CHAPTER I

INTRODUCTION

A cataract is a clouding of the eye's natural lens, which lies behind the iris and the
pupil. The lens works much like a camera lens, focusing light into the retina at the back of the
eye. The lens also adjusts the eye's focus, letting us see things clearly both up close and far
away.
Aging is the most common cause of cataract (esp. persons over 65-70 years) but many
other factors can be involved, including trauma, toxins, systemic disease, and heredity. Age
related cataract is a common cause of visual impairment. Cataract usually happens in both
eyes, but traumatic cataract may happen in only one eye. The sexes are equally affected.
Cataracts also run in families. The condition is estimated to have blinded more than 25
million people worldwide.
The crystalline lens is implicated as a causative element in producing several forms of
glaucoma. Etiologically they represent a diversity in the presentation of the glaucomatous
process. These conditions include glaucoma related to: lens dislocation (ectopia lentis), lens
swelling (intumescent cataract), classical pupillary block, aqueous misdirection - ciliary
block, phacoanaphylaxis, lens particle, and phacolytic glaucoma. In normal eye, there is a
balance between the production and outflow of the aqueous. When its blocked, the
intraocular pressure increased leads to the damage of optic nerve.The management of
elevated intraocular pressure often requires altering the intraocular relationship of anatomic
structures surrounding the lens or lens removal. In glaucoma there is a weakness in eye
function caused of the visual field decreased and anatomical damage and the degeneration of
the optic disc which can resulting blindness.








CHAPTER II
LITERATURE REVIEW
Anatomy and Physiology of lens
The crystalline lens focuses a clear image on the retina. The lens is suspended by thin
filamentous zonules from the ciliary body between the iris anteriorly and the vitreous
humor posteriorly. Contraction of the ciliary muscle permits focusing of the lens. The
lens is enclosed in a capsule of transparent elastic basement membrane. The capsule
encloses the cortex and the nucleus of the lens as well as a single anterior layer of
cuboidal epithelium. The lens has no innervation or blood supply. Nourishment comes
from the aqueous fluid and the vitreous.
The normal lens continues to grow throughout life. The epithelial cells continue to
produce new cortical lens fibers, yielding a slow increase in size, weight, and density over
the years. The normal lens consists of 35% protein by mass. The percentage of insoluble
protein increases as the lens ages and as a cataract develops.
Definition of Cataract
A cataract is any opacity or discoloration of the lens, whether a small, local opacity or
the complete loss of transparency. Clinically, the term cataract is usually reserved for
opacities that affect visual acuity because many normal lenses have small, visually
opacities. A cataract is described in terms of the zones of the lens involved in the opacity.
These zones of opacity may be subcapsular, cortical, or nuclear and may be anterior or
posterior in location. In addition to of the nucleus and cortex, there may be a yellow or
amber color change to the lens. A cataract also can be described in terms of its stage of
development. A cataract with a clear cortex remaining is immature. A mature cataract
has a totally opacified cortex.


Epidemiology
Age-related cataract is responsible for 48% of world blindness, which represents
about 18 million people, according to the World Health Organization (WHO). In many
countries surgical services are inadequate, and cataracts remain the leading cause of
blindness. As populations age, the number of people with cataracts is growing. Cataracts
are also an important cause of low vision in both developed and developing countries.
Even where surgical services are available, low vision associated with cataracts may still
be prevalent, as a result of long waits for operations and barriers to surgical uptake, such
as cost, lack of information and transportation problems. In the United States, age-related
lenticular changes have been reported in 42% of those between the ages of 52 to 64, 60%
of those between the ages 65 and 74, and 91% of those between the ages of 75 and 85.The
increase in ultraviolet radiation resulting from depletion of the ozone layer is expected to
increase the incidence of cataracts.
Classification of Cataract
1. Congenital Cataract : Some babies are born with cataracts or develop them in
childhood, often in both eyes. These cataracts may be so small that they do not affect
vision. If they do, the lenses may need to be removed.
2. Traumatic Cataracts : Cataracts can develop after an eye injury, sometimes years later.
3. Secondary Cataracts :Cataracts can form after surgery for other eye problems, such as
glaucoma. Cataracts also can develop in people who have other health problems, such
as diabetes. Cataracts are sometimes linked to steroid use
4. Senile Cataract.

5. Pathophysiology
The pathophysiology behind senile cataracts is complex and yet to be fully
understood. In all probability, its pathogenesis is multifactorial involving complex
interactions between various physiologic processes. As the lens ages, its weight and
thickness increases while its accommodative power decreases. As the new cortical layers
are added in a concentric pattern, the central nucleus is compressed and hardened in a
process called nuclear sclerosis.
Multiple mechanisms contribute to the progressive loss of transparency of the lens.
The lens epithelium is believed to undergo age-related changes, particularly a decrease in
lens epithelial cell density and an aberrant differentiation of lens fiber cells. Although the
epithelium of cataractous lenses experiences a low rate of apoptotic death, which is
unlikely to cause a significant decrease in cell density, the accumulation of small scale
epithelial losses may consequently result in an alteration of lens fiber formation and
homeostasis, ultimately leading to loss of lens transparency. Furthermore, as the lens ages,
a reduction in the rate at which water and, perhaps, water-soluble low-molecular weight
metabolites can enter the cells of the lens nucleus via the epithelium and cortex occurs
with a subsequent decrease in the rate of transport of water, nutrients, and antioxidants.
Consequently, progressive oxidative damage to the lens with aging takes place,
leading to senile cataract development. Various studies showing an increase in products of
oxidation (eg, oxidized glutathione) and a decrease in antioxidant vitamins and the enzyme
superoxide dismutase underscore the important role of oxidative processes in
cataractogenesis.
Another mechanism involved is the conversion of soluble low-molecular weight
cytoplasmic lens proteins to soluble high molecular weight aggregates, insoluble phases,
and insoluble membrane-protein matrices. The resulting protein changes cause abrupt
fluctuations in the refractive index of the lens, scatter light rays, and reduce transparency.
Other areas being investigated include the role of nutrition in cataract development,
particularly the involvement of glucose and trace minerals and vitamins.

6. Stage
In clinical, senile cataract devided to 4 stage:
1) Insipient Cataracts
In this stadium opacity start from marginal equator to anterior and posterior cortex.
This opacity can arised poliopia because refraction index is not same in the all of lens.
2) Immature Cataracts
Opacity at a part of lens. In this stadium lens volume will increase and make osmotic
pressure increase too. Subsequently, lens more convex and occure block pupil,finally can
arise secunder glaucoma.
3) Mature Catarcts
Opacity can found in all of lens. This opacity can occure because there is calcium
depotitions in the lens. Fluid in the lens will remove out so that lens will back at normal
size, anterior chambers back at normal depth and there isnt iris image at the opaque lens
so shadow test is negative.
4) Hipermature Cataracts
Mass lens move out from the lens capsule so lens becomes small,yellow colored and
dry. In the examination seen anterior chamber is deep and there is lens capsule fold. If
cataract process continued accompanied with thicken capsule so cortex degeneration can
not move out and can seen like a milk pack accompanied nucleus that concentrate in basal
lens cortex. This condition called Morgagni Cataract.

Symptoms and Sign
a. Symptoms
Many patients complain of blurred vision, which is usually worse when viewing
distant objects. If the patient is unable to read small print, the surgeon might suspect that
other pathology, such as macular degeneration, could be present. One must bear in mind
that some elderly patients say that they cannot read when it is found that they can read
small print if carefully tested. It is a curious fact that when the cataract is unilateral, the
patient can claim that the loss of vision has been quite sudden. Elucidation of the history
in these cases sometimes reveals that the visual loss was noted when washing and
observing the face in the mirror.
When one hand is lowered before the other, the unilateral visual loss is noticed for the
first time and interpreted as a sudden event. The history in cataract cases might be further
confused by a natural tendency for patients to project their symptoms into the spectacles,
and several pairs might be obtained before the true cause of the problem is found. In order
to understand the symptoms of cataract, it is essential to understand what is meant by
index myopia. This simply refers to the change in refractive power of the lens, which
occurs as a preliminary to cataract formation. Index myopia can also result from
uncontrolled diabetes. If we imagine an elderly patient who requires reading glasses (for
presbyopia) in the normal way but no glasses for viewing distant objects, the onset of
index myopia will produce blurring of distance vision, but also the patient will discover to
his or her surprise that it is possible to read again without glasses. In the same way, the
hypermetropic patient will become less hypermetropic and find that it is possible to see
again in the distance without glasses. The ageing fibres in the precataractous lens become
more effective at converging light rays so that parallel rays of light are brought to a focus
more anteriorly in the eye. A part from blurring of vision, the cataract patient often
complains of monocular diplopia.
Sometimes even a slight and subtle opacity in the posterior part of the lens can cause
the patient to notice, for example, that car rear lights appear doubled, and this can be
reproduced with the ophthalmoscope light. Monocular diplopia is suspect symptom, the
suggestion being that if a patient continues to see double, even when one eye is closed,
then he or she might not be giving an accurate history. In actual practice nothing could be
further from the truth and this is quite a common presenting feature of cataract. Glare is
another common presenting symptom.










Picture 2. Opaque areas in the lens can be seen clearly
against the red reflex.

The patient complains that he or she cannot see so well in bright light and might even
be wearing a pair of dark glasses. Glare is a photographic term but here it refers to a
significant reduction in visual acuity when an extraneous light source is introduced.
Light shining from the side is scattered in the cataractous lens and reduces the quality
of the image on the retina. Glare becomes an important consideration when advising
an elderly cataractous patient on fitness to drive. The visual acuity might be within the
requirements laid down by law (seeing a number plate at 20.5 m) but only when the
patient is tested in the absence of glare.
A consideration of all these factors makes itrelatively easy to diagnose cataract even
before examining the patient. To summarise, a typical patient might complain that the
glasses have been inaccurately prescribed, that the vision is much worse in bright
sunlight, that sometimes things look double and that there is difficulty in recognising
peoples faces in the street rather than difficulty in reading. Patients with cataracts
alone do not usually complain that things look distorted or that straight lines look
bent, nor do they experience pain in the eye. Rarely, cataracts become hypermature;
that is to say, the lens enlarges in the eye and this in turn can lead to secondary
glaucoma and pain in the eye. Urgent surgery might be needed under these
circumstances. In its late stages, acataract matures and becomes white, so that
exceptionally a patient might complain of a white spot in the middle of the pupil.
b. Signs
1) Reduced Visual Acuity
A reduction in visual acuity can, of course, be an early sign of cataract formation but this
is not always the case. Some patients see surprisingly well through marked lens opacities, and
the effect on visual acuity as measured by the Snellen test type depends as much on the
position of the opacities in the lens as on the density of the opacities.

2) Findings of Ophthalmoscopy
The best way of picking up a cataract in its early stages is to view the pupil through the
ophthalmoscope from a distance of about 50 cm. In this way, the red reflex is clearly seen.
The red reflex is simply the reflection of light from the fundus and it is viewed in exactly the
same manner that one might view a cats eyes in the headlamps of ones car or the eyes of
ones friends in an illjudged flash photograph. In fact, such a flash photo could well show up
an early cataract if an elderly relative were included in the photograph. When using the
ophthalmoscope, the opacities in the lens are often seen as black spokes against the red
reflex. It is important to focus ones eyes onto the plane of the patients pupil if the cataract is
to be well seen, and it is preferable to dilate the pupil beforehand or at least examine in a
darkened room. Typical age-related lens opacities are wedge shaped, pointing towards the
centre of the pupil. At the same time, the central nucleus of the lens can take on a yellowish-
brown colour, the appearance being termed lens sclerosis, and ultimately, the lens can
become nearly black in some instances. After inspecting a cataract with the ophthalmoscope
held at a distance from the eye, one must then approach closer and attempt to examine the
fundus. Further useful information about the density of the cataract can be obtained in this
way. It is generally true that if Cataract Opaque areas in the lens can be seen clearly against
the red reflex. the observer can see in, the patient can see out. If there is an obvious
discrepancy between the clarity of the fundus and the visual acuity of the patient, some other
pathology might be suspected. Sometimes the patient might not have performed too well on
subjective testing and such an error should be apparent when the fundus is viewed. Some
types of cataract can be misleading in this respect and this applies particularly to those seen in
highly myopic patients. Here, there is sometimes a preponderance of nuclear sclerosis, which
simply causes distortion of the fundus while the disc and macula can be seen quite clearly.
1


Management
At the present time, there is no effective medical treatment for cataract in spite of a
number of claims over the years. A recent report has suggested that oral aspirin can delay the
progress of cataract in female diabetics. Although this might be expected to have some effect
on theoretical grounds, any benefit is probably marginal. Occasionally, patients claim that
their cataracts seem to have cleared, but such fluctuation in density of the lens opacities has
not been demonstrated in a scientific manner. Cataracts associated with galactosaemia are
thought to clear under the influence of prompt treatment of the underlying problem. Cataract
is, therefore, essentially a surgical problem, and the management of a patient with cataract
depends on deciding at what point the visual impairment of the patient justifies undergoing
the risks of surgery. The cataractoperation itself has been practiced since pre-Christian times,
and developments in recent years have made it safe and effective in a large proportion of
cases. The operation entails removal of all the opaque lens fibres from within the lens capsule
and replacing them with a clear plastic lens. Common Eye Diseases and their Management In
the early part of the last century the technical side of cataract surgery necessitated waiting for
the cataract to become ripe.Nowadays no such waiting is needed and it is theoretically
possible to remove a clear lens. The decision to operate is based on whether the patient will
see better afterwards. Modern cataract surgery can restore the vision in a remarkable way and
patients often say that theyhave not seen so well for many years. Indeed, many patients have
quite reasonable vision without glasses but this cannot be guaranteed and, because the plastic
lens implant gives a fixed focus, glasses will inevitably be needed for some distances.
Probably the worst thing that can happen after the operation is infection leading to
endophthalmitis and loss of the sight of the eye. Although this only occurs in about one out of
a thousand cases, the patient contemplating cataract surgery needs to be aware of the
possibility. Before the operation, it is now a routine to measure the length of the eye and the
corneal curvature.Knowing these two measurements, one can assess the strength of
lensimplant that is needed. When deciding on thestrength of implant, it is necessary to
considerthe other eye. The aim is usually to make the two eyes optically similar because
patients find it difficult to tolerate two different eyes.





b. When To Operate
Even though the decision to operate on a cataract must be made by the ophthalmic
surgeon, optometrists and the nonspecialist general practitioner need to understand the
reasoning behind this decision. Elderly patients tend to forget what they have been told in the
clinic and might not, for example, understand why cataract surgery is being delayed when
macular degeneration is the main cause of visual loss. An operation is usually not required if
the patient has not noticed any problem, although sometimes the patient can deny the
problem through some unexpressed fear. The requirements of the patient need to be
considered; those of the chairbound arthritic 80-year-old subject who can still read small print
quite easily are different from the younger business person who needs to be able to see a car
number plate at 20.5 m in order to drive. The visual acuity by itself is not always a reliable
guide.Some patients who have marked glare might need surgery with a visual acuity of 6/9,
whereas others with less visual demands might be quite happy with a vision of 6/12 or 6/18.
Early surgery might be needed to keep a joiner or bus driver at work for which good
binocular vision is needed.

b. The Cataract Operation
The definitive management for senile cataract is lens extraction. Over the years, various
surgical techniques have evolved from the ancient method of couching to the present-day
technique of phacoemulsification. Almost parallel is the evolution of the IOLs being used,
which vary in ocular location, material, and manner of implantation. Depending on the
integrity of the posterior lens capsule, the 2 main types of lens surgery are the intracapsular
cataract extraction (ICCE) and the extracapsular cataract extraction (ECCE). Below is a
general description of the 3 commonly used surgical procedures in cataract extraction,
namely ICCE, standard ECCE, and phacoemulsification. Reading books on cataract surgeries
for a more in-depth discussion of the topic, particularly with regard to technique and
procedure, is also recommended.
4

1). Intracapsular cataract extraction
Prior to the onset of more modern microsurgical instruments and better IOLs, ICCE
was the preferred method for cataract removal. It involves extraction of the entire
lens, including the posterior capsule. In performing this technique, there is no need to
worry about subsequent development and management of capsular opacity. The
technique can be performed with less sophisticated equipment and in areas where
operating microscopes and irrigating systems are not available.
However, a number of disadvantages and postoperative complications accompany
ICCE. The larger limbal incision, often 160-180, is associated with the following
risks: delayed healing, delayed visual rehabilitation, significant against-the-rule
astigmatism, iris incarceration, postoperative wound leaks, and vitreous incarceration.
Corneal edema is a common intraoperative and immediate postoperative
complication.
Furthermore, endothelial cell loss is greater in ICCE than in ECCE. The same is true
about the incidence of postoperative cystoid macular edema (CME) and retinal
detachment. The broken integrity of the vitreous can lead to postoperative
complications even after a seemingly uneventful operation. Finally, because the
posterior capsule is not intact, the IOL to be implanted must either be placed in the
anterior chamber or sutured to the posterior chamber. Both techniques are more
difficult to perform than simply placing an IOL in the capsular bag and are associated
with postoperative complications, the most notorious of which is pseudophakic
bullous keratopathy.
5

Although the myriad of postoperative complications has led to the decline in
popularity and use of ICCE, it still can be used in cases where zonular integrity is too
severely impaired to allow successful lens removal and IOL implantation in ECCE.
Furthermore, ICCE can be performed in remote areas where more sophisticated
equipment is not available.
ICCE is contraindicated absolutely in children and young adults with cataracts and
cases with traumatic capsular rupture. Relative contraindications include high myopia,
Marfan syndrome, morgagnian cataracts, and vitreous presenting in the anterior
chamber.

2. Extracapsular cataract extraction
In contrast to ICCE, ECCE involves the removal of the lens nucleus through an
opening in the anterior capsule with retention of the integrity of the posterior capsule.
ECCE possesses a number of advantages over ICCE, most of which are related to an
intact posterior capsule, as follows:
A smaller incision is required in ECCE, and, as such, less trauma to the corneal
endothelium is expected.
Short- and long-term complications of vitreous adherence to the cornea, iris, and
incision are minimized or eliminated.
A better anatomical placement of the IOL is achieved with an intact posterior capsule.
An intact posterior capsule also (1) reduces the iris and vitreous mobility that occurs
with saccadic movements (eg, endophthalmodonesis), (2) provides a barrier
restricting the exchange of some molecules between the aqueous and the vitreous, and
(3) reduces the incidence of CME, retinal detachment, and corneal edema.
Conversely, an intact capsule prevents bacteria and other microorganisms
inadvertently introduced into the anterior chamber during surgery from gaining access
to the posterior vitreous cavity and causing endophthalmitis.
Secondary IOL implantation, filtration surgery, corneal transplantation, and wound
repairs are performed more easily with a higher degree of safety with an intact
posterior capsule.
The main requirement for a successful ECCE and posterior capsule IOL implantation
is zonular integrity. As such, when zonular support is insufficient or appears suspect to
allow a safe removal of the cataract via ECCE, ICCE or pars plana lensectomy should be
considered.

3. Standard ECCE and phacoemulsification
Standard ECCE and phacoemulsification are similar in that extraction of the lens
nucleus is performed through an opening in the anterior capsule or anterior capsulotomy.
Both techniques also require mechanisms to irrigate and aspirate fluid and cortical
material during surgery. Finally, both procedures place the IOL in the posterior capsular
bag that is more anatomical than the anteriorly placed IOL.
Needless to say, significant differences exist between the 2 techniques. Removal of the
lens nucleus in ECCE can be performed manually in standard ECCE or with an
ultrasonically driven needle to fragment the nucleus of the cataract and then to aspirate
the lens substrate through a needle port in a process termed phacoemulsification.
The more modern of the 2 techniques, phacoemulsification offers the advantage of
using smaller incisions, minimizing complications arising from improper wound closure,
and affording more rapid wound healing and faster visual rehabilitation. Furthermore, it
uses a relatively closed system during both phacoemulsification and aspiration with better
control of intraocular pressure during surgery, providing safeguards against positive
vitreous pressure and choroidal hemorrhage. However, more sophisticated machines and
instruments are required to perform phacoemulsification.
Ultimately, the choice of which of the 2 procedures to use in cataract extraction
depends on the patient, the type of cataract, the availability of the proper instruments, and
the degree at which the surgeon is comfortable and proficient in performing standard
ECCE or phacoemulsification

GLAUCOMA
A condition of increased fluid pressure inside the eye so it make the compression of the
retina and the optic nerve then make the nerve damage end.
Glaucoma can cause partial vision loss, with blindness as a possible eventual outcome
one of the leading causes of blindness, is estimated to affect 1 of every 50 adults. This is
the diagram of pathophysiology of glaucoma.



There are some risk factor of glaucoma:
Age
Family History
Drug consumption (steroid)
Trauma
Severe Hypermethrophya
Other systemic disease (ex ; DM, Hypertension)

The classification may include:
1. Open Angle Glaucoma
2. Angle closure glaucoma
3. Congenital Glaucoma
4. Secondary glaucoma
Glaucoma can be divided roughly into two main categories, "open angle" and "closed angle"
glaucoma.


Open Angle Glaucoma
Primary open-angle glaucoma (POAG), the most common form of glaucoma, accounts
for 6070% of all glaucomas and 9095% of primary glaucomas. POAG is a bilateral,
chronic progressive condition that typically appears in individuals over 60 years of
age.
Symptoms
a) asymptomatic (as moderately elevated IOP usually causes no symptoms but the IOP is
still high enough to cause glaucomatous optic neuropathy)
b) loss of part of their visual field cf tunnel vision
c) blindness in one or both eyes (advanced optic nerve damage)
Genetic factors are important and therefore the family history should be considered.
Signs
a) open angle
b) elevated IOP
c) glaucomatous optic nerve cupping
d) may have visual field loss


Mild glaucomatous cupping Advanced glaucomatous cupping
The goal is to maintain IOP less than 21 mmHg and continued visual field loss should be
minimal. In fact, medications have been shown to control IOP in 6080% of patients over
a five-year period. Various treatmentmodalities include medical treatment, laser
therapy,and surgery. Patients will initially start with topical ocular drug therapy.
Prognosis : If discovered early and treated adequately, the prognosis for POAG is excellent.
Closure Angle Glaucoma
Less than 5% of all primary glaucomas. Requires immediate attention within hours to
avoid dramatic vision loss. In primary the pathophysiology is a shallow ocular anterior
chamber so the angle between the cornea and iris become narrow.This creates a situation
where pupil dilation can physically occlude the trabecular meshwork. And secondary
angle-closure glaucoma results from any type of blockage throughout this drainage
pathway.

figure. Primary close angle glaucoma
Diagnosis is determined by visualization of the angle by gonioscopy as well as provoking an IOP
increase through mydriasis (dark room test) or by gravity (prone test).
Treatment of angle-closure glaucoma
Requires a rapid reduction in IOP to prevent a hypertensive event and ultimately preserve vision.
For an acute hypertensive attack it can be given pilocarpine or secretory inhibitors (topical B-
blockers, a2-agonists, CAIs). At IOPs greater than 60 mmHg, the iris becomes ischemic and may
be unresponsive to pilocarpine even at high and frequent doses. An osmotic agent (oral glycerin,
oral isosorbide, and intravenous Mannitol) is usually administered because of its rapid lowering
of IOP. A peripheral iridectomy should be performed only when IOP is controlled.
Normal-Tension Glaucoma
Condition in which optic nerve damage and vision loss have occurred despite a normal pressure
inside the eye (TIO< 21 mmHg). The patient has open, normal-appearing angles. In fact, the
features of normal-tension glaucoma are similar to primary open-angle glaucoma.
The pathogenesis because of abnormal sensitivity to intraocular pressure caused by vascular or
mechanically in the optical nerve
Others sign & symptoms:
Spasm of phertpheral vessel
Chepalgia
Hipotension at night
Decrease of blood flow

Primary Congenital Glaucoma
Primary congenital glaucoma present at birth; however, but its manifestations may not be
recognized until infancy or early childhood. The pathophysiology of primary congenital glaucoma
is restricted to a developmental abnormality that affects the trabecular meshwork. Primary
congenital glaucoma estimated to affect fewer than 0.05% of ophthalmic patients. The disease is
bilateral in approximately 75% of cases.
Primary congenital glaucoma usually is diagnosed at birth or shortly thereafter, and most cases are
diagnosed in the first year of life. Most cases are sporadic in occurrence and may be transmitted
through an autosomal recessive pattern. Male patients are found to have a higher incidence of the
disease, comprising approximately 65% of cases.
The triad of manifestations of primary congenital glaucoma are epiphora, photophobia , and
blepharospasm. Blepharospasm is a spasm and closure of the eyelids.

Physically of congenital glaucoma there was:
Changes within the cornea, especially within the first few years of life, provide strong
additional support for the diagnosis.
Enlargement of the cornea
The early presence of glaucoma may deepen the anterior chamber. Because of the
frequent occurrence of iris abnormalities in many types of both primary and
secondary childhood glaucomas, the iris and angles always should be studied
carefully and with thorough gonioscopy.
The optic nerve head is usually abnormal. Variable cupping is present, usually
annular in form, with nasalization of vessels and preservation of the well-vascularized
rim. Pallor is first seen temporally when present at an advanced stage.

The Treatment of Congenital Glaucoma
Unlike adult glaucoma, the initial treatment for congenital glaucoma is often surgical. A
drainage angle surgery is often recommended for congenital glaucoma.
Secondary Glaucoma
Glaucoma can occur as the result of an eye injury, inflammation, tumor or in advanced cases of
cataract or diabetes. It can also be caused by certain drugs such as steroids. This form of
glaucoma may be mild or severe. The type of treatment will depend on whether it is open-angle or
angle-closure glaucoma.
Pseudoexfoliative Glaucoma
This form of secondary open-angle glaucoma occurs when a flaky, dandruff-like material peels
off the outer layer of the lens within the eye. The material collects in the angle between the cornea
and iris and can clog the drainage system of the eye, causing eye pressure to rise.
Pseudoexfoliative Glaucoma is common in those of Scandinavian descent. Treatment usually
includes medications or surgery.

Pigmentary Glaucoma
A form of secondary open-angle glaucoma, this occurs when the pigment granules in the back of
the iris (the colored part of the eye) break into the clear fluid produced inside the eye. These tiny
pigment granules flow toward the drainage canals in the eye and slowly clog them, causing eye
pressure to rise. Treatment usually includes medications or surgery.
Traumatic Glaucoma
Injury to the eye may cause secondary open-angle glaucoma. This type of glaucoma can occur
immediately after the injury or years later.
It can be caused by blunt injuries that bruise the eye (called blunt trauma) or by injuries that
penetrate the eye.
In addition, conditions such as severe nearsightedness, previous injury, infection, or prior surgery
may make the eye more vulnerable to a serious eye injury.
Neovascular Glaucoma
The abnormal formation of new blood vessels on the iris and over the eyes drainage channels can
cause a form of secondary open-angle glaucoma.
Neovascular glaucoma is always associated with other abnormalities, most often diabetes. It never
occurs on its own. The new blood vessels block the eyes fluid from exiting through the trabecular
meshwork (the eyes drainage canals), causing an increase in eye pressure. This type of glaucoma
is very difficult to treat.
Irido Corneal Endothelial Syndrome (ICE)
This rare form of glaucoma usually appears in only one eye, rather than both. Cells on the back
surface of the cornea spread over the eyes drainage tissue and across the surface of the iris,
increasing eye pressure and damaging the optic nerve. These corneal cells also form adhesions
that bind the iris to the cornea, further blocking the drainage channels.
Irido Corneal Endothelial Syndrome occurs more frequently in light-skinned females. Symptoms
can include hazy vision upon awakening and the appearance of halos around lights. Treatment can
include medications and filtering surgery. Laser therapy is not effective in these cases.
Absolute Glaucoma
Absolute glaucoma is the end stage of glaucoma (open angle/angle closure glaucoma). The
clinical sign patien have total blindness. In absolute glaucoma, the cornea looks not clear, shallow
of the chamber, athrofi of papil with excavation of glaucomatous, the eye become harder like a
stone dan also painfull.
The treatment of absolute glaucoma can by given beta light into ciliary body for compres the
function of ciliary body or doing the nucleation because the eye doesnt have function anymore so
the eye cant painfull anymore.




CHAPTER III
CASE REPORT
1. Patient identity
Name : Mrs. S
Sex : female
Age : 84 years old
Address : Kuala Secapah
Job : housewife
Religion : Moslem
Patient was examined on January 21st, 2014
2. Anamnesis
Main complaint :
Red eye, watery, blindness.
History of desease :
Patient complains blurry vision is affected in right eye. Blurry vision of the
right eye since a few months ago, that become worse especially during this
two weeks. Then, she told that her eye became redness until now. Not only
red, but also pain and watery. Now, patient have cloudy in her eye (right eye),
so patient really cant see anything from right eye. She also complaining the
blurry vision at the left eye. Sometimes she had a headache. The
manifestation of clinical from this patient : Headache (+), pain in the eyes (+),
redness in the eye (+ right eye), itch feeling in the eyes (-), and traumatic
history (-).
Past clinical history :
Hypertension (-)
Diabetes Mellitus (denied) because patient never did clinical check.
Glasses wearing (-)
Traumatic history (-)
Family history
Hypertension (-)
Diabetes Mellitus (-)
Glasses wearing (-)




3. General Physical assestment
General condition : Moderate
Awareness : Compos mentis
Vital sign :
a. Blood Pressure : 130/90 mmHg
b. RR : 18/minute
c. Temperture : 36,5C
4. Ophthalmological status
Visual acuity :
a. OD : 0
b. OS : 6/12
c. Last glasses : the patient never use glasses
OD OS
Ortho Eye ball position Ortho

Eye Movement

Movement(+), ptosis (-),
lagoftalmos (-)
Palpebra Movement (+), ptosis (-),
lagoftalmos (-)
redness (+), discharge (-),
degeneration plaque (-), foreign
body (-), injection (-)
conjungtiva redness (-), discharge (-),
degeneration plaque (-), foreign
body (-), injection (-)
ulcer (-)
arcus senilis (+)
Cornea ulcer (-)
arcus senilis (+)
Not clear Anterior chamber clear, deep impression
Iris colour : brown, sinekia (-)
Circular pupil, isochore
Iris/pupil Iris colour : brown, sinekia (-)
Circular pupil, isochore
Milky Lense Cloudy
- Shadow test +
- Fundus -

Shadow test : negatif (- right eye) , positive (+ left eye)
Intra Ocular pressure (tonometry) : OD 26 mmHg, OS 15 mm Hg
Funduscopy : -
Visual field test: OD cannot be done, OS normal

5. Resume
A woman, 84 years old, came to ophthalmologist with the complain of blurry
vision in right eye since a few months ago, and become worse during this two weeks.
She told that her eye became redness until now. Not only red, but also pain and
watery. Now, patient have cloudy in her eye (right eye), so patient really cant see
anything from right eye. She also complaining the blurry vision at the left eye.
Sometimes she had a headache. The manifestation of clinical from this patient
Headache (+), pain in the eyes (+), redness in the eye (+ right eye), watery (+), itch
feeling in the eyes (-), and traumatic history (-).
Visual acuity is 0 for OD, 6/12 for OS. Right lense seems milky. Left lense
seems cloudy. Intraocular presure for OD 26mmHg, for OS 15 mmHg. Funduscopy
cannot be done because of the lense opacity. Shadow test for left eye is positive.
Confrontation test just be done at the left eye and the result is normal.

6. Diagnosis
Diagnose :
a. OD : mature cataract with secondary glaucoma (absolute glaucoma)
b. OS : immature cataract (senilis)
DDx :
OD : hipermature cataract with absolute galucoma
OS : -

7. Plan for examination
a. Slit lamp
b. Perimetri
c. Whole blood test and blood glucose
d. Eyes USG
8. Treatment
a. OD
i. Pharmacological:
1. Timolol
2. Asetazolamide
ii. Surgery : Extra Capsular Cataract Extraction

b. OS
i. Non-pharmacological
1. Using eye protection

ii. Surgery : Pachoemulsification + IOL
9. Prognosis
a. OD:
i. Ad vitam : bonam
ii. Ad functionam : malam
iii. Ad sanactionam : dubia ad malam

b. OS :
i. Ad vitam : bonam
ii. Ad functionam : dubia ad bonam
iii. Ad sanactionam : dubia ad bonam


CHAPTER IV
DISCUSSION

A woman, 84 years old complained blurry vision clinic with complain redness,
painfull, watery, even blindness in the right eye since a few months ago. The history before
the eye became redness, patient had migrain at right part of head. The pain felt into her right
eye. Then, she told that her eye became redness until now. Not only red, but also pain and
watery. Now, patient have cloudy in her eye (right eye), so patient really cant see anything
from her right eye. There were no history of eye trauma.
Visual acuity is 0 for OD, 6/12 for OS. Palpebra, conjunctiva, cornea and anterior
chamber is inspected normally, while the right lens seems milky and the left eye seems
blurry. No foreign body was found. Intra ocular pressure is 26 mmHg for OD, 15 mmHg for
OS. Funduscopy cannot be done because of the lense opacity. Confrontation test for OD
cannot be described, and for OS is normal, shadow test negative for right eye and positive for
left eye.
The abnormality found in physical examination is the opacity of the lens. We can get
rid of inherited disorders because the patient is geriatric, and new phenomena arising in
recent years. In addition, the symptoms that arise in these patients as well as typical
symptoms of cataract, like the the visual loss is slowly, and there is a cloud on the view that
closes the view. Beside the opacity of left lense, the shadow test results is positive.
In lens assesment found that at the right eye the lens is totally opaque, milky
appearance, funduscopy cant be done cause the light cant passes through the lens and it
indicated that is mature cataract at the right eye and for the left eye the lens looks cloudy and
shadow test is positive (+), show that it is an immature cataract at the left eye.
These are some discussion about the clinical finding from the anamnesis and
examination to the patient :
Blurred vision is caused by the opacity of the lense, that can cause disrupting the
refraction media and finally, it can hampered the light to retinal
Vision slowly burred because of the progression of opacity in the lense (thickness of
opacity influence the degree of vision lost)
VA : 0 for OD with good projection, 6/12 for OS opacity of OD is thicker than
OS so OD must be treated firstly

Based on the examination, known that the visual acuity for right eye is 0. The
patient cant see at all, even with light perception.
There are some specific symptoms that can lead to diagnose the condition of the
right eye. The IOP level for right eye is measure 26 mmHg. It indicated the raised of
IOP greater than normal range. Raised IPO is determine by the balance between
aqueous production inside the eye and aqueous drainage of the eye through the
trabecular meshwork. The resistance to outflow through the trabecular meshwork
gradually increase, causing the damage to the nerve. Pressure on the nerve fibres and
chronic ischaemia at the optic nerve head cause damage to the retinal nerve fibres that
leads to rapid loss of vision. Once optic nerve damage is occured, it cannot be
repaired. It indicated that is absolute glaucoma at the right eye.
In mature cataract, there is degenerative lens capsule that cause the material out
from the lens and enter the anterior chamber,stuck at the trabecular meshwork, block
the drainage angle and cause the problem in excretion of aqueous humor. Type of
glaucoma of this patient is absolute glaucoma indicated by the high level of IOP,
visual acuity is 0, and the pain sensation inside the eye. So, the diagnosis of the right
eye is absolute glaucoma e.c mature cataract
Treatment to this patient is to lower the IOP. Common medical therapy that
used in this condition are combination of beta-blocker and carbonic anhidrase
inhibitor, such as timolol 0,5 % and asetazolamide. Both of them action on the
secretion system, that result the decrease in producing aqueous from ciliary body.
Definitive therapy for both eye is surgery. For the right eye should be treated by lens
extraction. Medication that given to lower the IOP is aimed to controls the IPO and
can minimize the symptoms. For the left eye with immature cataract the
phacoemulsification is choosen as the therapy.






CHAPTER V
CONCLUSION

The diagnosis of this patient is Mature Cataract with Secondary right eye. And for
the right eye is immature cataract. The therapy for OD is doing the treatment of glaucoma
and surgery for the lens extraction.

















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