Lens diseases

Wen Xu
Eye Center, 2nd Affiliated Hospital
Zhejiang University
The most common cause
of painless, progressive
loss of vision today is
Cataract
 Anatomy of the lens

Location
posterior to iris
anterior to vitreous
Shape biconvex
Structure
lens capsule
lens cortex
lens nucleus
 Physiology of the lens

No vessel, nerve and transparent.

Derive nutrients from the aqueous humor
Significant refractive medium
Accommodative function
No immediate relation with adjacent tissues
Complex metabolism
Simple disorders: transparency and location change
Cataract

Definition: opacification of the lens

epidemiology:
clinical cataract

corrected vision<0.5
Cataract

Mechanism:
many factors lens capsular damage
osmosis increase,loss of protective
screen,metabolic disorders protein degeneration,
cell apoptosis lens opacify cataract
 Cataract

Classification:
by cause: congenital, senile(age-related), complicated,
metabolitic, drug-induced, toxic, traumatic, secondary
by age:congenital, acquired
by location: cortical, nuclear, subcapsular
by shape: dot-like, coronary, lamellar
by degree: immature, intumescent, mature,
hypermature
Cataract
Symptoms:

decreased vision: most obvious and important

decreased contrast sensitity
refractive error: myopia,astigmatism
monocular diplopia or multiple vision
glare: scattered light rays
poor color discrimination:blue spectrum
Cataract

Signs:
The lens is best examined with the pupil
dilated. A magnified view of the lens can be
obtained with a slit-lamp or by using the
direct ophthalmoscope with a high plus (10+)
setting
Cataract

Grades standards of nuclear

hardness:
transparent,no nucleus,soft
yellow-white or yellow,soft
dark yellow,moderate hard
brown or amber, hard
brown or black,extremely hard
(I) Age-related cataract
Description:

the most common type, most patients are beyond

their 50s. The incidence goes up with aging. It is
the first rank of ophthalmic diseases leading to
blindness
Risk factors:

Many factors are involved include age, occupation,

sex, ultraviolet radiation, diabetes, hypertension,
positive family history, nutritious condition
(i) Cortical Cataract

The most common type

Four stages:
(1) incipient stage
(2) intumescent stage or immature stage
(3) mature stage
(4) hypermature stage
 1. incipient stage

Features:
acuneiform(['kjun,frm]) opacity
blamellar seperate
cvacuole
dcracks
eno vision damage

Tests: aslit-lamp btransillumination

 2. intumescent stage or
immature stage
Features:
amore serious opacity
blarger volume and more shallow anterior
chamber
ciris shadow
dobvious vision decrease
emyopia
Tests: aslit-lamp boblique illumination
Matter needs attention: angle-closure glaucoma
3. mature stage

Features:
acomplete opacity, milky white, iris
shadow disappear
bvolumn and anterior chamber
regain normal
cvision: LP or HM before the eye
Tests: aslit-lamp
bflashlight
 4. hypermature stage
Features:
asmaller volumn,wrinkled lens capsule,claybank
and fallen nucleus (Morgagnian
cataract) ,superior
of anterior chamber deepens while inferior is the
opposite,ridodonesis.
blaceration of lens capsule,lens luxation.
cphacoanaphylactic uveitis,phacolytic glaucoma
(ii) Nuclear Cataract

Features:
astart earlier,generally on 40s,slowly
progressive, not likely to be mature.
bnuclear opacity: start by embryonic
nucleus.
cvision: no vision damage early on,
myopia
Tests: slit-lamp transillumination
oblique illumination
(iii) Subcapsular Cataract

Features:
astart earlier
bposterior subcapsular cataract:
cause
obvious vision defect early on
ccupuliform() opacity of
posterior pole
(II) Congenital Cataract
Features:
present at birth or appear shortly thereafter; unilateral or
bilateral; may be alone or associated with other ocular or
systemic congenital abnomalities

Etiology:
(1) hereditary factors(chromosome,gene)

(2) environmental factors (matrix disease) when pregnance <3 m:

virus infection; drugs,metabolic diseases
(3) undetermined causes
Classification

According to location, form and degree

anterior polar cataract
posterior polar cataract
perinuclear cataract
coronary cataract
punctate cataract
total cataract
membrane cataract
nuclear cataract
Congenital cataract
Anterior polar cataract
Posterior polar cataract
Perinuclear cataract
Coronary cataract
Punctate cataract
Total cataract
Membrane cataract
Nuclear cataract
(III) complicated cataract

Features:
ocular inflammation or degenerative
disorders nutritious or metabolic defect
lens opacity
Common causes:
corneal ulcer, glaucoma, uveitis,retinal
detachment, retinitis pigmentosa, intraocular
tumor,high myopia, etc.
Clinical findings:
1. primary disease changes
2. cataract

Treatment:
1. treat the primary disease.
2.do the surgery after 3 m of
inflammation control
(IV) Metabolic cataract

Diabetic cataract
Galactose cataract: lack of enzyme
Tetany cataract: low blood calcium
Wilsons disease
(Hepatolenticular Degeneration):
KF ring, sunflower-shaped opacity,copper.
1. Diabetic cataract

Mechanism:
blood sugar sugar in the lens change into
sorbitolplasma osmotic pressure absorb
waterfibers swellen and degeneratelens opacity
 classification:
(1) real diabetic cataract
(2) age-related cataract of diabetic patients
Clinical findings:
(1) the first type: teenagers,bilateral,rapidly
progressive,eading to total cataract,combined
with refractive changes according to blood sugar
(2) the second type: high incidence,start earlier, fast
progressive, easy to be mature,similar with
senile cortical cataract
 Treatment:
(1) positively treat diabetes,control blood
sugar
(2) do the surgery if permitted
(3) positively postoperational infection and
bleeding prevention
(V) Drug-induced and toxic
cataract
Corticosteroid cataract
Chlorpromazine cataract
Miotic cataract
Trinitrotoluence cataract
Metals
Trinitrotoluence cataract
(VI) Traumatic cataract

Classification:
Contusive cataract
Penetrating cataract
Chemical injuries cataract
Radiation cataract
Electric cataract
Treatment: observation or surgery
(VII) Secondary cataract

Definitions:

opacification of the posterior capsule due to

partially absorbed traumatic cataract or following
extracapsular cataract extraction (posterior capsular
opacification). It is the most common complication
of cataract surgery
Clinical findings:

vision decrease after cataract surgery;

Elschnigs pearls
 It is a significant problem in almost all pediatric
patients unless the posterior capsule and anterior
vitreous are removed at the time of surgery. Up to
30%-50% of all adult patients develop an opaque
secondary membrane after cataract surgery

Treatment:
neodymium:YAG capsulotomy
 Treatment of cataract

There are many kinds of medicines,but none

has certain positive effect
Surgery is the chief method
Surgical treatment

Timing of the surgery:

amature stagevisual acuity
bconsider the surgery
conditions and the subjective
requirements of patients
 Preoperative Examination &
preparation
Ocular:
VA,LP,color vision,anterior
segment,fundus,IOP,SLE ,EKG,VEP,ultrasonic,etc.
System:BP,blood sugar,etc.
Corneal curvature,the axial length of the
eye.calculate the diopter of the IOL
Endothelial cell acount (specular microscopy)
Wash conjunctival sac and lacrimal canal,dilate
the pupil
Way of the surgery

Couching() of lens
Intracapsular cataract extraction (ICCE)
Extracapsular cataract extraction
(ECCE)
Phacoemulsification (PHACO)
Laseremulsification
Intraocular lens implantation
Surgical complications

Complications during the

surgery
(1)shallow or no anterior chamber

(2)intraocular tissue lesion

(3)hemorrhage
(4)posterior capsular rupture
 Postoperational complication
(1)hemorrhage
(2)high IOP
(3)endophthalmitis
(4)chronic uveitis
(5)posterior capsular opacification
(6)corneal astigmatism
(7)retinal phototoxicity
(8)cystoid macular edema, CME
 Postoperational complications of IOL
implantation
(1)pericorneal fibrous proteins exudation
(2)dislocation of IOL
(3)secondary glaucoma and decompensation of
corneal endothelium
(4)diopter inaccuracy of IOL
Refractive correction of
aphakia
IOLs :Multifocal, Accommodatable
Spectacles
Contact lens
Refractive surgeries: keratophakia,
keratomileusis, epikeratophakia
Dislocated lens or ectopia
lentis
Causes
(1) congenital
simple dislocation; combined with lens or ocular
abnormalities; systemic syndromes (Marfan syndrome,
homocystinuria, Marchesani syndrome, Ehlers-Danlos
syndrome)
(2) traumatic
(3) spontaneous
 Clinical findings
(1) Partial dislocation:
the edge of the lens and the zonular fibers holding it in
place can be seen in the pupil. It is often complicated
by deepen anterior chamber,iridodonesis and vitreous
hernia. High myopia and monocular diplopia,or even
secondary glaucoma may occur
(2) Complete dislocation:
include pupil entrapment,dislocated into anterior
chamber, dislocated into vitreous cavity,dislocated into
subconjunctiva or even extraocular
 complications
(1)Uveitis
(2)Secondary glaucoma
(3)Retinal detachment: the most common
(4)Corneal opacification
 Treatment
(1) nonsurgical therapy:

If no complications, dislocated lenses are best left

untreated. Close conservation and spectacles or
contacts may have some value
(2) surgical therapy:

If uveitis or uncontrollable glaucoma occurs, lens

extraction must be done. The technique of choice is
limbal or pars plana lensectomy using a motor-driven
lens & vitreous cutter
Dislocated in anterior chamber
Partial dislocation
Partial dislocation