19 October 2019

19 October 2019
Objectives:-
• Lens Anatomy
• Lens Physiology
• Lens Functions
• Definition of Cataract
• Pathology of Cataract
• Etiology of Cataract
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• It is a highly organized,
transparent, biconvex spheroid
structure.
• It does not posses, nerve or
blood vessels . Post
Ant

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• Diameter varies from 8.8 to 9.2
• Antero-posterior thickness
changes with accommodation.
• Circumference is known as
equator Ant Post

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 • Lens is suspended in eye, by
Zonules, which are inserted
on anterior surface and
equatorial lens capsule and
attached to ciliary body.
Ant
cb
cb

Post
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 Lens

ciliary body Zonules

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L Lens
e ciliary body
n Zonules
s

A
n
a
t
o
m
y
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 ciliary body

Zonules

Lens

Zonules

ciliary body

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 • Histologically, lens
consists of three major
components
• 1)Capsule
2) Lens Epithelium
3)Lens substance
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 1. Capsule – is a thick
membrane, which is transparent,
elastic, acellular- envelop, thick
at anterior pre-equatorial region ,
thinnest at the posterior pole .
equator
Pre equatorial region
Post
Ant

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 Anterior pole contains, the
-
epithelial cells and fibres, as
a structural unit and allows,
a passage of small
molecules, both into and out
of the lens.
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 -The lens capsule, regulate the
transport of metabolite, nutrients
and electrolytes, to the lens
fibres.

Continuous curvilinear
Can – opener ant capsulorrhexis ( CCC )
capsulotomy
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 2. Lens Epithelium – It is a
single layer of cells, lining
the anterior capsule and
extends to the equator.

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Ant lens capsule Post lens capsule

epithelium

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These cells are actively dividing
and elongating to form new lens
fibres throughout the life.

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 3. Lens substance: It
constitute, the main mass of the
lens.
It is divided into-
a. Nucleus
b. Cortex

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 Nucleus: consists of
(i) Embryonic nucleus
(ii) Fetal nucleus
(iii)Infantile nucleus
(iv)Adult nucleus

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 (i)Embryonic nucleus : It
contains primary lens fibres,
that are formed in lens vesicle.
( 1 to 3 months of gestation )

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 ii) Fetal nucleus: it contains
embryonic nucleus and all fibres
added to the lens before birth
( from 3 months gestation till
birth )

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 (iii) Infantile nucleus: it
contains embryonic , fetal
nucleus together with all
the fibres added up-to the
age of 4 years.

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(iv) Adult nucleus: composed of
all fibres added before puberty.

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The nucleus consists of, densely
compacted lens fibres and it has
higher refractive index than
cortex.

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 c

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 • It is located peripherally, and is
composed of secondary fibres formed
continuously after puberty. It is
further divided into:
– Deep cortex N
U
– Intermediate cortex C
L
– Superficial cortex E
U
S

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 –Lens fibres contain high
concentrations of
crystalline protein.

–It is a major protein of the

lens
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• The region between embryonic and fetal
nuclear core and soft cortex i.e. infantile
and adult nucleus is sometimes referred
to as epinucleus.
Cortex

Adult Nucleus
epinucleus
Infantile Nucleus

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• Are found both at anterior and
posterior poles. They are formed
by overlap of ends of secondary
fibres. These secondary fibres
formed before birth (fetal
nucleus). Anterior suture is
shaped as an erect Y, and a
posterior suture shaped as an
inverted Y.
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Anterior Suture posterior suture
( erect Y )
inverted Y

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• Function of the Lens ,and it’s
transparency, is dependant on
the supply of appropriate
nutrients to its various
structures. Metabolic needs of
a adult lens, is met by the,
aqueous and vitreous.
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• Lens function is dependent on the
1) metabolism of glucose to
produce energy , and
2) protein synthesis.
• Glutathione –(anti-oxidant) is
found in high concentration in
lens and it protect lens from
oxidative damage.
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 Lens - Physiology

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 • The transparency is
dependent on, highly
organized structure of lens.

• By act of accommodation, it
changes focusing power.
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 Lens - Functions

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 • Age related changes in the structure.
• Overall light transmission decreases
with age, lens becomes less elastic.
• Reducing its ability to accommodate
which leads to presbyopia.

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 I. Subluxation
It is partial displacement in which lens is moved sideways (up,
down, medially or laterally), but remains behind the pupil. It
results from partial rupture or unequal stretching of the zonules

II. Dislocation or luxation of the lens

In it all the zonules are absent or destroyed. A dislocated lens
may be incarcerated into the pupil or present in the anterior
chamber or the vitreous
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 Subluxation of the lens

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 Dislocation or luxation of
the lens

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 Antero-posterior thickness
of Lens changes
1) In accommodation
2) While looking up
3) In sleep
4) By rubbing the eyes

Ans :- 1) in accommodation
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Lens is suspended in the eye by

1) Capsule
2) Vitreous
3) Iris
4) Zonules
Ans :- 4) Zonules
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What are major 3 parts of Lens

1) Capsule
2) Epithelium
3) Substance

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Lens substance is divided into
two parts -

1) Cortex
2) Nucleus

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4 parts of the Nucleus

(i) Embryonic nucleus

(ii) Fetal nucleus
(iii)Infantile nucleus
(iv)Adult nucleus

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Which is the major protein of the
lens :-

Crystalline protein.

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What is epinucleus ? ?
Adult &
infantile
nucleus
together
called as
epinucleus

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Which anti-oxidant is
synthesized in the lens ?

Glutathione

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What are the functions of lens ?

1) Focusing the rays on the

fovea
2) Protects the retina from
the UV radiation

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 Sub-luxation

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 Dis-location

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 • Cataract Definition
•Cataract Pathology
• Cataract Etiology
• Classification of Cataract

• Cataract Symptoms
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• Any opacity in the lens or
its capsule, whether
developmental or acquired
is called cataract.

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Developmental opacities
are usually partial and
stationary, whereas
acquired opacities are
progressive.

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Cataract is caused by
• [Link] degeneration and
opacification of existing lens
fibres,
• [Link] of aberrant lens fibres
• [Link] of other material in
their place.
2009 - 2010 Suhas Kulkarni 55

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Any factor, physical or chemical,
which disturbs the critical intra – and
extra-cellular equilibrium of water and
electrolytes or deranges the colloid
system within the fibres tends to bring
about opacification.

56

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• Fibrous metaplasia of fibres may
occur in complicated cataract)
• Epithelial cell necrosis leads to
focal opacification of the lens
epithelium as ‘Glaucomflecken’
in acute angle closure glaucoma.

2009 - 2010 Suhas Kulkarni 57

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Abnormal products of metabolism,
drugs or metals can be deposited in
 storage diseases ( Fabry ),
metabolic diseases ( Wilson )
and toxic reactions ( siderosis ).

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• Biochemically three factors are
evident in the Process of cataract
formation.
–Hydration
–Denaturation of Lens Proteins
–Sclerosis
2009 - 2010 Suhas Kulkarni 59

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[Link]
In the early stages of cataract or rapidly
developing forms, actual droplets of
fluid, gather under the capsule, forming
lacunae between the fibres, and the
entire tissue swells (intumescence) and
lens becomes opaque.

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This process may be reversible and
opacities thus formed, may clear up, as
in juvenile insulin dependent diabetic
patients whose lens becomes clearer
after control of hyperglycaemia.
Hydration may be due to osmotic
changes within the lens or due to
changes in the semipermeability of the
capsule. Traumatic cataract develops
by hydration process.
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2. Denaturation of Lens Proteins
If the proteins are denatured, with an
increase in insoluble proteins, a dense
opacity is produced, a process which is
irreversible . This occurs in young lens
or cortex of adult lens. This type of
cataract is called as soft cataract.
3. Sclerosis
Slow degenerative process occurs in
nucleus of the lens. This type of cataract
is called as hard cataract.
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 Part – II Cataract
--Etiology
--Classification
--Symptoms

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 Etiology
A -Age-related

B -Trauma

C -Metabolic or secondary

D -Toxic due to drugs

E -Complicated Cataract

F -After cataract or PCO

G -Syndromes associated with

cataract
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• A. Age-related
1. Sub-capsular
a. Anterior: due to fibrous
metaplasia of the anterior lens
epithelium
b. Posterior: just in front
of the posterior capsule. It is
associated with the posterior
migration of the anterior epithelium of
the lens
2009 - 2010

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 2. Nuclear Cataract
• -Exaggeration of the normal aging
involving the lens nucleus
-Often associated with myopia due to
the increase in the refractive index .
- Some elderly patients with Nuclear
Sclerosis may be able to read again without
their spectacles, due to the induced myopia:
this is called the "second sight ".

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• B. Trauma : can cause cataract:
• concussion, penetrating injury,
electric shock, lightening, or
radiation
Flower
shaped
(rosette)
cataract
Suhas Kulkarni 67

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C.. Metabolic or secondary
1. Diabetes -Senile cataract is
accelerated
-True diabetic cataract: associated
with over-hydration. Results in bilateral
snowflake posterior or anterior sub-
capsular opacities

Suhas Kulkarni 68

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 2. Galactosemia- multifocal white
flakes are seen in lens (inborn error of
galactose metabolism)
3. Wilson’s disease – green sunflower
cataract
(inborn error of copper metabolism)

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• D. Toxic due to drugs

• -Steroids: systemic cause more

cataract than topical.
causes anterior and posterior sub-
capsular lens opacities.

-Chlorpromazine: causes anterior lens

capsule opacities

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 -Gold (used in Rheumatoid Arthritis):
50% have posterior lens
opacities

-Miotics: cause anterior sub-capsular

opacities

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 • E. Complicated Cataract
(due to some other ocular disease)

-Chronic anterior uveitis

- Retinitis Pigmentosa
- High Myopia
- Acute angle closure glaucoma
(Glaukomfleckens)

Suhas Kulkarni 72

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 F. After cataract or PCO
posterior capsular opacity formed after
cataract surgery ( extra capsular cataract
extraction )
It is white membranous
opacity formed by remains of anterior
capsule and cortex.

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• G. Syndromes associated with cataract
Down’s ( mental retardation )
anterior, posterior subcapsular cataract
Lowe’s ( oculo-cerebro-renal )
total cataract
Wilson’s disease ( hepatolenticular degeneration )
green sunflower cataract
Congenital rubella
total cataract

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1. Developmental
2. Age related (senile)
3. Cataract associated with ocular diseases
4. Cataract associated with systemic
diseases
5. Traumatic Cataract
6. Drug induced cataract
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Classification of Cataract (2)
[Link]
[Link]- a) Senile b) Traumatic
c) Complicated d) secondary e) Toxic
f) Syndromes associated with cataract

[Link] Cataract
Suhas Kulkarni 76

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Classification of Cataract (3)

A. Morphologic
B. With respect to
maturity of Cataract
C. Age of onset

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• A. Morphologic:

1. Capsular Cataract
2. Subcapsular Cataract
3. Nuclear Cataract
4. Cortical Cataract
5. Lamellar Cataract
6. Sutural Cataract

2009 - 2010 Suhas Kulkarni 78

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 1. Capsular Cataract
a. Anterior Capsular
-Congenital: from persistent pupillary
membrane
-Acquired: Pseudoexfoliation syndromes,
chlorpromazine, in association with
posterior synechiae
b. Posterior capsular:
-Congenital: in association with persistent
hyaloid remnants
(Mittendorf's dot)
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2009 - 2010 Anterior Capsular cataract
Suhas Kulkarni 80

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• 2. Subcapsular Cataract
a. Posterior Subcapsular
-Complicated (e.g. in Diabetes Mellitis,
Myotonic Dystrophy, steroids,
irradiation)

b. Anterior Subcapsular
-Acute angle closure glaucoma
(Glaukomfleckens),
- miotics
- Wilson's disease

2009 - 2010 Suhas Kulkarni 81

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Anterior Subcapsular Posterior Subcapsular
2009 - 2010 Suhas Kulkarni 82

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 Anterior Subcapsular

(Glaukomfleckens)
2009 - 2010 Suhas Kulkarni

Acute angle
19 October 2019 closure glaucoma
3. Nuclear Cataract
-Age-related
-Congenital: Rubella, Galactosemia

Nuclear Cataract

2009 - 2010 Suhas Kulkarni 85

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4. Cortical Cataract
-Usually spoke-like, can be anterior or
posterior
-Can be congenital (very common)
-Usually doesn't interfere with vision

Cortical Cataract

2009 - 2010 Suhas Kulkarni 86

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 Cortical Cataract on retroillmination

2009 - 2010 Suhas Kulkarni 87

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5. Lamellar Cataract
-Congenital.
Involves one lamella of the fetal or
nuclear zone

2009 - 2010 Suhas Kulkarni 88

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6. Sutural Cataract
-Congenital
-Very common
-Y-shaped opacity in the lens nucleus
-No clinical significance

Anterior Sutural (erect Y )

2009 - 2010 Suhas Kulkarni 89

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B. With Respect to Maturity of Cataract
1. Stage of lamellar separation.
2. Stage of incipient cataract.
3. Immature senile cataract (ISC).
4. Mature senile cataract (MSC).
5. Hypermature senile cataract (HMSC).

2009 - 2010 Suhas Kulkarni 90

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1). Lameller separation:- cortical fibres are
separated by fluid. This phenomenon
(lamellar separation) can only be seen with a slit-lamp
and not with ophthalmoscope.
The general increase in the refractive index of the cortex
in old people
gives a grey
appearance.

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2. Stage of incipient cataract.
In this stage early detectable opacities with
clear areas between them are seen.
Two distinct types of senile cortical
cataracts can be recognized at this stage:
(a) Cuneiform senile cortical cataract.

(b) Cupuliform senile cortical cataract.

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 Cuneiform Cataract
Incipient stage:- wedge-shaped spokes of
opacity with clear areas between them
appear in the periphery of the lens and lie in
cortex, some in front of and some behind
the nucleus. Lens fibres, thus producing
irregularities in refraction, some visual
deterioration and polyopia. The bases of the
wedge-shaped opacities (cuneiform
Opacities) are peripheral and they are most
common in the lower nasal quadrant.
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Cuneiform senile cortical cataract

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Cupuliform senile cortical cataract.
saucer shaped opacity develops just below
the capsule usually in the central part of
posterior cortex (posterior subcapsular
cataract),which gradually extends outwards.
Cupuliform cataract lies right in the pathway
of the axial rays and thus causes an early
loss of visual acuity.

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 Cupuliform
cataract

posterior
subcapsular
cataract
2009 - 2010 Suhas Kulkarni 97

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 3. Immature Cataract
-scattered opacities are separated by clear areas
when opacification becomes more diffuse and
irregular. The lens appears greyish white but
clear cortex is still present and so iris shadow is
visible.

2009 - 2010 Suhas Kulkarni 98

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 Iris
Shadow

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 Intumescent cataract
The lens has become swollen by imbibed water
-Can be mature or immature
The progressive hydration of the cortical layers
may cause a swelling of the lens, thus making the
anterior chamber shallow (intumescent cataract).

2009 - 2010 Suhas Kulkarni 100

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 4. Mature senile cataract (MSC). Cortical
In this stage, opacification becomes complete,
i.e., whole of the cortex is involved.
Lens becomes pearly white in colour. Such a
cataract is also labelled as ‘ripe cataract.’

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 Mature cataract Cortical
-Cortex is totally opaque

2009 - 2010 Suhas Kulkarni 102

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 Nuclear senile cataract.
degenerative changes are intensified and
associated with dehydration this leads to
compaction of the nucleus resulting in formation
of a hard cataract.
The nucleus may become diffusely cloudy
(greyish) or tinted (yellow to black) due to
deposition of pigments. The commonly observed
pigmented nuclear cataracts are either
amber, brown (cataracta brunescens) or
black (cataracta nigra) and rarely
reddish (cataracta rubra) in colour

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 5. Hypermature Cataract
-Mature cataract that has become swollen and has
a wrinkled capsule as a result of leakage of water
out of the lens.

2009 - 2010 Suhas Kulkarni 105

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 A) Morgagnian Cataract:
-Hypermature cataract leading to total liquefaction of
the cortex making the nucleus sink inferiorly

Some times cortex

becomes fluid and
nucleus may sink to
the bottom of the
lens. The liquefied
cortex is milky, and
the nucleus is as
brown mass, altering
it’s position with
position of head.
2009 - 2010 Suhas Kulkarni 106

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(b) Sclerotic type hypermature cataract:
Sometimes after the stage of maturity, the cortex
becomes disintegrated and the lens becomes
shrunken due to leakage of water. The anterior
capsule is wrinkled and thickened due to
proliferation of anterior cells and a dense white
capsular cataract may be formed in the pupillary
area. Due to shrinkage of lens, anterior chamber
becomes deep and iris becomes tremulous
(iridodonesis).

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C . Age of onset
1. Congenital Cataract -- Present at birth
2. Infantile Cataract --- up to 1 yr of age
3. Juvenile Cataract -------- Infancy to
adolescence
4. Pre-senile Cataract ------ up to the
age of 40
5. Senile Cataract ------ after the age of 40

2009 - 2010 Suhas Kulkarni 109

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 1. Blurring of vision
2. Frequent change of glasses due to rapid
change in refractive index of the lens
3. Painless, progressive gradual diminution of
vision due to reduction in transparency of
the lens
4. Second sight or myopic shift in case of
nuclear cataract causing index myopia,
improving near vision.

2009 - 2010 Suhas Kulkarni 110

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5. Loss or marked diminution of vision in
bright sunlight or bright light beam in
central posterior subcapsular cataract.
6. Monocular diplopia or polyopia in presence
of cortical spoke opacities
7. Glare in posterior subcapsular cortical
cataract due to increased scattering of light

2009 - 2010 Suhas Kulkarni 111

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8. Colored haloes around the light as seen in
cortical cataract due to irregular refractive
index in different parts of the lens.
9. Color shift , reds are accentuated
10. Visual field loss, generalized reduction in
sensitivity due to loss of transparency

2009 - 2010 Suhas Kulkarni 112

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 Cataract risk factors
Demographic RF
Age- The strongest RF for cataract
The risk of cataract at age 70 is about 13-fold that at age 50

Race
Some types of cataracts (cortical & nuclear) are more
common in african americans

Sex
Women slightly greater risk than men

Geographic
Especially prevalent in developing countries in the tropical bel
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 Medical RF
Diabetes
Drugs
Miotic cholinergic compounds
Cancer chemotherapy agents
Diuretics
Various photosenthesitizing drugs
Major tranquillizers
Gout medications
Steroids
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Environmental RF
• Nutrition- conflicting reports

Dietary intake of riboflavin, vit C &E & carotenoids (antioxidants)- protective ef

Intake of niacin, thiamine & iron- also protective
Radiation

Exposure to UV--> cortical & PSC

IR

Smoking- increased risk of nuclear cataracts

Alcohol use

> 2 drinks/ day--> increased risk of all types of cataract

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 • Chronic open angle glaucoma
• Macular degeneration
• Optic atrophy
• Corneal dystrophy
• Retinopathy associated with
systemic disorders (hypertension or
diabetes)
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 Grading of nucleus for
Phaco-emulsification

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 Examination of the Eye
Visual acuity for RE / LE With or without spects
For distance and near
Pin hole vision
Pupil dilatation
Slit-lamp examination
Fundus examination
B-Scan
A-Scan
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 Sac Syringing
IOT

Other investigations

Urine and Blood Test

B.P. and ECG with Physicians fitness
Anaethetist’s examination and fitness

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