Management of Cataract

By Kevin J Ambadan

MANAGEMENT OF

CATARACT

NON SURGICAL

MANAGEMENT

TREATMENT OF THE CAUSE OF CATARACT

• Adequate control of diabetes mellitus,

• Removal of cataractogenic drugs such as

corticosteroids, phenothiazenes and

strong miotics

• Removal of irradiation (infrared or X-rays)

• Early and adequate treatment of ocular

diseases like uveitis

MEASURES TO DELAY PROGRESSION

• Commercially available preparations

containing iodide salts of calcium and

potassium are being prescribed in

abundance in early stages of cataract

• Vit E and aspirin also delays the process

of cataractogenesis

MEASURES TO IMPROVE CATARACT IN THE

PRESENCE OF INCIPIENT AND IMMATURE

CATARACT

• Refraction should be corrected at frequent

intervals

• Arrangement of illumination-patients with

peripheral opacities brilliant illumination

• Use of dark goggles in patients with central

opacities

• Mydriatics- 5%phenyephrine or 1%

tropicamide b.i.d in affected eye

SURGICAL

MANAGEMENT

INDICATIONS

a) Visual improvement

b) Medical indications:

-Lens induced glaucoma

-Phacoanaphylactic endophthalmitis

-Retinal diseases like diabetic retinopathy or

retinal detachment

c) Cosmetic indication-to obtain black

pupil

PREOPERATIVE

EVALUATION

I. GENERAL MEDICAL EXAMINATION OF

THE PATIENT

II. OCULAR EXAMINATION

The following information is essential before

the patient is considered for surgery:

A. RETINAL FUNCTION TESTS

i. Light Perception

ii. Test for Marcus Gunn pupillary

response

iii. Projection of rays - Test for function of

peripheral retina

iv. Two light discrimination test - Macular

function

v. Maddox rod test

vi. Colour perception-macular function

and optic nerve

vii. Entoptic visualisation-retinal function

viii. Laser interferometry

ix. Objective tests for evaluating retina-

ultrasonic evaluation, ERG, EOG, VER

and indirect ophthalmoscopy

III. SEARCH FOR LOCAL SOURCE OF

INFECTION - to rule out conjunctival infection

or lacrimal sac infection

IV. ANTERIOR SEGMENT EVALUATION

V. IOP MEASURMENT - raised IOP needs priority

management

PRE-OP MEDICATIONS AND PREPERATIONS

1. TOPICAL ANTIBIOTICS - Tobramycin and Gentamicin QID for 3days before surgery

2. PREPARATION OF THE EYE TO BE OPERATED

3. CONSENT

4. SCRUB BATH AND CARE OF HAIR

5. DRUGS TO LOWER IOP - Acetazolamide 500mg stat 2hrs before surgery and Glycerol 60ml mixed with water 1hr before surgery

6. DRUGS TO SUSTAIN DILATED PUPIL -AntiProstaglandin eye drops(Indomethacin)

ANAESTHESIA

Cataract extraction can be performed

under gen or local anaesthesia. Local is

preferred.

SURGICAL TECHNIQUE

FOR CATARACT

EXTRACTION

INTRACAPSULAR CATARACT EXTRACTION

• The entire cataractous lens along with the intact

capsule is removed.

• Therefore weak and degenerated zonules are a

pre-requisite for this method. Because of this

reason, this technique cannot be employed in

younger patients where zonules are strong.

• ICCE can be performed between 40-50 years of

age by use of the enzyme alphachymotrypsin

(which will dissolve the zonules).

• Beyond 50 years of age usually there is no need of

this enzyme.

INDICATION

- Subluxated and dislocated lens

SURGICAL STEPS OF ICCE TECHNIQUE:

i. Superior rectus (bridle) suture

ii. Conjunctival flap

iii. Partial thickness groove/gutter

iv. Corneoscleral section

v. Iridectomy

vi. Methods of lens delivery

• Indian smith method

• Cryoextraction

• Capsule forceps method

• Irisophake method

• Wire vectis method

vii. Formation of Anterior Chamber

viii. Implantation of anterior chamber IOL(ACIOL)

ix. Closure of incision- 5-7 interrupted sutures

x. Conjunctival flap reposited

xi. Subconjunctival injection-dexamethasone

0.25ml and gentamicin 0.5ml given

xii. Patching of the eye

A. Passing of superior rectus

suture

B. Fornix based conjunctival

flap

C. Partial thickness groove

D. Completion of

corneoscleral section

E. Peripheral iridectomy

F. Cryolens extraction

G. Insertion of Kelman

multiflex IOL in anterior

chamber

H. Insertion of Kelman

multiflex IOL in anterior

chamber

I. Corneo-scleral suturing

EXTRACAPSULAR CATARACT EXTRACTION

• Major portion of anterior capsule with

epithelium, nucleus and cortex are

removed; leaving behind intact posterior

capsule.

• Indications: Presently, it is the surgery of

choice for all types of adulthood as well

as childhood cataracts unless

contraindicated.

• Contraindications - Subluxated and

dislocated lens

TYPES OF EXTRACAPSULAR CATARACT EXTRACTION

a) Conventional Extracapsular Cataract

Extraction (ECCE)

b) Manual Small Incision Cataract Surgery

(SICS),

c) Phacoemulsification

CONVENTIONAL ECCE

i. Superior rectus (bridle) suture

ii. Conjunctival flap (fornix based)

iii. Partial thickness groove/gutter

iv. Corneoscleral section.

v. Injection of viscoelastic substance in

anterior chamber - 2% MethylCellulose or

1% Sodium Hyaluronate (Maintains anterior

chamber and protects endothelium)

vi.Anterior capsulotomy.

• Can-opener's technique

• Linear capsulotomy (Envelope technique)

• Continuous circular capsulorrhexis (CCC)

vii.Removal of anterior capsule

viii.Completion of corneoscleral section

ix. Hydrodissection (ie., seperation of capsule from

cortex by injecting fluid between the two) -

Balanced salt solution injected under peripheral

part of ant capsule to separate corticonuclear

mass from the capsule

x. Removal of nucleus

After hydrodissection the nucleus can be

removed by any of the following techniques:

• Pressure and counter-pressure method

• Irrigating wire vectis technique

xi. Aspiration of the cortex

xii. Implantation of IOL

xiii.Closure of the incision - 3-5 interrupted sutures

xiv. Removal of viscoelastic substance

xv. Conjunctival flap is reposited and secured

xvi. Subconjunctival injection

xvii. Patching of eye

A. Anterior capsulotomy Can

Opener's technique

B. Removal of anterior capsule

C. Completion of corneo-scleral

section

D. Removal of nucleus (pressure

and counter-pressure method)

E. Aspiration of cortex

F. Insertion of inferior haptic of

posterior chamber IOL

G. Insertion of superior haptic of

PCIOL

H. Dialing of the IOL

I. Corneo-scleral suturing

MANUAL SMALL INCISION CATARACT

SURGERY

1. Superior rectus suture

2. Conjunctival flap and exposure of sclera

3. Haemostasis

4. Sclero corneal tunnel incision:

External scleral incision - 5.5mm to 7.5mm

Sclero corneal tunnel - 1-1.5mm

Internal corneal incision

5. Side port entry

6.Anterior capsulotomy - can be can-

openers,envelope or continuous circular

capsulorrhexis (CCC)

7.Hydrodissection

8.Nuclear management

a)prolapse of nucleus into ant chamber

b)delivery of nucleus through corneoscleral

tunnel

9.Aspiration of cortex

10.IOL implantation

11.Removal of viscoelastic material

12.Wound closure

A. Superior rectus bridle suture

B. Conjunctival flap and exposure of sclera

C, D & E. External Scleral incisions (straight,

frown shaped, and chevron,

respectively) part of tunnel incision

F. Sclero-corneal tunnel with crescent knife

G. nternal corneal incision

H. Side port entry

I. Anterior capsulotomy-Large CCC

J. Hydrodissection

K. Prolapse of nucleus into anterior chamber

L. Nucleus delivery with irrigating

wire vectis

M. Aspiration of cortex

N. Insertion of inferior haptic of posterior

chamber IOL

O. Insertion of

superior haptic of PCIOL

P. Dialing of the IOL

Q. Reposition and anchoring of conjunctival flap.

PHACOEMULSIFICATION

1. Corneoscleral incision-very small 3mm

2. Continuous curvilinear capsulorrhexis of

4-6mm

3. Hydrodissection

4. Nucleus is emulsified and aspirated

5. Remaining cortical lens matter is

aspirated

6. IOL Implantation

7. Removal of viscoelastic material

8. Wound closure

A. Continuous curvilinear capsulorrhexis

B. Hydrodissection;

C. Hydrodelineation

D & E. Nucleus emulsification by divide and conquer technique

F. Aspiration of cortex.

SURGICAL TECHNIQUE FOR ECCE FOR

CHILDHOOD CATARACT

Surgical techniques employed for childhood

cataract are essentially of two types:

• Irrigation and aspiration of lens

matter

• Lensectomy

1. Irrigation and aspiration of lens matter

i. Conventional ECCE technique

ii. Corneo-scleral tunnel techniques which

include :

• Manual SICS technique

• Phaco-aspiration technique

SURGICAL STEPS OF IRRIGATION AND

ASPIRATION OF LENS MATTER BY

CORNEOSCLERAL TUNNEL INCISION

1-5. Initial steps upto making of side port entry are

same as SICS

6. Anterior capsulorhexis of about 5mm size

7. Irrigation and aspiration of lens matter

8. Posterior capsulorhexis of about 3-4 mm size is

recommended in children to avoid posterior capsule opacification

9. Anterior vitrectomy

10. Implantation of IOL after inflating capsular bag

with viscoelastic substance-heparin or flourine

coated PMMA IOL preferred in children.

11. Removal of viscoelastic substance is done

12. Wound closure.

LENSECTOMY

In this operation most of the lens including anterior

and posterior capsule along with anterior vitreous

are removed with the help of a vitreous cutter,

infusion and suction machine .

Childhood cataracts, both

congenital/developmental and acquired, being

soft are easily dealt with this procedure especially

in very young children (less than 2 years of age) in

which primary IOL implantation is not planned.

Lensectomy in children is performed under general

anaesthesia

INTRAOCULAR LENS IMPLANTATION

Presently, intraocular lens (IOL) implantation is the method of choice for correcting aphakia.

Types of intraocular lenses:

The commonly used material for their manufacture of lens is polymethylmethacrylate (PMMA).

The major classes of IOLs based on the method of fixation in the eye are as follows:

1. Anterior chamber IOL

• Lie entirely in front of the iris and are supported in the angle of anterior chamber.

• ACIOL can be inserted after ICCE or ECCE.

• Not very popular due to comparatively higher incidence of bullous keratopathy.

• When indicated, ‘Kelman multiflex’ type of ACIOL is used commonly.

2. Iris-supported lenses

• These lenses are fixed on the iris with the help of sutures, loops or

claws.

• High incidence of postoperative complications.

• Example of iris supported lens is Singh and Worst’s iris claw lens .

3. Posterior chamber lenses

• PCIOLs rest entirely behind the iris . They may be supported by the

ciliary sulcus or the capsular bag. Commonly used model of

PCIOLs is modified C-loop .

• Depending on the material of manufacturing, three types of

PCIOLs are available:

i. Rigid IOLs -made entirely from PMMA.

ii. Foldable IOLs-made of silicone, acrylic, hydrogel and

collamer.

iii. Rollable IOLs are ultra thin IOLs-These are made of hydrogel.

Kelman multiflex Singh & Worst's iris claw lens Posterior chamber IOL

(an anterior chamber IOL) (modified C-loop type)

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