Lens

Cystoid macular edema

• Seen six to ten weeks post complicated cataract surgery

• Will appear cystic on OCT

• Treatment: topical NSAID and steroid

Anterior capsular fibrosis and contraction

• Only seen when capsulorhexis is performed

• Risk factors: small capsulorhexis and pseudoexfoliation

• Treatment: anterior capsulotomy with Nd:YAG

Dysphotopsia

• Patients will report dark shadows in temporal periphery, scintillations, halos and central or peripheral flashes

  • 1st 6-10 weeks

• Common with multifocal IOL

• Treatment: none

Pseudophakia bullous keratopathy

• Commonly seen in patients with compromised endothelium prior to cataract surgery

• Also seen in complicated cataract surgery, prolonged surgery or intraoperative endothelial trauma

• ptosis

• malposition of IOL

• edema

Rhegmatogenous retinal detachment

• post op complication of phacoemulsification

• Risk factors include lattice degeneration, retinal breaks, high myopia and vitreal loss during surgery

Refractive “surprise”

• post op complication of phacoemulsification

• Post operative refractive error does not match pre operative refractive error calculation

Congenital cataracts

• lenticular opacities present at birth

• Highest prevalence in Asia

• May have unilateral or bilateral presentation

• Symptoms: infants are unable to express symptoms, parents will present their concerns

  • Leukocoria (white pupil)

  • Nystagmus

  • Strabismus

• 4 causes: genetic (50%, mostly AD), chromosomal abnormalities, metabolic disorders, intrauterine infections

• 4 categories: zonular, polar, total/mature, membranous

Zonular congenital cataracts

• affect one zone of lens

• Nuclear: opacities are confined to the embryonic or the fetal nucleus

  • dense or fine dust-like

    • dense significantly dec. acuity

  • tend to be 3mm in size

  • bilateral

  • assoc. w/ microcornea

  • inc risk of developing glaucoma after cataract removal

• Cortical lamellar opacities: most common

  • discrete and round shape

  • Will affect one or more of the rings in the developing cortex

    • Nucleus will be relatively clear

  • 5 mm or larger in diameter

  • Radial extensions or riders

  • Affect on vision is variable

• Sutural: lenticular opacity following anterior or posterior Y suture

  • slow progression

  • minimum affect on VA

• Cerulean (blue dot):

  • Numerous small blue opacities in cortex and nucleus

  • typically non-progressive

  • minimum affect on VA

Polar cataracts (congenital)

• Anterior polar: small white lenticular opacity of the anterior capsule

  • May have an associated underlying cortical opacity that is slightly larger than the capsular opacity

  • can project into anterior chamber

  • most don’t affect vision

    • pts do tend to have assoc. hyperopic anisometropia = amblyopia risk

• Posterior polar: opacity of the posterior capsule

  • arise from the end of the hyaloid artery remnant

  • bilateral

  • glare and halos

Total cataracts (congenital)

• More commonly found in developing countries

• entire lens being opaque = VA significantly affected

• commonly assoc. with nystagmus

Membranous cataracts (congenital)

• lens proteins are resorbed when leaving the anterior & posterior capsule

  • they fuse together and form a dense white membrane

Congenital cataracts treatment

Lens extraction w/ IOL Implantation

• Time of lens extraction is critical (earlier = higher risk of developing juvenile glaucoma)

• Bilateral dense cataracts require surgery between 4-10 weeks of age (prevent AMBLYOPIA)

• Bilateral partial may not require surgery until later in life

• Unilateral dense require surgery between 4-10 weeks of age (prevent AMBLYOPIA)

• Unilateral partial may be observed

Ectopia lentis

• displacement of the lens from its normal position

• Will occur due to broken zonular fibers

• Can be hereditary or acquired

• seen in Marfan’s syndrome

  • Superior temporal subluxation of the lens

  • Bilateral presentation will be seen 80% of the time

• Luxated: complete dislocation of the lens

• Subluxated: partial dislocation of the lens

  • portion still seen in pupillary area

  • Phacodonesis: early sign of lens subluxation

    • The lens will wobble when the eye rapidly moves and returns to primary gaze

• Treatment: cataract surgery

Acquired ectopia lentis

• displacement of lens d/t blunt trauma

• Pathophys:

  • Blunt trauma compresses the eye in the anterior-posterior direction

  • compression causes the eye to expand laterally, superior and inferior

  • zonules to stretch and eventually rupture

  • Lens movement will be dependent on:

    • Complete zonular rupture = dislocation

    • Incomplete zonular rupture = subluxation, lens will move towards intact zonules

• Symptoms:

  • Monocular diplopia (diff focusing pts)

  • Distant blurred vision due to increase in astigmatism and myopia

    • high hyperopia may also be seen

  • Near blurred vision due to loss of accommodation

• Presentation: lens subluxation or dislocation

  • lens can free float in the posterior chamber or migrate to anterior chamber

    • When the lens moves to the anterior chamber, the patient is at risk for glaucoma

• Treatment:

  • Refractive error correction

  • lens extraction

  • tx of complications - glaucoma

Microspherophakia

• small, spherical lens

• Systemic condition association: Marfan, congenital rubella

• Presentation:

  • Refractive error: high myopia

    • Accommodation dysfunction

  • Lens: thick crystalline lens with small diameter

    • Entire equatorial margin will be seen with dilation

    • Movement of lens with change in posture

    • ectopia lentis

• Complications: glaucoma (51%)

  • d/t pupillary block, angle blockage, or angle abnormalities

• Treatment:

  • Surgical management: lens extraction

  • Surgical management of glaucoma

Vossius ring

• pigment on the anterior capsule of the lens from posterior aspect of the iris

• Cause: blunt trauma

• Presentation: circle of iris pigmentation on the anterior capsule of the lens

  • Circle may be complete or incomplete

• Treatment: none

  • As the pupil constricts and dilates, the iris will rub the pigment off the anterior capsule