MANAGEMENT OF CATARACT

TREATMENT OF CATARACT ESSENTIALLY

CONSIST OF ITS SURGICAL REMOVAL..

NON SURGICAL MEASURES MAY BE OF HELP

TILL SURGERY IS TAKEN UP.

NON SURGICAL MEASURES

TREATMENT OF CAUSE OF CATARACT
MEASURES TO DELAY PROGRESSION OF

CATARACT
MEASURES TO IMPROVE VISION IN

PRESENCE OF IMMATURE CATARACT.

NON SURGICAL.
1.Treatment of cause of cataract:
Control of diabetes mellitus. Avoid cataractogenic drugs.
Corticosteroids Phenothiazines Miotics

Removal of irradiation.
Rx of Ocular diseases.

NON SURGICAL:
2.Measures to delay progression:
Iodide salts of calcium and

potassium Vitamin E & Aspirin

NON SURGICAL:
presence of immature cataract:
Refraction correction.
Arrangement of illumination.
brilliant illumination dull light peripheral opacity central opacity

3.Measures to improve vision in

Use of dark goggles. Mydriatics : Phenylephrine 5% /

Tropicamide 1%
Allows clear paraxial lens to participate in light transmission, image formation & foccussing

SURGICAL MANAGEMENT:
Indications:
Visual improvement
Medical indications lens induced glaucoma,
phacoanaphylactic endophthalmitis, retinal diseases

Cosmetic indication

Pre operative evaluation

General examination ocular examination

Retinal function tests Infections

IOP anterior segment by slit lamp

Preoperative evaluations:
General medical examination:
R/O DM, HTN, cardiac

problems,obstructive lung diseases,any potential source of infection.

Preoperative evaluations:
Retinal function tests

PL A test for RAPD PR(peripheral retina fn) 2 light discrimination test(macula fn) Maddox rod test

Colour perception Entoptic visualisation(rubbing point source of light against closed eyelids) Laser interferometry(measurin macular potential for visual acuity in d presenc f opaque media) Objective tests ERG,EOG,VER(Visually
evoked response)

Preoperative evaluations:
Anterior segment pathology
Slit lamp examination

Gross focal sepsis:

Conjunctival infections. Lacrimal sac

IOP

Pre-op preparation:
Informed & detailed consent. Topical antibiotics. Gentamycin, Tobramycin,ciprofloxacin-QID, 3 days prior. (endophthalmitis) Preparation of the eye. Scrub bath, care of hair. Lower IOP:
Acetazolamide 5

00mg stat, 2hrs before.

IV mannitol

1 gm/kg, 1/2hr before or glycerol 60 ml mixed with H2O or lemon juice 1 hr b4

Pre-op preparation:
Dilate pupil:
1% tropicamide, 5% phenylephrine.

every 10 min 1 hr before surgery Anti prostaglandin eyedrops: indomethacin,flurbiprofen. 3 times the previous day hourly for 2 hours before surgery

Anaesthesia:
GA & LA
LA is preferred whenever possible

Cataract surgery:

Intracapsular cataract

extraction-ICCE Extracapsular cataract extraction-ECCE

Conventional ECCE. Manual small incision cataract

surgery.(SICS) Phacoemulsification.

ICCE
Whole lens with intact capsule removed. Prerequisite- weak & degenerated zonules

ICCE

ICCE
Indications
Markedly subluxated & dislocated

lens
About 50 yrs of age (40-50 yrs alpha chymotrypsin)

ICCE Procedure
Superior rectus suture to fix eye in downward
gaze Preparation of conjunctival flap-expose limbus Making a partial thickness groove or gutter Corneoscleral section-ant.chamber is opened (3.2mm keratome or razor blade) Peripheral Iridectomy to prevent post- op pupil block glaucoma

 Methods of lens delivery-

Indian smith method, cryoextraction, capsule forceps method, irisophake method, wire vectis method

ICCE Procedure
Formation of anterior chamber(iris

reposited n sterile air /BSS) Implantation of anterior chamber lens Closure of incision Reposition of conjunctival flap Subconjunctival injectionDexamethasone .25ml & gentamycin o.5ml Patching of eye

ECCE
Major portion of anterior

Capsule with epithelium,nucleus & cortex removed Leave intact posterior capsule

ECCE

ECCE

Indication
Surgery of choice

Contraindication
Markedly subluxated & dislocated lens

ECCE Procedure
1.. Superior Rectus (bridle) suture to fix the eye in downward gaze. 2. Conjunctival flap preparation to expose the limbus
Haemostastis by wet field cautery

ECCE Procedure
6. Corneo-scleral section razor blade or 3.2mm keratome 7. Anterior chamber opened 8. Injection of viscoelastic substance into anterior chamber (2% methyl cellulose or 1%Sodium Hyaluronate) maintains the anterior chamber n protects endothelium 9. Anterior capsulotomy ( can opener(cystitome) , linear capsulotomy or continuous circular capsulorrhexis, CCC) 10.Removal of anterior capsule(Kelman McPhersons forceps)

ECCE Procedure
11. Completion of corneoscleral section 12. Hydrodissection inj BSS:separates corticonuclear mass from capsule. 13. Nucleus delivery

Pressure & counter pressure method Irrigating wire vectis technique 14. Aspiration and irrigation (BSS or Ringer lactate is used as irrigating fluid) of cortex 15. Filling of lens capsule (capsular bag) with visco elastic substance

ECCE Procedure
16. Insertion of posterior chamber IOL in the capsular bag 17.Closure of the incision 18.Removal of viscoelastic substance and AC filled with BSS 19.Reposition of conjunctival flap 20.Subconjunctival injection 21.Patching of eye

Advantage of ECCE over ICCE

ECCE- In all age gp ICCE- above 40yrs

PCIOL cannot be implanted after ICCE

Postoperative vitreous related

problems with ICCE Postoperative complicationendophthalmitis,cystoid macular edema,RD.less after ECCE Postoperative astigmatism is less in ECCE as smaller incision in ECCE

Advantage of ICCE over ECCE

Simple,easy & cheap
Postoperative opacification

of posterior capsule absent Less time consuming- mass scale operation

SICS
ECCE with IOL implantation. Surgery is performed thru a

sutureless self sealing valvular sclerocorneo tunnel incision Incision size- 5.5 to 7.5 mm Lens nucleus and cortex removed Capsular bag left behind. Post operative astigmatism less

Sics
Superior rectus suture to fix eye in downward gaze
Preparation of conjunctival flap & Haemostasis sclerocorneal tunnel incision:consist of Ext Scl(straight,frown or chevron) incision sclero corneal tunnel Internal corneal incsn Side-port entry: valvular corneal incision @ 9 oclock

position (aspirtn of subincisional cortex & deepening ant chamb) Ant capsulotomy Hydrodissectn

 Nuclear management:
Prolapse of nucleus during HD& compl eted wt

Sinskeys hook Delivery of the nucleus outside by wire vectis/ blumenthal/Phacosandwich/Phacofracture/ Fishhook techniques Aspirn of cortex IOL implntn & removal of visco elastic substance Wound closure

Phacoemulsification:

Phacoemulsification
Corneo scleral

incision is very small CCC (continuous circular capsulorrhexis) is preferred over other methods of ant.capsulotomy

Phacoemulsification
The surgeon

then uses the probe, which vibrates with ultrasound waves, to break up (emulsify) the cataract and suction out the fragments

Phacoemulsification
Once the cataract

is removed, a clear artificial lens is implanted to replace the original clouded lens IOL- Foldable or rollable type

Phacoemulsification
Sutureless self sealing small incision
Visual rehabilitation quicker Postoperative astigmatism less

Laser phacoemulsificn
under trial
ADVANTAGE: laser energy used for emulsification not

exposed to other IO structures.

SICS
Universal,easier,non machine

Phacoemulsification
Machine dep,high cost small incisn More complications lyk

dep,less time ,cost effective Less complicn Conjunctival congestn 5-7d post op hyphaema ,surgical ind astigmatism is more

nuclear drop Congesn minimum & Post op astigmatism is less Visual rehab quickr