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  1. Developmental cataract: Affects particular zone of the lens.
    1. Causes
      1. Maternal malnutrition
      2. Infantile malnutrition – Zonular cataract
      3. Maternal infection e.g. rubella, toxoplasmosis, cytomegalovirus*
      4. Deficient oxygenation e.g. placental hemorrhage
      5. Maternal drug ingestion – thalidomide, corticosteroid*
    2. Types
      1. Punctate : Most common*. Eg. Blue Dot Cataract : Blue dots scattered all over the lens
      2. Sutural cataract : Y suture opaque
      3. Fusiform or spindle shaped or coralliform : Anteroposterior spindle shaped opacity. Familial
      4.  Discoid : Disc shaped opacity in the posterior cortex. Familial
      5.  Embryonal nuclear cataract
      6. Rubella: Progressive nuclear cataract which finally leads to total opacity. Associated with maternal   infection contracted in 2nd/3rd trimester. Virus can be cultured from the lens. Associated is Salt and pepper retinopathy. Other signs of rubella – CHD (PDA), microphthalmos, mental retardation, deafness, dental abnormalities.
      7. Zonular cataract
        1. Sharply demarcated areas
        2. Riders may be present
        3. Usually bilateral
        4. May affect vision
          Causes –    familial (AD)/malnutrition/Vitamin D deficiency (may be associated with rickets)
          Anterior capsular (polar) cataract : 
          Cause –
          1. delayed formation of anterior chamber
          2. More commonly acquired (due to corneal perforation)
          3. May be anterior pyramidal cataract or reduplicated cataract
          4. Non progressive
      8. Posterior capsular (polar) cataract :
        Cause –
        1. Persistent hyaloid artery
        2. Usually minimal, but may be total
    3. Treatment :     
      1. Required only if vision affected.
      2. Needling (discission) obsolete
      3. Lensectomy if child less than 2 years*  
      4. Lens Aspiration done if child more than 2 years*
  2. Problems associated with paediatric cataract surgery :
    1. Posterior capsular opacification
    2. Post operative inflammation
    3. Pre operative lens power calculation
  3. Indications for early surgery :    
    1. Unilateral total cataract (operate < 6 weeks)
    2. Development of squint/strabismus
  4. Acquired cataract causes
    1. Age
    2. Deficiency of amino acid tryptophane and vitamin B2, riboflavine*
    3. Toxic substances – naphthalene, lactose*, galactose, thallium etc
    4. Dinitrophenol, paradichlorobenzene, Chlorpromazine, Busulphan, Gold, amiodarone
    5. Hypocalcemia – parathyroid tetany*
    6. Drugs – anticholinesterase*
    7. Corticosteroids – topical and systemic*
    8. Diabetes – osmotic cataract*
    9. Trauma – mechanical and irradiation
  5. Senile cataract: Phenomenon of anticipation in presenile cataract- Cataract occurs easily in next generation Senile cataract can be cortical (soft cataract) due to hydration or nuclear (hard cataract) due to denaturation of proteins
  1. Cortical cataract
    1. Stage of lamellar separation
    2. Stage of Incipient Cataract

: Stages


: In drawing of fluid. Leads to hydration and lamellar separation.



  1. (Cuneiform cataract)
    1. Intumescent Cataract
    2. Cupuliform cataract

    3. Nuclear Cataract





: Stage of incipient cataract shows the presence of wedge shaped spokes,

especially in lower nasal quadrant.

: Increasing hydration leads to swollen lens.


: Posterior subcapsular cataract. Causes more visual disturbance than the cuneiform variety due to involvement of the nodal point of the eye.        

Vision worse in bright light.

: Progressive nuclear sclerosis. Melanin and urochrome pigment

deposition leads to formation of cataracta brunescence, nigra, rubra etc.

Nuclear cataract leads to progressive myopia and is therefor associated

with ‘second sight’*. 


  1. Mature Senile Cataract


: Further leads to mature cataract


  1. Hyper Mature Cataract
: Hypermature cataract may become morgagnian (liquified cortex with
sunken nucleus) or sclerotic (shrunken).  May cause Phacotoxic uveitis
and Phacolytic Glaucoma
  1. Complicated Cataract
    Associated with eye diseases like uveitis, high myopia, retinitis pigmentosa, retinal detachment, glaucoma, intraocular neoplasia
    Signs - Polychromatic lustre, Bread crumb appearance, Posterior subcapsular cataract which extends peripherally as well as axially towards the centre.
  2. Systemic diseases Causing Cataract:
1. Diabetes
Senile cataract appears earlier and matures faster.
True diabetic cataract is Snowflake cataract – anterior and posterior         
subcapsular, and is reversible. Seen in younger age group and is  associated with high blood sugar.
2. Parathyroid Crystalline deposits. Subcapsular cataract
3. Myotonic dystrophy Christmas tree
4. Galactosemia Bilateral ‘oil droplet*’ cataract in early life.
5. Mongolian Down’s syndrome  punctate
6. Atopic cataract seen in atopic eczema, scleroderma etc – Syndermatotic cataract
7.  Wilson’s disease Sunflower cataract* (as in chalcosis)
8. Radiation cataract:
Heat, X rays, Gamma rays, UV rays cause posterior subcapsular cataract  
Infrared radiation cataract (Heat) specifically seen in glass blowers and   iron workers. Associated with pseudoexfoliation of the lens capsule.
9. Traumatic cataract :
Concussion cataract has Rosette cataract –      Early and late. In   
posterior subcapsular area. May progress, remain stationary or occasionally disappear. Penetrating injury gives rise to localized cataract or diffuse cataract Trauma effects on lens – Vossius ring*
Ring of iris pigment on lens, cataract with or without capsular rupture,       
subluxation, dislocation
10. Syndromes with cataract
  1. Symptoms of Cataract:
    1. Black shadow in front of Eyes
    2. Glare
    3. Uniocular diplopia/ polyopia- in incipient cataract
    4. Coloured halos – break in Fincham’s test
    5. Decreased vision – more in posterior subcapsular cataract
    6. Progressive myopia, second sight
    7. Lens induced glaucoma:
  • Phacomorphic glaucoma: Intunesscent lens moves forward causing papillary block through intact capsule
  • Phacolytic glaucoma: Hypermaturity leads to leakage of lens proteins thereafter glaucoma. and angle is open deep in lytic. Capsule is intact
  • Lens particle glaucoma : due to release of lens proteins in anterior chamber post trauma/ surgery.
  • Capsule is not intact  
  • Phaco anaphylactic : hypersensitivity to lens proteins
  • Glaucoma due to subluxated lens : causes angle closure
Phacomorphic ag. Intumlscent eat AC shallow Closed
Phacomorphic ag. HM Morgagnias act AC deep Open angle
  1. Surgeries : ICCE v/s ECCE
    1. Methods of ICCE – Obsolete now except wire Vectis that is used to remove subluxated lens
    2. Table: Materials for manufacturing intraocular lenses
      1. IOL materials                        
        1. Non-foldable                         
        • Polymethyl methacrylate (PMMA)     
        1. Foldable                                   
        • Silicone    
        • Acrylic             
      2. Ocular anaesthesia:   
        Retrobulbar / Peribulbar / topical      
        1. Safer is peribulbar
        2. Retrobulbar – Last muscle to be blocked is superior oblique as its outside muscle cone      
    3. Complications          
      1. Retrobulbar haemorrhage        
      2. Globe perforation             
      3. Optic Nerve injury
      4. CRAO                              
      5. CNS complications
  2. Types of Surgeries
    1. ICCE has more chances of:        
      1. Retinal detachment          
      2. Vitreous loss
      3. Cystoid macular edema           
      4. PCIOL implantation not possible                                       
      5. Associated problems like corneal decompensation, glaucoma worsen
    2. ECCE : Steps
      1. Anaesthesia                     
      2. Superior rectus suture              
      3. Conjunctival flap
      4. Corneo scleral groove              
      5. Anterior chamber entry            
      6. Injection of viscoelastic
    3. Capsulotomy :
      1. Can opener              
      2. Envelope         
      3. Capsulorrhexis
      4. Extension of corneoscleral section            
      5. Nucleus delivery
      6. Cortex aspiration                             
      7. PCIOL implantation +
        Corneoscleral suture : Subconjunctival denamethasone+gentamioin
  1. SICS Small incision Cataract Surgery. Incision 6-7mm self-sealing, no suture    
  2. Phacoemulsification: Most preferred nowadays.
    Advantages due to small incision:<3mm 
    1. Less post operative astigmatism
    2. Faster visual recovery & aspiration fragmentation of nucleus
Phacoemulsification involves breaking down the lens into small fragments within the capsular bag (with the help of 40-50KHz frequency ultrasonic tip*) and then aspirating the same.
  1. The surgery is done through a self sealing scleral or a corneal tunnel, therefore there is no need of stitches – sutureless cataract surgery.
  2. As the opening in the eye is small and it is self sealing, the surgery can be done under topical anaesthesia.
    1. Steps: Wound-Rhexis-Hydrodissection-Hydrodelamination-Nucleus emulsification-Cortical aspiration-foldable IOL-Wound closure
    2. Techniques of Nucleus splitting- Divide and Conquer, Chip and Flip, Phaco-chop
  3. Disadvantages are the high cost of equipment and the steep learning curve.
    Latest advances in cataract surgery: femtosecond laser cataract surgery (Bladeless cataract surgery) laser used to make incisions, capsulorrhexis and nucleus fragmentation
  1. Complications of cataract surgery
    1. Posterior capsule rupture                 
    2. Vitreous loss
    3. Expulsive haemorrhage                    
    4. Shallow anterior chamber
    5. Glaucoma                        
    6. Uveitis
    7. Iris prolapse                            
    8. Epithelial down growth and fibrous ingrowth
    9. Corneal edema: Bullous keratopathy* much more common with iris supported and ACIOL than With PCIOL. Endothelial cell loss <5% with ECCE. Slightly more when IOL implanted. About 8-10% with phacoemulsification with IOL. With improving techniques and viscoelastics, this rate is decreasing.
    10. Cystoid macular edema
    11. Endophthalmitis : Most commonly by Staphylococcus epidermidis. Delayed endophthalmitis is due to either fungi or Propionibacterium acnes.
      1. Intravitreal treatment for endophthalmitis:      
        1. Vancomycin 1mg + Cefazoline 2.25mg/Ceftazidime 2.25mg.
        2. Gentamycin is contraindicated intra-vitreal as retinotoxic
    12. Posterior capsular opacification: Most common complication of ECCE. About 50% cases require treatment for posterior capsular opacification after 5 years of surgery. Two forms:
      1. Ring of Soemmering and Elschnig’s pearls
      2. The treatment is YAG laser capsulotomy.
    13. Aphakia problems : 30% magnification and therefore diplopia in monocular aphakes Spherical aberration – Pin cushion defect Lack of physical coordination.  
      1. 30% magnification and therefore diplopia in monocular aphakes Spherical aberration – Pin cushion defect Lack of coordination.
      2. 5% magnification with contact lens
      3. hand eye coordination
      4. Roving ring scotoma
      5. Jack in the box phenomenon               
    14. Visual field defects : Decreased visual field Roving Ring scotoma, Jack in the box phenomenon
      Prismatic aberration, Loss of accommodation Heavy glasses, cosmetic problem
Contact lenses
  1. Advantages : 7% magnification, No spherical aberration, No visual field defect
  2. Intraocular lenses (IOL) : Posterior chamber IOL (PCIOL) : In the bag or in ciliary sulcus
  3. Anterior chamber IOL (ACIOL): Placed in anterior chamber against scleral spur
  4. IOL power calculation (Biometry):
Using SRK II formula which takes into account the axial length (L) and the keratometry (K) reading
A is A Constant
= A-(2.5L+0.9K)
K-Corneal Curvature
L-axial length
Other formulae
SRK-T (preferred for longer axial length >26mm)
Hoffer Q ( for small eyes. Axial length<22mm

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