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Important Forms of Age-Related Cataract

• Overview of symptoms
• Nuclear Sclerotic
  • Opacification of the lens nucleus
  • Often associated with myopia
  • Initial yellow, later brown changes of the lens nucleus
  • Grading: Nuclear sclerosis according to BCN 10 (Nuclear Cataract Grading)¹
• Cortical
  • Can affect anterior, posterior, or equatorial cortex
  • Initial fissures and vacuoles, then typical wedge-shaped or radial, spoke-like opacities
  • Often causes glare
• Posterior Capsular Opacification
  • Well-visible in retroillumination
  • Opacity located directly in front of the posterior capsule
  • Vacuolated, granular, or plaque-like appearance
  • Often causes glare

Stages

• Immature Cataract: Lens partially opacified
• Mature Cataract: Lens completely opacified
• Hypermature Cataract: Shrunken and wrinkled capsule due to water leakage from the lens
• Morgagnian Cataract: Hypermature cataract where liquefaction of the cortex causes the nucleus to sink downward

Risk Factors

• Steroid therapy, trauma, UV light, smoking, diabetes, myopia

Postoperative Follow-up Day 1

• Visual acuity not obligatory
• Corneal edema?
• Anterior chamber:
  • Deep? If shallow: Seidel test
  • Cells/flare/fibrin/blood/hypopyon?
  • IOL positioned correctly? Is the posterior capsule intact?
  • Round/distorted pupil? If teardrop-shaped: Vitreous in the anterior chamber?
• IOP
  • < 5mmHg: Seidel test
    • If anterior chamber is shallow and Seidel test positive -> Bandage contact lens (16mm diameter), Floxal UD 4x/d, Dexafree 4x/d, follow-up after 1-2 days
    • If anterior chamber is collapsed: Inform senior physician/surgeon
  • 5 – 25mmHg: Treatment and follow-up as planned
  • 26 – 35mmHg: Lower IOP
    • Known glaucoma and glaucoma drops not taken yet: Re-administer own glaucoma drops first, follow-up after 1-2 days
    • No known glaucoma: Diamox 250mg 2×1 tbl./d, follow-up after 1-2 days
  • >35mmHg: Inform senior physician/surgeon
    • Viscoelastic in anterior chamber? (little/no convection)
      • Consider releasing pressure via paracentesis
• Retinal examination only if symptoms of detachment

Postoperative Complications

• Increased IOP (see above)
• Wound leakage (see above)
• IOL (Sub-)luxation
• Posterior capsule opacification (“second cataract”)
• Toxic Anterior Segment Syndrome (TASS)
  • within 24 hours postoperatively!
• Endophthalmitis
• Corneal edema
  • IOP decompensation? Endothelial defect? Fuchs endothelial dystrophy?
• Macular edema (Irvine-Gass syndrome?)
• Retinal detachment
• Ptosis
• Expulsive suprachoroidal haemorrhage
  • very rare, acute severe pain, loss of vision, IOP increased, +/- shallow anterior chamber

Sources

• EyeWiki Cataract
• EyeWiki Morgagnian Cataract
• EyeWiki Cataract Surgery Complications
• ¹Barraquer R, I, Pinilla Cortés L, Allende M, J, Montenegro G, A, Ivankovic B, D’Antin J, C, Martínez Osorio H, Michael R: Validation of the Nuclear Cataract Grading System BCN 10. Ophthalmic Res 2017;57:247-251. doi: 10.1159/000456720
• The Wills Eye Manual: Office and Emergency Room Diagnosis and Treatment of Eye Disease; Nika Bagheri MD, Brynn Wajda MD, et al; Lippincott Williams&Wilkins; 7th Edition (2016)
• Kanski’s Clinical Ophthalmology: A Systematic Approach; Jack J. Kanski MD, Brad Bowling MD; Saunders Ltd.; 8th Edition (2015)