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24 October 2013
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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Zonules
L e n s A n a t o m y
ciliary body
Lens
Zonules
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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
1. Capsule is a thick membrane, which is transparent, elastic, acellular- envelop, thick at anterior pre-equatorial region , thinnest at the posterior pole .
equator
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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.
2. Lens Epithelium It is a single layer of cells, lining the anterior capsule and extends to the equator.
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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 intoa. 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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The nucleus consists of, densely compacted lens fibres and it has higher refractive index than cortex.
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c a i f
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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 Intermediate cortex Superficial cortex
N U C L E U S
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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
( erect Y )
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Function of the Lens ,and its 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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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
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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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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Ans :- 4) Zonules
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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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Sub-luxation
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Dis-location
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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 1.The degeneration and opacification of existing lens fibres, 2.formation of aberrant lens fibres 3.deposition of other material in their place.
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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.
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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.
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Abnormal products of metabolism, drugs or metals can be deposited in storage diseases ( Fabry ),
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1.Hydration
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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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
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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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1. Diabetes -Senile cataract is accelerated -True diabetic cataract: associated with over-hydration. Results in bilateral snowflake posterior or anterior subcapsular opacities
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2. Galactosemia- multifocal white flakes are seen in lens (inborn error of galactose metabolism) 3. Wilsons disease green sunflower cataract (inborn error of copper metabolism)
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-Steroids: systemic cause more cataract than topical. causes anterior and posterior subcapsular lens opacities. -Chlorpromazine: causes anterior lens capsule 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)
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G. Syndromes associated with cataract Downs ( mental retardation ) anterior, posterior subcapsular cataract Lowes ( oculo-cerebro-renal ) total cataract Wilsons 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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3.After Cataract
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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
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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
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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
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Anterior Subcapsular
2009 - 2010
Posterior Subcapsular
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Anterior Subcapsular
(Glaukomfleckens)
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3. Nuclear Cataract
-Age-related -Congenital: Rubella, Galactosemia
Nuclear Cataract
2009 - 2010
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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
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2009 - 2010
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5. Lamellar Cataract
-Congenital. Involves one lamella of the fetal or nuclear zone
2009 - 2010
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6. Sutural Cataract
-Congenital -Very common -Y-shaped opacity in the lens nucleus -No clinical significance
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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).
2009 - 2010
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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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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 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
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3.
Immature Cataract
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
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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
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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
-Cortex is totally opaque
Cortical
2009 - 2010
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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
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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 its position with position of head.
2009 - 2010
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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
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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.
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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
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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
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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
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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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Sac Syringing
IOT
Other investigations
Urine and Blood Test B.P. and ECG with Physicians fitness Anaethetists examination and fitness
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