OVERVIEW

Cataracts are changes in clarity of the natural lens inside the eye that gradually degrade visual quality. The natural lens sits behind the colored part of the eye (iris) in the area of the pupil, and cannot be directly seen with the naked eye unless it becomes extremely cloudy. The lens plays a crucial role in focusing unimpeded light on the retina at the back of the eye. The retina transforms light to a neurologic signal that the brain interprets as vision. Significant cataracts block and distort light passing through the lens, causing visual symptoms and complaints.

The lens is a portion of the eye that is normally clear. It assists in focusing rays of light entering the eye onto the retina, the light-sensitive tissue at the back of the eye. In order to get a clear image onto the retina, the portions of the eye in front of the retina, including the lens, must be clear and transparent. Once light reaches the retina, the light initiates a chemical reaction within the retina. The chemical reaction, in turn, initiates an electrical response which is carried to the brain through the optic nerve. The brain then interprets what the eye sees. In a normal eye, light passes through the transparent lens to the retina. The lens must be clear for the retina to receive a sharp image. If the lens is cloudy from a cataract, the image striking the retina will be blurry and the vision will be blurry. The extent of the visual disturbance is dependent upon the degree of cloudiness of the lens.

The term cataract is derived from the Greek word cataractos, which describes rapidly running water. When water is turbulent, it is transformed from a clear medium to white and cloudy. Keen Greek observers noticed similar-appearing changes in the eye and attributed visual loss from "cataracts" as an accumulation of this turbulent fluid, having no knowledge of the anatomy of the eye or the status or importance of the lens.

PREVALENCE
Cataract development is usually a very gradual process of normal aging but can occasionally occur rapidly. Many people are in fact unaware that they have cataracts because the changes in their vision have been so gradual. Cataracts commonly affect both eyes, but it is not uncommon for cataracts in one eye to advance more rapidly. Cataracts are very common, affecting roughly 60% of people over the age of 60, and over 1.5 million cataract surgeries are performed in the United States each year. Experts have estimated that visual disability associated with cataracts accounts for over 8 million physician office visits a year in the United States. This number will likely continue to increase as the proportion of people over the age of 60 rises. When people develop cataracts, they begin to have difficulty doing activities they need to do for daily living or for enjoyment. Some of the most common complaints include difficulty driving at night, reading, participating in sports such as golfing, or traveling to unfamiliar areas; these are all activities for which clear vision is essential.

CAUSES

The lens is made of mostly water and protein. The protein is arranged in a specific way that keeps the lens clear and allows light to pass through it to focus a clear image onto the retinal surface. As we age, some of the protein may clump together and start to cloud a small area of the

lens. This is our understanding of the cause of an age-related cataract. Over time, the cataract may become more dense or cloud more of the lens, making it more difficult to see through. A cataract is not a growth or tumor. There are many causes of non age-related cataracts or secondary cataracts. Secondary cataracts are a result of similar changes to the protein of the lens, also resulting in visual blurring or visual loss. Blunt or penetrating injury to the eye may cause secondary cataracts, either immediately after the injury or some weeks to years afterward. A cataract following an injury may appear and then not increase in density (be stationary) or be progressive. Eye surgery for other conditions can also cause cataracts. Excessive exposure to ionizing radiation (X-ray), infrared radiation (as in glass blowers), or ultraviolet radiation cause secondary cataracts. Diabetes is associated with the development of secondary cataracts. Inflammatory disease of the eye, such as iritis or uveitis, may cause or accelerate the development of cataract in the involved eye. There are many genetic illnesses that are associated with the development of secondary cataracts. These include myotonic plus dystrophy, many others. galactosemia, Congenital homocystinuria, Wilson's infections with herpes

disease and Down

syndrome,

simplex, rubella, toxoplasmosis, syphilis, and cytomegalic inclusion disease may also result in cataracts. There are many medications which, when taken over a long period of time, can cause secondary cataracts. The most common of these are oral corticosteroids, such as prednisone, which are used for a wide variety of medical conditions. The term "congenital cataract" is used when a baby is born with any clouding of the lens. This may be present in one or both eyes, be stationary or be progressive. Causes include genetic disorders or intrauterine developmental disorders, both often associated with other physical abnormalities of the baby. Atopic dermatitis, other diseases of the skin and mucous membranes,hypothyroidism, and hyperparathyroidism are associated with the early development of cataracts. Patients who develop cataracts in both eyes at an early age often have family members who have also developed cataracts prematurely, implying a genetic cause, even in the absence of a recognized underlying disease.

RISK FACTORS
AGING Loss of lens transparency Clumping or aggregation of lens protein(leads to light scattering) Accumulation of a yellow-brown pigment due to the breakdown of lens protein Decreased oxygen uptake Increase in sodium and calcium Decrease in levels of Vitamin C, protein and glutathione ASSOCIATED OCULAR CONDITIONS Retinitis Pigmentosa Myopia Retinal Detachment and retinal surgery Infection (e.g. herpes zoster, uveitis) TOXIC FACTORS Corticosteroisds, especially at high doses and in long-term use Alkaline chemical eye burns, poisoning Cigarette Smoking Calcium, copper, iron, gold, silver, and mercury, which tend to deposit in the pupillary area of the lens NUTRITIONAL FACTORS

 Reduced levels of antioxidants Poor nutrition obesity PHYSICAL FACTORS Dehydration Blunt Trauma UV radiation in sunlight and x-ray SYSTEMIC DISEASES AND SYNDROMES Diabetes Mellitus Down Syndrome Disorders related to Lipid Metabolism Renal Disorders Musculoskeletal disorders

TYPES OF CATARACTS
Traumatic cataract results from a perforating wound of the capsule of the lens. The entire lens becomes opaque, and a portion usually remains so; but at times, unless inflammation of other portions follows, the cloudiness entirely disappears. Congenital cataract is due to an intrauterine infection, chromosomal disorder, or metabolic disease that causes imperfect development or inflammation Congenital cataract may occur because the mother had rubella during pregnancy. Other problems during pregnancy can also cause cataract. Sometimes congenital cataract is an independent problem, but it can also be part of another syndrome.

Juvenile cataract may be hereditary. The lens is soft and white in both congenital and juvenile cataracts. Both are treated by needling, an operation in which a needlelike knife or a laser beam is used to cut and break up the lens. The injured lens tissue is then absorbed by the body. Juvenile and adult cataracts can also be caused by exposure to radiation and by drugs such as glucocorticoids. Senile cataract, the most common form, usually occurs in people over 50 years of age and generally involves both eyes. It may also occur at a younger age in people with diabetes mellitus. Beginning in the form of dark streaks extending from the periphery toward the center of the lens, or as spots in any portion, it eventually makes the entire lens opaque. As the fluid of the lens is absorbed, the lens becomes easily separated from its capsule and is considered mature, or ripe for operation. Later, if not extracted, the lens undergoes degenerative changes, or liquefies, and the capsule becomes thickened and opaque, making the results of operation less satisfactory. The only method of relieving senile cataract is extraction of the lens. Sight can be restored in most instances by wearing special eyeglasses or contact lenses or by a surgeon implanting an artificial lens in the affected eye. Cataract removal is one of the most common surgeries in the United States, with over 1.5 million cataract surgeries performed each year. In about 90 percent of cases, people who have cataract surgery have better vision afterward. A cataract may develop in any of these areas and is described based on its location in the lens:

A nuclear cataract is located in the center of the lens. The nucleus tends to darken changing from clear to yellow and sometimes brown.

A cortical cataract affects the layer of the lens surrounding the nucleus. It is identified by its unique wedge or spoke appearance.

A posterior capsular cataract is found in the back outer layer of the lens. This type often develops more rapidly.

Types of Cataracts

Nuclear cataract 2009 Eyemaginations, Inc.

Cortical cataract

Posterior capsular cataract

CATARACT SYMPTOMS
Having cataracts is often compared to looking through a foggy windshield of a car or through the dirty lens of a camera. Cataracts may cause a variety of complaints and visual changes, including blurred vision, difficulty with glare (often with bright sun or automobile headlights while driving at night), dulled color vision, increased nearsightedness accompanied by frequent changes in eyeglass prescription, and occasionally double vision in one eye. Some people notice a phenomenon called "second sight" in which one's reading vision improves as a result of their increased nearsightedness from swelling of the cataract. A change in glasses may help initially once vision begins to change from cataracts; however, as cataracts continue to progress and opacify, vision becomes cloudy and stronger glasses or contact lenses will no longer improve sight. Cataracts are usually gradual and usually not painful or associated with any eye redness or other symptoms unless they become extremely advanced. Rapid and/or painful changes in vision are suspicious for other eye diseases and should be evaluated by an eye-care professional. Cataracts can be diagnosed through a comprehensive eye examination. This examination may include:

Patient history to determine vision difficulties experienced by the patient that may limit their daily activities and other general health concerns affecting vision.

Visual acuity measurement to determine to what extent a cataract may be limiting clear vision at distance and near.

Refraction to determine the need for changes in an eyeglass or contact lens prescription. Evaluation of the lens under high magnification and illumination to determine the extent and location of any cataracts.

Evaluation of the retina of the eye through a dilated pupil. Measurement of pressure within the eye. Supplemental testing for color vision and glare sensitivity. Additional testing may be needed to determine the extent of impairment to vision caused

by a cataract and to evaluate whether other eye diseases may limit vision following cataract surgery.

PATHOPHYSIOLOGY
Cataract formation is characterized chemically by a reduction in oxygen uptake and an initial increase in water content followed by dehydration of the lens. Sodium and calcium contents are increased; potassium, ascorbic acid, and protein contents are decreased. The protein in the lens undergoes numerous age-related changes, including yellowing from formation of fluorescent compounds and molecular changes. These changes, along with the photoabsorption of ultraviolet radiation throughout life, suggest that cataracts may be caused by a photochemical process. Cataracts progress through the following clinical stages of development: IMMATURE CATARACTS are not completely opaque, and some light is transmitted through them, allowing useful vision. MATURE CATARACTS are completely opaque. The former term for this stage was ripe. Vision is significantly reduced. INTUMESCENT CATARACTS are those in which the lens absorbs water and increases in size. The lens may be mature or immature. The increases in size may result in glaucoma.

HYPERMATURE CATARACTS are those in which the lens proteins breakdown into shortchain polypeptides that leak-out through the lens capsule. The pieces of protein are engulfed by macrophages, which may obstruct the trabecular meshwork, causing phacolytic glaucoma.

MEDICAL MANAGEMENT
No non-surgical treatment cures cataract. Ongoing studies are investigating ways to slow cataract progression such as intake of antioxidants (e.g. vitamin C, beta-carotene, Vitamin E). in the early stages of cataract development, glasses, contact lenses, strong bifocals, or magnifying lenses may improve vision. Reducing glare with proper light and appropriate lighting can facilitate reading. Mydriatics can be used as short-term treatment to dilate the pupil and allow more light to reach the retina, although this increases glare.

SURGICAL MANAGEMENT
INTRACAPSULAR CATARACT EXTRACTION (ICCE) From the late 1800s until the 1970s, the technique of choice for cataract extraction was intracapsular cataract extraction (ICCE). The entire lens (i.e. nucleus, cortex and capsule) is removed and fine sutures close the incision. ICCE is infrequently used today; however it is indicated when there is a need to remove the entire lens, such as Subluxated cataract (i.e. partially or completely dislocated lens) EXTRACAPSULAR CATARACT EXTRACTION (ECCE) ECCE achieves the intactness of smaller incisional wounds and maintenance of the posterior capsule of the lens, reducing postoperative complications, particularly aphakic retinal detachment and cystoids macular edema. A portion of the anterior capsule is removed, allowing extraction of the lens nucleus and cortex. The posterior capsule and zonular support are left intact. An intact zonular-capsule diaphragm provides for needed safe and anchor for the posterior chamber intraocular lens (IOL). After the pupil is dilated and the surgeon has made a

small incision on the upper edge of the cornea, a viscoelastic substance is injected into the space between the cornea and lens. This prevents the space from collapsing and facilitates insertion of the IOL. PHACOEMULSIFICATION

Phaco-emulsification. The natural crystalline lens is pulverized and removed by suction. The small bag remains.

Uses an ultrasonic device that liquefies the nucleus and cortex which are then suctioned out through a tube. Posterior capsule is left intact. Because the incision is even smaller than the standard ECCE, the wound heals more rapidly, and there is early stabilization of refractive error and less astigmatism. Hardware and software advances in ultrasonic technologyincluding new phaco needles that are used to cut and aspirate the cataract-permit safe and efficient removal of nearly all cataracts through a clear cornea incision that is as small or smaller than required for available foldable lenses. Ultimately, advances in technology will achieve an injectable IOL. LENS REPLACEMENT After removal of the crystalline lens, the patient is referred to as aphakic (i.e. without lens). The lens, which focuses light on the retina, must be replaced for the patient to see clearly. There are three lens replacement options: aphakic eyeglasses, contact lenses, and IOL Implants. Aphakic glasses are effective but heavy. Objects are magnified by 25% making them appear closer that they actually are. Objects are magnified unequally, creating distortion, peripheral vision is also limited and binocular vision is impossible if the other eye is phakic. Contact lenses provide patients with almost normal vision, but because contact lenses need to be removed occasionally, the patient also needs a pair of aphakic glasses. Contact lenses

ae not advised for patients who have difficulty inserting, removing and cleaning them. Frequent handling and improper disinfection increase the risk for infection. Insertion of IOL during cataract surgery is the usual approach to lens replacement. After ICCE, the surgeon implants an anterior chamber IOL in front of the iris. Posterior chamber lenses, generally used in ECCE, are implanted behind the iris. ECCE and posterior chamber IOLs are associated.

CATARACT TREATMENT ILLUSTRATION:

The opaque lens blocks off the light that enters the eye.

The capsular bag containing the natural crystalline lens is opened up.

Using a phaco, the natural crystalline lens is pulverized and aspirated. The remnants are carefully removed until the capsular sac is completely clean again.

The artificial lens is implanted into the capsular bag.

The artificial lens is carefully positioned in front of the pupil.

After lens implantation, light can enter the eye once more optimally.

CARE AFTER CATARACT REMOVAL

Leave the eye patch in place For 24 hours, limit your activity to sitting in a chair, resting in bed and walking to your bathroom Do not rub your eye You can wear your glasses Do not lift more than 5 pounds

 Do not strain Do not sleep on the side of the body that was operated on. Take your eye drops Take acetaminophen as needed Do not take aspirin Report any part of pain that is unrelieved, redness around the eye and nausea and vomiting Wear eye shield to protect your eye