LENS AND CATARACT

ANATOMY

1. Normal Crystalline Lens

The crystalline lens is transparent, biconvex structure located posterior to the iris and
anterior to the vitreous body.Component of the lens are capsule, epithelium, cortex and
nucleus.
2. Capsule
The lens capsule is an elastic, transparent basement membrane that is composed of type IV
collagen and other matrix proteins and laid down by the epithelial cells. The capsule
contains the lens substance and is capable of molding it during accommodative changes.
3. Zonular Fibers
The lens is supported by the system of fibers (the zonule)that originate from the basal lamina
of the nonpigmented epithelium of the pars plana and pars plicata of the ciliary body.
4. Lens Epithelium
These cells are metabolically active and carry out all normal cell actives, including
biosynthesis of DNA, RNA, protein and lipid.
5. Nucleus and Cortex
No cells are lost from the lens, as new fibers are laid down, they crowd and compact the
previously formed fibers, with the older layers located toward the center.
The outermost fibers are the most recently formed and make uo the cortex of the lens
Biochemistry and physiology

Lens Proteins

Water Soluble Water Insoluble

(Intracellular proteins)

α - Crystalline ꞵ,ꝩ Crystalline Urea Soluble Urea Insoluble

(Most cytoskeletal (Most lens fiber cell
protein ) membrane proteins;
includes major intrinsic
protein [MIP])
Embryology and Developmental Defects

 Ectopia Lentis
 Ectopia Lentis is a displacement of the lens that may be congenital, developmental, or
acquired.
 Dislocation of the lens posteriorsly into the vitreous cavity often has no adverse sequlae
aside from a profound into the anterior chamber or pupil may cause pupillary block and
angle closure glaucoma
 Marfan Syndrome
 Marfan syndrome is a heritable disorder with ocular, cardiovascular, and skeletal
manifestations.
Other ocular abnormalities associated with marfan syndrome include axial myopia and an
increased risk of retinal detachment
 Homocystinuria
 Homocystinuria is an inborn error of methuinine metablosm that is transmitted in an
autosomal recessive pattern.
 Affected individuals are healthy at birth: however, seizures and osteoporosis develop, and
cognitive impairment soon becomes apparent.

 Hyperlysinemia
 Hyperlysinemia, an inborn error of metabolism of the amino acid lysine, is associated
with ectopia lentis.
Affected individuals also how cognitive impairment and muscular hypotony
 Genetic Constributions to Age – Related Cataracts
 Studies of identical and fraternal twins and of familial association suggest that a large
propotion of the risk of age related cataracts is inherited.

 Ectopia Lentis et pupillae

 In the autosomal recessive disorder ectopia lentis et pupil are displaced in opposite
directions.
 Persistent Fetal Vasculature
 Also known as persistent hyperplastic vitreous (PHPV), is a congenital , nonhereditary
ocular malformation that frequently involves the lens.
 In 90% of patients, it is unilateral
PATHOLOGY

 NUCLEAR CATARACTS
 Progress slowly
 Bilateral but may be asymmetric
 In the early stages of cataract development, the progressive hardening of the lens nucleus
frequently causesban increase in the refractive index of the lens and thus a myotic shift in
refraction (lenticular myopia)
 Cortical Cataract
 In contrast to nuclear cataracts, cortical cataracts are associated with the local disruption
of the structure of mature lens fiber cells
 Like nuclear cataracts, cortical cataract are usually bilateral buat are often asymmetric
 When degenerated cortical material leaks through the lens capsule, leaving the capsule
wrinkled and shrunken, the cataract is referred to as hypermature. When further
liquefaction of the cortex allows free movement of the nucleus within the capsular bag,
the cataract is described as morgagnian
 Posterior Subcapsular cataract
 Patient with posterior cataract (PSCs) are often younger than those presenting with
nuclear or cortical cataracts.
 As states earlier, PSCs are one of the main type of cataract related to aging
 Histologically, PSCs are associated with posterior migration of the lens epithelial cells
from the lens equator to the visual axis on the inner surface of the posterior capsule.
Drugs Induced Lens Changes
• Corticosteroids
• Phenothiazines
• Miotics
• Amiodarone
• Statins
• Tamoxifen
Trauma
• Contusion
• Vossius Ring
• Traumatic Cataract
• Dislocation and Subluxation
• Perforating or Penetrating Injury
Radiation
Ionizing Radiation
Infrared Radiation
Ultraviolet Radiation

Metallosis
o Siderosis Bulbi
- Intraocular iron – containing foreign bodies can cause siderosis bulbi, a condition
characterized by deposition of iron molecules in the trabecular meshwork, lens epithelium,
iris, and retina.
o Chalacosis
- Chalacosis occurs when an intraocular foreign bodies deposits copper in the descement
membrane, anterior lens capsule, or other intraocular basement membranes.
- The resulting “ sunflower” cataract is a petal- shaped deposition of yellow or brown
pigment in the lens capsule that radiates from the anterior axial pole of the lens to the
equator.

o Electrical Injury
- Electrical shock can cause protein coagulation and cataract formation

o Chemical Injury
- Alkali Injuries to the ocular surface often result in cataract, in addition to damaging the
cornea, conjungtiva, and iris
o Galactosemia
- Galactosemia is an inherited recessive inability to convert galactose to glucose.

o Hypocalcemia
- Usually bilateral, hyopocalcemic cataracts are punctate iridescent opacities in the anterior
and posterior cortex.

o Wilson Disease
- Wilson disease ( Hepatocelular degeneration) in an inherited autosomal dominant
condition characterized by delayed relaxation of contracted muscles , ptosis, weakness of
the facial musculature, cardiac conduction defects, and prominent frontal balding in
affected male patients
o Myotonic Distrophy
Patients with this disorder typically develop polychromatic iridescent crystal in the lens
cortex, with sequential PSC progressing to complete cortical opacification
EVALUATION AND MANAGEMENT OF
CATARACTS IN ADULTS

External Examination
- Motility
- Pupils

Slit- Lamp Examination

- Conjungtiva
- Cornea
- Anterior Chamber and Iris
- Crystalline Lens
- Limitations of Slit- Lamp Examination
Fundus Evaluation
- Opthalmoscopy
- Optic Nerve
- Fundus Evaluation With Opaque Media

Special Tests
- Potential Acuity Estimation
- Visual Field Testing
- Objective Test of Macular Function
Preoperative Measurements
- Biometry
- Corneal Topography
- Additional Evaluation of the cornea
Surgery For Cataract

Before Surgery
Before the day of surgery, the surgeon should identify and reduce infections risk factors as
much as possible through preoperative treatment of coexisting eyelid disorders such as
conjungtivitis blepharitis, hordeolum and chalazion

In Surgery
A 5 % povidone –iodine solution (not scrub or soap) placed in the conjungtival fornix prior
to surgery has been associated with a reduction in bacterial colony counts in cultures from
the ocular surface at the time of surgery and a decreased risk of culture-proven
endopthalmitis.
After Surgery
- After routine cataract surgery, use of antibiotic eyedrops is commonly continued or
instituted
- Although reduced bacterial counts have been documented with the administration of
topical antibiotics, there is no definitive evidence that their use reduces the incidence of
endofthalmitis.
- Phacoemulsification

Alternative Technologies for Cataract Extraction

- Laser Photolysis
- Fluid Based Phacolysis
- Femtosecond Laser Cataract Extraction
Outcome of Cataract Surgery
Cotemporary cataract surgery has an excellent success rate in both improving visual acuity
and enchancing subjective visual function
Complication of Cataract Surgery

• Cornea Edema
• Brown- McLean Syndrome
• Vitreocorneal adherence and persistent corneal edema
• Incision and Wound Complications
• Thermal Wound Burn
• Wound dehiscence or rupture
• Descemet Membren Detachment
• Induced Astigmatism
• Corneal Melting
Other Anterior Segment Complications

• Epithelial or Fibrous Ingrowth

• Toxic Anterior Segment Syndrome
• Shallow or Flat Anterior Chamber
• Elevated Intraocular Pressure
• Intraoperative Floppy Iris Syndrome
• Lens- Iris Diaphragm Retropulsion Syndrome
• Irididialysis and Iris Trauma
• Cyclodialysis
• Ciliary Block Glaucoma
• Postoperative Uveitis
• Retained Lens Material
• Capsular Rupture
• Vitreous Prolapse in the Anterior Chamber
COMPLICATION OF IOL IMPLANTATION

• Dececntration and Dislocation

• Pupillary Capture
• Capsular Block Syndrome
• Uveitis- Glaucoma- Hyphema Syndrome
• Pseudophakic Bullous Keratopathy
• Unexpected Refractive Results
• IOL Glare , Dysphotopsia, and Opacification
Capsular Opacification and Contraction
• Posterior Capsule Opacification
• Anterior Capsule Fibrosis and Phymosis
TH/ :
Nd : Yag Laser Capsulotomy – is now a standard procedure for the treatment of secondary
opacification of the posterior capsule or contraction of the anterior capsule
Complication

• Hemorrhage
• Endopthalmitis
Th :Neddle biopsy for anterior chamber and vitreous samples for culture and gram stain
will help determine the appropriate antibiotic selections
• Retinal complications
- Cystoid Macular Edema
- Retinal Light Toxicity
- Retinal Detachment