LENS.pdf

1 LENS Department Of Ophthalmology MELAKA-MANIPAL MEDICAL COLLEGE MALAYSIA MANI PAL U N I V E R SI T Y 3 ANATOMY Transparent Biconvex structure Situated behind the iris in the posterior chamber Suspended by the zonules from the ciliary body which are attached to equator & anterior surface of lens. M...

1 LENS Department Of Ophthalmology MELAKA-MANIPAL MEDICAL COLLEGE MALAYSIA MANI PAL U N I V E R SI T Y 3 ANATOMY Transparent Biconvex structure Situated behind the iris in the posterior chamber Suspended by the zonules from the ciliary body which are attached to equator & anterior surface of lens. MELAKA-MANIPAL MEDICAL COLLEGE MALAYSIA MANI PAL U N I V E R SI T Y 4 DIMENSIONS Diameter = 9.0 to 10.0 mm Thickness = varies with age Curvature of anterior surface = 10 mm Curvature of posterior surface = 6mm Power inside eye = 15-16 D MELAKA-MANIPAL MEDICAL COLLEGE MALAYSIA MANI PAL U N I V E R SI T Y 5 ANATOMY Anterior pole Posterior pole Equator Capsule Anterior Posterior Anterior Pole Posterior Pole Nucleus Cortex MELAKA-MANIPAL MEDICAL COLLEGE MALAYSIA MANI PAL U N I V E R SI T Y 6 ANATOMY Capsule Thinnest at posterior pole Capsular epithelium Single layer under the anterior capsule and equator Lens substance Cortex: Consist of lens fibers produced by mitosis of epithelial cells As the lens fibers elongate & new fibers form the older ones are pushed deep in the lens Nucleus: Consists of embryonic, fetal, infantile & adult nucleus MELAKA-MANIPAL MEDICAL COLLEGE MALAYSIA MANI PAL U N I V E R SI T Y 7 COMPOSITION OF LENS 64% water 35% proteins Highest among body tissues Soluble crystallins Alpha (31%) Beta (55%) Gamma 92%) Insoluble albuminoids (12%) 1% lipids MELAKA-MANIPAL MEDICAL COLLEGE MALAYSIA MANI PAL U N I V E R SI T Y Factors - clarity and transparency of lens are: Avascularity Tightly-packed lens cells The arrangement of lens proteins, Semipermeable character of lens capsule, Pump mechanism of lens fibre membranes that regulate the electrolyte and water balance in the lens, maintaining relative dehydration MELAKA-MANIPAL MEDICAL COLLEGE MALAYSIA MANI PAL U N I V E R SI T Y Auto-oxidation and high concentration of reduced glutathione in the lens maintains the lens proteins in a reduced state and ensures the integrity of the cell membrane pump. MELAKA-MANIPAL MEDICAL COLLEGE MALAYSIA MANI PAL U N I V E R SI T Y 10 FUNCTIONS OF LENS Transmit 80% of light between 400nm & 1400nm Refraction 35% of total eye Accommodation To see distant as well as near objects MELAKA-MANIPAL MEDICAL COLLEGE MALAYSIA MANI PAL U N I V E R SI T Y 11 CATARACT DEFINITION Any opacity in the lens or its capsule is called as ‘cataract’. Opacities can be partial & stationary as in developmental cataracts OR Can be progressive & complete as occurs usually in acquired types MELAKA-MANIPAL MEDICAL COLLEGE MALAYSIA MANI PAL U N I V E R SI T Y 12 ETIOLOGICAL CLASSIFICATION CONGENITAL/DEVELOPMENTAL Punctate Zonular Fusiform (coralliform) Nuclear Coronary Anterior capsular (polar) Posterior capsular (polar) MELAKA-MANIPAL MEDICAL COLLEGE MALAYSIA MANI PAL U N I V E R SI T Y 13 ETIOLOGICAL CLASSIFICATION SENILE Cortical Posterior subcapsular Nuclear COMPLICATED Uveitis High Myopia Retinits pigmentosa Retinal detachment Glaucoma MELAKA-MANIPAL MEDICAL COLLEGE Ocular ischemia MALAYSIA MANI PAL U N I V E R SI T Y 14 ETIOLOGICAL CLASSIFICATION METABOLIC Diabetes mellitus Tetany Galactosemia Lowe’s syndrome Wilson’s disease TRAUMATIC Concussion injuries Penetrating Injuries DERMATOGENIC MATERNAL INFECTIONS TOXIC ASSOCIATED WITH SYSTEMIC DISEASES MELAKA-MANIPAL MEDICAL COLLEGE MALAYSIA MANI PAL U N I V E R SI T Y 15 ETIOLOGICAL CLASSIFICATION RADIATIONAL Ionizing Infrared Ultraviolet Nuclear DERMATOGENIC Atopic dermatitis MATERNAL INFECTIONS Rubella Toxoplasmosis Cytomegalo virus Syphilis MELAKA-MANIPAL MEDICAL COLLEGE MALAYSIA MANI PAL U N I V E R SI T Y 16 ETIOLOGICAL CLASSIFICATION TOXIC Corticosteroids Miotics Phenothiazines ASSOCIATED WITH SYSTEMIC DISEASES Myotonic dystrophy Down’s syndrome ELECTRIC SHOCK MELAKA-MANIPAL MEDICAL COLLEGE MALAYSIA MANI PAL U N I V E R SI T Y 17 ACQUIRED CATARACT Three biochemical processes occur Hydration Accumulation of fluid between lens fibers Reversible in early stages Denaturation of lens proteins Due to increase in insoluble proteins Irreversible Slow necrosis Occurs in older & inactive fibers of the nucleus MELAKA-MANIPAL MEDICAL COLLEGE MALAYSIA MANI PAL U N I V E R SI T Y 18 RISK FACTORS Advanced age Smoking Diabetes Mellitus Exposure to ultraviolet & infrared radiations Hyperbaric oxygen Dehydration due to diarrhea Deficiency of Vitamins E & C and carotinoids. MELAKA-MANIPAL MEDICAL COLLEGE MALAYSIA MANI PAL U N I V E R SI T Y 19 ACQUIRED CATARACT SENILE CATARACT Also called as ‘Age Related Cataract’ Common after the age of 60 years Bilateral & equal in both sexes Occurs earlier in tropical climate then temprate Clinical types: Cortical (70%) Nuclear (20%) Posterior subcapsular (5%) MELAKA-MANIPAL MEDICAL nuclear COLLEGE (5%) Cortico MALAYSIA MANI PAL U N I V E R SI T Y 20 SENILE CATARACT SYMPTOMS Painless progressive diminution of vision Diplopia/Polyopia Coloured haloes White opacity in pupillary area Index myopia (second sight) – only in nuclear cataract MELAKA-MANIPAL MEDICAL COLLEGE MALAYSIA MANI PAL U N I V E R SI T Y 21 SENILE CORTICAL CATARACT The opacity affects cortex and spares nucleus, Affects periphery of lens first & then becomes total. 3 stages Immature Lamellar separation Incipient Intumescent Mature Hypermature Morgagnian Shrunken or sclerotic MELAKA-MANIPAL MEDICAL COLLEGE MALAYSIA MANI PAL U N I V E R SI T Y 22 IMMATURE SENILE CATARACT LAMELLAR SEPARATION Fluid accumulates between cortical fibers Can be seen only on slit lamp Pupil colour changes to greyish white due to increase in reflection & scattering of light INCIPIENT Wedge shaped spokes of opacity at the periphery Appear as black against red background by ophthalmoscope & slit lamp Iris shadow is seen MELAKA-MANIPAL MEDICAL COLLEGE MALAYSIA MANI PAL U N I V E R SI T Y 23 Lamellar separation Incipient MELAKA-MANIPAL MEDICAL COLLEGE MALAYSIA Immature Cataract Grey White Iris shadow present Red glow has black opacity MANI PAL U N I V E R SI T Y 25 IMMATURE SENILE CATARACT INTUMESCENT Progressive hydration causes swelling of the lens Anterior chamber becomes shallow May sometimes lead to ‘Phacomorphic glaucoma’ Vision is reduced usually to CF MELAKA-MANIPAL MEDICAL COLLEGE MALAYSIA MANI PAL U N I V E R SI T Y 26 MATURE SENILE CATARACT All the lens fibers become opaque No red glow seen on ophthalmoscope Pupil is pearly white in colour Vision is reduced to PL, PR accurate, HM+, may be CF close to face MELAKA-MANIPAL MEDICAL COLLEGE MALAYSIA MANI PAL U N I V E R SI T Y 27 HYPERMATURE SENILE CATARACT SHRUNKEN Cortex becomes disintegrated Anterior capsule is thickened Pupil colour is milky white A C is deep Iridodonesis may be present Vision is only PL & PR MELAKA-MANIPAL MEDICAL COLLEGE MALAYSIA MANI PAL U N I V E R SI T Y 28 HYPERMATURE SENILE CATARACT MORGAGNIAN Cortex becomes fluid & gives milky white colour Nucleus sinks in bottom seen as brownish semicircular line Vision is PL & PR Lens may show sublaxtion or dislocation May cause ‘Phacolytic glaucoma’ MELAKA-MANIPAL MEDICAL COLLEGE MALAYSIA MANI PAL U N I V E R SI T Y 29 POSTERIOR SUBCAPSULAR CATARACT (PSC) Type of cortical cataract – involving posterior layers Occurs at relatively young age. Axial usually Complaints of poor vision in bright light. Diagnosis by slit lamp in a dilated pupil. MELAKA-MANIPAL MEDICAL COLLEGE MALAYSIA MANI PAL U N I V E R SI T Y 31 NUCLEAR SCLEROSIS Nuclear fibers sclerose Cortex remains transparent Leads to myopia so distant vision is affected more than near vision Usually brown or black colour Progression is slow Lens never becomes hypermature MELAKA-MANIPAL MEDICAL COLLEGE MALAYSIA MANI PAL U N I V E R SI T Y 32 COMPLICATED CATARACT CAUSES: Iridocyclitis Ciliary body tumors Choroiditis Degenerative myopia Anterior segment ischaemia Retinitis pigmentosa Gyrate atrophy Retinal detachment MELAKA-MANIPAL MEDICAL COLLEGE MALAYSIA MANI PAL U N I V E R SI T Y 33 COMPLICATED CATARACT It occurs in any age It occurs from disturbance of lens metabolism Earliest to be affected is posterior cortex due to thin posterior capsule & absence of epithelium It is seen as polychromatic luster May be stationary or progressive Vision is affected very early (more in day light) MELAKA-MANIPAL MEDICAL COLLEGE MALAYSIA MANI PAL U N I V E R SI T Y 34 CATARACT ASSOCIATED WITH SYSTEMIC DISEASES DIABETIES True diabetic cataract Occurs in Juvenile diabetics Reversible in early stages ‘Snowflake’ appearance Senescent cataract Earlier development of cataract than non diabetic (15 years) Diabetes causes early progression & maturation of cataract Depends on duration & blood sugar levels. MELAKA-MANIPAL MEDICAL COLLEGE MALAYSIA MANI PAL U N I V E R SI T Y 35 TRAUMATIC CATARACT Usually follows blunt trauma or penetrating trauma involving lens ‘Rosette-shaped’ cataract MELAKA-MANIPAL MEDICAL COLLEGE MALAYSIA MANI PAL U N I V E R SI T Y Dislocation and subluxations These results from the partial or complete rupture of zonules and the lens goes out of its normal place. This usually occurs congenitally or by the trauma. MELAKA-MANIPAL MEDICAL COLLEGE MALAYSIA MANI PAL U N I V E R SI T Y 37 Dislocation and subluxations MELAKA-MANIPAL MEDICAL COLLEGE MALAYSIA MANI PAL U N I V E R SI T Y CONGENITAL DISLOCATIONS. 1. Simple ectopia lentis. 2. Ectopia lentis with systemic anomalies. a) b) c) d) e) f) Marfan’s syndrome. Homocystinuria. Weil Marchasani syndrome. Ehlers Danlos syndrome. Hyperlysinaemia. Stickler syndrome. MELAKA-MANIPAL MEDICAL COLLEGE MALAYSIA MANI PAL U N I V E R SI T Y OTHER AETIOLOGIES. Traumatic. Consecutive or spontaneous displacement Hyper mature cataract MELAKA-MANIPAL MEDICAL COLLEGE MALAYSIA MANI PAL U N I V E R SI T Y CLINICAL FEATURES Defective vision. Uniocular diplopia. Deep anterior chamber. Iridodonesis. Distant direct ophthalmoscopy will show the dark edge. MANI PAL MELAKA-MANIPAL MEDICAL COLLEGE MALAYSIA. U N I V E R SI T Y COMPLICATIONS OF DISLOCATION Cataract formation Secondary glaucoma. Uveitis. MELAKA-MANIPAL MEDICAL COLLEGE MALAYSIA MANI PAL U N I V E R SI T Y SITES OF DISLOCATION Incarcerated in the pupil itself. In the anterior chamber. In the vitreous chamber. a) as lens nutans or lens fixata. Extruded out of the eye. MELAKA-MANIPAL MEDICAL COLLEGE MALAYSIA MANI PAL U N I V E R SI T Y Management Lens in the pupil or anterior chamber should be removed at the earliest possible time. Lens in the vitreous should be removed only if it is causing problems like uveitis or glaucoma. Surgery includes vitrectomy along with the removal of lens. MELAKA-MANIPAL MEDICAL COLLEGE MALAYSIA MANI PAL U N I V E R SI T Y Scenario: 1 HOPI: A 62 year-old lady presented with complaints of gradual decrease in vision in both the eyes since 2 years mostly during evening time. She was unable to carry out her daily activities and could not recognize people at some distance till they came quite close. Watching television and reading were becoming increasingly difficult for her. She is having glare while driving and seeing coloured rings around light bulb and sometimes multiple bulbs in place of a single bulb. MELAKA-MANIPAL MEDICAL There is no painCOLLEGE redness MALAYSIA or watering MANI PAL U N I V E R SI T Y Scenario: 1 Old age gradual painless blurring of vision glare mainly while driving seeing coloured rings around light bulb multiple images. (polyopia) MELAKA-MANIPAL MEDICAL COLLEGE MALAYSIA MANI PAL U N I V E R SI T Y Ocular examination: Visual Acuity: RE:6/60 MELAKA-MANIPAL MEDICAL COLLEGE MALAYSIA LE: 6/36 MANI PAL U N I V E R SI T Y Examination of Eye TORCH Anterior Segment Examination: Iris shadow present, Greyish white opacity in Both eyes MELAKA-MANIPAL MEDICAL COLLEGE MALAYSIA MANI PAL U N I V E R SI T Y Eye Exam. Cont. Lids and Lashes Normal both eyes Conjunctiva/Sclera Normal both eyes Cornea Clear both eyes Anterior Chamber Deep and quiet both eyes Iris Normal Iris shadow present, Greyish white opacity in Both MELAKA-MANIPAL MEDICAL COLLEGE MANI PAL eyes U N I V E R SI T Y MALAYSIA Lens MELAKA-MANIPAL MEDICAL COLLEGE MALAYSIA MANI PAL U N I V E R SI T Y Eye Exam. Cont Distant direct ophthalmoscopy Dark shadow against the red fundal glow on distant direct ophthalmoscopy Dilated Fundus Examination: BE LE No clear view of fundus. No clear view of fundus. MELAKA-MANIPAL MEDICAL COLLEGE MALAYSIA MANI PAL U N I V E R SI T Y Scenario: 2 HOPI: A 75 year-old man presented with complaints of gradual decrease in vision in both the eyes since 3 years. Since 2 months he is unable to see from one eye. He had gone to a doctor one year back and was advised to see a specialist but he ignored as he is retired and could carry out his daily activities at home. MELAKA-MANIPAL MEDICAL COLLEGE MALAYSIA MANI PAL U N I V E R SI T Y Scenario: 2 HOPI: A 75 year-old gradual decrease in vision 3 years. 2 months unable to see from one eye. one year back advised to see a specialist but he ignored. MELAKA-MANIPAL MEDICAL COLLEGE MALAYSIA MANI PAL U N I V E R SI T Y Ocular examination: Visual Acuity: RE:PL+;PRAccurate LE: 6/36 MELAKA-MANIPAL MEDICAL COLLEGE MALAYSIA MANI PAL U N I V E R SI T Y MELAKA-MANIPAL MEDICAL COLLEGE MALAYSIA MANI PAL U N I V E R SI T Y Examination of Eye Torch No Iris Shadow present, pearly white opacity in Right eye : MELAKA-MANIPAL MEDICAL COLLEGE MALAYSIA MANI PAL U N I V E R SI T Y Slit Lamp: Lids Lashes and Normal both eyes Conjunctiva/ Normal both eyes Sclera Cornea Clear both eyes Anterior Chamber Deep and quiet both eyes Iris Normal No Iris Shadow present, pearly white opacity in Right eye Lens Iris shadow present, Greyish white opacity in Left eye MELAKA-MANIPAL MEDICAL COLLEGE MANI PAL MALAYSIA U N I V E R SI T Y Eye Exam. Cont Distant direct ophthalmoscopy Right Eye No fundal glow on distant direct ophthalmoscopy Dilated Fundus Examination: RE No view of fundus MELAKA-MANIPAL MEDICAL COLLEGE MALAYSIA MANI PAL U N I V E R SI T Y Examination of Eye IOP (Applantation): RE:14mmHg LE: 12 mmHg Sac Regurgitation test negative A SCAN: Keratometry B SCAN Posterior segment appears normal. No retinal Detatchment MELAKA-MANIPAL MEDICAL COLLEGE MALAYSIA MANI PAL U N I V E R SI T Y Activity: Self-Assessment: 1) The commonest cause of cataract is trauma diabetes hypo-parathyroidism TORCH infections old age MELAKA-MANIPAL MEDICAL COLLEGE MALAYSIA MANI PAL U N I V E R SI T Y 2.Identify the structures MELAKA-MANIPAL MEDICAL COLLEGE MALAYSIA ?1 ?2 MANI PAL U N I V E R SI T Y MELAKA-MANIPAL MEDICAL COLLEGE MALAYSIA MANI PAL U N I V E R SI T Y Take Home message & assignment 1. Causes of gradual loss of vision 2 Signs of immature cataract. 3.Surgery of cataract MELAKA-MANIPAL MEDICAL COLLEGE MALAYSIA MANI PAL U N I V E R SI T Y 63 THANK YOIU TO BE CONTINUED…………………. MELAKA-MANIPAL MEDICAL COLLEGE MALAYSIA MANI PAL U N I V E R SI T Y 64 LENS -2 Department Of Ophthalmology MELAKA-MANIPAL MEDICAL COLLEGE MALAYSIA MANI PAL U N I V E R SI T Y 65 MANAGEMENT OF CATARACT Treatment is surgical removal of lens followed by visual rehabilitation using Glasses Contact lens OR Intra ocular lens (IOL) MELAKA-MANIPAL MEDICAL COLLEGE MALAYSIA MANI PAL U N I V E R SI T Y 66 INDICATION OF CATARACT SURGERY Visual When vision loss interferes with normal functioning of the patient Medical Secondary glaucoma Surgical To visualize & treat the posterior segment diseases MELAKA-MANIPAL MEDICAL COLLEGE MALAYSIA MANI PAL U N I V E R SI T Y 67 PRE OPERATIVE EVALUATION GENERAL BP Blood sugar levels Breathlessness Any septic focus in the body To rule out any other systemic disease or any allergies MELAKA-MANIPAL MEDICAL COLLEGE MALAYSIA MANI PAL U N I V E R SI T Y 68 PRE OPERATIVE EVALUATION OCULAR IOP – to rule out any glaucoma Conjunctival sac – for any infection Lacrimal sac – regurgitation test to find the patency of NLD Lids – for blephritis or any infection Complete eye checkup – to find any other disease like pseudoexfoliation MELAKA-MANIPAL MEDICAL COLLEGE MALAYSIA MANI PAL U N I V E R SI T Y 69 PRE OPERATIVE EVALUATION SPECIFIC EXAMINATION Type & grade of lens opacity (LOCS III) Pupillary reaction Visual Acuity – particularly PL & PR Macular function tests Two point discrimination test MELAKA-MANIPAL MEDICAL COLLEGE MALAYSIA MANI PAL U N I V E R SI T Y 70 ISCHIHARA CHART MADDOX ROD LOCS III MELAKA-MANIPAL MEDICAL COLLEGE MALAYSIA MANI PAL U N I V E R SI T Y 71 PRE OPERATIVE EVALUATION SPECIFIC EXAMINATION Fundus examination Using indirect ophthalmoscope after dilatation of pupil B scan ultrasound For any retinal pathology like vitreous hemorrhage or Retinal detachment MELAKA-MANIPAL MEDICAL COLLEGE MALAYSIA MANI PAL U N I V E R SI T Y 72 INDIRECT OPHTHALMOSCOPE MELAKA-MANIPAL MEDICAL COLLEGE MALAYSIA ERG B SCAN VEP MANI PAL U N I V E R SI T Y 73 PRE OPERATIVE PREPARATION ANTIBIOTICS Broad spectrum antibiotic eye drops locally 4 to 6 times a day for at least two days prior to surgery MYDRIATICS NSAID eye drop 4 times a day for two days prior to surgery (to prevent per operative meiosis) Combination of tropicamide 1% & phenylepherine 0.5% eye drop 4 to 6 times at 10 minutes interval starting ½ hour before surgery MELAKA-MANIPAL MEDICAL COLLEGE MALAYSIA MANI PAL U N I V E R SI T Y 74 ANESTHESIA GENERAL ANESTHESIA Children Uncooperative &/or apprehensive patient LOCAL ANESTHESIA Regional block (2% lignocaine injection +/- 0.75% bupivacaine)– provides anesthesia as well as akinesia Peribulbar Topical ( Paracaine eye drops or 2% lignocaine jelly) MELAKA-MANIPAL MEDICAL COLLEGE MALAYSIA MANI PAL U N I V E R SI T Y 75 TYPES OF SURGERY INTRA CAPSULAR CATARACT EXTRACTION (ICCE) Total lens along with capsule is removed. Indications Dislocation of lens More than 180° sublaxation of lens MELAKA-MANIPAL MEDICAL COLLEGE MALAYSIA MANI PAL U N I V E R SI T Y 76 TYPES OF SURGERY INTRA CAPSULAR CATARACT EXTRACTION (ICCE) Problems Large incision Inability to implant a posterior chamber IOL & High rate of complications High astigmatism Vitreous loss Retinal detachment Cystoid macular oedema (CME) MELAKA-MANIPAL MEDICAL COLLEGE MALAYSIA MANI PAL U N I V E R SI T Y 77 TYPES OF SURGERY EXTRA CAPSULAR CATARACT EXTRACTION (ECCE) An opening is made in anterior capsule (capsulotomy) & nucleus & cortex removed leaving posterior capsule behind. Different methods are Conventional ECCE Small incision cataract surgery (SICS) Phacoemulsification MELAKA-MANIPAL MEDICAL COLLEGE MALAYSIA MANI PAL U N I V E R SI T Y 78 PHACOEMULSIFICATION 1. Capsulorrhexis 2. Hydrodissection 3. Sculpting of nucleus 4. Cracking of nucleus 5. Emulsification of each quadrant 6. Cortical cleanup and insertion of IOL MELAKA-MANIPAL MEDICAL COLLEGE MALAYSIA MANI PAL U N I V E R SI T Y 79 PHACOEMULSIFICATION MELAKA-MANIPAL MEDICAL COLLEGE MALAYSIA MANI PAL U N I V E R SI T Y 80 POST OPERATIVE MANAGEMENT Topical steroids till about 6 weeks Topical antibiotics Topical NSAID drops Topical cycloplegics MELAKA-MANIPAL MEDICAL COLLEGE MALAYSIA MANI PAL U N I V E R SI T Y 81 INTRA OCULAR LENS HAPTIC OPTIC DIALING HOLES MELAKA-MANIPAL MEDICAL COLLEGE MALAYSIA MANI PAL U N I V E R SI T Y 82 TYPES OF IOL Anterior Chamber Iris Supported Posterior Chamber In the sulcus In the posterior capsule Type Rigid (non foldable) Foldable MELAKA-MANIPAL MEDICAL COLLEGE MALAYSIA MANI PAL U N I V E R SI T Y 83 TYPES OF IOL MELAKA-MANIPAL MEDICAL COLLEGE MALAYSIA MANI PAL U N I V E R SI T Y 84 IOL POWER Various formulas Most common is SRK II E = A - 2.5 L – 0.9K E = Emetropic power A = Constant L = Axial length of eye ball K = Average keratometer reading MELAKA-MANIPAL MEDICAL COLLEGE MALAYSIA MANI PAL U N I V E R SI T Y 86 COMPLICATIONS OF CATARACT SURGERY POST OPERATIVE COMPLICATIONS EARLY (within few days to 4 weeks) Wound leak leading to shallow AC Corneal oedema (Striate keratopathy) Iris prolapse Hyphaema Retained lens matter Toxic Anterior Segment Syndrome (TASS) Endophthalmitis – bacterial or fungal Retinal Detachment MELAKA-MANIPAL MEDICAL COLLEGE MALAYSIA MANI PAL U N I V E R SI T Y 87 POST OPERATIVE COMPLICATIONS IRIS PROLAPSE MELAKA-MANIPAL MEDICAL COLLEGE MALAYSIA STRIATE KERATOPATHY MANI PAL U N I V E R SI T Y 88 POST OPERATIVE COMPLICATIONS HYPHAEMA MELAKA-MANIPAL MEDICAL COLLEGE MALAYSIA ENDOPHTHALMITIS MANI PAL U N I V E R SI T Y 89 POST OPERATIVE COMPLICATIONS RETAINED LENS MATTER RETINAL DETACHMENT MELAKA-MANIPAL MEDICAL COLLEGE MALAYSIA MANI PAL U N I V E R SI T Y 90 COMPLICATIONS OF CATARACT SURGERY LATE ( after 4 weeks to years) Endophthalmitis due to Propanicum bacteria Retinal detachment Cystoid macular oedema Displacement of IOL Vitreous touch syndrome leading to secondary glaucoma Posterior capsule opacification (PCO) also called as secondary cataract. MELAKA-MANIPAL MEDICAL COLLEGE MALAYSIA MANI PAL U N I V E R SI T Y 91 POST OPERATIVE COMPLICATIONS CME FFA MELAKA-MANIPAL MEDICAL COLLEGE MALAYSIA OCT MANI PAL IOL DISPLACEMENT U N I V E R SI T Y 92 SECONDARY CATARACT Also called as ‘After Cataract’ or “Posterior Capsule Opacification” (PCO) Clinically two types Ring of Sommerring Elsching pearls Treatment is by ‘YAG’ laser capsulotomy MELAKA-MANIPAL MEDICAL COLLEGE MALAYSIA MANI PAL U N I V E R SI T Y 93 SECONDARY CATARACT ELSCHING PEARLS MELAKA-MANIPAL MEDICAL COLLEGE MALAYSIA SOMMERRING RING MANI PAL U N I V E R SI T Y Scenario Based Learning Theme:60 year-old lady presented with complaints of pain ,redness and sudden detoriation of vision MELAKA-MANIPAL MEDICAL COLLEGE MALAYSIA ) MANI PAL U N I V E R SI T Y Scenario: 4 HOPI: A 60 year-old lady presented with complaints of pain ,redness and sudden detoriation of vision in left eye. The left eye was operated for cataract surgery 2 days back. The patient says that after the operation she was alright, there was no pain ,she could read the second last line the next day after surgery. MELAKA-MANIPAL MEDICAL COLLEGE MALAYSIA MANI PAL U N I V E R SI T Y History Cont. Past Ocular History: Cataract surgery ( phaco) was done 2 days back. No hx of eye trauma Ocular Medications: Patient is on antibiotic and steroid drops three times a day. Past Medical History: Diabetic since 7 years which is under control MELAKA-MANIPAL MEDICAL COLLEGE MALAYSIA MANI PAL U N I V E R SI T Y Large group Interaction 1 Visual Acuity: RE:6/9 LE: 6/60 MELAKA-MANIPAL MEDICAL COLLEGE MALAYSIA MANI PAL U N I V E R SI T Y Large group Interaction 2 IDENTIFY abnormal clinical findings in the following photo of the patient MELAKA-MANIPAL MEDICAL COLLEGE MALAYSIA MANI PAL U N I V E R SI T Y Slit Lamp: left eye Right eye normals Lids and LE shows lid oedema Lashes Conjunctiva/ Both conjunctival and circumcorneal congestion Sclera Cornea Corneal oedema Anterior Chamber Flare 3 + ,cells 3+,Hypopyon 2mm Iris muddy pupil 3 mm ,not reacting to light MANI PAL U N I V E R SI T Y Faint shimmering reflex suggestive of IOL is present MELAKA-MANIPAL MEDICAL COLLEGE Lens MALAYSIA Eye Exam. Cont Distant direct ophthalmoscopy Very faint red fundal glow on distant direct ophthalmoscopy Dilated Fundus Examination: RE LE Disc with 0.3 cup and normal clear margins vessels and background appear normal macula normal No clear view of fundus. Disc seen hazily with 0.3 cup MELAKA-MANIPAL MEDICAL COLLEGE MALAYSIA MANI PAL U N I V E R SI T Y Examination of Eye IOP (Applantation): OD:14mmHg OS: 12 mmHg B SCAN Vitrous opacities Vitrous tap and intravitreal antibiotic given. MELAKA-MANIPAL MEDICAL COLLEGE MALAYSIA MANI PAL U N I V E R SI T Y Scenario Based Learning Theme: 50 year-old lady presented with complaints of gradual detoriation of vision MELAKA-MANIPAL MEDICAL COLLEGE MALAYSIA MANI PAL U N I V E R SI T Y Scenario: 4 HOPI: A 50 year-old lady presented with complaints of gradual detoriation of vision in left eye. The left eye was operated for cataract surgery 1 year back. The patient says that after the operation she was alright, there was no pain ,she could read the second last line the next day after surgery and the vision remained good for 6 months, But for the recent 6 months it is gradually decreasing. There is no pain or redness or watering. MELAKA-MANIPAL MEDICAL COLLEGE MALAYSIA MANI PAL U N I V E R SI T Y History Cont. Past Ocular History: Cataract surgery ( phaco) was done 1 year back. No hx of eye trauma Ocular Medications: Patient is on antibiotic and steroid drops three times a day for 2 weeks after surgery. now she is not taking any drop. Past Medical History: Diabetic since 17 years which is under control MELAKA-MANIPAL MEDICAL COLLEGE MALAYSIA MANI PAL U N I V E R SI T Y Large group Interaction 1 Visual Acuity: RE:6/9 LE: 6/60 MELAKA-MANIPAL MEDICAL COLLEGE MALAYSIA MANI PAL U N I V E R SI T Y Large group Interaction 2 IDENTIFY abnormal clinical findings in the following photo of the patient MELAKA-MANIPAL MEDICAL COLLEGE MALAYSIA MANI PAL U N I V E R SI T Y Lids and Lashes LE lids normal Conjunctiva/Sclera normal Cornea Corneal clear Anterior Chamber Deep and quiet Iris Normal in colour and pattern pupil 3 mm ,round,reacting to light Lens shimmering reflex suggestive of IOL is present,There is white membranous thickening posterior to lens MELAKA-MANIPAL MEDICAL COLLEGE MALAYSIA MANI PAL U N I V E R SI T Y Eye Exam. Cont Distant direct ophthalmoscopy Very faint red fundal glow on distant direct ophthalmoscopy Dilated Fundus Examination: RE Disc with 0.3 cup and normal clear margins vessels and background appear normal macula normal No clear view of fundus. Disc seen hazily with 0.3 cup LE MELAKA-MANIPAL MEDICALMacula COLLEGE ,vessels and background appearsM A N I P A L U N I V E R SI T Y MALAYSIA normal. Examination of Eye IOP (Applantation): OD:14mmHg OS: 14 mmHg B SCAN B SCAN shows normal posterior segment Nd Yag laser Posterior capsuloomy was done and Patient regained vision.. MELAKA-MANIPAL MEDICAL COLLEGE MALAYSIA MANI PAL U N I V E R SI T Y 1. A patient who was operated for cataract four months back comes to you with foggy vision. On examination there was posterior capsular thickening, which mode of treatment is most useful. a. Excimer laser b. YAG-Laser c. Argon laser d Diode laser MELAKA-MANIPAL MEDICAL COLLEGE MALAYSIA MANI PAL U N I V E R SI T Y 2). The Picture below shows A Bacteria on IOL B Elschnig’s pearls C Ring of Soemmering D Cells in vitrous MELAKA-MANIPAL MEDICAL COLLEGE MALAYSIA MANI PAL U N I V E R SI T Y 3) The opacity which develops after cataract surgery is called as all except A after cataract B secondary cataract C complicated Cataract D Posterior capsular opacification (PCO) MELAKA-MANIPAL MEDICAL COLLEGE MALAYSIA MANI PAL U N I V E R SI T Y 1 After 48 hours of a cataract extraction operation, a patient complained of ocular pain and visual loss. On examination, this eye looked red with ciliary injection, corneal oedema and absent red reflex. The first suspicion must be: 1. Secondary glaucoma. 2. Anterior uveitis. 3. Bacterial endophthalmitis. 4. Acute conjunctivitis MELAKA-MANIPAL MEDICAL COLLEGE MALAYSIA MANI PAL U N I V E R SI T Y 2). Which of the following is the most important factor in the prevention of the endophthalmitis in cataract surgery? a) Preoperative prepartion with povidone iodine b) One week antibiotic therapy prior to sugery c) Trimming of eyelashes d) Use of intravitreal antibiotics MELAKA-MANIPAL MEDICAL COLLEGE MALAYSIA MANI PAL U N I V E R SI T Y 3) List Three signs in the photograph MELAKA-MANIPAL MEDICAL COLLEGE MALAYSIA MANI PAL U N I V E R SI T Y 116 LENS -3 Department Of Ophthalmology MELAKA-MANIPAL MEDICAL COLLEGE MALAYSIA MANI PAL U N I V E R SI T Y 117 CONGENITAL/DEVELOPMENTAL CATARACT Congenital if present at birth & developmental when develops later in childhood. Very common. Developmental cataract affects a particular zone which was affected at that time of lens development. Usually stationary Doesn’t affect vision unless large in size or central in position. MELAKA-MANIPAL MEDICAL COLLEGE MALAYSIA MANI PAL U N I V E R SI T Y 118 AETIOLOGY Heredity Maternal Malnutrition Infections like rubella, CMV, toxoplasmosis & Syphilis Drugs Radiation Fetal Anoxia – placental hemorrhage Metabolic diseases like hypocalcaemia & storage diseases. Birth trauma Malnutrition Idiopathic MELAKA-MANIPAL MEDICAL COLLEGE MALAYSIA MANI PAL U N I V E R SI T Y 119 MORPHOLOGICAL TYPES Punctate Zonular Fusiform (coralliform) Nuclear Coronary Anterior capsular (polar) Posterior capsular (polar) MELAKA-MANIPAL MEDICAL COLLEGE MALAYSIA MANI PAL U N I V E R SI T Y 120 MORPHOLOGICAL TYPES Punctate MELAKA-MANIPAL MEDICAL COLLEGE MALAYSIA MANI PAL U N I V E R SI T Y 121 MORPHOLOGICAL TYPES Zonular MELAKA-MANIPAL MEDICAL COLLEGE MALAYSIA MANI PAL U N I V E R SI T Y 122 SYMPTOMS Leucocoria (white pupil) Retinoblastoma Retrolental fibroplasia PPHV (persistent primary hypertrophic vitreous) Coat’s disease Toxocara infection Defective vision Nystagmus in bilateral cases Squint & Amblyopia in unilateral cases MELAKA-MANIPAL MEDICAL COLLEGE MALAYSIA MANI PAL U N I V E R SI T Y 123 MANAGEMENT Detailed History LAB INVESTIGATIONS (for bilateral non hereditary cataract) Blood Tests Biochemistry for sugar, calcium, & phosphorus. Red blood cell transferase & galactokinase levels TORCH & hepatitis B Urine Tests Presence of reducing substances (galactosaemia) Presence of amino acids ( Lowe syndrome) MELAKA-MANIPAL MEDICAL COLLEGE MALAYSIA MANI PAL U N I V E R SI T Y 124 MANAGEMENT Treatment depends upon Amount of opacity Density of cataract Bilaterality Age MELAKA-MANIPAL MEDICAL COLLEGE MALAYSIA MANI PAL U N I V E R SI T Y 125 MANAGEMENT Partial cataract Wait & watch (depends upon whether stationary or progressive) Mydriasis Total cataract Surgical removal of lens Lens aspiration Lensectomy Phacoemulsification MELAKA-MANIPAL MEDICAL COLLEGE MALAYSIA MANI PAL U N I V E R SI T Y 126 MANAGEMENT Optical rehabilitation IOL ( if child is more than 2 year old) PMMA Acrylic foldable Contact lens Glasses Treatment of amblyopia MELAKA-MANIPAL MEDICAL COLLEGE MALAYSIA MANI PAL U N I V E R SI T Y Scenario HOPI: Parents of a 1 year old child presented with complaints of observing a white mass in both the eyes since 3 months. They said that he does not focuses and is not able to locate and grasp objects given to him. The mother sometimes feels that one of the eye is deviating outwards. They had not observed any redness or watering in eyes. The pregnancy was uneventful. It was a full term normal delivery. The mother had not taken any drugs (particularly steroids). MELAKA-MANIPAL MEDICAL COLLEGE MANI PAL MALAYSIA U N I V E R SI T Y Ocular examination: Visual Acuity: BE: unable to take fixation, does not follow objects or grasp objects given to him MELAKA-MANIPAL MEDICAL COLLEGE MALAYSIA MANI PAL U N I V E R SI T Y IDENTIFY abnormal clinical findings in the following photo of the patient MELAKA-MANIPAL MEDICAL COLLEGE MALAYSIA MANI PAL U N I V E R SI T Y Examination of Eye Pupils: Equal, round and reactive to light, no APD External: Intermittent squint Sac Regurgitation test negative MELAKA-MANIPAL MEDICAL COLLEGE MALAYSIA MANI PAL U N I V E R SI T Y Slit Lamp: Lids and Lashes Normal both eyes Conjunctiva/Scl Normal both eyes era Cornea Clear both eyes,size normal Anterior Chamber Deep and quiet both eyes Iris Normal MELAKA-MANIPAL MEDICAL COLLEGE Lens white opacity in the centre in both eye MALAYSIA MANI PAL U N I V E R SI T Y Other ocular investigations: UNDER EUA Distant direct ophthalmoscopy MELAKA-MANIPAL MEDICAL COLLEGE MALAYSIA MANI PAL U N I V E R SI T Y Eye Exam. Cont Distant direct ophthalmoscopy Dark shadow against the red ophthalmoscopy fundal glow on distant direct Dilated Fundus Examination: RE No clear view of fundus. Disc seen hazily with 0.3 cup As best seen vessels and background appear normal No clear view of fundus. LE Disc seen hazily with 0.3 cup MELAKA-MANIPAL MEDICAL COLLEGE M Anormal NI PAL As best seen vessels and background appear U N I V E R SI T Y MALAYSIA Examination of Eye IOP (Applantation): RE:14mmHg LE: 12 mmHg B SCAN Posterior segment appears normal. WITH CLEAR VITROUS AND NORMAL ATTACHED RETINA BLOOD INVESTIGATIONS CHILD WAS DONES AND PAEDIATRIC REFERRAL OF TORCH PROFILE OF MOTHER MELAKA-MANIPAL MEDICAL COLLEGE MALAYSIA MANI PAL U N I V E R SI T Y 4.What type of cataract? ? MELAKA-MANIPAL MEDICAL COLLEGE MALAYSIA MANI PAL U N I V E R SI T Y 5.Spot Diagnosis MELAKA-MANIPAL MEDICAL COLLEGE MALAYSIA MANI PAL U N I V E R SI T Y 6.ECCE or ICCE? MELAKA-MANIPAL MEDICAL COLLEGE MALAYSIA MANI PAL U N I V E R SI T Y 138 8. TYPE OF CATARACT? MELAKA-MANIPAL MEDICAL COLLEGE MALAYSIA MANI PAL U N I V E R SI T Y 9.WHAT IS THE NAME OF COMPLICATION MELAKA-MANIPAL MEDICAL COLLEGE MALAYSIA MANI PAL U N I V E R SI T Y 10.Regarding early post operative complications after cataract surgery NOT TRUE 1. 2. 3. 4. 5. Hyphaema. Iris prolapse. Cystoid macular oedema Post operative Uveitis. Endophthalmitis. MELAKA-MANIPAL MEDICAL COLLEGE MALAYSIA MANI PAL U N I V E R SI T Y 141 THANK YOIU MELAKA-MANIPAL MEDICAL COLLEGE MALAYSIA MANI PAL U N I V E R SI T Y