24 October 2013

24 October 2013

Objectives: Lens Anatomy Lens Physiology Lens Functions Definition of Cataract Pathology of Cataract Etiology of Cataract
24 October 2013

24 October 2013

It is a highly organized, transparent, biconvex spheroid structure. It does not posses, nerve or blood vessels . Post

Ant
24 October 2013

 Diameter varies from 8.8 to 9.2 Antero-posterior thickness changes with accommodation. Circumference is known as equator Ant Post
24 October 2013

 Lens is suspended in eye, by Zonules, which are inserted on anterior surface and equatorial lens capsule and attached to ciliary body.
Ant
cb
cb

Post
24 October 2013

Lens ciliary body

24 October 2013

Zonules

L e n s A n a t o m y

ciliary body

Lens
Zonules

24 October 2013

ciliary body

Zonules
Lens Zonules

ciliary body

24 October 2013

24 October 2013

Histologically, lens consists of three major components 1)Capsule 2) Lens Epithelium 3)Lens substance

1. Capsule is a thick membrane, which is transparent, elastic, acellular- envelop, thick at anterior pre-equatorial region , thinnest at the posterior pole .
equator

Pre equatorial region

Ant Post

24 October 2013

Anterior pole contains, the epithelial cells and fibres, as a structural unit and allows, a passage of small molecules, both into and out of the lens.
24 October 2013

-The lens capsule, regulate the transport of metabolite, nutrients and electrolytes, to the lens fibres.

Can opener ant capsulotomy 24 October 2013

Continuous curvilinear capsulorrhexis ( CCC )

2. Lens Epithelium It is a single layer of cells, lining the anterior capsule and extends to the equator.

24 October 2013

Ant lens capsule

Post lens capsule

epithelium

24 October 2013

These cells are actively dividing and elongating to form new lens fibres throughout the life.

24 October 2013

3. Lens substance: It constitute, the main mass of the lens. It is divided intoa. Nucleus b. Cortex

24 October 2013

Nucleus: consists of (i) Embryonic nucleus (ii) Fetal nucleus (iii)Infantile nucleus

(iv)Adult nucleus
24 October 2013

(i)Embryonic nucleus : It contains primary lens fibres, that are formed in lens vesicle. ( 1 to 3 months of gestation )

24 October 2013

ii) Fetal nucleus: it contains embryonic nucleus and all fibres added to the lens before birth ( from 3 months gestation till birth )
24 October 2013

(iii) Infantile nucleus: it contains embryonic , fetal nucleus together with all the fibres added up-to the age of 4 years.

24 October 2013

(iv) Adult nucleus: composed of all fibres added before puberty.

24 October 2013

The nucleus consists of, densely compacted lens fibres and it has higher refractive index than cortex.

24 October 2013

c a i f

24 October 2013

 It is located peripherally, and is composed of secondary fibres formed continuously after puberty. It is further divided into:
Deep cortex Intermediate cortex Superficial cortex
N U C L E U S

24 October 2013

Lens fibres contain high concentrations of crystalline protein.

It is a major protein of the lens

24 October 2013

 The region between embryonic and fetal nuclear core and soft cortex i.e. infantile and adult nucleus is sometimes referred to as epinucleus.
Cortex
Adult Nucleus

epinucleus

Infantile Nucleus

24 October 2013

 Are found both at anterior and posterior poles. They are formed by overlap of ends of secondary fibres. These secondary fibres formed before birth (fetal nucleus). Anterior suture is shaped as an erect Y, and a posterior suture shaped as an inverted Y.
24 October 2013

Anterior Suture

( erect Y )

posterior suture inverted Y

24 October 2013

 Function of the Lens ,and its transparency, is dependant on the supply of appropriate nutrients to its various structures. Metabolic needs of a adult lens, is met by the, aqueous and vitreous.
24 October 2013

 Lens function is dependent on the 1) metabolism of glucose to produce energy , and 2) protein synthesis. Glutathione (anti-oxidant) is found in high concentration in lens and it protect lens from oxidative damage.
24 October 2013

Lens - Physiology
24 October 2013

 The transparency is dependent on, highly organized structure of lens.

By act of accommodation, it changes focusing power.

24 October 2013

Lens - Functions

24 October 2013

 Age related changes in the structure. Overall light transmission decreases with age, lens becomes less elastic. Reducing its ability to accommodate which leads to presbyopia.

24 October 2013

I. Subluxation

It is partial displacement in which lens is moved sideways (up, down, medially or laterally), but remains behind the pupil. It results from partial rupture or unequal stretching of the zonules

II. Dislocation or luxation of the lens

In it all the zonules are absent or destroyed. A dislocated lens may be incarcerated into the pupil or present in the anterior chamber or the vitreous
24 October 2013

Subluxation of the lens

24 October 2013

Dislocation or luxation of the lens

24 October 2013

24 October 2013

Antero-posterior thickness of Lens changes 1) In accommodation 2) While looking up 3) In sleep 4) By rubbing the eyes
Ans :- 1) in accommodation
24 October 2013

Lens is suspended in the eye by 1) 2) 3) 4) Capsule Vitreous Iris Zonules

Ans :- 4) Zonules
24 October 2013

What are major 3 parts of Lens 1) Capsule 2) Epithelium 3) Substance

24 October 2013

Lens substance is divided into two parts 1) Cortex 2) Nucleus

24 October 2013

4 parts of the Nucleus (i) Embryonic nucleus (ii) Fetal nucleus (iii)Infantile nucleus

(iv)Adult nucleus

24 October 2013

Which is the major protein of the lens :Crystalline protein.

24 October 2013

What is epinucleus ? ? Adult & infantile nucleus together called as epinucleus

24 October 2013

Which anti-oxidant is synthesized in the lens ?

Glutathione

24 October 2013

What are the functions of lens ?

1) Focusing the rays on the fovea 2) Protects the retina from the UV radiation
24 October 2013

Sub-luxation

24 October 2013

Dis-location

24 October 2013

 Cataract Definition Cataract Pathology

Cataract Etiology Classification of Cataract

Cataract Symptoms
24 October 2013

 Any opacity in the lens or its capsule, whether developmental or acquired is called cataract.
24 October 2013

Developmental opacities are usually partial and stationary, whereas acquired opacities are progressive.

24 October 2013

Cataract is caused by 1.The degeneration and opacification of existing lens fibres, 2.formation of aberrant lens fibres 3.deposition of other material in their place.
2009 - 2010 Suhas Kulkarni 55

24 October 2013

Any factor, physical or chemical, which disturbs the critical intra and extra-cellular equilibrium of water and electrolytes or deranges the colloid system within the fibres tends to bring about opacification.
56

24 October 2013

 Fibrous metaplasia of fibres may occur in complicated cataract) Epithelial cell necrosis leads to focal opacification of the lens epithelium as Glaucomflecken in acute angle closure glaucoma.
2009 - 2010 Suhas Kulkarni 57

24 October 2013

Abnormal products of metabolism, drugs or metals can be deposited in storage diseases ( Fabry ),

metabolic diseases ( Wilson )

and toxic reactions ( siderosis ).

24 October 2013

 Biochemically three factors are evident in the Process of cataract formation.

Hydration Denaturation of Lens Proteins Sclerosis
2009 - 2010 Suhas Kulkarni 59

24 October 2013

1.Hydration

In the early stages of cataract or rapidly developing forms, actual droplets of fluid, gather under the capsule, forming lacunae between the fibres, and the entire tissue swells (intumescence) and lens becomes opaque.

24 October 2013

This process may be reversible and opacities thus formed, may clear up, as in juvenile insulin dependent diabetic patients whose lens becomes clearer after control of hyperglycaemia. Hydration may be due to osmotic changes within the lens or due to changes in the semipermeability of the capsule. Traumatic cataract develops by hydration process.
24 October 2013

2. Denaturation of Lens Proteins

If the proteins are denatured, with an increase in insoluble proteins, a dense opacity is produced, a process which is irreversible . This occurs in young lens or cortex of adult lens. This type of cataract is called as soft cataract.
3. Sclerosis

Slow degenerative process occurs in nucleus of the lens. This type of cataract is called as hard cataract.
24 October 2013

Part II

Cataract

--Etiology --Classification --Symptoms

24 October 2013

Etiology A -Age-related B -Trauma C -Metabolic or secondary D -Toxic due to drugs E -Complicated Cataract F -After cataract or PCO G -Syndromes associated with cataract
24 October 2013

 A. Age-related
1. Sub-capsular a. Anterior: due to fibrous metaplasia of the anterior lens epithelium b. Posterior: just in front of the posterior capsule. It is associated with the posterior migration of the anterior epithelium of the lens
2009 - 2010

24 October 2013

2. Nuclear Cataract

-Exaggeration of the normal aging involving the lens nucleus -Often associated with myopia due to the increase in the refractive index . - Some elderly patients with Nuclear Sclerosis may be able to read again without their spectacles, due to the induced myopia: this is called the "second sight ".

24 October 2013

 B. Trauma : can cause cataract:

concussion, penetrating injury, electric shock, lightening, or radiation

Flower shaped (rosette) cataract

Suhas Kulkarni 67

24 October 2013

C.. Metabolic or secondary

1. Diabetes -Senile cataract is accelerated -True diabetic cataract: associated with over-hydration. Results in bilateral snowflake posterior or anterior subcapsular opacities

Suhas Kulkarni

68

24 October 2013

2. Galactosemia- multifocal white flakes are seen in lens (inborn error of galactose metabolism) 3. Wilsons disease green sunflower cataract (inborn error of copper metabolism)

24 October 2013

 D. Toxic due to drugs

-Steroids: systemic cause more cataract than topical. causes anterior and posterior subcapsular lens opacities. -Chlorpromazine: causes anterior lens capsule opacities

24 October 2013

-Gold (used in Rheumatoid Arthritis): 50% have posterior lens opacities

-Miotics: cause anterior sub-capsular opacities

24 October 2013

 E. Complicated Cataract
(due to some other ocular disease)

-Chronic anterior uveitis - Retinitis Pigmentosa - High Myopia - Acute angle closure glaucoma (Glaukomfleckens)
Suhas Kulkarni 72

24 October 2013

F. After cataract or PCO

posterior capsular opacity formed after cataract surgery ( extra capsular cataract extraction )

It is white membranous opacity formed by remains of anterior capsule and cortex.

24 October 2013

 G. Syndromes associated with cataract Downs ( mental retardation ) anterior, posterior subcapsular cataract Lowes ( oculo-cerebro-renal ) total cataract Wilsons disease ( hepatolenticular degeneration ) green sunflower cataract Congenital rubella total cataract
24 October 2013

1. Developmental 2. Age related (senile) 3. Cataract associated with ocular diseases 4. Cataract associated with systemic diseases 5. Traumatic Cataract 6. Drug induced cataract
24 October 2013

Classification of Cataract (2) 1.Congenital 2.Acquireda) Senile b) Traumatic

c) Complicated d) secondary e) Toxic f) Syndromes associated with cataract

3.After Cataract
Suhas Kulkarni 76

24 October 2013

Classification of Cataract (3)

A. Morphologic B. With respect to maturity of Cataract C. Age of onset

24 October 2013

 A. Morphologic:
1. Capsular Cataract 2. Subcapsular Cataract 3. Nuclear Cataract 4. Cortical Cataract 5. Lamellar Cataract 6. Sutural Cataract

2009 - 2010

Suhas Kulkarni

78

24 October 2013

1. Capsular Cataract
a. Anterior Capsular -Congenital: from persistent pupillary membrane -Acquired: Pseudoexfoliation syndromes, chlorpromazine, in association with posterior synechiae b. Posterior capsular: -Congenital: in association with persistent hyaloid remnants (Mittendorf's dot)
24 October 2013

2009 - 2010

Anterior Capsular cataract

Suhas Kulkarni

80

24 October 2013

 2. Subcapsular Cataract

a. Posterior Subcapsular -Complicated (e.g. in Diabetes Mellitis, Myotonic Dystrophy, steroids, irradiation)
b. Anterior Subcapsular -Acute angle closure glaucoma (Glaukomfleckens), - miotics - Wilson's disease
2009 - 2010 Suhas Kulkarni 81

24 October 2013

Anterior Subcapsular
2009 - 2010

Posterior Subcapsular
82

Suhas Kulkarni

24 October 2013

24 October 2013

Anterior Subcapsular

(Glaukomfleckens)
2009 - 2010 Suhas Kulkarni

24 October 2013 Acute angle closure glaucoma

3. Nuclear Cataract
-Age-related -Congenital: Rubella, Galactosemia

Nuclear Cataract

2009 - 2010

Suhas Kulkarni

85

24 October 2013

4. Cortical Cataract
-Usually spoke-like, can be anterior or posterior -Can be congenital (very common) -Usually doesn't interfere with vision

Cortical Cataract

2009 - 2010

Suhas Kulkarni

86

24 October 2013

Cortical Cataract on retroillmination

2009 - 2010

Suhas Kulkarni

87

24 October 2013

5. Lamellar Cataract
-Congenital. Involves one lamella of the fetal or nuclear zone

2009 - 2010

Suhas Kulkarni

88

24 October 2013

6. Sutural Cataract
-Congenital -Very common -Y-shaped opacity in the lens nucleus -No clinical significance

Anterior Sutural (erect Y )

2009 - 2010 Suhas Kulkarni 89

24 October 2013

B. With Respect to Maturity of Cataract 1. Stage of lamellar separation. 2. Stage of incipient cataract.
3. Immature senile cataract (ISC).

4. Mature senile cataract (MSC).

5. Hypermature senile cataract (HMSC).

2009 - 2010

Suhas Kulkarni

90

24 October 2013

1). Lameller separation:- cortical fibres are

separated by fluid. This phenomenon (lamellar separation) can only be seen with a slit-lamp and not with ophthalmoscope. The general increase in the refractive index of the cortex in old people gives a grey appearance.

24 October 2013

2. Stage of incipient cataract. In this stage early detectable opacities with clear areas between them are seen. Two distinct types of senile cortical cataracts can be recognized at this stage: (a) Cuneiform senile cortical cataract.
(b) Cupuliform senile cortical cataract.

24 October 2013

Incipient stage:- wedge-shaped spokes of opacity with clear areas between them appear in the periphery of the lens and lie in cortex, some in front of and some behind the nucleus. Lens fibres, thus producing irregularities in refraction, some visual deterioration and polyopia. The bases of the wedge-shaped opacities (cuneiform Opacities) are peripheral and they are most common in the lower nasal quadrant.
24 October 2013

Cuneiform Cataract

24 October 2013

Cuneiform senile cortical cataract

24 October 2013

Cupuliform senile cortical cataract. saucer shaped opacity develops just below the capsule usually in the central part of posterior cortex (posterior subcapsular cataract),which gradually extends outwards. Cupuliform cataract lies right in the pathway of the axial rays and thus causes an early loss of visual acuity.

24 October 2013

Cupuliform cataract

posterior subcapsular cataract

2009 - 2010

Suhas Kulkarni

97

24 October 2013

3.

Immature Cataract

-scattered opacities are separated by clear areas

when opacification becomes more diffuse and irregular. The lens appears greyish white but clear cortex is still present and so iris shadow is visible.

2009 - 2010

Suhas Kulkarni

98

24 October 2013

Iris Shadow

24 October 2013

Intumescent cataract
The lens has become swollen by imbibed water -Can be mature or immature The progressive hydration of the cortical layers may cause a swelling of the lens, thus making the anterior chamber shallow (intumescent cataract).

2009 - 2010

Suhas Kulkarni

100

24 October 2013

4. Mature senile cataract (MSC). Cortical In this stage, opacification becomes complete, i.e., whole of the cortex is involved. Lens becomes pearly white in colour. Such a cataract is also labelled as ripe cataract.

24 October 2013

Mature cataract
-Cortex is totally opaque

Cortical

2009 - 2010

Suhas Kulkarni

102

24 October 2013

Nuclear senile cataract. degenerative changes are intensified and associated with dehydration this leads to compaction of the nucleus resulting in formation of a hard cataract. The nucleus may become diffusely cloudy (greyish) or tinted (yellow to black) due to deposition of pigments. The commonly observed pigmented nuclear cataracts are either amber, brown (cataracta brunescens) or black (cataracta nigra) and rarely reddish (cataracta rubra) in colour
24 October 2013

24 October 2013

5.

Hypermature Cataract

-Mature cataract that has become swollen and has a wrinkled capsule as a result of leakage of water out of the lens.

2009 - 2010

Suhas Kulkarni

105

24 October 2013

A) Morgagnian Cataract:
-Hypermature cataract leading to total liquefaction of the cortex making the nucleus sink inferiorly

Some times cortex becomes fluid and nucleus may sink to the bottom of the lens. The liquefied cortex is milky, and the nucleus is as brown mass, altering its position with position of head.
2009 - 2010

Suhas Kulkarni

106

24 October 2013

24 October 2013

(b) Sclerotic type hypermature cataract:

Sometimes after the stage of maturity, the cortex becomes disintegrated and the lens becomes shrunken due to leakage of water. The anterior capsule is wrinkled and thickened due to proliferation of anterior cells and a dense white capsular cataract may be formed in the pupillary area. Due to shrinkage of lens, anterior chamber becomes deep and iris becomes tremulous (iridodonesis).

24 October 2013

C . Age of onset
1. Congenital Cataract -- Present at birth 2. Infantile Cataract --- up to 1 yr of age 3. Juvenile Cataract -------- Infancy to adolescence

4. Pre-senile Cataract ------ up to the age of 40 5. Senile Cataract ------ after the age of 40
2009 - 2010 Suhas Kulkarni 109

24 October 2013

1. Blurring of vision 2. Frequent change of glasses due to rapid change in refractive index of the lens 3. Painless, progressive gradual diminution of vision due to reduction in transparency of the lens 4. Second sight or myopic shift in case of nuclear cataract causing index myopia, improving near vision.
2009 - 2010 Suhas Kulkarni 110

24 October 2013

5. Loss or marked diminution of vision in bright sunlight or bright light beam in central posterior subcapsular cataract. 6. Monocular diplopia or polyopia in presence of cortical spoke opacities 7. Glare in posterior subcapsular cortical cataract due to increased scattering of light

2009 - 2010

Suhas Kulkarni

111

24 October 2013

8. Colored haloes around the light as seen in cortical cataract due to irregular refractive index in different parts of the lens. 9. Color shift , reds are accentuated 10. Visual field loss, generalized reduction in sensitivity due to loss of transparency

2009 - 2010

Suhas Kulkarni

112

24 October 2013

24 October 2013

Cataract risk factors

Demographic RF
Age- The strongest RF for cataract The risk of cataract at age 70 is about 13-fold that at age 50 Race

Some types of cataracts (cortical & nuclear) are more

common in african americans Sex Women slightly greater risk than men Geographic
24 October 2013

Especially prevalent in developing countries in the tropical bel

Medical RF
Diabetes

Drugs
Miotic cholinergic compounds Cancer chemotherapy agents Diuretics Various photosenthesitizing drugs

Major tranquillizers
Gout medications Steroids
24 October 2013

Environmental RF
Nutrition- conflicting reports

Dietary intake of riboflavin, vit C &E & carotenoids (antioxidants)- protective ef

Intake of niacin, thiamine & iron- also protective Radiation

Exposure to UV--> cortical & PSC

IR Smoking- increased risk of nuclear cataracts Alcohol use > 2 drinks/ day--> increased risk of all types of cataract
24 October 2013

24 October 2013

Chronic open angle glaucoma Macular degeneration Optic atrophy Corneal dystrophy Retinopathy associated with systemic disorders (hypertension or diabetes)

24 October 2013

24 October 2013

Grading of nucleus for Phaco-emulsification

24 October 2013

Examination of the Eye

Visual acuity for RE / LE With or without spects For distance and near Pin hole vision Pupil dilatation Slit-lamp examination Fundus examination B-Scan A-Scan
24 October 2013

Sac Syringing
IOT

Other investigations
Urine and Blood Test B.P. and ECG with Physicians fitness Anaethetists examination and fitness

24 October 2013

24 October 2013

24 October 2013

24 October 2013

24 October 2013