CATARACTS

DEFINITION
A cataract is a clouding of the eye's natural lens, which lies behind the iris and
the pupil. The lens works much like a camera lens, focusing light onto the retina at the
back of the eye. The lens also adjusts the eye's focus, letting us see things clearly both
up close and far away.
The lens is mostly made of water and protein. The protein is arranged in a precise way
that keeps the lens clear and lets light pass through it.
But as we age, some of the protein may clump together and start to cloud a small area
of the lens. This is a cataract, and over time, it may grow larger and cloud more of the
lens, making it harder to see.
Researchers are gaining additional insights about what causes these specific types of
proteins (crystallins) to cluster in abnormal ways to cause lens cloudiness and
cataracts. One recent finding suggests that fragmented versions of these proteins bind
with normal proteins, disrupting normal function.
Cataracts are classified as one of three types:
• A subcapsular cataract begins at the back of the lens. People with diabetes,
high farsightedness or retinitis pigmentosa, or those taking high doses of
steroids, may develop a subcapsular cataract.
• A nuclear cataract is most commonly seen as it forms. This cataract forms in
the nucleus, the center of the lens, and is due to natural aging changes.
• A cortical cataract, which forms in the lens cortex, gradually extends its spokes
from the outside of the lens to the center. Many diabetics develop cortical
cataracts.
SIGNS AND SYMPTOMS
As a cataract becomes more opaque, clear vision is compromised. A loss of
visual acuity is noted. Contrast sensitivity is also lost, so that contours, shadows and
color vision are less vivid. Veiling glare can be a problem as light is scattered by the
cataract into the eye. A contrast sensitivity test should be performed and if a loss in
contrast sensitivity is demonstrated an eye specialist consultation is recommended.
In the developed world, particularly in high-risk groups such as diabetics, it may be
advisable to seek medical opinion if a 'halo' is observed around street lights at night,
especially if this phenomenon appears to be confined to one eye only.

CAUSES
Cataracts develop from a variety of reasons, including long-term exposure to
ultraviolet light, exposure to radiation, secondary effects of diseases such as diabetes,
hypertension and advanced age, or trauma (possibly much earlier); they are usually a
result of denaturation of lens protein. Genetic factors are often a cause of congenital
cataracts and positive family history may also play a role in predisposing someone to
cataracts at an earlier age, a phenomenon of "anticipation" in pre-senile cataracts.
Cataracts may also be produced by eye injury or physical trauma. A study among
Icelandair pilots showed commercial airline pilots are three times more likely to develop
cataracts than people with non-flying jobs. This is thought to be caused by excessive
exposure to radiation coming from outer space. Cataracts are also unusually common in
persons exposed to infrared radiation, such as glassblowers who suffer from "exfoliation
syndrome". Exposure to microwave radiation can cause cataracts. Atopic or allergic
conditions are also known to quicken the progression of cataracts, especially in
children. Cataracts may be partial or complete, stationary or progressive, hard or soft.
Some drugs can induce cataract development, such as corticosteroids and Ezetimibe
and Seroquel. There are various types of cataracts, e.g. nuclear, cortical, mature, and
hypermature. Cataracts are also classified by their location, e.g. posterior (classically
due to steroid use) and anterior (common (senile) cataract related to aging).
PATHOPHYSIOLOGY
Among the transparent tissues of the eye, the lens is a rather bradytrophic
compartment having a relatively xenobiotic metabolism. It is composed of specialized
proteins, whose optical properties are dependent on the fine arrangement of their three-
dimensional structure and hydration. Protein-bound SH-groups of the crystallins are
protected against oxidation and cross-linking by high concentrations of reduced
glutathione. Their molecular composition as well tertiary and quaternary structures
provide a high spatial and timely stability (heat-shock proteins) especially of the larger
crystallins, who are able to absorbed radiation energy (shortwave visible light, ultraviolet
and infrared radiation) over longer time periods without basically changing their optical
qualities. This provides considerable protective function also for the activity of various
enzymes of the carbohydrate metabolism. The glucose metabolic pathway is functioning
rather anaerobically with low energetic efficiency; nevertheless it has to provide the
metabolic energy for protein synthesis, transport and membrane synthesis. In addition,
the syncytial metabolic function of the denucleated fiber cells has to be maintained by
the epithelium and the small group of fiber cells, which still have their metabolic
machinery. This results in a steep inside-out metabolic gradient, which is complicated
by the fact that the lens has a kind of repair system shutting of damaged groups of fiber
cells (wedge- or sectorial cataracts). All epithelial cells of the lens are subjected to light
and radiation stress leading to alterations of the genetic code. Because defective cells
cannot be extruded, these are either degraded (apoptosis, necrosis), or they are moved
to the posterior capsular area, where they contribute to the formation of posterior
subcapsular cataracts. Ageing generally reduces the metabolic efficiency of the lens
thus increasing its susceptibility to noxious factors. Ageing provides the grounds where
cataract noxae can act and interact to induce the formation of a variety of cataracts,
many of them being associated with high protein-related light scattering and
discoloration.
TREATMENT
 Cataract surgery, using a temporal approach phacoemulsification probe (in
right hand) and "chopper" (in left hand) being done under operating microscope. When
a cataract is sufficiently developed to be removed by surgery, the most effective and
common treatment is to make an incision (capsulotomy) into the capsule of the cloudy
lens in order to surgically remove the lens. There are two types of eye surgery that can
be used to remove cataracts: extra-capsular (extracapsular cataract extraction, or
ECCE) and intra-capsular (intracapsular cataract extraction, or ICCE).

Extra-capsular (ECCE) surgery consists of removing the lens but leaving the
majority of the lens capsule intact. High frequency sound waves (phacoemulsification)
are sometimes used to break up the lens before extraction.
Intra-capsular (ICCE) surgery involves removing the entire lens of the eye,
including the lens capsule, but it is rarely performed in modern practice.
In either extra-capsular surgery or intra-capsular surgery, the cataractous lens is
removed and replaced with a plastic lens (an intraocular lens implant) which stays in the
eye permanently.
Cataract operations are usually performed using a local anaesthetic and the
patient is allowed to go home the same day. Recent improvements in intraocular
technology now allow cataract patients to choose a multifocal lens to create a visual
environment in which they are less dependent on glasses. Under some medical
systems multifocal lenses cost extra. Traditional intraocular lenses are monofocal.
Complications are possible after cataract surgery, including endophthalmitis,
posterior capsular opacification and retinal detachment.
In ICCE there is the issue of the Jack in the box phenomenon [14] where the
patient has to wear aphakic glasses—alternatives include contact lenses but these can
prove to be high maintenance, particularly in dusty areas.

Hazy or blurred vision may mean you have a cataract.

Bilateral cataracts in an infant due to Congenital rubella syndrome

Slit lamp photo of anterior capsular opacification visible a few months after implantation of
Intraocular lens in eye, magnified view

Slit lamp photo of posterior capsular opacification visible a few months after
implantation of Intraocular lens in eye, seen on retroillumination