemulsification.
An incision of 2-3 mm is created at the peripheral cornea. After the opening
incision and anterior capsulotomy, an ultrasonic probe emulsifies the hard
nucleus, enabling the surgeon to remove the lens material using a suction
device. This procedure maintains the normal depth of the anterior chamber. The
incision may be closed without sutures.

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 Intracapsular cataract extraction.

A large incision is made at the limbal region (10 mm). Following the opening
incision, the entire lens is extracted in one piece, including its capsule. Because
this procedure requires a very large incision and carries a much higher risk of
vitreous loss and postoperative complications, it is seldom performed. However,
it may be preferable to remove the cataract by this procedure in special
circumstances (e.g., dislocated lens).
Intraocular Lens Implantation
Current cataract surgery is almost always followed by intraocular lens
(IOL) implantation. The artificial lens can be made of solid material such as
polymethylmethacrylate or foldable material from silicone or acrylic. These
lenses are usually placed inside the capsular bag. When the capsular bag is not
intact or removed (such as in ICCE), the intraocular lens can be fixated by
sutures to sclera.
Visual rehabilitation after IOL implantation can be satisfactory by reaching a 6/6
vision. Patient with implanted IOL are termed pseudophakia as apposed to
aphakia for those who does not have lens implant. When IOL implantation is not
feasible, visual rehabilitation can be achieved with glasses or contact lens.
However, thick glasses can cause image magnification and anisometropia, and
therefore cannot be used for monocular correction when the other eye has a
good visual acuity.
Post surgical rehabilitation and complication
Modern cataract surgery is considered as a safe and effective procedure.
Rehabilitation after surgery is relatively quick and complete wound healing and
visual stability can be achieved between 4-12 weeks (depending on surgical
technique). However, few complications can occur and must be cared with
awareness. Some complication of cataract surgery include:
Endophthalmitis, wound leak, iris prolapse, uveitis, increased intraocular
pressure, corneal edema, bullous keratopathy, dislocated IOL, vitreous lost,
cystoid macular edema, retinal detachment, and choroidal hemorrhage.
After surgery, the patient should be evaluated in the first day, followed by
weekly observation. Evaluation include patients complaint, visual acuity,
anterior segment condition, signs of inflammation, intraocular pressure and
wound healing. Patient should be advised to avoid load bearing and physical
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tasks until the wound is completely healed. Personal hygiene, especially on the
operated eye should be concerned. Topical eye drops of antibiotics and
antiinflamation are usually given for a few weeks. Spectacle correction or reading
adds can be prescribed after the visual function is stable.

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Community Ophthalmology of Cataract

The blindness rate in Indonesia is estimated around 1.5%, the highest in
South East Asia. This figure is higher than other countries such as Bangladesh,
India, and Thailand. The most common cause of blindness in Indonesia is
cataract, which is categorized as treatable blindness. According to WHO, a
blindness rate over 1% is a social problem. Therefore, the handling of the
problem cannot be accomplished by the Department of Health alone, rather by
multidisciplinary approach, involvement of nongovernmental organizations and
the community itself. The high blindness rate is caused by low human resource
capacity, geographical factor, limited infrastructure, and socio-economic status.
The number of ophthalmologist in Indonesia is still small.
The incidence of cataract in Indonesia is around 1% or 210.000 people
annually. On the other hand, the surgical capacity is only 80,000 per year.
Therefore, there would be an additional number of cataract sufferer or backlog of
130,000 people every year. This high backlog is affected by several factors,
including the unawareness of the community, high cost of surgery, shortage of
ophthalmologist, and the reach of surgical capacity which is still low.
One of the aim of community ophthalmology is elimination of cataract
blindness. The program consists of promotion (education), prevention, cure, and
rehabilitation. Execution of the programs may involve ophthalmologist, general
healthcare workers, and non healthcare personnel in the community. Through
this approach it is expected that cataract screening and surgery can be
performed efficiently and effectively to reduce cataract blindness.

References
American Academy of Ophthalmology Staff. Basic And Clinical Science Course:
Lens and Cataract.
San Fransisco: American Academy of Ophthalmology. 2008-2009
Kanski JJ, Clinical Ophthalmology, A Systematic Approach. 6 th ed. Edinburgh:
ButterworthHeinemann. 2007
Vaughan D, Asbury T, Riordan-Eva P. General Ophthalmology. 15 th ed. Stamford:
Prentice Hall. 1999

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Willson

F,

Gurland

JE,

Hamed

LM,

Johnes

KJ,

Wilhelmus

KR.

Practical

Ophthalmology, A manual for

Beginning Residence. San Fransisco: American Academy of Ophthalmology.
1996

Module Task
Answer the questions below after discussing with your group and reading the
suggested references
1. Mention alterations of the lens that can cause visual disturbance. (Two)

2. Mention physiological and biochemical alteration that can lead to cataract

formation

3. Explain how cataract is diagnosed

4. When /at what stage should a patient have cataract surgery?

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5. Describe the principal difference of cataract surgical procedures comparing

ICCE, ECCE, and
Phacoemulsification surgery

6. What should you look for when evaluating the post surgical cataract patient?

7. Mention several optical devices for rehabilitation of cataract patient after

surgery

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