Ophtalmic Record Examiners :
Catherine Maname Uli Purnomo Hyaswicaksono Ferry Kurniawan Birgitta Wangsa Chrestella Hartanuh Aurelia Vania Farrell Tanoto Yuanita Buiman
I. Pati Patien entt ident identit ity y !ame " Ms# $ $e% " Female Age " &' years ol (thnic " )a*anese +eligion " ,slam -ccu.ation " ,ce cream seller Aress " Muara Angke II. History History taking Chie/ com.laint" Patient /eel her *ision were 0lurre1 0oth o/ her eyes since & year 0e/ore
amission# Aitional Aitional com.laint" com.laint" Patient Patient /elt 0oth o/ her eyes /eel tire1 i22y1 i22y1 /eeling tire easily1 easily1 .hoto.ho0ia 3451 lacrimation 3451 itchy# itchy# History o/ .resent illness" $ince & years 0e/ore amission1 .atient /eel her right eyes start starte e to 0lur 0lur11 then then her her le/t le/t eye# eye# $he $he sai sai its its so har har to recogni2e other .eo.le# $he also starte to 0e a/rai to greet .eo.le she met an 0um.e them them while walking# Past occular history" -.# Cataract -6 last month1 month1 history o/ using eye7glasses was enie# 8eneral 8eneral meical " ia0etes ia0etes was enie1 allergy allergy was enie1 enie1 hy.ertensio hy.ertension n 345 Familial meical meical history" no .re*ious history o/ same com.laint com.laint no .re*ious history o/ systemic isease no .re*ious .re*ious history o/ malignancy III. III. Gener General al status status 8eneral conition 9e*el o/ o/ co consciousness Bloo .ressure Heart rate +es.iratory rate Tem.erature
" /atigue " /u /ully aw awake " :&;<=; mmHg " >? " @; " 'oC
IV. Ophtalamic status
Periocular a..earance 8eneral conition (ye0all .osition (ye0all mo*ement Visual acuity $u.ercillia Cilia $u.<,n/ Margo Pal.e0ra $u.<,n/ Tarsal Conuncti*a Bul0ar conuncti*a Cornea
-
Clearness (ema ,n/iltrate Ulcer Crust 6estruction
Right eye !ormal Well -rtho.horic Can mo*e to > irections ?<&; Full1 symetric !ormal Well7.ositione Hy.eremic
Let eye !ormal Well -rtho.horic Can mo*e to > irections ?<'; 3$4@#?5 ?
!ormal
!ormal
Clear
-
Clear 7 7 7 7
Anterior Cham0er ,ris Pu.il
9ens Pal.e0ra
V.
!ummary
Mil e.th
7 Mil e.th
Clear 6arkish 0rown
Clear 6arkish 0rown
Cry.t 345 Center
Cry.t 345 Center
+oun
+oun
∅ 'mm
∅ 'mm
9ight re/le% 345<345
9ight re/le% 345<345
,sochoric Pseuo.hacia
,sochoric Clouy 3.osterior
Hy.eremic 4
su0ca.sular5 Hy.eremic 4
eema 4
eema 4
tenerness 4
tenerness 4
noule 7
noule 7
&' y#o# /emale came with com.laint ha*ing 0lurry *ision 0oth o/ her eyes since & years 0e/ore amission# $he also /eel /atigue1 .hoto.ho0ic1 watery# History o/ trauma was enie1 an she hasnDt taken any meication# Few months 0e/ore amission1 she canDt recogni2e other .eo.le /ace an starte to 0um. them while walking# From the eye e%am we /oun reuce *isual acuity1 an clouy lens# VI.
"linical diagnosis Pre7senile immature .osterior su0ca.sular cataract
VII. #ierential diagnosis Pre7senile immature .osterior .olar cataract Congenital .osterior .olar cataract VIII. $reatment
I%.
-6$
" micro incision cataract e%traction 3PHAC-5
Meication
" Tro0oson : ro.s<@ hour
!uggested examination
$lit lam. e%amination %.
Prognosis Euo a *itam " 0onam Euo a /unctionam " u0ia a 0onam Euo a sanationam " u0ia a 0onam
%I.
"omplication +u.ture or atro.hy o/ the o.tical ner*e
%II. #iscussion #einition Any o.acity o/ the eye lens than can 0e cause 0y lens hyration1 lens .rotein
enaturation1 or 0oth# "lassiication Base on .atientsD ages1 cataracts can 0e classi/ie as" :# Congenital cataract" cataract that ha..ens 0e/ore or soon a/ter 0irth an the 0a0y is
uner one years ol# Congenital cataract can 0e i*ie into /our ty.es" a# onular or lamellar Most common ty.e o/ congenital cataract# This ty.e is characteri2e 0y white o.acities that surroun the nucleus with alternating clear an white cortical lamella like an onion skin# 9amellar cataract usually in*ol*es 0ilateral eyes#
0#
Polar This ty.e is characteri2e 0y small o.acities o/ the lens ca.sule an aacent corte% on the anterior or .osterior .ole o/ the lens# This .olar ty.e usually has
little e/ect on *ision# c# !uclear !uclear ty.e has o.acity within em0ryonic
coral /lower# Posterior lenticonus This ty.e is characteri2e 0y a .osterior .rotrusion1 usually o.aci/ie 1 in the
.osterior ca.sule# 2. )u*enile cataract" cataract which ha..ens a/ter one years ol an occurs in young .eo.le uner @; years ol# The o.acity o/ lens in u*enile cataract occurs when lens '# &#
/i0ers is still e*elo.ing1 so it has so/t consistency 3so/t cataract5# Pre7senile cataract" cataract which occurs until ?; years ol# $enile cataract" cataract which occurs a/ter ?; years ol# $enile cataract is associate with the aging .rocess in the lens# The changes inclue increasing thickness o/ nucleus with the e*elo.ing o/ corte% lens# $tage o/ the senile cataract" a# ,nci.ient cataract" irregular o.acity likes cogwheel7like s.ot# ,n this stage1 .olyo.ia is common com.laints 0ecause o/ the asimilarity o/ re/raction ine% 0#
in all .art o/ lens# ,mmature cataract" thicker o.acity 0ut it hasnDt in*ol*e all .art o/ lens# ,n this stage1 hyration o/ corte% causes intumescence lens# ,ntumescence lens causes
c#
changes o/ re/raction ine% which the eyes 0ecomes myo.ic# Mature cataract" all o/ lens .rotein is o.aue# The lens /lui will come out
#
/rom lens1 so the si2e o/ lens will 0e normal again# Hy.ermature cataract" later egeneration .rocess will cause the lens 0ecome liui# This liui may esca.e through the intact ca.sule1 lea*ing a shrunken lens with a wrinkle ca.sule# A hy.ermature cataract in which the lens nucleus /loats /reely in the ca.sular 0ag is calle a morgagnian cataract#
The 6i//erences Between $enile Cataract $taging Opacity Lens luid Iris 'nteriorcham(er !hado) test
Incipient mil normal normal
Immature moerate increase G0eing
&ature se*ere normal normal
Hypermature massi*e ecrease tremulans
normal negati*e
.ushe shallow .ositi*e
normal negati/
ee. Pseuo.ositi*e
Based on location of opacities, cataract can be classied as:
a. Nuclear cataract Nucleus of adult lens will increase and become sclerotic. This later white nuclear will become yellow, brown, and black, and it is called brunescence cataract (nira cataract!. b. "ortical cataract #arly stae cortical cataract demonstrates water clefts and $acuoles, which may chane o$er time resultin in irre$ersible opacities. %n a more ad$anced stae, spoke-like or wede-shaped peripheral opacities proress circumferentially, initially sparin the clear central a&is of the lens. %t can cause lare and often asymptomatic until central chanes c.
de$elop. 'osterior subcapsular cataract 'lauelike opacity near the posterior aspect of the lens. )lare and reduced $ision under briht lihtin are common complaints. This cataract type classically occurs in patients *+ years. 'osterior subcapsular cataract is associated with ocular inammation, steroid use,
diabetes, trauma, or radiation. d. 'osterior polar cataract posterior polar cataract is a round, discoid, opaue mass that is composed of malformed and distorted lens bers located in the central posterior part of the lens. posterior polar cataract consists of dysplastic lens bers, which, in ther miration posteriorly lens opacity with the formation of a characteristic discoid posterior polar plauelike cataract. e. nterior polar cataract /ay present as a conenital (autosomal dominantly inherited! or acuired cataract secondary to u$eitis or trauma (associated with anterior subcapsular opacities!. 0mall anterior polar opacication usually is sharply dened. The 1ens pacities "lassication 0ystem %%% (1"0 %%%! is a standard system used for radin and comparison of cataract se$erity and type342. %t was deri$ed from the 1"0 %% classication5, and it consist of three sets of standardi6ed photoraphs. The classication e$aluates four features: nuclear opalescence (N!, nuclear color (N"!, cortical cataract ("!, posterior subcapsular cataract ('!. Nuclear opalesecence (N! and nuclear color (N"! are raded on a decimal scale of .3 to 7.8, based on a set of si& standardi6ed photoraphs. "ortical cataract ("! and posterior subcapsular cataract ('! are raded on a decimal scale of .3 to +.8, based on a set of $e standardi6ed photoraphs each.
*igure +
Etiology and Risk *actor :# Congenital cataract" - ,io.athic - Familial1 autosomal ominant - +u0ella" .early white nuclear cataract - Maternal ia0etes mellitus1 to%o.lasmosis @# Acuire cataract" - Age7relate cataract - Traumatic cataract Traumatic cataract is most commonly ue to a /oreign 0oy inury to the lens
or 0lunt trauma to the eye0all# The lens 0ecomes white soon a/ter the entry o/ a /oreign 0oy1 since interru.tion o/ the lens ca.sule allows aueous an sometimes *itreous to .enetrate into the lens structure# - Com.licate cataract o Cataract seconary to intraocular isease Cataract may e*elo. as a irect e//ect o/ intraocular isease u.on the .hysiology o/ the lens1 e%am.le" u*eitis 3.osterior su0ca.sular cataract51 glaucoma 3cataract *ogt" anterior su0ka.sular .ungtata cataract51 retina o
a0latio1 an se*ere myo.ia# Cataract associate with systemic isease This cataract usually in*ol*e 0oth o/ eyes although it may not a..ear in the same time# The e%am.le o/ systemic isease that can cause cataract are ia0etes mellitus 3white snow/lake o.acities in the anterior an .osterior su0ca.sular hy.ocalcemia#
locations51
hy.o.aratyroiism1
myotonia
ystro.hy1
- 6rug7inuce Cataract 6rugs that can inuce lens o.acities inclue sterois1 miotics1 anti.syhotics# - A/ter7Cataract 3$econary Cataract5 A/ter7Cataract enotes o.aci/ication o/ .osterior ca.sule /ollowing e%traca.sular cataract e%traction or .hacoemulci/ication# This cataract ty.e thickening o/ .osterior ca.sule cause 0y in/lammatory cell .roli/eration in resiue corte%1 gi*ing the .osterior ca.sule a I/ish eggI a..earance 3(lschnigJs .earls5# Epidemiology At least ';;#;;;7&;;#;;; new *isually isa0ling cataract occur annually in the Unite
$tates# For the olest age grou.1 ? years an oler1 the nuclear1 cortical1 an .osterior su0ca.sular cataracts were /oun in ?1?L1 @1L1 an :=1L o/ the stuy .o.ulation1 res.ecti*ely# ,n the Framingham (ye $tuy /rom :='7:=?1 /emales ha a higher than males in 0oth lens changes 3'L *s ?&1:L5 an senile cataract 3:1:L *s :'1@L5# Pathogenesis o pre,senile cataract The term .resenile cataract is use when the cataractous changes similar to senile
cataract occur 0e/ore ?; years o/ age# ,ts common causes are" 1. Heredity. As mentione a0o*e 0ecause o/ in/luence o/ hereity1 the cataractous 2.
changes may occur at an earlier age in successi*e generations#: Diabetes mellitus. Age7relate cataract occurs earlier in ia0etics# !uclear
3.
cataract is more common an tens to .rogress ra.ily# Myotonic dystrophy is associate with .osterior su0ca.sular ty.e o/ .resenile
4.
cataract# Atopic dermatitis may 0e associate with .re7 senile cataract 3ato.ic cataract5 in :;L o/ the cases#
Mechanism of loss of transparency
,t is 0asically i//erent in nuclear an cortical senile cataracts# +.
Cortical senile cataract. ,ts main 0iochemical /eatures are ecrease le*els o/ total
.roteins1 amino acis an .otassium associate with increase concentration o/ soium an marke hyration o/ the lens1 /ollowe 0y coagulation o/ .roteins# The .ro0a0le course o/ e*ents leaing to senile o.aci/ication o/ corte% is as shown in the Figure -. Nuclear senile cataract. ,n it the usual egenerati*e changes are intensi/ication o/ the age7 relate nuclear sclerosis associate with ehyration an com.action o/
the nucleus resulting in a har cataract# ,t is accom.anie 0y a signi/icant increase in water insolu0le .roteins# Howe*er1 the total .rotein content an istri0ution o/ cations remain normal# There may or may not 0e associate e.osition o/ .igment urochrome an
*igure -
"linical &aniestation
The thickening o/ the lens sur/ace can 0e occurre without making any clinical signs or sym.toms1 an also can 0e /oun in routine eye check u.# The general signs an sym.toms o/ caratact are " •
Photo.ho0ia -ne o/ early sym.toms that is /elt 0y the .atient# The egree o/ the .hoto.ho0ia
•
e.ens on the location o/ the lession an the cataract stage# Unicolar .olyo.ia 3ou0le *ision5 (arly mani/estation# ,t is cause 0y the irreguler light e/lection .assing through
•
the lens# Coloure halo Cause 0y the is.ersion o/ the white light into colour s.ectrums an the water
• • •
ro.let on the lens# Black s.ot in /ront o/ the eye Blurry eye sight1 istortion o/ the image can 0e acuire in the early stage 6eclining *isual acuity to loss o/ eye sight# Can 0e *arious in any ty.e o/ cataract# Painless1 an .rogressi*e# Patient with central thickening o/ the lens 3ku.uli/orm5 o/ten lose the *ision in early stage# Patient with .eri/eral thickening o/ the lens comes with a late *ision lost#
#iagnosis History Taking
:# @#
Patient ata" name1 aress1 se%1 age<ate o/ 0irth1 race1 occu.ational Patient history" a# Chie/ com.laint" main .ro0lems an other .ro0lems 0# Present illness - Time - $e*erity - ,n/luences - Constancy - 9aterality - Clari/ication o/ certain com.laints - 6ocumentation c# Past ocular history" - 8lasses
-
isease 6ia0etes mellitus Thyroi isease Malignancy
Physical Examination
a#
Com.lete ocular e%amination1 incluing istance an near *ision1 .u.ilary e%amination1 an re/raction
0#
A ilate slit7lam. e%amination using 0oth irect an retroillumination techniues
c#
is reuire to *iew the cataract .ro.erly Funus e%amination1 concentrating on the macula1 is essential in ruling out other causes o/ ecrease *ision
Supported Examination
a# 0#
B7scan Ultrasonogra.hy ,/ /unus is o0scure to rule out etecta0le .osterior segment isease Keratometry reaings an an A7scan Ultrasonogra.hy Measurement o/ a%ial length are reuire /or etermining the .ower o/ the esire intraocular lens# Corneal .achymetry or enothelial cell count is occasionaly hel./ul i/ cornea guttata are .resent#
$reatment Bilateral cataract • Cataract e%traction is usually elaye until *isual loss a//ects the .atientJs li/e#
This is an inication o/ the relati*e an will *ary /rom .atient to .atient# This ty.e o/ cataract is im.ortant 0ecause cataracts can 0e associate with .osterior su07 ca.sular glare e*en though *isual acuity was relati*ely goo# ,t is im.ortant /or re/racti*e .atients care/ully an recor 0oth near an /ar *ision# To make recommenations cataract e%traction is im.ortant to know the li*es o/ .atients •
an *isual nees# Unilateral cataract (%traction is reuire i/ the .atient has a esire to work reuirements1 0inocular *ision1 or i/ the cataract 0ecomes hy.ermature# ,n some cases1 contact lens or .lastic lens im.lant will cause the image si2e an the .ossi0ility o/ euality o/ *ision 0inoculars# ,ntraocular lens im.lant is ieally .lace on the .osterior ca.sule#
Cataract Surgery
a#
,CC( is ,ntraca.sular Cataract (%traction1 all the com.onent o/ the lens is
0#
remo*e1 inclue the ca.sule# Usually .er/orm when 2onula 2inn is amage# (CC( 3(%traCa.sular Cataract (%traction5" classic1 $,C$ 3$mall ,ncision Cataract $urgery51 Micro incision with Phacoemulsi/ication# (CC( is .er/orme 0y making an o.ening on anterior .ole ca.sule1 lea*ing a 0owl7sha.e to .ut an ,ntra
-cular 9ens# Phacoemulsi/ication" is a metho to remo*e the har .art o/ cataract 0y using an ultrasoun1 then rain the remnant#
Prognosis ,/ there are no other eye iseases that accom.any 0e/ore surgery1 which will ha*e an
e//ect s.eci/ically on *ision such as ru.ture or egeneration o/ o.tic ner*e atro.hy1 a stanar (CC( or .haco7emulci/ication 0ring a *ery .romising .rognosis /or *ision in which at least can see the @ lines on the $nellen istance *ision chart # The main cause o/ *isual mor0iity is .osto.erati*e CM(# A maor risk /actors that a//ect the *isual .rognosis is the .resence o/ ia0etes mellitus an ia0etic retino.athy# Howe*er1 accoring to research 0y Kumar et al# .haco7emulci/ication .olar o.acity in the eye with the larger si2e has the risk o/ ca.sule ru.ture .osterior#
Reerences
:#
,lyas $1 Mailangkay HHB1 Taim H1 eitor# 9ensa Mata# ,lmu Penyakit Mata# ( ke7@# CV
@#
$agung $eto# @;:;" :&'# ,lyas H$# Penglihatan Turun Perlahan Tan.a Mata Merah# ,lmu Penyakit Mata# ( ke7'#
'#
Balai Pener0it FKU,# @;;=" @;;# (hlers )P1 $hah CP1 eitor# Acuire Cataract# The Wills (ye Manual# ( ke7&# 9i..incott
&#
Williams Wilkins# @;;&" '># (*a P+1 Whitcher )P1 eitor# Cataract# Vaughan As0ury Ns 8eneral -.thalmology# 9ange# @;;#
