Opt236A Cataracts

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Y-suture (white)- on anterior fetal nucleus.Iif on posterior, inverted Y suture

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Y-suture (dark)- as seen by retro-illumination

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Young Lens

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Adult Lens

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Vitreous (far right)

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1. Embryonic

2. Fetal

3. Juvenile

4. Adult

5. Cortex

6. Capsule

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Mittendorf dot (developmental abnorm.)- remnant of hyaloid system, small circular white opacity located inferior nasal on posterior lens capsule

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Mittendorf dot (direct view of lens)

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Mittendorf dot (retro illumination)

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Vogt’s reflex line (developmental abnorm.)- remnant of hyaloid system, faint gray reversed C-shaped line on posterior lens capsule.

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Coloboma (developmental abnorm.) - incomplete lens development; typically notch in lens edge.

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Ectopia lentis-lens luxation (developmental abnorm.)- displacement of lens associated w/ trauma, genetic syndromes, zonule weakness

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Marfan’s syndrome (lens luxation-developmental abnorm.) - fibrillin glycoprotein defect where lens is displaced upward

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Homocystinuria (lens luxation-develop. abnorm.) - effects connective tissue, lens displaced downward

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Lens luxation into pupil (pupillary block) - risk of pupillary block glaucoma

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Len luxation (dislocation) into vitreous

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Dislocation of lens into anterior chamber

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Anterior lenticonus (develop. abnorm.) associated with Alport’s syndrome - conical deformity with protrusion of anterior lens. Typically unilateral.

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Posterior lenticonus associated with Lowe's syndrome- exaggerated outward curve, can lead to mental retardation and glaucoma

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Posterior lenticonus associated with Lowe's syndrome - appears dark, oil drop appearance. Posterior lens capsule is permeated outward. Seen here through retro illumination.

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Microphakia (develop. abnorm.) - abnormally small lens

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Embryonic nuclear cataract (congenital cataract) - grainy gray axial central opacity, bilateral, dominantly inherited, expression of abnormal crystalline protein.

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Retroillumination of embryonic nuclear cataract

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Cataracta centralis pulveralenta (congenital) - granular central opacity (pulverized little dots)

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Fetal Cataract (congenital) - gray opacification of either anterior or posterior fetal nucleus

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Sutural Cataract (congenital) - stellate, stalagmite or coral (coralliform) in shape. Typically bilateral and ~30% of congenital cataracts.

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Sutural Cataract

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Sutural Cataract

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Anterior polar cataract (congenital) - cotton ball-like opacity anterior subcapsular location , sharply demarcated edge, may be associated with persistent pupillary membrane. Little or no effect on vision.

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Anterior polar cataract

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Persistent pupillary membrane (colarette)

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Posterior polar cataract (congenital) - under posterior capsule, associated with hyaloid remnant, sharply demarcated edge. Greater effect on vision due to proximity to nodal point.

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Pyramidal cataract (congenital) - cone or pyramid-shaped opacity that protrudes into AC. Involves anterior capsule.

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Zonular or lamellar cataract (congential) - most common congenital cataract (40%), usually bilateral, affects one lamella or zone of lens fibers. Opacification of the circular zone surrounding the nucleus, center is clear.

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Zonular or lamellar cataract - disc- shaped when viewed frontally

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Zonular or lamellar cataract - spokes or "riders" of overlying fibers. Associated with abnormal Ca metabolism; tooth enamel & tooth formation anomalies.

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Total – diffuse (congential) - white calcified pupillay mass, all lens fibers affected, & causes capsule shrinkage. Frequently inherited.

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Cortical cataract (vacuoles: circular pocket of fluid) - break down of proteins with lens opacification, cataract is "soft" due to fluid component.

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Cortical cataracts (water clefts:linear fluid filled zones)

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Cortical cataracts (spokes (cuneiform)):wedge shaped

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Cortical cataracts (Lamellar separation): thin lamellae separations by fluid

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Cortical cataract (spokes) by direct illumination

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Cortical cataract spokes (retro) by retro illumination

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Cortical cataract (coalescing spokes)

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Cortical cataract (coalescing spokes)

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Cortical cataract (shadows)

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Cortical cataract (vacuoles, spokes, and wedges)

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Cortical cataract - diffuse opacification. Mature, cortex is hazy grayish-white.

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Cortical cataract - hyper mature, entire cortex up to capsule is opaque white.

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Cortical cataract (Phacomorphic glaucoma) - swelling of cortex increases lens size, shallows AC w/ opposition of posterior iris to anterior lens capsule with iris bombe & angle closure + secondary angle closure glaucoma.

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Cortical cataract- Phacomorphic glaucoma

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Cortical cataract –lens opacity classification system (scale of 1+ to 4+).

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Nuclear cataract - nuclear sclerosis (NS) - newly formed lens fibers push & compress older fibers towards center of lens, results in hardening (sclerosis) of fibers. Increase in insoluble protein. Formation of urochrome (yellow-brown color). Scatters light- alters color perception.

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Nuclear cataract: (NS=0) - visibility of lens lines still present in early onset of NS.

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Nuclear cataract: (NS=1+) - slight yellow color from reflected light from posterior nuclear layers.

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Nuclear cataract (mature nuclear sclerosis) - mature when entire nucleus is brown (brunescent)

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Nuclear cataract-nuclear sclerosis

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Nuclear cataract-nuclear sclerosis grading systems (scale 1+ to 4+)

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Nuclear cataract-nuclear sclerosis (1+ NS)

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Nuclear cataract (Opalescence)

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Nuclear cataract (2+ NS)

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Nuclear cataract (3+ NS)

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Cortical cataract (age-related cataracts): Morgagnian cataract - solid "hard" nucleus floating within liquified white cortex

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Posterior subcapsular cataracts (cupiliform) - saucer shaped granular opacification under posterior subcapsular region. Opacification spreads along zone & does not extend into cortex. Most common type of posterior subcapsular cataracts.

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Posterior subcapsular cataracts (cupiliform) -faint iridescent blue/green color)

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Posterior subcapsular cataracts (cupiliform) -opacification spread along zone, does not extend into cortex)

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Posterior subcapsular cataracts (complicated cataracts) - opacification in posterior subcapsular region and into adjacent cortex. Polychromatic blue, green and red colors are characteristic of this type of cataract.

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Traumatic cataract (direct- "stellate" or "rosette shape")

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Traumatic cataract (retro- "stellate/star", "rosette shape")

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Pseudocataract (Vossius ring) - pigment, from iris, imprint on anterior lens capsule secondary to blunt trauma and compression of anterior segment. Pigment from old posterior synechiae.

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Pseudocataract (Epicapsular stars) - remnant of hyaloid system associated with persistent pupillary membrane.

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Pseudoexfoliation (pseudocataract):

- basement membrane abnormality in epithelial cells of eye, lung, BVs, meninges, etc.

- amyloid-like fibrillar material on lens capsule, iris

- high risk of glaucoma

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Coronary cataract (Crown shaped opacification) - arranged in radial distribution around and over periphery of adult nucleus or cortex. Idiopathic.

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Coronary cataract (Crown shaped opacification)

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Cerulean (blue dot) cataract (miscellaneous) - Bluish punctate opacities within the adult nucleus or cortex. Idiopathic.

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Diabetes cataract (miscellaneous) - white punctate or "snowflake-like" opacities within anterior or posterior subcapsular regions. Rapid progression.

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Glaucomflechen cataract (miscellaneous) - grayish flecks in anterior subcapsular region. Associated with episodes of rapid high increase in IOP (>50 mmHg)

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Crystalline cataract (miscellaneous) - multicolored crystalline- like opacities within adult nucleus or cortex. Idiopathic.

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Crystalline cataract (miscellaneous) - multicolored opacities

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Initial IOPs were rigid and attached to iris (prohibited pupil dilation)

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Anterior chamber IOL (still used) - pupil dilation OK

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Posterior chamber IOL

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Diffractive IOL (restore)

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Accommodating IOL (crystalens)

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Surgical development- clear corneal incision

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Capsulorhexis: Circular opening anterior capsule, technique used to remove anterior lens capsule in cataract surgery

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Corneal Edema - endothelial damage, cell loss with corneal decompensation, may resolve. Permanent edema may result in pseudophakic bullous keratopathy and corneal transplant.

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Surgical complications - endopthalmitis

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Surgical complications - iris prolapse

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Surgical complications - iris “capture” of IOL

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Iris atrophy

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IOL decentration - causes "halos" and visual aberrations

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Cystoid macular edema

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Tear in posterior capsule with loss of cortex leading to prolonged inflammation. Will have cystoid macular edema seen on retina.

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"Secondary membrane" or "Elschnig's pearls" (surgical complications) - opacification of posterior capsule from regeneration of lens fibers

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"Secondary membrane" or "Elschnig's pearls" - opacification of posterior capsule

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YAS laser: Capsulotomy treatment - uses central opening in capsule

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Clear posterior capsule

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Fibrosed anterior capsule

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Secondary membrane

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lens after S/P YAG