Competency 6.1.6

Question 1

What is Nuclear Sclerotic Cataract?

Answer 1

• Is an exaggeration of normal aging changes
• associated with a myopic shift due to an increase in refractive index
• Upon retro-illumination there is not much to see but a subtle distinction between the affected nucleus and the cortex.

Question 2

Nuclear Sclerotic Cataract Symptoms

Answer 2

• Slow development of symptoms
• Bilateral but often asymmetrical
• Improvement in near vision
• Blurring of vision
• Colors may appear faded or yellowed

Question 3

Nuclear Sclerotic Cataract Signs

Answer 3

• Opacity densest in centre of lens
• Yellow discolouration
• Colour progresses to brown as progresses
• Reduced VA

Question 4

What is a Cortical Cataract?

Answer 4

• May involve any part of the lens cortex
• The opacities start as small clefts between lens fibres due to cortical hydration
• These clefts then develop into spoke-like opacities in the lens cortex.

Question 5

Cortical Cataract Symptoms

Answer 5

• Slow development of symptoms
• Bilateral but often asymmetrical
• VA may be unaffected
• Glare
• Monocular diplopia

Question 6

Cortical Cataract Signs

Answer 6

• Mid-peripheral opacities
• Clear nucleus
• Straight line/wedge shaped cortical opacities
• Black shadows on retro-illumination

Question 7

What is a Posterior Subcapsular Cataract?

Answer 7

• Lies just infront of the posterior capsule
• and has grainy appearance on direct viewing
• Retro-illumination reveals a black opacity with vacuoles present
• Is very commonly associated with steroid use.

Question 8

Posterior Subcapsular Cataract Symptoms

Answer 8

• Profound effect on vision
  o Disproportionate to signs
  o Near vision typically more affected
  o VA more affected in bright light (miosis)
  o Glare

Question 9

Posterior Subcapsular Cataract Signs

Answer 9

• White/yellow opacity at centre of pupil
• Rough texture visible on high magnification

Question 10

What is a Morgagnian Cataract?

Answer 10

• an advanced stage of a cataract where the cortical lens has become liquified and the dense and hardened lens nucleus has sunk down to the bottom of the lens capsule
• Morgagnian cataracts will typically present with profound visual loss (hand-motions or light-perception)
• Morgagnian cataract may undergo spontaneous rupture into anterior chamber causing inflammatory reaction

Question 11

Morgagnian Cataract Prognosis

Answer 11

• Patients should be counseled about the increased risk of complications and the possible need of more than one surgery to achieve the best visual outcome.
• Preoperative assessment for projection of light and relative afferent pupillary defect are important prognostic factors.
• Patients should also be cautioned about possible binocular diplopia post cataract removal if morgagnian cataract was longstanding and may have lead to loss of fusion.

Question 11

Causes of Traumatic Cataract

Answer 11

• Penetrating trauma
• Blunt trauma
• Electric shock
• IR/ionising radiation

Question 12

Causes of Cataract in Young Individuals

Answer 12

• The majority of bilateral congenital or infantile cataracts not associated with a syndrome have no identifiable cause
• Trauma is a known cause of pediatric cataracts
• If there is no known history of trauma to explain an acquired cataract in this age group, investigation must be considered in children who present with other signs suggestive of child abuse
• In many cases of congenital cataracts, there is a family history.

Question 13

Management of Cataract in Young Individuals

Answer 13

• Not all pediatric cataracts require surgery
• small, partial or paracentral cataracts can be managed by observation.
• Management of a cataract in a child is different from adults because of the anatomically younger ocular tissues, continuous ocular growth and other associated structural anomalies

Question 14

Indications for Cataract in Young Individuals

Answer 14

• Cataract < 3mm in diameter
• Peripheral or paracentral cataract not obscuring the visual axis
• Blue-dot cataract which is not afftecting the vision
• Presence of good red reflex viewed with direct ophthalmoscope or retinoscope
• Absence of strabismus or nystagmus

Question 14

Non-surgical Management Options for Cataract in Young Individuals

Answer 14

• Observation with careful regular monitoring to look for any change or progression in cataract and/or development of amblyopia. If either occurs, treatment is recommended.
• Pharmacologic pupillary dilation can be used to increase the pupil size and allow the child to see through a clear portion of the lens. Cycloplegic drops should be avoided as they can cause loss of accommodation and can lead to amblyopia by themselves.
• Occlusion of the other eye is useful in case of unilateral cataract, to prevent amblyopia until surgery is completed.

Question 15

What is Cerulean Cataract?

Answer 15

• also known as blue dot cataracts
• inherited as an autosomal dominant trait
• usually have preserved visual acuity and rarely need cataract extraction before adult age
• children who develop signs of visually significant cataracts such as nystagmus and amblyopia may require cataract surgery earlier

Question 16

How Does Diabetes Mellitus Cause Cataract

Answer 16

• Hyperglycaemia results in high glucose levels in the aqueous humour which diffuses into the lens
• Within the lens the glucose is metabolized into sorbitol which can result in changes in refraction or cataract formation.

Question 17

What Does Cataract from Diabetes Mellitus Look Like

Answer 17

• Classic diabetic cataract looks like a snowflake of white cortical opacities which occurs in the young, but this is rare. It can mature within a short period or may spontaneously resolve
• In addition, age-related cataract (mostly NS) occurs earlier in diabetics.

Question 18

Cataract in Myotonic Dystrophy

Answer 18

90% of patients with myogenic dystrophy will develop a distinctive cataract which follows the following course:
- 3rd Decade of Life
o Fine cortical opacities
o Sometimes resembles a Christmas tree cataract
- 5th Decade of Life
o Evolve into visually disabling wedge-shaped cortical and posterior-subcapsular opacities

Question 19

Principles and Requirements for a Cataract Referral

Answer 19

• Patients must have a full and comprehensive optometric assessment and refraction
• A patient’s visual acuity cannot be improved by an optimal updated refraction
  o Visual acuities included for near and distance with pinhole and with glasses/contact lenses
• Identify other pathologies such as AMD which may be more pressing or the more significant cause of visual disability
• Identify any history of refractive surgery and flag accordingly in referral
• Identify and treat any dry eye as this speeds up post-operative recovery
• Visual grade the cataract- – non visually significant, mild, moderate, severe, no
  fundal view
• Flag up potential causes of higher risk surgery
• Baseline ophthalmic health assessment – IOP, anterior segment, dilated fundal exam

Question 20

Patient Lifestyle and Cataract Referral

Answer 20

• Assess the patient’s daily visual requirements and consequent visual disability to establish if it can be improved with cataract surgery.
• Document driving status
• mention in referral how the patient would like the surgeon to attempt to leave their vision e.g remain myopic or distance corrected

Question 21

NHS Cataract Referral Risks

Answer 21

• 2 in 100 risk of moderate complication resulting in vision not as good as hoped for
• 1 in 100 risk of serior complication resulting in poor vision (further surgery may be required)
• 1 in 100 risk of blindness
• 1 in 10,000 risk of having to remove eye

Question 22

Cataract Risk Grade 1

Answer 22

• Deep set eyes
• Tremor/cough
• Diabetic
• Finasteride/tamulosin (alpha blockers)

Question 23

Cataract Risk Grade 2

Answer 23

- History of uveitis - Poor dilation - Dense cataract - Long or short AL

Question 24

Cataract Risk Grade 3

Answer 24

- Pseudoexfoliation - Posterior synechiae

Question 25

Cataract Risk Grade 4

Answer 25

- History of trauma to eye - Very shallow eye - Black cataract

Question 26

Non-Surgical Cataract Management

Answer 26

- Always protect your eyes from UV light by wearing sunglasses and a hat. - If you smoke, quit, as it is a risk factor for cataracts. - Stay on top of other health problems, particularly diabetes. - Make sure your eyeglass or contact lens prescriptions are current.