JUVENILE CATARACT

Subheading goes here

OUTLINE

INTRODUCTION
LITERATURE REVIEW
CASE REPORT
DISCUSSION
CONCLUSION

INTRODUCTION
Cataract is opacity of the lens which occur because of
lens hidration, lens protein denaturation, or both.
Cataract remain the leading cause of blindness

LITERATURE REVIEW

Anatomy
Shape

a biconvex lens and capable of changing shape

colorless
transparent
avascular

size

4mm thick and 9mm in

diameter

position

behind the iris and

the pupil
In front of the vitreous
suspended by suspensary ligament

Lens

Anatomy
structure
capsule:an elastic transparent basement membrane
admit water and electrolytes pass through
the lens fibers are enveloped in it
epithelium : this single cell layer located anteriorly and
extending to the equator

fibers:continuously produced by epthelium

the nucleus:old fibers ,harder at the centre
the cortex: new fibers,softer, at the periphery

With age,the lens gradually becomes larger, harder

and less elastic

Physiology
composition
water -64% The water content of the lens decreases with age.
protein -35% the highest protein content in any body tissue
soluble protein
insoluble protein:With age, the percent of it increases
1%- A trace of minerals are present (Potassium, Ascorbic acid
and Glutathione)
The lens has complex metabolic process. It`s nourishment
comes from aqueous humor.When there are changes of
aqueous or capsule or metabolism,the transparent lens
becomes opaque.

Physiology
Function
one of important refractive medias
focus light rays upon the retina
filter a part of ultraviolet rays ,it is beneficial to
the retina

Cataract
Cataract transparent lens becomes opaque

Cataract
Epidemiology
Cataract is a common ocular disease and one of the main
causes of blindness.It is estimated that 30 to 45 million
people in the world are blind,with cataract accounting for
as much as 45% of this blindness.
The prevalence of cataract varies widely with striking
regional differences.It is more common in areas where
people eyes expose to sunlight greatly.
The prevalence rises with age and is higher in females.
WHO defines blindness as best corrected visual acuity
less than 20/400(0.05) or visual field restricted to 10or
less.

Etiology

The actual cause of cataracts is unknown juvenile and in cases that are
found usually familial , so it is very important to know the patient's family
history in detail.
Cataracts can be found in the absence of eye or systemic disorders ( senile
cataract , juvenile cataracts , cataract hereditary ) or congenital
abnormalities of the eye .
Cataracts are caused by various factors :

Physical
Chemistry
Disease predisposing
Genetic and developmental disorders
Viral infections future growth of the fetus
Age

Juvenile cataract is usually a complication of systemic or metabolic disease and other

diseases such as
1. Cataracts metabolic
diabetic cataract and galaktosemik
cataract hypocalcemic ( tetany )
cataract nutritional deficiency
cataract aminoaciduria
2. Muscle : myotonic dystrophy
3. Traumatic Cataract
4. Complicated Cataract
Congenital and hereditary disorders ( microphthalmia , aniridia , and
others )
degenerative cataract ( with myopia and vitreoretinal
dystrophy )
cataract anoxic
toxic ( systemic or topical corticosteroids , ergot , and others )
radiation cataract
other congenital abnormalities , specific syndrome ,
accompanied by
abnormalities of the skin, bones and chromosomes .

Diagnosis
Cataracts diagnosed by history, physical examination , and investigations
are complete . Complaint that brought the patient comes , among others :
1.Blur vision
2.Glare vision
3.Sensitive toward contrast
4.Miopisasi
5.Diurnal Variation Vision
6.Distortion
7.Halo
8.Diplopia monokuler
9.Change of colour perception
10.Black spot

 Several checks are needed to see signs of

cataracts
-visual acuity test
-oblique illumination
-Direct Opthalmoscope examination
-Iris shadow test
-Slit lamp examination

Management of cataract
Medical management
No medical treatment has been proven conclusively
to delay,prevent,or reverse the development of
cataract

Indication for surgery

The most common indication for cataract surgery is
the patient`s desire for improved visual function.
When visual acuity impairment interferes with the
patient`s normal activities,the surgery of cataract well
be performed.

Lens surgery
Microsurgical techniques is employed for all
cataract surgery.
There are 3 principal types of lens extraction
Intracapsular cataract extraction(ICCE)
It involves complete removal of the lens within its
capsule.
through a larger (12mm length) superior limbal incision
The larger incision may increase the risk of woundrelated problems.

Lens surgery
Extracapsular cataract extraction(ECCE)
It involves removal of the lens nucleus and cortex
through an opening in the anterior capsule, leaving
the posterior capsule in place.
A superior limbal incision is made,it is shorter than
ICCE
The anterior portion of the capsule is ruptured and
removed
The nucleus is extracted
The cortex is either irrigated or aspirated from the eye
leaving the posterior capsule behind.

ECCE and IOL

IOL

Lens surgery
Phacoemulsification(Phaco)
It is a relatively new technique.In recent years, it has
become popular.
It is a method of extracting the nucleus through a
small incision(3mm).
The nucleus is extracted by ultrasonic vibration.
This technique results in a lower incidence of woundrelated complications, faster healing, and more rapid
visual rehabilitation than procedures requiring larger
incisions.

Phaco

ICCE vs ECCE vs Phaco

TYPE
ICCE

ECCE

Phaco

ADVANTAGES
Removes all lens
material, no posterior
capsular opacity

DISADVANTAGES
Larger incision
Cystoid macular edema
Vitreous complications
Endophthalmodonesis
Increased incidence of RD
Posterior capsule opacity

Smaller incision
No vitreous complications
Less endophthalmodonesis
Less CME,RD
Allows implants pcIOL
Smallest incision
Demanding technique
Less induced astigmatism Complications while learning
Fastest technique

CASE REPORT

PATIENT IDENTITY
Name
: Si Luh Nyoman Puspa Juniarti
MR
: 15020708
Age
: 7 y.o
Sex
: Female
Address
: Br Kutaraga, Bongkasa, Abiansemal,
Badung
Religion
: Hindu
Date of exam: 15th April 2015 at 11.00 AM

ANAMNESIS
CHIEF COMPLAINT: blurry vision
PRESENT ILLNESS:
Patient refered from RSUD Badung to Eye Clinic Sanglah Hospital with
chief complaint of blurry vision on her right eye since 3 months ago. The
blurry vision appear insidiously, the right eye was getting blurred like
seeing a cloud and it was getting worse since 3 days ago. The right eye
became clouded and disturbed the vision. Patient denied history of
recently trauma, redness on the eyes, watery eyes, pain, and fever.
HISTORY OF MEDICATION:
Patient used Insto eye drop to relieve the blurry vision but it didnt improve.

 PAST HISTORY:
Patient complained redness on the eye about 1 year ago but it relieved
by using Insto eye drop. Trauma and allergic history were denied.
History f fever, cough, and sneezing were also denied.
FAMILY HISTORY:
None of family members had the same symptoms as the patient did.
Any history of systemic disease, asthma, drug or food allergy were
also denied.
SOCIAL HISTORY :
Patient was a Elementary School student. Patient read, write, and
count well. Patient had some problems on study because of the
blurry vision.

PHYSICAL EXAMINATION
PRESENT STATUS:
Consciousness
: compos mentis
Blood pressure
: 110/70 mmHg
Pulse rate
: 80x/minute
Respiration
: 20x/minute
Temperature axilla : 36o C

 LOCAL STATUS:
Visus
Supra cilia
Madarosis
Sikatriks
Palpebra superior
Edema
Hiperemi
Enteropion
Ekteropion
Benjolan
Palpebra inferior
Edema
Hiperemi
Enteropion
Ekteropion
Benjolan
Pungtum lakrimalis
Pungsi
Benjolan

Oculi Dextra (OD)

Oculi Sinistra (OS)

0,5/60

6/12 PH 6/7,5

Tidak ada
Tidak ada

Tidak ada
Tidak ada

Tidak ada
Tidak ada
Tidak ada
Tidak ada
Tidak ada

Tidak ada
Tidak ada
Tidak ada
Tidak ada
Tidak ada

Tidak ada
Tidak ada
Tidak ada
Tidak ada
Tidak ada

Tidak ada
Tidak ada
Tidak ada
Tidak ada
Tidak ada

Tidak dilakukan
Tidak ada

Tidak dilakukan
Tidak ada

Konjungtiva tarsal superior

Hiperemi
Folikel
Sikatriks
Benjolan
Sekret
Papil

Tidak ada
Tidak ada
Tidak ada
Tidak ada
Tidak ada
Tidak ada

Tidak ada
Tidak ada
Tidak ada
Tidak ada
Tidak ada
Tidak ada

Konjungtiva tarsal inferior

Hiperemi
Folikel
Sikatriks
Benjolan

Tidak ada
Tidak ada
Tidak ada
Tidak ada

Tidak ada
Tidak ada
Tidak ada
Tidak ada

Tidak ada
Tidak ada
Tidak ada

Tidak ada
Tidak ada
Tidak ada

Tidak ada
Tidak ada
Tidak ada

Tidak ada
Tidak ada
Tidak ada

Konjungtiva bulbi
Kemosis
Hiperemi
-Konjungtiva
-Silier
Perdarahan subkonjungtiva
Pterigium
Pingueculae

Sklera
Warna
Pigmentasi
Kornea
Odem
Infiltrat
Ulkus
Sikatriks
Keratik presifitat
Kamera okuli anterior
Kejernihan
Kedalaman
Iris
Warna
Koloboma
Sinekia anterior
Sinekia posterior
Pupil
Bentuk
Regularitas
Refleks cahaya langsung
Refleks cahaya konsensual

Tenang
Tidak ada

Tenang
Tidak ada

Tidak ada
Tidak ada
Tidak ada
Tidak ada
Tidak ada

Tidak ada
Tidak ada
Tidak ada
Tidak ada
Tidak ada

Jernih
Dangkal

Jernih
Dalam

Coklat
Tidak ada
Tidak ada
Ada, jam 5-6

Coklat
Tidak ada
Tidak ada
Tidak ada

Oval
Ireguler
Ada
Ada

Bulat
Reguler
Ada
Ada

Lensa
Kejernihan
Dislokasi/subluksasi

Keruh
Tidak ada

Jernih
Tidak ada

SUMMARY
Patient female, 7 y.o, came with chief complaint of blurry
vision on her right eye since 3 months ago and getting
worse since 3 days ago. The right eye became clouded and
disturbed the vision. Patient complained redness on the
eye about 1 year ago but it relieved by using Insto eye
drop. Trauma and other systemic disease were denied.
Patient was a Elementary School student.

OD
0,5/60
Ortophoria

Pemeriksaan
Mata
Visus
Kedudukan
Pergerakan

OS
6/12 PH 6/7,5
Ortophoria

Hiperemi (-), Edema (-), spasme (-)

Palpebra

Hiperemi (-), Edema (-), spasme (-)

Hiperemi (-) jaringan fibrovaskular

(-)

Konjungtiva

Hiperemi (-), jaringan fibrovaskular (-)

Jernih, Edema(-), infiltrate (-)

Kornea

Jernih, Edema (-), infiltrate (-)

Dangkal

COA

Dalam

Irregular, sinekia posterior jam 5-6

Iris

Bulat, regular

Sentral, oval, reflek cahaya (+),

5 mm
Keruh
Sulit dievaluasi

Pupil
Lensa
Vitreus

Sentral, round, reflek cahaya (+), 5

mm
Jernih
Jernih

Sulit dievaluasi

Funduskopi

Refleks (+), papil N II bulat, batas

tegas, CD ratio 0,3; a/v 2/3; retina
baik, reflex macula (-)

11

NCT

16,5

ULTRASONOGRAPHY (15th April 2015)

Conclusion: vitreous opacity

DIAGNOSIS
DIFFERENTIAL DIAGNOSIS:
OD Juvenile Cataract
OD Uveitis Posterior
OD Vitreous Opacity
WORKING DIAGNOSIS:
OD Juvenile Cataract

MANAGEMENT AND PROGNOSIS

Supporting examination:
Laboratory: CBC, BSN, BTCT
Thorak photo
Therapy:
OD Pro lens mass aspiration and IOL insertion with general
anesthesia
Prognosis:
Ad vitam : dubia ad bonam
Ad fungsionam : dubia ad bonam
Ad sanasionam : dubia ad bonam

DISCUSSION

CASE

THEORY

From anamnesis obtained

complaint of blurry vision. On
physical examination found
lens opacity.

Cataract diagnosis based on anamnesis,

physical examination, and supporting
examination. The subjective findings such as
cloudy vision, lens discoloration, myopic shift,
poor night vision, glare and halos, and double
vision. The lens opacity could be partly or
whole part, the iris shadow positive or
negative, and any spot of red reflex on fundus
reflex.

Patient diagnosed as OD
juvenile cataract.

According to age, cataract divides into

congenital, juvenile, and senile cataract.
Juvenile cataract cause decreasing of vision
gradually and lens opacity formed between
age of 36 months 9 years when lens fibers
are developed so that the consistency of lens
is soft and milky-like. Juvenile cataract is
usually the continuation of congenital cataract

CASE

THEORY

Patient had history of redness

of the eye about 1 year ago.
On physical examination found
posterior sinechia on 5-6
oclock. We suspect this
patient had uveitis. On eye
ultrasonography found vitreous
opacity.

In case of unilateral cataract usually realted to

local disease such as glaucoma, uveitis, local
or systemic steroid use, high myopia, retina
ablation, retinitis pigmentous, and intraocular
tumor. Uveitis is a chronic inflammation on
choroid, cilliary body, or iris. The symptoms
such as pain, photophobia, and blurry vision.
Usually the type of cataract in children is
subcapsular. Posterior sinechia sometimes
found in this patient with necrosis on capsule
area and lens opacity.

No history of familial cataract

and other risk factors related
to patient disease.

Mostly cataract appears in late age as the

consequences of exposure to environment.
But in case of juvenile cataract, the related risk
factor including hereditary, uv radiation, and
increase of blood glucose.

CASE

THEORY

In this patient planned to OD

Pro lens mass aspiration and
IOL insertion with general
anesthesia.

Some cataracts dont alter the vision and dont

need surgical intervention. If the cataract
disturbs the vision, we can consider surgical
therapy to extract the lens.

In this patient lens mass

aspiration surgery with IOL
fixation was performed

Patient who are considered for IOL fixation

must be at least 8 months to 11 years of age.
Best results are observed in patients above 1
years old.

Conclusion

Have been reported cases , female patients aged 7 years ,

complained of blurred right eye since 3 months ago and was
advancing since 3 days ago with the growing white white round is in
the eye and impair vision .
The patient never complained red eyes about 1 year ago and
improved with eye drops.
From the results of a careful history and examination has been
carried out , the working diagnosis OD obtained Cataract Juvenil .
Patients will be given in the form of handling pro OD + IOL lens
mass aspiration with general anesthesia .
This patient prognosis ad vitam : bonam dubious ad , ad
fungsionam : bonam dubious ad , ad sanationam : dubious ad
bonam