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Cataract

Unspecified Cataract

Cataract is defined as clouding or progressive thickening of the lens. It is mainly a disease of the elderly and it is the leading cause of blindness worldwide. There are three types of cataracts, the subcapsular cataract, when it occurs at the back of the lens; nuclear when it is in the nucleus and cortical when it starts peripherally and works its way to the center.


Presentation

The patient will complain of decreased visual acuity. This is the most common complaint and only when the visual acuity is affected significantly is a cataract considered clinically relevant. Another frequent complaint is increased glare from oncoming headlights at night and brightly lit environment during the day. Patient with cataract may also experience varying degrees of myopia due to the increase in diopteric power of the lens, patient will report an improvement in their near vision and a decreased need for their reading glasses. This improved vision is unfortunately temporary and will disappear as the cataract worsens.
The cataract is also staged at presentation with the use of a visual acuity chart. A patient who cannot see better than 20/200 is said to have a mature cataract[6].

Down Syndrome
  • About 25 percent of the time, congenital cataracts have a genetic cause and may be related to a metabolic, hormonal or chromosomal , such as Down syndrome .[childrenshospital.org]
  • These include myotonic dystrophy, galactosemia, homocystinuria , Wilson's disease and Down syndrome , plus many others.[medicinenet.com]
  • These include: Down’s syndrome Werner’s syndrome Atopic dermatitis Myotonic dystrophy Occult tumors (e.g., choroidal melanoma in adults and retinoblastoma in children) Cataract Surgery The only effective treatment for cataracts is to have them surgically[eyehealthweb.com]
Dutch
  • To measure patient-reported outcomes, Catquest-9SF data were collected between 2014 and 2015 in five Dutch hospitals. Data from 870 pairs of questionnaires - completed before and after cataract surgery - were compared with clinical data.[ncbi.nlm.nih.gov]
  • […] trastorno) , catarata , forma de la catarata (entidad observable) , forma de la catarata , Catarata German KATARAKT , Katarakt NNB , unspezifischer Katarakt , Katarakt unspezifisch , Katarakte , Katarakt, nicht naeher bezeichnet , Katarakt , Star, grauer Dutch[fpnotebook.com]
Heart Failure
  • Presence of an LVAD or heart failure, however, can cause physicians to perceive these patients to be at prohibitively high risk for elective surgery.[ncbi.nlm.nih.gov]
Blurred Vision
  • Cloudy or blurred vision.[eyenm.com]
  • A cataract is a clouding of the lens in your eye, which causes blurred vision. If you’ve been diagnosed with cataracts, or you suspect you may have a cataract, there’s no need to worry. They are very common, and occur naturally with age.[eyeinstitute.co.nz]
  • Some of the signs and symptoms of cataracts are cloudy or blurred vision, sensitivity to glare, seeing halos around lights, colors appearing faded or yellowed, and double vision.[eyecare-consultants.net]
Diplopia
  • Cataract Symptom: Double Vision Diplopia, or double vision, when looking with one eye can be another symptom of cataracts. This is not the same as diplopia that arises from improper alignment of the eyes.[onhealth.com]
  • Second sight Opacities within the red reflex , darkening of the red reflex, or obscuration of ocular fundus detail during opthalmoscopy Grey, white, yellow, or brownish clouding of the lens Monocular diplopia Hyperopia (in cortical cataract) Change in[amboss.com]
  • Once symptoms of cataracts develop, they may include: cloudy or blurry vision; double vision (diplopia) ; a sense that colors appear faded; seeing halos around lights; an increased sensitivity to glare; and a distortion of vision that makes objects appear[hopkinsmedicine.org]
  • - - At times, the nuclear changes are concentrated in the inner layers of the lens, resulting in a refractile area in the center of the lens, the so called “lens within a lens” phenomenon, which may lead to monocular diplopia that is not correctable[emedicine.medscape.com]
Vision Disorder
  • In addition to cataracts, our optometrists will check for signs of age-related macular degeneration, glaucoma, and other vision disorders. Early treatment for many eye diseases may save your sight.[mastereyeassociates.com]
Corneal Opacity
  • Investigating the efficacy and safety of phacoemulsification with intraocular lens (IOL) implantation in corneal opacities. This retrospective study was conducted in a tertiary medical center.[ncbi.nlm.nih.gov]
  • Corneal opacity that would interfere with the laser beam. Hypotony or the presence of a corneal implant.[lensxlasers.com]
  • ., severe edema, partial or total tarsorrhaphy), keratoprosthesis, corneal opacities (e.g., scars, severe edema), hyphema, hypopyon, miosis, pupillary membranes, dense cataracts, or vitreous opacities (e.g., hemorrhage, inflammatory debris).[aetna.com]
Scotoma
  • The problem may be confirmed with wavefront analysis. there may a type of peripheral ring scotoma (section of vision missing), an optical problem from edge of the lens implant.[goodhopeeyeclinic.org.uk]

Workup

A thorough history and physical examination is enough to make a diagnosis a cataracts. However, laboratory investigations may be required to screen for underlying diseases like blood sugar for diabetes mellitus. Also, laboratory tests are an essential part of pre-surgical work up so the baseline investigations should be carried out and clotting factors to prevent perioperative bleeding.
Imaging studies are ordered when a dense cataract obscures the view of the posterior part of the eye when a posterior pole pathology is suspected.
There are special tests that could also be requested there is suspicion of coexisting ocular disease e.g a Maddox rod test in a patient with suspected macular problems[7].

Treatment

The treatment for cataract is surgical and there has been no proven medical remedy till date and the definitive surgical remedy is lens extraction and replacement with an intraocular lens and there are various techniques for this procedure.
The intracapsular cataract extraction or ICCE involves the extraction of the entire lens and posterior capsule. This procedure is contraindicated in children and young adults.
Extracapsular cataract extraction or ECCE involves the removal of the lens through an opening in the anterior capsule and preserving the posterior capsule. This procedure has a number of advantages over ICCE[8].
Phacoemulsification is a more modern technique. It involves the use of an ultrasonically driven needle to break the lens down to tinier bits and aspirate these bits through a needle port. It offers some advantages over the ECCE like smaller incisions and faster wound healing.

Prognosis

The prognosis following surgery is very favorable if there are no accompanying ocular diseases prior to surgery that could affect vision. Cystoid macular edema is the main cause of morbidity following cataract surgery. In patients with diabetes and diabetic retinopathy, the visual prognosis is not very good[6].

Etiology

The precise cause of the changes that occur in the lens with age is not known, however many factors have been implicated as contributory including chronic illnesses like diabetes and hypertension, ultraviolet light, smoking, previous eye injury, positive family history, prolonged corticosteroid use, previous eye surgery, alcoholism, hormone replacement therapy and use of statins (cholesterol lowering drugs).
Congenital cataracts could be caused by intrauterine infections like rubella, syphillis and cytomegalovirus, genetically transmitted syndromes and metabolic disorders[2].

Epidemiology

Cataract is the leading cause of blindness worldwide and is responsible for as much as 51% of the world's blindness. As at 2004, it was estimated that about 53.8million of the world’s population experience some form of disability due to cataract. Of that number, 52.2million are in developing and underdeveloped countries. This is probably due to the inadequacy of surgical services in those countries or barriers in assessing these services. The incidence of senile cataract increases with advancing age and as much as 67% in patients aged 70 and over. The costs of treating cataract yearly is estimated at 6.8 billion dollars making it a public health concern[3].
Cataract affects more women than men and there is no documented evidence to show racial predilection.

Sex distribution
Age distribution

Pathophysiology

The pathophysiology of cataract cuts across many factors and involves intricate interactions between various physiological processes. The weight and thickness of the lens increases as it ages while the accommodative power decreases, a process called nuclear sclerosis then occurs. It is when the central nucleus of the lens becomes compressed and hardened due to the addition of cortical layers in a concentric pattern. Another mechanism is the decrease in epithelial cell density due to the accumulation of small scale epithelial losses which eventually leads to loss of lens transparency. Also, there could be progressive oxidative damage to the lens. Another mechanism is the when soluble low molecular weight cytoplasmic lens proteins are converted to soluble high molecular weight aggregates[4].

Prevention

Some preventive steps include wearing sunglasses to block UV lights, preventing risk factors like diabetes and hypercholesterolemia, and use of dietary supplement like vitamins E and C. There is however no literature to back this up[9].

Summary

Cataract is usually a visible opacity in the lens. When it located on the visual axis, it will lead to visual loss. Although there are other types of cataracts like secondary, traumatic, congenital and radiation cataracts, the commonest type is the one related to aging also known as senile cataracts. Visual loss in cataract is gradual and it can affect either or both eyes. It cannot be transmitted from one eye to the other[1].

Patient Information

  • Definition: cataract is the clouding or progressive thickening of the lens in the eye. It is mostly a disease of old age although it can be seen in younger adult following trauma and also, some babies are born with it. 
  • Cause: some of the factors that could lead to development of cataract are diabetes, hypertension, drugs like oral contraceptive and cholesterol lowering drugs, UV radiation from the sun, smoking, chronic alcoholism, and hormone replacement therapy.
  • Symptoms: The main symptom is poor vision, you could also experience glare when in a brightly lit room or from headlamps in oncoming vehicles. You could also experience improved near vision but this is usually short-lived[10].
  • Diagnosis: Diagnosis is often made on the basis of the history and physical examination. Some laboratory tests may however be required to check for underlying diseases and to check the normal functioning of the body prior to surgery.
  • Treatment. The main treatment of cataract is surgical. Surgery involves removal of the lens through one of many procedures and implantation of a plastic device known as intraocular lens.

References

Article

  1. Kuszak JR, Deutsch TA, Brown HG. Anatomy of aged and senile cataractous lens. In: Principles and Practice of Ophthalmology, Albert DM, Jakobiec FA. (Eds), WB Saunders Company, Philadelphia 1994. p.564.
  2. Congdon N, O'Colmain B, Klaver CC. Causes and prevalence of visual impairment among adults in the United States. Arch Ophthalmol 2004; 122:477.
  3. Schaumberg DA, Mendes F, Balaram M. Accumulated lead exposure and risk of age-related cataract in men. JAMA 2004; 292:2750.
  4. Clark A, Morlet N, Ng JQ. Whole population trends in complications of cataract surgery over 22 years in Western Australia. Ophthalmology 2011; 118:1055.
  5. Hamed WW, Fedorowicz Z. Day care versus in-patient surgery for age-related cataract. Cochrane Database Syst Rev 2004; :CD004242.
  6. Kessel L, Tendal B, Jørgensen KJ. Post-cataract prevention of inflammation and macular edema by steroid and nonsteroidal anti-inflammatory eye drops: a systematic review. Ophthalmology 2014; 121:1915.
  7. Kessel L, Tendal B, Jørgensen KJ. Post-cataract prevention of inflammation and macular edema by steroid and nonsteroidal anti-inflammatory eye drops: a systematic review. Ophthalmology 2014; 121:1915.
  8. Agarwal A, Kumar DA. Cost-effectiveness of cataract surgery. Curr Opin Ophthalmol 2011; 22:15.
  9. Shingleton BJ, Hersh PS, Kenyon KR. Lens injuries. In: Eye Trauma. 1991:126-34.
  10. Kanski JJ. Clinical Ophthalmology: A Systematic Approach. 1989:257-8.

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Last updated: 2017-08-09 18:10