CASE REPORT DIABETIC CATARACT and PRESBYOPIA

MARIA SUPRIYATI SINDE I11108059

Introduction
Old age is accompanied by a number of

pathological eye conditions. Etiologically, the most common types of cataract are those associated with aging and diabetes. Cataractogenesis is one of the earliest secondary complications of diabetes mellitus. Diabetic patients are about 60% more likely to develop these eye conditions.

CASE

Anamnesis
Patient identity Name : Mrs. M Sex : Female Age : 53 years old Address : Jalan Imam Bonjol Gg. H. Mursyid Ethnic : Bugis Job : IRT Religion : Moslem No.MR : 514902 Patient was examined on July 20rd, 2012

Anamnesis
CHIEF COMPLAINT:
Blurred vision in both of eyes

Anamnesis
HISTORY OF DISEASE: Patient complained feel blurred in both of her eyes since 1 years ago, and it became worse since 4 month ago. Patient told that her right eye feel more blurred than the left eye. She told that she feel blurred vision when reading and also when looking things at distance. She did not complained for redness, swelling, itching, discharge/drainage, a sense that something is in the eye, increased or decreased tearing or other ocular complaints. She claimed, that she never feel pain in both of

Anamnesis
PAST CLINICAL HISTORY:
She did not experience any trauma of the eyes and

never had any eyes complaint before. She got the eyedrops from the alternative medicine seller, that was believed to heal any eye diseases, but the patient did not feel any improvement for her visual acuity. She also said that she does not have allergic reaction and never experienced any surgery. She told that she never use a glasses.

Anamnesis
PAST CLINICAL HISTORY:
Patient told that there is no history of the same

symptoms before. Patient had history of diabetic mellitus, but she did not know when the diabetic mellitus began. She knew that she had a diabetic mellitus in 2011 when her check blood sugar after she visit the internist. Now, she often visites to the doctor to control her blood sugar. She has a hypertension history, but rarely feel headache.

Anamnesis
FAMILY HISTORY :

According to the patient said that one

of her brother have complaining the same symptoms and her brother use a glasses.

General Physical Assessment

General condition

Awareness
Vital Signs:
Heart Rate

: Good : Compos mentis

: 85x/minute Respiration freq. : 22x/minute Blood Pressure : 150/100 mmHg Temperature : 36,8oC

Ophtalmology Status
Visual acuity (with Autorefractor and Snellen

Chart Test)
: 6/25 + 100 200 x 1000 6/10 OS : 6/20 125 x 900 6/10 OD/OS : add + 250
OD

Ophtalmologic Status

Ophtalmologic Status

Ophtalmologic Status
Eyeball Movement

Intraocular pressure (tonometry) : OD 15 mmHg,

OS 13 mmHg

Addition Examination
Random blood glucose level: 355 mg/dl (Patient

was examined on July 20th, 2012)

Resume
Mrs.M, 53 years old, complained that she feel in both

of her eyes since 1 years ago, and it became worse since 4 month ago. Patient told that her right eye feel more blurred than the left eye. She told that she feel blurred vision when reading and also when looking things at distance. She got the eyedrops from the alternative medicine seller, but the patient did not feel any improvement for her visual acuity. She also said that she does not have allergic reaction and never experienced any surgery. She told that she never use a glasses. Patient had history of diabetic mellitus and hypertension history. Her brother have complaining the same symptoms

Resume
Vital signs of this patient are in normal range

except blood pressure, she had a relatively high blood pressure namely 150/100. Random blood glucose level: 355 mg/dl Visual acuity of OD is 6/25, after pin hole test become 6/10. Visual acuity of OS is 6/20, after pin hole test become 6/10 and for OD/OS add 250. The lens OD and OS partially opaque. In fundus examination with dilated pupil, there are founding opacities in subcapsular (Snowflake).

Diagnose
WORKING DIAGNOSE:

OD

: Diabetic cataract and Presbyopia OS : Diabetic cataract and Presbyopia

Diagnose
DIFFERENTIAL DIAGNOSE : OD : - Diabetic retinopathy Hipertensive retinopathy OS : - Diabetic retinopathy Hipertensive retinopathy

Plan for examination

Slit lamp

Indirectly funduscopy
Glucose blood examination

Treatment
Non medicamentous: Education for the patient to control her blood glucose and blood presurre with diet. Use glasses With a diabetes mellitus and hypertensive history, the patient must do a screening. Educate patient to do an ocular examination at least once a year to prevent the progression of the disease.

Treatment
Medicamentous: vitamin for

patients eyes
Vitamin A Vitamin C Vitamin E Zink

Complications
Glaucoma

Prognosis
OD
Ad vitam: bonam Ad functionam: dubia

OS
Ad vitam : bonam Ad functionam : dubia

ad bonam Ad sanactionam: dubia ad bonam

ad bonam Ad sanactionam : dubia ad bonam

LITERATURE REVIEW

Eye Lens

Cataract
A cataract is present when the transparency of

the lens is reduced to the point that the patients vision is impaired. Patients experience the various symptoms such as seeing only shades of gray, visual impairment, blurred vision, distorted vision, glare or star bursts, monocular diplopia, altered color perception, etc.

Cataract
Classification of cataracts according to

time of occurrence:
Acquired cataracts (over 99% of all

cataracts) Senile cataract (over 90% of all cataracts), Cataract with systemic disease, Secondary and complicated cataracts, Postoperative cataracts, Traumatic cataracts, and Toxic cataract Congenital cataracts (less than 1% of all cataracts) Hereditary cataracts and Cataracts due to early embryonic (transplacental) damage.

Diabetic Cataract
The possibility of diabetes should be

considered in all patients with unexplained retinopathy, cataract, extraocular muscle palsy, optic neuropathy, or sudden changes in refractive error. The typical diabetic cataract is rare in young diabetic patients. Transient metabolic decompensation promotes the occurrence of a typical radial snowflake pattern of cortical opacities (snowflake cataract).

Diabetic Cataract
Diabetic cataract progresses rapidly.

Senile cataracts are observed about five times as

often in older diabetics as in patients the same age with normal metabolism. These cataracts usually also occur two to three years earlier.

Diabetic Cataract
Th ere are two clasification:
True Diabetic Cataract (Rare)

Bilateral cataracts occasionally occur with a rapid onset in severe juvenile diabetes. The lens may become completely opaque in several weeks. Senile Cataract in the Diabetic (Common) Typical senile nuclear sclerosis, posterior subcapsular changes, and cortical opacities occur earlier and more frequently in diabetics.

Diabetes mellitus as a risk factor for cataract development

Chronic elevation of blood glucose in diabetes

plays a critical role in the development and progression of major diabetic complications. The injurious effects of hyperglycemia are characteristically observed in tissues that are not dependent on insulin for glucose entry into the cell (e.g., eye lens, kidneys) and, hence, they are not capable of down-regulating glucose transport along with the increase of extracellular sugar concentrations.

Pathogenesis of Diabetic Cataract

The enzyme aldose reductase (AR) catalyzes

the reduction of glucose to sorbitol through the polyol pathway, a process linked to the development of diabetic cataract. The intracellular accumulation of sorbitol leads to osmotic changes resulting in hydropic lens fibers that degenerate and form sugar cataracts. Multiple mechanisms that have been proposed to explain how hyperglycemia might cause these abnormalities (cataract development) nonenzymatic glycation; oxidative stress; and polyol pathway.

Pathogenesis of Diabetic Cataract

In the lens, sorbitol is produced faster than it

is converted to fructose by the enzyme sorbitol dehydrogenase. In addition, the polar character of sorbitol prevents its intracellular removal through diffusion. The increased accumulation of sorbitol creates a hyperosmotic effect that results in an infusion of fluid to countervail the osmotic gradient. The intracellular accumulation of polyols leads to a collapse and liquefaction of lens fibers,

Pathogenesis of Diabetic Cataract

Osmotic stress in the lens caused by sorbitol

accumulation induces apoptosis in lens epithelial cells (LEC) leading to the development of cataract. These findings show that impairments in the osmoregulation may render the lens susceptible to even small increases of Armediated osmotic stress, potentially leading to progressive cataract formation.

Pathogenesis of Diabetic Cataract

The polyol pathway has been described as the

primary mediator of diabetes-induced oxidative stress in the lens.

Presbyopia
The loss of accommodation that comes with

aging to all people is called presbyopia.

Presbyopia
Presbyopia is corrected by use of a plus

lens to make up for the lost automatic focusing power of the lens. Reading glasses have the near correction in the entire aperture of the glasses, making them fine for reading but blurred for distant objects.

Presbyopia
Symptoms of presbyopia include:
Blurred vision at a normal reading distance. The need to hold reading material at arm's length. Headaches or fatigue from doing close work.

Presbyopia
People with presbyopia usually need treatment

for both close up vision and distance vision. Eyeglasses and contacts are the obvious choice. A few surgical techniques are available with several still under testing and trials. Current surgery for presbyopia includes Laser assisted in situ keratomileusis, or LASIK, and CK, Conductive keratoplasty.

DISCUSSION

 Mrs.M, 53 years old, complained that she feel

blurred in both of her eyes since 1 years ago, and it became worse since 4 month ago. Blurred vision is defined as the blurring of vision or images. The blurred vision is because the abnormality of the optical media. Cataractous lenses are characterized by protein aggregates that scatter light rays and reduce transparency. Genetic, metabolic, nutritional, and environmental insults and ocular and systemic diseases cause cataracts by affecting lens clarity.

 She feel the left eye has a more blurred vision. From the eye examination, it found that the visual

aquity of her both eyes had been decreased.

Visual acuity of OD is 6/25, with the changes after pin

hole test and correctional refraction became 6/10.

Visual acuity of OS is 6/20, with the changes after pin

hole test and correctional refraction became 6/10. And aaditional lens for OD and OS is + 250.
This decreased visual aquity can be corrected by a

common correctional refraction. Presbyopia is generally believed to stem from a gradual loss of flexibility in the natural lens inside your eye although changes in the lens's curvature from continual growth and loss of power of the ciliary muscles (the muscles that bend and

 But she still felt blurred in her vision.

This condition can happen due to the

opacitification of her lens that can be seen by an examination using the loop. Normally, crystalline lens has a transparent structure. Its transparency may be disturbed due to degenerative process leading to opacification of lens fibres. Development of an opacity in the lens is known as cataract. The loss of lens transparency can result in blurred vision for both near and distance objects,

 Patient had history of diabetic mellitus (Random blood

glucose level: 355 mg/dl ) They are more prevalent with longer duration of the diabetes, occur earlier, and progress more rapidly than other age-related cataracts. Many mechanisms are involved and include sorbitol accumulation. Hyperglycemia causes glucose to diffuse into the lens where it is converted to sorbitol by the enzyme aldose reductase. The cell membrane is impermeable to sorbitol, therefore it accumulates in the lens fiber. Diabetes was also related to posterior subcapsular opacities. Glycated hemoglobin levels were positively associated

 Patient had history of hypertension (Blood Presure

: 150/100 mmHg) The Framingham eye study found an association of high systolic blood pressure and senile cataract, while Clayton et al reported a significant relationship with high diastolic blood pressure. Barbados eye study7 suggested that a diastolic blood pressure of more than 95 mmHg was related to an increased risk of opacities.

 The working diagnose of this patient eye is Diabetic

cataract and Presbyopia. The predispotition factor of the cataract is her diabetic mellitus history than can lead to an earlier onset of senile catarract. Persons with diabetes mellitus are at higher risk for cataracts, and persons with diabetes who have cataracts have a higher morbidity than those without cataracts.

 Recomended therapy for this patient includes

nonmedicamentous such as:

education for the patient to control her blood glucose

and blood presurre by a diet and do the light exercise regularly to prevent the progression of the diseases. With a diabetes mellitus and hypertensive history, the patient must do a screening. As a clinician, we must educate patient to do an ocular examination at least once a year to prevent the progression of the disease and also to earlier diagnosis of hiperensive retinopathy and diabetic retinopathy and another complications such as a glaucoma.

 Medicamentous therapy for this patient is

with vitamin for patients eyes . Vitamin is used as an antioxidant to maintenance of eye health & function.

CONCLUSION

From the anamnesis:

Mrs.M, 53 years old, complained that she feel

blurred and slowly decreased in her visual acuity in both of her eyes since 1 years ago, and it became worse since 4 month ago. Patient told that her right eye feel more blurred than the left eye. She told that she feel blurred vision when reading and also when looking things at distance. Patient had history of diabetic mellitus and hypertension history.

From the eye examination

It found that the visual aquity of her both eyes

had been decreased. Visual acuity of OD is 6/25 and visual acuity of OS is 6/20, with the changes after pin hole test and correctional refraction became 6/10. And aaditional lens for OD and OS is + 250. But she still felt blurred in her vision. The lens OD and OS partially opaque. In fundus examination with dilated pupil, there are founding opacities in subcapsular (Snowflake).

After did the anemnesis dan examination of the patient , the working diagnose of this patient eye is Diabetic cataract and Presbyopia. The patient has a high risk to an occurs of the diabetic retinopathy and hipertensive retinopathy. The differential diagnosis for the patient is diabetic retinopathy and hipertensive retinopathy.

Recomended therapy for this patient includes nonmedicamentous such as education for the patient to control her blood glucose and blood presurre by a diet and do the light exercise regularly to prevent the progression of the diseases. Educate patient to do an ocular examination at least once a year to prevent the progression of the disease and also to earlier diagnosis of hiperensive retinopathy and diabetic retinopathy and another complications such as a glaucoma. Medicamentous therapy for this patient is

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Risk factors for cortical,nuclear, and posterior subcapsular cataracts: The POLA study. Pathologies Oculaires Liees a` lAge. Am J Epidemiol 2000. Lu M-P, Wang R, Song X, Chibbar R, Wang X, Wu L, Q Meng QH. Dietary soy isoflavones increase insulin secretion and prevent the development of diabetic cataracts in streptozotocininduced diabetic rats. 2008. Y. Takamura, Y. Sugimoto, E. Kubo, Y. Takahashi, and Y. Akagi, Immuno-histochemical study of apoptosis of lens epithelial cells in human and diabetic rat cataracts, Japanese Journal of Ophthalmology, vol. 45, no. 6, 2001. S. K. Srivastava, K. V. Ramana, and A. Bhatnagar, Role of aldose reductase and oxidative damage in diabetes and the consequent potential for therapeutic options, Endocrine Reviews, vol. 26, no. 3, 2005. P. Huang, Z. Jiang, S. Teng, et al., Synergism between phospholipase D2 and sorbitol accumulation in diabetic cataract formation through modulation of Na,K-ATPase activity and osmotic stress, Experimental Eye Research, vol. 83, no. 4,

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