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1. Management of Adult Cataract
Prof. Naimatullah Khan Kundi
Head, Department of Ophthalmology
Khyber Teaching Hospital
Peshawar

2. Cataract Surgery
Types:
1. ICCE
1. ECCE
 Standard (Manual Nuclear Expression)
 Phacoemulsification (Ultrasonic Nuclear
Fragmentation)
Management of Adult Cataract

3. Cataract Surgery
Intra Capsular Cataract Extraction (ICCE)
Definition:
 Removal of cataractous lens in its entirety
from the eye
 Complete removal of the lens and its capsule

4. Cataract Surgery
Extra Capsular Cataract Extraction (ECCE)
Definition:
 ECCE involves removal of the nucleus and cortex
through an opening in the anterior capsule,
leaving the posterior capsule in place

5. Cataract Surgery
ICCE
 ICCE evolved into a very successful operation
 Preferred surgical technique before the refinement of
modern ECCE surgery
 However there remained 5% rate of potentially
blinding complications including:
 Infection
 Hemorrhage
 RD
 CME

6. Cataract Surgery
 ECCE has replaced ICCE, almost entirely in most
parts of the world:
1. Better operating microscopes
2. More sophisticated surgical aspiration systems
3. More sophisticated IOL implants

7. Pre-operative evaluation and information
 General health
 Drug History
 Ocular and social histories
 Ocular examination
 Measurement of visual function
 Preoperative measurement

8. Pre-operative evaluation and information
 General health
 A complete medical history starting point
 Ophthalmic surgeon should work with patient’s
primary care physician to achieve optimal
management of all medical problems like:
 DM
 IHD
 COPD
 Bleeding Disorders
 Adrenal Suppression by Corticosteroids

9. Pre-operative evaluation and information
 Awareness of any Drug sensitivities and
medications:
 Immunosuppressants
 Anticoagulants:
These may alter the outcome of surgery

10. Pre-operative evaluation and information
 Ocular history
 Helps ophthalmologist identify conditions that
could affect:
 Surgical Approach
 Visual Prognosis
 Hx of:
 Trauma
 Inflammation
 Amblyopia can affect visual prognosis
 Glaucoma
 Optic nerve
 Retinal disease
 Past record may show patient’s visual acuity prior
to development of cataract

11. Pre-operative evaluation and information
 Ocular history (cont’d)
 Information about the postoperative course in
fellow eye
 Any problem in the first operation:
 ↑ IOP
 Vitreous loss
 CME
 Endophthalmitis
 Hemorrhage
 The surgical approach & post operative follow-up can be
modified for the 2nd
operation to ↓ risk of similar
complications

12. Pre-operative evaluation and information
 Social History
 Important for documenting patient’s subjective
visual disability
 Surgeons should be aware of patient’s occupation
and life style

13. External examination (pre-op Evaluation)
 Body habits:
 Bull Neck, Kyphosis, Obesity, Head Tremor
 These have effect on surgical approach
 Enophthalmos, prominent brow
 Entropion, Ectropion & other lid abnormalities noted
and treated
 Blepharitis: Diagnosed and treated
 Abnormal tear dynamics, exposure keratitis ↓ corneal
sensation noted

14. External examination (pre-op Evaluation)
 Motility:
 Ocular alignment evaluated
 EOM tested for their range of movements
 Cover testing (muscle balance):
 Any abnormality might suggest pre-existing strabismus
with amblyopia as cause of visual loss
 Tropia: may result in diplopia following surgery

15. External examination (pre-op Evaluation)
 Pupil
 Pupillary responses to light and accommodation
evaluated
 Direct & consensual constriction of pupil
 Swinging-flashlight Test:
 To detect RAPD (Indicative of serious
retinal / optic nerve dysfunction)

16. External examination (pre-op Evaluation)
 Biomicroscopic examination
 Conjunctiva
 Scarring / lack of mobility over sclera
 Symblepharon / shortening of fornices
(underlying systemic/ocular surface disease):
 Can limit surgical approach
 Loss of vascularization (Previous chemical
injury / scarring from ocular surgery):
 Change in surgical approach

17. External examination (pre-op Evaluation)
 Biomicroscopic examination
 Conrnea
 Corneal thickness, presence of Guttata and
marked abnormalities of endothelium
 Specular reflection and SL examination
provide estimate of endothelial cell count and
morphology

18. External examination (pre-op Evaluation)
 Biomicroscopic examination
 Conrnea (cont’d)
 Thickness> 600 µm suggest poor prognosis
for corneal clarity following cataract surgery.
Surgery tailored to minimize trauma to corneal
endothelium
 Cornea inspected for corneal arcus / stromal
opacities (may limit view during surgery)

19. External examination (pre-op Evaluation)
 Biomicroscopic examination
 Anterior Chamber
 Shallow AC:
 Intumescent lens
 Forward displacement by posterior pathology
(e.g. CB Tumor)
 AC depth observation and lens nucleus size:
 Help surgeon plan and choose between
expression / phacoemulsification
 Preoperative gonioscopy (esp. when AC-IOL is
anticipated)
 PAS
 Neovascularization
 Prominent major arterial circle

20. External examination (pre-op Evaluation)
 Biomicroscopic examination
 Iris
 Pupil size after dilation noted (important for
planning surgical technique)
 Presence of PS noted
 Poor pupillary dilation: the following measures
may provide adequate exposure
1. Radial iridotomy
2. Sector iridectomy
3. Posterior synechiolysis
4. Sphincterotomy
5. Iris retraction

21. External examination (pre-op Evaluation)
 Biomicroscopic examination
 Lens
 Lens appearance noted before and after dilation of pupil
 Visual significance of “oil droplet” nuclear cataracts and
small PSCs best appreciated before dilation of pupil
 Exfoliation syndrome best seen following dilation
 Nuclear size and brunescence evaluated for
phacoemulcification (after dilation)

22. External examination (pre-op Evaluation)
 Biomicroscopic examination
 Lens (cont’d)
 Medial clarity in visual axis evaluated to
assess lenticular contribution to the visual
deficit
 Posterior capsule focused with thin SL beam,
the light then changed to cobalt blue and if PC
no longer illuminated, the media is 20/50 or
worse (blue light scatter)

23. External examination (pre-op Evaluation)
 Biomicroscopic examination
 Lens (cont’d)
 PSC (small) may cause severe visual loss:
 Conversely dense brunescent nuclear sclerotic
cataracts may allow surprisingly good visual
acuity

24. External examination (pre-op Evaluation)
 Biomicroscopic examination
 Lens (cont’d)
 Lens position and zonular fibers integrity also
evaluated
 Lens decentration
 Excessive distance between lens and
pupillary margin (may indicate subluxation)
 Indentation/flattening of lens periphery
might indicate focal loss of zonular support

25. Fundus Evaluation
 Ophthalmoscopy (Direct & Indirect)
1. Anatomical integrity of posterior segment assessed
2. Media clarity (direct opthalmoscope)
3. Macular, ON, Retinal vessels, Retinal periphery
evaluated
4. ARM may limit visual rehabilitation after otherwise
uneventful cataract ext.

26. Fundus Evaluation
 Ophthalmoscopy (Direct & Indirect) (cont’d)
5. Diabetic patients examined carefully for:
 Macular edema
 Retinal ischaemia
 Neovascularization ±
Retinal ischaemia may progress to posterior or
anterior neovascularization in case of
 ICCE or
 ECCE (with PC rupture)

27. Fundus Evaluation
 Ophthalmoscopy (Direct & Indirect) (cont’d)
6. Peripheral retinal examination may reveal:
 Vitreo-retinal traction
 Lattice degeneration
 Preexisting retinal holes
ICCE & Primary decision of PC are associated with
↑ incidence of RD and CME
Which may warrant
preoperative treatment

28. Optic Nerve
 Examined for color, CD ratio or any other
abnormality
 ON functions further evaluated by:
 VA
 Confrontation VF testing
 Pupillary Examination

29. Other Methods
Mature cataract prevents direct visualization of
posterior segment
 B-Scan ultrasonography
 RD
 Posterior segment tumor
 Light projection
 Maddox Rod projection
Helpful in detecting
retinal pathology

30. Measurements of visual function
1. VA Testing
2. Brightness Acuity
3. Contrast Sensitivity
4. Visual Field Testing

31. Measurements of visual function
1. VA Testing
 Test both near and distant visual acuity
 Refraction to determine BCVA
 PH VA
 VA can improve after pupillary dilation (esp. in PSC)

32. Measurements of visual function
2. Brightness Acuity
 Test near and distance visual acuity in well lighted
room of patient with complaint of glare
 Under these conditions, patient with cataract shows
↓ 3 or more lines compared with VA in the dark
 Variety of instruments available to standardize and
facilitate this measurement

33. Measurements of visual function
3. Contrast Sensitivity
 Patients with cataracts may experience ↓ contrast
sensitivity even when Snellen acuity is preserved
 Variety of instruments and charts available to test
in clinical setting

34. Measurements of visual function
4. Visual Field Testing (VFT)
 VFT may help to identify visual loss from other
disease process:
 Glaucoma
 ON disease
 Retinal abnormalities
 Confrontation VFs should be tested
 Goldmann or automated VF testing helps to
document degree of preoperative visual loss
 Light projection helpful to test peripheral VF in
patients with dense cataracts

35. Measurements of visual function
5. Special Tests
1. Potential acuity estimation
 Helpful in assessing the lenticular contribution to
visual loss
 Methods:
 Laser interferometry
 Potential acuity meter

36. Measurements of visual function
5. Special Tests
1. Potential acuity estimation (cont’d)
 Laser interferometer:
 Twin sources of monochromic helium-neon laser
light creates a diffraction fringe pattern on the
retinal surface
 Transmission of this pattern mostly independent
of lens opacities
 Retinal VA estimated by varying the spacing of
the fringe

37. Measurements of visual function
5. Special Tests
1. Potential acuity estimation
 Laser interferometer (cont’d)
 The area of pattern subtending the retina is considerably
larger than fovea
 Thus small foveal lesions that limit VA may not be
detected
 Potential acuity meter: Projects a numerical or
snellen vision chart through a small entrance pupil
 Image can be projected into the eye around lenticular
opacities

38. Measurements of visual function
5. Special Tests
1. Potential acuity estimation
 Potential acuity meter
 Projects a numerical or Snellen vision chart through a
small entrance pupil
 Image can be projected into the eye around lenticular
opacities

39. Measurements of visual function
5. Special Tests
1. Potential acuity estimation (cont’d)
 Laser interfermeter & potential acuity meter
determinations useful in estimating VA before surgery
 Both much predictive in moderate lens opacities
 Misleading In:
 ARM
 Amblyopia
 Glaucoma
 Serous Retinal Detachment
 Small macular scar
 Macular edema
 Accurate clinical examination of the eye is as good
a predictor of the visual outcome as these tests

40. Measurements of visual function
 Cataracts obstruct fundus view
 Direct examination may be difficult
1. Maddox Rod
2. Photo-Stress Recovery Test
3. Blue-light entoptoscopy
4. Purkinje’s entoptic phenomenon
5. Electro-retino-graphy (ERG)
These tests measure
function rather than
appearance

41. Measurements of visual function
1. Maddox Rod
 Red line viewed by the patient (orientation)
 Grossly evaluates macular function
 Large scotoma appears as loss of red line as
viewed by the patient

42. Measurements of visual function
2. Photo-stress recovery test
 Photo stress recovery time used to semiquantitavely judge
macular function
 Penlight shown into a normal eye (photo stress) and
recovery period noted
 This period is necessary before the patient can identify the
Snellen letters one line larger than that individual’s baseline
VA (photo stress recovery time)
 Normal average time: 27 sec. With std. Deviation of 11 sec.
 In most cases this time is 50 sec. Or less
 Prolonged time is an indication of macular disease

43. Measurements of visual function
3. Blue-light entoptoscopy
 Patient is asked to view intense, homogenous
blue-light background
 White blood cells produce shadows as they course
through perifoveal capillaries
 If the patient sees these shadows, macular
function is probably intact
 Many patients find the test difficult to comprehend,
which limits its usefulness

44. Measurements of visual function
4. Purkingje’s Entoptic Phenomenon
 Subjective test
 Rapidly oscillating point source of light is shown
through closed eye lids
 Ability of the patient to detect shadow images of
his/her retinal vasculature provides a very rough
indication that retina is attached

45. Measurements of visual function
5. Electro-retino-Graphy (ERG) & Visual Evoked
Response (VER)
 In rare cases these tests can be done to
evaluate retinal and or ON function
where other testing is inconclusive