Test 1: Cataracts Flashcards
types of cataract surgery
couching
ICCE (intracapsular)
ECCE (extracapsular)
intraocular implants
iris fixated
anterior chamber
posterior chamber
iris fixated IOLs
can’t dilate
rare now
have to have iridectomy
suture techniques
interrupted sutures
continuous
no-stitich - clear corneal incision
incision techniques
limbal
scleral tunnel - 1-2 mm into sclera superiorly
self sealing
all done at a shallow tangential angle
anesthesia
general or local
local - retrobulbar & peribulbar
retrobulbar anesthesia
2% lidocaine short onset
0.75% marcaine long acting
epinephrine
general classification of cataract
first appear after ages 30-40 occurring in 90+% of people over age 70
generally progress at varying rates and result in decreased VA
typically classified as: location within the lens and stage of development
major types of cataracts include
nuclear
cortical
subcapsular
subdivisions of nuclear
early or advanced
brunescent, milky
subdivisions of cortical
early or incipient
immature or intumescent
mature
hypermature
subdivisions of sub capsular
early
moderate
advanced
nuclear cataract
normal lens nucleus hardens and pigments with age
known as nuclear sclerosis and only when advanced will it interfere with VA
color progresses from orange to dark brown
involves fetal nucleus which can appear darker than adult nucleus
can result in lenticular myopia or second sight
refraction become difficult in advanced stages
decreased VA from non-focused rays from above phenomenon
monocular diplopia may also be seen by patient with small nuclear change acting like prism
cortical cataract
most common opacity
early stage results in lens swelling and subsequent shallowing of anterior chamber
mature stage results from water and wast products exit the capsule
cortical cataract early stage reveals
water clefts - most common location is anterior cortex
lamellar separation - most common location is inferonasal anterior cortex
cuneiform opacity - most characteristic sign
clear vacuoles
senile punctate opacities - may be called snowflake cataract if in large numbers
further degeneration of cortical cataract can lead to
hyper mature cataract
shrunken, dry yellow lens
possible capsular folding
can appear as bag of milky fluid
morgagnian cataract
type of cortical cataract
brown nucleus which sinks to bottom of liquefied lens
christmas tree cataract
type of cortical cataract
formed by cholesterol crystals scattered throughout cortex
myotonic dystrophy
subcapsular cataract
chronic NSAIDs use
also known as cumuliform cataract because of its characteristic mature cup shape
typically occurs at earlier age than nuclear or cortical
posterior sub capsular much more common than anterior
consists of thin layer of granules beneath the capsule which may exhibit as small granular opacity
over time will enlarge to form round or irregular plaque
plaque consiste of vacuoles and crystals scattered between irregular granules
remainder of lens is clear outside of plaque
VA is affected greatly if develops in axial location, especially in glare situations
subcapsular cataract symptoms
excess glare while driving at night
trouble seeing in bright sunlight
reading difficulties with otherwise good reading lamp
promazine hydrochloride
med that can cause cataract
indications for surgery
unhappy with VA (night glare) phacoanaphylaxis phacomorphic glaucoma phacolytic glaucoma dislocation of lens amblyopia in young patient to provide unobscured access for treatment of eye disease
indications for IOL implantation
IOL implantation is considered a routine procedure and si therefore performed in the majority of cases
contraindications for surgery
visual reduction secondary to coexisting condition patient satisfied with current VA poor systemic health patient doesn't desire surgery surgery won't improve visual function
complications of cataract surgery
post capsular opacification
CME
posterior capsular rupture
endophthalmitis
contraindications for IOL implantation
corneal endothelial disease
unilateral aphakia with spectacle correction
rubeosis irides and/or neovascular glaucoma
young patient
conditions which require additional evaluation before surgery
monocular patients high myopia traumatic cataract Fuch's dystrophy glaucoma history of lattice degeneration or retinal detachment chronic iritis/uveitis
eligibility for cataract surgery
snellen 20/40 or worse
reduction in VA of 2 lines under glare testing
2D of anise
have to have a functional complaint
pre-surgical care ocular evaluation
keratometry potential acuity assessment BAT contrast sensitivity endothelial cell cunt A scan B scan medications patient edu
pre-surgical medical evaluation
detailed history - cardiovascular, respiratory, hepatic, neuro/musculoskeletal, renal/metabolic, social, misc.
physical assessment - cardiovascular, chest/lungs, abdomen, extremities, neurological, mental status
pre-surgical lab testing
CBC with differential
ECG
urinalysis
electrolytes
post surgical care examination procedures performed at each visit
case history including amount of discomfort and quality of vision
VA
keratometry
refraction
biomicroscope - cornea, AC reaction and depth, iris and pupil, intraocular lens, capsule
wound - no-stitch surgery, suture type and placement, integrity with Seidel test
tonometry
posterior pole evaluation, vitreous, ONH, macula, surrounding retina
schedule of visits
one day one week (evaluate fellow eye at 1 week) 3-6 weeks 2 months three months six months 12 months
medications
topical corticosteroids topical borad spectrum antibiotics combo steroid/antibiotic anti glaucoma meds lubricants
patient instructions
avoid activities which are associated with risk of trauma or toxic and infectious exposure
check vision every day for significant change
use meds as directed
metal shield at bedtime for 3 days
sunglasses and/or glasses for protection
avoid lifting heavy objects or bending over for long periods
suture removal
the amount of post-op suture induced astigmatism is based upon the type of surgery performed
larger incisions show higher amounts and no stitch show very little
incisions of 3-4 mm show ~1-2D of refractive astigmatism, 5-8 mm usually 2-3 D
this, of course is based on the surgeon and how tight the suture is tied
interrupted sutures
can be removed as soon as 1 week post-op
remove suture in steep K meridian
if refraction shows -2.00 -4.00 x 010 remove the suture at axis 100
continuous sutures
should not be removed for ~6 weeks post op
technique consists of cutting the suture nearest the inferior insertion into the eye
forceps are used to grab long free end of suture and gently pull the suture through
refractive cataract surgery
used in cases of preexisting or induced high corneal astigmatism
can be performed as an adjunct technique at the time of surgery or post op behind the slit lamp
one or two corneal incisions are made along the limbus at the steepest corneal meridian
no stitch scleral incision made at the steepest corneal meridian
posterior capsulotomy
initial complaint of clouding or film decreasing VA
posterior capsule reveals significant haze
typically performed with nd YAG laser
photo disruptive laser designed to disrupt or separate tissue
opening usually 3-4 mm and is usually performed 6-8 weeks post-op
surgical eligibility for posterior capsulotomy
patient has decreased ability to carry out activities of DL including but not limited to reading, TV, etc.
pt has BCVA in which glare testing decreases VA by 2 lines
pt has determined that he or she is no longer able to function adequately with the current level of visual function
other eye diseases have been excluded as the primary cause of visual functional disability, except for instance in which significant visual debility
physician concurrence with significant pt defined improvement in visual function an be expected as a result of surgery
pt has been edu on risks and benefits
eyelid complications
bruising
ptosis
edema and erythema
conjunctiva complications
subconjunctival hemorrhage
chemosis
localized GPC
cornea complications
astigmatism
edema
bulls keratopathy
descemet’s membrane detachment
anterior chamber complications
hypopyon hyphema shallow chamber wound leak epithelial downgrowth increased IOP
iris complications
iritis
iris prolapse into wound
pupil complications
pupillary distortion (peaked pupil)
pupillary capture
atonic pupil
lens, capsule, and IOL complications
torn posterior capsule retained cortex posterior capsule opacification anterior capsular contraction dislocated IOL
complications involving anterior chamber lenses
UGH syndrome partial or total erosion through angle anterior synechia dislocation pupillary capture reverse pupillary block
contraindications of anterior chamber IOL’s include
chronic open angle glaucoma
extensive peripheral anterior synechia
recurrent uveitis
low endothelial cell count
complications involving posterior chamber lenses
malposition of IOL - sunset syndrome, sunrise syndrome, horizontal decantation, windshield wiper syndrome pupil capture posterior synechiae posterior chafing syndrome erosion of ciliary body loop perforation through peripheral iridectomy posterior capsular opacification vitreous retina and choroid
sunset syndrome
optic displaced toward 6:00
can be caused by inferior haptic in sulcus and superior haptic in capsular bag
disturbs patient from aphakic/pseudophakic correction
minor displacements corrected with pilo
surgical intervention may be necessary
sunrise syndrome
optic displaced toward 12:00
can be caused by superior haptic in sulcus and inferior haptic in capsular bag
disturbs patient from aphakic/pseudophakic correction
minor displacements corrected with pilo
surgical intervention may be necessary
horizontal decentration
optic displaced horizontally
can be caused by one haptic in sulcus and another haptic in capsular bag
disturbs patient from aphakic/pseudophakic correction
minor displacements corrected with pilo
surgical intervention may be necessary
windshield wiper syndrome
implant too small and not placed within capsular bag
most common in myopic eyes
found out common with sulcus-fixated lenses placed in a vertical position
superior loop rotates to the left and right head movement
pupil capture
lens falls forward and iris closes around lens
creates irregular pupil
may cause inflammation
may have to be repaired by dilating pupil and pushing lens posteriors
long standing pupillary capture does not require treatment
all sulcus lenses
posterior synechiae
results from chronic inflammation
related to the following: IOL equator with pigment epithelium of iris, IOL with pigment epithelium of iris
posterior chafing syndrome
can occur in two forms
first form reveals iris transillumination defects and microhyphemas and is characterized by the following: associated with intermittent blurring known as white out attacks, typically occurs in sulcus-fixated lenses which liberates WBCs
second form caused by pigment dispersion resulting in glaucoma
erosion of ciliary body
seen in ciliary sulcus supported IOLs
erosion and perforation can be seen through the ciliary body
haptic can also erode through pars plicata, muscular
loop perforation through peripheral iridectomy
seen in sulcus-fixated lenses
may need surgical repair
posterior capsular opacification
misnomer since opacification occurs secondary to lens epithelial cells that cover capsule
collagen production of lens epithelial cells results in white fibrotic opacification
lens epi cells migrate from anterior capsule to posterior capsule
lens epi cells can form dense clusters known as Elschnig’s pearls
opacification and Elschnig’s pearls best seen through retro illumination
opacification advancement occurs more rapidly in younger patients
treatment consists of a YAG laser capsulotomy which opens the capsule
vitreous
vitreal hemorrhage
vitreal attachment to wound
vitreal touch
retina and choroid
choroidal detachment
retinal detachment
cystoid macular edema
medications that causes anterior capsule cataracts
amiodarone
mercury, gold, silver
phenothiazines
medications that cause anterior sub capsular cataracts
allopurinol
miotics
medications that cause cortical cataracts
hydrocarbons
medications that cause posterior subcapsular cataracts
corticosteroids
systemic antimetabolites or chemotherapy
hydroxychloroquine
conditions associated with nuclear sclerotic cataracts
acquired: drugs, radiation, trauma
age related: yes
congenital/genetic: down’s syndrome, norris disease, X-linked ichthyosis
inflammatory or vascular: ocular ischemia
intraocular diseases: angle closure glaucoma, chronic uveitis, high myopia, pseudoexfoliation, stickler syndrome
metabolic: chronic malnutrition or dehydration, diabetes mellitus
conditions associated with cortical cataracts
acquired: chemical injury, siderosis, trauma
age related: yes
congenital/genetic: alport syndrome, down’s syndrome, lowe syndrome, myotonic dystrophy, osteogenesis imperfecta
inflammatory or vascular: eczema or atopic dermatitis
intraocular diseases: angle closure glaucoma, chronic uveitis, fuch’s heterochromic iridocyclitis, high myopia, stickler syndrome
metabolic: diabetes mellitus, galactosemia, hypocalcemia, pseudohypoparathyroidism, wilson’s disease or chalcosis
radiation: infrared or thermal, ionizing
conditions associated with subcapsular cataracts
acquired: electric shock, trauma, vitreoretinal surgery
age related: yes
congenital/genetic: fabry’s disease, hyperornithinermia or gyrate atrophy, myotonic dystrophy, refsum’s disease, RP or Usher’s disease, werner’s syndrome
inflammatory or vascular: ocular ischemia
intraocular diseases: aniridia, chronic uveitis, high myopia, iridocorneal endothelial syndromes, persistent hyperplastic primary vitreous, peter’s anomaly
metabolic: diabetes mellitus, mannosidosis, neonatal hypoglycemia
radiation: ionizing, ultraviolet
neoplastic: neurofibromatosis type II, retinoblastoma, uveal melanoma
