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Cataract

Cataract

(For developmental or congenital cataracts, see Eye Defects and Conditions in Children: Congenital Cataract.)

A cataract is a congenital or degenerative opacity of the lens. The main symptom is gradual, painless vision blurring. Diagnosis is by ophthalmoscopy and slit-lamp examination. Treatment is surgical removal and placement of an intraocular lens.

Lens opacity can develop in several locations:
Central lens nucleus (nuclear cataract)
Beneath the posterior lens capsule (posterior subcapsular cataract)

Etiology

Cataracts occur with aging. Other risk factors may include the following:
Trauma (sometimes years later)
Smoking
Alcohol use
Exposure to x-rays
Heat from infrared exposure
Systemic disease (eg, diabetes)
Uveitis
Systemic drugs (eg, corticosteroids)
Undernutrition
Dark eyes
Possibly chronic ultraviolet exposure

Many people have no risk factors other than age. Some cataracts are congenital, associated with numerous syndromes and diseases.

Symptoms and Signs

Cataracts generally develop slowly over years. Early symptoms may be loss of contrast, glare (halos and starbursts around lights), needing more light to see well, and problems distinguishing dark blue from black. Painless blurring eventually occurs. The degree of blurring depends on the location and extent of the opacity. Double vision occurs rarely.

With a nuclear cataract, distance vision worsens. Near vision may improve in the early stages because of changes in the refractive index of the lens; presbyopic patients may be temporarily able to read without glasses (second sight).

A posterior subcapsular cataract disproportionately affects vision because the opacity is located at the crossing point of incoming light rays. Such cataracts reduce visual acuity more when the pupil constricts (eg, in bright light or during reading). They are also the type most likely to cause loss of contrast as well as glare, especially from bright lights or from car headlights while driving at night.

Rarely, the cataract swells, occluding the trabecular drainage meshwork and causing secondary closed-angle glaucoma and pain.
Cataract

Diagnosis

Ophthalmoscopy followed by slit-lamp examination

Diagnosis is best made with the pupil dilated. Well-developed cataracts appear as gray, white, or yellow-brown opacities in the lens. Examination of the red reflex through the dilated pupil with the ophthalmoscope held about 30 cm away usually discloses subtle opacities. Small cataracts stand out as dark defects in the red reflex. A large cataract may obliterate the red reflex. Slit-lamp examination provides more details about the character, location, and extent of the opacity

Treatment

Surgical removal of the cataract
Placement of an intraocular lens

Frequent refractions and corrective lens prescription changes may help maintain useful vision during cataract development. Occasionally, long-term pupillary dilation (with phenylephrine

2.5% q 4 to 8 h) is helpful for small centrally located cataracts. Indirect
lighting while reading minimizes pupillary constriction and may optimize vision for close tasks. Polarized lenses reduces glare.

Usual indications for surgery include all of the following:
Best vision obtained with glasses is worse than 20/40 (< 6/12), or there is a significant decrease in vision under glare conditions (eg, oblique lighting while trying to read a chart) in a patient who complains of bothersome halos or starbursts
The sense that vision is limiting, such as preventing activities of daily living (eg, driving, reading, hobbies, occupational activities)
The potential exists for meaningfully improved vision if the cataract is removed (ie, a significant portion of the vision loss must be caused by the cataract)

Far less common indications include cataracts that cause glaucoma or the need to examine the fundus for the management of diseases such as diabetic retinopathy and glaucoma. There is no advantage to removing a cataract early.

Cataract extraction usually is done under topical or local anesthesia and IV sedation. There are 3 extraction techniques: intracapsular cataract extraction, in which the cataract and lens capsule are removed in one piece is rarely done; extracapsular cataract extraction, in which the hard central nucleus is removed in one piece and then the soft cortex is removed in multiple small pieces; and phacoemulsification, in which the hard central nucleus is dissolved by ultrasound and then the soft cortex is removed in multiple small pieces. Phacoemulsification requires the smallest incision, thus enabling the fastest healing, and is usually the preferred procedure. In extracapsular extraction (including phacoemulsification), the lens capsule is not removed.

A plastic or silicone lens is almost always implanted intraocularly to replace the optical focusing power lost by removal of the crystalline lens. The lens implant is usually placed on or within the lens capsule (posterior chamber lens). The lens also can be placed in front of the iris (anterior chamber lens) or attached to the iris and within the pupil (iris plane lens). Iris plane lenses are rarely used in the US because many designs led to a high frequency of postoperative complications. Multifocal intraocular lenses are newer and have different focusing zones that may reduce dependence on glasses following surgery. Patients occasionally experience glare or halos with these lenses, especially under low light conditions.

In most cases, a tapering schedule of topical antibiotics (eg, moxifloxacin

0.5% 1 drop
qid) and topical corticosteroids (eg, prednisolone

acetate 1% 1 drop qid) is used for up
to 4 wk postsurgery. Patients often wear an eye shield while sleeping and should avoid the Valsalva maneuver, heavy lifting, excessive forward bending, and eye rubbing for several weeks.

Major complications of cataract surgery are rare. Complications include the following:
Intraoperative: Bleeding beneath the retina, causing the intraocular contents to extrude through the incision (choroidal hemorrhage), vitreous prolapsing out of the incision (vitreous loss), fragments of the cataract dislocating into the vitreous, incisional burn, and detachment of corneal endothelium and its basement membrane (Descemet’s membrane)
Within the 1st week: Endophthalmitis (infection within the eye) and glaucoma
Within the 1st month: Cystoid macular edema
Months later: Bullous keratopathy (ie, swelling of the cornea from damage to the corneal “pump” cells during cataract surgery), retinal detachment, and posterior capsular opacification (common, but treatable with laser)

When preexisting disorders such as amblyopia, retinopathy, macular degeneration, and glaucoma are excluded, 95% of eyes achieve vision of 20/40 (6/12) or better. If an intraocular lens is not implanted, contact lenses or thick glasses are needed to correct the resulting hyperopia.

Prevention

Many ophthalmologists recommend ultraviolet-coated eyeglasses or sunglasses as a preventive measure. Reducing risk factors such as alcohol, tobacco, and corticosteroids and controlling blood glucose in diabetes delay onset. A diet high in vitamin C, vitamin A, and substances known as carotenoids (contained in vegetables such as spinach and kale) may protect against cataracts.

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