Mature cataract

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Mature cataract

hypermature senile cataract (Morganian)

Clinical features

Ø Symptoms

1. Glare

2. Uniocular polyopia

3. Colored halos

4. Black spots in front of eyes

5. Image blur, distortion of images

6. Loss of vision

Ø Signs

1. Visual acuity testing

2. Test for iris shadow

3. Oblique illumination examination

4. Distant direct ophthalmoscopic examination

5. Slit-lamp examination

Etiologies of Congenital and Developmental Cataracts

Mendelian Inheritance

A. Autosomal dominant

B. Autosomal recessive

C. X-linked

II. Intrauterine Infection

A. Rubella

B. Chickenpox/herpes zoster

C. Herpes simplex

D. Cytomegalovirus

III. Prematurity

IV. Metabolic Disorders

A. Galactosemia

B. Hypoparathyroidism

C. Pseudohypoparathyroidism

D. Diabetes mellitus

E. Refsum's syndrome

F. Oculocerebrorenal (Lowe's) syndrome

G. Hypoglycemia

H. Mannosidosis

I. Hereditary familial congenital hemorrhagic nephritis (Alport's syndrome)

V. Chromosomal Disorders

A. Trisomy 21 (Down's syndrome)

B. Trisomy 13

C. Trisomy 18

VI. Ocular Abnormalities

A. Microphthalmia

B. Mesodermal dysgenesis

C. Coloboma

D. Aniridia

E. Persistent pupillary membrane

F. Posterior lenticonus

G. Persistent hyperplastic primary vitreous

VII. Systemic Syndromes

A. Hallermann-Streiff syndrome

B. Marinesco Sjogren Marinesco-Sjцgren syndrome

C. Congenital stippled epiphysis (Conradi's) syndrome

D. Myotonic dystrophy

E. Smith-Lemli-Opitz syndrome

F. Stickler's syndrome

G. Cerebral gigantism (Soto's) syndrome

H. Potter's syndrome

I. Chondrodystrophic myotonia

J. Schwartz-Jampel syndrome

K. Cockayne's syndrome

L. Meckel's syndrome

M. syndrome

VIII. Dermatologic Disorders

A. Poikiloderma atrophicans (Rothmund-Thomson syndrome)

B. Congenital ichthyosis

C. Ectodermal dysplasia

D. Incontinentia pigmenti of Bloch-Sulzberger

E. Atopic dermatitis

IX. Craniofacial Dysostosis

A. Crouzon's syndrome

B. Apert's syndrome

C. Oxycephaly

Congenital cataract

occur in a variety of morphologic configuration, including polar, nuclear, lamellar, sutural, diffuse, membranous, polymorphic, anterior and posterior

Total or Complete

Ø These cataracts are completely opaque or hazy at birth. Most of these are associated with systemic disorders or abnormalities such as galactosemia, rubella, and Lowe's syndrome. They may also be hereditary (autosomal-dominant or autosomal-recessive)

Partial or Incomplete

A. Anterior and posterior polar cataract: These cataracts involve the lens capsule in the anterior or posterior pole of the lens. They are sometimes associated with a localized anatomic abnormality in the region. For example, posterior polar cataracts commonly occur in cases of posterior lenticonus.

B. Zonular cataract: In this type of cataract, only a region or zone of the lens is opaque. They may be stationary but may also progress. There are various subtypes:

Ø 1. Lamellar: This is the most common type of congenital cataract. Such cases are usually bilateral and symmetric, and the density of opacification may vary considerably. Less opaque lamellar cataractsmay be compatible with good vision and minimal medical intervention (e.g., optical correction, therapeutic mydriasis). These cataracts may be inherited as an autosomal-dominant trait, but in some cases they may be attributed to a transient intrauterine toxic agent, affecting only the layer of cells developing at the time of fetal exposure.

Ø 2. Stellate: These cataracts affect the region of the sutures. They may be Y-shaped if the cataract occurs in the intrauterine stage of development, since the sutures have this configuration during this period. Anterior sutural cataracts are Y-shaped; posterior sutural cataracts are shaped like an inverted Y. Sutural cataracts that develop later on have a more stellate shape in keeping with the shape of the sutures after birth.

Ø 3. Nuclear : These cataracts are usually bilateral and involve the fetal or embryonal nucleus. They may be inherited as an autosomal-dominant, autosomal-recessive, or X-linked trait.

Ø 4. Coronary : These cataracts are radial, club-shaped discrete opacities located in the cortex and are called "coronary" because they appear like the top of a crown. Because of their peripheral location, they do not decrease visual acuity. Coronary cataracts are dominantly inherited and have been described in cases of Down's syndrome and myotonic dystrophy.

Ø 5. Cerulean: These cataracts consist of small, discrete opacities that have a distinct bluish hue. These opacities are located in the cortex, are nonprogressive, and do not cause visual symptoms. They may be present together with other congenital cataracts.

Ø 6. Membranous cataracts: These cataracts are thin but dense and contain fibrous tissue. They may occur when lens proteins are reabsorbed (e.g., traumatized lens; see following section), such that the anterior and posterior lens capsules fuse, producing a dense membrane.

11.

Marfan's syndrome

Ø The hereditary pattern of Marfan's syndrome is autosomal dominant with variable expressivity. It is characterized by skeletal (increased length of extremities, arachnodactyly, loose joints, scoliosis, pectus excavatum, high palate), cardiovascular (aortic dilatation, dissecting aneurysm, floppy mitral valve), and ocular anomalies (ectopia lentis, increased corneal diameter and axial length, flattened iris surface with transillumination at its base, miotic pupil, angle abnormalities, high myopia, retinal detachment, may be glaucoma, megalocornea and nystagmus ).

Ø Ectopia lentis is found in 50% to 80% of patients with Marfan's syndrome. The subluxation is nearly always bilateral, rarely progressive, and usually located upward and temporally. The lens may be tilted.

Weill-Marchesani syndrome

Ø The hereditary pattern of Weill-Marchesani syndrome is autosomal dominant or recessive

Ø Patients with Weill-Marchesani syndrome are brachymorphic with short stature and stubby hands, with stiff joints. There is no mental retardation, and heredity may be dominant or recessive. There is a high rate of consanguinity. A nonprogressive dislocation of the lens in an upward and temporal direction is frequent, although inferior dislocation is also reported. Microphakia and spherophakia may be present prior to the subluxation or dislocation, and pupillary-block glaucoma may occur. The zonules appear abnormally elongated, allowing the lens to change position. Myopia, cataracts, microcornea, megalocornea, and angle abnormalities have been reported.

Rieger's syndrome

Ø Autosomal dominant inheritance patterns in families have been identified.

Ø Rieger's Syndrome probably includes those entities sometimes described as mesodermal dysgenesis and anterior chamber cleavage syndrome.

Ø Rieger's syndrome often has Axenfeld's anomaly as one of its ocular findings, along with marked anomalous development of the iris, and systemic anomalies mainly consisting of facial and dental abnormalities. Corectopia (displaced in the direction of prominent peripheral tissue strands), dyscoria, slit pupil, iris hypoplasia, and prominent iris strands have been reported. Glaucoma eventually may be found in 50% of affected people; however, the glaucoma may not be manifest until childhood or early adulthood, Extraocular abnormalities include enamel hypoplasia; conical and misshapen teeth; hypodontia; impactions; underdevelopment of the maxilla, mandible, and cranial base (anterior and posterior); low set ears; wide nasal bridge; bilateral microcondyles; and bilateral choanal atresia.

Gregg’s syndrome or congenital rubella syndrome

Ø In 1941, Gregg described the triad of cataracts, deafness, and congenital heart disease in infants born to mothers who had experienced rubella during the first trimester of pregnancy

Ø Cataract may be associated with pigmentary retinopathy, microphthalmia, mesodermal dysgenesis, glaucoma, strabismus, and nystagmus, coloboma or atrophy of iris.

Ø Ear and heart defects

Acquired cataract

Senile cataract may be subcapsuar, nuclear, cortical.

Classification according to maturity

1. An immature cataract is one in which scattered opacities are separated by clear zones

2. A mature cataract is one in which the cortex is totally opaque

3. An intumescent cataract is one in which the lens has become swollen by imbibed water. It can be mature or immature

4. A hypermature cataract is a mature cataract which has become smaller and has a wrinkled capsule as a result of leakage of water out of the lens

5. A morganian cataract is a hypermature cataract in which the total liquefaction of the cortex has allowed the nucleus to sink inferiorly

Differentiation between senile immature nuclear
cataract and immature cortical cataract

Features	Senile immature nuclear cataract	Senile immature cortical cataract
Vision Age of onset Lens opacities Site Shape Colour Maturity Hypermaturity	Poor in day time, may improve with minus lenses Usually starts in forties Central Nearly round or oval Brown or black Takes long time to become mature Rarely becomes hypermature	Poor in night time, may improve with plus lenses Usually starts in fifties Peripheral Wedge-shaped spokes Usually white Matures relatively early If unattended reaches hypermaturity

CATARACT ASSOCIATED WITH SYSTEMIC DISEASES

Ø Systemic conditions associated with cataract formation can be grouped into five broad categories:

Ø 1. Metabolic disorders

Ø 2. Skin disease

Ø 3. Connective tissue/skeletal disorders

Ø 4. Renal disease

Ø 5. Central nervous system disorders

Diabetic cataract

Ø The most common ocular manifestations of diabetes are bilateral cataract, retinopathy, lesion of optic disc and other.

Ø A special type of cortical cataract has been seen in many diabetic patients. This abnormality was noted to have a type of "snowflake" appearance with bilateral, widespread subcapsular changes (saucer-shaped cataract).

Tetanic cataract

Ø This condition is usually the result of the accidental removal of the parathyroid glands during thyroidectomy, although it may be idiopathic in origin.

Ø Tetany is characterized by muscle cramps, carpopedal spasms, laryngeal stridor, and convulsions. More chronic manifestations of hypocalcemia include skin changes, loss of pubic and axillary hair, brittle nails, hypoplastic teeth, and personality changes.

Ø The lens develops multiple, small, white or multicolored punctate opacities usually located in the subcapsular region, which with progression, involves the lenticular cortex. Eventually, more widespread changes develop with vacuolation and diffuse opacities.

Cataract by Rheumatoid Arthritis

Ø The arthritis is classically described as an additive, symmetric, deforming polyarthritis.

Ø The most common ocular manifestations of RA are keratoconjunctivitis sicca (secondary Sjogrens Sjögrens syndrome), scleritis, iridocyclitis cataract and rheumatoid corneal melts.

Treatment of cataract

Ø Non-surgical measures

1. Treatment of cause of cataract

2. Measures to delay progression (Ophthancatahrom, Catalin, Qinax)

3. Measures to improve vision in the presence of incipient and immature cataract

Ø Surgical management

Ø Intracapsular cataract extraction

Ø Extracapsular cataract extraction

Ø Phacoemulsification

Ø Correction of aphakia (pediatric)

Ø Correction of amblyopia (pediatric)

Correction of pediatric aphakia

EXTRACAPSULAR CATARACT EXTRACTION

PHACOEMULSIFICATION

YAG laser posterior capsulotomy.

Thank you for your attention!

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