11 - Lens and Cataract

1. Which of the following is not a function of the crystalline lens?

a. maintaining clarity
b. providing accommodation
c. metabolizing toxins
d. refracting light
2. What is a normal change in the normal human crystalline lens as it ages?
a. It develops an increasingly curved shape, resulting in more refractive power.
b. It develops an increasingly flatter shape, resulting in less refractive power.
c. It undergoes an increase in the index of refraction as a result of the decreasing
presence of insoluble protein particles.
d. It undergoes a decrease in the index of refraction as a result of the decreasing
presence of insoluble protein particles.
3. What occurs during terminal differentiation?
a. Lens epithelial cells elongate into lens fibers.
b. The mass of cellular proteins is decreased.
c. Glycolysis assumes a lesser role in metabolism.
d. Cell organelles increase their metabolic activity.
4. What is the first presenting sign of Marfan syndrome in the eye?
a. pupillary block glaucoma
b. monocular diplopia
c. the need for aphakic correction
d. inferonasal subluxation
5. Why are glutathione and vitamins A and C present in the anterior
chamber?
a. to adjust the pH and act as a buffer
b. to protect the corneal endothelium
c. to scavenge free radicals
d. to induce DNA damage

6. What occurs when the ciliary muscle contracts?

a. The diameter of the muscle ring is reduced, thereby increasing tension on
zonular fibers, allowing the lens to become more spherical.
b. The diameter of the muscle ring is increased, thereby increasing tension on
zonular fibers, allowing the lens to become more spherical.
c. The diameter of the muscle ring is reduced, thereby relaxing tension on
zonular fibers, allowing the lens to become more spherical.
d. The diameter of the muscle ring is increased, thereby relaxing tension on
zonular fibers, allowing the lens to become more spherical.

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7. The Y-sutures seen in the adult lens are the result of which of the following?
a. the junction of the adult nucleus with the surrounding cortex
b. scarring from the tunica vasculosa lentis
c. the elaboration of the adult nucleus around the fetal nucleus
d. fusion of the embryonic cells within the fetal nucleus
8. Which of the following systemic diseases is not associated with ectopia
lentis?
a. homocystinuria
b. Ehlers-Danlos syndrome
c. Marfan syndrome
d. myotonic dystrophy
9. What is a typical characteristic of a lens coloboma?
a. usually associated with previous lens trauma
b. typically located superiorly
c. typically associated with normal zonular attachments
d. often associated with cortical lens opacification
10. Which of the following is seen in Peters anomaly?
a. treatment with rigid gas-permeable contact lenses
b. defects in the corneal endothelium and Descemet membrane
c. identification of PAX6 mutation in all cases
d. bilaterality in 10% of cases

11. "Oil droplet;' crystalline, and "snowflake" cataracts are characteristic of

which diseases, respectively?
a. diabetes, myotonic dystrophy, galactosemia
b. myotonic dystrophy, galactosemia, diabetes
c. galactosemia, diabetes, myotonic dystrophy
d. galactosemia, myotonic dystrophy, diabetes
12. A patient presents with a mature lens and secondary glaucoma without
evidence of pupillary block. What is the most likely diagnosis?
a. phacomorphic glaucoma
b. phacolytic glaucoma
c. phacoantigenic uveitis
d. lens particle glaucoma
13. Which change is most characteristic of exfoliation syndrome?
a. exfoliative material confined to the lens capsule
b. strong zonular fibers
c. increased pigmentation of the trabecular meshwork
d. hypotony
14. A 65-year-old patient presents with a gradual reduction in vision 1 year
after Vitrectomy to repair a retinal detachment. What is the most likely
explanation?
a. Redetachment of the retina
b. posterior subcapsular cataract from intensive steroid therapy
c. nuclear cataract after vitrectomy to repair the retinal detachment
d. phacoantigenic uveitis from leakage of lens protein
15. Which of the following is true regarding the epidemiology of cataracts?
a. They are more prevalent in persons younger than 65 years.
b. They are more prevalent in men.
c. They occur only as a consequence of age.
d. They are the leading cause of reversible blindness.
16. In the developing world, which of the following could apply to a patient
who develops a visually significant cataract?
a. An additional person may be removed from the workforce for care of the patient.
b. The patient must receive prompt attention to have the cataract removed.
c. The patient is at lower risk for falls.
d. The patient is older than 65 years.

17. What did the Beaver Dam Eye Study determine regarding visually
significant cataracts?
a. They occur earlier in men than in women.
b. They interfere with vision only after patients are older than 75 years.
c. They are more likely to be cortical than nuclear.
d. The incidence of visually significant cataract increases slowly from age 54 to 75.
18. If the best -corrected visual acuity for a patient with cataract is 20/100, a
surgeon would be most likely to recommend surgery if
a. pinhole acuity is also 20/100
b. potential acuity meter (PAM) acuity is 20/25
c. laser interferometry reveals that the patient has no ability to recognize the
orientation of the diffraction pattern
d. a Maddox rod test shows multiple interruptions in the red light streak
19. If a patient has a dense white cataract and the posterior pole is not visible,
which of the following would be most helpful for the clinician in deciding
whether to perform surgery?
a. Specular microscopy
b. B-scan ultrasonography
c. laser interferometry
d. Maddox rod test
20. If a patient is found to have a best-corrected visual acuity of20/40 in each
eye but reports that vision is adequate for his needs, which factor would cause
the ophthalmologist to consider cataract surgery?
a. The level of lens opacity equals the level of vision loss.
b. The patient has no medical problems that would contraindicate surgery.
c. The ophthalmologist is unable to see the patient's retina well enough to evaluate
it.
d. The patient would be able to perform his activities of daily living more easily
with better vision.
21 . In a highly myopic patient, which of the following best describes an
appropriate step in decreasing operative risks?
a. raising the height of the irrigating bottle
b. maintaining a loose incision to allow for increased leakage
c. carefully examining the peripheral retina preoperatively
d. warning the patient of blurred vision from postoperative anisometropia

22. Which of the following is a source of potential complications during

cataract surgery in a uveitis patient?
a. shallow anterior chamber
b. zonular laxity
c. endogenous endophthalmitis
d. phacolytic glaucoma
23. Which one of the following steps would reduce the operative risks of
surgery for a mature, white cataract?
a. placing a small initial incision in the anterior capsule and injecting sufficient
viscoelastic into the lens to expel liquid cortex prior to completing the
capsulorrhexis
b. steepening the dome of the anterior capsule by removing the viscoelastic after
the initial capsule puncture
c. staining the capsule with trypan blue or indocyanine green dye
d. creating numerous radial relaxing incisions in the anterior capsule with long
Vannas scissors
24. A patient with visually significant cataract is found to dilate poorly on
preoperative examination.
Which of the following is the most likely cause of this poor dilation?
a. pigment dispersion syndrome
b. atopic dermatitis
c. exfoliation syndrome
d. hypertension
25. Which of the following would be the best initial treatment of a
postoperative shallow anterior chamber caused by ciliary block glaucoma?
a. miotics and peripheral iridotomy
b. cycloplegia and aqueous suppressants
c. emergent vitrectomy
d. cyclophotocoagulation
26. In operating on a patient with exfoliation syndrome, a surgeon chooses to
make a large anterior continuous curvilinear capsulorrhexis (CCC).
What postoperative complication will most likely be avoided?
a. opacification of the posterior lens capsule
b. postoperative phimosis of the anterior capsule
c. postoperative spike in intraocular pressure
d. glare and halos

27. In cataract surgery in which the posterior lens capsule ruptures and
vitreous presents in the anterior chamber, when is anterior Vitrectomy
complete?
a. when vitreous is removed from the wound
b. when a posterior chamber intraocular lens (IOL) can be placed
c. when the surgeon can see the retina
d. when vitreous is removed anterior to the posterior lens capsule

Answers
1. c. Lens cells have no mechanism for metabolizing toxins. The lens remains clear
because the lens fibers contain no nuclei or organelles that would scatter light. The
lens refracts light because the relative density of the lens is greater than that of the
fluids (aqueous and vitreous) surrounding it. The lens, until the onset of
presbyopia, remains flexible to provide accommodation in response to the tension
placed on the capsule from the ciliary muscle and zonular fibers.
2. a. With age, the human lens develops an increasingly curved shape, which
results in more refractive power. This change may be accompanied by- and
sometimes offset by-a decrease in the index of refraction of the lens, probably
resulting from an increase in water insoluble proteins.
3. a. Terminal differentiation involves elongation of the lens epithelial cells into
lens fibers.
This change is associated with a tremendous increase in the mass of cellular
proteins in each cell. The cells lose organelles, including nuclei, mitochondria, and
ribosomes.
The loss of cell organelles is optically advantageous; however, the cells then
become more dependent on glycolysis for energy production and less active
metabolically.
4. b. Monocular diplopia occurs when the lens is partially dislocated, and light can
pass both through and around the edge of the lens. Pupillary block glaucoma from
anterior dislocation of the lens is a rare event. Aphakic correction is required when
the lens is totally subluxed into the vitreous. When the lens subluxates, it usually
does so superotemporally.
5. c. Glutathione and vitamins A and C are powerful free radical scavengers. They
have no effect on the pH or the corneal endothelium. They actually protect DNA
from being damaged by free radicals.
6. c. The ciliary muscle is a ring, but upon contraction it does not have the effect
that one would intuitively expect of a sphincter. When it contracts, the diameter of
the muscle ring is reduced, thereby relaxing tension on the zonular fibers, allowing
the lens to become more spherical.

7. d. The Y-sutures represent the edges of the secondary lens fibers of the fetal
nucleus. The anterior Y is erect and the posterior one is inverted. They can be seen
in the center of the adult nucleus in a clear lens. The junction of the adult nucleus
and surrounding cortex is invisible until the nucleus develops sclerosis. The tunica
vasculosa lentis surrounds the lens as it grows. The Y-sutures are within the fetal
nucleus, not around it.
8. d. Myotonic dystrophy is not associated with ectopia lentis.
9. d. A lens coloboma is a wedge-shaped defect or indentation of the lens periphery
that occurs as an isolated anomaly or is secondary to the lack of ciliary body or
zonular development.
Cortical lens opacification or thickening of the lens capsule may appear adjacent
to the defect.
Lens colobomas are typically located inferiorly and may be associated with
colobomas of the uvea.
10. b. Peters anomaly is bilateral in 80% of cases. PAX6 mutations occur in
patients with Peters anomaly, but many cases are associated with mutations in
other alleles. Treatment usually involves sector iridectomy and/or penetrating
keratoplasty as well as management of coexisting glaucoma. Rigid gas-permeable
contact lenses would be ineffective since they do not address the effects of the
central corneal opacity.
11. d. Galactosemia produces an "oil droplet" cataract that appears within the first
few weeks of life. Untreated, galactosemia is rapidly fatal. Crystalline cataracts in
myotonic dystrophy develop a Christmas tree-appearing cortical cataract as well as
posterior subcapsular changes that will lead to complete opacification. The acute
cataract of uncontrolled diabetes has a snowflake appearance in the anterior and
posterior subcapsular region.
12. b. Phacolytic glaucoma occurs when denatured lens protein leaks through an
intact but permeable capsule. In phacomorphic glaucoma, the mature lens causes
pupillary block and secondary angle closure. In phacoantigenic uveitis, leaking of
lens protein produces a granulomatous inflammatory reaction. Lens particle
glaucoma is associated with penetrating lens injury or surgery.

13. c. Increased pigmentation of the trabeculum and reduced outflow occur

frequently in exfoliation syndrome. Exfoliative material has been found in many
bodily organs as well as on the iris and corneal endothelium. Intraocular pressure
may rise as a result of the obstruction of the trabecular meshwork by the exfoliative
material.
14. c. Nuclear cataract is common in patients older than 50 years if vitrectomy has
been used to repair a retinal detachment. Redetachment of the retina is an acute
phenomenon and unlikely 1 year after repair. Steroid therapy after retinal
detachment is usually brief and unlikely to cause nuclear cataract. Phacoantigenic
uveitis produces an inflammatory reaction and is extremely rare.
15. d. Census data confirm that cataracts are the leading cause of reversible
blindness. Cataracts increase in prevalence with increasing age and are a leading
cause of blindness worldwide. They can occur as a congenital condition or as a
result of trauma, metabolic diseases, or medications. Major epidemiologic studies
confirm an increased prevalence in women.
16. a. When 1 individual is incapacitated by blindness, the care that is required to
provide for that person may remove the caregiver from the workforce as well. The
ratio of surgeries to population in the developing world is as low as 50 per million.
Reduced vision is a primary factor in decreasing mobility and increasing the risk of
falls. Cataracts form earlier in life in populations in which nutrition is not optimal.
17. d. Cataracts begin to interfere with vision in persons aged 43-54 years, and,
from that age range, the incidence increases 13-fold in those aged 75 years or older.
The overall incidence of cataract is greater in women than in men. Nuclear
cataracts are more frequent than cortical cataracts at all ages.
18. b. The potential acuity meter (PAM) projects the equivalent of a Snellen visual
acuity chart into the eye, specifically through clear spaces in the lens, by means of
a beam of light to allow an estimate of macular function. The pinhole test
approximates the PAM; a reduced acuity would signal other ocular conditions that
cataract surgery might not improve.
Laser interferometry usually is beneficial in denser cataracts: the patient's failure to
discern the orientation of the diffraction pattern would indicate reduced visual
potential.
The patient's inability to see a continuous red line on a Maddox rod test would
suggest areas of decreased retinal sensitivity in the macula.

19. b. B-scan ultrasonography is indicated to evaluate for occult tumors, retinal

detachment, and posterior staphyloma or other posterior pathology that could affect
the visual outcome.
Laser interferometry and Maddox rod testing are not reliable with such a dense
cataract. Specular microscopy would be indicated only if signs of corneal
endothelial dysfunction were present.
20. c. The only consideration that would prompt the surgeon to consider operating
would be the inability to evaluate the patient's retina. This would be the case even if
the cataract explained the vision loss and the patient appeared well enough to
undergo surgery. If the patient reports that his vision is adequate for his needs,
surgery should be postponed.
21. c. Careful examination of the retinal periphery may reveal the presence of
lattice degeneration, retinal holes, and other abnormalities that warrant
consideration of preoperative treatment and/or diligent postoperative evaluation.
Lowering the height of the irrigating bottle produces less stress on the zonular
fibers and reduces the risk of posterior capsule tears. All incisions should be
carefully closed to reduce the risk of infection. Myopic patients do need to be
cautioned about anisometropia, and intolerable imbalances may prompt
consideration of second-eye surgery.
22. b. Chronic ciliary body inflammation at the zonular fibers may lead to zonular
laxity similar to that seen in exfoliation syndrome. The technical aspects of cataract
surgery can be more difficult in patients with uveitis. There may be limited access
to the lens because of posterior synechiae, a pupillary membrane, pupillary
sphincter fibrosis, and a floppy iris. Lysing synechiae, excising pupillary
membranes, and using pupil expanders and viscoelastic can counteract and
overcome the effects of an abnormal iris. Rupture of the capsulorrhexis with
extension to the zonular fibers can further complicate the procedure, and capsular
dyes may be necessary to maintain a continuous capsular tear during the rhexis.
23. c. When cataract surgery is performed on a patient with a white lens, there is
little or no red reflection. This makes it difficult to perform a circular
capsulorrhexis. Utilizing a capsular dye improves visualization of the capsule,
facilitating the creation of an anterior capsulorrhexis. The other methods described
increase the operative risks. Steepening the dome of the anterior capsule increases
the propensity for radial anterior capsule tearing and therefore should be avoided.
Maximally filling the anterior chamber with viscoelastic during the capsulorrhexis
can reduce leakage of white lens material into the anterior chamber, improving the

view of the anterior capsule. Creation of numerous radial relaxing incisions is a

method used when the initial capsulorrhexis is unsuccessful; it would not be the
primary step in creation of a capsulorrhexis. A small puncture in the anterior
capsule with injection of viscoelastic to expel liquid cortex prior to the completion
of the capsulorrhexis can be used initially but is not considered necessary with the
advent of capsular dyes.
24. c. Exfoliation syndrome is a common disorder associated with the deposition of
a fibrillo granular material on the anterior surface of the lens and elsewhere in the
anterior segment. With respect to cataract surgery, patients with this condition may
have zonular laxity, capsular fragility, and poor pupillary dilation.
25. b. Causes of a shallow chamber postoperatively include wound leak, pupillary
block, suprachoroidal effusion or hemorrhage, and ciliary block glaucoma with
aqueous misdirection into the vitreous cavity. If the cause is known to be ciliary
block glaucoma, initia treatment with cycloplegia and aqueous suppressants may
relieve the condition. Surgical disruption of the vitreous face by YAG laser or a
Vitrectomy may be necessary at a later time to permanently restore normal aqueous
circulation and anterior chamber depth if the initial treatment fails.
26. b. A large capsulorrhexis will reduce the risk of phimosis and increased tension
on the weakened zonular fibers of the patient, also reducing the risk of late
posterior dislocation of the intraocular lens. Opacification of the posterior lens
capsule is dependent not on the size of the capsulorrhexis but rather on the anterior
capsule overlapping the edge of the intraocular lens. Postoperative pressure spikes
are not dependent on capsulorrhexis size, although they are more common in
patients with exfoliation. Glare and halos are also not caused by a large anterior
capsulorrhexis.
27. d. Loss of vitreous is not a problem for the eye; vitreous traction is. The goal of
vitreous removal is to reduce the possibility of traction. The clinician may prevent
traction by removing enough vitreous to keep it away from the incision. Therefore,
a Vitrectomy is not complete until all vitreous is removed anterior to the posterior
capsule. This ensures a lower risk of traction, and it is also the best way to decrease
the risk of postoperative cystoid macular edema (CME).