Mata Tenang Visus Turun

Perlahan
ALI MUSTAGI
I11108022
Topik
• Katarak
• Glaukoma
• Retinopati
katarak
Definition
• A cataract is present when the transparency of
the lens is reduced to the point that the
patient’s vision impaired
Classification
• Congenital and developmental cataract
– a result of developmental disturbance of lens during
the process of development of the fetus
• Aquired cataract
– Senile cataract; age related cataract
– Traumatic cataract; eye trauma cause lens opacities
– Complicated cataract; due to ocular inflammation or
degeneration affects lens metabolism
– Metabolic cataract; metabolic disturbance
– Toxic cataract; drugs and chemicals that induce
cataracts
Causes
• Age
• Hereditery
• DM
• UV Rays
• Toxic
Aquired Cataract
Age related/Senile Cataract
• Clinical findings
– Symptom :
Progressively blurred
vision
– Types : According to
the place of opacity
appear first
• Subcapsular cataract
• Nuclear Cataract
• Cortical Cataract
Subcapsular cataract
• Nodal point effect on vision, troubled by
glare, headlights from incoming cars
• 2 types of subcapsular cataract
– Anterior subcapsular : lies directly under the lens
capsule, associated with fibrous metaplasia of
the lens epithelium
– Posterior subcapsular : lies in front of the
posterior capsule, has granular or plaque-like
appearance on slit lamp. Typically appears black
and vacuolated on retroillumination
Subcapsular cataract
A. Posterior subcapsular, granular or plaque
like appearance
B. Black and vacuolated on retroillumination

Bowling B. Kanski's Clinical Ophtalmology; A Systematic

Approach, Eight Edition. 2016. Elsevier: Sydney, Australia
Nuclear sclerotic cataract
• Exaggeration of normal ageing change
• Associated with myopia – increase in the
refractive index of the nucleus
• Characterized by a yellowish hue –
deposition of urochrome pigment
Nuclear sclerotic cataract
C. Yellowish hue
D. Appearance of brown and black in nucleus

Bowling B. Kanski's Clinical Ophtalmology; A Systematic

Approach, Eight Edition. 2016. Elsevier: Sydney, Australia
 Cortical cataract
• May involve • Cuneiform
the anterior, (wedge-
posterior or shaped)
equatorial appearance
cortex

Bowling B. Kanski's Clinical Ophtalmology; A Systematic

Approach, Eight Edition. 2016. Elsevier: Sydney, Australia
Cataract maturity
Cataract maturity
• Immature cataract is one in which the lens is
partially opaque
• Mature cataract is one in which the lens is
completely opaque
• Hypermature cataract has a shrunken and
wrinkled anterior capsule due to leakage of
water out of the lens
• Morgagnian catcaract is a hypermature cataract
in which liquefaction of the cortex has allowed
the nucleus to sink inferiorly
Cataract maturity
A. Mature cataract
B. Hypermatur cataract
C. Morgagnian cataract
Cataract in systemic disease
Cataract in systemic disease - DM
• Hyperglycaemia is reflected in a high level of
glucose in aqueous humour, diffuses into the
lens
• Glucose sorbitol affect the
refractive index of the lens cortical
fluid vacuoles develop and evolve into frank
opacities
• Diabetic cataract – snowflake cortical
opacities
Cataract in systemic disease – DM (1)
• Diabetic cataract –
snowflake cortical
opacities

Bowling B. Kanski's Clinical Ophtalmology; A Systematic

Approach, Eight Edition. 2016. Elsevier: Sydney, Australia
Cataract in systemic disease – Myotonic dystrophy

• 90% patient with

myotonic dystrophy –
iridescent cortical
opacities in the third
decade
• Star-like
conformation by the
fifth decade
Bowling B. Kanski's Clinical Ophtalmology; A Systematic
Approach, Eight Edition. 2016. Elsevier: Sydney, Australia
Cataract in systemic disease – Atopic dermatitis

• 10% of patient with • Shield-like dense

severe atopic anterior subcapsular
dermatitis – develop plaque
cataract in the
second to fourth
decades
• Bilateral, mature
quickly

Bowling B. Kanski's Clinical Ophtalmology; A Systematic

Approach, Eight Edition. 2016. Elsevier: Sydney, Australia
Secondary cataract
Chronic anterior uveitis
• The most common cause
• Polychromatic lustre at the posterior pole of
the lens
• Inflammation – posterior and anterior
opacities develop
• Posterior synechiae – progress more rapidly
Chronic anterior uveitis (1)
A. Polychromatic luster
B. Posterior and anterior opacities
C. Posterior synechiae

Bowling B. Kanski's Clinical Ophtalmology; A Systematic

Approach, Eight Edition. 2016. Elsevier: Sydney, Australia
Acute congestive angle closure
• Grey white
subcapsular or
capsular opacities,
glaukomflecken
High myopia
• High myopia can be
associated with
posterior subcapsular
lens opacities
• Can increase the
myopic refractive
error
Hereditary fundus dystrophies
• Posterior, less
commonly anterior
subcapsular lens
opacities
• Cataract surgery –
improve visual
function – several
retinal changes
Traumatic cataract
Traumatic cataract
A. Penetrating trauma
B. Blunt trauma –
flower shaped
opacity
C. Electrical shock –
diffuse milky-white
opacification,
multiple snowflake-
like oppacities
D. Infrared radiation
E. Ionizing radiation
Management of cataract
• Medical management – surgery
• Indication for surgery
– Visual improvement, difficulty in performing
essential daily activities
• Microsurgical techniques is employed for all
cataract surgery
Management of cataract (1)
• Lens surgery
– Intracapsular cataract extraction (ICCE)
– Extracapsular cataract extraction (ECCE)
– Phacoemulsification (Phaco)
ICCE ECCE
 Large incision (>10 mm)  Smaller incision (5 or 6 mm or less)
 Requires sutures  Self-sealing no sutures with
“tunnel” technique
 Removes lens rewuiring spectacle of  IOL placement maintains optical
contact lens correction correction
 High rate of lost glasses (56% first  Lower rate of post operation retinal
year in Nepal) detachment
 Higher incidence of post operation
retinal detachment
Management of cataract (2)
A. Povidone iodine 5%
conjunctival fornix
instillation
B. Cleaning the skin with
povidone iodine
C. Plastic drape and speculum
isolating the operation field
from the eyelids
Management of cataract (3)
A. Corneal incision
B. Capsulorhexis
C. Hydrodissection
D. Cracking the nucleus
E. Phaco and
aspirationof nuclear
F. Cortical aspiration
using bimanual
automated technique
Glaucoma
Definition and classification
• Increased intraocular pressure – damages
the optic nerve
• Leads to blindness in the affected eye
– Primary glaucoma – not caused by other ocular
disorder
– Secondary glaucoma – result of another ocular
disorder side effect of medication or other
therapy
 Glaucoma

Movement of
the fluid in the
eye
Pathophisiology
• The aqueous humor is formed by the ciliary
processes and secreted into the posterior
chamber of the eye
• 2 Physiologic Resistance of Aqueos Flow:
– 1st Resistance: Pupil  Closed-Angle
– 2nd Resistance: Trabecular Meshwork  Open-Angle
Classification
• Glaucoma Primary
(unknown etiology)
– Closed angle glaucoma
– Acute congestive
glaucoma
• Glaucoma Secondary
(caused by another
diseases)
– Abnormality lens
– Abnormality uvea
– Trauma
– Surgery
– And the other
• Glaucoma congenital
Examination
• Measuring Intraocular Pressure
–Palpation
–Schiotz Indentation Tonometry
–Applanation tonometry
–Pneumatic non – contact tonometry
Palpation
• Palpation
– If the examiner can
indent the eyeball,
which fluctuates under
palpation, pressure is
less than 20 mmHg.
– An eyeball that is not
resilient but rock hard
is a sign of about 60–70
mmHg of pressure
(acute angle closure
glaucoma).
 Schiotz indentation tonometry

The lower the intraocular

pressure, the deeper the
tonometer pin sinks and
greater distance the needle
moves
Applanation tonometry
– most common method
of measuring
intraocular pressure
– A flat tonometer tip
has a diameter of 3.06
mm for applanation of
the cornea over a
corresponding area
(7.35 mm2).
– This method
eliminates the rigidity
of the sclera as a
source of error
Pneumatic non-contact tonometry
• The tonometer records the deflection of the
cornea and calculates the intraocular
pressure on the basis of this deformation
Optic disc ophtalmoscopy
• In the presence of persistently elevated
intraocular pressure, the optic cup becomes
enlarged and can be evaluated by
ophthalmoscopy
• The optic nerve is the eye’s “glaucoma
memory.”
• Evaluating this structure will tell the examiner
whether damage from glaucoma is present
and how far advanced it is.
Optic disc ophtalmoscopy (1)
Glaucomatous changes in the optic nerve
• Glaucoma produces typical changes in the
shape of the optic cup.
• Progressive destruction of nerve fibers,
fibrous and vascular tissue, and glial tissue
will be observable.
• This tissue atrophy leads to an increase in
the size of the optic cup and to pale
discoloration of the optic disk
Glaucomatous changes in the optic nerve (1)
Visual field testing
• Detecting glaucoma as early as possible
requires documenting glaucomatous visual
field defects at the earliest possible stage
• Glaucomatous visual field defects initially
manifest themselves in the superior
paracentral nasal visual field or, less
frequently, in the inferior field, as relative
scotomas that later progress to absolute
scotomas
Visual field testing (1)
Trias Glaucoma
Based on methods before, there are 3 major
Exam Results appoint to Glaucoma
• Raise of Intra Ocular Pressure
• Optic Nerve Change
• Defect on Visual Field
Treatment
Treatment (1)
• Open Angle Glaucoma
– Argon laser trabeculoplasty : burns in the
trabecular meshwork cause tissue contraction
that widens the intervening spaces and improves
outflowthrough the trabecular meshwork
• Primary Angle Closure Glaucoma
– An acute glaucoma attack : EMERGENCY
– Requires surgical treatment, initial therapy is
conservative
Treatment (2)
• Childhood glaucoma
– Treated surgically
– Prognosis improves the earlier surgery is
performed
• Goals of conservative therapy
– Decrease intraocular pressure
– Allow the cornea to clear
– Relieve pain
– Surgical management
Retinophaty
Diabetic Retinopathy
• Is an ocular microangiopathy
• One of the main cause of aquired blindness
in the industrialized countries
Diabetic Retinopathy (1)
Diabetic Retinopathy (2)
Diabetic Retinopathy (3)
Diabetic Retinopathy (4)
Treatment
• Clinically significant macular edema, macular
edema that threatens vision, is managed
with focal laser treatment at the posterior
pole. Proliferative diabetic retinopathy is
treated with scatter photocoagulation
performed in three to five sessions
Treatment
Hipertensive retinopathy
• High blood pressure – breakdown the blood
retina barrier, obliteration of capillaries
• Symptoms :
• Differential diagnosis : Diabetic retinopathy
(parenchymal and vascular change),
ophtalmoscopy should be performed
– High blood pressure : headache, eye pain,
impaired vision, loss of visual acuity (stage III or
IV)
Hipertensive retinopathy (1)
Hipertensive retinopathy (2)
Hipertensive retinopathy (3)
Hipertensive retinopathy (4)
Treatment
• Blood pressure should be reduced to below
140/90mm Hg
• Fundus changes due to arteriosclerosis are
untreat-able
Retinopathy of Prematurity
• A retinal disorder attributable to disruption
of normal development of the retinal
vasculature in preterm infants with birth
weight less than 2500g
• Preterm birth, exposure to oxygen – disturbs
the normal development of the retinal
vasculature
• Neovascularization – retinal detachment,
vitreous hemorrhage
Retinopathy of Prematurity (1)
Retinopathy of Prematurity (2)
Diagnostic consideration
• Retina should be examination with the pupil
dilated four weeks after a birth athe latest
• Routine examination of the newborn
• Follow up examinations will depend on the
degree of retinal vascularization
Treatment
• Stage IV and V : Surgery is rarely succesful
• Stage III : Laser photocoagulation,
cryoteeraphy is performed in the
nonvascularized portion of the retina
Thank You