ramadology - lens chapter

Crystalline lens

Crystalline lens

��

� Anatomy ��

� Cataract ��

- Congenital

- Senile

- Complicated

- Traumatic

� Ectopia Lentis �

- Subluxation

- Dislocation

Crystalline lens

Crystalline lensــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــ

Ramadology ـــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــ Dr. Ahmed Omara

CCCCrystalline LenSSSS

Suspensory zonules = Zonules of Zinn = Ciliary zonulesSuspensory zonules = Zonules of Zinn = Ciliary zonulesSuspensory zonules = Zonules of Zinn = Ciliary zonulesSuspensory zonules = Zonules of Zinn = Ciliary zonules

5 mm 10 mm



---- Avascular, biconvex, elastic, transparent structure.

Suspended in its place by the suspensory ligament ( Zonule( Zonule( Zonule( Zonulessss of of of of ZZZZinn )inn )inn )inn ). -

Gross Anatomy

ite:SSSS1.

- AnteriorAnteriorAnteriorAnterior to it : Iris ( separated by posterior chamber )

- PosteriorPosteriorPosteriorPosterior to it : Vitreous ( separated by RetroRetroRetroRetro----lental spacelental spacelental spacelental space ) �

hape:SSSS2.

- Anterior Anterior Anterior Anterior surfacesurfacesurfacesurface: LESS convex than posterior [ its centre is : Anterior pole ] �

- Posterior Posterior Posterior Posterior surfacesurfacesurfacesurface: MORE convex [ its centre is : posterior pole ] �

- Axis = Axis = Axis = Axis = ThicknessThicknessThicknessThickness: Line joins the anterior & posterior poles ( 5555 mm ).

---- Equator = lens Equator = lens Equator = lens Equator = lens edgeedgeedgeedge: Gives attachment to the suspensory ligament ( 10101010 mm ).

onsistency:CCCC3.

- YoungYoungYoungYoung: Soft

- OldOldOldOld : Hard

olor:CCCC4.

- ChildrenChildrenChildrenChildren: Colorless�

- AdultAdultAdultAdult : Yellowish tinge

- OldOldOldOld : Grayish

�� ) 1.4= (Average ndex:i efractiveefractiveefractiveefractiveRRRR5.

- CortexCortexCortexCortex: 1.38

- NucleusNucleusNucleusNucleus: 1.42

The ability of lens to converge parallel rays. :powerpowerpowerpowerefractive efractive efractive efractive RRRR6.

- Inside the eye : +18 DDDD (Un-accommodated)

- Outside the eye: + 70 DDDD due to :

1) � Curvature (Becomes spherical)

2) � Refractive index

So, the Cornea is the Main refractive So, the Cornea is the Main refractive So, the Cornea is the Main refractive So, the Cornea is the Main refractive mediamediamediamedia in the eye.in the eye.in the eye.in the eye. ��

P O W

1 1 3 Anatomy

72

Crystalline lensــــــــــــــــــــ

Dr. Ahmed Omara

ـــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــ

ـــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــ

Minute anatomyMinute anatomyMinute anatomyMinute anatomy

SutureSutureSutureSutures in Lenss in Lenss in Lenss in Lens

ـــــــــــــــــــــــــــــــــــــــــــــ

Ramadology ـــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــ



Minute Anatomy

1. 1. 1. 1. CCCCapsuleapsuleapsuleapsule::::

Character Significance

capsular epithelium.-anterior subby SecretedSecretedSecretedSecreted

membrane. Elastichighly Accommodation

Semi-permeable membrane - Diffusion of nutrients in & waste products out

- Protection: Of lens fibers from aqueous enzymes

anterior capsule > posterior. Thickness:Thickness:Thickness:Thickness: ……………….……………….……………….……………….……………….……………….

ubcapsular epitheliumubcapsular epitheliumubcapsular epitheliumubcapsular epitheliumSSSS2. 2. 2. 2.

- SSSSite: Lines the capsule ( anteriorly & at equator ) NOTNOTNOTNOT posterior. �

- SSSShape: Cuboid , columnar & pyramidal.

♣♣♣♣ Function :Function :Function :Function :

1. AAAAnterior cells: secrete capsule.

2. PPPPosterior sub-capsular : in 3333rdrdrdrd

month of pregnancy form embryonic nucleus. �

3. PPPPyramidal ( Equatorial ) cells : differentiate into lens fibers.

ibers of lens:ibers of lens:ibers of lens:ibers of lens:FFFF3. 3. 3. 3.

- DifferentiateDifferentiateDifferentiateDifferentiate from: Equatorial cells.

---- DividedDividedDividedDivided into:

1) Peripheral fibers: Sost ( corFex ).

2) CentGal fibers : Hard ( nucleus ) d.t. compression & sclerosis ( loss of water )

---- SuturesSuturesSuturesSutures: Site of articulation of lens fibers (In FetalFetalFetalFetal nucleus � erect Yerect Yerect Yerect Y----shapshapshapshaped anteriorly ed anteriorly ed anteriorly ed anteriorly & Inverted Y posteriorly Inverted Y posteriorly Inverted Y posteriorly Inverted Y posteriorly ) �

into:is divided NucleusNucleusNucleusNucleusIf a section in eye is done by slit lam, the N.B.N.B.N.B.N.B. ��

1) EmbryonicEmbryonicEmbryonicEmbryonic nucleus: 1-3 months intGauterine.

2) FetalFetalFetalFetal nucleus: From 3rd

month till birth

3) InfantileInfantileInfantileInfantile nucleus: up to puberty.

4) Adult Adult Adult Adult nucleus: After puberty.

ciliary zonules ciliary zonules ciliary zonules ciliary zonules = = = = inn inn inn inn ZZZZof of of of sssszonulezonulezonulezonule= = = = N.B.: Suspensory ligaments of lens N.B.: Suspensory ligaments of lens N.B.: Suspensory ligaments of lens N.B.: Suspensory ligaments of lens ��

---- Extend Extend Extend Extend from:from:from:from: ciliary body to the edge ( equator ) of lens.

---- Secreted Secreted Secreted Secreted by:by:by:by: ciliary body epithelium.

---- Function:Function:Function:Function: Accommodation.

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Dr. Ahmed Omara

Mechanism of

Contraction of ciliary muscle �



Hyaloid arteryHyaloid arteryHyaloid arteryHyaloid artery

AccommodationMechanism of

� relaxation of zonules � � lens curvature �



� � power of lens


Dr. Ahmed Omara

1) Water : 65%

2) Proteins : 34% [ Highest protein content of any other tissue in the body

3) Minerals : 1%

1) Before Before Before Before birthbirthbirthbirth: Hyaloid artery.

2) After After After After birthbirthbirthbirth: diffusion from aqueous (through

- AnaerobicAnaerobicAnaerobicAnaerobic ( as the lens is avascular = NO

carriers as vitamin C & Glutathione.

1) RefractiRefractiRefractiRefractionononon of light.

2) AccommodationAccommodationAccommodationAccommodation: The ability of the eye to change its power to see

distances ]

3) Protection of the Protection of the Protection of the Protection of the retinaretinaretinaretina by absorbing the U.V. rays.

If remnantremnantremnantremnant of hyaloid artery is present after birth, it will leave opacity at the posterior pole of lens

Deficiency of vitamin C & Glutathione

Cataract cause



Composition

Highest protein content of any other tissue in the body ] �

Blood supply

" AvascularAvascularAvascularAvascular """"

(through the semisemisemisemi----permeablepermeablepermeablepermeable membrane of capsule)

Metabolism

NO enough O2 ). Oxidation occurs by dehydrogenation which requires hydrogen

Nerve supply

NONONONO nerve supply

Lymph supply

NONONONO lymph supply

Function of lens

The ability of the eye to change its power to see clearly at different distances [ far or near

absorbing the U.V. rays.

of hyaloid artery is present after birth, it will leave opacity at the posterior pole of lens

� Posterior polar cataract Posterior polar cataract Posterior polar cataract Posterior polar cataract

Deficiency of vitamin C & Glutathione � Disturbed metabolism � Opacity of lens (Cataract)

of vision � PAINLESSCataract cause

74



). Oxidation occurs by dehydrogenation which requires hydrogen

different distances [ far or near

of hyaloid artery is present after birth, it will leave opacity at the posterior pole of lens

Opacity of lens (Cataract)


Dr. Ahmed Omara

of the lens. opacityopacityopacityopacityIt is the : DefinitionDefinitionDefinitionDefinition

Classifications :Classifications :Classifications :Classifications :

A. According to the cause:A. According to the cause:A. According to the cause:A. According to the cause:

1) Congenital

2) Acquired [Traumatic, Complicated or Senile]

B. According to the site:B. According to the site:B. According to the site:B. According to the site:

1) Capsular: anterior or posterior

2) CorFical: anterior or posterior

3) Nuclear

4) CorFico-nuclear

C. According to the age:C. According to the age:C. According to the age:C. According to the age:

1) Soft CataractSoft CataractSoft CataractSoft Cataract: before 25252525 years.

CauseCauseCauseCause: Congenital, Traumatic or Complicated.

nucleus. Soft: NucleusNucleusNucleusNucleus

crystalline crystalline crystalline crystalline mainly Lens protein:Lens protein:Lens protein:Lens protein:

TTTTTTTTTTTT: as in congenital cataract.

2) Hard cataractHard cataractHard cataractHard cataract: above 25252525 years

CauseCauseCauseCause: Senile, Traumatic or Complicated.

nucleus. hard: NucleusNucleusNucleusNucleus

albuminoid protein (albuminoid protein (albuminoid protein (albuminoid protein (: mainly Lens proteinLens proteinLens proteinLens protein

enzymes.

TTTTTTTTTTTT: as in senile cataract.

After cataractAfter cataractAfter cataractAfter cataract

NONONONO



of the lens.

2) Acquired [Traumatic, Complicated or Senile]

: Congenital, Traumatic or Complicated.

which can be digested by aqueous enzymes. ))))protein solublesolublesolublesolubleprotein (protein (protein (protein (crystalline crystalline crystalline crystalline

: as in congenital cataract.

: Senile, Traumatic or Complicated.

be digested by aqueous NOTNOTNOTNOTwhich can ))))protein insolubleinsolubleinsolubleinsolublealbuminoid protein (albuminoid protein (albuminoid protein (albuminoid protein (

Cataractالميّه البيضا

After cataractAfter cataractAfter cataractAfter cataract, if some lens particles are left

after cataract, if some lens particles are left



which can be digested by aqueous enzymes.

be digested by aqueous



Definition Definition Definition Definition

BilateralBilateralBilateralBilateral, Gradually progressiveGradually progressiveGradually progressiveGradually progressive lens opacity, affecting oldoldoldold age, NOTNOTNOTNOT d.t. trauma, local or general disease. ��

Incidence:Incidence:Incidence:Incidence:

• AgeAgeAgeAge: > 50 years

• SexSexSexSex: ♀ = ♂

• HereditaryHereditaryHereditaryHereditary: may play role

[Cataract tends to appear at an earlier ageearlier ageearlier ageearlier age in successive generations (anticipation ) (anticipation ) (anticipation ) (anticipation ) ]

• SideSideSideSide : Bilateral (One eye precedes the other eye) ��

Etiology:Etiology:Etiology:Etiology:

Types: Types: Types: Types:

1) CorFical 75%1) CorFical 75%1) CorFical 75%1) CorFical 75% 2) Nuclear 20%2) Nuclear 20%2) Nuclear 20%2) Nuclear 20% 3) CorFico3) CorFico3) CorFico3) CorFico----nuclear 5%nuclear 5%nuclear 5%nuclear 5%

P O W

5 5 5

Senile Cataract

�� Metabolic disturbancesMetabolic disturbancesMetabolic disturbancesMetabolic disturbances �

� Change in Lens proteins:proteins:proteins:proteins: Coagulation

� Change in WaterWaterWaterWater content: Hydration.

The metabolic disturbances may occur due to :

permeability. capsule1) DistLrbed

break down �activate dormant enzymes ( α & β proteases ) �: d.t. accumulation of lactic acid pH2) DistLrbed

of lens protein � opacity.

.vitamin C & glutathione3) Deficiency in

disturbances. Endocrinal4)

.U.V. rays5)

6) � Fat content & insoluble protein with � in soluble protein.

7) � Na, Ca , � K.

75


Dr. Ahmed Omara



Slit lamp ( BioSlit lamp ( BioSlit lamp ( BioSlit lamp ( Bio----microscopy )microscopy )microscopy )microscopy )

Direct ophthalmoscopeDirect ophthalmoscopeDirect ophthalmoscopeDirect ophthalmoscope




Dr. Ahmed Omara

Method of examination of lens Method of examination of lens Method of examination of lens Method of examination of lens

By TorchTorchTorchTorch OrOrOrOr Slit lampSlit lampSlit lampSlit lamp (gives more details with powerful illumination & magnification).

To examine:

1) LensLensLensLens Capsule

2) LensLensLensLens Opacity

3) Anterior chamber depth

4) IrisIrisIrisIris

5) IrisIrisIrisIris shadow

In dark room to dilate pupil [Red Reflex �

� Clear areas: appears Red.

� Opacity: appears Dark.

�: To know if there is Tonometry

[Glaucoma should be tGeated 1should be tGeated 1should be tGeated 1should be tGeated 1

� Def. The shadow of iris on the lens opacity.

� Shape: Black Crescent in the pupil.

Oblique Illumination is directed to eye at 45 to see shadow : How �

lear C When to see shadow : �

� It is present in:

( Immature cataract

[Iris shadow becomes smaller while

Hypermature cataract �

Oblique illumination

Red Reflex is a more reliable



Method of examination of lens Method of examination of lens Method of examination of lens Method of examination of lens

Oblique illumination

details with powerful illumination & magnification).

3) Anterior chamber depth

]In dark room to dilate pupil

lytic glaucoma-morphic glaucoma & phaco-e.g. Phaco in I.O.P. �

should be tGeated 1should be tGeated 1should be tGeated 1should be tGeated 1stststst for fear of optic nerve atrophy ]

��Iris Shadow��

�

The shadow of iris on the lens opacity.

in the pupil.

°Oblique Illumination is directed to eye at 45

.Opacitybetween iris & the intervallear

is occupied by clear lens fibers ) interval(

[Iris shadow becomes smaller while the cataract is going to maturity]

i.e. NO Iris shadow in Mature cataract

is occupied by aqueous ) interval( Hypermature cataract

blique illumination �Red Reflex

more reliable method in estimation the maturity of cataract than iris

shadow.�

76



lytic glaucoma

atrophy ]

.°

is occupied by clear lens fibers )

the cataract is going to maturity]

ed Reflex Tonometry

method in estimation the maturity of cataract than iris



Types of senile cataract :Table

Nuclear Hypermature Mature Intumescent Immature

6/9 �H.M H.M H.M C.F or H.M 6/9 � C.F. Symptoms

Visual acuity

Central lens

opacity

Shrunken +

deposits Totally Opaque

Sectors + Swollen

+ water vacuoles.

Grayish sectors

at periphery

Signs Lens

N. Thickened N. Glistening N. Lens

capsule

N. Deep N. Shallow N. A.C. depth

N. Tremulous N. Pushed anteriorly N. Iris

Present May be Absent May be Present Iris shadow

Dark central

disc against a

reddish

background

(Black reflex in

cataracta nigra)

Absent Absent Partially seen

Black triangular

sectors against a

reddish

background

Red Reflex

N. may � N. may � N. Tension

of visionof visionof visionof vision �� lesslesslesslessD.D. of gradual painD.D. of gradual painD.D. of gradual painD.D. of gradual pain - Open angle glaucoma. - Senile cataract - Age related macular degeneration ( ARMD ). - Progressive (malignant) myopia. - Diabetic retinopathy. - Optic neuropathy / atrophy

Senile cataractSenile cataractSenile cataractSenile cataract A.RA.RA.RA.R.M.D.M.D.M.D.M.D OOOOpen angle glaucomapen angle glaucomapen angle glaucomapen angle glaucoma OOOOptic atrophyptic atrophyptic atrophyptic atrophy

LensLensLensLens Greyish white N. N N

Red ReflexRed ReflexRed ReflexRed Reflex Affected N. N. N.

Light ReflexLight ReflexLight ReflexLight Reflex Present Present Present � down to loss

IOPIOPIOPIOP N. N. � N

FundFundFundFunduuuus s s s N. Macular degeneration Optic cupping Optic atrophy

FieldFieldFieldField N. Central scotoma Central & peripheral

defect Complete field defect



Senile Nuclear cataract Senile Cortical cataract

Pathological lens sclerosislens sclerosislens sclerosislens sclerosis � Nuclear opacification Cortical opacification DefinitionDefinitionDefinitionDefinition

� Progression is very slow.very slow.very slow.very slow.

� NO stages NO stages NO stages NO stages i.e NONONONO intumescent, NONONONO hypermature.

� The lens acquires a colourcolourcolourcolour

(due to Urochrome pigment)

� Opacity is affecting the cortexcortexcortexcortex

[ PeripheryPeripheryPeripheryPeriphery of lens at first thenthenthenthen become total ]total ]total ]total ]

� Last fibersLast fibersLast fibersLast fibers to be opaque are the subcapsular fiberssubcapsular fiberssubcapsular fiberssubcapsular fibers.

� Most common tSTe of senile cataract ( 75% ). ��

CharacterCharacterCharacterCharacter

No stages �

GradesGradesGradesGrades Grade I : GGGGrey

Grade II : YYYYellow

Grade III : Light BBBBrown

Grade IV : BBBBrown (cataracta brunescens) �

or

BBBBlack (Cataracta nigra) �

Immature

( Lens is NOTNOTNOTNOT totally opaque )

with its base Opacity begins as triangular streaksOpacity begins as triangular streaksOpacity begins as triangular streaksOpacity begins as triangular streaks

directed towards the equator.

�Mature

(lens is Totally Totally Totally Totally Opaque) Hypermature

Degeneration & liquefaction of lens matter �

loss of water � shrinkage

Stages: Stages: Stages: Stages:

Nuclear [ Immature stage ] SymptomSymptomSymptomSymptomssss

d.t. opacity & of vision of vision of vision of vision � lesslesslesslessGradual painGradual painGradual painGradual pain �

( increased R.I ). myopiaindex

Fixed muscaFixed muscaFixed muscaFixed musca d.t. opacity.

� UniUniUniUni----ocular diplopia ocular diplopia ocular diplopia ocular diplopia d.t. sectorial change in

refractive index.

� Gradual painGradual painGradual painGradual painlesslesslessless � of vision (Uom 6/6 of vision (Uom 6/6 of vision (Uom 6/6 of vision (Uom 6/6 ��

C.F) C.F) C.F) C.F) d.t. opacity & index hypermetropia

Fixed muscaFixed muscaFixed muscaFixed musca d.t. opacity.

� UniUniUniUni----ocular diplopia ocular diplopia ocular diplopia ocular diplopia d.t. sectorial change in

refractive index.

� Day BlindnessDay BlindnessDay BlindnessDay Blindness (as there is miosis during the

day)�

� 2222ndndndnd

sightsightsightsight� : sclerosis ��RI �� lens power

�� index myopia �

SOSOSOSO, a presbyopic patient Can read again without his

reading glasses.

� Night blindnessNight blindnessNight blindnessNight blindness as the peripheral opacity

interfere with the entry of light to peripheral

retina (where rods present) �

� Glare & colored halosGlare & colored halosGlare & colored halosGlare & colored halos around light.

See Table SignsSignsSignsSigns

Types of senile cataract ………….

� Causes of gradual painless � of vision………....

Senile nuclear sclerosis…………..

Types of senile cataract ………….

� Causes of gradual painless � of vision………....

Complicated Cataract …..……

D.D.D.D.D.D.D.D.

77


Dr. Ahmed Omara

�

DefDefDefDef.... It is a physiologicalphysiologicalphysiologicalphysiological nucleus sclerosis (loss of water)

C/P: C/P: C/P: C/P:

�Symptoms:Symptoms:Symptoms:Symptoms: VisionVisionVisionVision is NOTNOTNOTNOT affected!

�Signs: Signs: Signs: Signs:

�� Oblique illumination:Oblique illumination:Oblique illumination:Oblique illumination: Grayish pupil

�� Red Reflex:Red Reflex:Red Reflex:Red Reflex: Normal (as lens is transparent)



Immature cataract

Mature cataract

Hypermature cataract

Senile nuclear sclerosis �

sclerosis (loss of water)

affected! (as lens is transparent )

Grayish pupil ( d.t. � R.I of lens)

(as lens is transparent)




Dr. Ahmed Omara

N.B. Hypermature cataract

The nucleus sinksnucleus sinksnucleus sinksnucleus sinks by gravity to the lower portion of lens [ The Upper edge of nucleus may be seen when the pupil is

dilated ] as the degenerated lens matter becomes liquefied into a milky fluid.

Complications of hypermature cataract

is irritant ) (whichof lens protein DegenerationDegenerationDegenerationDegeneration1) 1) 1) 1)

lens displacement (subluxation or dislocation) � of zonules DegenerationDegenerationDegenerationDegeneration 2)2)2)2)

Intumescent Cataract (Swelling) N.B. �� Mechanism: Mechanism: Mechanism: Mechanism: Rapid break down of lens protein

PhacoPhacoPhacoPhaco [[[[ predisposed eyein �may IOP : IOP : IOP : IOP : ��

�� Treatment :Treatment :Treatment :Treatment : Do laser iridotomy before cataract operation .



N.B. Hypermature cataract

2 types

TypicalTypicalTypicalTypical �

(Discussed B4)

�typetypetypetype MorgagnianMorgagnianMorgagnianMorgagnian

by gravity to the lower portion of lens [ The Upper edge of nucleus may be seen when the pupil is

dilated ] as the degenerated lens matter becomes liquefied into a milky fluid. [[[[ Lens does NOT Lens does NOT Lens does NOT Lens does NOT

Complications of hypermature cataract�toxic uveitis-Phacoi) � is irritant )

ii) Phaco-lytic glaucoma�

lens displacement (subluxation or dislocation)

Intumescent Cataract (Swelling)

Rapid break down of lens protein � Rapid � in osmolarity of lens � Rapid hydrationRapid hydrationRapid hydrationRapid hydration

as the iris is pushed by lens � ]]]]morphic glaucoma morphic glaucoma morphic glaucoma morphic glaucoma ----PhacoPhacoPhacoPhaco

Do laser iridotomy before cataract operation .

78



by gravity to the lower portion of lens [ The Upper edge of nucleus may be seen when the pupil is

Lens does NOT Lens does NOT Lens does NOT Lens does NOT shrink ]shrink ]shrink ]shrink ]

Complications of hypermature cataract

Intumescent Cataract (Swelling)

Rapid hydrationRapid hydrationRapid hydrationRapid hydration of lens.

Closure of angle �as the iris is pushed by lens



work !work !work !work !Unable to do his Unable to do his Unable to do his Unable to do his

NONONONO Medical TTT of cataract till NOW [Everyone has his own needs]

Types of IOL

:site1. According to the

A.C. IOL

i) Angle fixed

ii) Iris fixed

� P.C. IOL:

The best correction of aphakia because it is the nearest to nodal point.

i) In the bag

ii) Sulcus fixed

iii) Iris sutured

:material2. According to the

Hard : PMMA ( poly methyl meth-acrylate )

� Soft ( foldable ) : made from silicon or acrylic.

Accommodative

:II K formulaRS ⌧

P = A - 0.9 K - 2.5 L



Treatment of senile cataractTreatment of senile cataractTreatment of senile cataractTreatment of senile cataract

�� The Treatment is The Treatment is The Treatment is The Treatment is ONLYONLYONLYONLY Surgical Surgical Surgical Surgical (lens(lens(lens(lens extraction)extraction)extraction)extraction) ��

� Cataract extractionCataract extractionCataract extractionCataract extraction Correction of aphakiaCorrection of aphakiaCorrection of aphakiaCorrection of aphakia

Time of operation ?Time of operation ?Time of operation ?Time of operation ?

When the patient is unable to do his work irrespective

to the stage, depending on patient's requirement.

�� Type of operation ?Type of operation ?Type of operation ?Type of operation ?

- Intra-capsular cataract Extraction (ICCE) ………..

- Extra-capsular cataract Extraction (ECCE) ………..

- Phaco-emulsification ………..

Which eye 1Which eye 1Which eye 1Which eye 1stststst ????

The more advanced stagemore advanced stagemore advanced stagemore advanced stage (Except (Except (Except (Except in intumescent

cataract which is tGeated 1st for fear of glaucoma))))

��

N.B. N.B. N.B. N.B. We NEVER operate on the 2 eyes in the same siYing We NEVER operate on the 2 eyes in the same siYing We NEVER operate on the 2 eyes in the same siYing We NEVER operate on the 2 eyes in the same siYing

for the fear of bilateral complication as

endophthalmitis d.t. hidden septic focus.

N.B. N.B. N.B. N.B. Least intervalLeast intervalLeast intervalLeast interval betZeen the 2 operations is 7 days.7 days.7 days.7 days.

� Special consideration Special consideration Special consideration Special consideration beforebeforebeforebefore operationoperationoperationoperation

1. General examination1. General examination1. General examination1. General examination

- General medical check up to ensure surgery fitness.

- Control of any systemic disease especially D.M. &

hypertension.

�� Uncontrolled hypertensionUncontrolled hypertensionUncontrolled hypertensionUncontrolled hypertension � expulsive

hemorrhage.

�� Uncontrolled D.MUncontrolled D.MUncontrolled D.MUncontrolled D.M �

� Possibility of infection.

Possibility of Hemorrhage

(during or after the operation)

� Delayed wound healing.

- Exclude presence of any septic focus in the body

( e.g. Tonsilitis, nasal sinusitis, dental, renal ..) for the

fear of endophthalmitis.

- Exclude & treat any cause of straining e.g. chronic

cough, enlarged prostate & constipation

to avoid � IOP � post operative hyphema, iris

prolapse & delayed reformation of A.C.

2. Local examination2. Local examination2. Local examination2. Local examination

- Complete ophthalmic examinationexaminationexaminationexamination to exclude other

ocular pathology.

- Treat Treat Treat Treat any local disease 1st e.g. chalazion, stye &

rubbing lash

- Exclude presence of any septic focusseptic focusseptic focusseptic focus in the eye,

especially chronic dacryocystitis. �

- If glaucomaIf glaucomaIf glaucomaIf glaucoma, tGeat it 1st. �

- Be sure that the visual acuityvisual acuityvisual acuityvisual acuity of the patient

corresponds to the cataract density.

- Test posterior segment & macular functionTest posterior segment & macular functionTest posterior segment & macular functionTest posterior segment & macular function in presence

of dense cataract.

3. Calculate the power of I.O.L which will be 3. Calculate the power of I.O.L which will be 3. Calculate the power of I.O.L which will be 3. Calculate the power of I.O.L which will be

implantedimplantedimplantedimplanted

Measure the AxiaL lensAxiaL lensAxiaL lensAxiaL lens of the eye

(using AAAA scan Ultrasound ) [Biometry][Biometry][Biometry][Biometry]

� Measure the power of corneapower of corneapower of corneapower of cornea

(using Keratometry )

Then we put & � in a formula to calculate the

power of IOL needed to be implanted.

79

E.C.C.E

EEEE....CCCC....CCCC....EEEE

PhacoPhacoPhacoPhaco----emulsificationemulsificationemulsificationemulsification



LLLLTypes of Operation ?Types of Operation ?Types of Operation ?Types of Operation ? LLLL

ICCEICCEICCEICCE ECCEECCEECCEECCE

Principle

Complete removal of lens within its capsule

after cutting the zonules.

Removal of anterior capsule (Anterior

capsulotomy ) leaving the posterior capsule

intact.

� Delivery of nucleus

Washing the remaining lens matter by

irrigation aspiration.

� Implantation of P.C. IOL.

Indication

Rarely done exceptexceptexceptexcept in :

Hypermature cataract with sublaxation of

lens.

SurgerySurgerySurgerySurgery ofofofof choicechoicechoicechoice, unless it is contraindicated

with markedly sublaxated or dislocated lens.

Disadvantage

- VerS large incision (Uom 3 to 9 O'clock )

- High incidence of vitreous prolapse.

- Inability to implant P.C. IOL, SoSoSoSo the eye is

left aphakic !!

)))) PhacoPhacoPhacoPhaco----emulsificationemulsificationemulsificationemulsification))))

�� [ The most widely technique used nowadays ] [ The most widely technique used nowadays ] [ The most widely technique used nowadays ] [ The most widely technique used nowadays ] ��

Small incision < 3mm ��

� Removal of anterior capsule

Emulsification of nucleus by introducing a probe having ultrasonic power.

� Irrigation & aspiration.

� Implantation of folded IOL ( by special forceps or injector ) inside capsular bag & it will be unfolded there.

AdvantageAdvantageAdvantageAdvantage

Small incision�

� Rapid visual recovery�

Rapid return to daily activity�

� Less astigmatism�

80


Dr. Ahmed Omara

Down syndromeDown syndromeDown syndromeDown syndrome



Snowflake cataractSnowflake cataractSnowflake cataractSnowflake cataract

GalactosaemiaGalactosaemiaGalactosaemiaGalactosaemia





Complicated CataractComplicated CataractComplicated CataractComplicated Cataract

Definition:Definition:Definition:Definition: Lens opacificationLens opacificationLens opacificationLens opacification d.t. local eye disease or a general disease.


Local causes:Local causes:Local causes:Local causes:

1) CorneaCorneaCorneaCornea: : : : e.g. keratitis

2) AAAA.C..C..C..C.: e.g. glaucoma.

3) Uveal tractUveal tractUveal tractUveal tract: e.g. chronic iridocyclitis.

4) LensLensLensLens: e.g. subluxation and dislocation

5) RetinaRetinaRetinaRetina: e.g.

� Retinal detachment. � Retinitis pigmentosa � Chorio-retinitis

6) OtherOtherOtherOther causes: as

� High myopia� � Intra-ocular tumors � Topical drugs: as prolonged use of steroids

� Local irradiation & exposure to infra red rays [[[[ Glass blower cataractGlass blower cataractGlass blower cataractGlass blower cataract ]]]] �

�� General:General:General:General:

� Diseasesiseasesiseasesiseases: as

� Diabetes Mellitusiabetes Mellitusiabetes Mellitusiabetes Mellitus �� 2 types of cataract may occur

i. Snowflake cataract: occur in juvenile uncontrolled D.M. [[[[ True Diabetic CataractTrue Diabetic CataractTrue Diabetic CataractTrue Diabetic Cataract ]]]] �

ii. Pre-senile cataract: as senile cataract but occurs earlierearlierearlierearlier < 45yG & matures rapidly.matures rapidly.matures rapidly.matures rapidly. �

Down syndrome

� HypOparathyroidismparathyroidismparathyroidismparathyroidism: tetany appear 1st then cataract develops. �

� HypOcalcaemiacalcaemiacalcaemiacalcaemia

� HypOthyroidism.thyroidism.thyroidism.thyroidism.

� Galactoseamia

� Immune diseasesImmune diseasesImmune diseasesImmune diseases as: Atopic dermatitis , Myotonic dystrophy

� Drugs intake rugs intake rugs intake rugs intake : Prolonged use of steroid

� Drugrugrugrug ToxicityToxicityToxicityToxicity: e.g. Ergot – Thalium – Di-nitro-phenol

� Doooooooodoooooooodoooooooodooooooood ! (Parasitic infestation)(Parasitic infestation)(Parasitic infestation)(Parasitic infestation): especially ankylostoma (was common in Egypt)

d.t.: (i) anaemia (↓ nutrition) (ii) toxins of worm

� IrraIrraIrraIrraDiationiationiationiation: by X-ray

MechanismMechanismMechanismMechanism

The metabolic disturbance is d.t.:

(1)(1)(1)(1) Diffusion of toxins

(2)(2)(2)(2) Interference with lens nutrition

81


Dr. Ahmed Omara

� If the complicated cataract is d.t. a local

� If the complicated cataract is d.t. a general

Except, High Myopia



local disease � Unilateral Cataract

general disease � Bilateral Cataract

High Myopia (which is a local disease)� Bilateral Cataract.



Cataract. ��



Clinical picture:Clinical picture:Clinical picture:Clinical picture:

1- History : : : :

�� Age:Age:Age:Age: Any age �� HistoryHistoryHistoryHistory of any local eye disease or general disease. 2- Examination

- General examination:General examination:General examination:General examination: for any general disease

- Local examination:Local examination:Local examination:Local examination:

� � Visual acuity : always less than expected from the density of cataract�

� � Signs of other local disease e.g. glaucoma, iridocyclitis ….…

� � Lens �� EarlyEarlyEarlyEarly shows : (1) PoPoPoPosterior cortical opacity : this site is due to

No epithelium lining to the posterior capsule.

� Very thin posterior capsule.

(2) PoPoPoPoly chromatic luster: due to diffraction of the slit lamp light by the

granular opacity "cholesterol"�

��LateLateLateLate shows : chalky white lenschalky white lenschalky white lenschalky white lens (due to Ca deposition)

� � Retinal function tests: often bad

3- Investigations: e.g. ultrasonography & retinal functions tests.

D.D. D.D. D.D. D.D.

Senile Cataract Complicated cataract

History of local or general diseaseHistory of local or general diseaseHistory of local or general diseaseHistory of local or general disease -ve +ve

AgeAgeAgeAge Above 50 years Any age

Opacity: Opacity: Opacity: Opacity: ---- EarlyEarlyEarlyEarly

---- LateLateLateLate

Grayish sectors

Grayish white

Posterior cortical "Saucer shapeSaucer shapeSaucer shapeSaucer shape"

Chalky white

Polychromatic lusterPolychromatic lusterPolychromatic lusterPolychromatic luster Not present Present

Local examinationLocal examinationLocal examinationLocal examination Free May show a local disease

RetRetRetRetinal final final final functionunctionunctionunction Good Often bad

PrognosisPrognosisPrognosisPrognosis Good Bad

ManagementManagementManagementManagement: : : : According to CauseCauseCauseCause & AgeAgeAgeAge

EEEExample:xample:xample:xample: CCCComplicated cataract with omplicated cataract with omplicated cataract with omplicated cataract with iridocylitisiridocylitisiridocylitisiridocylitis ��

1. TTT of iridocylitis ( The patient become stable for 6 months )

2. We give CorFicosteroids for 10101010 days

3. Do cataract operation ( Under the umbrella of Corticosteroids)

82



YAG laser capsulotomyYAG laser capsulotomyYAG laser capsulotomyYAG laser capsulotomy


Dr. Ahmed Omara

Definition:

It is an opacity in the pupillary area, seen

� Cataract operation (ECCE) �

OR

� Perforating trauma (with capsular injury)

Composition:

After cataract is composed of :

Part of anterior capsule & posterior capsule

� Remnants of lens matter

Hge & exudates

� Proliferated subcapsular epithelium

Clinical Types:

Posterior capsular opacification ( PCO

� Sommering ring [It is opaque ring behind the iris due to adherence of the ant

Posterior capsules with lens fibres in

Elschnig pearls [It is proliferation of t

transparent pearls like soap bubblespearls like soap bubblespearls like soap bubblespearls like soap bubbles

Complications:

� of vision

� Iridocyclitis

Posterior synechia.

� 2ry glaucoma

Treatment:

�� If thin � YAG laser Capsulotomy

�� If thick with :

a. NO posterior synechia : do

b. Posterior synechia



cataract After

pillary area, seen After:

�

Perforating trauma (with capsular injury) �

Part of anterior capsule & posterior capsule

Proliferated subcapsular epithelium

Posterior capsular opacification ( PCO ) [ Thin after cataract ] ( Most common

opaque ring behind the iris due to adherence of the ant

capsules with lens fibres in-between ]

[It is proliferation of the equatorial subcapsular epithelium

pearls like soap bubblespearls like soap bubblespearls like soap bubblespearls like soap bubbles in the pupillary area along the posterior

otomy.

posterior synechia : do capsulectomy

Posterior synechia : do capsule-iridectomy

83



Most common )

opaque ring behind the iris due to adherence of the anterior &

he equatorial subcapsular epithelium with formation of

erior capsule.]



Anterior polar cataract formation

Types

§§§§ ZAPT-Sut-blue.com §§§§

- Zonular

- Anterior X Posterior

- Total

ــــــــــــــــــــــــــــــــــــــــــــــــ

- Sutural

- Blue dot

- Coronary


Dr. Ahmed Omara

since birthin lens OpacityOpacityOpacityOpacity Definition Definition Definition Definition

Etiology: Etiology: Etiology: Etiology:

1) Heredddditary: usually A.D. (autosomal- dominant)

2) MalnutGition of mother during preg_ancy as Vitamin

3) IntGauterine infection ( as Rubella infection )

4) Teratogenic DDDDrugs

5) Irraddddiations.

Characters of congenital cataract: Characters of congenital cataract: Characters of congenital cataract: Characters of congenital cataract:

1) Commonly Bilateral.

congenital anomaliesother eside it, B2) Commonly

3) Commonly Stationary.

4) Soft cataract.

5) HereditarS may play a role.

Types: Types: Types: Types:


Delayed formation of the anterior chamberDelayed formation of the anterior chamberDelayed formation of the anterior chamberDelayed formation of the anterior chamber

subcapsular epithelium at the anterior pole

Opacity.

Clinical picture:Clinical picture:Clinical picture:Clinical picture:

, but if present:ABSENTABSENTABSENTABSENTUsually :SymptomsSymptomsSymptomsSymptoms �

� SignsSignsSignsSigns: Small opacity at the anterior pole in one of these shapes

at anterior pole. (Immediate separation) shaped opacity DiscDiscDiscDisc1)

. (Delayed separation)opacity PyramidalPyramidalPyramidalPyramidal2)

. ( no separation )opacity glassglassglassglass-HourHourHourHour3)

. (anterior polar + anterior cortical + clear fibers in between )opacity ReduplicatedReduplicatedReduplicatedReduplicated4)

Congenital Cataract



� ) DevelopmentalDevelopmentalDevelopmentalDevelopmental( shortly after birth, or since birth

dominant)

2) MalnutGition of mother during preg_ancy as Vitamin DDDD & Ca deficiency.

��infection )

Characters of congenital cataract: Characters of congenital cataract: Characters of congenital cataract: Characters of congenital cataract:

.congenital anomalies

Delayed formation of the anterior chamberDelayed formation of the anterior chamberDelayed formation of the anterior chamberDelayed formation of the anterior chamber � prolonged contact between cornea & lens �

subcapsular epithelium at the anterior pole � proliferation & formation of a mass of cells with Ca deposition

, but if present:

1) Day blindness as the opacity is central. �

2) Diminution of vision.

or pole in one of these shapes

at anterior pole. (Immediate separation)

. (Delayed separation)

. ( no separation )

. (anterior polar + anterior cortical + clear fibers in between )

Congenital Cataract

Anterior polar cataract

84



� irritation of anterior

proliferation & formation of a mass of cells with Ca deposition �

. (anterior polar + anterior cortical + clear fibers in between )

P O W

2 4 5


Dr. Ahmed Omara

Hyaloid artery

LeucoLeucoLeucoLeuco----coria = White pupil = coria = White pupil = coria = White pupil = coria = White pupil =

A. Retinoblastoma A. Retinoblastoma A. Retinoblastoma A. Retinoblastoma ��

B. B. B. B. NOT NOT NOT NOT RetinoblastomaRetinoblastomaRetinoblastomaRetinoblastoma

1. Congenital cataractCongenital cataractCongenital cataractCongenital cataract.

2. Cyclitic membraneCyclitic membraneCyclitic membraneCyclitic membrane

3. PHPV PHPV PHPV PHPV ( persistent hyperplastic primary vitreous ) : congenital anomaly with fibrosis of the anterior vitreous.

4. Exudate or fibrosis of vitreous after chorioditis Exudate or fibrosis of vitreous after chorioditis Exudate or fibrosis of vitreous after chorioditis Exudate or fibrosis of vitreous after chorioditis

5. EndophthalmitisEndophthalmitisEndophthalmitisEndophthalmitis

6. Organized vitreous hemorrhageOrganized vitreous hemorrhageOrganized vitreous hemorrhageOrganized vitreous hemorrhage.

7. Coloboma Coloboma Coloboma Coloboma of the retina& choroids showing sclera.

8. RetinalRetinalRetinalRetinal dysplasiadysplasiadysplasiadysplasia : d.t. chromosomal defect.

9. ROPROPROPROP ( retinopathy of prematurity )

Exudative retinitis = Retinal telangiectasis): Exudative retinitis = Retinal telangiectasis): Exudative retinitis = Retinal telangiectasis): Exudative retinitis = Retinal telangiectasis): : (= diseasediseasediseasedisease Coat'sCoat'sCoat'sCoat's10.

breakdown of the blood-retinal barrier

macrophages into the retina and subretinal space

11. RDRDRDRD (especially if extensive)

12. PosteriorPosteriorPosteriorPosterior polepolepolepole toxocariasistoxocariasistoxocariasistoxocariasis: granuloma caused by toxocara



coria = White pupil = coria = White pupil = coria = White pupil = coria = White pupil = Yellow reflex = Amaurotic cat's eyeYellow reflex = Amaurotic cat's eyeYellow reflex = Amaurotic cat's eyeYellow reflex = Amaurotic cat's eye

Causes:Causes:Causes:Causes:

( persistent hyperplastic primary vitreous ) : congenital anomaly with fibrosis of the anterior vitreous.

Exudate or fibrosis of vitreous after chorioditis Exudate or fibrosis of vitreous after chorioditis Exudate or fibrosis of vitreous after chorioditis Exudate or fibrosis of vitreous after chorioditis [ either : exudative or granulomatous as T.B. ]

of the retina& choroids showing sclera.

: d.t. chromosomal defect.

( retinopathy of prematurity )

disease characterized by CongenitalExudative retinitis = Retinal telangiectasis): Exudative retinitis = Retinal telangiectasis): Exudative retinitis = Retinal telangiectasis): Exudative retinitis = Retinal telangiectasis):

retinal barrier in the endothelial cell � leakage of cholesterol

into the retina and subretinal space � Exudative retinal detachment.

: granuloma caused by toxocara- canis

Nodal point = Optical centreNodal point = Optical centreNodal point = Optical centreNodal point = Optical centre

Def.Def.Def.Def. A point of a lens through which a ray of light pass without

being bent (i.e. refracted).

Site :Site :Site :Site : Just in front of posterior pole of lens.



Yellow reflex = Amaurotic cat's eyeYellow reflex = Amaurotic cat's eyeYellow reflex = Amaurotic cat's eyeYellow reflex = Amaurotic cat's eye

( persistent hyperplastic primary vitreous ) : congenital anomaly with fibrosis of the anterior vitreous.

[ either : exudative or granulomatous as T.B. ]

disease characterized by

cholesterol crystals and lipid-laden

Nodal point = Optical centreNodal point = Optical centreNodal point = Optical centreNodal point = Optical centre

A point of a lens through which a ray of light pass without

front of posterior pole of lens.



D.D. D.D. D.D. D.D.

1) Acquired Cataract1) Acquired Cataract1) Acquired Cataract1) Acquired Cataract caused by a small central perforation. (MORE COMMONCOMMONCOMMONCOMMON) �

Acquired Congenital

At any age Since birth Age

+ ve - ve History of red eye

+ve -ve ( exceptexceptexceptexcept in hour-glass) �� Corneal opacity

Unilateral Bilateral Side

2) Causes of 2) Causes of 2) Causes of 2) Causes of lllleucocoriaeucocoriaeucocoriaeucocoria = White pupil= White pupil= White pupil= White pupil ��......

::::TreatmentTreatmentTreatmentTreatment

»» If smallsmallsmallsmall opacity NOTNOTNOTNOT affecting the vision (common) � NONONONO TTT is needed.

»» If largelargelargelarge opacity affecting the vision (less common) � Visual iridectomy after mydriatic testVisual iridectomy after mydriatic testVisual iridectomy after mydriatic testVisual iridectomy after mydriatic test.

� of hyaloid artery. of remnantsPersistence ::::EtiologyEtiologyEtiologyEtiology

Clinical pictureClinical pictureClinical pictureClinical picture::::

of vision. �Marked : SymptomsSymptomsSymptomsSymptoms �

� Signs:Signs:Signs:Signs:

- Disc shaped opacity at posterior pole of lens.

- Marked � of vision � [as the opacity is near the nodal point] NOTNOTNOTNOT improved by mydriasis.

correction of aphakia.Lens extraction + ::::TreatmentTreatmentTreatmentTreatment

[ The most common type of congenital cataract [ The most common type of congenital cataract [ The most common type of congenital cataract [ The most common type of congenital cataract �� ]]]] �

� nucleus)fetal (aroundOpacity of one or more lamellae of lens ::::DefinitionDefinitionDefinitionDefinition

Unknown ::::EtiologyEtiologyEtiologyEtiology

� Hereditary

� Malnutrition of mother during pregnancy especially deficiency of Vit D & Ca.

: The child osten has : 1) Rickets. 2) Abnorcalities in percanent teeth. EvidenceEvidenceEvidenceEvidence

Signs:Signs:Signs:Signs: Lens opacity is composed of : Central disc � Projections ( riders )

[Giving the appearance of: Steering wheel of a ship or Cart Steering wheel of a ship or Cart Steering wheel of a ship or Cart Steering wheel of a ship or Cart wheelwheelwheelwheel] �

Posterior polar cataract

Zonular cataract = Lamellar Cataract

85


Dr. Ahmed Omara

" Rubella is a trivial infection,



" Rubella is a trivial infection, Except in pregnant women ! " Dr. Mostafa AkarDr. Mostafa AkarDr. Mostafa AkarDr. Mostafa Akar

SutureSutureSutureSuture in FETAL Lensin FETAL Lensin FETAL Lensin FETAL Lens



Dr. Mostafa AkarDr. Mostafa AkarDr. Mostafa AkarDr. Mostafa Akar


Dr. Ahmed Omara

to mother in infection RubellaRubellaRubellaRubella ::::EtiologyEtiologyEtiologyEtiology

Note : The operation is RISKY to patient because :Note : The operation is RISKY to patient because :Note : The operation is RISKY to patient because :Note : The operation is RISKY to patient because :

1) Risk of anesthesia ( d.t. associated cardiac anomalies )

2) VirLs become dorcant inside the eye for

( i.e. If the operation is done

They are discovered accidentally during routine examination & do

5) Sutural Cataract (Opacity at the YYYY Suture)

6) Blue dot = Punctate (Small dots scattered in

7) Coronary cataract (Club shaped opacity at the

Clinical picture of congenital cataract:Clinical picture of congenital cataract:Clinical picture of congenital cataract:Clinical picture of congenital cataract:

( given by mother )( given by mother )( given by mother )( given by mother ) :Symptoms

» White pupil

» Child does NOTNOTNOTNOT see well.

Symptoms of complications [ e.g. abnormal eye movement or deviation of eye ] +»

Signs: One of the previous types is seen +

Leucocoria (White pupil) …….. ……… D.D.D.D.D.D.D.D.

Bilateral Opacity

�� Mental Retardation ( MR )

�� Nystagmus (opacity interferes

with foveal development that occurs

in 1st 3 months)

Leucocoria is a retinoblastoma until proved otherwise



� trimester. stststst

1111to mother in

Note : The operation is RISKY to patient because :Note : The operation is RISKY to patient because :Note : The operation is RISKY to patient because :Note : The operation is RISKY to patient because :

1) Risk of anesthesia ( d.t. associated cardiac anomalies )

2) VirLs become dorcant inside the eye for 2222----3 years3 years3 years3 years

( i.e. If the operation is done � endophthamitis )

They are discovered accidentally during routine examination & do NOTNOTNOTNOT affect the vision.

Suture)

dots scattered in lens)

shaped opacity at the equator)

Clinical picture of congenital cataract:Clinical picture of congenital cataract:Clinical picture of congenital cataract:Clinical picture of congenital cataract:

Symptoms of complications [ e.g. abnormal eye movement or deviation of eye ]

+ signs of complications [ Nystagmus, squint or ambylopia ]

Leucocoria (White pupil) …….. ………

Total cataract

Other Types

(opacity interferes

with foveal development that occurs

Unilateral opacity

�� Squint

Or

�� Amblyopia

(Irreversible after 6 years)

Complications �


86



affect the vision.

or ambylopia ]

Unilateral opacity

Amblyopia

(Irreversible after 6 years)



Dr. Ahmed Omara

Operate as early as possibleas early as possibleas early as possibleas early as possible

Dense Opacity

Operate Early:

Before the 3rd month to avoid nystagmus.

Visual acuity

.With Glasses

Give Glasses

Visual Acuity of 6/18 in presence of accommodation is Better than

Asses the Asses the Asses the Asses the

( child < 2 years ) methodsmethodsmethodsmethods ObjectiveObjectiveObjectiveObjective1)

► Red Reflex

► Fundus examination

► Optokinetic nystagmus ( On looking to movable object e.g. Catford drum )

► Preferential looking ( child prefers to look to stripped cards )

► VEP ( Visual evoked potential ) : Recording electrical activity of occipital cortex.

( child > 2 years ) :methodsmethodsmethodsmethods SubjectiveSubjectiveSubjectiveSubjective2)

♦ Hand test.

♦ Sheridan cards.



as early as possibleas early as possibleas early as possibleas early as possible to avoid dense amblyopia (before 6 yearsbefore 6 yearsbefore 6 yearsbefore 6 years

to avoid nystagmus.

dense opacityNot

Wait until the patient can tell about his visual

acuity ( about 6 years )

.Visual acuity ≥ 6/18 Visual acuity

Do the Operation

Treatment

Unilateral cases

Bilateral cases

.After Mydriasis

Do Visual iridectomy

in presence of accommodation is Better than

accommodation.

by :by :by :by : visual acuityvisual acuityvisual acuityvisual acuity & the& the& the& the opacityopacityopacityopacityAsses the Asses the Asses the Asses the

( child < 2 years )

Fundus examination

Optokinetic nystagmus ( On looking to movable object e.g. Catford drum )

Preferential looking ( child prefers to look to stripped cards )

VEP ( Visual evoked potential ) : Recording electrical activity of occipital cortex.

( child > 2 years )



before 6 yearsbefore 6 yearsbefore 6 yearsbefore 6 years )

dense opacity

until the patient can tell about his visual

.6/18˂ Visual acuity

�� Do the Operation

without in presence of accommodation is Better than 6/6

Optokinetic nystagmus ( On looking to movable object e.g. Catford drum )

VEP ( Visual evoked potential ) : Recording electrical activity of occipital cortex.


Dr. Ahmed Omara

Cataract extraction1)

A )A )A )A )----Aspiration ( IAspiration ( IAspiration ( IAspiration ( I ----A. Irrigation A. Irrigation A. Irrigation A. Irrigation

� Procedure:

2 mm limbal incision. �

AspirationAspirationAspirationAspiration of lens matter ( with simultaneous )

� Complication:

PCO (Posterior Capsule Opacification ).

� RD (Retinal Detachment ) Less common.

Mild iridocylitis, 2ry

glaucoma.

B.Pars plana lensectomy:B.Pars plana lensectomy:B.Pars plana lensectomy:B.Pars plana lensectomy:

� Procedure:

Pars plana incision. �

� Advantage:

NONONONO PCO (Posterior Capsular Opacification)

� Used in posterior polar cataract.

�Disadvantage:

RD is more common d.t very strong zonules in children.

Aim :Aim :Aim :Aim : To avoid amblyopia.

Optical TTTOptical TTTOptical TTTOptical TTT

GlassesGlassesGlassesGlasses

��

Anisometropia � AnisoKonia

Diplopia

UnilateralUnilateralUnilateralUnilateral

�� BilateralBilateralBilateralBilateral

N.B. N.B. N.B. N.B. Although IOL is the best correction of aphakia, but

Because of the rapid growth of the eye that occurs up to



2) CorGection of aphakia Cataract extraction

1) Cataract exFGaction1) Cataract exFGaction1) Cataract exFGaction1) Cataract exFGaction

� Anterior capsulotomy.

of lens matter ( with simultaneous ) IrrigationIrrigationIrrigationIrrigation by saline.

Capsule Opacification ). ��

Detachment ) Less common. ��

glaucoma.

� Lens removal using vitrectomy machine or with knife.

PCO (Posterior Capsular Opacification)

Used in posterior polar cataract.

RD is more common d.t very strong zonules in children. ��

2) CorGection of aphakia2) CorGection of aphakia2) CorGection of aphakia2) CorGection of aphakia

Optical TTTOptical TTTOptical TTTOptical TTT

Refractive surgeryRefractive surgeryRefractive surgeryRefractive surgery Contact lensContact lensContact lensContact lens

�� AnisoKonia �

��

IOL is the best correction of aphakia, but we postpone its use;we postpone its use;we postpone its use;we postpone its use;

of the eye that occurs up to 2 Years [Hence, Marked change in refraction]

Lines of Treatment

NowNowNowNow, we do posterior capsulotomy &

remove anterior vitreous face

87



2) CorGection of aphakia

Lens removal using vitrectomy machine or with knife.

Surgical TTTSurgical TTTSurgical TTTSurgical TTT

IOLIOLIOLIOL Refractive surgeryRefractive surgeryRefractive surgeryRefractive surgery

Aster 2 yearsAster 2 yearsAster 2 yearsAster 2 years

Aster 2 yearsAster 2 yearsAster 2 yearsAster 2 years

we postpone its use;we postpone its use;we postpone its use;we postpone its use;

Years [Hence, Marked change in refraction]

, we do posterior capsulotomy &

remove anterior vitreous face



Weil Marchesania Marfan syndrome



Ectopia lentis

).Subluxation or Dislocation( Displacement of lens from its position Definition

Etiology :

AcquiredAcquiredAcquiredAcquired CongenitalCongenitalCongenitalCongenital

1. Trauma �� 1. Marfan Syndrome

2. Degenerative myopia 2. Weil Marchesania syndrome

3. Hypermature cataract 3. Down syndrome Homocystinuria

Subluxation of lens Definition Displacement of lens d.t. partial absence OR tearing of zonules

[ The lens will be displaced towards the untorn portion of zonules & may undergo rotation ]

B4 ………as Etiology :

Clinical picture

Symptoms:

1.DDDDiminution of vision d.t. :

� Myopia ( d.t. increased lens curvature )

Astigmatism ( d.t. tilting of lens )

� Interference with accommodation.

� Complication

2. Uniocular DDDDiplopia : [ if the edge of lens is : Clear � Crosses the pupillary area ]

( One image through the phakic portion of the pupil & another through the aphakic portion )

Signs :

(1) A.C : Irregular depth

(2) Iris : Tremulous ( iridodonesis )

(3) Lens : - edge may be seen

- Tremulous ( phacodonesis )

Complication

2ry glaucoma. � Iridocyclitis. Cataract. (4) Dislocation.

Treatment

(1) if NO complications Nor diplopia � glasses

(2) If there are complications or diplopia � lens extraction

P O W

1 1 2

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Aphakia Definition: Absence of lens from pupillary area.

Symptoms:

- Defective visionDefective visionDefective visionDefective vision [ far & near ] defect is especially for near ( no accommodation )

- Blue or violet visionBlue or violet visionBlue or violet visionBlue or violet vision [ d.t. lens absence which was absorbing U.V. rays ]

Signs:

� + ve history of operation

Scar of pervious operation

� A.C. � Deep

� Iris : Tremulous iris + Iridectomy

� Pupil : Jet black ( No posterior capsule ) OR grayish in ECCE d.t. glistening posterior capsule OR Grayish

white d.t. after cataract

� Purkenje – Sanson image : absent of 2 out of 3 ��

� Refraction : Shift towards hypermetropia



Dislocation of the lens

Definition : Displacement of lens d.t. total absence OR tearing of the zonules.

Aetiology : as B4 ……..

Types :

1) Anterior Dislocation. [ lens in A.C. ]

2) Posterior Dislocation. [ lens in P.C. ]

3) Subconjunctival dislocation : ( lens lies under conjunctiva )

Anterior Dislocation ( Anterior Dislocation ( Anterior Dislocation ( Anterior Dislocation ( in A.C ))))

Clinical picture:

Signs :

� The lens becomes spherical with golden yellow edges which resemble a droplet of oildroplet of oildroplet of oildroplet of oil in A.C.

� pupillary block

Complication

2ry glaucoma d.t. pupillary block [glaucoma inversus] � Iridocyclitis. Cataract.

(4) Corneal opacification d.t. endothelium damage.

Management: Removal of lens through anterior approach after miosis.

Posterior Dislocation ( Posterior Dislocation ( Posterior Dislocation ( Posterior Dislocation ( in vitreous ))))

Clinical picture:

The same clinical picture of aphakia ……..

++++ dislocated lens can be seen in vitreous.

Fate : either;

Remains quite

� Absorbed

Leads to Complications: 2ry glaucoma. � Iridocyclitis. Cataract.

Management: Removal of lens through Posterior approach [ pars plana vitrectomy ]

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ramadology - lens chapter

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