OPHTHALMOLOGY©POKEMONMDTRANSES

LENSANDCATARACTS
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THE CRYSTALLINE LENS Types of errors of refraction

• The lens is suspended by a thin filament of zonules from the ciliary Myopia Near-sightedness Presbyopia Physiologic error
body to the iris anteriorly and vitreous posteriorly. As the light enters Hyperopia Far-sightedness Astigmatism Irregular vision
the eye, the image is focused exactly at the retina. *Emmetropia is the term used for a normal refractive index*

ANATOMY OF THE EYE

❖ Outside are the cornea and other surrounding structures

❖ Middle area iris and the lens ❖ (Left) No Accommodation – Ciliary muscles relaxes, suspensory
❖ Back area is the most important area which contains the retina and its ligament taut, lens flat
photoreceptors ❖ (Right) With Accommodation – Ciliary muscle contracts,
suspensory ligament is lax, and Lens becomes globular
Parts of the lens: *What type of nerves innervate your ciliary muscles? Parasympathetic*
LENS CAPSULE Outer part and engulfs the whole lens structure
Elastic membrane containing the cortex nucleus. PRESBYOPIA
CORTEX Middle part Physiologic; after 40yo accommodation starts to fail.
NUCLEUS Central part Loss of accommodation due to aging
SUSPENSORY Thin filamentous fibers mainly hold the lens in place The lens loses its flexibility with increasing age
ZONULES OF ZINN attaching it to the ciliary body
* Remember: the eye has 60D (40 from cornea, 20 from lens) *
The Lens capsule is line by epithelial cells anteriorly and they continuously AGE DIOPTER IN LENS
produce lens fibers that is why the lens continuously increase in size, length, ADOLESCENTS 12-16 D
and weight through the years. 40 YEARS OLD 4-8 D
>5O YRS OLD <2 D
FUNCTIONS OF THE LENS
1. Refraction SYMPTOMS Inability to read fine print or discriminate fine close objects
to about age 40
• To focus the light exactly at the retina
TREATMENT Corrected by plus lenses
• Bending of light rays that passes through one medium to another
refractive medium
SIGNS AND SYMPTOMS OF LENS DISORDER
Presbyopic symptoms
2. Accommodation
• Inability to perform near tasks
• Physiologic interplay of the ciliary body, zonule and lens that results
• Accommodation starts to fail, lens loses its ability to resolve, separate,
in focusing of near objects upon the retina.
distinguish, and refract the light rays causing blurring of vision.
❖ When there is no accommodation, the muscles are
• Due to irregular refraction within the lens, they may have multiple
relaxed, the zonules are taut, and the lens as a whole is
images, stardust, or difficulty of driving at night.
flat.
❖ When there is accommodation, the ciliary body
Loss of lens transparency
contracts, zonules relax, and the lens assumes a more
• Blurring of vision, glare, second sight and color discrimination
globular formation.
• Trauma, drug related, systemic, or metabolic such as diabetes which is
the most common cause of blindness by metabolic disorder.
In simpler words, lets you see adjust from far to near Accommodation is a
*But most common overall is age related*
gift for young people of <40 y/o because they have strong accommodation.
• With lens becoming more yellow to brown in color, objects appear darker
As you age the lens cannot expand for you to adjust seeing from afar
in color that color discrimination becomes more difficult.

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SUBCAPSULAR LENS OPACITY – Patients will complain of decreased vision,
glare, and image distortion. AGE RELATED CATARACTS
CLASSIFICATIONS OF CATARACTS ACCDNG TO OPACIFICATION
NUCLEAR SCLEROSIS – Patients have increased refractive power because of a
denser nucleus, developing lenticular myopia. They progressively become more
myopic, such that they can read without the glasses they normally need in a IMMATURE •
Opacity can be observed, but no opacity in between
phenomenon called second sight. •
Transparent lens fibers are present
•
Opacity is located centrally
Dislocation •
Little clarity of cataract
INTUMESCENT •
Swelling of the lens with the presence of fluid clefts
• Refractive symptoms
•
Opacification of all lens fibers is observed
• Most likely from trauma
MATURE •
Whole lens homogenously opacified, appears as a
white pupil
SIGNS
• Opacification of all lens fiber
• Whitish pupillary reflex
HYPER- • Liquefaction of opaque lens fibers (Morgagnian)
• Iridodonesis - condition where there is tremulousness in the iris or
vibration or agitated motion of the iris with eye movement
MATURE • Nucleus is not centrally located (Inferiorly)
• Ophthalmoscopic sign • Waited for a few months or years then becomes
❖ (+) central dark reflex with peripheral orange reflex liquefied to the point that the nucleus becomes
❖ Spoke-wheel sign - Peripheral dark reflex with central orange mobile
red reflex (if you can’t see the red orange reflex, its probably • Some of the lens fibers have liquefied, with calcific
a mature type of spokes wheel sign for lens disorder.) areas
AFTER- • Opacification of the posterior capsule after cataract
CATARACT surgery.
EXAMINATION OF THE LENS
• Primary complication of cataract surgery
• Best done with a dilated pupil *Morgagnian lens means that the lens liquefaction has caused the lens
DENSE CATARACT You can use Penlight/slitlamp/ophthalmoscope nucleus to go down.*
LESS DENSE CATARACT You can use Slitlamp/opthalmoscope
CLASSIFICATIONS OF CATARACTS ACCDNG TO LOCATION
• Penlight
• Slit lamp - provides a magnified view of the lens to describe the type,
severity, and location of the cataract. NUCLEAR CORTICAL POSTERIOR SUBCAPSULAR
• Ophthalmoscope or bio microscopy and lens Hard Soft Soft
❖ Also needed to evaluate the optic nerve and retina to detect the Condensation of lens Opacity of lens Appears as gold white
eye problems that could affect visual acuity such as macula; Nucleus fibers in spoke like granules, almost always
especially when the patient reports metamorphopsia or pattern granular
difficulty with near objects. Myopic shift and Decreased vision
❖ Assessment of the red-orange reflex will assist on the better near vision disproportionate to size
identification of posterior subcapsular cataract. More of the inside More of the Always at the back, it is the
❖ If the lens is dense enough such that the ophthalmoscope will part, it does not intermediate part most common cataract in
not allow for the retina and the optic nerve to be viewed, a B- liquefy that much. diabetic patient.
scan may be required.
‘Pag Nuclear yung characteristics n’ya is yung parang sa matatanda when
CATARACT theu say “Pag tumatanda, uy lumilinaw ang malapit ko malabo ang malayo”
• Any opacity of the lens ‘Pag Cortical yung itsura n’ya is parang MAGS/rim ng gulong ng kotse
Causes ‘Pag Posterior subcapsular, ito yung madalas na nangyayari sa diabetic
patients, those who take steroids, radiation at trauma
ACQUIRED CHILDHOOD
NUCLEAR CORTICAL POST. SUBCAPS.
• Age related • Congenital
• Traumatic/Radiation • Acquired
• Ocular disease (uveitis,
glaucoma etc)
• Systemic diseases (DM very
quick, etc)
• Previous eye surgeries
NUCLEAR SCLEROSIS
PATHOPHYSIOLOGY OF AGE-RELATED CATARACT FORMATION • Normal condensation process of the lens that occurs after middle age
• Occurs from an increase in the refractive power of the central lens,
• Cataracts are product of protein denaturation and oxidative stress
creating a myopic (nearsighted) shift in refraction.
from subsequent hydrolysis
• The earliest symptom is improved near vision without glasses (second
• Widespread oxidative changes decrease glutathione concentration
and oxidation of methionine and cysteine sight).
• Other symptoms may include poor hue discrimination or mononuclear
Biochemical changes diplopia. Most nuclear cataracts are bilateral but may be asymmetric.
❖ Increased sodium and insoluble protein CORTICAL CATARACTS
❖ Decreased soluble protein • Opacities in the lens cortex.
❖ Bound water reflecting loss of binding sites • Changes in the hydration of lens fibers creates clefts in a radial pattern
around the equatorial region.
• Tends to be bilateral, but are often asymmetric.
• Visual function is variably affected, depending on how near the opacities
are to the visual axis

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POSTERIOR SUBCAPSULAR LENS INDUCED UVEITIS
• Located in the cortex adjacent to the posterior capsule. • Accidental rupture of the lens capsule
• They tend to cause visual symptoms earlier in the development owing to liberates lens proteins
the involvement of the visual axis. • Uveitis sometimes with glaucoma occur
• Common symptoms include glare, reduced vision under bright lighting • Mutton-fat precipitates, posterior
• condition. synechiae (adhesions) and pupillary
• This lens opacity can also result from trauma, steroid use, inflammation, membranes may form (only seen in
or exposure to radiation lens-induced uveitis)
*Treatment for this lesion is lens extraction
and corticosteroid administration*
Common Symptoms
❖ Decreased vision
LENS-PARTICLE GLAUCOMA
❖ Painless
❖ Reduced vision in bright illumination, more apparent at night or • Following a penetrating lens injury or surgical procedure, particle of lens
during the day when the lens is at the center. cortex migrates to the anterior chamber obstructing the trabecular
❖ Spots in the visual field meshwork
❖ Ability to read without glasses (second sight) • Occurs within weeks to months or years
*Treatment is to lower IOP and Corticosteroid administration / surgical
TRAUMATIC CATARACT removal of retained lens material*
• Contusion may produce a cataract months after the event
• Rupture of the lens capsule CATARACT ASSOCIATED WITH SYSTEMIC DISEASE METABOLIC CATARACT
• Extrusion of lens material into the anterior chamber • Diabetes mellitus - Most common and is more on posterior subcapsular
• Intraocular foreign body • Wilsons’s disease - Sunflower cataract
• Myotonic dystrophy - Christmas tree appearance
• Galactosemia
• Hypocalcemia

DRUG INDUCED/TOXIC CATARACTS

• Corticosteroids – Posterior subcaps. opacification (PSC)
• Miotics like anticholinesterases – Anterior subcaps. opacification (ASC)
• Amiodarone - Stellate anterior axial pigment deposition. Still noted to
LENS-INDUCED OCULAR DISEASE have cataract but the literatures have told that people that used
PHACOMORPHIC (PHACOGENIC) GLAUCOMA amiodarone have developed cataract.
• Rapid swelling of lens follows hydration of lens fibers in intumescent • Statins
cataract • Phenothiazines
• May follow surgical or accidental rupture of lens capsule
• Increases AP dimension of the lens causing pupillary block with forward CHILDHOOD CATARACT
movement of the iris
• May result in secondary angle closure glaucoma Congenital cataract Acquired cataract
• Lens is really hard to the point that it disrupts the point of AC hence • Hereditary 30% • Trauma • Infection
creating increased pressure and provides more inflammation, • Secondary to • Uveitis • DM
• Painful type of lesion of the lens metabolic/infectious diseases • Drugs
*Main treatment is to decrease the pressure by taking out the lens* • Undetermined causes

I just want to stress out why we need surgery – if the vision is developed,
we always do medical or non-invasive treatment, but if it is more than 2mm
and the vision is occluded you have to do it before they develop the vision.
Why? Amblyopia

PHACOLYTIC GLAUCOMA AMBLYOPIA – AKA Lazy eye Is an eye that does not develop the proper
• Leakage of lens proteins from a hypermature cataract cause uveitis visual acuity
• Uveitic type of inflammation but can also increase the intraocular
pressure Why is lasik not commonly performed? The cornea might burst
• As it matures, protein leaks out of the capsule then it blocks the vision
*Needs immediate surgery because the lesion is very minute* CONGENITAL CATARACT
• Common condition but usually small and not significant
• May not require surgery unless visually significant (>2mm size) any more
than 2mm creates visual problems
• Most of the time it is hereditary, systemic diseases, and infection
(rubella)

Note the macrophage plugging the trabecular meshwork, Hypermature

cataract leaking proteins into the anterior chamber

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Manual Small Incision Cataract Surgery (MSICS)
LENS-DEVELOPMENT ANOMALIES Steps are based on the traditional nuclear expression form of ECCE. Nucleus is
ECTOPIA LENTIS removed intact, using a small incision. Cortex is removed by manual aspiration.
• Displacement or malposition of the eye’s crystalline lens from its Indicated for dense cataracts unsuitable for phacoemulsification.
normal location
Phacoemulsification UTZ
Dislocation loses entire support of zonular fibers Now the most common form of ECCE in developed countries. Uses a handheld
Subluxation some zonular fibers remain attached acting as hinge (lens ultrasonic vibrator to disintegrate the hard nucleus. Nuclear material and cortex
subluxated from usual position) are aspirated via a 2.5 – 3 mm incision then insertion of foldable intraocular
lenses.
Signs and Symptoms of Ectopia Major syndromes associated with
lentis Ectopia Lentis Typical Lenses
❖ Iridodonesis ❖ Marfan syndrome Monofocal If you correct the patient the patient can only see one
❖ Decreased vision ❖ Homocystinuria vision either far or near
❖ Weill-Marchesani syndrome
Multifocal Several focalities (far, near, immediate, at the same
time)
SPHEROPHAKIA
Accommodative Improves your accommodation
•
Small lens with increased anterior and posterior curvatures Toric designed for people with astigmatism. Toric contact
•
Increased curvature leading to Myopia lenses correct for astigmatism issues that arise from a
•
Iridodonesis different curvature of the cornea or lens in your eye.
•
Subulxation of lens is common This gives you monofocal vision
LENTICONUS
• Rare; Cone-shaped anterior pole of the crystalline lens COMPLICATIONS OF SURGERY
• Marked thinning of anterior lens capsule End opthalmitis infection of the globe that leads to inflammation
APHAKIA Panendopthalmitis whole globe is affected, one of the most common
• Condition where the lens is not present (wala na yung lens) complication even if you did the surgery well
Pseudophakia - Term who have artificial lenses are Retinal corneal decompensation because of so much
detachment power and heat, because the cornea has a delicate
structure (malabo parin ang mata niya)
VISUAL REHABILITATION OF APHAKIA
Vitreous loss once you rupture the capsule the vitreous goes out,
METHODS OF CORRECTION
it is another factor why we keep the capsule in
• Spectacles • Intraocular lens place
• Contact lens • Lasik Cystoid macular it can happen when the surgery is very long and the
edema pressure drops then you can have hemorrhage
INDICATIONS OF CATARACT SURGERY After cataracts cloudiness post-operatively, because of the
• Lens threatens to cause secondary glaucoma or uveitis retained inflammatory materials (happens 2-3 years
• Visual defect interferes with patient’s vocation after surgery) treated only with laser.
• Permit fundus visualization to monitor glaucoma
• Permit adequate visualization of the fundus for retinal/vitreous conditions REFERENCE: Previous transes, Lecture of Dr. Angbue-Te
• As a refractive measure
*Philhealth is not an indication*

TECHNIQUES OF CATARACT SURGERY

Intra-Caps. Cataract Extra-caps. Cataract

Extraction (ICCE) Extraction (ECCE)
• The entire lens is removed • Nucleus and cortex removed, capsule
• Make an incision take is intact
everything out
Includes:
❖ Traditional ECCE
❖ Manual small incision cataract
surgery (MSICS)
❖ Phacoemulsification – UTZ
❖ Laser assisted cataract surgery
Phacoemulsification – highest and quickest recovery rate, you can do this in 8
minutes and earn 6 figures by melting and suctioning the cataract in place

Traditional ECCE
an incision is made at the limbus either superiorly or temporally. An opening is
created in the anterior capsule (anterior capsulorhexis), and the nucleus and
cortex of the lens are removed. An intraocular lens is placed in the empty
“capsular bag” thus supported by the intact posterior capsule.